Every finding on record at Thompson House Nursing Home

Based on observation and interview, the facility failed to ensure an effective, functioning resident call system was accessible to all 32 residents on the first floor. Specifically, the facility failed to maintain a system that effectively alerted staff when a call light was disconnected from the wall at the bedside, which occurred in Resident #1's room and was confirmed through sampling in Resident #4's room. On [DATE], Resident #1-who was at high risk for falls and was receiving laxatives-was found deceased on the floor with the call light detached and unalarmed at the nurses' station. The facility failed to implement any policies or routine testing procedures to ensure the call system's audible and visual indicators remained operational. These failures resulted in an Immediate Jeopardy due to the outcome of death for Resident #1 and potentially left all other residents without a reliable means of calling for assistance during an emergency, if their call bell fails to alarm adequately to alert staff when accidentally disconnected. Findings Include:1. Per record review of Resident #1's medical record, Resident #1 had end stage heart failure, chronic kidney disease, hypertension, and was placed on hospice care on [DATE]. Resident #1 required substantial to maximum assistance for his/her toileting and hygiene needs per his/her Minimum Data Set (a tool used to identify resident abilities) dated [DATE]. Resident #1 was at a high risk for falls, with his/her most recent fall assessment dated [DATE] with a score of 13. The Fall Risk Evaluation form states that a Score 10 or higher indicated the resident is at high risk of fall. Per Resident #1's care plan reviewed [DATE], they were care planned on [DATE] for Q1hr [every hour] checks in resident while in bed to ensure all needs are met as a fall intervention due to Resident #1's risk for falls due to impaired mobility and incontinence. Additionally, Resident #1 was care planned for Toilet use: The resident requires substantial/maximal assistance dated [DATE] stating The resident has an ADL self-care performance deficit r/t [due to] terminal prognosis, impaired mobility, pain and incontinence. Resident #1 also had a motion sensor as a fall intervention on [DATE]. Resident #1 has the call light intervention of having a pad style call light being in reach at all times, dated [DATE]. Resident #1 had a history of five falls identified in their care plan since [DATE] with their sixth fall occurring on [DATE].Resident #1 had been given scheduled Senna Docusate Sodium Oral tablet 8.6-50 MG Give 2 tablet by mouth every morning and at bedtime for bowel management with a start date of [DATE] (a medication used to help alleviate constipation) on [DATE] at 9:00 AM and again at 9:00 PM. Additionally, Resident #1 was given a PRN Senna Tablet 8.6 MG with a start date of [DATE] Give 2 tablet by mouth as needed for constipation give 2 tablets = total dose of 17.2 mg for constipation. Bowel Protocol step 1, PRN for no BM in 72 hours . The PRN Senna was given on [DATE] at 9:31 AM. Per the documented survey report for the month of 11/25, Resident #1 had not had a bowel movement for approximately 72 hours with the last bowel movement dated [DATE] at 10:57 PM.Per record review of Resident #1's progress notes on [DATE] at 2:30 AM, Resident #1 was found unresponsive and without a pulse and had expired. The medical record does not reveal the circumstances surrounding Resident #1's death.Per interview with Registered Nurse #1 (RN #1) on [DATE] at 12:38 PM, she stated that she found Resident #1 on the ground deceased on [DATE] at 2:30 AM, the basin was on his/her bed with feces in it, the call light was detached from the wall on the ground by Resident #1's feet at the head of the bed, and that Resident #1 was lying on his/her right lateral side and there was feces on the floor. RN #1 stated that she thinks the call light is supposed to alarm when it is detached from the wall, and it alarms at the nursing station, but that there was no indicator that the call light was detached or that Resident #1 had been moving in his/her room as she did not hear anything at the nurses station.2. Per observation of how the call light system functions on [DATE] at 6:29 PM, the Director of Nursing (DON) went to sample disconnected call lights from the wall. The DON disconnected the call light from the wall in the room that Resident #1 had been in. A soft and quiet beep could just barely be heard coming from the facilities call light system at the nurses' station. When sampling a second room, Resident #4's room, the call light system again, did not effectively notify nursing staff that the call light was disconnected. There was no visual indicator over either Resident #1's room or Resident #4's room to notify staff that the call light was detached from the wall.Per interview with a Licensed Nursing Assistant (LNA) at the nurse's station on [DATE] at 6:31 PM, she initially confirmed that she could not hear the call light making a noise when it was disconnected, and then she stated that she could barely hear the beeping from the call light after pausing and listening closely.Per interview with a RN #2 at the nurse's station on [DATE] at 6:32 PM, she stated that she could not hear the call light alarming when it was disconnected from the wall, and that they must do frequent checks in the hallways to make sure they do not miss anything.Per interview with the DON on [DATE] at approximately 6:38 PM, he confirmed that the call light is supposed to make a loud noise when disconnected from the wall and that it is only making a soft beeping noise.Per interview with the DON on [DATE] at approximately 7 PM, he stated that the call lights are easy to pull out of the wall and that residents do it all the time.Per interview with the Administrator on [DATE] at 7:02 PM, she confirmed that they do not have a policy or procedure for maintaining their call lights or a system in place to ensure that they are functioning effectively.Per phone interview with the Administrator on [DATE] at 1:32 PM, she confirmed that the call light does not alarm above the room when the call light is disconnected from the wall.Per email correspondence with the Administrator and Executive Administrator on [DATE] at 4:37 PM, she confirmed that they don't regularly test the call light system.

Based on interview and record review, the facility failed to implement a comprehensive care plan to ensure the safety and well-being of 3 of 4 residents (Residents #1, #2, and #3). For Resident #1, the facility failed to provide required hourly safety rounds. The facility failed to ensure a functioning motion sensor was used as planned for a resident at high risk of falls. Specifically, Resident #1-who had received laxatives, was non-ambulatory, and required maximal assistance for toileting-was found deceased on the floor with a detached call light and feces present, after nursing staff failed to monitor the resident according to the established fall-prevention interventions. These failures resulted in an Immediate Jeopardy due to the outcome of death for Resident #1. Findings include:1. There was no evidence documented in the medical record that Resident #1 was receiving hourly rounding consistently, every hour, or had toileting hygiene completed since [DATE] at 14:59 PM. Resident #1 had been given scheduled Senna Docusate Sodium Oral tablet 8.6-50 MG Give 2 tablet by mouth every morning and at bedtime for bowel management with a start date of [DATE] (a medication used to help alleviate constipation) on [DATE] at 9:00 AM and again at 9:00 PM. Additionally, Resident #1 was given a PRN Senna Tablet 8.6 MG with a start date of [DATE]. Give 2 tablet by mouth as needed for constipation give 2 tablets = total dose of 17.2 mg for constipation. Bowel Protocol step 1, PRN for no BM in 72 hours. The PRN was given on [DATE] at 9:31 AM. Per the documented survey report for the month of 11/25, Resident #1 had not had a bowel movement for approximately 72 hours with the last bowel movement dated [DATE] at 10:57 PM.Per record review, Resident #1 had end stage heart failure, chronic kidney disease, hypertension, and was placed on hospice care on [DATE]. Resident #1 required substantial to maximum assistance for his/her toileting and hygiene needs per his/her Minimum Data Set (a tool used to identify resident abilities) dated [DATE]. Resident #1 was at a high risk for falls, with his/her most recent fall assessment dated [DATE] with a score of 13. The Fall Risk Evaluation form states that a Score 10 or higher indicated the resident is at high risk of fall. Per Resident #1's care plan reviewed on [DATE], they were care planned on [DATE] for Q1hr checks in [on] resident while in bed to ensure all needs are met as a fall intervention due to Resident #1's risk for falls due to impaired mobility and incontinence. Additionally, Resident #1 was care planned for Toilet use: The resident requires substantial/maximal assistance dated [DATE] stating The resident has an ADL self-care performance deficit r/t [due to] terminal prognosis, impaired mobility, pain and incontinence. Resident #1 also had a motion sensor as a fall intervention on [DATE]. Resident #1 had a history of five falls identified in their care plan since [DATE] with their sixth fall occurring on [DATE].Per interview with RN #1 on [DATE] at 4:00 PM, she reported that Resident #1 had not been acting like themselves during their shift. She reported she was visually checking in on all the residents and found Resident #1 on the ground deceased . When asked if any nursing staff was sleeping on the job, the RN #1 stated that she didn't witness anyone sleeping, but that the Licensed Nursing Assistant assigned to Resident #1 had taken a break that was longer than I think was reasonable and that he was gone way longer than he should have been. She stated that it is fine if the LNA's want to clump their breaks together but that should be communicated to the nurse and she indicated that it wasn't communicated to her.Per interview with RN #1 on [DATE] at 12:38 PM, she stated that she had found Resident #1 deceased on the ground, the basin was on his/her bed with feces in it, the call light was detached from the wall on the ground by Resident #1's feet at the head of the bed, and that Resident #1 was lying on his/her right lateral side and there was feces on the floor. She confirmed that she told the DON all of this on [DATE]. RN #1 confirmed that she was not aware that Resident #1 was on hourly checks and that it should have been added to the clipboard, care plan, computer, Medication Administration Record, or the Treatment Administration Record. When RN #1 was asked if she thought this accident with Resident #1 could have been prevented, she stated that Resident #1 was more agitated that night. RN #1 additionally stated that she couldn't leave the floor to find the LNA that was taking a long break because she would have left the floor unattended. When asked about the lack of documentation in Resident #1's medical record, she reported that this accident was traumatizing to her and that she contacted management to get instruction on what to do and that she confirmed that she didn't document the fall in the medical record or the circumstances surrounding Resident #1's death.Per interview with the ADON on [DATE] at 8:34 AM, she reported that RN #1 had found Resident #1 deceased on the floor and that she instructed them to move Resident #1 from the floor to the bed. When asked if she had heard anything about LNA's taking longer breaks than usual, she reported she heard from nursing staff on [DATE] that an LNA had left the floor and that LNA's were gone for a long period of time for that break. The ADON then stated that they have had some LNAs sleeping in their car and taking a nap, but that it is the expectation they are on the premises and let someone know where they are going in case of an emergency. The ADON confirmed that she was not aware that the call light was detached from the wall or that Resident #1 had defecated in a large basin prior to his/her death. The ADON stated that Resident #1 would self-transfer to the commode, that s/he wasn't care planned to self transfer, that Resident #1 was substantial to maximal assistance for transfers and didn't ambulate while they were there as they were bedbound by choice.Per interview with a Licensed Nursing Assistant #1 (LNA) on [DATE] at 4:22 PM, he confirmed that he was assigned to Resident #1's care at the time of their death. The LNA stated that the last time he visualized Resident #1 s/he was sleeping and then the LNA said that it was kind of creepy that Resident #1 could have passed and that he could have checked on [Resident #1] and missed that. When asked if Resident #1 required any additional supervision, he reported that he didn't think they had any special rounding instructions that were any different from the other residents. When the LNA was asked about their documentation from their shift 11pm-7am ([DATE]-[DATE]) he reported that he wasn't sure what documentation he did but confirmed that any care given should be charted in the patient record. When asked about how long of a break the LNA #1 took that night, he said that he took a long one that night saying that some of the overnight crew sometimes take it all at once during the shift usually between 2-4 AM when there isn't a lot going on.Per record review, there is no evidence that LNA #1 provided care to Resident #1 for LNA #1's shift. The last documented toileting care for Resident #1 was on [DATE] at 14:59PM.Per interview with LNA #3 on [DATE] at 3:29 PM, she confirmed that she was unable to finishing documenting on Resident #1's care the evening shift on [DATE], prior to Resident #1's death. She reported that she was only able to document Resident #1's nutrition at 22:39 PM on [DATE]. LNA #3 reported that shift was a busy shift so she couldn't finish her documentation. She confirmed that they are supposed to complete their charting by the end of the shift, and that she should be documenting toilet care at least once a shift and she didn't. She also confirmed that she was not aware that Resident #1 required additional supervision or hourly checks.Per interview with RN #2 on [DATE] at 12:30 PM, she confirmed that she was caring for Resident #1 on the evening shift [DATE] prior to Resident #1's death. She reported that there were a couple times during that shift that Resident #1 was trying to sit on the edge of the bed and trying to use the bathroom and that s/he appeared very stable at that time. RN #2 stated that Resident #1 was hallucinating and that s/he had been having hallucinations over the past month, but that they had been increasing. When asked how they keep track of who is completing the hourly checks, she reported that they have a document they use that gets split up between LNA's and nurses, and that once completed it gets scanned into the patient's chart. She stated that she was not aware that Resident #1 was on additional supervision checks. RN #2 reported that Resident #1 was eating, drinking, and taking medications like s/he usually did.Per record review of Resident #1's progress notes on [DATE] at 2:30 AM, Resident #1 was found unresponsive and without a pulse. The record does not reveal the circumstances surrounding Resident #1's death.Per interview with the Director of Nursing (DON) and Administrator on [DATE] at 5:35 PM, when asked what happened to Resident #1 they stated that they came in the following Monday morning after Resident #1's death ([DATE]) and interviewed RN #1 and LNA #2. They stated the nursing staff informed them that when RN #1 found Resident #1 deceased on the floor with a large amount of bowel movement. When asked why the fall was not in Resident #1's medical record, they reported that the RN #1 did not document it.The facility was unable to provide evidence from the medical record that Resident #1 consistently received hourly rounding per Resident #1's care plan intervention.2. Per record review of Resident #2's medical record, Resident #2 has a medical diagnosis of Dementia, Muscle Weakness, Major Depressive Disorder, Peripheral vascular disease, Chronic Pain, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Shortness of Breath, and Other Abnormalities of Gait and Mobility. Per review of their Fall Risk assessment dated [DATE], it indicates a score of 12 and of Resident #2 being at a high risk of falls. Per Resident #2's care plan, they had a fall intervention of ensuring Resident #2's needs are met every hour when in common areas to reduce the risk of impulsiveness and falls dated [DATE] that were discontinued on [DATE] to frequently. Additional care plan interventions are to utilize wheelchair following during evening ambulation and extended distances due to increased fatigue and decreased stability dated [DATE], offering toileting after resident finishes each meal dated [DATE], and checking and changing Resident #2 every two hours at minimum during the night to ensures that the resident is comfortable and has a dry brief and to offer toileting opportunities when rounding to prevent incontinence and provide supervision when walking to the bathroom at night dated [DATE]. Additionally, Resident #2 is care planned for a motion sensor in his/her room to help reduce the risk of falls dated [DATE].Per record review of a progress note, Resident #2 had a fall on [DATE] at 3:46 AM where the Resident was found sitting on the floor sideways on the right side of their bed with their pants pulled part way down and his/her brief was wet. This note mentions that the alarm bell did not sound at nurse station. This nurse was able to determine the reason the alarm did not go off was because when resident gets up from left side of bed alarm sound. When resident gets up from the right side of the bed the censor is too far away to pick up the movement. Per review of Resident #2's toileting hygiene in the Kardex, there was no toileting hygiene documented for the overnight shift from the hours of 11pm to 7am on [DATE] including for any refusals.Per interview with the Administrator on [DATE] at 12:29 PM, she confirmed that Resident #2 did not have any documentation for his/her toileting and hygiene care for the hours of 11pm to 7am on [DATE] and that staff should have documented that.Per record review of a progress note dated [DATE] at 6:23 AM, it indicates that Resident #2 refused incontinence care at 2300 and 0100 and then fell out of bed at 3:20 AM and that hygiene care was then provided and Resident #2 was compliant with care given at 6:00 AM.A progress note dated [DATE] at 9:36 AM states that staff were reeducated on the care plan intervention placed on [DATE] and that Resident #2 is incontinent at night and should be checked and changed Q2 (every two hours) hours at minimum to ensure Resident #2 is comfortable and dry. It also states to offer toileting opportunities when rounding to prevent incontinence and provide supervision when walking to the bathroom at night.A progress note dated [DATE] at 2:33 PM states that Resident #2 denies pain but has a bruise noted on skin check from the fall. The note does not state where this bruise is.Per interview with LNA #5 on [DATE] at 5:31 PM, she initially stated she had assignment list #1, but confirmed she was actually assigned to assignment list #3 after being informed that a different staff member stated they had list #1. When asking about how to tell if residents are on fall precautions or have fall interventions, she reported the way to tell if a resident is on fall precautions and has fall interventions is if they have a mat on the floor, a motion sensor, or if they have wedges used to secure them in bed. When asked about how she knows if other residents require additional supervision, she stated that it would be communicated to her via other LNA's and nursing staff at the beginning of the shift. She reported not being aware of any residents recently on hourly checks in the past week or any who were actively on them. When asked how often she views the care plan, she stated that she views it as she deems it necessary, and that she reviews them monthly. When asked if she knew about any specific interventions for Resident #2, she was only able to mention that s/he had a motion sensor in their room. LNA #5 was not able to identify nonvisual resident specific interventions. She was not able to identify that Resident #2 was care planned for utilizing wheelchair follow during evening ambulation and extended distances due to increased fatigue and decreased gait stability (Fall intervention [DATE]) or Fall intervention [DATE] Offer toileting after resident finishes each meal, or Fall intervention [DATE] Resident is incontinent at night and should be checked and changed Q2 hours at minimum to ensure [s/he] is comfortable and brief is dry. Offer toileting opportunities when rounding to prevent incontinence and provide supervision when walking to the bathroom at night. Additionally, she was not able to identify the Fall intervention dated [DATE] that states, utilize wheelchair for transfers when [Resident #2] is experiencing episodes of weakness.Per interview with the Charge Nurse who is an RN on [DATE] at 3:18 PM, she reported she had south and east end of the hall. She stated that she wasn't aware of anyone on hourly checks or who required additional supervision currently or over the past couple of weeks. The Charge Nurse had Resident's #2, Resident #3, and Resident #4 in her assignment, all were residents who had required additional supervision and had been on the hourly checks on [DATE]. Resident #4 was still on Q1 hourly checks when in common areas as of [DATE].Per interview with LNA #4 on [DATE] at 5:08 PM, she reported that she is assigned to List #1 and that almost her whole list of residents were Hoyer transfers (a device used to assist with moving residents who need substantial assistance) and because of that, she didn't have anyone on fall precautions. She reported the way she knows if someone is on fall precautions is because it's on the clipboard and that you are supposed to check it every day. She stated that Residents who are Hoyer transfers aren't typically on fall precautions unless they roll a lot. When asked if she uses the care plan she admitted to not really using them and that she should probably look at it more.Per interview with LNA #5 on [DATE] at 2:59 PM, when asked if any residents were on additional checks or required additional supervision, she stated that she was not sure how to access the care plan and that the nurse tells her if a resident is on additional checks. She could not indicate if residents were on additional checks. This LNA had Resident #4 who was still actively on hourly checks in common areas as a fall intervention dated [DATE], and Resident #3 who had recently been changed from hourly checks to ensuring Resident #3's needs are met regularly when in unsupervised areas revised on [DATE].Per interview with a Licensed Practical Nurse (LPN) on [DATE] at 3:02 PM, she stated that she was not aware of anyone who required additional supervision or scheduled checks and that they have a paper for 15 minute neuro checks after a fall, or 15 minute checks for residents with suicidal ideation.3. Per record review, Resident #3 has medical diagnosis of Parkinson's disease, tremor, Traumatic Fracture, Generalized Anxiety Disorder, Chronic Pain Syndrome, Muscle Weakness, Presence of Right Artificial Hip Joint, Overactive Bladder, and Bladder Neck Obstruction. Per Resident #3's Fall assessment dated [DATE], they have a fall risk score of 11 indicating that they are at a high risk of falls. Per Resident #3's care plan, they have fall interventions of using a motion censor dated [DATE], when resident is showing signs of being uncomfortable and restless in bed, staff to provide 30 minute checks dated [DATE], offering the resident toileting assistance as frequently as they will tolerate dated [DATE], and they had been care planned for ensuring needs are met every hour when in unsupervised areas dated [DATE], which was changed on [DATE] to ensuring that Resident #3 needs are met regularly when in unsupervised areas.Per record review of facility incident reports provided via email communication on [DATE] at 10:01 AM , Resident #3 had 11 unwitnessed falls on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The Administrator confirmed that Resident #3 had these falls and that the Resident had hip surgery.Per record review of progress notes dated [DATE], Resident #3 had a fall around 12:20 AM and then was later sent out at 13:56 via emergency services to the hospital for evaluation of their right groin pain and low blood pressure. A progress note later that day at 16:35 states that Resident #3 had fracture their hip and would be admitted to the hospital.Per interview with the Administrator on [DATE] at approximately 5 pm, she confirmed that Resident #3 had a fall between [DATE] and [DATE] and that the care plan was not updated after this fall and that the facility did not complete an incident report for this fall.Per interview with the administrator on [DATE] at 4:59PM, she confirmed that they do not document the hourly checks for any residents that are on them.Per record review of the Q1 Hourly check list provided by the facility on [DATE], Resident #4 is not on this list as of [DATE]. Per review of the documents provided by the facility of care plan updates and reviews for all residents who were on the hourly checks, Resident #4 is not identified as a resident in these documents. Per review of the Immediate Jeopardy removal education on Q2h Checks Standard it states At this time, no residents require checks more frequently than Q2H [every two hours], dated [DATE]. Additionally, the education to nursing leadership titled Education:Q1 hour checks, [DATE] states, The facility may add Q1 hour checks to a resident care plan if it is determined that all other interventions have already been used and the IDT [Interdisciplinary Team] agrees the more frequent checks may increase safety for the resident. If a Q1 hour check is added to the resident care plan, it MUST: Be added to the Kardex with included in the positions. Be educated to the direct care staff (LPN, LNA, RN, leadership team).Per interview on [DATE] at 11:21 AM, the Administrator and Executive Director confirmed that no Residents were currently on Q1 (hourly) checks and that per their Immediate Jeopardy removal plan, all residents who were on Q1 hour checks would have care plans updated as of [DATE] and that the Interdisciplinary Team would have reviewed all residents with Q1 hour checks in their care plan. They then confirmed that Resident #4 was on Q1 hourly checks with the date of [DATE], and were unable to provide evidence that the care plan had been updated. When asked how they determined who was on Q1 Hourly checks they reported that they had nursing leadership go through the residents' charts.Per interview on [DATE] at 11:40 AM, the Administrator and ADON stated they intentionally left Resident #3 on hourly checks when in common areas. They confirmed they were not documenting or monitoring the effectiveness of the hourly checks. The Administrator and ADON also stated that a different Resident had been placed on the Q1 H (hourly) Check list that the facility created on [DATE] accidentally, and that this Resident was never on Q1 hourly checks.Per interview on [DATE] at 12:29 PM, the Administrator confirmed that they that don't have a policy for untimely death, for what to do when a resident is found on the floor deceased , and that they don't have a supervision policy, or a call light policy.Per review of the facilities Bowel Protocol policy, no date, it does not identify a timeframe to monitor the resident after being given bowel meds.

Based on interview and record review, the facility failed to ensure an environment free from accident hazards and failed to provide adequate supervision to prevent avoidable accidents for 3 of 3 residents (Residents #1, #2, and #3). Specifically, for Resident #1-who was at high risk for falls and required maximal assistance-staff failed to implement care-planned hourly safety rounds and failed to ensure functioning motion sensors and a working call light system were in place. On [DATE], Resident #1 experienced an unwitnessed fall and was found deceased on the floor with the call light detached. These systemic failures in supervision and equipment maintenance constituted an Immediate Jeopardy due to the outcome of death for Resident #1. This is a repeat deficiency for this facility, with violations cited during the previous recertification survey dated [DATE]. Findings Include:Per observation on [DATE] the facility call light system was not working effectively, see F919 for more information.Per interviews conducted on [DATE], [DATE], [DATE], [DATE], and [DATE] with LNAs, an LPN, and RN's, they were not aware that any Residents required additional supervision checks, see F656 for more information.Per interviews and record review, Resident #1 was found deceased on the floor on [DATE] at 2:30 AM, had defecated in a basin, the call light was detached from the wall, the resident had bowel movement on the bed, in the basin, and on the floor.The facility was unable to provide evidence that Resident #1 received hourly rounding as the facility does not document hourly rounding for residents who are care planned for hourly rounding. There is no evidence that Resident #1 was receiving hourly rounding consistently, every hour, in the medical record, or had toileting hygiene completed since [DATE] at 14:59 PM. Resident #1 had been given scheduled Senna Docusate Sodium Oral tablet 8.6-50 MG Give 2 tablet by mouth every morning and at bedtime for bowel management with a start date of [DATE] (a medication used to help alleviate constipation) on [DATE] at 9:00 AM and again at 9:00 PM. Additionally, Resident #1 was given a PRN Senna Tablet 8.6 MG with a start date of [DATE]. Give 2 tablet by mouth as needed for constipation give 2 tablets = total dose of 17.2 mg for constipation. Bowel Protocol step 1, PRN for no BM in 72 hours. The PRN Senna was given on [DATE] at 9:31 AM. Per the documented survey report for the month of 11/25, Resident #1 had not had a bowel movement for approximately 72 hours with the last bowel movement dated [DATE] at 10:57 PM.1. Per record review, Resident #1 had end stage heart failure, chronic kidney disease, hypertension, and was placed on hospice care on [DATE]. Resident #1 required substantial to maximum assistance for his/her toileting and hygiene needs per his/her Minimum Data Set (a tool used to identify resident abilities) dated [DATE]. Resident #1 was at a high risk for falls, with his/her most recent fall assessment dated [DATE] with a score of 13. The Fall Risk Evaluation form states that a Score 10 or higher indicated the resident is at high risk of fall. Per Resident #1's care plan reviewed [DATE], they were care planned on [DATE] for Q1hr checks in [on] resident while in bed to ensure all needs are met as a fall intervention due to Resident #1's risk for falls due to impaired mobility and incontinence. Additionally, Resident #1 was care planned for Toilet use: The resident requires substantial/maximal assistance dated [DATE] stating The resident has an ADL self-care performance deficit r/t [due to] terminal prognosis, impaired mobility, pain and incontinence. Resident #1 also had a motion sensor as a fall intervention on [DATE]. Resident #1 had a history of five falls identified in their care plan since [DATE] with their sixth fall occurring on [DATE].Per interview with Registered Nurse (RN) #1 on [DATE] at 4:00 PM, she reported that Resident #1 had not been acting like themselves during their shift. She reported she was visually checking in on all the resident and found Resident #1 on the ground deceased . When asked if any nursing staff was sleeping on the job, the RN #1 stated that she didn't witness anyone sleeping, but that the Licensed Nursing Assistant (LNA) assigned to Resident #1 had taken a break that was longer than I think was reasonable and that he was gone way longer than he should have been. She stated that it is fine if the LNA's want to clump their breaks together but that should be communicated to the nurse and she indicated that it wasn't communicated to her.Per interview with RN #1 on [DATE] at 12:38 PM, she stated that she had found Resident #1 deceased on the ground, the basin was on his/her bed with feces in it, the call light was detached from the wall on the ground by Resident #1's feet at the head of the bed, and that Resident #1 was lying on his/her right lateral side and there was feces on the floor. She confirmed that she told the DON all of this on [DATE]. RN #1 confirmed that she was not aware that Resident #1 was on hourly checks and that it should have been added to the clipboard, care plan, computer, Medication Administration Record, or the Treatment Administration Record. When RN #1 was asked if she thought this accident with Resident #1 could have been prevented, Resident #1 was more agitated that night. RN #1 additionally stated that she couldn't leave the floor to find LNA #1 that was taking a long break because she would have left the floor unattended. When asked about the lack of documentation in Resident #1's medical record, she reported that this accident was traumatizing to her and that she contacted management to get instruction on what to do. RN #1 confirmed that she didn't document the fall in the medical record or the circumstances surrounding Resident #1's death.Per interview with the Assistant Director of Nursing (ADON) on [DATE] at 8:34 AM, she reported that RN #1 had found Resident #1 deceased on the floor and that she instructed them to move Resident #1 from the floor to the bed. When asked if she had heard anything about LNAs taking longer breaks than usual, she reported she heard from nursing staff on [DATE] that an LNA had left the floor and that LNAs were gone for a long period of time for that break. The ADON then stated that they have had some LNAs sleeping in their car and taking a nap, but that it is the expectation they are on the premises and let someone know where they are going in case of an emergency. The ADON confirmed that she was not aware that the call light was detached from the wall or that Resident #1 had defecated in a large basin prior to his/her death. The ADON stated that Resident #1 would self-transfer to the commode, that s/he wasn't care planned to self transfer, that Resident #1 was substantial to maximal assistance for transfers and didn't ambulate while they were there as they were bedbound by choice.Per interview with a Licensed Nursing Assistant #1 (LNA) on [DATE] at 4:22 PM, he confirmed that he was assigned to Resident #1's care at the time of their death. The LNA stated that the last time he visualized Resident #1 s/he was sleeping and then the LNA said that it was kind of creepy that Resident #1 could have passed and that he could have checked on [Resident #1] and missed that. When asked if Resident #1 required any additional supervision, he reported that he didn't think they had any special rounding instructions that were any different from the other residents. When the LNA was asked about their documentation from their shift 11pm-7am ([DATE]-[DATE]) he reported that he wasn't sure what documentation he did but confirmed that any care given should be charted in the patient record. When asked about how long of a break the LNA #1 took that night, he said that he took a long one that night saying that some of the overnight crew sometimes take it all at once during the shift usually between 2-4 AM when there isn't a lot going on.Per record review, there is no evidence that LNA #1 provided care to Resident #1 for LNA #1's shift. The last documented toileting care for Resident #1 was on [DATE] at 2:59 PM.Per interview with LNA #3 on [DATE] at 3:29 PM, she confirmed that she was unable to finishing documenting on Resident #1's care the evening shift on [DATE], prior to Resident #1's death. She reported that she was only able to document Resident #1's nutrition at 10:39 PM on [DATE]. LNA #3 reported that shift was a busy shift so she couldn't finish her documentation. She confirmed that they are supposed to complete their charting by the end of the shift, and that she should be documenting toilet care at least once a shift and she didn't. She also confirmed that she was not aware that Resident #1 required additional supervision or hourly checks.Per interview with RN #2 on [DATE] at 12:30 PM, she confirmed that she was caring for Resident #1 on the evening shift [DATE] prior to Resident #1's death. She reported that there were a couple times during that shift that Resident #1 was trying to sit on the edge of the bed and trying to use the bathroom and that s/he appeared very stable at that time. RN #2 stated that Resident #1 was hallucinating and that s/he had been having hallucinations over the past month, but that they had been increasing. When asked how they keep track of who is completing the hourly checks, she reported that they have a document they use that gets split up between LNA's and nurses, and that once completed it gets scanned into the patient's chart. She stated that she was not aware that Resident #1 was on additional supervision checks. RN #2 reported that Resident #1 was eating, drinking, and taking medications like s/he usual did.Per record review of Resident #1's progress notes on [DATE] at 2:30 AM, Resident #1 was found unresponsive and without a pulse. The record does not reveal the circumstances surrounding Resident #1's death.Per interview with the Director of Nursing (DON) and Administrator on [DATE] at 5:35 PM, when asked what happened to Resident #1 they stated that they came in the following Monday morning after Resident #1's death ([DATE]) and interviewed RN #1 and LNA #2. They stated the nursing staff informed them that when RN #1 found Resident #1 deceased on the floor with a large amount of bowel movement. They confirmed that Resident #1 had received bowel meds. When asked why the fall was not in Resident #1's medical record, they reported that the RN #1 did not document it.Per interview with the DON, Administrator and Executive Director on [DATE] at 1:41 PM, they reported not being given all the information about Resident #1 having defecated in a basin and the call light being disconnected from the wall and that if they had been given that information, they would have likely completed a different investigation.The facility was unable to provide evidence from the medical record that Resident #1 consistently received hourly rounding per Resident #1's care plan intervention.2. Per record review of Resident #2's medical record, Resident #2 has a medical diagnosis of Dementia, Muscle Weakness, Major Depressive Disorder, Peripheral vascular disease, Chronic Pain, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Shortness of Breath, and Other Abnormalities of Gait and Mobility. Per review of their Fall Risk assessment dated [DATE], it indicates a score of 12 and of Resident #2 being at a high risk of falls. Per Resident #2's care plan, they had a fall intervention of ensuring Resident #2's needs are met every hour when in common areas to reduce the risk of impulsiveness and falls dated [DATE] that were discontinued on [DATE] to frequently. Additional care plan interventions are to utilize wheelchair following during evening ambulation and extended distances due to increased fatigue and decreased stability dated [DATE], offering toileting after resident finishes each meal dated [DATE], and checking and changing Resident #2 every two hours at minimum during the night to ensures that the resident is comfortable and has a dry brief and to offer toileting opportunities when rounding to prevent incontinence and provide supervision when walking to the bathroom at night dated [DATE]. Additionally, Resident #2 is care planned for a motion sensor in his/her room to help reduce the risk of falls dated [DATE].Per record review of a progress note, Resident #2 had a fall on [DATE] at 3:46 AM where the Resident was found sitting on the floor sideways on the right side of their bed with their pants pulled part way down and his/her brief was wet. This note mentions that the alarm bell did not sound at nurse station. This nurse was able to determine the reason the alarm did not go off was because when resident gets up from left side of bed alarm sound. When resident gets up from the right side of the bed the censor is too far away to pick up the movement. Per review of Resident #2's toileting hygiene in the Kardex, there was no toileting hygiene documented for the overnight shift from the hours of 11pm to 7am on [DATE] including for any refusals.Per interview with the Administrator on [DATE] at 12:29 PM, she confirmed that Resident #2 did not have any documentation on the Kardex for his/her toileting and hygiene care for the hours of 11pm to 7am on [DATE] and that staff should have documented that.Per record review of a progress note dated [DATE] at 6:23 AM, it indicates that Resident #2 refused incontinence care at 2300 and 0100 and then fell out of bed at 3:20 AM and that hygiene care was then provided and Resident #2 was compliant with care given at 6:00 AM. There is no evidence that staff attempted toileting or incontinence care at the next 2 hour interval (at 3:00 AM), as required by the care plan, prior to the fall occurring.A progress note dated [DATE] at 9:36 AM states that staff were reeducated on the care plan intervention placed on [DATE] and that Resident #2 is incontinent at night and should be checked and changed Q2 (every two hours) hours at minimum to ensure Resident #2 is comfortable and dry. It also states to offer toileting opportunities when rounding to prevent incontinence and provide supervision when walking to the bathroom at night.A progress note dated [DATE] at 14:33 states that Resident #2 denies pain but has a bruise noted on skin check from fall.Per interview with LNA #5 on [DATE] at 5:31 PM, she initially stated she had assignment list #1, but confirmed she was actually assigned to assignment list #3 after being informed that a different staff member stated they had list #1. When asking about how to tell if residents are on fall precautions or have fall interventions, she reported the way to tell if a resident is on fall precautions and has fall interventions is if they have a mat on the floor, a motion sensor, or if they have wedges used to secure them in bed. When asked about how she knows if other residents require additional supervision, she stated that it would be communicated to her via other LNA's and nursing staff at the beginning of the shift. She reported not being aware of any residents recently on hourly checks in the past week or any who were actively on them. When asked how often she views the care plan, she stated that she views it as she deems it necessary, and that she reviews them monthly. When asked if she knew about any specific interventions for Resident #2, she was only able to mention that s/he had a motion sensor in their room. LNA #5 was not able to identify nonvisual resident specific interventions. She was not able to identify that Resident #2 was care planned for utilizing wheelchair follow during evening ambulation and extended distances due to increased fatigue and decreased gait stability (Fall intervention [DATE]) or Fall intervention [DATE] Offer toileting after resident finishes each meal, or Fall intervention [DATE] Resident is incontinent at night and should be checked and changed Q2 hours at minimum to ensure [s/he] is comfortable and brief is dry. Offer toileting opportunities when rounding to prevent incontinence and provide supervision when walking to the bathroom at night. Additionally, she was not able to identify the Fall intervention dated [DATE] that states, utilize wheelchair for transfers when [Resident #2] is experiencing episodes of weakness.Per interview with the Charge Nurse who is a Registered Nurse on [DATE] at 3:18 PM, she reported she had south and east end of the hall. She stated that she wasn't aware of anyone on hourly checks or who required additional supervision currently or over the past couple of weeks. The Charge Nurse had Resident's #2 and Resident #3 in her assignment, all were residents who had required additional supervision and had been on the hourly checks on [DATE].Per interview with a Licensed Practical Nurse (LPN) on [DATE] at 3:02 PM, she stated that she was not aware of anyone who required additional supervision or scheduled checks and that they have a paper for 15 minute neuro checks after a fall, or 15 minute checks for residents with suicidal ideation.3. Per record review, Resident #3 has medical diagnosis of Parkinson's disease, tremor, Traumatic Fracture, Generalized Anxiety Disorder, Chronic Pain Syndrome, Muscle Weakness, Presence of Right Artificial Hip Joint, Overactive Bladder, and Bladder Neck Obstruction. Per Resident #3's Fall assessment dated [DATE], they have a fall risk score of 11 indicating that they are at a high risk of falls. Per Resident #3's care plan, they have fall interventions of using a motion sensor dated [DATE], when resident is showing signs of being uncomfortable and restless in bed, staff to provide 30 minute checks dated [DATE], offering the resident toileting assistance as frequently as they will tolerate dated [DATE], and they had been care planned for ensuring needs are met every hour when in unsupervised areas dated [DATE], which was changed on [DATE] to ensuring that Resident #3 needs are met regularly when in unsupervised areas.Per record review of facility incident reports provided via email communication on [DATE] at 10:01 AM , Resident #3 had 11 unwitnessed falls on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The Administrator confirmed that Resident #3 had these falls and that the Resident #3 had hip surgery.Per record review of progress notes dated [DATE], Resident #3 had a fall around 12:20 AM and then was later sent out at 1:56 PM via emergency services to the hospital for evaluation of their right groin pain and low blood pressure. A progress note later that day at 4:35 PM states that Resident #3 had fractured their hip and would be admitted to the hospital.Per interview with the Administrator on [DATE] at approximately 5 PM, she confirmed that Resident #3 had a fall between [DATE] and [DATE] and that the care plan was not updated after this fall and that the facility did not complete an incident report for this fall.Per interview on [DATE] at 11:40 AM, the Administrator and ADON confirmed they were not documenting or monitoring the effectiveness of the hourly checks.Per interview on [DATE] at 12:29 PM, the Administrator confirmed that they that don't have a policy for untimely death, for what to do when a resident is found on the floor deceased , and that they don't have a supervision policy, or a call light policy relating to maintenance.Per review of the facilities Bowel Protocol policy, no date, it does not identify a timeframe to monitor the resident after being given bowel meds.

Based on observation, interview, and record review the facility failed to ensure that all grievances were tracked through to their conclusion by failing to document all decisions including steps taken to investigate the grievance, a summary of the pertinent findings or conclusions, whether the grievance was confirmed or not confirmed, and any corrective action taken or to be taken, and the date the written decision was issued. During observations on the second floor on 9/18/2023 at 1:00 PM there was a clear file holder containing a stack of papers that was affixed to the wall diagonally across the nurses station. Review of the papers in the holder revealed that they were Concern Forms that are intended to be used to file grievances. The provided contact information for the grievance officer included the name of the past Administrator, and there was no identifying information to indicate to residents and others that the Concern Forms were available in the holder. Per observation of the first floor on 9/20/2023 at 10:30 AM there was a file holder containing a manilla folder with papers in it affixed to the wall between the elevator and the Administrators office. Review of the papers revealed that they were Concern Forms. These forms did have the current Administrator's name and contact information however, there was no signage or writing on the folder to alert residents that there were Concern Forms available in the folder. Review of the Grievance Log and Grievances filed revealed that nine grievances filed since January of 2023 did not have documented action taken or the date they were resolved. During interview on 9/20/2023 at 1:16 PM with the administrator and director of nursing the administrator confirmed that the grievance forms did not have evidence that the grievances were acted on or the date they were resolved. At approximately 2:20 PM the DNS did provide email documentation of the actions taken however, this had not been tracked through the grievance process, and there was no documentation regarding written responses to these grievances.

Based on observations the facility failed to store food in accordance with professional standards. Findings include: On September 20, 2023, at approximately 1PM during a tour of the dry food storage area with the Food Service Manager and Regional Food Service Director, the following observations were made: In the corners of shelves holding both bags and cans of food, there are accumulations of dried white, brown, and black debris, it is not possible to identify or rule out insect or rodent droppings in this debris. On another shelf there was a large bag (50 lbs.) of semolina that had the corner taped closed. Upon closer review it was noted the tape was not firmly adhered leaving the contents accessible. The Kitchen Manager and Regional Director noted they did not know the composition of the debris, and acknowledged the semolina bag was not sealed.

Based on observations and interviews the facility failed to treat 4 of 24 residents (Residents #39, 5, 28 & 14) with dignity and respect. Findings include: 1. On September 20, 2023, at approximately 10:30 AM the Surveyor walked through the dining/activities room observing a group activity involving several residents. Also in this room, 3 wheelchair-bound residents (Residents # 39, 5, and 28) were noted to each have a yellow 3x3 post-it note adhered to the front of their clothing. Upon further inspection, each note had what appeared to be a time written (10:32, 10:25, 10:40) on it. The Director of Nursing was consulted at 10:31 AM and stated residents were being provided with vaccines and these post-it notes indicated when the post-vaccine monitoring could end. The Director of Nursing stated the notes should not be affixed to residents. 2. On September 18, 2023, during observation of lunch service in the dining room, Resident #14 was noted to be seated at a round table with 2 other residents. At 12:25 PM the two diners seated with Resident #14 were provided with meals which they began to eat. At 12:35 PM Resident #14 made eye contact with and motioned for the Surveyor to approach. The Surveyor spoke to Resident #14 who appeared to be non-verbal but tapped on the table where their plate should be. The Surveyor then asked the Registered Nurse where Resident # 14's lunch was, the nurse stated, That's a good question and questioned the kitchen staff who passed the lunch out. The kitchen staff informed the nurse the resident had been noted to require increased assistance therefore the resident's lunch had been held back until feeding assistance was available. On September 19, 2023, at 1 PM the Director of Nursing confirmed all residents seated together should be served at the same time. 46442 3. Per observation on 9/20/2023 at 11:40 am, Resident #5 was seen being assisted off the elevator to the basement level of the facility by the Business Office Manager (BOM). The BOM turned the resident in the wheelchair and attempted to wheel her/him backwards off the elevator stating [s/he] won't pick up [his/her] feet. As the wheelchair started to move, the resident grabbed the hand bar in the elevator. The resident's facial expression was distressed, and he/she was attempting to communicate by making distressed verbal sounds. The BOM stated to the resident Come on dear let go and removed the resident's hand from the handrail by pulling her/his fingers off the rail. The BOM then brought the resident out of the elevator backwards. The BOM then turned the resident in a forward-facing position to proceed down the hall. The resident grabbed the handrail in the hall continuing to have a distressed facial expression. Again, the BOM removed the residents' hand from the handrail, making the resident release his/her grasp, stating, let go dear, we have to go. Per record review Resident #5 has diagnoses that include dementia, anxiety, and is deaf non-speaking. Review of Resident #5's care plan reveals that s/he has a communication problem related to deafness, non-speaking, impaired vision, and cognitive decline. Care plan interventions reveal that the resident can understand and communicate by lip reading, writing, communication board, gestures, sign language, and translator. Further interventions include face when speaking and make eye contact. At no time during the interaction between the BOM and Resident #5 was the BOM observed to be communicating with the resident by sign language, nor was s/he facing the resident when speaking to ensure that the Resident could read her/his lips. On 09/20/23 at 11:50 am the Director of Nurses (DON) and the facility Administrator, were informed of the interaction that was witnessed between the BOM and the resident. The DON revealed resident #5 is deaf and communicates only through sign language and lip reading. The DON and Administrator both confirmed that the interaction between the BOM and Resident #5 should not have happened in this manner.

Based on staff interview and record review, the facility failed to ensure each resident was free from neglect related to medication administration for 11 of 15 sampled residents (Residents #1-11). Findings include: Per review of the facility's investigation report for a facility reported event, the investigation states, [LPN (Licensed Practical Nurse) 1] did not administer 36 medications on East/South medication care on the day shift weekend of 2/18/23 and 2/19/23 and did not administer 14 medications on day shift upper level East on 2/20/23. [They] signed off that these medications had been administered and initially denied not having administered the medications . During [their] termination [they] admitted to signing off medications which were not given. The investigation report goes on to state that the facility has routine medications delivered on a monthly cycle. LPN 2 received all new medication cards prior to their shift on 2/17/23. For medications administered once a day on the day shift, they administered the first pill in each card for Residents #1-7. On 2/20/23, LPN 2 came in for their shift after being off for 2/18 and 2/19 and discovered that the expected amount of pills had not been removed from the medication cards over the weekend for those medications. LPN 2 brought this to the attention of the DON (Director of Nursing), who performed an audit. The DON determined that the following medications were not administered to Residents #1-7 sometime between 2/18/23 and 2/19/23: Resident #1: Amlodipine 1 tablet Gabapentin 1 tablet Omeprazole 1 tablet Sertraline 1 tablet Oxybutynin 4 tablets Resident #2 Amlodipine 1 tablet Carbidopa Levodopa 1 tablet Resident #3 Keppra 1 tablet Metoprolol 1 tablet Omeprazole 1 tablet Resident #4 Montelukast 1 tablet Resident #5 Celexa 1 tablet Hydrochlorothiazide 1 tablet Potassium Chloride 3 tablets Buspirone 1 tablet Resident #6 Torsemide 1 tablet Seroquel 3 tablets Resident #7 Clopidogrel 2 tablets Losartan 2 tablets Potassium 3 tablets Sertraline 2 tablets Metoprolol 2 tablets Per review of the MARs (Medication Administration Records) for Residents #1-7, the following medications are all marked as having been administered by LPN 1. The DON then audited the medication cards for all Residents who had received care from LPN 1 the morning of 2/20/23 and found that the following medications were not administered to Residents #8-11 on 2/20/23: Resident #8 Sertraline 1 tablet Resident #9 Chlorthiadone 1 tablet Plavix 1 tablet B12 1 tablet Potassium 1 tablet Prednisone 1 tablet Sodium Chloride 1 tablet Resident #10 Amlodipine 1 tablet Omeprazole 1 tablet Resident #11 Fludrocortisone 1 tablet Mitodrine 1 tablet Carbidopa levodopa 3 tablets Per review of the MARs (Medication Administration Records) for Residents #8-11, the following medications are all marked as having been administered by LPN 1. Per review of a statement from Resident #11's spouse, who was visiting Resident #11 through the entire day shift, reports that Resident #11 did not receive any morning medications or either of their two scheduled gastrointestinal tube feedings from LPN 1 on 2/20/23. The MAR shows that these tube feedings were signed off as having been administered by LPN 1. Per interview on 2/28/23 at approximately 10:00 AM, the DON confirmed that LPN 1 admitted to having not administered the above medications to Residents #1-11, despite having signed them off as administered. The facility provided evidence of the following corrective measures taken by the facility prior to the start of the investigation: - All nurses were reevaluated for competency in medication pass procedure using a new evaluation tool. - All nurses were mandated to watch two inservice videos on medication pass expectations and pharmacy exchange practices and a roster was kept of those who completed the videos. - The Director of Nursing conducted a cycle exchange audit of March 2023 and plans to audit the next few monthly cycle exchanges in full as well as random audits thereafter. - The QAPI agenda for April 2023 includes a Performance Improvement Plan and agenda topics for prevention of future instances of medication withholding. As a result of these actions, this finding is considered past noncompliance.

Based on staff interview and record review, the facility failed to ensure that medical records for each resident are accurately documented related to medication administration records for 12 of 15 sampled Residents (Residents #1-12). Findings include: Per review of the facility's investigation report for a facility reported event, the facility investigation confirms that LPN 1 marked all medications as administered on the day shifts that they worked on 2/18/23 and 2/19/23 for Residents #1-11 even though evidence shows that LPN 1 did not administer several medications for these residents (see F600). Per review of the MAR (medication administration record), Resident #12's 2:00 PM dose of Carbidopa-Levodopa 10-100 MG tablet 1.5 Tablets was left undocumented. Per review of the facility's investigation report, Resident #12's medication card audit did not show that a dose was skipped throughout the weekend of 2/18-2/19/23. Per interview on 2/28/23 at approximately 1:00 PM, the DON confirmed that LPN 1 did not document administration of Resident #12's 2:00 PM dose of Carbidopa-Levodopa despite the medication card audit showing that all expected doses were removed from the card. The facility provided evidence of the following corrective measures taken by the facility prior to the start of the investigation: - All nurses were reevaluated for competency in medication pass procedure using a new evaluation tool. - All nurses were mandated to watch two inservice videos on medication pass expectations and pharmacy exchange practices and a roster was kept of those who completed the videos. - The Director of Nursing conducted a cycle exchange audit of March 2023 and plans to audit the next few monthly cycle exchanges in full as well as random audits thereafter. - The QAPI agenda for April 2023 includes a Performance Improvement Plan and agenda topics for prevention of future instances of medication withholding. As a result of these actions, this finding is considered past noncompliance.

Based on observations, interviews and record reviews, the facility failed to develop a comprehensive care plan to include measurable objectives and time frames for 3 residents in a sample size of 16 (# 18, 44 and 46). Findings include: 1. Review of medical record for resident # 44, reveals an admission to [NAME] House Rehabilitation and Nursing on [DATE] due to a fall with a right femur fracture. S/he was discharged on [DATE] (21 days) to a Residential Care home. This resident has numerous diagnoses: (not all inclusive) Parkinson's Disease, Insomnia, Irritable Bowel Syndrome, Cataract, Repeated Falls, Anxiety Disorder, Major Depressive Disorder, Abnormalities of Gait, Muscle Weakness, Cognitive Communication Deficit, Osteoporosis, Gastro-Esophageal Reflux Disease, and unspecified psychosis. Present in the record was evidence of an initial comprehensive assessment ([DATE]) which contained general information about the resident. This document is titled Baseline Care Plan v1.0, however there is no comprehensive person-centered care plan developed and implemented within 7 days after completion of the comprehensive assessment. The Comprehensive Care Plan must contain problem areas, goals, in which address the resident's medical, physical, mental, and psychosocial needs and include interventions in which the Interdisciplinary Team reviews and updates quarterly and as needed for any changes. There is evidence of a Care conference conducted on [DATE]. The Director of Nursing (DON) and Care Coordinator confirms by interview ([DATE] at 09:20AM) that a comprehensive care plan for resident #44 had not been completed. 2. Review of medical record for resident # 46, reveals an admission to [NAME] House Rehabilitation and Nursing on [DATE] and was found deceased on [DATE] (40 days). This resident had numerous diagnoses: (not all inclusive) Cerebral Infarction due to Thrombosis, Stenosis of Right Carotid Arteries, Cerebral Edema, Aftercare following Surgery on the Nervous System, Hypertension, Dysphagia, Major Depressive Disorder, Multinodular Goiter, Hemiplegia and Hemiparesis affecting Left Non-Dominant Side, and Gastroenteritis. Present in the record was evidence of an initial comprehensive assessment ([DATE]) which contained general information about the resident. This document is titled Baseline Care Plan v1.0, however there is no comprehensive person-centered care plan developed and implemented within 7 days after completion of the comprehensive assessment. The Comprehensive Care Plan must contain problem areas, goals, in which address the resident's medical, physical, mental, and psychosocial needs and include interventions in which the Interdisciplinary Team reviews and updates quarterly and as needed for any changes. There is evidence of a Care conference conducted on [DATE]. The Director of Nursing (DON) and Care Coordinator confirms by interview ([DATE] at 09:20AM) that a comprehensive care plan for resident #46 had not been completed. 46442 3. Per record review, resident #18 was admitted to the facility on [DATE] with diagnoses of Delusional disorder, Depression, Schizophrenia, Anxiety disorder and Parkinson's (not all inclusive). The resident was prescribed Quetiapine (Seroquel) 25 milligrams (mg) twice daily and 75 mg at bedtime. S/he is also prescribed Fluoxetine 40 mg once daily for depression. Both drugs are considered Psychotropic medications. Psychotropic medications alter mood, perceptions, and behavior. The Minimum Data Set (MDS) is a Federally mandated clinical assessment tool used for long term care residents. The admission MDS had an Assessment Reference Date (ARD) of [DATE], Psychotropic medication use was triggered to be care planned as the resident is receiving Seroquel and Fluoxetine. On record review it was discovered the resident did not have a comprehensive care plan for Psychotropic drug use. [DATE] 09:30 AM The Director of Nursing (DON) and Care Coordinator confirms that there is not a care plan for Anti-psychotic medications in the resident's comprehensive care plan.

Based on observation, record review, and interviews, it was determined that the facility failed to update 2 of 12 resident care plans in the survey sample. (Resident #22 and #25) 1. Record review revealed Resident #22's care plan listed a goal of [proper name omitted]will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions for this goal were as follows: Educate [proper name omitted]/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of Ativan. This goal was initiated on 08/20/2021 and was revised on 02/17/2022 with a target date of 09/18/2022. Review of the residents Medication Administration Record (MAR) revealed the resident did not have an order for Ativan. Review of all active and discontinued medications revealed an order for Ativan on 9/28/2021, this order was discontinued on 10/05/2021 and was not renewed. This order was discontinued 10/05/2021, prior to the care plan revision of this goal on 02/17/2022. Observation on 9/13/22 at approximately 12:45 PM in the main dining room on the first floor, revealed Resident #22 eating independently and she/he had a high edge/high lipped, divided plate with 3 sections for her/his meal. The resident had a goal listed on her/his care plan as follows: [proper name omitted] will improve [pronoun omitted] current level of function in ADLs [Activities of Daily Living] and mobility through the review date and an intervention specific to EATING that stated, [proper name omitted] is dependent on one staff for all meals and drinks. This care plan was initiated on 12/14/2020, it was revised on 12/15/2020, and has a target date of 9/18/2022. There was no mention in this care plan regarding the residents use of specialty equipment for eating. Interview on 9/13/22 at approximately 2:45 PM with the Director of Nursing (DON), confirmed the above findings and stated the residents care plan should have been updated to reflect Resident #22's care needs accurately. 46442 2. Per record review, resident #25 was admitted to the facility on [DATE] with diagnoses of parkinson's disease, unsteadiness on feet, muscle weakness, history of falling and diabetes (not all inclusive). On 09/13/22 1045 am during observation, it was noted the resident suffers from tremors that could increases his/her fall risk. An interview on 9/12/22 at 11:00 AM with the resident reveals s/he had a fall out of his/her bed because s/he was having tremors in his/her lower extremities that caused him/her to slip out of bed to the floor. Per record review it was noted that on 9/12/22 at 0203 AM this resident fell out of bed. It was also documented that the resident also had a fall on 08/18/22 at 14:56 PM from the wheelchair at the nurse's station. Review of the Resident's comprehensive care plan does not reflect any updates or interventions for the 2 falls. Interview on 09/13/22 at 12:38 PM with Director of Nursing confirms that the care plan was not updated after recent falls and that the Care Plan should have been reviewed and updated after falls.

Based on observation, staff interview, and record review, the facility failed to establish an infection prevention and control program that includes a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases, as well as process linens so as to prevent the spread of infection. Findings include: 1. Per review of all documentation provided for the facility's infection prevention and control program (IPCP), there was not sufficient evidence in the IPCP documents provided that there is historical or ongoing monitoring, documenting, or reporting of all actual infections and communicable diseases within the facility that meets the regulation. Per interview with the Director of Nursing (DON) on 7/20/2021 at approximately 5:30 pm, they confirmed that they could not provide evidence of historical or ongoing infection and communicable disease surveillance in the IPCP. On 7/22/21 at 12:23 pm, additional documentation was provided by the DON. They confirmed that they could not provide evidence of a record of detailed infection and disease data tracked by the facility. The additional documentation provided was not sufficient to meet the regulation. 2. The facility's laundry processing area was first observed on 7/19/2021 at 3:00 pm. Outside the area, a sign on the locked door stated that the laundry department was open from 6am to 3pm. Upon entry, the lights were off and there were no staff present. There was a large industrial washing machine containing facility stock sheets, towels, and other reusable linens. The machine's interface read that this was a completed cycle. There was also a smaller washing machine running that contained mop covers and other various cleaning rags that had approximately 30 minutes left on the cycle. Upon return to the laundry processing area that day at 3:30 pm, the lights remained off, no staff were present, and the large washing machine still contained washed facility linens. The small washing machine with cleaning rags had one minute left in the cycle. Upon return to the laundry processing area that day at 4:15 pm, both washing machines still contained the items from completed wash cycles. No staff were present and the lights were off. Per interview with the Manager of housekeeping and laundry on 7/20/21 at 11:00 am, the laundry room hours are from 6am to 2pm daily, and there is sometimes a laundry aide at night. The Manager also confirmed that it is a regular, but not daily, practice that the last laundry staff member to leave for the day will start a load of facility linens prior to leaving. Those linens then sit overnight in the washing machine to be placed in the dryer the next morning. Housekeeping staff also start a load of their mop covers and/or cleaning rags after their shifts that then sit overnight to be placed in the dryer when the next laundry staff member comes on. Per interview with a laundry staff member on 7/20/21 at 12:00 pm, they confirmed that they regularly start a load of facility linens and a load of resident personal clothing in the washers prior to leaving for the day. They also confirmed that they regularly come in for their shift in the mornings to completed wash cycles awaiting placement in the dryers. They stated that they are not to leave linen in the dryers when there is no laundry staff member working, and it would be difficult to process enough facility linens (sheets, towels, washcloths, etc.) for the following day without starting one last load in the washer as they leave. Per review of the laundry staffing schedules on 7/20/21 at approximately 7:00 pm, there was evidence of staff being scheduled to work during evening hours on many days of the week, but there were on average three days a week with no one scheduled after 3pm. Leaving wet linens for long periods of time (or overnight) in washing machines without any ventilation creates the risk for the growth of mold and other microorganisms which may not all be killed by the dryer cycle. Since the reprocessed linens are used for every resident throughout the facility, this practice has the potential to impact all residents.

Based on staff interview and record review, the facility failed to ensure that each resident or resident representative receives education regarding the benefits and potential side effects of the COVID-19 vaccine and that the medical record includes documentation that indicates this education was provided for one of 5 residents (Resident #36). Findings include: 1. Per review of Resident #36's medical record, consent for the COVID-19 vaccine was refused by Resident #36. Per Resident #36's MD (Medical Doctor)/NP (Nurse Practitioner)/PA (Physicians Assistant) Admission note from 7/1/2021, [they state] that [they have] not had a COVID-19 vaccine and does not intend to have one. There was no documented evidence in Resident #36's record that education regarding the benefits and potential side effects of the COVID-19 vaccine was provided to the resident or a resident representative. Per interview with the Director of Nursing on 7/20/21 at approximately 5:30 pm, they confirmed that no documentation could be found in Resident #36's record regarding COVID-19 vaccination education provided to the Resident or a resident representative.

Based on staff interview and record review, the facility failed to ensure that each resident or resident representative receives education regarding the benefits and potential side effects of the pneumococcal immunization and that the medical record includes documentation that indicates this education was provided for one of 5 residents (Resident #22). Findings include: 1. Per review of Resident #22's record, consent for the pneumococcal immunization was refused by Resident #22 for both the 1st and 2nd dose. This is also reflected in Resident #22's care plan. There was no documented evidence in Resident #22's record that education regarding the benefits and potential side effects of the pneumococcal immunization was provided to the resident or a resident representative. Per interview with the Director of Nursing on 7/20/21 at approximately 5:30 pm, they confirmed that no documentation could be found in Resident #22's record regarding pneumococcal immunization education provided to the Resident or a resident representative.

Based on staff interview and record review the facility failed to ensure that appropriate assistive devices were used to prevent a fall that resulted in a major injury for one (1) of three (3) sampled residents, (Resident #1). Findings include: Per record review, on [DATE] at 11:50 AM Resident #1 was Lowered to the floor by a Licensed Nursing Assistant (LNA) on the way to the bathroom. Per Resident #1's care plan at the time of the fall s/he required an extensive assist from 1 staff with ambulation, toileting, and transferring. The care plan did not reflect the use of a gait-belt. A Post Fall Investigation & Review form completed by a Registered Nurse (RN) dated [DATE], indicated that assistive devices assigned to the resident were a walker and gait-belt. Per Nurses Note dated [DATE] 22:48 the nurse was Called into res bathroom by LNA, the resident was complaining of left leg pain and only doing partial weight bearing. Pain to left femur on palpation. On [DATE] the nurse obtained an order for [REDACTED]. S/he was transported to the hospital for X-ray and returned with the [DIAGNOSES REDACTED]. S/he was placed on pallitaive (comfort) care and expired at the facility on [DATE]. On [DATE] at approximately 2:30 PM, during interview with the LNA, s/he stated that staff ambulated Resident #1 with a walker almost every day, but some days (Resident #1) required a wheelchair because s/he was too unsteady. The LNA also stated that s/he usually would use a gait-belt, but s/he has seen one both used and not used. According to the LNA s/he was ambulating the resident to her/his room with a walker. While entering the room the resident lost her/his balance and fell to the left, landing on her/his left side. The LNA confirmed that s/he had not used a gait-belt and that the resident fell , rather than being lowered to the floor as s/he had originally reported. On [DATE] at 3:08 PM, during an interview with the RN, s/he stated that the LNA had told him/her that the resident had become unsteady and was lowered to the floor. The RN confirmed that the resident had a gait-belt assigned to her/him however there was no gait-belt on her/him at the time of the fall. The RN stated that a gait-belt is used to keep the resident from going to the left or right and a gait-belt can help lower a patient to the floor and prevent further injury. Per interview with the Director of Nursing on [DATE] at 1:20 PM, s/he had not been aware that the resident fell rather than being lowered to the floor. The DNS confirmed that staff are expected to use a gait-belt when assisting a resident who is extensive assistance with transfers or ambulation.

Based on interview and record review the facility failed to to ensure that resident's drug regimens were free from unnecessary [MEDICAL CONDITION] drug use for 2 of 5 applicable residents in the sample (Resident #6 and #240). Findings include: 1. Per record review a physician's orders [REDACTED]. There was no evidence in the medical record that the physician documented the rationale for the use of the PRN [MEDICATION NAME] beyond the 14 day period as per regulation. Per interview on 4/10/19 at 12:45 PM with the DNS, s/he confirmed that the physician did not document the rationale and/or duration of use for the PRN [MEDICATION NAME] in the medical record. 2. Per review of the nursing progress notes from (MONTH) 2019, Resident #240 had received [MEDICATION NAME] (antipsychotic medication) IM (intramuscularly) on two separate occasions: 1/19/19 and 1/25/19. On 1/19/19, at 7:00 PM the resident spit out his/her scheduled medications. At 7:20 PM, the resident became weepy and required one to one attention. At 8:15 PM, the resident was assisted to his/her room by a Licensed Nursing Assistant (LNA) and began to scream. At that time, a Licensed Practical Nurse (LPN) attempted to administer an as needed medication ([MEDICATION NAME]-medication used to treat anxiety and agitation) to the resident and s/he spit the medication out. At 8:45 PM, the LPN called the on-call physician and received an order for [REDACTED].#240 in his/her right arm. On 1/24/19, at 11:15 PM the resident was agitated and combative. S/he kicked a LNA and a RN. On 1/25/19 at 12:15 AM, The RN called the physician and received an order for [REDACTED].#240 received scheduled and PRN [MEDICATION NAME] for behaviors with no evidence of non-pharmacological interventions. There was also no evidence in the record that Resident #240 consented to receiving the medication IM and/or that his/her healthcare representative was notified that the medication was given in this manner. Per interview on 4/10/19 at 10:55 AM with a LPN, s/he stated that on the evening of 1/19/19, Resident #240 was screaming no matter what the staff did. There was just no consoling the resident. S/he was disrupting other residents on the unit. The resident spit out his/her scheduled medications; and due to the resident's agitation the LPN attempted to administer a PRN dose of [MEDICATION NAME]. The resident spit the PRN medication out as well. S/he obtained a PRN order from the physician for a dose of [MEDICATION NAME] IM. S/he stated that a LNA was gently holding the resident's arm while s/he was administering the injection in case the resident became out of control. During an interview on 4/10/19 at 11:23 AM with a RN, s/he confirmed that the resident had behavior problems and became combative at times requiring staff to give him/her PRN (as needed) medication. S/he stated that s/he could not really recall this particular incident (on 1/25/19). S/he stated that the resident had refused his/her scheduled medications on 1/25/19; however, allowed the injection of [MEDICATION NAME] with encouragement from the LNA.

Based on staff interview and record review the facility failed to ensure that 1 of 16 residents, Resident #240, was free from chemical restraints for agitated/aggressive behaviors. Findings include: Per review of the nursing progress notes from 1/19/19, at 7:00 PM the resident spit out his/her scheduled medications. At 7:20 PM, the resident became weepy and required one to one attention. At 8:15 PM, the resident was assisted to his/her room by a Licensed Nursing Assistant (LNA) and began to scream. At that time, a Licensed Practical Nurse (LPN) had attempted to administer an as needed medication ([MEDICATION NAME]-medication used to treat anxiety and agitation) to the resident and s/he spit the medication out. At 8:45 PM, the LPN called the on-call physician and received an order for [REDACTED].#240 in his/her right arm. On 1/24/19, at 11:15 PM the resident was agitated and combative. S/he kicked a LNA and a RN. On 1/25/19 at 12:15 AM, The RN called the physician and received an order for [REDACTED].#240 received scheduled and PRN [MEDICATION NAME] for behaviors with no evidence of non-pharmacological interventions. There was also no evidence in the record that Resident #240 consented to receiving the medications IM and/or that his/her healthcare representative was notified that the medication was given in this manner. Per interview on 4/10/19 at 10:55 AM with a LPN, s/he stated that on the evening of 1/19/19, Resident #240 was screaming no matter what the staff did. There was just no consoling the resident. S/he was disrupting other residents on the unit. The resident spit out his/her scheduled medications; and due to the resident's agitation the LPN attempted to administer a prn dose of [MEDICATION NAME]. The resident spit the prn medication out as well. S/he obtained a prn order from the physician for a dose of [MEDICATION NAME] IM. S/he stated that a LNA was gently holding the resident's arm while s/he was administering the injection in case the resident became out of control. During an interview on 4/10/19 at 11:23 AM with a RN, s/he confirmed that the resident had behavior problems and became combative at times requiring staff to give him/her PRN (as needed) medication. S/he stated that s/he could not really recall this particular incident (on 1/25/19). S/he stated that the resident had refused his/her scheduled medications on 1/25/19; however, allowed the injection of [MEDICATION NAME] with encouragement from the LNA.

Based on interview and record review, the facility failed to notify the resident and/or resident's representative in writing of a transfer/discharge for two (2) of three (3) residents in the applicable sample, (Resident #6 and #7). The findings include the following: 1. Per record review, Resident #7 was transferred to the emergency room for evaluation after a fall on 9/2/18 at approximately 7:30 AM. The resident returned to the facility 9/3/19 at 12:50 PM. Per review of the medical record for Resident #7, there is no evidence that a transfer/discharge notice was sent in writing to the resident and/or the resident's representative. The Social Service Designee confirmed on 4/10/19 at approximately 10 AM, that the transfer/discharge written notice was never provided at time of transfer/discharge or as soon as possible to the resident and/or representative. Confirmation was also made that the facility did not follow their policy 3.14 (d) notice before transfer or discharge. Per review of the facility document, identified as Discharge/Transfer Notice, evidences that the contents of the facility notice does not contain all required elements per Federal CMS (Centers for Medicare Services) requirements listed in this regulation. Since the notice was not provided the information was not available to the resident and/or representative. 2. Per record review, Resident #6 was transferred to the Emergency Department (ED) on 11/17/18, after a fall. There was no evidence in the medical record that a written transfer/discharge notice was given to the resident and/or resident's representative upon the transfer to the ED. Per interview on 4/10/19 at 9:41 AM with the Social Worker, s/he confirmed that a written transfer/discharge notice was not given to the resident and/or resident's representative upon the transfer to the ED.

Based on interview and record review the facility failed to notify the resident and/or resident's representative of a bed hold in writing for 1 of 3 applicable residents (Resident #6). Findings include: Per record review, Resident #6 was transferred to the Emergency Department (ED) on 11/17/18, after a fall. There was no evidence in the medical record that a bed hold notice was given to the resident and/or resident's representative in writing upon the transfer to the ED. Per interview on 4/10/19 at 9:41 AM with the Social Worker, s/he confirmed that a bed hold notice was not given to the resident and/or resident's representative in writing upon the transfer.

Based on interview and record review the facility pharmacist failed to report drug irregularities to the attending physician, medical director, and/or director of nursing for 1 of 5 applicable residents in the sample (Resident #17). Findings include: Per record review a physician's orders [REDACTED]. The pharmacist reviewed Resident #6's medications on 2/26/19 and noted that the [MEDICATION NAME] was ordered prn (as needed); however, did not denote that the order was past the required renewal period of 14 days per regulation. S/he also reviewed the resident's medications on 3/27/19, and did not report any irregularities. Per interview on 4/10/19 at approximately 2:00 PM with the Director of Nursing (DNS), s/he confirmed the above information.

Based on record review and interview the facility failed to document the Facility Assessment which contained all the required information. Findings include: In a review of the facility assessment it is found that the Facility Assessment consisted of documentation on a Facility Assessment Tool but did not contain all the required information and was not individualized but was instead on the Facility Assessment Tool template. The template was provided to facilities, by the Center for Medicare & Medicaid Services (CMS), to assist in writing the Facility Assessment. The document contains facility information and the instructions provided by CMS on how to document a facility assessment. The above was confirmed by the facility Administrator on 4/10/19 at 2:20 PM.

Based on record review and confirmed by staff interviews the facility failed to meet professional standards of quality for 1 of 3 sampled residents, by not following physician orders, not following standards of care for the insertion of a catheter and not monitoring for adequate drainage from a newly inserted Foley catheter. For Resident #1, the findings include the following: 1. Per medical record review, Resident #1 has a physician order [REDACTED]. The order states to not use Coude' catheter. Per interview with the Director of Nurses (DNS) at 10:10 AM confirmation is made that the Foley catheter was changed on 10/28/16 at approximately 11 AM, using an 18 French catheter with a 30 cc balloon. Foley was patent and draining slightly cloudy urine. On 10/28/16 at approximately 5 PM, after being transferred via mechanical lift from the toilet to the recliner, a nurses note states catheter came out, balloon burst. A second catheter was inserted, while the resident was in the recliner, seated at a 45-60 degree angle. A 16 French catheter with a 30 cc balloon was utilized, but only 15 cc of water was inserted into the balloon. A small amount of clear urine returned. Nurses notes identify that 500 cc of urine had drained into the drainage bag prior to the second catheterization. Per facility policy Lippincott's Nursing Procedures sixth edition identifies that for a male/female patient: Place the patient in the supine position with legs extended and flat on the bed. Confirmation by the DNS at 10:45 AM that a 16 French catheter was inserted, because the facility did not have an 18 French catheter available. Since the Foley stayed in place with only 15 cc of water, the DNS felt that was adequate to keep the Foley in the resident's bladder. Per interview at 11:20 AM with the Licensed Practical Nurse (LPN), who was responsible for the resident during the evening of 10/28/16, observed the resident while in bed, provided him/her with ordered treatments and had not observed anything unusual. S/He voices that there was an observed 15 cc of urine in the Foley tubing, the resident denied pain and had no concerns regarding the patency of the Foley. Intake and Output records dated 10/28/16 identify that the resident consumed 820 cc of fluids on the evening shift and 500 cc of urine output, prior to the catheter insertion at 5 PM. Per review of RN notes dated 10/29/16, evidence yelling at midnight, complaining of stomach hurting, abdomen distended. Patient diaphoretic. Foley not draining. Physician notified and sent to the emergency room via rescue at 12:45 AM. Per review of hospital documents, the initial bladder scan identified 326 cc of urine in Resident #1's bladder and a second scan evidenced 662 cc. Bleeding noted from the resident's meatus. (Also see F282) Reference for failing to follow physician's orders [REDACTED].). Wolters Kluwer Health/Lippincott Williams & Wilkins, pg 17. Reference for failing to follow standards of nursing practice regarding insertion and monitoring of catheter: Lippincott Manual of Nursing Practice (9th ed.). Wolters Kluwer Health/Lippincott Williams & Wilkins, pg 781-785; 820-822.

Based on medical record review and staff interview the facility failed to provide services by a qualified person in accordance with a written plan of care of 1 of 3 sampled resident's . For Resident #1, the findings include the following: Per medical record review, Resident #1 has a physician order [REDACTED]. Comprehensive care plan identifies the need for the indwelling catheter and identifies physician orders [REDACTED]. On 10/28/16 a catheter was inserted, while the resident was in the recliner, seated at a 45-60 degree angle. A 16 French catheter with a 30 cc balloon was utilized, but only 15 cc of water was inserted into the balloon. Confirmation by the DNS at 10:45 AM that a 16 French catheter was inserted, because the facility did not have an 18 French catheter available. Since the Foley stayed in place with only 15 cc of water, the DNS felt that was adequate to keep the Foley in the resident's bladder. Per review of RN notes dated 10/29/16, evidence yelling at midnight, complaining of stomach hurting, abdomen distended. Patient diaphoretic. Foley not draining. Physician notified and sent to the emergency room via rescue at 12:45 AM. (see F 281)

Based on observation, staff interview and medical review, the facility failed to ensure that 1 of 3 residents in the Stage 2 sample, Resident #13, was free from developing pressure sores and received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Findings include: 1. Per medical record review on 07/22/14, Resident #13 was admitted to the facility with a wound and Stage 2 pressure sore however, during survey an additional pressure ulcer was noted. Per the Nursing assessment upon admitted d 05/27/14, notes 2 open areas (#1- a skin slit 1 centimeter (cm) at mid sacrum-bony region above spine, thin-skinned; and area #2 -stage 2 pressure ulcer on the right buttocks superficial depth redness/bruise surrounding 1.2 cm x 1.2 cm.) The resident was identified in the comprehensive assessment as having a stage 2 pressure ulcer as well as another wound upon admission on 05/27/14, however, there was no comprehensive care plan that includes measurable objectives and goals for the pressure ulcer and wound. The care plan dated 06/05/14 - potential for skin breakdown- related to needs assist with ADLs and mobility, has as the interventions as, monitor skin daily, report changes to charge nurse immediately, assist with repositioning as needed and throughout the day, encourage turning, treatments as ordered. The care plan did not identify the intermediate steps nor the objectives to monitor and evaluate the resident's progress for the pressure ulcer or to revise treatments as appropriate. The physician's admission order dated 05/27/14 states ''[MEDICATION NAME] border dressing to right buttock open area; skin prep to periwound, wash with normal saline change every three days and as needed (PRN)''. Per review of the TAR (treatment administration record) no treatments were provided after 06/08/14 for skin issues. There were no wound monitoring sheets found. In addition, the June TAR as written, does not clearly show two separate wound dressing areas but only a dressing change to be done every three days. Per nursing notes dated June 1, 2, 3, 5, 7, 8, 9, 10,11 does not mention wounds. The nursing note on 06/04/14 states ''sacral wounds are largely healed, the dressing is protective only to newly healed tissue''. On 06/06/14 the nursing notes states ''two caregiver assist with dressing (as) resident uncooperative, noted small <1 cm red area right buttocks''. Per interview on 07/23/14 at 11:58 A.M., the LNA stated ''when I dressed (resident) today there was two brown-colored dressings (and pointed to buttocks area).... not sure what the skin underneath looks like. If it needed to be changed then the nurse will do that on bath day''. Per interview on 07/23/14 at 2:45 P.M. the MDS (minimum data set) coordinator stated 'when a person comes in with multiple (skin) areas there would be a care plan with the wound number and the specific treatment ordered, when healed, the TAR would be yellowed out (resolved)." The MDS coordinator further stated the wound would be on a wound sheet and monitor at least weekly by nursing. The resident's bath day was on July 20th however, there is no skin assessment that notes any skin issues. The MDS coordinator then stated ''I don't think the resident has a pressure ulcer''. Per observation on 07/23/14 at 3:50 PM in the presence of the nurse (who stated 'I thought the wounds were healed'), MDS coordinator and LNA, two dressings, one on each buttock, were noted. When the dressings were removed, dried blood was noted on the dressings as well as red open areas. The MDS coordinator confirmed that there was not consistent monitoring, assessments, consistent treatments, or revisions of the interventions as appropriate to treat the pressure ulcers. (also see F-157 & F-279)

Based on record review and staff interview the facility failed insure residents receive necessary treatment and services to promote healing and prevent new sores from developing for 2 of 4 residents in the sample (Resident #50 and #12). Findings include: 1. Resident #50 developed an unstageable pressure ulcer within one month of admission. Per a nursing assessment upon admission on 08/11/14 the skin exam shows only bruising on the top of the feet and a right hip incision. The 08/12/14 Braden Assessment Score was '12' - High Risk' for skin breakdown. The admission care plan directs staff to provide air mattress, booties in bed, hip precautions, encourage turning, treatment as ordered, abduction pillow, monitor incision right hip and heels up when in bed. The TAR (Treatment Administration Record) for August 2014 directs staff to apply a barrier dressing (Allyum) to the sacrum and to apply skin prep to bilateral heels plus 'booties' when in bed''. Per a nursing note on 08/20/14 states red area heels/toes, skin prep applied. On 08/27/14 a nursing notes states ''eschar to left heel and bruising...skin prep applied'' with measurements of 1.5 cm x 1.7 cm.. The Weekly Wound assessment dated [DATE] (3 days late) notes the heel measurement as 1 cm x 1.8 cm. Per observation on 09/16/14 at 2:25 PM the nurse measured the eschar wound, which increased, at 2 cm x 1.8 cm. Per review of Thompson's House Pressure Ulcer and Treatment Guidelines and Treatment option presents that debridement is indicated if there are signs and symptom of infection and may be contradicted in some situations as well as using products such as Hypergel or Mepilx. The Guidelines further states that the wound team is a collaboration of several disciplines, the physician leads the team and orders the treatments and if not improved in 2 weeks consult the team. Per review of the chart there is no indication that the physician had been notified. During interview at 2:50 PM on 09/16/14 the DNS (Director of Nursing Services) stated "I think it (heel) was red and then turned into eschar''. The DNS confirmed that the facility failed insure residents receive necessary treatment and services to promote healing and prevent new sores from developing. Also see F-157 and F-281 2. Per record review on 09/16/14 for Resident #12, the care plan presents with a care plan dated 12/11/12 to do weekly skin assessments and there is no evidence in the record to present that these assessments have been done. Resident #12 currently presents with Stage 2 pressure ulcers on his/her feet and there is no evidence that the wounds were measured or assessed consistently and this was confirmed by the Licensed Practical Nurse (LPN). Per the LPN at 2:35 PM, there are no "official" skin assessment trackers that are used. S/he further stated that when the resident is getting a shower, s/he tells the Licensed Nursing Assistant to get him/her if there are any areas of concern. S/he then stated that s/he will go to look at the resident if it is reported. The LPN further stated that s/he did not know what the other nurses do. Per Minimum Data Set (MDS) Registered Nurse (RN) coordinator at this time, s/he confirmed that there is no tool to assess skin weekly and that there is no evidence that it is consistently done. Measurements of the wounds presented in the nurse progress note indicate that areas on heels were first presented to the physical on 07/18/14 but on 07/05/14 s/he presented to have large macerated area on heel of right foot and it was measured on 07/07/14. On 07/08/14 the resident presented with a need for skin prep to left heel. Evidence of measuring not done again until 07/25/14 and 08/03/14 with a notation that the area was 2.0 x 3.0 cm and still improving. The next measurement and assessment was not done until 09/05/14 at which time the wound to the right heel was 2.0 x 3.0 cm. Measurements documented on 09/08/14 presents that left heel resolved and right heel was 4.0 x 1.2 cm which is larger. There was also confirmation from the RN on 09/17/14 at 9:18 AM that there is no evidence that a Braden Skin Risk assessment was completed for Resident #12, per facility policy of completing upon admission and then every week for four weeks and then quarterly and if skin conditions arise.