Every finding on record at Villa del Rio Gardens

Based on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Resident 76 and 179) received care to prevent pressure ulcer (localized areas of injury that occur when skin and underlying tissue are compressed between a bony prominence and an external surface such as a mattress) development, by failing to: 1. Implement Resident 179's care plan which indicated staff were to check the resident's skin for presence of sores, breakdown, impairment, and skin trauma, and use pressure reducing devices. 2. Implement its policy which indicated to initiate a care plan to address Resident 76's newly developed deep tissue injury ([DTI] an injury to a residents underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) to the left heel, obtain treatment orders, and monitor the effectiveness of the treatment. This deficient practice resulted in Resident 179 developing an unstageable pressure ulcer on the sacrococcygeal (base of the spine, tailbone) area and Resident 76 developing a DTI on the left heel. Findings: a. A review of Resident 179's Admission Record indicated the resident was admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 179's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 179's Quarterly Minimum Data Set (MDS), a standardized assessment and screening tool, dated January 23, 2022, indicated the resident had severe cognitive (ability to think and reason) impairment. The MDS indicated Resident 179 required limited assistance with transfer, dressing, toilet, personal hygiene and bathing. The MDS indicated Resident 179 was at risk for pressure ulcer development. A review of Resident 179's Admission Body assessment dated [DATE], indicated Resident 179 had a surgical wound on her left hip, otherwise the resident's skin integrity was intact. A review of Resident 179's Braden Scale for Predicting Pressure Ulcers dated January 29, 2022, indicated the resident scored a 12, indicating a high risk. A review of Resident 179's Physician's Admission Order dated January 29, 2022, indicated that there were no pressure ulcer preventions ordered. A review of the facility's Change of Condition logbook dated from January 29, 2022, to February 6, 2022, indicated that there were no reported records that Resident 179 had skin breakdown. A review of the facility's Treatment Monitoring logbook for the month of February 2022, indicated there was no treatment monitoring documented for Resident 179's sacrum (base of the spine) and coccyx areas. During a concurrent observation and interview on February 9, 2022, at 11:46 a.m., in Resident 179's room, Resident 179 was lying in bed in a supine (face up) position with an abduction pillow (a device used to prevent your hip from moving out of the joint) in between the legs. Licensed Vocational Nurse (LVN) 1 and LVN 4 were observed performing a routine body skin assessment for Resident 179. Resident 179 was observed to have an unstageable wound (full thickness tissue loss) covered with slough (dead, separated tissue) and eschar (collection of dry, dead tissue within a wound) to the sacrococcygeal area measuring approximately three (3) centimeters (cm) by 3 cm. LVN 1 and LVN 4 stated they did not know Resident 179 had developed a pressure ulcer. LVN 4 stated a skin assessment should have been performed properly and thoroughly on a daily basis for Resident 179 who was at risk for developing pressure ulcers. During an interview on February 10, 2022, at 10:23 a.m., LVN 1 stated certified nurse assistants (CNAs) were supposed to inform the licensed nurses of any skin changes on the residents. LVN 1 stated registered nurses (RNs) performed resident skin assessment on admission, and CNAs performed skin assessments on every shower day and were to report any abnormal findings. During an interview on February 10, 2022, at 2:30 p.m., Certified Nurse Assistant (CNA) 8 stated it was Resident 179's shower day but confirmed he did not shower Resident 179 on that day (2/10/22). CNA 8 stated the charge nurse and the supervisor told him not to touch Resident 179 because of the surgical wound on the resident's left hip. CNA 8 stated there were no other wounds on Resident 179 per his knowledge. CNA 8 stated the facility had a resident turning schedule that staff followed, but there was no documentation indicating Resident 179 was turned every two (2) hours. A review of Resident 179's Care Plan dated January 30, 2022, and titled Pressure Ulcer Risk, indicated a goal for Resident 179 was to minimize pressure ulcer risk daily for 3 months. The staff's interventions included to check skin for presence of sores, breakdowns, impairment, and skin trauma, notify physician if reddened areas, change in weight, change in intake or abnormal laboratory, assist with position changes, and use pressure reducing devices. A review of the Nurse Assistant Notes logbook dated February 1, 2022, to February 10, 2022, indicated there was no documentation Resident 179 had been repositioned every 2 hours and had no pressure reducing devices used during that timeframe. A review of the facility's Daily Skin Inspection Tool dated from January 29, 2022, to February 10, 2022, used by CNAs during the residents shower day indicated that Resident 179's skin integrity was not inspected. There was no record Resident 179 received a shower during this period. During an interview on February 10, 2022, at 11:24 a.m., the Director of Nursing (DON) stated for newly admitted and readmitted residents the licensed nurses were expected to perform a resident admission assessment which included a body assessment. The DON stated all licensed nurses were expected to perform a daily skin assessment during the residents' shower days. The DON was not able to explain why Resident 179's unstageable pressure ulcers at the sacrum and coccyx areas was not identified timely during the earlier stage. b. A review of Resident 76's Admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 76's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 76's Quarterly MDS dated [DATE], indicated the resident had severe cognitive impairment. The MDS indicated Resident 76 required extensive assistance with bed mobility, dressing, personal hygiene and total dependence with eating, toilet use, and bathing. The MDS indicated Resident 76 was at risk for pressure ulcer development. A review of Resident 76's Readmission Body assessment dated [DATE], indicated the resident's skin integrity was intact. A review of Resident 76's Physician's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's Change of Condition logbook dated from January 7, 2022, to February 6, 2022, indicated Resident 76 was reported to have a DTI with no specific location documented on January 20, 2022. A review of Resident 76's Change of Condition (COC) dated January 20, 2022, indicated a DTI was identified to the resident's left heel. There was no documentation that treatment was ordered. During a concurrent observation and interview with LVN 4 on February 10, 2022, at 9:30 a.m., Resident 76 was observed lying in bed with both knees in a bent position with a pillow underneath his knees and both heels were touching the mattress. Resident 76 was observed with a DTI on the left heel measuring approximately 2 cm by 2 cm. LVN 4 stated there was no care plan initiated for Resident 76's DTI of the left heel. LVN 4 confirmed that a wound specialist had not seen Resident 76 and there was no treatment ordered by the physician. LVN 4 stated the facility had issues with the wound care contractor. LVN 4 stated he followed up with the wound specialist multiple times but did not document. LVN 4 stated the facility did not have a wound care nurse at the time and that the charge nurses were responsible for the current wound care of residents. During an interview on February 10, 2022, at 9:48 a.m., CNA 6 stated she followed Resident 76's turning schedule every 2 hours, but she stated that there was no documentation of the repositioning in the resident's chart. A review of Resident 76's Nursing Notes from January 20, 2022, to January 25, 2022, indicated that LVN 6 noted the resident's DTI was reported by a CNA when a shower was given. Physician was notified and referred to a wound specialist, however, no follow up notes with wound specialist was documented. A review of the facility's undated policy and procedure (P/P) titled, Change in a Resident's Condition or Status, indicated that the facility shall promptly notify the resident, his or her attending Physician, and representative of change in the resident's medical/mental condition and/or status. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-call Physician when there has been: 1. An accident or incident involving the resident. 2. A discovery of injuries of an unknown source. 3. A significant change in the resident's physical/ emotional/ mental condition. 4. A need to alter the resident's medical treatment significantly. 5. Refusal of treatment or medications two (2) or more consecutive times. 6. Instructions to notify the physician of changes in the resident's condition. A review of the facility's undated P/P titled, Pressure Ulcers Prevention Guidelines, indicated to implement evidenced-based interventions for all residents who are assessed at [NAME] or who have a pressure ulcer present. Preventive skin care: 1. Inspect skin while providing care, paying close attention to bony prominences. 2. Inspect skin underneath medical devices at least twice daily. Keep skin clean and dry underneath. Adjust devices as needed for proper fit. 3. Avoid positioning the resident on an area of redness whenever possible. 4. Keep the skin clean and dry. Manage incontinence with absorptive products. Check every 2 hours, and provide perineal care as needed after incontinent episodes. Diaper usage in bed is not recommended. Protect skin from exposure to excessive moisture with barrier products. 5. Moisturize dry skin. 6. Use positioning devices or folded linens to keep body surfaces from rubbing against one another. Nutrition/Hydration: Consult for nutritional screen for each resident who is at risk for a pressure ulcer or has a pressure ulcer present. Repositioning: Reposition all residents at risk of, or with existing pressure ulcers, unless contraindicated due to medical condition. Utilize small shifts in repositioning, if otherwise contraindicated. Pressure relieving devices: Support surfaces do not eliminate the need for turning and repositioning. Provide alternative support surfaces as needed. Considerations for utilizing specialized support surfaces. A review of the facility's undated P/P titled Wound Treatment Guidelines, indicated to promote wound healing of various types of wounds, the facility must provide evidence-based treatments in accordance with current standards of practice and physician orders. 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change. 2. In the absence of treatments orders the license nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatments nurse. 3. Treatments will be documented on the Treatment Administration Record. 4. The effectiveness of treatments will be monitored through ongoing assessment of the wound.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices were followed in the kitchen when: 1. The foods were not labeled with opened dates, there was no received dates, foods were stored in bins, refrigerator, and freezer without removing from original packaging. 2. The ice machine was not maintained in a clean and sanitary condition to ensure the ice was safe to consume. These failures had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) for 80 of 81 medically compromised residents who received food and ice from the kitchen. Findings. a. During a concurrent kitchen observation and interview with Dietary Aide 1 (DA 1) on 2/8/22 at 9:11 a.m., there was one box of orange juice concentrate and one box of grape juice concentrate observed without received and opened dates. DA 1 stated both juice concentrates should be dated with the received date and use by date when they were opened. DA 1 stated he was responsible for labeling the items and missed labeling the two boxes. During a concurrent kitchen observation and interview with the Dietary Service Supervisor (DSS) on 2/8/22 at 9:29 a.m., there was one opened box of baking soda with a received date of 4/22/2021 and a use by date of 12/28/2022. The opened date was 1/22/2022 however the box was left opened and uncovered. The DSS stated the box should have been covered with plastic wrap to prevent the baking soda from being contaminated. During a concurrent kitchen observation and interview with DSS on 2/8/22 at 9:32 a.m., there was a bottle of nutmeg with a date received on 9/30/2021 and opened date on 10/4/2021. The use by date was 5/4/23 however the lid was left opened. The DSS stated the lid should always be kept closed to prevent possible contamination. The DSS stated it was important to ensure foods were free from possible contamination as harmful bacteria may grow that could lead to foodborne illness. During a concurrent kitchen observation and interview with the DSS on 2/8/22 at 9:35 a.m., the white rice, powdered milk, brown sugar, brown rice, oatmeal, and white sugar were observed stored in plastic bins with no label indicating the received date, use by date, and opened date. The white sugar was observed in the plastic bin with its original packaging. The DSS stated all foods should be stored with labels indicating the received date, used by date and open date. The DSS stated the white sugar should have been removed from the original packaging prior to placing in the bin. During a concurrent kitchen observation and interview with the DSS on 2/8/22 at 9:45 a.m., there were boxes of graham crackers, salt, sugar, pepper, chips, and cans of pureed chicken stored with its original packaging in the storage rack. There were also boxes of wheat roll dough, egg rolls, and pork sausages that were stored in its original packaging. The DSS stated the graham crackers, salt, sugar, pepper, chips, pureed chicken cans, wheat roll dough, egg rolls, and pork sausages should have been removed from the original carton boxes or packaging it was delivered in because the carton boxes could possibly be contaminated during transport and might cause the residents to become sick or be source of pest problem. A review of the facility's undated policy and procedure (P/P) titled, Food Receiving and Storage, indicated foods shall be received and stored in a manner that complies with safe food handling practices. The P/P indicated dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). Opened containers must be dated and sealed or covered during storage. b. During an initial tour of the kitchen on 2/8/2022 at 8:34 a.m. with Dietary Aide 1 (DA 1), a black substance approximately 4 (four) inches in length was noted on the plastic in the upper, inner, right corner of the interior of the ice machine. This finding was photographed. During a concurrent interview and record review, on 2/8/2022 at 3:10 p.m., with the Maintenance Manager (MM) and Assistant Maintenance Manager (AM), the photograph taken of the interior of the ice machine was reviewed. The MM acknowledged the black substance noted on the ice machine. The MM stated the ice machine was supposed to be cleaned daily by the dietary aid, but the MM could not verbalize why the ice machine had black dirt in it. The MM stated the ice machine should be clean all the time and cannot have a black substance. During an interview with Dietary Service Supervisor 2 (DSS 2) on 2/8/2022 at 3:45 p.m., DSS 2 stated that it was the responsibility of DA 1 to clean the ice machine daily, but staff did not log who completed the task. DSS 2 stated that it would be obviously dirty because we hold the ice scooper every time which means that it needs cleaning. During a review of the facility's P/P titled, Ice Machines and Ice Storage Chests, revised 2021, indicated ice-making machines, ice storage chest/containers, and ice can all become contaminated by: unsanitary manipulation by employees, residents, and visitors. Waterborne microorganisms naturally occurring in the water source, colonization by microorganisms and/or improper storage or handling of ice. Facility has established procedure for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the spread of the coronavirus disease ([COVID-19 a disease caused by virus called [CONDITION(S)]-CoV-2}) an illness caused by a virus that can easily spread from person to person) by failing to: 1. Ensure housekeeping that was assigned to clean the hallway at the green zone (a room or group of rooms designated for residents who do not have nor were exposed to Covid-19) was wearing an N-95 (a type of mask worn over the face to cover the nose and mouth that provides respiratory protections against aerosols [a suspension of fine solid particles or liquid droplets in air] and prevent infections). 2. Ensure one of one residents (229) was cohorted (creating distinct roommates or small groups of COVID-19 positive residents or Covid-19 exposed residents that stay together to ensure minimal or no interaction with residents who do not have COVID-19) at the yellow zone (an area housing covid 19 suspected, symptomatic or exposed residents) upon return from the hospital( re-admission). 3. Ensure two out of 2 Licensed vocational nurses performed hand hygiene in between resident's contact for three of three Residents (34, 53 and 57). Findings: 1. During an initial tour of the facility on 02/08/2022 at 10:19 am., housekeeping staff (HS) was in the hallway wearing a face shield without face mask. During an interview with HS on 02/08/2022 at 10:38 a.m., HS stated that he was responsible for cleaning all the hallways and he did it early morning. HS stated he usually wears an N95 mask and a face shield as personal protective equipment(PPE- equipment worn to minimize exposure to virus that cause serious infection/Covid-19 ). HS stated he forgot the N95 mask today and just used a face shield. During an interview on 02/08/2022 at 11:06 a.m. with Infection Preventionist (I/P), IP stated that HK should be wearing appropriate PPE like the rest of the staff in the facility, an N95 and face shield to prevent the spread of the virus. IP stated that HK spends more than 15 minutes cleaning the hallways and he cleans every 2 hours all the high touch surfaces in the facility. 2. During a review of the admission record, the record indicated Resident 229 was admitted to the facility on [DATE] and re admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the Resident 229's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/15/2021, the MDS indicated Resident 229 had clear speech, made self-understood, and had the ability to understand others, needed limited assistance from one staff for bed mobility, transfer, locomotion, walking in the room, toilet use and personal hygiene, and extensive assistance for dressing and bathing. During an initial tour of the facility on 2/08/2022, around 10:19 a.m., there were no residents in the yellow zone of the facility. During a review of the census (number of residents in the facility) dated 02/06/2022, the census indicated that green zone had 81 residents. During an interview on 02/10/2022 at 4:12p.m. with I/P nurse, IP stated that Resident 229 came to the facility on [DATE] and was assigned to the green zone, when asked about the new California Department of Public health (CDPH) guidance that new admission and re- admissions regardless of the vaccination status, should be placed in the yellow zone, IP stated that she was not aware of the update, IP stated that Resident 229 should have been in the yellow zone when she came to the facility on [DATE]. During a review of all facility letter ( AFL 20-87.1), the AFL indicated that regardless of vaccination status, residents who may have prolonged close contact (within 6 feet for a cumulative total of 15 minutes or more over a 24-hour period) with someone with [CONDITION(S)]-CoV-2 infection while outside the facility should quarantine in the yellow-observation area for 14 days and be tested immediately, at 5-7 days after exposure, and again prior to return to their usual room in green-unexposed/recovered area. During a review of the CDPH illustration titled, Cohorting dated 12/16/2021, indicated regardless of vaccination status; admissions and re admissions go straight to the yellow zone for 14 days. 3. During a medication administration observation on 02/09/2022 at 09:45 a.m., the licensed vocational nurse (LVN 1) administered oral medication for Residents 34, 53 and 57 and was observed not washing hands in between care of these three residents. During an interview on 02/09/2022 at 09:58 a.m., LVN 1 stated that hand washing must be done in between care, when passing medications and providing direct care to the resident. LVN 1 acknowledged that it was an infection control issue when staff does not wash hands or use hand sanitizer before providing care to the resident and the potential outcome is putting the residents at risk for getting infected with infectious disease such as COVID-19 infection and vice versa. During an interview on 02/11/2022 at 10:19 a.m., the Infection Preventionist (IP) stated that when a licensed nurses are passing medications, staff must wash hands or use hand sanitizer in between resident care to prevent cross contamination, if such practice are not followed, the potential is to spread the infection and putting the resident at risk or the staff for getting infected with any infectious disease the hand carries and IP acknowledged that it was an infection control issues. During a review of the facility policy (P/P) titled, Infection Prevention and Control Program, the P/P indicated all staff will wash their hands when coming on duty, between resident contact, after handling contaminated objects. Staff shall wash their hands before and after performing resident care procedures. Hands shall be washed in accordance with facility's established hand washing procedure.

Based on interview and record review, the facility failed to perform [CONDITION(S)] assessments and provide non-pharmacological interventions to Residents 6, 33, 43, and 49 prior to start of [CONDITION(S)] medications (medication that affects brain activities associated with mental processes and behavior) to ensure the use of psychotropics were necessary to treat a specific condition; and perform a gradual dose reduction ([GDR] an attempt to decrease or discontinue [CONDITION(S)] medication after no more than three months after starting on the [CONDITION(S)] medication) for Resident 49. These deficient practices had the potential to result in Residents 6, 33, 43, and 49 receiving unnecessary medications. Findings: A review of Resident 43's Admission Record indicated Resident 43 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 43's diagnoses included [CONDITION(S)] ([[CONDITION(S)]] group of lung diseases that block airflow and make it difficult to breathe), anxiety disorder (feeling of worry, nervousness, or unease), and other lack of coordination. During a review of Resident 43's Minimum Data Set (MDS), a resident assessment and care-screening tool), dated 12/20/2021, the MDS indicated Resident 43 was usually understood by others and was able to understand others. The MDS indicated Resident 43 required limited assistance with one-person physical assistance for bed mobility and personal hygiene, and extensive assistance with locomotion (how resident moves) on/off unit, walking in the corridor, dressing, transfer, and toilet use. A review of Resident 49's Admission Record indicated Resident 49 was initially admitted to the facility on [DATE]. Resident 49's diagnoses included [CONDITION(S)] (elevated lipids in the blood), Alzheimer's disease (progressive mental deterioration due to generalized degeneration of the brain), and [CONDITION(S)] unspecified (neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions). During a review of Resident 49's MDS, dated [DATE], the MDS indicated Resident 49 had unclear speech, was usually understood and able to understand others. The MDS indicated Resident 49 required supervision with set up help for bed mobility and eating, and limited assistance with a one-person physical assistance with transfer, personal hygiene, locomotion on/off unit, walking in the room and corridor, dressing, transfer, and toilet use. A review of Resident 33's Admission Record indicated Resident 33 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 33's diagnoses included diabetes mellitus (high blood sugar), hepatic failure (loss of liver function), and hypertensive heart disease (refers to heart conditions caused by high blood pressure). During a review of Resident 33's MDS, dated [DATE], the MDS indicated Resident 33 had clear speech, was usually understood and able to understand others. The MDS indicated Resident 33 required supervision with set up help for bed mobility and eating, and limited assistance with a one-person physical assist with transfer, personal hygiene, locomotion on/off unit, walking in the room and corridor, dressing, transfer, and toilet use. A review of Resident 6's Admission Record indicated Resident 6 was initially admitted to the facility on [DATE]. Resident 6's diagnoses included [CONDITION(S)] unspecified, [CONDITION(S)], and [CONDITION(S)] (condition in which the [CONDITION(S)] doesn't produce enough [CONDITION(S)] hormone). During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had clear speech, was understood by others and was able to understand others. The MDS indicated Resident 6 required supervision with set up help with bed mobility and eating, transfer, locomotion on/off unit, walking in the room and corridor, and a limited assistance with dressing, transfer, personal hygiene, and toilet use. During an interview on 2/10/2022 at 9:07 a.m. with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated the staff did not document non-pharmacological interventions prior to the use of [CONDITION(S)] medication because staff was familiar with every resident who had behavioral changes. LVN 4 stated the licensed nurses completed a change of condition (COC) form when the resident had behavioral changes, and the psychiatrist was to determine if they want to take a pharmacological approach. During an interview on 2/10/2022 at 10:10 a.m. with LVN 1, LVN 1 stated licensed nurses did not assess the residents before the start of [CONDITION(S)] medication. LVN 1 stated she was not familiar with the [CONDITION(S)] assessment form indicated in the resident's medical chart. LVN 1 stated there was no documentation that non- pharmacological interventions were documented in the resident's medical record prior to the start of the [CONDITION(S)] medication. During an interview and record review of Resident 49's medical chart on 2/11/2022 at 9:56 a.m. with the Infection Preventionist Nurse (IP), IP stated residents that were receiving [CONDITION(S)] medication did not have an assessment prior to start of the medication. When asked if nonpharmacological interventions were documented in the chart, IP stated that staff did perform nonpharmacological interventions but did not document in the resident's chart. When asked when Resident 49 was last offered a GDR, IP stated there was no GDR since September of 2021. During an interview on 2/10/2022 at 11:15 a.m. with the Director of Nursing (DON), DON stated there were no [CONDITION(S)] assessments performed with any of the residents receiving [CONDITION(S)] medication. The DON stated an evaluation was made by the psychiatrist if medication was necessary for the resident to continue or discontinue medication. During a record review of the facility's policy and procedure (P/P) dated January 2022 and titled, Medication Monitoring Medication Management, the P/P indicated when selecting medications and non-pharmacological approaches, members of the IDT included resident participation in the care process to identify, assess, address, advocate for, monitor and communicate the residents needs and changes in condition. The P/P indicated medication management is based on the care process and includes recognition or identification of the problem/need, assessment, diagnosis/cause identification, management/treatment, monitoring and revising interventions, as warranted as well as documenting management steps.

Based on observation, interview, and record review, the facility failed to accurately assess two of eight sampled residents' skin integrity (Residents 76 and 179). Cross Referenced F686. This deficient practice resulted in Resident 179 developing an unstageable pressure ulcer (localized areas of injury that occur when skin and underlying tissue are compressed between a bony prominence and an external surface such as a mattress) on the sacrococcygeal (base of the spine, tailbone) area and Resident 76 developing a deep tissue injury ([DTI] an injury to a residents underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) on the left heel. Findings: a. A review of Resident 179's Admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 179's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 179's Quarterly Minimum Data Set (MDS), a standardized assessment and screening tool, dated January 24, 2022, indicated the resident had severe cognitive (ability to think and reason) impairment. The MDS indicated Resident 179 required limited assistance with transfer, dressing, toilet use, personal hygiene and bathing. The MDS indicated Resident 179 was at risk for pressure ulcer development. A review of Resident 179's Braden Scale for Predicting Pressure Ulcers dated January 29, 2022 indicated Resident 179 was a high risk for pressure ulcer development. A review of Resident 179's Admission Body assessment dated [DATE], indicated Resident 179 had a surgical wound to the left hip, otherwise the resident's skin integrity was intact. A review of Resident 179's Physician's Admission Order dated January 29, 2022, indicated that there were no pressure injury/ulcer preventative measures ordered. A review of the facility's Change of Condition logbook dated from January 29, 2022, to February 6, 2022, indicated that there were no reported records that Resident 179 had skin breakdown. A review of the facility's Treatment Monitoring logbook dated February 2022, indicated that there was no treatment monitoring recorded for Resident 179's sacrum and coccyx areas. During a concurrent observation and interview on February 9, 2022, at 11:46 a.m., in Resident 179's room, Resident 179 was lying in bed in a supine (face up) position with an abduction pillow (a device used to prevent your hip from moving out of the joint) in between the legs. Licensed Vocational Nurse (LVN) 1 and LVN 4 were observed performing a routine body skin assessment for Resident 179. Resident 179 was observed to have an unstageable wound (full thickness tissue loss) covered with slough (dead, separated tissue) and eschar (collection of dry, dead tissue within a wound) to the sacrococcygeal area measuring approximately three (3) centimeters (cm) by 3 cm. LVN 1 and LVN 4 stated they did not know Resident 179 had developed a pressure ulcer. LVN 4 stated a skin assessment should have been performed properly and thoroughly on a daily basis for Resident 179 who was at risk for developing pressure ulcers. During an interview on February 10, 2022, at 10:23 a.m., LVN 1 stated certified nurse assistants (CNAs) were supposed to inform the licensed nurses of any skin changes on the residents. LVN 1 stated the registered nurses (RNs) performed a resident skin assessment on admission, and CNAs performed skin assessments on every shower day and reported any abnormal findings to the charge nurse. During an interview on February 10, 2022, at 2:30 p.m., Certified Nurse Assistant (CNA) 8 stated it was Resident 179's shower day but confirmed he did not shower Resident 179 on that day (2/10/22). CNA 8 stated the charge nurse and the supervisor told him not to touch Resident 179 because of the surgical wound on the resident's left hip. CNA 8 stated there were no other wounds on Resident 179 per his knowledge. CNA 8 stated the facility had a resident turning schedule that staff followed, but there was no documentation indicating Resident 179 was turned every two (2) hours. A review of Resident 179's Care Plan dated January 30, 2022, and titled Pressure Ulcer Risk, indicated a goal for Resident 179 was to minimize pressure ulcer risk daily for 3 months. The staff's interventions included to check skin for presence of sores, breakdowns, impairment, and skin trauma, notify physician if reddened areas, change in weight, change in intake or abnormal laboratory, assist with position changes, and use pressure reducing devices. A review of the Nurse Assistant Notes logbook dated February 1, 2022, to February 10, 2022, indicated there was no documentation Resident 179 had been repositioned every 2 hours and had no pressure reducing devices used during that timeframe. A review of the facility's Daily Skin Inspection Tool dated from January 29, 2022, to February 10, 2022, used by CNAs during the residents shower day indicated that Resident 179's skin integrity was not inspected. There was no record Resident 179 received a shower during this period. During an interview on February 10, 2022, at 11:24 a.m., the Director of Nursing (DON) stated for newly admitted and readmitted residents the licensed nurses were expected to perform a resident admission assessment which included a body assessment. The DON stated all licensed nurses were expected to perform a daily skin assessment during the residents' shower days. The DON was not able to explain why Resident 179's unstageable pressure ulcers at the sacrum and coccyx areas was not identified timely during the earlier stage. b. A review of Resident 76's Admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 76's with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 76's Quarterly Minimum Data Set (MDS - a standardized assessment and screening tool) dated January 24, 2022, indicated the resident has Brief Interview for Mental Status (BIMS) score was 0 with interpretation of severe impaired cognition. The MDS indicated Resident 76 required extensive assistance with bed mobility, dressing, personal hygiene and total dependence with eating, toilet, bathing. The MDS indicated Resident 76 was at risk for pressure ulcer development. A review of Resident 76's Readmission Body assessment dated [DATE], indicated the resident's skin integrity was intact. A review of Resident 76's Physician's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's Change of Condition logbook dated from January 7, 2022, to February 6, 2022, indicated Resident 76 was reported to have a DTI with no specific location documented on January 20, 2022. During a concurrent observation and interview with LVN 4 on February 10, 2022, at 9:30 a.m., Resident 76 was observed lying in bed with both knees in a bent position with a pillow underneath his knees and both heels were touching the mattress. Resident 76 was observed with a DTI on the left heel measuring approximately 2 cm by 2 cm. LVN 4 stated there was no care plan initiated for Resident 76's DTI of the left heel. LVN 4 confirmed that a wound specialist had not seen Resident 76 and there was no treatment ordered by the physician. LVN 4 stated the facility had issues with the wound care contractor. LVN 4 stated he followed up with the wound specialist multiple but did not document. LVN 4 stated the facility did not have a wound care nurse at the time and that the charge nurses were responsible for the current wound care of residents. During an interview on February 10, 2022, at 9:48 a.m., CNA 6 stated she followed Resident 76's turning schedule every 2 hours, but she stated that there was no documentation of the repositioning in the resident's chart. A review of Resident 76's Nursing Notes from January 20, 2022, to January 25, 2022, indicated that LVN 6 noted the resident's DTI was reported by a CNA when a shower was given. Physician was notified and referred to a wound specialist, however, no follow up notes with wound specialist was documented. A review of the facility's undated policy and procedure (P/P) titled, Change in a Resident's Condition or Status, indicated that the facility shall promptly notify the resident, his or her attending Physician, and representative of change in the resident's medical/mental condition and/or status. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-call Physician when there has been: 1. An accident or incident involving the resident. 2. A discovery of injuries of an unknown source. 3. A significant change in the resident's physical/ emotional/ mental condition. 4. A need to alter the resident's medical treatment significantly. 5. Refusal of treatment or medications two (2) or more consecutive times. 6. Instructions to notify the physician of changes in the resident's condition. A review of the facility's undated P/P titled, Charge Nurse, indicated that the primary purpose of the job position was to provide direct nursing care to the residents and to supervise the day-to day nursing activities performed by the CNAs. All care and supervision must be in accordance with the current federal, state, local standards, guidelines, regulations and laws that govern out facility. 1. Observe, report and record findings/changes in resident conditions to physician, and nursing personnel. 2. Report changes of condition to physician and families. Follow-up on orders and document. 3. Communicate resident's condition and nursing care to appropriate people (i.e. supervisor, administrator, physician, family, etc. A review of the facility's undated P/P titled, Resident Assessment, indicated that this facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences using the resident assessment instrument (RAI) specified by CMS.

Based on observation, interview and record review, the facility failed to: a. Ensure the facility offered/implemented non-pharmacological interventions for one of one Residents 33, before starting Anti-Psychotic (a type of psychiatric medication which is used to treat [CONDITION(S)] [a mental disorder characterized by a disconnection from reality]) medication. b. Ensure that Residents 33 was assessed for the appropriateness of anti-psychotic medication before starting the medications. These deficient practices had the potential to result in Resident 33 receiving unnecessary medications, and adverse effects from those medications. Findings: During a review of the admission record, the record indicated Resident 33 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the MDS dated [DATE], the MDS indicated Resident 33 has clear speech usually understood and understand by others. Resident 33 required supervision with set up help for bed mobility and eating, limited assistance with one person assists on transfer, personal hygiene, locomotion (how resident moves) on/off unit, walking in the room and corridor, getting dressed, transfers, and toilet use. During a review of Resident 33's physicians orders dated 12/7/2021, the orders indicated: a. [MEDICATION(S)] (medication used to treat depression), 20 milligrams (m.g a unit of measure), 1 tablet daily for depression manifested by negative statements about self, complaints of sadness. b. [MEDICATION(S)] (a medication used to treat disorders involving breaks with reality), 15 m.g, 1 tablet daily for [CONDITION(S)] manifested by hearing voices. During an interview on 02/10/2022 at 9:07 a.m., with Licensed Vocational Nurse (LVN4), LVN 4 confirmed that there was no evidence of non-pharmacological interventions in Resident 33's clinical records, before residents were medicated with antipsychotics. LVN 4 stated that since staff were familiar with every resident, when a resident had behavioral changes, LVN's let the psychiatrists know, then it was up to the Psychiatrist if he/she wanted to initiate a pharmacological approach. During an interview and record review on 2/10/2022 at 10:10 a.m. with LVN1, LVN 1 stated that they do not assess Resident 33 before start of [CONDITION(S)] medication, LVN 1 stated that she was not familiar with the [CONDITION(S)] assessment form that was indicated in the medical chart. LVN 1 added there was no documentation that non- pharmacological interventions were documented on the medical record prior to start of the anti- psychotic medication. During an interview and record review on 2/11/2022 at 9:56 a.m. with Infection Preventionist(I/P), I/P stated that residents that are on Anti- Psychotic medication does not have an assessment prior to start of medication, when asked if non- pharmacologic interventions are documented in the chart, IP stated that staff do it but don't document anywhere in the chart. During an interview on 2/10/2022 at 11:15 a.m., with Director of Nursing (DON), DON stated that there is no [CONDITION(S)] assessment done with any of the resident that are taking anti- psychotic medications, DON added that evaluation is made by the psychiatrist if medication is necessary for the resident to continue or discontinue medication. During a record review of policy and procedure(p/p) dated 01/22 title Medication monitoring medication management indicated when selecting medications and non-pharmacological approaches members of the IDT, including the resident participate in the care process to identify, assess address, advocate for, monitor and communicate the residents needs and changes in condition. Medication management is based on the care process and includes recognition or identification of the problem/need, assessment, diagnosis/cause identification, management/treatment, monitoring and revising interventions, as warranted as well as documenting management steps. During a review of the undated policy and procedure(P/P) titled admission assessment and follow up: Role of the nurse indicated, conduct supplemental assessment, activity level, pain assessment, fall risk assessment, neurological assessment, skin assessment, functional assessment, behavioral assessment. The following information should be recorded in the resident's medical record, the date and time the assessment was performed.

Based on observation, interview and record review, the facility failed to ensure the resident's physician took an active role in supervising the skin impairment of one of eight sampled residents (Resident 76), who was admitted to the facility with intact skin integrity, as per their policy. This deficient practice had the potential for delay in necessary services, poor continuity of care and follow up on Resident 76's deep tissue injury ([DTI] an injury to a residents underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) to the left heel. Findings: A review of Resident 76's Admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 76's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 76's Quarterly MDS dated [DATE], indicated the resident had severe cognitive impairment. The MDS indicated Resident 76 required extensive assistance with bed mobility, dressing, personal hygiene and total dependence with eating, toilet use, and bathing. The MDS indicated Resident 76 was at risk for pressure ulcer development. A review of Resident 76's Readmission Body assessment dated [DATE], indicated the resident's skin integrity was intact. A review of Resident 76's History of Present Illness dated January 6, 2022, indicated Resident 76 was dependent on staff for activities of daily living ([ADLs] self-care activities performed daily) including eating, transfers, bed mobility and toileting. A review of the facility's Change of Condition logbook dated from January 7, 2022, to February 6, 2022, indicated Resident 76 was reported to have a DTI with no specific location documented on January 20, 2022. During a concurrent observation and interview with LVN 4 on February 10, 2022, at 9:30 a.m., Resident 76 was observed lying in bed with both knees in a bent position with a pillow underneath his knees and both heels were touching the mattress. Resident 76 was observed with a DTI on the left heel measuring approximately 2 centimeters ([cm] unit of measurement) by 2 cm. LVN 4 stated there was no care plan initiated for Resident 76's DTI of the left heel. LVN 4 confirmed that a wound specialist had not seen Resident 76 and there was no treatment ordered by the physician. LVN 4 stated the facility had issues with the wound care contractor. LVN 4 stated he followed up with the wound specialist multiple times but did not document. LVN 4 stated the facility did not have a wound care nurse at the time and that the charge nurses were responsible for the current wound care of residents. During an interview on February 10, 2022, at 9:48 a.m., CNA 6 stated she followed Resident 76's turning schedule every 2 hours, but she stated that there was no documentation of the repositioning in the resident's chart. A review of Resident 76's Nursing Notes dated January 20, 2022, indicated LVN 6 noted the resident's DTI was reported by a CNA when a shower was given. Physician was notified and referred to a wound specialist. A review of Resident 76's Nursing notes from January 20, 2022, to January 25, 2022, indicated there was no written notes that a wound specialist saw Resident 76 for her DTI to the left heel. A review of the facility's undated policy and procedure (P/P) titled, Wound Treatment Guidelines, indicated to promote wound healing of various types of wounds, it is the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change. 2. In the absence of treatments orders the license nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatments nurse. 3. Treatments will be documented on the Treatment Administration Record. 4. The effectiveness of treatments will be monitored through ongoing assessment of the wound. A review of the facility's undated P/P titled, Physician Visits and Physician Delegation, indicated to ensure the physician takes an active role in supervising the care of residents. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs. A resident's attending physician may delegate the task of writing therapy orders to a qualified therapist who is acting within the scope of practice as defined by state of law and is under the supervision of the physician.

Based on observation, interview, and record review, the facility failed to enhance a resident's dignity and respect by failing to ensure for one of eight residents (13) that Resident 13's wet clothes and bedding were changed timely to prevent strong urine odors. This deficient practice had the potential to negatively affect the resident's psychosocial and physical wellbeing by feelings of being neglected and possible skin breakdown. Findings: During a review of Resident 13's admission record, the record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 13's Minimum Data Set (MDS - a standardized assessment and screening tool) dated January 24, 2022, the MDS indicated the resident had intact cognition (ability to think, understand and make decisions of daily living). The MDS indicated Resident 13 required supervision with personal hygiene and bathing. During concurrent observation and interview on February 8, 2022, at 9:45 a.m. in room [ROOM NUMBER] B., Resident 13's room had a strong urine odor. Resident 13 was lying in bed covered all over underneath blanket showing part of under pad sheet. Resident 13 stated that she was not wet (with urine), speaking in soft voice, however Resident 13 smelled of urine and her under pad, linen and pants had a yellow to brown stain. During a concurrent observation and interview on February 8, 2022, 10:45 a.m., Certified Nurse Assistant (CNA) 5 stated that Resident 13 was scheduled for a shower that day. CNA 5 stated that she comes to work before 7 a.m. and she said that all residents occupying the B bed (in every room) were scheduled for showering. CNA 5 stated that since she started her shift at 7:00 a.m. until 11:00 a.m., she had not seen Resident 13, and she has no idea what was going on with the resident. CNA 5 then checked Resident 13's pants by hand touching and she stated that it was dry, however Resident 13 still smelled of urine. CNA 5 stated that Resident 13 had possibly been wet, but is dry now. CNA 5 stated she did not know how long it would take for Resident 13 clothing to dry out after she had an incontinent episode. CNA 5 stated that she should have checked Resident 13 at the start of the shift, during her morning rounds, since Resident 13 is schedule for showering. CNA 5 stated that leaving Resident 13 in urine-soaked undergarments and bedding, placed her at risk for skin breakdown due to prolong period of being wet with urine. CNA 5 acknowledged that an overactive bladder means resident cannot control their urination making them incontinent. During a review of the Resident 13's shower schedule, the schedule indicated Tuesdays and Saturdays as shower days for Resident 13. During a review of the care plan dated January 26, 2021, the care plan indicated Resident 13 had a potential for skin breakdown due to episodes of urinary incontinence secondary to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan intervention indicated to assess incontinence and clean after each episode of incontinence, remind to turn and reposition every 2 hours, assess skin condition daily, administer medication as prescribed and assess for effectiveness, and anticipate need to use the bathroom to void. During a review of facility's policy and procedure (P/P) undated, titled Certified Nursing Assistant, the P/P indicated that the primary purpose of your job description is to provide each of your assigned residents with routine daily nursing care and service in accordance with the resident's assessment and care plan and as may you be directed by supervisors. As CNA, you are delegated the administrative authority, responsibility, accountability necessary for carrying out your assigned duties. Such duties and responsibilities: making resident comfortable, keep residents dry (i.e., change gown, clothing, linen, etc., when wet and soiled and assist with bowel and bladder functions. During a review of facility's P/P undated, titled Activities of Daily Living (ADLs), the P/P indicated that the facility ensures a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. This includes the resident's ability to bathe, dress and groom, toilet use. A review of facility's P/P undated titled Quality of Life-Dignity, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Treated with dignity means the resident will be assisted in maintain and enhancing his or her self-esteem and self-worth.

Based on observations, interviews and record review, the facility failed to ensure Resident 20 received the necessary care and services needed to attain the highest practicable level of physical, mental, and psychosocial well-being. These deficient practices had the potential to result in Residents 20 not receiving the quality of care that was needed. Findings: During a review of Resident 20's Face Sheet (admission record), the Face Sheet indicated Resident 20 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 20's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 20's Minimum Data Set (MDS a comprehensive assessment and care planning tool) dated 11/25/2021, the MDS indicated Resident 20 had intact cognitive function (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During review of Resident 20's Care Plan (CP) for compromised mobility, dated 01/22/2022 , the CP indicated to provide assistance with position changes as needed; CP for pain due to sacral wound, dated 01/23/2022 indicated to stay with the resident and provide one on one interaction; CP for assistance with activities of daily living (ADL's), dated 01/22/2022 indicated to keep resident clean and dry as much as possible; CP for wound dehiscence (splitting open of a wound) from previous surgery at the sacral area, dated 12/22/2022 indicated to keep skin clean and dry, protect skin from moisture and reposition every two hours as needed. During an observation on 02/09/2022 at 08:41 a.m., Resident 20 was lying in bed, on the top sheet, with foul smelling wound discharge from his sacral (lowest part of the spine, just above the tailbone) area. During an observation on 02/09/2022 at 10:11 a.m., Resident 20 was still lying in bed, on the top sheet with foul smelling wound discharge from his sacral area . During an observation on 02/09/2022 at 12:03 p.m., Resident 20 was lying to his left side with Sacro coccyx wound dressing saturated with foul smelling drainage and still dripping to the top sheet of the bed. During an observation on 02/09/2022 at 02:41 p.m., Resident 20 was lying to his left side with Sacro coccyx wound dressing saturated with foul smelling drainage and still dripping on the top sheet of the bed. During an interview on 02/10/2022 at 11:17 a.m., the certified nursing assistant (CNA 6) stated that Resident 20 must be turned from side to side every two hours as scheduled and ordered, but when CNA 6 were asked why Resident 20 were soaked with foul smelling wound discharges and was not cleaned, CNA 6 replied that she does not have any excuses for the incident. CNA 6 stated that the practice can make the wound get worse and can lead to a deeper wound infection. When CNA 6 were asked why there were small flies all over the wound drainage and top sheet of the bed, CNA 6 replied that foul smelling discharges attracts flies. During an interview on 02/10/2022 at 11:22 a.m., CNA 5 stated that Residents must be repositioned every two hours to prevent the wound from getting worsts and if I was the resident and was soaking with foul smelling wound discharge, it would make me very uncomfortable and affect my psychosocial being. During an interview on 02/10/2022 at 11:34 a.m., the licensed vocational nurse (LVN 1) acknowledged that it was a quality-of-care issue and stated that if the assigned CNA was turning Resident 20 every two hours, then the top sheet should have been clean and not soaked with wound drainage. During an interview on 02/10/2022 at 11:45 a.m., LVN 1 stated that if it was her or a family member then it would affect the psychosocial aspect of the resident, turning the resident every two hours as ordered is one of the ways to help promote wound healing by taking the pressure out of the way so that the wound can breathe. LVN 1 acknowledged that the reason why there's a lot of small flies on the top sheet was due to foul smelling drainage that attracted insects and it was also an infection control issue. During the review of facility's policy and procedure (P/P) titled Provision of Quality Care undated, the P/P indicated: Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.

Based on interview, and record review, the facility failed to develop a person- centered care plan for two of two sampled residents (46 and 43), who were taking anti- psychotic (a type of psychiatric medication which is used to treat [CONDITION(S)] [a mental disorder characterized by a disconnection from reality]) medication. This deficiency had the potential to result in a delay in delivery of care and services. Findings: During a review of the admission record, the record indicated Resident 46 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the Minimum Data Set (MDS- a comprehensive assessment tool) dated 12/22/2021, indicated Resident 46 has unclear speech usually understood and understand by others. Resident 46 required limited assistance with one-person physical assistance for bed mobility and personal hygiene, extensive assistance locomotion (how resident moves) on/off unit, walking in the corridor, dressing, transfer, and toilet use. During a record review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the admission record, the record indicated Resident 43 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of the Minimum Data Set (MDS- a comprehensive assessment tool) dated 12/20/2021, indicated Resident 43 has unclear speech usually understood and understand by others. Resident 43 required limited assistance with one-person physical assistance for bed mobility and personal hygiene, extensive assistance locomotion (how resident moves) on/off unit, walking in the corridor, dressing, transfer, and toilet use. During a record review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 02/10/2022 at 11:15 a.m. with Director of Nursing (DON), DON stated that care plan should be initiated upon admission, every time there is significant change of condition, or any update with medication or approaches with interventions. During an interview on 02/10/2022 at 3:02 p.m. with I/P, IP stated that Resident 43 was taking [MEDICATION(S)] since 8/2/2021 care plan was not done until 9/20/2021, IP added that the care plan should reflect the exact physician order, or it was not resident specific. During a concurrent interview and record review on 02/10/2022 at 4:27p.m. with I/P, of Resident 43 and 46's medical records, IP stated that physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . I/P stated that Resident 46 was on [CONDITION(S)] medication care plan, however the care plan was not initiated and updated when Resident 46 started taking the medications. IP stated that whoever gets the order should update the care plan. Resident 43's care plan did not reflect dosage or route of the [CONDITION(S)] medication, I/P stated it was not specific for resident. During a review of the undated policy and procedure(P/P) titled Care Plans- Comprehensive, the P/P indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.

Based on observation, interview, and record review the facility failed to maintain an infection control program which prevents the spread of COVID-19 (a respiratory disease caused by a coronavirus called [CONDITION(S)]-CoV-2) when: a. Three staff, the Housekeeper Supervisor (HS), Activities Director (AD), and Activities Assistant (AA) failed to complete a self-screen for temperature and symptoms of COVID-19 prior to starting their shift. b. Two staff, Licensed Vocation Nurse 1 (LVN1), and Licensed Vocational Nurse 2 (LVN2) and Certified Nurse Assistant 1 (CNA1), failed to disinfect the clock-in machine. This deficient practice could potentially spread and expose 74 residents and 56 staff to COVID-19. Findings: During an interview on 9/20/21 at 9:41 am, with the Infection Preventionist (IP) and the Administrator (Admin), the I/P and Admin stated that all staff self-screen for temperature at the front lobby. All staff proceed to clocking-in at the clock machine. The IP and the Admin stated the clock machine is disinfected before and after each use, as indicated by signage posted next to the clock machine. During a concurrent observation and interview on 9/20/2021, at 11:30 am with LVN1, LVN1 was observed clocking-in. LVN1 sanitized his hands, then touched the clock machine screen to clock-in and sanitized his hands again. LVN 1 stated the clock machine is cleaned periodically by housekeeping. LVN1 acknowledged that he was supposed clean the clock machine before and after use but did not. During a concurrent observation and interview on 9/20/202,1 at 11:32 am with LVN 1, LVN 1 confirmed CNA1 was observed clocking-in on the clock machine without first performing hand hygiene. CNA 1 did not disinfect the clock machine prior and after its use. CNA1 stated she does not disinfect the clock machine prior and after its use. During an interview on 9/20/2021, at 11:40 am with LVN2, LVN2 admitted she does not disinfect the clock machine after each use. During an interview on 9/20/2021, at 12:00 pm, with IP and the Director of Staff Development (DSD), the IP stated the process for screening staff upon entering the facility was self-screening and logging of temperature on the screening log. Staff members proceed to perform hand hygiene after self-screening for temperature and symptoms of COVID-19, clock-in on the clock machine, get resident assignment, and make rounds to check on their residents. The DSD confirmed this process. During a concurrent interview and record review, on 9/20/2021 at 12:42 pm, with the Admin, the staff screening log, dated 9/20/21, was reviewed. The Admin confirmed the HS did not self-screen for temperature. The Admin stated all staff must self-screen for temperature and symptoms of COVID-19 and document the screening before starting their shift. During an interview on 9/20/2021, at 1:00 pm with the HS, the HS stated HS performed a self-screen for temperature. The HS confirmed he did not document a self-screen for temperature and symptoms of COVID-19. During a concurrent interview and record review, on 9/20/2021 at 1:09 pm, with the DSD, the staff screening log, dated 9/20/21, was reviewed. The DSD confirmed there is no documented evidence that the HS, the Activities Director (AD), and the Activities Assistant (AA) self-screen for temperatures and symptoms of COVID-19 prior to starting work on 9/20/21. During a record review of COVID-19 Mitigation Plan Manual, dated 8/12/2021, the Mitigation Plan Manual indicated the facility has a designated staff who screens and documents every individual entering the facility (including staff) for COVID-19 symptoms. Proper screening includes temperature checks, at least at the start of the work shift and at the end of the shift. During record review of the policy and procedure titled COVID-19 Reporting revised 2020 indicated Staff screening logs and resident symptom tracking logs are reviewed daily by the Infection Preventionist, or designee. Data is analyzed for triggers that warrant reporting: a. Presence of new-onset respiratory symptoms, b. Suspected/confirmed COVID-19, or c. A severe respiratory infection resulting in hospitalization or death.

Based on observation, interview and record review, the facility failed to observe infection control measures for one out of two housekeepers by failing to: 1. To ensure one unvaccinated staff member wore a N95 mask respirator (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) while working in the healthcare center. 2.To provide in-services in regards to unvaccinated staff wearing N95 respirator while performing job duties in the facility. These deficient practices placed the residents and staff at risk for infection and the transmission of Coronavirus disease (COVID 19, an infectious disease caused by a newly discovered coronavirus). Findings: During an observation and concurrent interview on 8/9/2021 at 2:06 p.m., Housekeeper 1 (HK 1) was observed not wearing an N95 respirator (a devise designed to protect the wearer from inhaling hazardous airborne microorganisms) while on duty. During an interview HK 1 stated, she had not received an in-serviced on how to wear the N95 respirator, if unvaccinated. The Infection Preventionist (IP) nurse confirmed that HK 1 was not in-serviced on wearing the N95 respirator while working in the facility as an unvaccinated employee. During an interview on 8/9/2021 at 2:10 p.m., the Infection Prevention nurse stated it was important to wear the N95 respirator because it can stop the spread of germs related to the COVID-19 virus in unvaccinated staff and residents. During an interview on 8/9/2021 at 2:10 p.m., the Certified Nurse Assistant (CNA) stated that unvaccinated employees must wear the N95 respirator because unvaccinated individuals are at higher risk to spread and catch the virus. During an interview on 8/9/2021 at 4:10 p.m., the Director of Nursing (DON) stated the importance of in-servicing staff, including housekeepers about wearing the N95 respirator is to prevent the spread of COVID-19. During a review of the facility's Mitigation Plan Manual undated, titled Personal Protective Equipment (PPE) indicated under procedures, all staff who are unvaccinated or incompletely vaccinated must wear an N95 face covering while in the facility.

Based on observation, interview and record review, the facility's nursing staff failed to ensure one of three sampled residents (Resident A) was adequately supervised on a locked unit and the facility grounds were appropriately staffed to monitor residents and their whereabouts. This deficient practice resulted in Resident A eloping (escaping) from a locked facility without staff knowledge. Resident A has not been located. Findings: During an interview on 12/12/2020 at 2:37 p.m., the Director of Nursing (DON) stated, Resident A was admitted to the skilled nursing facility on 12/7/2020 and eloped from the facility on 12/9/2020. The DON stated, Resident A mostly stayed in her room and was non-compliant with care (baths, vital signs and weights) and taking medication. The DON stated, prior to admission Resident A was homeless and had recently been appointed with a conservator and placed on 72 hour monitoring as a newly admitted resident. The DON stated at approximately 1:30 p.m., (12/9/2020) Resident A was observed in front of the nursing station but went back to her room when she was asked to put a mask on. At approximately 2:30 p.m., and again at 3:30 p.m., (12/9/2020) Resident A was observed in her room sitting on her bed. At approximately 4:45 p.m., (12/9/2020) staff took Resident A a dinner tray and discovered she was not there. At approximately 5 p.m., a Certified Nursing Assistant (CNA) observed Resident A's dinner tray was untouched and the resident was not in her room. The DON stated, the CNA searched for Resident A and when she could not find her, she reported Resident A was missing to the charge nurse. The DON started a search of the buildings, the grounds and the surrounding areas. The local police agency was notified. During a tour of the facility and the facility grounds on 12/12/2020 at 3 p.m., the following was observed: 1. Multiple residents were observed outside of the facility without staff present. The DON stated, residents move freely about the inside and outside of the facility until 7 p.m., that's when the doors to the facility are alarmed. 2. There were cameras inside the facility near Resident A's room were observed directed toward the nursing station, not residents' rooms. Both the DON and Administrator stated at approximately 1:30 p.m., Resident A was seen on video surveillance at the nursing station but Resident A was not seen on film after that. They believed Resident A eloped from the door leading to the outside of the facility, which was near Resident A's room that was not monitored nor recorded by cameras. 3. Multiple cameras were observed on the outside of the facility however, all cameras were positioned toward the street and the parking lot, not on the door leading in and out of the facility where it was thought Resident A had eloped from. 4. The back of the facility was observed without any cameras, multiple chairs, two tables, a broken Geri-chair and a chain link fence surrounding the perimeter of the facility. There was a large tree with branches that hung over the chain link fence. Behind the chain link fence was a dry river bed where it was believed Resident A eloped to. During a review of the General Acute Care Hospital (GACH) records dated 9/21/2020, indicated Resident A was brought to the GACH for a psychiatric evaluation. Per the report, Resident A was detained by a police agency at a gas station for vandalizing the station and attempting to strike at a clerk. On arrival to the GACH, Resident A was alert and oriented to her name, was hyper-verbal, agitated, anxious, restless and refusing labs and vital signs. During a review of an Office of the Public Guardian document dated 12/3/2020, indicated Resident A was appointed a Conservator. During a review of Resident A's Admission Records indicated, the resident was admitted to the facility on [DATE]. Resident A had a diagnosis of paranoid [CONDITION(S)] (a mental disorder often characterized by abnormal social behavior, distrust of others and failure to recognize what is real). During a review of Resident A's Initial Wandering Assessment and Elopement Risk Assessment / Interventions records dated 12/7/2020, indicated Resident A was at risk for wandering. The wandering / elopement assessment record indicated the resident was suppose to be frequently monitored. The check off box for making staff aware of this resident's wandering risk, was not checked as an intervention. During a review of Resident A's 48 Hour Baseline Care Plan dated 12/7/2020, indicated the resident was not at risk for elopement. The facility's written interventions for this problem indicated to monitor the resident's whereabouts closely. During a telephone interview on 3/4/2021 at 10:03 a.m., the DON stated Resident A was newly admitted and they did not really know her and that she did not have a typical wandering / elopement behavior. The DON stated, the wandering and elopement portions of the assessment went hand in hand and their interventions were to monitor the resident. The DON stated, because Resident A was a new admit they had to place her in the observation unit until she was cleared for COVID (a highly contagious infection). The DON stated, she was not sure if there were female beds available that were not near an outside doorway, at the time Resident A was admitted to the facility. During a review of the Licensed Nurses Notes dated 12/9/2020 at 5:30 p.m., indicated a CNA had reported Resident A was not in her room and that the resident's dinner tray was left untouched. The CNA was instructed to look for Resident A and at 5:45 p.m., the CNA reported she was unable to find the resident. All staff then initiated a head count and facility / grounds search. During an interview on 4/12/2021 at 2:17 p.m., the Social Services Designee (SSD) stated, when Resident A was initially admitted to the facility Resident A had stated she did not want to be at the facility with old people. The SSD stated, she reported Resident A's statement to their physical therapist and to Resident A's conservator. During an interview on 4/12/2021 at 2:28 p.m., Licensed Vocational Nurse 1 (LVN 1) stated, he is the Director of Staff Development (DSD) but was covering the 3-11 shift that day (12/9/2020) when it was reported to him that Resident A was missing. LVN 1 stated, they conducted a search of the building, the grounds and the surrounding community but could not find the resident. During an interview on 4/12/2021 at 2:33 p.m., CNA 1 stated, she brought Resident A's dinner tray to her but Resident A told her she did not want it so she left it there for her. CNA 1 stated, later she came back to collect the tray and noticed Resident A had not eaten anything and was not in her room. CNA 1 stated, she looked for Resident A but could not find her and reported to her charge nurse that the resident was missing. During a review, a facility policy titled Elopements and Wandering Residents dated 2020, indicated this facility ensures that residents who exhibit wandering behavior and/or are risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering. Adequate supervision will be provided to help prevent accidents or elopements.

Based on observation, interview, and record review, the facility failed to establish, and maintain an infection prevention and control program, designed to provide a safe, sanitary environment, that can help prevent the development, and transmission of communicable diseases, and infections by not monitoring: a. One of 10 healthcare workers, who had long, sharp, fake nails, was caring for one COVID-19 (an illness caused by [MEDICAL CONDITION] that can spread from person to person), and non-COVID-19 residents. The facility did not establish and implement a policy on how to manage employees long, fake nails. b. Two of the three residents (2, 3), who were exposed to a roommate that was confirmed positive for COVID-19, were not cohorted (keeping residents who are COVID-19 positive or are suspected to have COVID-19 in the same space (wing, floor, etc.) that is separate from those who are COVID-19 negative or do not have exposure to COVID-19) with other suspected residents, but were placed in two separate rooms that housed non-COVID residents. These deficient practices had the potential to result in wide-spread of COVID-19 infections in the facility and the community. Findings: a. During a concurrent observation and interview with certified nurse assistant (CNA 2), on 7/1/20 at 4:22 p.m., was observed with long, sharp nails. During interview CNA 2 stated she had fake nails but the facility allowed her to have long, fake nails. However, CNA 2 immediately retracted her answer and stated she did not know if she could have fake nails. During an interview with the Director of Nursing (DON), on 7/1/20 at 4:31 p.m., stated the healthcare workers could not have long nails. The DON stated the charge nurses were responsible for monitoring the nails of healthcare workers. During an interview with Infection Preventionist (IP 1) on 7/1/20 stated the healthcare workers were not allowed to have long, fake nails. IP 1 stated fake nails trapped particles inside the nail and could spread COVID-19 to other residents. IP 1 stated the facility did not establish a policy on how to manage employees long, fake nails. b. During an observation with the Director of Nurses (DON) on July 1, 2020 at 4 p.m., of the hallway with rooms 80-84 (designated as COVID area/red zone), the observed room [ROOM NUMBER] had an isolation cart (cart to put and organize gowns, face shield, gloves and alcohol sanitizer, to protect individuals from exposure to the germs) outside, by the door. There was also signage for donning and doffing of Personal Protective Equipment ((PPE) materials worn to protect from exposure to germs), and droplet and contact precaution signs (signs to indicate the level of protection needed) posted above the isolation cart. The door of the room was closed. During a interview with the DON on July 1, 2020 at 4:09 p.m., stated Resident 1, who was confirmed Covid-19 positive during the latest testing done by the facility, was placed in room [ROOM NUMBER] bed C. The DON also stated the roommates of Resident 1 were placed in room [ROOM NUMBER] bed C (Resident 2), and 76 bed C (Resident 3). However, during an observation of the hallway 70 to 79 along with the DON, Resident 2 was housed in room [ROOM NUMBER] bed C with another resident in bed A. Bed B in room [ROOM NUMBER] was empty and not occupied by any other residents. Resident 3 was placed in room [ROOM NUMBER] bed C with 2 other residents. During a review of the facility's map indicated the cohorting zones for the COVID-19 cases, were rooms 70 to 79, and 90 to 95, designated for confirmed non-COVID residents (green zone). Rooms 60 to 67 were designated as a yellow zone which was dedicated for the residents on isolation/quarantined (new admits or readmission, where the Covid-19 status was unclear, or for the residents possibly exposed to COVID-19). The red zone was designated rooms 80 to 84 for confirmed COVID-19 positive residents only. During an interview with IP 1 on July 1, 2020 at 4:40 p.m., acknowledged and stated Resident 2 and 3 should have been placed in the yellow zone, which was designated for isolation and not with the residents who were tested , and confirmed as non-COVID. During a review of an undated facility's policy and procedures titled Cohorting of Residents, indicated: Patients who are close contacts of COVID+ patient (roommates): should be placed in quarantine (yellow) unit, ideally in single rooms if space allows.

Based on observation, interview, and record review, the facility failed to: a. Maintain the correct concentration of chlorine (a chemical sanitizing agent) sanitizing agent used in the low-temperature dishwasher, according to the manufacturer's guidelines. b. Ensure one Kitchen Staff performed hand washing before starting work, and prior to handling foods, when in the kitchen area. These deficient practices had the potential to increase the risk of food contamination, which could cause foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) for the residents. Findings: a. On 08/08/2019 at 8:24 a.m., during a concurrent observation and interview in the initial kitchen tour, Assistant Dietary Supervisor (ADS 2) checked the concentration of sanitation on the newly washed dishes with a chlorine test strip. The test strip measured less than 10 parts per million ((ppm) unit of concentration). ADS 2 repeated the test process five times on various dishes that came out of the automated dish washer. All five test strip resulted in less than 10 ppm reading. ADS 2 placed a new load of dishes and completed the dish washing cycle. ADS 2 acknowledged the manufacturer's guidelines for proper concentration of chlorine sanitation solution on the dishes was to be 50 ppm. A review of the facility's Kitchen Dishwashing Monitoring log on 08/08/2019 at 9:00 a.m., did not indicate the chlorine chemical sanitizing agent was checked prior to using the automated dishwasher. On 8/08/2019 at 10:20 a.m., during an interview, ADS 2 stated she called the manufacturer help line to trouble shoot the dishwasher sanitation cycle. ADS 2 stated she thought there was a kink in the line that dispensed the chemical sanitizer on the dishes. ADS 2 stated the recommended concentration of sanitizing solution was not properly dispensing into the dish washer, that was why it registered a 10 ppm. ADS 2 also stated staff were improperly trained on how to check for the proper concentration of sanitizer on the dishes. ADS 2 stated that all of the dishes that were washed that morning would be rewashed manually until the problem was corrected. b. On 8/13/2019 at 12:10 p.m., during a tray line observation, Kitchen Staff 2 did not perform hand washing technique, prior to observing the following: Kitchen Staff 2 exited the kitchen into the resident dining area, returned into the kitchen, obtained a bagged package of cup lids from storage room, exited the kitchen, returned into the kitchen, walked to the food preparation area area, and picked up a container of strawberries. On 8/13/2019 at 12:15 p.m , during an interview, Kitchen Staff 2 stated he went in and out of the kitchen without having performed hand washing. Kitchen staff 2 stated he picked up a container of strawberries at the food preparation station. Kitchen Staff 2 stated he we rushing and did not think about it but should have washed his hand upon entering the kitchen. On 8/13/2019 at 12:21 p.m., during an interview, Assistant Dietary Supervisor (ADS 2) stated kitchen staff are trained, with no exceptions, were to wash their hands upon entering the kitchen. ADS 2 stated Kitchen staff 2 will be in serviced concerning the hand washing policy. A review of facility's policy, dated (YEAR), titled Hand Washing Procedure, indicated hands need to be washed before starting work in the kitchen.

Based on interview, and record review, the facility failed to report a change of condition to the attending physician for one of 19 sampled residents (23), when the saturation levels (oxygen level in the blood) registered below the average normal range of between 95 to 100 percent (%). This deficient practice had the potentially caused a delay of medical treatment for [REDACTED]. Findings: A review of Resident 23's face sheet indicated an original admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. contagious infection caused by bacteria that mainly affects the lungs but also can affect any other organ). A review of Resident 23's History and Physical assessment from the physician dated 04/22/19 indicated the resident was hospitalized for [REDACTED]. A review of Resident 23's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated for 02/28/19 indicated the resident had intact level of cognition (process of acquiring knowledge and understanding) for daily decision making. A review of Resident 23's Physician order [REDACTED]. - Monitor oxygen saturation every shift, maintain oxygen saturation to 90 % and or above at all times. - [MEDICATION NAME] Diskus (medicine used for [MEDICAL CONDITION]) aerosol powder 250-50 microgram (mcg) dose, 1 puff, twice a day (BID) - [MEDICATION NAME] (medicine to prevent the wheezing and shortness of breath) 10 milligram (mg), at bedtime, and - Oxygen (O2) at 2 liters per minute (LPM) for O2 less than 90 %. A review of Resident 23's Medication Administration Record [REDACTED]. The MAR further indicated Resident 23's O2 saturation was 86 % at 6 a.m., while receiving oxygen. A review of Resident 23's MAR for (MONTH) 8, 2019 indicated the resident had an O2 saturation of 80 % on 11 p.m. to 7 a.m. shift. The MAR further indicated the resident's O2 saturation was 88 % at 6 a.m., while receiving oxygen and the resident was redirected to breath through the nose. On 08/14/19 at 9:17 a.m., during a concurrent interview and record review, Licensed Vocational Nurse (LVN 1) stated the nurse should have contacted the physician when the resident had an oxygen level of 86 % and 88 % on 4/2/19 and 4/8/19, respectively. LVN 1 also stated there was no documentation in the resident's records indicating the facility notified the attending physician. LVN also stated, I would have called as soon as it reached less than that. On 08/14/19, at 9:27 a.m., during an interview, the Director of Nursing (DON) stated the physician should have been contacted as soon as the nurse had to use the supplemental oxygen to increase Resident 23's blood oxygen saturation levels. A review of Resident 23's medical record indicated the resident was sent to the hospital on [DATE] for respiratory distress with a low oxygen saturation of 68 % while receiving supplemental oxygen at 2 liters per minute. A review of Resident 23's care plan dated 3/26/19 indicated under concerns and problems, Resident at risk for shortness of breath (SOB), anxiety from dyspnea, diminished ability to perform activities of daily living (ADLs) due to: [MEDICAL CONDITION]. The care plan listed the resident's goals as Resident will display optimal breathing pattern daily. Will minimize signs and symptoms of acute respiratory insufficiency: anxiety, confusion, restlessness, SOB, cyanosis, and somnolence. The approaches on the plan of care included, Monitor for symptoms of acute respiratory insufficiency and notify MD promptly. A review of Resident 23's care plan dated 3/26/19 indicated under concerns and problems, Resident requires oxygen use related to history of [MEDICAL CONDITION]. The care plan listed the resident's goals as Resident will be able to participate/perform ADLS without signs and symptoms of SOB on a daily basis. The approach of the care plan included, Provide O2 at 2 liters per minute by nasal cannula. Monitor for episodes of SOB. Check oxygen saturation every shift. Teach resident breathing techniques purse lip, cough and deep breathing. Monitor labs and notify MD. A review of Resident 23's interdisciplinary team (professionals who assess, coordinate, and manage each resident's comprehensive health care, including his or her medical, psychological, social, and functional needs) meeting conference form dated 3/27/19 indicated, .He was recently readmitted from hospital following treatment for [REDACTED].O2 sat continues to decline with minimal exertion . A review of Resident 23's nurses notes for 4/14/19 at 7 a.m. indicated, Vital signs (V/S) 140/70 milligram per deciliter, pulse 77, respiration 23, temp 99.3, O2 stat was 68% on continuous 2L of oxygen via NC (nasal cannula; device used to deliver oxygen thru the nose); sent out 911 per MD order because of desaturation; skin was pale, and clammy; no SOB noted; resident denied pain, no s/s (signs and symptoms) of distress noted. A review of Resident 23's face sheet from the emergency room (ER) dated 4/15/19 indicated the reason of the visit, Acute [MEDICAL CONDITION] exacerbation with hypoxemia/hypercapnia. A review of Resident 23's history and physical from the acute hospital, dated 4/15/19, indicated under history of present illness: As per patient, for the last 2 or 3 days, he has been having progressive worse shortness of breath with significant wheezing as well as a cough which is predominantly dry, but occasionally productive of whitish to tan colored sputum. Upon presentation in the ER, he was found to be hypoxemic requiring high flow nasal cannula to maintain his saturation above ninety percent. A review of the facility's undated policy and procedure titled, Notification of Changes, indicated, .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notify, consistent with his or her authority, resident's representative when there is a change requiring notification .Compliance Guidelines .Circumstances requiring notification include .Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental or psychosocial status . This may include .life-threatening conditions, or clinical complications .

Based on interview, and record review, the facility failed to develop a plan of care for the use of [MEDICATION NAME] (medication used as a mood stabilizer), for [MEDICAL CONDITION] disorder manifested by self-isolation for one of 19 sampled residents (66). This deficient practice placed Resident 66 at increased risk for adverse reactions for the use of [MEDICATION NAME] and psychological harm related to isolation. Findings: A review of Resident 66's face sheet indicated the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 66's Physician order [REDACTED]. A review of Resident 66's Psychotherapy Progress notes dated 07/09/19 indicated a therapeutic goal of decreased social Isolation/withdrawal and decreased depression. A review of Resident 66's Social Service Assessment notes dated 7/13/2019, indicated the resident was withdrawn. However, a review of Resident 66's Care plans did not show a plan of care developed for the identified behavior of social isolation/withdrawn, and to identify interventions to decrease the episodes for the use of [MEDICATION NAME]. On 8/13/2019 at 3:55 p.m., during an interview the Assistant Director of Nursing (ADON) stated all [MEDICAL CONDITION] medications should have a care plan to help staff identify, and prevent adverse reactions from [MEDICAL CONDITION] medications. The ADON also stated a plan of care was not developed for Resident 66 related to the identified behavior of isolation. The ADON also state there are no interventions to prevent further episodes of isolation. A review of an undated facility's policy and procedure titled, Care Plan -Comprehensive, indicated each resident's comprehensive care plan is designed to incorporate risk factors associated with identified problems and aid in preventing or reducing declines in the resident's functional status and/or functional level.

Based on interview, and record review, the facility failed ensure a Registered Nurse (RN) was on duty, for at least eight consecutive hours a day, for three consecutive days (August 11, 12 and 13, 2019). This deficient practice had the potential for the residents not be provided with the appropriate nursing observations, and assessments, which could only be performed by an RN. Findings: A review of the Daily Nursing hours' projection sheet that included the day shift, evening shift, and night shift, dated (MONTH) 11, 12, and 13, 2019 did not indicate an RN, who was scheduled to work in the facility. On 8/14/19 at 10:01 a.m., during an interview, the Administrator stated the facility did not have a waiver for nurse staffing (to assure that sufficient qualified nursing staff are available on a daily basis to meet residents' needs for nursing care in a manner and in an environment which promotes each resident's physical, mental and psychosocial well-being, thus enhancing their quality of life). The Administrator stated the facility did not have a required RN, for at least eight hours per day, which usually happens on the weekends. The Administrator stated the facility needed to have a RN at least 8 hours a day, 7 days a week, because they usually have 70 or more residents in the facility. The Administrator further stated they were in the process of screening applicants for an RN staff position. A review of an undated facility's policy and procedure titled, Nursing Services and Sufficient Staff, indicated it was the policy of the facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial wee-being of each resident. The policy further indicated that except when waived, the facility must use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week.

Based on interview, and record review, the facility failed to follow its protocols for antibiotic stewardship program (a program designed to optimize the use of antibiotics and reduce the adverse events usually associated with antibiotic use), when administering [MEDICATION NAME] (an antibiotic used to treat infections), to one of 19 sampled residents (47), who did not meet the criteria for antibiotic use while being treated for [REDACTED]. This deficient practice had the potential to place Resident 47 at risk for the developing antibiotic-resistant organisms (a strain of infectious organisms that developed resistance to antibiotics), and suffer side effects of unnecessary or inappropriate antibiotic use. Findings: A review of the Admission Records indicated Resident 47 was admitted on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 47's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 6/25/19 indicated Resident 47 was severely cognitively (ability to make decisions of daily living) impaired for daily decision making. The MDS assessment indicated Resident 47 required assistance in activities of daily living such as getting dressed, toilet use, and personal hygiene. A review of a physician order [REDACTED]. A review of the medication administration records dated (MONTH) 2019 indicated Resident 47 received the [MEDICATION NAME] at 9:00 a.m. and 9:00 p.m. on (MONTH) 9, 10, 11, 13, 14 and on (MONTH) 15 at 9:00 p.m. During a concurrent interview, and record review on 8/13/19, at 8:31 a.m. Licensed Vocational Nurse (LVN 1) stated she was responsible for the antibiotic stewardship program. LVN 1 stated as part of the facility antibiotic stewardship program, she documents the date of admission, any signs and symptoms, where the infection was, the medications the resident was on, and whether the resident met the criteria for antibiotic use. LVN 1 stated the facility used the McGeer Criteria. A review of National Institute of Health (a governmental bio-medical research agency), McGeer Criteria was used as a standard of practice that included categories that must be met to determine if a resident was a candidate for antibiotic use. A review of the McGeer's criteria indicated a resident must meet at least two of the following criteria of signs and symptoms of infection to be treated with antibiotics for a suspected urinary tract infection: Positive urine culture, and acute dysuria (pain or discomfort when urinating) or a fever (greater than 100 degrees Fahrenheit) and lower abdominal pain, urinary frequency, blood in the urine, and incontinence). During a concurrent interview, and record review on 08/13/19 8:31 a.m., LVN 1 stated according to McGeer's Criteria, Resident 47 did not meet the criteria for getting antibiotics for a UTI. LVN 1 stated Resident 47 had a urine culture test (a test performed to grow and identify organisms that may cause a urinary tract infection) that showed positive for bacteria. However, when compared to McGeer Criteria, a review of Resident 47's medical record indicated the resident did not have fever, urinary urgency, pain, frequency, incontinence, or blood in the urine to qualify and justify the use of [MEDICATION NAME]. During an interview on 8/13/19 at 8:58 a.m., LVN 1 acknowledged Resident 47 did not meet the criteria for antibiotic use according to McGeer's Criteria, so the resident should not have been on [MEDICATION NAME]. LVN 1 stated use of antibiotics exposed the resident to side effects and possible antibiotic resistance bacteria. A review of the facility's policy titled Infection Control, dated 1/2017 indicated it was the policy of the facility to implement an antimicrobial stewardship program which will promote appropriate use of antimicrobials while optimizing the treatment of [REDACTED]. This policy has the potential to limit antimicrobial resistance in the facilities environment.

Based on observation, interview, and record review, the facility failed to prepare the appropriate consistency of a breaded chicken for a residents who was on a mechanical soft diet (a diet that involves only foods that are physically soft, with the goal of reducing or eliminating the need to chew the food), per the menu, and the physician order. This deficient practiced of not grinding, but cutting the breaded chicken in to one-inch or bigger size, had the potential to place the residents who was to receive mechanical soft diet, at increased risk for choking. Findings: On 8/13/2019 at 12:07 p.m., during the tray line observation, kitchen staff cut the breaded chicken with a spatula into one-inch or bigger cuts. During observation the kitchen staff placed the cut breaded chicken on the tray of a resident that had an order for [REDACTED].>A review of the facility's Summer Menus spreadsheet dated 8/13/19 indicated on the same day, the residents were to be served baked chicken with cordon bleu cheese sauce for lunch. However, the Summer Menus spreadsheet indicated to grind the baked chicken for mechanical soft diet orders, and not cut it into one-inch or bigger cuts. A review of the facility's Recipe for baked chicken with cordon bleu cheese sauce indicated to grind and serve to the residents who had a physician order [REDACTED].>On 8/13/2019 at 12:09 p.m., during an interview, the Assistant Dietary Supervisor (ADS 2) also acknowledged cut pieces of baked chicken were assessed to be too big for a resident who had an order for [REDACTED]. A review of an undated facility's policy and procedure, titled Therapeutic Diet Orders, indicated therapeutic diets will be provided to residents in the appropriate form and/or the appropriate nutritive content as prescribed by the physician and/or assessed by the interdisciplinary team to support the treatment and plan of care.

Based on interview and record review, the facility failed to follow the physician's order for blood test, the resident's care plan, and its policy on hydration (the process of causing something to absorb water) for one of three sampled residents (Resident 1). Resident 1's physician ordered for blood test to be drawn on 2/6/18 due to [MEDICAL CONDITION] (condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body), but it was not done. This deficient practice resulted in a delay in diagnosis, care and treatment of [REDACTED]. Resident 1 became weak and less responsive requiring a transfer to the general acute care hospital (GACH) and was diagnosed with [REDACTED]. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE]. The Admission Record indicated Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS) a resident assessment and care planning tool, dated 1/16/18, indicated Resident 1 was moderately impaired in cognitive skills for daily decision-making and had memory problems. The MDS indicated Resident 1 was frequently incontinent (having no or insufficient voluntary control over urination or defecation) of bowel and had no pressure sores (areas of damaged skin caused by staying in one position for too long), and required extensive assistance (resident involved in activity, staff provide weight-bearing support) for transferring, dressing, toileting, and personal hygiene and supervision for eating. A review of a Nurses' Note, dated 2/5/18 and timed at 12:30 p.m., indicated Resident 1 was observed with plus (+) three (3) [MEDICAL CONDITION] (moderate deep pitting, 6 mm indent, 30 seconds). The note indicated the physician ordered for Resident 1 to have blood drawn for basic metabolic panel ((BMP)-8 blood levels that provided information about the resident's metabolism, kidneys, blood glucose level, and electrolyte and acid/base balance), complete blood count ((CBC) measures the cells that make up the blood ) and brain natriuretic peptide ((BNP)-test performed to test for hearth failure) on 2/6/18 and to administered [MEDICATION NAME] (diuretic that increases the production or urine) 20 milligrams (mg) for swelling. A review of the physician's order, dated 2/5/18 and timed at 12:20 p.m., indicated for Resident 1 to take [MEDICATION NAME] 20 mg one tablet by mouth for [MEDICAL CONDITION]. Another physician's order, dated 2/5/18 and timed at 12:30 p.m., indicated for Resident 1's blood to be drawn for BMP, CBC, and BNP on 2/6/18. A review of a care plan titled, At Risk for Dehydration (significant loss of total body water)-Diuretic Use, dated 2/6/18, indicated Resident 1 would not have signs of dehydration such as an elevated laboratory results and changes in level of consciousness. The staff interventions included labs to be done as ordered and to notify the physician of abnormal results. A review of the Nurses' Note, dated 2/14/18 and timed at 5:45 p.m., indicated a certified nurse assistant (CNA) notified the licensed vocational nurse (LVN) that Resident 1 was weak and unable to answer questions with an oxygen saturations was 96 percent (%) on room air. The Nurses' Note indicated Resident 1 was transfer to the GACH on 2/14/18 at 6:30 p.m., for poor oral intake and weakness. On 2/21/18 at 3:44 p.m., during a concurrent interview and record review, Registered Nurse 1 (RN 1) stated that she was unable to locate Resident 1's Activities of Daily Living (ADLs) sheets to assess oral intake and output information. A review of Resident 1's blood test drawn on 1/23/18 indicated a sodium level(detects abnormal concentrations of salt in the blood) of 140 milliEquivalent per liter (normal reference range (NRR) 136-146 mEq/L), creatinine (test that indicates kidney function) 39.6 (NRR=10-20) and BUN ((blood/urea/nitrogen)test done to check the function of the kidneys) 40 milligrams/deciliter (NRR 7-25 mg/dL). The diagnostic laboratory results had a hand written note indicating no new orders. A review of Resident 1's GACH physician Consultation, dated 2/16/18, indicated Resident 1 was admitted to the hospital with [REDACTED]. According to the GACH's assessment, Resident 1's confusion was related to an infection caused by leukocytosis and a complicated UTI. The consultation indicated Resident 1 was lethargic (sluggish) and had no voluntary or involuntary body movements. A review of Resident 1's GACH's laboratory results, dated 2/15/18, indicated high sodium level at 147 mg/dl, high BUN level at 92 mg/dL (NRR 7-18 mg/dL), and high creatinine at 4.8 mg/dL. On 4/24/18 at 5:10 p.m., during a telephone interview, the complainant stated Resident 1 arrived to the GACH severely dehydrated with pressure sores on bilateral heels and buttocks, and [MEDICAL CONDITION] due to dehydration. A review of an online article, indicated that dehydration can lead to serious complications, including UTI, electrolyte imbalance, such as with potassium and sodium, which could lead to involuntary muscle contractions and sometimes to a loss of consciousness, low blood volume shock (hypovolemic shock), one of the most serious, and sometimes life-threatening, complications of dehydration, occurs when low blood volume causes a drop in blood pressure and a drop in the amount of oxygen in the body. https://www.mayoclinic.org/diseases-conditions/dehydration/symptoms-causes/syc- 086?p=1, A review of an online American Kidney Fund article, dated (YEAR), indicated that the common causes of an acute [MEDICAL CONDITION] was related to the insufficiency of water consumption and blood flowing through the kidneys. http://www.kidneyfund.org/kidney-disease/kidney-failure/ On 5/14/18 at 11:15 a.m., during a telephone interview, RN 2 stated that residents receiving [MEDICATION NAME] needed to be monitored for fluid input and output. RN 2 stated Resident 1's water intake was difficult to monitor due to the resident being ambulatory and not knowing the whereabouts of the resident. A review of an online article, revised on 2/27/18, indicated that [MEDICATION NAME] could produce large amounts of increase production of urine that can result in fluid and electrolyte reduction. Excessive dehydration can occur in the elderly population; elevated BUN may be associated with dehydration. http://www.lexicomponline.com/lco/action/doc/retrieve/docid/complete_ashp/ 9 On 5/14/18 at 3 p.m., during an interview, the DON stated Resident 1 should had been monitored while receiving [MEDICATION NAME] because is a potassium sparing diuretic (sic). The DON stated he was unable to locate the laboratory results for the laboratories ordered by the physician on 2/6/18. A review of the facility's policy titled, Hydration-Clinical Protocol, revised 10/2010, indicated that the staff and the physician will identify individuals with a significant risk for subsequent fluid and electrolyte imbalance; for example, those with prolonged vomiting, diarrhea, or fever, or who are taking diuretics and/or ACE inhibitors and who are not eating or drinking well.

Based on observation, interview, and record review, the facility failed to follow its policy by not protecting one of four sampled residents (Resident 2) from being physically abused by another resident (Resident 3). This deficient practice resulted in Resident 2 being hit in the face and sustaining a purplish discoloration to both eyes. Findings: A review of Resident 2's Face Sheet (Admission Record) indicated the resident was admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care-screening tool), dated 12/15/17, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 6 (0-7 = severe impairment of cognitive (thought process) skills), and had memory problems. The MDS indicated Resident 2 was totally dependent with one person physical assist for locomotion. According to the MDS, Resident 2 was dependent on a wheelchair or walker for locomotion and had no impairment of the upper and lower extremities. On 2/20/18 at 3:08 p.m., during a concurrent interview and record review, Registered Nurse 2 (RN 2) stated that Resident 2 was transferred to the general acute care hospital (GACH) on 2/19/18 for evaluation of behaviors. RN 2 stated that Resident 3 punched Resident 2 in the face causing the resident to sustain two purple eyes. A review of a Nurses Progress Note, dated 2/16/18, and timed at 3:30 p.m., indicated Resident 2 was punched in the face by Resident 3. The note indicated that Resident 2 kicked Resident 3 on the leg while propelling herself to the dining room. The note indicated that Resident 3 suddenly punched Resident 2 on the left side of the face. On 3/7/18 at 3:15 p.m., during an observation and concurrent interview, Resident 2 was observed with bilateral (both sides) purple/greenish bruising of both eyes, and a scab on the bottom of the right eye. Resident 2 stated that a man grabbed her by the shirt for no reason and punched her twice in the face. Resident 2 stated that she was scared and had complaints of pain to her face, but felt safe because the man ran away. A review of Resident 2's care plan titled, Incident/Accident, dated 1/13/18, indicated the staff's intervention included to monitor Resident 2's whereabouts at all times. A review of Resident 3's Face Sheet (Admission Record) indicated the resident was admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 3's [DIAGNOSES REDACTED]. A review of Resident 3's MDS, dated [DATE], indicated the resident had a BIMS score of 0 (0-7 = severe impairment of cognitive skills), and had memory problems. The MDS indicated Resident 3 required supervision for locomotion. On 3/7/18 at 3:25 p.m., during an interview, Resident 3 stated he did not remember hitting anyone. Resident 3 stated that he did not have any problems with the other residents at the facility. A review of the facility's undated policy and procedure titled, Abuse, Neglect and Exploitation, indicated residents shall not be subjected to abuse by anyone, including, but not limited to, facility staff; other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals.

Based on interview and record review, the facility failed to follow its policy and initiate a plan of care for one of three sampled residents (Resident 1) who had a history of [REDACTED]. (Cross reference F 684) This deficient practice resulted in Resident 1 being transferred to the general acute care hospital (GACH) for severe abdominal pain and distention (substances accumulated in the abdomen causing its outward expansion beyond the normal size of the stomach and waist) with fecal impaction (a solid, immobile bulk of feces that can develop as a result of chronic constipation). The resident had vomiting (a forceful discharge of stomach contents) episodes with aspiration (substances entering into the lungs) and went into respiratory distress requiring an emergent intubation (insertion of a tube into the passageway leading to the lungs to maintain an open airway) and septic shock (a life-threatening medical condition that occurs in response to infection) with multi-organ failure (a process that causes irreversible organ dysfunction). Resident 1 expired two days after being transferred to the GACH. Findings: A review of Resident 1's admission orders [REDACTED]. A review of Resident 1's History and Physical (H/P) from facility 2, dated [DATE], indicated the resident had fecal stasis. A review of Resident 1's Admission Record (Face sheet) indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. The Admission Record did not indicate Resident 1 had fecal stasis. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care screening tool), dated [DATE], indicated Resident 1's cognition (ability think and reason) was intact and the resident required supervision with toilet use. The MDS indicated Resident 1 was continent (ability to control fecal elimination) of bowel. On [DATE] at 11:30 a.m., during an interview and concurrent record review, Registered Nurse 3 (RN 3) stated Resident 1's [DIAGNOSES REDACTED]. RN 3 stated Resident 1 did not have a gastrointestinal (a physician who specializes in the medical care of body organs related to digestion and elimination) consultation. RN 3 stated when a resident had a history of [REDACTED]. RN 3 stated Resident 1 should be assessed for abdominal tenderness, discomfort, pain and distention. RN 3 stated if the resident had a complaint and change of condition related to the BM and/or abdomen, the physician should have been notified. RN 3 stated Resident 1's weekly summaries, dated from [DATE] to [DATE], did not indicate any abdominal and bowel sound assessment. RN 3 stated if a resident had fecal impaction then there was a risk for the resident to have vomiting and aspiration (substance that entered the lungs) with bowel rupture. According to the online article titled, Gastrointestinal Complications, dated [DATE], fecal impaction can be life-threatening. Impaction refers to the accumulation of dry, hardened feces in the rectum or colon. The patient with a fecal impaction may present with circulatory, cardiac, or respiratory symptoms rather than with gastrointestinal symptoms. According to the article, if the fecal impaction is not recognized, the signs and symptoms may progress and result in death. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH 26 A review of a Resident Transfer Record form indicated on [DATE], Resident 1 was transferred to the GACH for severe abdominal pain. The form was incomplete and did not indicate the date of Resident 1's last BM or the resident's skin and body assessment. A review of the GACH's Admission Record indicated Resident 1 was admitted to the hospital on [DATE] for [MEDICAL CONDITION]. The Emergency Department (ED) note, dated [DATE], and timed 11:20 p.m., indicated Resident 1 presented with complaints of abdominal pain for one month that worsened that day ([DATE]) with diffused (spread or scattered out) pain over the abdomen. The ED note indicated Resident 1 reported shortness of breath earlier that day with nausea and vomiting. The ED note indicated Resident 1 had not been seen by a physician for the pain nor did the resident have any medication for pain. The ED note indicated Resident 1 had significant abdominal distention with generalized tenderness and guarding (tensing of the abdominal wall muscles to guard abdomen from the pain of pressure upon them). According to the ED note, Resident 1 did not have bowel sounds (gurgling or rumbling sounds from the abdomen to indicate that the bowels are moving contents of the stomach and intestines downward) and the resident stated he had not had a bowel movement (pass feces out of the body) in a week. The ED note, dated [DATE], and timed at 2 a.m., indicated Resident 1 had a computed tomography ((CT), special x-ray tests that produce images of the body) scan of the abdomen and pelvis (a large bony structure at the base of the spine). The CT results indicated Resident 1 had significant retained feces with significant dilation (becoming wide or larger) of the [MEDICATION NAME] colon (the middle part of the large intestine passing across the abdomen from right to left below the stomach) and pneumotosis (gas cysts within the bowel wall) in the [MEDICAL CONDITION] (a tube that connects the throat with the stomach), gastric (stomach), and [DIAGNOSES REDACTED] (first part of the small intestine) wall as well as in the hepatic portal venous system (the system of veins that returns blood from the digestive tract to the liver). A review of the GACH's Code Blue (an emergency situation in which an individual was in cardiopulmonary arrest (heart and lungs stop functioning), requiring a team of healthcare providers to begin immediate resuscitative (to revive from apparent death or unconsciousness) efforts) note, dated [DATE] and timed at 7:25 p.m., indicated during hospitalization Resident 1 was vomiting and aspirated the emesis (vomit contents) and went into [MEDICAL CONDITION] that required emergent intubation. According to the Code Blue note, Resident 1 went into shock (a life-threatening medical condition that occurs in response to infection) with multi-organ failure and the resident required four vasopressors (medications used to treat severely low blood pressure in critically ill individuals). The note indicated Resident 1 went into asystole (a heart rhythm in which there is no electrical activity (the most serious form of [MEDICAL CONDITION])) and expired. A review of the facility's policy and procedure titled, Care Planning - Interdisciplinary Team ((IDT), a group of health care professionals from diverse fields who work together toward a common goal of the resident), revised (MONTH) 2008, indicated the facility's IDT was responsible for the development of an individualized comprehensive care plan for each resident within seven days of completion of the resident assessment (MDS).

Based on interview and record review, the facility failed to follow its policy and supervise the toilet use and monitor the quality of bowel movement (stool), conduct a thorough abdominal (the part of the body containing organs for digestion and elimination) assessment, and initiate a care plan for fecal (relating to feces, stool) stasis (delayed fecal emptying in chronic constipated individuals that can cause bowel obstruction) for one of three sampled residents (Resident 1) who had a history of [REDACTED]. This deficient practice resulted in the Resident 1 being transferred to a general acute care hospital (GACH) for severe abdominal pain and distention (substances accumulated in the abdomen causing its outward expansion beyond the normal size of the stomach and waist) with fecal impaction (a solid, immobile bulk of feces that can develop as a result of chronic constipation). The resident had vomiting (a forceful discharge of stomach contents) episodes with aspiration (substances entering into the lungs) and went into respiratory distress requiring an emergent intubation (insertion of a tube into the passageway leading to the lungs to maintain an open airway) and septic shock (a life-threatening medical condition that occurs in response to infection) with multi-organ failure (a process that causes irreversible organ dysfunction). After two days in the GACH, Resident 1 expired. Findings: A review of Resident 1's admission orders [REDACTED]. A review of Resident 1's History and Physical (H/P) from SNF 1, dated [DATE], indicated the resident had fecal stasis. A review of Resident 1's Admission Record (Face sheet) indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. The Admission Record did not indicate Resident 1 had fecal stasis. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care screening tool), dated [DATE], indicated Resident 1's cognition (ability think and reason) was intact and the resident required supervision with toilet use. The MDS indicated Resident 1 was continent (ability to control fecal elimination) of bowel. The MDS indicated Resident 1 required supervision when getting around in the facility and the resident used a wheelchair. A review of Resident 1's Weekly Nurse Summary, dated [DATE], [DATE], [DATE], [DATE], and [DATE] did not indicate an abdomen assessment that included an assessment for bowel sounds. According to the Weekly Summary, dated [DATE], [DATE], and [DATE], and [DATE], Resident 1 was independent with toileting. A review of the Certified Nurse Assistant Notes, form under the section for bowel: bedpan (a receptacle used for the toileting of a bedridden individual/bathroom privileges/commode (an adaptive bathroom equipment for toileting); continent (ability to control elimination)/ incontinent (no control over elimination); incontinent/ continent record number of times; and consistency of stool (hard, normal, diarrhea) was incomplete. There was no documentation of Resident 1's size of bowel movement ((BM), stool) and/or the type of assistance for bowel elimination. A review of Resident 1's Nurse Assistant Notes, for the months of (MONTH) and (MONTH) (YEAR), indicated the resident had bathroom privileges. The notes indicated there was no documentation of Resident 1's bowel movements, which included amounts and size, and the type of staff assistance provided. On [DATE] at 9 a.m., during an interview, Certified Nurse Assistant 1 (CNA 1) stated she usually took care of Resident 1. CNA 1 stated Resident 1 was continent and used the restroom without the staff's assistance. CNA 1 stated she had never seen the color and/or consistency of Resident 1's BM because the resident would independently use the toilet and flush the toilet afterwards. CNA 1 stated Resident 1 would inform the staff when he had a BM, but CNA 1 would not asked about the size of the BM, because the CNA documentation did not require that information. CNA 1 stated if a resident had changes with their BM, such as the presence of blood, odor, hard BM, diarrhea, and/or lack of BM for three days, then it should have been reported to the charge nurse. On [DATE] at 10:10 a.m., during an interview, CNA 2 stated she took care of Resident 1 and did not assist the resident with toilet use because the resident wanted privacy. CNA 2 stated when she took care of Resident 1 she would ask Resident 1 if he had a BM. CNA 2 stated if a resident had stomach pain, diarrhea, fever, vomiting, constipation, and/or no BM for one day then it should have been reported to the charge nurse. On [DATE] at 11:30 a.m., during an interview and concurrent record review, Registered Nurse 3 (RN 3) stated Resident 1's [DIAGNOSES REDACTED]. RN 3 stated Resident 1 did not have a gastrointestinal (a physician who specializes in the medical care of body organs related to digestion and elimination) consultation. RN 3 stated when a resident had a history of [REDACTED]. RN 3 stated Resident 1 should have been assessed for abdominal tenderness, discomfort, pain and distention. RN 3 stated if the resident had a complaint and change of condition related to the BM and/or abdomen, the physician should have been notified. RN 3 stated Resident 1's weekly summaries, dated from [DATE] to [DATE], did not indicate any abdominal and bowel sound assessment. RN 3 stated if a resident had fecal impaction then there was a risk for the resident to have vomiting and aspiration (substance that entered the lungs) with bowel rupture. On [DATE] at 3:25 p.m., during an interview and a concurrent record review, Licensed Vocational Nurse 1 (LVN 1) stated when assessing whether a resident had a BM, he would ask the resident or review the CNA notes. LVN 1 stated there were no nurse's notes for Resident 1 dated after [DATE]. LVN 1 stated the weekly summary was based on narrative nurse's notes and the weekly summary form did not indicate if an abdominal assessment was performed on Resident 1. LVN 1 stated there was no additional assessment done when Resident 1 had complaints of severe abdominal pain on [DATE]. A review of a Resident Transfer Record form indicated on [DATE], Resident 1 was transferred to the GACH for severe abdominal pain. The form was incomplete and did not indicate the date of Resident 1's last BM or the resident's skin and body assessment. A review of the GACH's Admission Record indicated Resident 1 was admitted to the hospital on [DATE] for [MEDICAL CONDITION]. The Emergency Department (ED) note, dated [DATE], and timed 11:20 p.m., indicated Resident 1 presented with complaints of abdominal pain for one month that worsened that day ([DATE]) with diffused (spread or scattered out) pain over the abdomen. The ED note indicated Resident 1 reported shortness of breath earlier that day with nausea and vomiting. The ED note indicated Resident 1 had not been seen by a physician in the facility for the pain nor did the resident have any medication for pain. The ED note indicated Resident 1 had significant abdominal distention with generalized tenderness and guarding (tensing of the abdominal wall muscles to guard abdomen from the pain of pressure upon them). According to the ED note, Resident 1 did not have bowel sounds (gurgling or rumbling sounds from the abdomen to indicate that the bowels are moving contents of the stomach and intestines downward) and the resident stated he had not had a bowel movement (pass feces out of the body) in a week. The ED note, dated [DATE], and timed at 2 a.m., indicated Resident 1 had a computed tomography ((CT), special x-ray tests that produce images of the body) scan of the abdomen and pelvis (a large bony structure at the base of the spine). The CT results indicated Resident 1 had significant retained feces with significant dilation (becoming wide or larger) of the [MEDICATION NAME] colon (the middle part of the large intestine passing across the abdomen from right to left below the stomach) and pneumotosis (gas cysts within the bowel wall) in the [MEDICAL CONDITION] (a tube that connects the throat with the stomach), gastric (stomach), and [DIAGNOSES REDACTED] (first part of the small intestine) wall as well as in the hepatic portal venous system (the system of veins that returns blood from the digestive tract to the liver). A review of the GACH's Code Blue (an emergency situation in which an individual was in cardiopulmonary arrest (heart and lungs stop functioning), requiring a team of healthcare providers to begin immediate resuscitative (to revive from apparent death or unconsciousness) efforts) note, dated [DATE] and timed at 7:25 p.m., indicated during hospitalization Resident 1 was vomiting and aspirated the emesis (vomit contents) and went into [MEDICAL CONDITION] that required emergent intubation. According to the Code Blue note, Resident 1 went into shock (a life-threatening medical condition that occurs in response to infection) with multi-organ failure and the resident required four vasopressors (medications used to treat severely low blood pressure in critically ill individuals). The note indicated Resident 1 went into asystole (a heart rhythm in which there is no electrical activity (the most serious form of [MEDICAL CONDITION])) and expired. A review of the facility's undated policy and procedure titled, Resident Examination and Assessment, indicated the facility was responsible for examining and assessing the resident for any abnormalities in health status, which provided a basis for the care plan. The policy indicated the facility was responsible for gastrointestinal assessment that included: abdominal distention and hardness; rebound or guarding; bowel sounds in all four quadrants for hypoactive (reduction in the regularity of sounds), normal, or hyperactive (increase in the regularity of sounds); stool consistency; diarrhea or constipation; hemorrhoids; and fecal impaction. The policy indicated the facility was responsible for notifying the physician of any abnormalities such as distended, hard abdomen or absence of bowel sounds and/or worsening pain. A review of the facility's policy and procedure titled, Care Planning - Interdisciplinary Team ((IDT), a group of health care professionals from diverse fields who work together toward a common goal of the resident), revised (MONTH) 2008, indicated the facility's IDT was responsible for the development of an individualized comprehensive care plan for each resident within seven days of completion of the resident assessment (MDS). A review of the facility's CNA job description, revised [DATE], indicated the purpose of the CNA position was to provide direct care to residents and report resident needs and concerns to a licensed nurse. The job description indicated the CNA was responsible for assuring residents were given adequate assistance with personal and oral hygiene needs.

Based on interview and record review, the facility failed to follow its policy and the Interdisciplinary Team ((IDT), a group of health care professionals from diverse fields who work together toward a common goal for the resident) recommendations to offer dietary substitute snacks and fluids for five months and the physician's orders [REDACTED]. Resident 3 was refusing meals that resulted in weight loss and the staff failed to offer substitutes and/or other dietary supplements. This deficient practice resulted in Resident 3 losing 17.4 pounds (lbs.) in five months (9/2/17 to 2/2018) and had the potential for continued weight loss, related to weight loss and low protein levels. Findings: A review of Resident 3's Admission Record (Face Sheet) indicated the resident was admitted to the facility on [DATE]. Resident 3's [DIAGNOSES REDACTED]. A review of Resident 3's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 12/15/17, indicated the resident was severely impaired in cognitive (ability to reason and think) skills for daily decision making. The MDS indicated Resident 3 required total assistance by staff for eating. A review of Resident 3's physician's orders [REDACTED]. A review of Resident 3's physician's monthly order summary report, dated 10/26/17, indicated the following orders: 1. 8/13/17, puree diet, no added sugar diet. 2. 9/16/16, one serving of PAB (prunes, applesauce, bran) in the morning with breakfast. 3. 9/16/16, four ounces (oz.) honey thick prune juice. 4. 9/16/16, four oz. yogurt at bedtime. A review of Resident 3's physician's orders [REDACTED]. A review of a physician's orders [REDACTED]. honey-thick prune juice in the morning with breakfast, and 4 oz. yogurt at bedtime. A review of a physician's orders [REDACTED]. A review of Resident 3's (YEAR) Weights and Vital Signs Sheet, dated (YEAR), indicated the resident weighed the following: on 9/2/17, 138.4 lb.; 10/4/17, 134.4 lb.; 11/4/17, 132.2 lb.; 12/4/17, 126 lb.; 12/13/17, 128.8 lb.; and 12/20/17, 128 lb. A review of Resident 3's Monthly Weight Record, indicated the resident weighed 121.2 lbs. in (MONTH) (YEAR) and 121 lbs. in (MONTH) (YEAR). A review of Resident 3's Certified Nursing Assistant (CNA) ADL (activities of daily living) Tracking form, for the month of 9/2017 on the 3 p.m. to 11 p.m. shift, indicated Resident 3 had 11 occasions of refusing meals, three occasions of meal intake of 20%, one occasion of meal intake of 30%, two occasions of meal intake of 40%, one occasion of meal intake of 50%, and three occasions of meal intake of 60% . A review of Resident 3's CNA ADL Tracking form, for the month of 10/2017 on the 3 p.m. to 11 p.m. shift, indicated the resident had eight occasions of refusing meals, five occasions of meal intake of 20%, three occasions of meal intake of 30%, one occasion of meal intake of 40%, and three occasions of meal intake of 60% . A review of Resident 3's CNA ADL Tracking form, for the month of 11/2017 on the 7 a.m. to 3 p.m. shift, indicated the resident had six occasions of refusing meals, three occasions of meal intake of 20%, one occasion of meal intake of 30%, three occasions of meal intake of 40%, seven occasions of meal intake of 50%, and one occasion of meal intake of 60% . A review of Resident 3's CNA ADL Tracking form, for the month of 11/2017 on the 3 p.m. to 11 p.m. shift, indicated the resident had thirteen occasions of refusing meals, four occasions of meal intake of 20%, six occasions of meal intake of 30%, and two occasions of 50% . A review of Resident 3's CNA ADL Tracking form, for the month of 12/2017 on the 7 a.m. to 3 p.m. shift, indicated fourteen occasions of refusing meals, four occasions of meal intake of 20%, four occasions of meal intake of 30%, two occasions of 40%, two occasions of 50%, and one occasion of 60% . A review of Resident 3's CNA ADL Tracking form, for the month of 12/2017 on the 3 p.m. to 11 p.m. shift, indicated fourteen occasions of refusing meals, one occasion of meal intake of 20%, 25%, 40%, and 45%. The form indicated Resident 3 had four occasions of meal intake of 50% . A review of Resident 3's CNA ADL Tracking form, for the months of 9/2017 to 12/2017, indicated handwritten documentation of 0 for snack not offered on 9/2017 at 7 a.m. to 3 p.m. shift and 11 p.m. to 7 a.m. shift, 10/2017 at 7 a.m. to 3 p.m. shift and 11 p.m. to 7 a.m. shift, 11/2017 at 7 a.m. to 3 p.m. shift and 11 p.m. to 7 a.m. shift, and 12/2017 at 7 a.m. to 3 p.m. shift and 11 p.m. to 7 a.m. shift. A review of Resident 3's CNA ADL Tracking form did not indicate that snacks, dietary substitute and/or fluids were offered to the resident from 9/2017 to 12/2017. A review of Resident 3's clinical record indicated there was no CNA ADL Tracking form for the month of (MONTH) (YEAR). A review of Resident 3's Nurse Assistant Notes, dated (MONTH) (YEAR) for A.M. shift (7 a.m. to 3 p.m.), indicated for breakfast there were seven occasions of Resident 3 refusing meals, two occasions of meal intake of 20%, seven occasions of meal intake of 30%, and one occasion of meal intake of 40% and 55% Resident 3's notes indicated, for lunch, the resident had nine occasions of refusing meals, two occasions of meal intake of 20%, three occasions of meal intake of 30%, and one occasion of meal intake of 40% Resident 3's notes indicated handwritten documentation of N/A for breakfast and lunch substitutes and nourishments at 10 a.m. and 2 p.m. A review of Resident 3's Nurse Assistant Notes, dated for the month of (MONTH) (YEAR) P.M. shift (3 p.m. to 11 p.m.), indicated for dinner there were fifteen occasions of Resident 3 refusing meals and one occasion of meal intake of 10%. The notes indicated Resident 3 refused dinner substitutes, nourishments, and bedtime snacks. A review of Resident 3's care plan titled, Nutritional Deficits, initiated on 11/28/14 and revised on 9/6/17, did not indicate revisions for interventions to address the resident's weight loss, refused meals, and meal intake of less than 75%. A review of the Interdisciplinary Team Conference Record form, dated 9/27/17, indicated the resident was on a puree, no added sugar diet, one serving of PAB, 4 ounces (oz.) of honey thick prune juice, and 4 oz. yogurt at bedtime. The IDT note indicated Resident 3's weight was 138.4 lb. on 9/2/17. The IDT note did not indicate additional interventions for weight loss. A review of the Weight Variance Program form, dated 10/4/17, indicated Resident 3's present weight was 134.4 lb. and the resident had weight loss of 4.4 lb. in one month, 12.8 lb. in three months, and 18.6 lb. in six months. The form indicated to continue to monitor Resident 3 monthly. The form did not indicate additional recommendations for weight loss. A review of the IDT Resident Weight Variance Assessment form, dated 11/9/17, indicated Resident 3's current weight was 132.2 lb. and the resident had a weight loss of 19.4 lbs. (12.7 %) in six months. The form indicated to discontinue Resident 3's no added sugar diet and to review in one month. The form did not indicate additional proposed interventions for the resident's weight loss. A review of the IDT Weight Management Care Plan, dated 11/24/17, indicated the IDT recommendations for weight maintenance and to discontinue weight variance at this time. The care plan did not indicate further additional recommendations. A review of the IDT Weight Management Care Plan, dated 12/13/17, indicated the IDT recommendations were for weekly weights and to discontinue weight variance, as Resident 3 was in ideal body weight range (IBWR). The care plan did not indicate additional recommendations. A review of Resident 3's IDT Conference Record, dated 12/20/17, indicated nourishment would be given to Resident 3 at 2:30 p.m. The IDT note did not indicate additional recommendations. A review of Resident 3's laboratory results, dated 11/28/17, indicated an [MEDICATION NAME] level of 3.4 g/dl. A review of Resident 3's laboratory results, dated 1/24/18, indicated an [MEDICATION NAME] level of 3.1 g/dl. On 4/17/18 at 2 p.m., during an interview and concurrent review of Resident 3's care plan for nutritional deficits, revised on 9/6/17, Registered Nurse 2 (RN 2) stated the care plan did not indicate further revisions or interventions to address Resident 3's weight loss. On 4/19/18 at 9:05 a.m., during an interview and concurrent review of Resident 3's CNA ADL Tracking form, for the months of 9/2017 to 12/2017, the form did not indicate that snacks, dietary substitutes, and fluids were offered for the resident from 9/2017 to 12/2017. RN 2 stated there were handwritten documentation of 0 for snacks not offered on 9/2017 at 7 a.m. to 3 p.m. shift and 11 p.m. to 7 a.m. shift, 10/2017 at 7 a.m. to 3 p.m. shift and 11 p.m. to 7 a.m. shift, 11/2017 at 7 a.m. to 3 p.m. shift and 11 p.m. to 7 a.m. shift, and 12/2017 at 7 a.m. to 3 p.m. shift and 11 p.m. to 7 a.m. shift. On 4/19/18 at 10:30 a.m., during an interview and concurrent record review, RN 2 stated and verified Resident 3 did not have Nurse Assistant Notes for the month of (MONTH) (YEAR). On 4/19/18 at 10:30 a.m., during an interview and concurrent record review of Resident 3's Nurse Assistant Notes for the month of (MONTH) (YEAR), RN 2 stated the resident refused meals and it was documented as not applicable (NA) for dietary substitutes and nourishments offered. RN 2 stated if a resident refused meals for three consecutive days, then the physician should have been notified and consulted interventions such as a transfer to the general acute care hospital (GACH) for evaluation. RN 2 stated when a resident had variable meal intake and consistent meal intake of less than 75%, then the physician should have been notified. RN 2 stated if a resident refused one meal or had a meal intake of less than 75% then a dietary substitute should have been offered. RN 2 stated snacks should have been offered between meals and at bedtime for all residents. On 4/19/18 at 10:30 a.m., a review of Resident 3's IDT and Weight Variance notes, dated from 9/27/17 to 12/20/17, indicated there were no recommendations to address the resident's weight loss. On 4/19/18 at 10:30 a.m., during an interview and review of Resident 3's physician's orders [REDACTED]. A review of Resident 3's Nurses Notes, dated from 9/2017 to 1/2018, did not indicate the resident's physician was informed of the resident's meal refusal and meal intake of less than 75%. A review of the facility's undated policy and procedure titled, Acute Condition Changes, indicated the staff would monitor and document the resident's progress and responses to treatment, and the Physician would adjust treatment accordingly, and the Physician would help the staff monitor a resident with a recent acute change of condition until the problem or condition had resolved or stabilized. A review of the facility's policy and procedure titled, Care Planning- Interdisciplinary Team, revised (MONTH) 2008, indicated the facility's care planning/ Interdisciplinary Team was responsible for the development of an individualized comprehensive care plan for each resident. A review of the facility's undated policy and procedure titled, Care Plans- Comprehensive, indicated an individualized comprehensive care plan must meet the resident's medical, nursing, mental and psychological needs. The policy indicated the facility was responsible for developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex clinical decision making, and the resident's physician was integral to this process. A review of the facility's policy and procedure titled, Weight Change Protocol, revised 11/2014, indicated the care plan must be revised as the goals and interventions change, the care plan should match the latest assessment. The policy indicated the evaluation process was done again if there was another significant weight change and interventions are changed if not effective. A review of the facility's policy and procedure titled, Weight Assessment and Intervention, revised (MONTH) 2012, indicated the multidisciplinary team would strive to prevent, monitor, and intervene for undesirable weight loss for our residents. The policy indicated interventions for undesirable weight loss shall be based on careful consideration.

Based on interview and record review, the facility failed to follow its policy titled, Change of Condition (C[NAME]), and a resident's plan of care for one of three sampled residents (Resident 1). Resident 1's attending physician was not notified of a change in condition of vomiting episodes until the resident became unresponsive and pulseless (Crossed referenced to F309). This deficient practice resulted in a delay of provision of care and a decline of Resident 1's health. Resident 1 expired at the facility on [DATE] at 9:11 p.m. Findings: A review of Resident 1's Face sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE]. The Admission Record indicated Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated [DATE], indicated a brief interview for mental status (BIMS) score of 6 (,[DATE] severe impairment in cognitive skills) and memory problems. The MDS indicated Resident 1 was total dependent of one staff for bed mobility, eating and personal hygiene. A review of Certified Nurse Assistant 1 (CNA 1) signed Declaration, dated [DATE], and timed at 5:16 p.m., indicated that on [DATE], Resident 1 vomited (eject matter from the stomach through the mouth) once before 7 p.m., and a second time approximately at 8:30 p.m., the vomitus content was white in color with bread pieces. A review of two Resident 1's care plans titled, [MEDICAL CONDITION] (GERD (digestive disease in which stomach acid or bile irritates the food pipe lining)) and Hepatic (liver) failure, both revised on [DATE], indicated that the facility staff would observe Resident 1 for changes in abdominal girth (measurement around the stomach); monitor for signs of coughing, choking when lying down, nausea and vomiting; encourage resident to avoid lying down in bed immediately after meals to avoid reflux; and to notify physician as needed. A review of Resident 1's Speech Therapy (ST) evaluation for dysphagia (difficulty swallowing) dated [DATE], indicated under assessment summary that Resident 1 was at risk for aspiration (condition in which food, liquids, saliva, or vomit is breathed into the airways) due to his physical impairments (bilateral facial impairment, and saliva management impaired). On [DATE] at 9:55 a.m., during a concurrent interview and record review, the Director of Nursing (DON) stated that vomiting was considered a change in condition (C[NAME]) and the Licensed Vocational Nurse should have notified the resident's primary physician. A review of Resident 1's record titled, Nurses Notes, dated [DATE] and timed at 5:40 p.m., indicated on [DATE], at 8:50 a.m., Resident 1 vomit his dinner, medium amount orange in color with chunks noted. On [DATE] at 4:17 p.m., during a telephone interview, Resident 1's primary physician (Physician 1) stated that she would had ordered a transfer of Resident 1 to the general acute care hospital (GACH) for evaluation. Physician 1 stated she should have been notified by the facility's staff that Resident 1 was having vomiting episodes. Physician 1 stated she was not expecting Resident 1 to die soon, especially the way he did and stated, The staff was aware that they should have notified me of any changes of condition that the resident was experiencing. On [DATE] at 4:31 p.m., during a telephone interview, LVN 1 stated that on [DATE] she was in charge of Resident 1's care. LVN 1 stated Resident 1 had a vomiting episode at 5:45 p.m. on [DATE], but she did not notify Physician 1 and/or RNs 1 and 2 during the first episode of vomiting at 5:45 p.m., regarding the resident's C[NAME], but just gave water to Resident 1. LVN 1 stated that approximately 8:45 p.m., on [DATE], the MS called her into Resident 1's room, and upon entering the resident's room she found the resident with a large amount of vomitus, orange in color, with big chunks of food coming from the resident's mouth, down his arm and onto the floor. LVN 1 stated, When I touched the resident, he had no pulse and his skin was a little cold, like if he had been expired for hours. LVN 1 stated she did not perform CPR on Resident 1, but left the room to call LVN 2 to confirm if Resident 1 had no pulse. LVN 1 stated that LVN 2 initiated CPR after ,[DATE] minutes of been called into room to confirm no pulse on Resident 1. On [DATE] at 4:58 p.m., during an interview, CNA 1 stated that on [DATE], Resident 1 vomited two times. CNA 1 stated that at 8:45 p.m., the maintenance supervisor (MS) came out of the Resident 1's room asking for the resident to be changed because he had vomited. CNA1 stated upon entering Resident 1's room, she observed a large amount of white/orange color vomit with chunks of bread coming from Resident 1's mouth onto the floor. On [DATE] at 12:05 p.m., during an interview, RN 1 stated LVNs 1 and 2 should have reported to the physician of Resident 1's C[NAME] immediately due to the residents' medical illness. RN 1 stated that she was not aware why LVNs 1 and 2 were left in the facility without a licensed supervisor. A review of the facility's policy and procedures titled, Change of Condition Notification, created on [DATE], indicated that the licensed nurse in charge of the resident's care should be responsible for immediate notification of the resident's change in condition such as significant change in residents' physical, mental or emotional status in either life-threatening conditions or clinical complications.

Based on interview and record review, the facility failed to follow its policy titled, Incident Management, and a resident's plan of care for one of three sampled residents (Resident 1); which included an accurate assessment to identify an emergency situation and reporting to the physician Resident 1's change of condition (C[NAME]), and providing cardiopulmonary resuscitation timely and accurately ((CPR) C=cardio (heart) P=pulmonary (lung) R=resuscitation (chest compression and artificial breathing are used to maintain blood circulation to the brain)). Resident 1 was found vomiting and became unresponsive and the facility had licensed registry nurses on duty, who were not knowledgeable in CPR and did not have access to emergency supplies such as oxygen mask, Ambu bag (manual resuscitator to provide positive pressure ventilation to patients who are not breathing or not breathing adequately), and a back board (used for CPR to provide a firm surface) Crossed Referenced to F353 and F157. These deficient practices resulted in Resident 1 not being properly diagnosed and receiving appropriate medical interventions when there was a C[NAME], which resulted in Resident 1's death. Resident 1 was pronounced deceased by the paramedics in the facility on [DATE], at 9:11 p.m. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated [DATE], indicated a brief interview for mental status (BIMS) score of 6 (,[DATE]= severe impairment in cognitive (thought process) skills) and memory problems. The MDS indicated Resident 1 was totally dependent in care of a one-person physical assist for bed mobility, eating, and personal hygiene. A review of Certified Nurse Assistant 1 (CNA 1) signed Declaration, dated [DATE], and timed at 5:16 p.m., indicated that on [DATE], Resident 1 vomited (eject matter from the stomach through the mouth) once before 7 p.m., and a second time approximately at 8:30 p.m., the vomitus content was white in color with bread pieces. A review of two of Resident 1's care plans titled, [MEDICAL CONDITION] (GERD (digestive disease in which stomach acid or bile irritates the food pipe lining)) and Hepatic (liver) failure, both revised on [DATE], indicated that the facility staff would observe Resident 1 for changes in abdominal girth (measurement around the stomach); monitor for signs of coughing, choking when lying down, nausea and vomiting; encourage resident to avoid lying down in bed immediately after meals to avoid reflux; and to notify the physician as needed. A review of Resident 1's Speech Therapy (ST) evaluation for dysphagia (difficulty in swallowing), dated [DATE], indicated under assessment summary that Resident 1 was at risk for aspiration (condition in which food, liquids, saliva, or vomit is breathed into the airways) due to his physical impairments (bilateral facial and saliva management impairment). A review of Resident 1's care plan titled, Nutritional Deficit, revised on [DATE], indicated that the resident would be free of aspiration through the review date of [DATE]. The facility's staff intervention included to instruct the resident to eat in an upright position, eat slowly, and chew each bite thoroughly. A review of Resident 1's Order Summary Report, indicated a physician's orders [REDACTED]. A review of Resident 1's Nurses Note, dated [DATE], and timed at 5:40 p.m., indicated the resident had vomited his dinner of a medium amount of orange in color vomitus with chunks. On [DATE] at 9:55 a.m., during a concurrent interview and record review, the Director of Nursing (DON) stated that vomiting was considered a change in condition (C[NAME]) and the Licensed Vocational Nurse should have notified the resident's primary physician. The DON stated that according to the staff interviews, the MS initiated CPR on Resident 1 and not the licensed nurses that were called into the room to assess the resident. On [DATE] at 10:40 a.m., during an interview, the MS stated that on [DATE] during the evening shift (3 p.m.-11 p.m.), he was assigned to one-to-one supervision of Resident 1's roommate (Resident 2). The MS stated that approximately ,[DATE]:30 p.m., on [DATE], he walked into the residents' (Resident 1 and 2) room and observed Resident 1 with a large amount of orange color, thick in consistency vomitus. The MS stated that he called LVN 1 to check Resident 1 and she stated the resident had no pulse (a rhythmical throbbing of the arteries as blood is propelled through them, typically as felt in the wrists or neck (heart beat)). The MS stated that while in the room, LVN 1 verbalized to LVN 2 of not knowing how to perform CPR. The MS stated while crying, that he initiated CPR on Resident 1, as he was certified to perform CPR. The MS stated he did chest compression on Resident 1 while the resident was lying on the bed and not on a firm surface, but he was aware that was incorrect. The MS stated he had to stop CPR, because the crash cart was needed. The MS stated LVNs 1 and 2, who were registry nurses, did not know the location of the crash cart and did not have keys to retrieve it from the treatment room, since he was the only one with keys on that night. The MS stated that if he had been with Resident 2 at the time Resident 1 was calling for help, perhaps they could have helped him sooner. On [DATE] at 11:54 a.m., during an interview, Registered Nurse 2 (RN 2) stated that on [DATE], on the evening shift, there was not a CNA assigned to care for Resident 1. RN 2 stated that everyone was aware that whomever was assigned to care for Resident 2 (Bed A) and also watches over the residents in Bed B (Resident 1) and Bed C. During a concurrent record review, RN 2 stated that she was not able to locate Resident 1's Physician order [REDACTED]. On [DATE] at 2:40 p.m., during an interview, the Administrator (ADM) stated that no investigation was conducted regarding Resident 1 expiring, because the resident died of natural causes (not unexpected). The ADM stated that he was not aware if an investigation was needed if Resident 1 was found with large amount of vomitus next to him and knowing the resident was totally dependent on staff for all care. On [DATE] at 4:17 p.m., during a telephone interview, Resident 1's primary physician (Physician 1) stated that she would had ordered a transfer of Resident 1 to the general acute care hospital (GACH) for evaluation had she known. Physician 1 stated she should have been notified by the facility's staff that Resident 1 was having vomiting episodes. Physician 1 stated she was not expecting Resident 1 to die soon, especially the way he did and stated, The staff was aware that they should have notified me of any changes of condition that the resident was experiencing. At 4:31 p.m., on [DATE], during a telephone interview, LVN 1 stated that on [DATE] she was in charge of Resident 1's care. LVN 1 stated Resident 1 had a vomiting episode at 5:45 p.m. on [DATE], but she did not notify Physician 1 and RNs 1 and 2 during the first episode of the resident vomiting at 5:45 p.m., regarding the resident's C[NAME], but just gave water to Resident 1. LVN 1 stated that approximately 8:45 p.m., on [DATE], the MS called her into Resident 1's room, and upon entering the resident's room she found the resident with a large amount of vomitus, orange in color, with big chunks of food coming from the resident's mouth, down his arm and onto the floor. LVN 1 stated, When I touched the resident, he had no pulse and his skin was a little cold, like if he had been expired for hours. LVN 1 stated she did not perform CPR on Resident 1, but left the room to call LVN 2 to confirm if Resident 1 had no pulse. LVN 1 stated that LVN 2 initiated CPR after ,[DATE] minutes of being called into the room to confirm there was no pulse on Resident 1. LVN 1 stated that on [DATE] there was no in-house supervisor and neither she nor LVN 2 knew where to find the crash cart or had access to it to initiate CPR. During the concurrent interview, LVN 1 stated that she was not given an in-service on where to locate the emergency supplies. On [DATE] at 4:58 p.m., during an interview, CNA 1 stated that on [DATE], Resident 1 vomited two times. CNA 1 stated that at 8:45 p.m., the maintenance supervisor (MS) came out of the Resident 1's room asking for the resident to be changed because he had vomited. CNA1 stated upon entering Resident 1's room, she observed a large amount of white/orange color vomit with chunks of bread coming from Resident 1's mouth onto the floor. A review of Resident 1's record titled, Nurses' Notes, dated [DATE], and timed at 8:45 p.m., indicated LVN 1 was called to look at Resident 1 who had vomited. The note indicated LVN 1 found Resident 1 unresponsive, with no pulse and had abdominal distention (occurs when substances, such as air (gas) or fluid, accumulate in the abdomen causing its outward expansion beyond the normal girth of the stomach and waist). The note indicated the paramedics arrived at the facility at 8:54 p.m. A review of a Prehospital Care Report Summary, documented by the 911 paramedics emergency services, dated [DATE], indicated a call was received from the facility at 8:49 p.m., and the paramedics were on the scene at 8:54 p.m., with resident contact made at 8:56 a.m. The Report Summary indicated Resident 1 was pronounced deceased at 9:11 p.m. by the paramedics. A review of a Police Department report, dated [DATE], and timed at 2100 (9 p.m.) indicated they were dispatched to the facility regarding a death investigation. The report indicated the police was escorted to Resident 1's room and saw that he was deceased after being found by staff unconscious and non-responsive. The report indicated the paramedics pronounced the resident deceased . On [DATE] at 4:58 p.m., during an interview, CNA 1 stated that on [DATE], at 8:30 p.m., she was told by MS to assist in changing Resident 1's clothes. CNA 1 stated that Resident 1 was found facing the window on his left side with his arms hanging down the bed and his tongue was hanging out the mouth with a large amount of white/orange in color and chunks of food that looked like bread vomitus. CNA 1 stated she was there to assist LVNs 1 and 2 clean the resident. On [DATE] at 12:05 p.m., during an interview, RN 1 stated LVN 1 and 2 should had reported to the physician Resident 1's C[NAME] immediately due to the residents' medical illness. RN 1 stated that registry nurses' (LVNs 1 and 2) were not provided a key to the treatment room where the crash cart was located. RN 1 stated both she and RN 2 left the facility that day ([DATE]) at 6 p.m. RN 1 stated that they do not give keys to the licensed registry nurses since they are not providing wound treatments during the night shift. RN 1 stated that she was not aware why LVNs 1 and 2 were left in the facility without a facility supervisor. On [DATE] at 12:20 p.m., during a concurrent interview and record review, in the presence of RN 1, the Administrator (ADM) stated that he overlooked the registry's contract that indicated registry licensed nurses could not be in the facility unsupervised. The ADM stated that a key should had been provided to the registry nurses. RN 1 stated that on [DATE], she was responsible to give the key to LVN 1. RN 1 stated that it could have made a difference if LVN 1 had access to the crash cart for Resident 1. RN 1 stated Resident 1 was a Full Code (medical personnel are ethically and legally obliged to perform life-saving measures (CPR)), during a cardiac of [MEDICAL CONDITION] arrest. A review of the Registry/Facility contract titled, Staffing Agreement between Registry and Skill Nursing Facility (SNF), signed [DATE], indicated that the SNF will properly supervised Registry employees performing its work and be responsible for its business .or entrust them with an unattended premises, cash, checks, keys, credit cards, and merchandise. On [DATE] at 11:41 a.m., during a telephone interview, the DON stated it was her responsibility to in-service new staff regarding the location of the emergency supplies to ensure that the staff knew where locate during an emergency situation. A review of Resident 1's death certificate indicated the resident expired on [DATE], with the immediate cause of death listed as cardiorespiratory arrest (the heart and lungs suddenly stopped functioning). A review of the facility's policy and procedures titled, Incident Management, created on [DATE], indicated that it was the responsibility of the Skill Nursing Facility (SNF) to assess, treat, document and investigate incidents and accidents in a timely manner to protect the safety of our residents, visitors, volunteers, and employees and identify ways to prevent reoccurrences such as sentinel events (unexpected occurrence involving death or serious physical or physical or psychological injury). When a resident incident occurs, the employees making the discovery immediately administer appropriate emergency care and notify the licensed nurse or appropriate supervisor.

Based on interview and record review, the facility failed to provide sufficient nursing staff with appropriate competencies and skill sets to provide the necessary care and services for one of three sampled residents (Resident 1). Resident 1 had a change in condition that resulted in the resident becoming unresponsive and the facility failed to provide services within the professional standard of care (Crossed referenced to F309 and F157). This deficient practice resulted in Resident 1 not receiving an appropriate medical interventions which resulted in Resident 1's death. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated [DATE], indicated a brief interview for mental status (BIMS) score of 6 (,[DATE]= severe impairment in cognitive (thought process) skills) and memory problems. The MDS indicated Resident 1 was totally dependent in care of one-person physical assist for bed mobility, eating, and personal hygiene. On [DATE] at 9:55 a.m., during a concurrent interview and record review, the Director of Nursing (DON) stated that vomiting was considered a change in condition (C[NAME]) and the Licensed Vocational Nurses (1 and 2) should have notified the resident's primary physician. The DON stated that according to the staff interviews, the MS initiated cardiopulmonary resuscitation ((CPR) a procedure designed to restore normal breathing after a cardiac/respiratory arrest that included the clearance of air passages to the lungs, the mouth-to-mouth method of artificial respiration, and cardiac massage by the exertion of pressure on the chest) on Resident 1 and not the licensed nurses that were called into the room to assess the resident. On [DATE] at 10:40 a.m., during an interview, the maintenance supervisor (MS) stated that on [DATE] during the evening shift (3 p.m.-11 p.m.) at approximately ,[DATE]:30 p.m., he walked into the residents' (Residents 1 and 2) room and observed Resident 1 with a large amount of orange color, thick in consistency vomitus. The MS stated that he called LVN 1 to check Resident 1 and she stated the resident had no pulse (a rhythmical throbbing of the arteries as blood is propelled through them, typically as felt in the wrists or neck (heart beat)). The MS stated that while in the room, LVN 1 verbalized to LVN 2 of not knowing how to perform CPR. The MS stated while crying, that he initiated CPR on Resident 1, as he was certified to perform CPR. The MS stated he did chest compression on Resident 1 while the resident was lying in the bed and not on a firm surface, and stated he was aware that was incorrect. On [DATE] at 11:54 a.m., during an interview, Registered Nurse 2 (RN 2) stated that on [DATE], on the evening shift, there was not a CNA assigned to care for Resident 1. RN 2 stated that everyone was aware that whomever was assigned to care for Resident 2 (Bed A) and also watches over the residents in Bed B (Resident 1) and Bed C. On [DATE] at 4:31 p.m., during a telephone interview, LVN 1 stated that on [DATE] she was in charge of Resident 1's care. LVN 1 stated Resident 1 had a vomiting episode at 5:45 p.m. on [DATE], but she did not notify Physician 1 and/or RNs 1 and 2 during the first episode of the resident vomiting at 5:45 p.m., regarding the resident's C[NAME], but just gave water to Resident 1. LVN 1 stated that approximately 8:45 p.m., on [DATE], the MS called her into Resident 1's room, and upon entering the resident's room she found the resident with a large amount of vomitus, orange in color, with big chunks of food coming from the resident's mouth, down his arm and onto the floor. LVN 1 stated, When I touched the resident, he had no pulse and his skin was a little cold, like if he had been expired for hours. LVN 1 stated she did not perform CPR on Resident 1, but left the room to call LVN 2 to confirm if Resident 1 had no pulse. LVN 1 stated that LVN 2 initiated CPR after ,[DATE] minutes of been called into room to confirm Resident 1 had no pulse on Resident 1. LVN 1 stated that on [DATE] there was no in-house supervisor and neither she nor LVN 2 knew where to find the crash cart or had access to it to initiate CPR. During the concurrent interview, LVN 1 stated that she was not given an in-service on where to locate the emergency supplies. On [DATE] at 12:05 p.m., during an interview, RN 1 stated LVNs 1 and 2 should had reported to the physician Resident 1's C[NAME] immediately due to the residents' medical illness. RN 1 stated that registry nurses' (LVNs 1 and 2) were not provided a key to the treatment room where the crash cart was located. RN 1 stated both she and RN 2 left the facility that day ([DATE]) at 6 p.m. RN 1 stated that they do not give keys to the licensed registry nurses since they are not providing wound treatments during the night shift. RN 1 stated that she was not aware why LVNs 1 and 2 were left in the facility unsupervised. On [DATE] at 12:20 p.m., during a concurrent interview and record review, in the presence of RN 1, the Administrator (ADM) stated that he overlooked the registry's contract that indicated registry licensed nurses could not be in the facility unsupervised. The ADM stated that a key should had been provided to the registry nurses. RN 1 stated that on [DATE], she was responsible to give the key to LVN 1. RN 1 stated that it could have made a difference if LVN 1 had access to the crash cart for Resident 1. RN 1 stated Resident 1 was a Full Code (medical personnel are ethically and legally obliged to perform life-saving measures (CPR)). On [DATE] at 11:41 a.m., during a telephone interview, the DON stated it was her responsibility to in-service new staff regarding the location of the emergency supplies to ensure that the staff knew where to locate them during an emergency situation. A review of the Registry/Facility contract titled, Staffing Agreement between Registry and Skill Nursing Facility (SNF), signed [DATE], indicated that the SNF will be properly supervised Registry employees performing its work and be responsible for its business .or entrust them with an unattended premises, cash, checks, keys, credit cards, and merchandise. On [DATE] at 9:55 a.m., during a concurrent interview and record review, the Director of Nursing (DON) stated that vomiting was considered a change in condition (C[NAME]) and the Licensed Vocational Nurses (1 and 2) should have notified the resident's primary physician. The DON stated that according to the staff interviews, the MS initiated cardiopulmonary resuscitation ((CPR) a procedure designed to restore normal breathing after a cardiac/respiratory arrest that included the clearance of air passages to the lungs, the mouth-to-mouth method of artificial respiration, and cardiac massage by the exertion of pressure on the chest) on Resident 1 and not the licensed nurses that were called into the room to assess the resident. On [DATE] at 10:40 a.m., during an interview, the MS stated that on [DATE] during the evening shift (3 p.m.-11 p.m.) that approximately ,[DATE]:30 p.m., on [DATE], he walked into the residents' (Residents 1 and 2) room and observed Resident 1 with a large amount of orange color, thick in consistency vomitus. The MS stated that he called LVN 1 to check Resident 1 and she stated the resident had no pulse (a rhythmical throbbing of the arteries as blood is propelled through them, typically as felt in the wrists or neck (heart beat)). The MS stated that while in the room, LVN 1 verbalized to LVN 2 of not knowing how to perform CPR. The MS stated while crying, that he initiated CPR on Resident 1, as he was certified to perform CPR. The MS stated he did chest compression on Resident 1 while the resident was lying in the bed and not on a firm surface, and stated he was aware that was incorrect.

Based on observation, interview, and record review, the facility failed to ensure residents were free from verbal and physical abuse and follow its policy and the resident's plan of care to protect five of six sampled residents (Residents 1, 2, 3, 4, and 5) from Resident 7's abuse. 1. - Resident 1 was hit on the left arm and felt unsafe around Resident 7. 2. - Resident 2 was hit on the back of his neck by Resident 7. 3. - Resident 3 was punched in her mouth and verbally abuse by Resident 7. 4. - Resident 4 was verbally attacked by Resident 7. 5. - Resident 5 was verbally attacked by Resident 7. These deficient practices resulted in Residents 1, 2, 3, 4, and 5 being physically and/or verbally abused expressing mental anguish and fear of Resident 7, which had the potential to affect other residents, who resided in the facility and witnessed the abusive behavior. On 8/16/17 at 6:01 p.m., an Immediate Jeopardy ((IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was declared under F223 for abuse. The facility's administrator was notified of the immediacy and seriousness of the residents' health and safety being threatened. The facility submitted a Plan of Action (POA) for the correction of the IJ which included: 1. Resident 7 would be placed on 1:1 supervision until the facility ensured the other residents were safe or Resident 7 was moved to another facility to meet his needs. 2. The staff would ensure that Resident 7 and Resident 1 would not eat in the same dining room. 3. The social service designee will continue to follow-up with Resident 7's behavior. 4. The Director of Nurses or designee will update Resident 7's care plans based on the incidents/behaviors. On 8/18/17 at 2:35 p.m., the administrator was notified that the IJ was removed, after the team verified that the POA was followed and implemented. Findings: On 8/16/17 at 7 a.m., an unannounced visit was conducted to the facility to investigate an entity reported incident (ERI) of a resident's (Resident 1) allegation of being abused by another resident (Resident 7). A review of the Admission Record (Face Sheet) indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 7's [DIAGNOSES REDACTED]. A review of Resident 7's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 7/27/17, indicated Resident 7 was moderately impaired for daily decision- making and had no behaviors. The MDS indicated Resident 7 used a walker and wheelchair for ambulation and locomotion and had no impairments of the bilateral (both) upper and lower extremities. A review of Resident 7's care plan, dated 6/17/17 and titled, Long Term Care Plan-Mood, indicated the goal was for the resident to not harm others. The staff's interventions included to provide 1:1 observation. During an observation on 8/16/17 at 7:17 a.m., Resident 7 was observed unsupervised with five (5)other residents, including Resident 2, watching television in the dining room. During an interview on 8/16/17 at 7:30 a.m., Resident 2 stated that Resident 7 hit him on the back of his head with a close fist, but was unable to provide the exact date and stated he did not report it. Resident 2 stated he felt unsafe, due to his fear of Resident 7 hitting him again. A review of Resident 2's Admission Record (Face Sheet) indicated the resident was initially admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's MDS, dated [DATE], indicated Resident 2's cognition (thought process) and memory was intact for daily decision-making. The MDS indicated Resident 2 used a wheelchair for ambulation and did not require staff assistance for ambulation on/off unit. During an interview on 8/16/17 at 7:34 a.m., Certified Nurse Assistant 1 (CNA 1) stated Resident 7 hits other residents when he becomes agitated or he bumps the other residents' wheelchair. On 8/16/17 at 8:10 a.m., during an interview, Resident 1 stated Resident 7 hit him on his left arm when we has on his way to the dining room and called him Mother F--ker a week prior. Resident 1 stated he too felt unsafe having Resident 7 around him. Resident 1 stated once he saw Resident 7's family member bring the resident a can of beer into the facility. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's MDS, dated [DATE], indicated Resident 1's cognition and memory was intact for daily decision-making. The MDS indicated Resident 1 used a wheelchair as a mobility device and did not require of staff for ambulation on/off unit. A review of a document titled, Social Services Notes dated 8/14/17, indicated Resident 7 would be move to a different dining room. The Social Service Note, dated 8/16/17 indicated Resident 1 asked the Social Services Director (SSD 1) why Resident 7 was sitting in the same dining room. During an interview on 8/16/17 at 8:15 a.m., Resident 4 stated Resident 7 was always cursing and hitting everyone and that all the staff were aware. Resident 4 stated, I feel safe because if Resident 7 attempted to hit me, I will hit him back, I just don't like to see hime treat the other residents that way. A review of the Admission Record (Face Sheet) indicated Resident 4 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 4's Minimum Data Set (MDS), dated [DATE], indicated Resident 4's cognition and memory were intact for daily decision-making. The MDS indicated Resident 4 was dependent of a wheelchair as a mobility device and did not require of staff for ambulation on/off unit. During an interview on 8/16/17 at 8:20 a.m., Resident 7 stated he was not aware of any incidents with other residents. Resident 7 stated that when he goes out on pass (OOP) he drinks alcohol and returns back to the facility. During an interview and record review of Resident 7's care plans on 8/16/17 at 11:06 a.m., the Director of Nurses (DON) stated that Resident 7 had three (3) incidents of aggressive behavior toward other residents documented. On 8/16/17 at 11:36 a.m., during an interview, with the Director of Nurses (DON) and Registered Nurse Supervisor (RN 1), they both stated that Resident 7 hits other residents when he becomes agitated and/or other residents are in his way. The DON stated, We should had taken action and move him to another facility; it seems like he likes hitting his peers. At 3:40 p.m., on 8/16/17, during an interview, Resident 3 stated that Resident 7 punched her in the face (mouth) once and used to call her a B--ch. Resident 3 stated the staff were all aware of the resident hitting her and she was scared that Resident 7 might hit her again. A review of the Admission Record (Face Sheet) indicated Resident 3 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 3's MDS, dated [DATE], indicated Resident 3's cognition and memory were intact for daily decision-making. The MDS indicated Resident 3 used a wheelchair as a mobility device for locomotion around the facility. During an interview on 8/16/17 at 4 p.m., Resident 5 stated Resident 7 have been verbally abusive towards her, but stated she did not report to anyone. Resident 5 stated will hit Resident 7 if he attempts to hit her. A review of the Admission Record (Face Sheet) indicated Resident 5 was initially admitted to the facility on [DATE]. Resident 5's [DIAGNOSES REDACTED]. A review of Resident 5's Minimum Data Set, dated dated [DATE], indicated Resident 5's cognition and memory were intact for daily decision-making. The MDS indicated Resident 5 was dependent on a wheelchair as a mobility device. During an interview on 8/16/17 at 4:43 p.m., CNA 4 stated Resident 7 was calm when watching television, but would strike out at resident peers when they were in his way or they bump his wheelchair. CNA 4 stated that all the facility's staff was aware of Resident 7's striking out behavior. During an observation on 8/16/17 at 5:23 p.m., Resident 7 was observed eating in the same dining room as Resident 1, which indicated the facility failed to follow the plan to keep Resident 1 and 7 separated, due to Resident 1's fear of Resident 7. On 8/17/17 at 7:15 a.m., during an observation, Resident 7 was observed in the dining room without 1:1 supervision, as part of the POA to provide 1:1 supervision. On 8/17/17 at 7:55 a.m., during an interview, the SSD stated that 1:1 supervision meant that one staff member would remain with the resident at all times. The SSD stated Resident 7 should have been evaluated for his behavior of hitting others due to the possibility of harm to self and others. A review of the document titled, 11-7 Daily Assignment, dated 8/17/17, indicated Resident 7 did not have a staff member for 1:1 supervision on the night shift. During an interview on 8/18/17 at 6:58 p.m., CNA 5 stated that she was assigned on 8/17/17 on the 11-7 a.m. shift to five (5) rooms with a total of 11 residents including Resident 7. CNA 5 stated that she was not with Resident 7 at all times because he was sleeping and she had other assignments. A review of a handwritten declaration, written by CNA 6, dated 8/16/17, and timed at 4:53 p.m., indicated Resident 7 hits other residents when they are in front of him moving slowly. A review of a handwritten declaration, written by the facility's Activity Coordinator (AC), dated 8/16/17 and timed at 4:46 p.m., indicated Resident 7 participated in activities and was calm until someone gets in his way or bumps him. The AC indicated that Resident 7 would strike out physically and become verbally abusive, depending on his mood. A review of the facility's undated policy and procedure titled, Abuse Prohibition, Patient, indicated that when the facility had knowledge that an individual has a history of abuse, appropriate actions will be taken to decrease the possibility of an abuse act. The Interdisciplinary (IDT) team will assess, care plan and monitor patients with needs and behaviors that might lead to conflict or abuse situations, such as a history of aggressive behaviors. The policy also indicated that if it involves patient to patient abuse, the patients involved would be separated.

Based on observation, interview, and record review, the facility failed to follow the resident's plan of care, Interdisciplinary ((IDT) a group of disciplines working towards a common goal of a resident) team's recommendations, the manufactures' guidelines and the facility's policy to ensure one of six sampled residents (Resident 1) was provided with a proper and safe technique during transfer using an assistive device. This deficient practice resulted in Resident 1 sustaining a fall sustaining a 2-centimeter (cm) laceration to the right side of the forehead and a 4.4 millimeters (mm)-subdural hematoma (a localized collection of blood outside the blood vessels, due to either disease or trauma including injury). Resident 1 required a transfer to the General Acute Care Hospital (GACH); requiring infusion of a blood product of fresh frozen plasma ((FFP) made from the liquid portion of whole blood; use in management of bleeding), vitamin K (maintains blood clothing), and four (4) staples (metal U shaped with sharp points) for the laceration (a deep cut or tear in skin or flesh) wound closure. Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 1's History and Physical (H & P), dated 7/30/17, indicated Resident 1 had right side weakness and a history of a deep vein thrombosis ((DVT) formation of a blood clot inside a blood vessel)). A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 7/21/17, indicated Resident 1 was able to report the correct year, month, and day of the week. The MDS indicated a brief interview for mental status (BIMS) score of 9 (8-12 moderately impaired in cognitive skills), which indicated Resident 1's cognition (thought process) was moderately impaired. The MDS indicated Resident 1 was totally dependent (full staff assistance) with two or more for physical assistance with transferring (moving between surfaces). The MDS indicated Resident 1 required extensive assistance from staff for toilet use and was dependent on a wheelchair for locomotion. The MDS indicated Resident 1 had impairment to one side of the upper extremity and on both sides of the lower extremity, and was not dependent of device for mobility. A review of the facility's investigation report sent to Department of Public Health (DPH), dated 8/12/17, indicated Resident 1 suffered a fall during a transfer from the bed to the shower chair using a Hoyer lift (an assistive device used to transfer between surfaces) by two CNAs. The report indicated Resident 1 began to move during the transfer and one side of the sling (a flexible strap or belt used in the form of a loop to support or raise) became unhooked from the Hoyer lift, causing the resident to fall to the floor in a prone (face downward) position on his right side of the forehead. A review of a Nurses' Progress Note, dated 8/12/17, and timed at 9:25 a.m., indicated Resident 1 was transfer to a GACH via an ambulance due to a fall. The Note indicated Resident 1 had a laceration to the right temple (the flat part of either side of the head between the forehead and the ear) area measuring 1.5 inches and scratches to the left side of his chin and left lateral side of leg. On 8/16/17 at 2:56 p.m., during an observation, Resident 1's face was observed to have a small laceration with four staples to the right side of the forehead and a purple bruise on the left side of the neck. A review of the facility's IDT notes, dated 11/27/16, indicated the Certified Nurse Assistants (CNAs) would be re-educated to carefully transfer Resident 1. A review of Resident 1's Care Plan titled, Mechanical Lift, dated 3/15/17, indicated under interventions for the resident to be transfer using a mechanical lift for transfer to and from bed. A review of Resident 1's Care Plan titled, At Risk for Falls-unable to ambulate revised on 7/18/17, indicated the staff's interventions included to evaluate the residents' fall risk factors and fall risk assessment per facility protocol. On 8/16/17 at 3:07 p.m., during an interview, CNA 2 stated that Resident 1 fell from the Hoyer lift during a transfer from the bed to the shower chair. CNA 1 stated she could not remember if the sling came off the Hoyer lift hooks. A review of the GACH report, dated 8/12/17 and timed at 5 p.m., indicated Resident 1 suffered a two centimeter (cm) laceration to the right side of the forehead and a 4.4 millimeters (mm)-subdural hematoma. The note indicated the forehead laceration required closure with four (4) staples. On 8/18/17 at 7:20 a.m., during a concurrent interview and observation, CNA 6 stated that if the legs of the Hoyer Lift were not properly secured under the bed, it could tilt and cause the resident to fall. CNA 6 stated there are staff members that do not know how to use the Hoyer lift properly. A review of the facility's documents titled, Training Roster-How to use the Hoyer Lift When Transferring a Resident, dated 4/6/17 and 4/15/17, indicated staff CNAs were in-service on the proper use of a Hoyer Lift. On 8/18/17 at 7:28 a.m., during an observation of a Residents' Hoyer lift transfer from bed to wheelchair. CNA 1 was observed not placing the sling securely into the hooks of the Hoyer lift. CNA 2 proceeded to lift Resident 1 from the bed using the Hoyer lift when CNA 1 told CNA 2 to stop, because the bottom side of the sling was not hooked to the Hoyer lift. CNA 6 had to intervene during the transfer due to CNAs 1 and 2 having trouble maneuvering the Hoyer lift to transfer Resident 1 from the bed to the wheelchair. On 8/18/17 at 7:38 a.m., during an interview, CNA 1 stated remembering that on 8/12/17, she hooked the bottom part of the sling onto the Hoyer lift while CNA 2 hooked the top part of the sling, CNA 1 stated Resident 1 fell from the Hoyer lift because he was constantly moving and the resident weighed 240 pounds (lbs), and The Hoyer Lift can only lift up to 240 lbs. (sic). A review of the Hoyer lift INVACARE warning sign located on the Hoyer lift, indicated the weight limitation is 450lbs. On 8/18/17 at 8 a.m., during an interview, Registered Nurse 1 (RN 1) indicated that she was called into Resident 1's room after the fall incident; RN 1 stated the resident was observed laying head down on the floor and blood was noted coming from the right side of his forehead. RN 1 stated that the slings bottom part was not hook into the Hoyer lift. On 8/18/17 at 11:40 a.m., during a concurrent observation and interview, a Physical Therapist (PT) stated that the Hoyer lift's sling have to be properly secured into the loops of the lift. On 8/18/17 at 11:46 a.m., during an interview, Resident 1 stated he couldn't remember how he fell , just that he was been transfer somewhere. A review of an undated Instruction Guide for the use of the Hoyer Lift, indicated before lifting the resident, to ensure to check the sling attachments each time the sling is removed and replaced, to ensure that its' properly attached before the Resident is removed from a stationary object (bed, chair or commode). The instructions indicated to be sure to check that the sling was properly connected to the hooks of the hanger bar when the resident was elevated a few inches from the stationary object; otherwise, injury or damage may occur. A review of the facility's Policy and Procedure, titled, Safe Lifting and Movement of Residents, revised on 12/2013, indicated the facility's staff are to follow safe lifting and movement of residents as part of an overall facility employee health and safety program.

Based on observation, interview and record review, the facility failed to protect five of six residents (Resident 1, 2, 3, 4, & 5) from being hit by another resident (Resident 7). 1. - Resident 1 was hit on the left arm and felt unsafe around Resident 7. 2. - Resident 2 was hit on the back of his neck. 3. - Resident 3 was punched on her mouth and verbally abuse. 4. - Resident 4 was verbally attacked by Resident 7. 5. - Resident 5 was verbally attacked by Resident 7. These deficient practices resulted in Resident 1, 2, 3, 4, & 5 being physically and verbally abused and to have mental anguish; and the potential to cause mental anguish and physically harmed to other residents. On [DATE] at 6:01 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was declared and the facility's administrator (ADM, a person responsible for managing an organization) was notified of the serious findings that threatened the health and safety of the residents. The IJ was abated on [DATE] at 2:35 p.m., in the presence of the administrator after the facility provided an acceptable written plan of correction (P(NAME)). The facility's P(NAME) indicated the following: 1.- Resident 7 will be put on one to one supervision until Resident 1 feels safe and other residents are safe and/or he is moved to a facility that can approve the care of him. The 11pm to 7am shift one to one supervision maybe also have a sitter with a CPR certification. The one on one supervision will only be dedicated to the resident; they will have no other residents. SSD will interview Residents 1, 2, 3, 4, 5, and 6 regarding Resident 7 and ensure they fell safe. Nursing staff will ensure Resident 7 is not seated near Resident 1. If residents ,[DATE] do not feel safe near Resident 7, staff will ensure that Resident 7 is not near them. Nursing staff will ensure care plans are updated to specific resident and aggressive behavior with each incident and as needed. Primary MD and Psych were notified for Resident 7 for review and recommendations immediately. 2.- SSD to interview rest of alert residents in facility to ensure they feel safe with other residents with behavior. IDT will meet before [DATE] and discuss other residents with aggressive behavior to meet each resident identified needs. Behavior Management meetings will be held monthly and as needed to discuss residents with aggressive behaviors. Any resident with identified with aggressive behaviors will be placed on one to one supervision till behavior has changed as determined by the MD/or when discharge. The one-on-one supervision will only be dedicated to that particular resident; they will not have other residents. Note the 11pm to 7am shift one to one supervision maybe also have a sitter with a CPR certification depending on the decision of the IDT. 3.-Director of nursing or designee will in-service nursing staff to monitor resident with aggressive behavior of residents, for residents, identify aggressive residents-what is abuse, types of abuse, policy of abuse and reporting, what is one-to-one supervision and knowing when it is appropriate. These in-service will be initiated for every resident aggressive altercations. 4.- Director on nursing will visually monitor residents with aggressive behaviors, initiate appropriate interventions and safety of residents during daily IDT/review of incidents. Any findings will be reported to CQI committee for review and recommendations. 5.- date completed is [DATE]. Cross Reference F279 Findings: On [DATE] at 7 a.m., an unannounced visit was conducted to the facility to investigate an entity report incident (ERI) of Resident 1 allegation of abuse perpetrated by Resident 7. A review of the Admission Record (Face Sheet) indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 7's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated [DATE], indicated Resident 7 was moderately impaired for daily decision making and had no behaviors. The MDS indicated Resident 7 was dependent of a walker and wheelchair for ambulation and did not require of staff for ambulation on/off unit (how resident moves between locations/moves to and returns from off-units such as dining room, activities and treatments), was independent (no help or staff oversight at any time) and had no impairments of bilateral upper and lower extremities. A review of the Physician order [REDACTED]. A review of a second Physician order [REDACTED]. A review of Resident 7's care plan dated [DATE] and titled, Long Term Care Plan-Mood Stated, indicated the goal was that resident would not harm others and with an intervention to provide 1:1 observation. A review of the facility's undated policy and procedure titled, Abuse Prohibition, Patient, indicated that when the facility gains knowledge that an individual has history of abuse, appropriate actions will be taken to decrease the possibility of an abuse act. The Interdisciplinary (IDT) team will assess, care plan and monitor patients with needs and behaviors that might lead to conflict or abuse situations such as a history of aggressive behaviors. The policy indicated that if it involves patient to patient abuse, the patients involved are separated. During an observation on [DATE] at 7:17 a.m., Resident 7 was observed unsupervised with other five (5) residents watching television in the dining room. During an interview on [DATE] at 7:30 a.m., Resident 2 stated that Resident 7 hit him on the back of his head with a close fist. Resident 2 stated feeling unsafe due to fear of being hit by Resident 7 again. A review of the Admission Record (Face Sheet) indicated Resident 2 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 2's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated [DATE], indicated Resident 2 was cognitively intact for daily decision making. The MDS indicated Resident 2 was dependent of a wheelchair for ambulation and did not require of staff for ambulation on/off unit (how resident moves between locations/moves to and returns from off-units such as dining room, activities and treatments), was independent (no help or staff oversight at any time) and had no impairments of bilateral upper and lower extremities. During an interview on [DATE] at 7:34 a.m., Certified Nurse Assistant (CNA 1) stated Resident 7 hits peer residents when he gets agitated or it's bumped by peer residents' wheelchair. During an interview on [DATE] at 8:10 a.m., Resident 1 stated that Resident 7 hit him on his left harm when we has on his way to the dining room and called him Mother [***] a week prior to [DATE]. Resident 1 stated feeling unsafe having Resident 7 around him; Resident 1 stated that he saw a family member bring a beer can to Resident 7. A review of the Admission Record (Face Sheet) indicated Resident 1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated [DATE], indicated Resident 1 was cognitively intact for daily decision making. The MDS indicated Resident 1 was dependent of a wheelchair as a mobility device and did not require of staff for ambulation on/off unit (how resident moves between locations/moves to and returns from off-units such as dining room, activities and treatments), was independent (no help or staff oversight at any time) and was impair on one side of the upper extremities. A Record Review of Resident 1's document titled, Social Services Notes dated on [DATE] indicated that Resident 7 would be move to a different dining room. The social Services Notes dated on [DATE] indicated that Resident 1 asked Social Services Director (SSD 1) why Resident 7 was sitting on the same dining room. During an interview on [DATE] at 8:15 a.m., Resident 4 stated that Resident 7 is always cursing and hitting everyone. Resident 4 stated I feel safe because if Resident 7 attempts to hit me, I will hit him back. A review of the Admission Record (Face Sheet) indicated Resident 4 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 4's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated [DATE], indicated Resident 4 was cognitively intact for daily decision making. The MDS indicated Resident 4 was dependent of a wheelchair as a mobility device and did not require of staff for ambulation on/off unit (how resident moves between locations/moves to and returns from off-units such as dining room, activities and treatments), was independent (no help or staff oversight at any time) and was impair on bilateral lower extremities. During an interview on [DATE] at 8:20 a.m., Resident 7 stated not been aware of any incidents with other residents. Resident 7 stated that when he goes Out On Pass (OOP) he drinks alcohol. During an interview on [DATE] at 11:06 a.m., in the presence of the Director of Nurses (DON), Registered Nurse Supervisor (RN 1) stated that Resident 7 hits other residents when he gets agitated or they are in his way. During the concurrent interview the DON stated We should had taken action and move him to another facility; it seems like he likes hitting peers. During an interview on [DATE] at 3:40 p.m., Resident 3 stated that Resident 7 punched her in the face once and used to call her [***] . Resident 3 stated been scared that Resident 7 might hit her again. A review of the Admission Record (Face Sheet) indicated Resident 3 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 3's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated [DATE], indicated Resident 3 was cognitively intact for daily decision making. The MDS indicated Resident 3 was dependent of a wheelchair as a mobility device and did not require of staff for ambulation on/off unit (how resident moves between locations/moves to and returns from off-units such as dining room, activities and treatments), was independent (no help or staff oversight at any time) and was impair on bilateral lower extremities. During an interview on [DATE] at 4 p.m., Resident 5 stated that Resident 7 was verbally abusive towards her. Resident 5 stated that she will hit Resident 7 if he attempts to hit her. A review of the Admission Record (Face Sheet) indicated Resident 5 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 5s Minimum Data Set (MDS, a standardized care screening and assessment tool), dated [DATE], indicated Resident 5 was cognitively intact for daily decision making. The MDS indicated Resident 5 was dependent of a wheelchair as a mobility device and did not require of staff for ambulation on/off unit (how resident moves between locations/moves to and returns from off-units such as dining room, activities and treatments), was independent (no help or staff oversight at any time) and was impair on one side of upper the upper extremities. During an interview on [DATE] at 4:43 p.m., CNA 4 stated that Resident is calm when watching TV, but will strike at resident peers when they are on his way or they bump on his wheelchair. CNA 4 stated that all facility staff was aware of Resident 7's striking behavior. During an observation on [DATE] at 5:23 p.m., Resident 7 was observed eating in the same dining room as Resident 1. During an observation on [DATE] at 7:15 a.m., Resident 7 was observed in the dining room with no 1:1 supervision. During an interview on [DATE] at 7:55 a.m., SSD stated that 1:1 supervision means one staff members' remains with the resident at all times. SSD stated that Resident 7 should have been evaluated for his behavior of hitting other due to the possibility of harm to self and others. A review of the document titled, ,[DATE] Daily Assignment dated [DATE] indicated Resident 7 did not have a staff member for 1:1 supervision for night shift. During an interview on [DATE] at 6:58 p.m., CNA 5 stated that she was assigned to five (5) rooms with a total of 11 resident including Resident 7 on [DATE] at ,[DATE] shift. CNA 5 stated that she was not with Resident 7 at all times because he was sleeping and she had other assignments. A review of the handwritten declaration of CNA 6 dated [DATE] and timed at 4:53 indicated that Resident 7 hits people when they are in front of him moving slowly. A review of the handwritten declaration of the Activity Coordinator (AC) dated [DATE] and timed at 4:46 p.m., indicated that Resident 7 participates in activities and its calm until someone gets on his way or bumps him. AC indicated that Resident 7 would strike out verbally and physically depending on his mood. A review of the Interdisciplinary Team (IDT) Notes dated on [DATE] did not state Resident 7's aggressive behavior was addressed during the meeting and in the plan of care.

Based on observation, interviews, and record reviews, the facility failed to create a care plan and provide interventions to prevent a pressure ulcer (an injury to the skin and underlying tissue that can range from mild reddening of the skin to severe tissue damage and sometimes infection that extends into muscle and bone) from developing. One of 15 sampled residents (Resident 14) developed a pressure ulcer that progressed to a stage IV (extensive loss or damage to tissue, muscles and bones, and often feature muscle and bone that is exposed) while in the facility. This deficient practice resulted in the development of a stage IV pressure ulcer on Resident 14's left hip Findings: On 8/28/17 at 10:25 a.m., an unannounced visit was made in the facility to conduct a recertification survey. Included in the survey was to investigate a complaint from an anonymous caller about a resident who had acquired multiple pressure sores. A review of Resident 14's face sheet (admission record) indicated that the facility admitted Resident 14 on 6/9/15. Resident 14's [DIAGNOSES REDACTED]. A review of Resident 14's minimum data set (MDS), a resident assessment and care screening tool), dated 6/22/17, indicated that Resident 14's cognition was severely impaired. The MDS indicated that Resident 14 was dependent on a person to perform activities of daily living (ADL) that included transfers from one surface to another, dressing, eating, toileting, and personal hygiene. According to the MDS, Resident14 was determined to be at risk for developing pressure ulcers based on the Pressure Ulcer Risk Evaluation tool the facility used. A review of Resident 14's clinical record titled, Pressure Ulcer Risk Evaluation indicated that the facility assessed the resident for pressure ulcer risk on 6/9/15, 9/22/15, 12/23/15, 3/22/16, 9/20/16, 12/21/16, 3/2017, and 6/2017. All of the assessments scored an 8 or 10, which indicated that the resident was a high risk for pressure ulcer development. During a record review with the director of nursing (DON) on 8/30/17 at 9: 20 a.m., the DON stated that she could not find any documentation that would show how Resident 14 developed a stage IV pressure ulcer on his left hip. The DON could neither provide proof that the facility made a care plan to address the problem. During a wound treatment observation for Resident 14 with registered nurse (RN) 1 and RN 2, the nurses changed eight wound dressings including a pressure ulcer to the resident's left hip. The measurement provided by the nurses on the left hip wound was approximately 10 cm X 7 cm X 0.2 cm, where 0.2 cm was the depth measurement. During a record review of Resident 14's clinical records with the assistant director of nursing (ADON) on 8/31/17 at 10 a.m., she stated that the physician gave an order to a licensed vocational nurse 5 (LVN 5) on 8/16/17. The physician gave an order to clean Resident 14's left hip with normal saline, pat dry, apply zinc oxide, and cover with a dry dressing twice a day for 21 days. LVN 5 who works for the registry did not create a care plan for the left hip pressure ulcer after she received the order. The ADON stated that the resident's clinical record indicated that the facility discovered the left hip pressure ulcer on 8/16/17. A review of Resident 14's clinical record titled, Multi Wound Chart Details made by Advantage Surgical & Wound Care, dated 8/17/17 indicated that the resident had a stage IV pressure ulcer on his left hip. A review of Resident 14's clinical record titled, Nurses Notes dated 8/18/17 indicated that the facility transferred Resident 14 to the hospital with a stage II pressure ulcer on his left hip, stage I on the right hip, excoriation to the right gluteal area, and a boil to the left lateral foot, left inner leg, and left 5th metatarsal. A review of the facility's undated policy and procedure titled, Pressure Ulcer, Prevention of indicated that it is the joint responsibility of the registered nurse, licensed nurse, and the certified nursing assistant to prevent a skin breakdown and development of pressure sores on residents. Procedures in the prevention included the development of a care plan to eliminate or minimize risk factors and to use pressure reducing or relieving devices as necessary.

Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) was transferred from a wheelchair to bed by two or more staff assistants as indicated in the Minimum Data Set (MDS, a standardized comprehensive assessment and care-screening tool), and/or for the staff to use the Mechanical lift (assistive device that allows a resident to be transferred from the bed to the chair or other similar resting places) per facility's protocol. As a result, Resident 1 sustained comminuted (a fracture in which the bone is broken into fragments) fractures of the left distal shafts of the tibia and the fibula (a break in the two long bones of the left lower leg), and a non-displaced (the bone cracks either part or all of the way through, but does move and maintains its proper alignment) fracture of the proximal (end of a bone) fibula. Resident 1 was transferred to a general acute care hospital (GACH), where a left lower leg cast was applied. Findings: On 12/20/16, at 1:10 p.m., an unannounced visit was made to the facility to investigate an injury of unknown origin that on 12/18/16, Resident 1 was found with a swollen left ankle with purple discoloration. The X-ray result indicated a fracture of the left distal shafts of the tibia and fibula. A review of Resident 1's Record of Admission indicated that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's MDS dated [DATE] indicated that the resident's cognitive skills for daily decision-making were severely impaired. The MDS indicated that the resident was totally dependent on two or more staff assistants for all activities of daily living including transfer. A review of Resident 1's Plan of Care, initiated on 3/2/12, and titled, Activity of daily living (ADL) deficit: required total assistance with bed mobility, transfers, ambulation, locomotion, eating, dressing, toileting, personal hygiene, and bathing. The Plan of Care did not indicate a need to use a Mechanical lift for transfer. A review of Resident 1's Nurses Notes dated 12/18/16 at 6:15 a.m. indicated that CNA 1 reported that the resident's left ankle was swollen and had a purple discoloration to his lower shin. The Nurses Notes indicated that Resident 1's left ankle and the entire foot to the toes were swollen, had purple discoloration and limited range of motion. The Nurses Notes indicated that the resident had facial grimacing when the left foot was touched. At 6:30 a.m. the physician was notified and an order was received for an X-ray of the foot and left ankle. A review of Resident 1's left ankle X-ray result dated 12/18/16 indicated acute (new) angulated (bend) moderately displaced comminuted fractures of the distal shafts of the tibia and fibula bones. A review of the Nurses Notes dated 12/18/16 at 1:30 p.m., indicated that Resident 1 was transferred to a GACH for acute displaced left ankle fractures. A review of Resident 1's GACH Discharge Summary dated 12/19/16 indicated a left fibula and tibia fracture in cast. The notes indicated that Resident 1's family member did not want the resident to return to the facility, as the family member questioned why and how would a non-ambulatory resident sustain ankle fractures. During an interview on 12/20/16 at 2:06 p.m., CNA 1 stated she was assigned to take care of Resident 1 on 12/18/16 on the 7 a.m. - 3 p.m., shift. CNA 1 stated between 6:00 a.m. and 6:15 a.m., and while providing care to Resident 1 she noticed that the resident's left ankle area was red and purple. CNA 1 stated that she notified the charge nurse. A review of CNA 1's written statement dated 12/18/16 indicated that on 12/17/16, Resident 1 did not have a problem with the left foot or left ankle. CNA 1 indicated that the next day 12/18/16, she noticed that resident's left foot was swollen and was reported right away to an LVN. During an interview on 12/20/16 at 3:40 p.m., CNA 2 stated she was assigned to Resident 1 on 12/17/16 from the 3 p.m. to the 11 p.m. shift. CNA 2 stated on 12/17/16 at 6:30 p.m., she transferred Resident 1 from a wheelchair to bed by herself. A concurrent record review of Resident 1's Plan of Care dated 3/2/12, titled, Activity of daily living (ADL) deficit and interview with the director of nursing (DON) on 12/20/16 at 4:35 p.m., indicated that Resident 1 required total assistance with bed mobility, transfers, ambulation, locomotion, eating, dressing, toileting, personal hygiene, and bathing. The DON stated that Resident 1's Plan of Care should have indicated that Resident 1 needed two or more staff assistants during transfers. The DON stated that Resident 1 needed a Mechanical lift during transfers and the facility's protocol indicated that the resident required two or more staff assistants for transfer. During an interview on 12/21/16 at 2:33 p.m., LVN 1 stated she was assigned to Resident 1 on 12/18/16 on the 11 p.m. - 7 a.m. shift as the charge nurse. LVN 1 stated that Resident 1 was in bed the whole night and on 12/18/16 at 6:10 a.m. to 6:15 a.m., CNA 1 reported to LVN 2 that Resident 1's left ankle was swollen. During an interview on 2/21/17 at 12:28 p.m., the MDS nurse stated that if the resident was assessed as requiring two or more person-transfer then, the information would have been communicated to the director of staff development (DSD). MDS nurse stated that the DSD would then communicate to the staffs (LVNs and CNAs) that the resident required two or more person-transfer during stand-up meetings and in-services. During an interview on 2/21/17 at 1:19 p.m., the DSD stated she gets her information of residents who require two or more person-transfer and needing a Mechanical lift from the DON. The DSD stated that she gives in-services to staff about this information and the residents are identified by green stickers on their foot board. On 2/21/17 at 3:34 p.m., during an interview, CNA 2 stated she did not receive in-service or report that Resident 1 was to be transferred with two or more person-assist. CNA 2 also stated that she was not aware that Resident 1 required the use of Mechanical lift during transfer. During an interview on 2/22/17 at 1:16 p.m., with the DON and subsequent record review of facility's Training Roster and In- service Training Record on topics titled, proper transfer to resident (patient), and/or transferring using Mechanical lift, dated 11/28/16, 12/21/16, and 2/15/17, the DON stated that CNA 2 was not in the attendance on any of the in-services. DON stated the green sticker to identify resident needing two or more staff assistance and use of a Mechanical lift for transfer had not been in place for at least 3 years. DON stated that the facility had no policy and procedures regarding the use of the Mechanical lift.

The facility's staff failure to thoroughly investigate a resident's fall incident with entrapment by ensuring that all risk factors were identified, such as an ill-fitting low air loss (LAL) mattress (that are commonly used to heal advanced bed sores) with the use of side rails, which created a large gap between the mattress and the side rail. This situation resulted in an immediate threat to health and safety of Resident 1 and other residents with LAL mattresses and use of side rails. During a fall from a low bed, Resident 1's head was entrapped between an ill-fitting LAL mattress on top of the bed frame and the side rail, due to a large gap between the mattress and the side rail. Resident 1's body was observed hanging from the low bed onto the floor, while Resident 1's head was entrapped in the gap on the left side of the bed, created by the LAL mattress not fitting the bed frame properly. Resident 1 had a red discoloration around the left side of the neck, a purplish discoloration skin tear measuring 1.5 centimeter (cm) by 1.5 cm to the right posterior forearm. Resident 1 was transferred to a general acute care hospital (GACH), for abnormal labs and a mechanical fall. Upon readmission to the facility, Resident 1 was placed back in the same bed with the ill-fitting LAL mattress with the side rails up creating a gap between the LAL mattress and the side rail, which put Resident at risk for entrapment again. On [DATE] at 12:30 p.m., an Immediate Jeopardy (IJ) was declared and the facility's administrator, assistant administrator, and director of nurses (DON) were notified noncompliance and risk. The facility submitted a plan of action (POA) on [DATE], which included the facility's culpability of placing Resident 1 in the same bed with the spacing resulting in Resident being entrapped between the side rail and LAL mattress of the same bed. The POA included removing all side rails of residents' beds with ill-fitting LAL mattresses (five beds). During a conference on [DATE] at 4:45 p.m., after the POA was submitted, the administrator and registered nurse supervisor were asked what they had in place to prevent the residents at risk for falls from falling after the side rails were removed. On the same day at 5 p.m., the facility presented another POA which included preventing residents with high risk for falls from falling and being injured. The new POA included applying bed alarms, using low beds and floor pads, and one to one monitoring for those residents that the physicians ordered to have side rails. The IJ was lifted on [DATE] at 5:45 p.m., the administrator, director of nurses, and the registered nurse supervisor (RN 1) were informed, after the survey team confirmed that the facility's plan of action was implemented as follows: 1. Immediately remove all half side rails from all residents' beds with LAL mattresses, upon approval of the physicians. In the event the physician insisted that the side rails remained in place, the resident will be placed on one-to-one nursing care. 2. Residents who are at high risk for falls with LAL mattress would be provided with a low bed, floor mats, and a bed alarm. 3. The residents' (five residents (Residents 1, 2, 3, 4, and 5)) care plans were up-dated to reflect the current plan of care. 4. The IDT recommended a low bed with floor mats, bed alarms at all hours when Resident 1 was in bed. Based on observation, interviews and record reviews, the facility failed to follow its undated policy titled, Restraint Devices, Physical, and implement the IDT recommendation of not using side rails due to the ill-fitting LAL that caused a gap for entrapment to occur for one of five sampled residents (Resident 1) after the resident was found entrapped. The facility placed Resident 1 back in the same bed upon his readmission that resulted in the resident's head being entrapped. Resident 1, who had dementia (brain diseases that cause a long term and often gradual decrease in the ability to think and remember) and was legally blind, was found on [DATE], by the facility's bed maker on her routine tour looking for unmade beds, with his head entrapped between the side rail and the LAL mattress, while his body dangled on the floor. The bed maker stated Resident 1, who usually made noises when his name was called, did not respond when she called out his name. These facility's failures resulted in Resident 1 being entrapped between the mattress and side rails sustaining a neck bruise/discoloration and a skin tear to the right forearm. These failures had the potential to affect four other residents (Residents 2, 3, 4, and 5), who had ill-fitting LAL mattresses with side rails up creating a gap for entrapment. Findings: During an unannounced visit on [DATE] at 12:15 p.m., an entity reported incident (ERI) was initially investigated. Resident 1 was observed in a wheelchair, eating in the dining room. There was a reddish discoloration on the left side of Resident 1's neck. A review of a nurse's progress note, dated [DATE], and timed at 8 a.m., indicated Resident 1 was found with the lower part of his body on the floor and the upper body stuck between the side rail and bed. According to the note, Resident 1 had a discoloration to the left side of the neck and a skin tear to the right posterior (of or nearer the rear or hind end) forearm. A review of the paramedic's sheet, dated [DATE] indicated Resident 1 was transferred to a GACH for abnormal labs and a mechanical fall. A review of Resident 1's Record of Admission face sheet indicated Resident 1 was admitted to the facility on [DATE] and recently re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED].). A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated [DATE], indicated Resident 1 had difficulty making himself understood and understanding others, and was moderately impaired in skills for decision-making with memory problems. According to the MDS, Resident 1 required extensive assistance in all activities of daily living. On [DATE] at 12:48 p.m., during a general tour of the facility and a concurrent interview with the maintenance supervisor, Resident 1's bed was observed with the side rails up and an ill-fitting LAL mattress that did not fit the bed frame. The maintenance supervisor measured the space between the mattress and the side rails which was 2 ½ inches on the right side facing the wall, and 3 inches on the left side. When hand pressure was applied to the mattress by the maintenance supervisor the spacing/gap increased in size. On [DATE] at 1:05 p.m., a certified nurse assistant (CNA 1) stated she was working with another resident on the day of the incident ([DATE]), when she was called to Resident 1's room, by the bed maker. CNA 1 stated Resident 1 was seen stuck between the side rail and mattress. CNA 1 stated Resident 1 was not screaming or calling out, as he would usually do when she entered the room. A review of an Interdisciplinary Team (IDT) note for Resident 1, dated [DATE], after the entrapment incident, indicated the plan for the resident to prevent another incident was to use a low bed without side rails, floor pads, and a bed alarm at all times while Resident 1 was in bed would be implemented. However, on [DATE], at approximately 12:15 p.m., Resident 1 was seen in the same low bed with the ill-fitting LAL mattress, with the side rails up resulting in a gap between the side rails and the LAL mattress. A review of Resident 1's physician's orders [REDACTED]. The physician's orders [REDACTED]. At 1:10 p.m., on [DATE], during an interview, the bed maker stated she saw the back of Resident 1's stuck head between the railing and the bed, when she was looking for beds and she called for help. A review of the bed maker's declaration, dated [DATE], and timed at 1:41 p.m., indicated she found Resident 1 in his bed with his head stuck in between the mattress and bed railing. The bed maker documented that Resident 1 was facing the wall and his body was on the floor. During an unannounced follow-up visit on [DATE], between the hours of 11:30 a.m. and 12 p.m., a tour of the facility indicated there were other beds with ill-fitting LAL mattresses, while using side rails; Rooms 67, 71 B, 74 B, and 77 B (Residents 2, 3, 4, and 5's bed). The beds were observed with large gaps between the side rails and mattresses. Resident 1 was observed lying in the same low bed he had been entrapped on [DATE], with the ill-fitting LAL mattress and the side rails up. Resident 1 was observed to have a red discoloration on his left neck. There was no bed alarm on Resident 1's bed. Resident 1's bed alarm and discontinuance of the half side rails were not implemented, as stipulated in the IDT's plan, dated [DATE], to prevent another entrapment incident. On [DATE] at 1 p.m., after an IJ was called, the maintenance supervisor was observed removing the side rails on Residents 1, 2, 3, 4, and 5's beds. On [DATE] by 5:45 p.m., safety measures were observed implemented as stipulated in the POA to prevent five residents (Residents 1, 2 , 3, 4, and 5) who had a high risk for falls and had ill-fitting LAL mattresses on their bed frame with side rails being used, from fall injuries. A review of the facility's undated policy titled, Restraints Devices, Physical, indicated under Assessment Guidelines, included functional ability and potential to injure self and others should be assessed and the staff approaches included to list observation for risks and complications. There was no documented evidence these areas were assessed for Resident 1, especially after being entrapped. According to an article titled, FDA (Food and Drug Administration) Issues Guidance on Hospital Bed Design to Reduce Patient Entrapment, dated [DATE], the FDA indicated there were approximately 691 entrapment reports over a period of [AGE] years from [DATE] to [DATE]. In these reports, 413 people died , 120 were injured, and 158 were near-miss events with no serious injury as a result of intervention. The entrapment events were a result of openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and the head or foot boards. The article indicated elderly patients in hospitals and nursing homes, especially those who are frail, confused, restless, or who have uncontrollable body movement, are most vulnerable to entrapment. <http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2006/ucm 2.htm> A review of an article titled, Low Air Loss (LAL) Therapy, dated ,[DATE], indicated most LAL systems do an excellent job of equalizing pressures, but most are simply not made to withstand a user ' s concentrated body weight in any one spot on the surface. The edge of the mattress can collapse when a user rolls or shifts sideways, which when the side rails are up, this collapse can leave a dangerous gap beneath the side rail. Such gaps pose an entrapment danger, as they have caused several suffocation deaths when the user's head has become entangled under the rail at www.spanamerica.com/ ./download.php? .easyairwh.