Every finding on record at Waterside Health & Rehab Center

Based on observation, family interview, staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide a necessary assistive device to prevent and protect a resident from fall related injuries (transfer the resident from a dialysis chair to a Geri-chair with a locking device to obtain optimal safety) which resulted in cervical-5 fracture which required a period of intubation and ventilation which constituted harm for one (1) of seven (7) residents (Resident #1), in the survey sample. The findings included: Resident #1 was originally admitted to the facility 1/20/23. The resident's current diagnoses included a history of cardiac arrest doing a procedure in 2019 with lasting effects from anoxic brain injury, a history of chronic respiratory failure with tracheostomy, a previous cervical neck fracture secondary to a fall, end stage renal disease requiring dialysis, a seizure disorder, chronic myoclonic jerks, and a history of multiple falls. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/27/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring total care of 2 or more people with transfers, total care of one person with toileting, and bathing, extensive assistance of one person with bed mobility, locomotion on unit, dressing, eating, and personal hygiene, and walking did not occur. A nurse's notes dated 7/30/2023 at 05:18 stated the resident was observed on the floor at the nurse's station bleeding from the head after a fall. The resident was transferred to a local hospital and the hospital's discharge summary dated 8/16/23 diagnosed the resident with a cervical-5 (C-5) fracture, a right eye corneal abrasion and lacerations to the head. While hospitalized he was vented but weaned back to a trach and put on a mechanically altered diet prior to discharging back to the nursing facility. The resident was also discharged with a dressing to the lacerations, an antibiotic ointment to the right eye and a collar to the neck when out of bed. A witness statement dated 7/29/23 from Certified Nursing Assistant (CNA) #1 stated on 7/29/23 she was monitoring the resident in the nurse's station because he was with periods of restlessness and attempting to self-transfer without assistance. CNA #1 stated the resident remained very restless therefore she repositioned the resident in the (dialysis) chair, reclining the resident to elevate his feet and placing a cover over his body to promote relaxation. CNA #1 stated she turned her back to the resident to complete some training and shortly thereafter heard a thump. CNA #1 stated when she turned around the resident was lying on the floor, and she yelled for help. The current care plan had a problem dated 1/22/23 which read; Risk for falls characterized by functional problem, gait/balance problems and tremors. The goal read; Minimize fall related injuries and will be free of complications associated with a fall through the next review. The interventions included a low bed with mats, move closer to the nurse's station, resident to be in Geri-chair when out of bed instead of a dialysis chair and return to bed after dialysis. On 11/27/23 at 2:50 PM, an interview was conducted with Family Member (FM) #1 in the resident's room. FM #1 stated the resident had a history of falls even at home and the admission to the facility was because of too many falls in the home. FM #1 also stated the facility's staff informed her that the fall which occurred on 7/29/23 which resulted in the C-5 fracture occurred at the nurse's station because one of the fall interventions was increased observation for periods of restlessness and attempting to stand unassisted. FM #1 stated the staff also informed her that the resident was seated in a dialysis chair at the time of the fall, and he should have been in a chair which had the ability to lock in place, a Geri-chair. An observation was made of Resident #1 on 11/27/23 at approximately 2:35 PM in the dialysis den. He was reclined back in a dialysis chair, absent of restlessness or attempting to reposition himself or attempting to climb out the chair. No further observations were made of Resident #1 because he had been transferred to the hospital when a visit was attempted on 11/28/23 and the resident had not returned to the facility at the time of exit on 11/29/23. An interview was conducted with the Licensed Physical Therapist Assistant (LPTA) on 11/28/23 at 10:03 AM. The LPTA stated the resident had been assessed multiple times after falls but he was not added to their caseload because of decreased cognition and his reluctance to participate with therapy services. The LPTA stated the nursing staff stated they spoke with FM #1 regarding the resident was unsafe in a wheelchair and a dialysis chair outside the dialysis den because of the involuntary muscle movements. A Geri-chair was recommended for safety and the wife agreed. An interview was also conducted with RN #1 on 11/28/23 at approximately 11:15 AM. RN #1 stated Resident #1 had been transferred to a local hospital that morning for removing the tracheal cannula, which provided a respiratory airway. RN #1 stated the chair outside of Resident #1's room was for him to utilize if he returned in time to receive the dialysis services. RN #1 also stated the dialysis chairs were no longer utilized for any other purpose and all staff had been educated on the type of chair the resident could utilize for recreational purposes. CNA #2 was interviewed on 11/29/23 at approximately 10:30 AM. CNA #2 stated Resident #1 was currently only using the dialysis chair (the off-white recliner chair) for dialysis purposes. CNA #2 also stated the resident was no longer using a Geri-chair because he was no longer sitting up in the chair because he was on isolation, and they were fearful of falls when left up in the chair in his room. The facility's Quality Assurance Program (QA&A) was reviewed relating to falls. The program reviewed falls on 8/3/23, 9/21/23 and 11/2/23. Resident #1 was identified in each QA review and many interventions were instituted including a medication review by the Practitioner and changes in medications, changes in assistive devices, as well as family involvement. A review of the nurse's notes revealed the resident was often restless in and out of bed and he had experienced nine falls from 1/23/23 to 7/29/23. A further review of Resident #1's nurses notes revealed he continued to have falls after the 7/29/23 fall with the C-5 fracture but, the falls were not related to inappropriate use of the dialysis chair or other assistive devices. The falls were from the bed to the mats at bedside and when staff were not present. Two additional residents were also reviewed for falls and non-compliance was not identified. The facility's Interdisciplinary Team developed a five-point Performance Improvement Plan (PIP) related to Resident #1's fall with a C-5 fracture on 7/29/23. The PIP was started on 7/31/23. The five-point PIP was reviewed during the survey and the facility was found to be in substantial compliance. 1. Resident #1 was noted at the nurse's station on 7/29/2023 in his dialysis chair when the resident had a fall. The resident was assessed and transported to the hospital for further evaluation and treatment. Resident #1 was admitted to the hospital with a diagnosis of a fractured C5. The facility failed to ensure Resident #1 was appropriately transferred from his dialysis chair to his chair with a locking device for optimal safety. 2. All dialysis residents have the potential to be affected. An audit was completed to ensure that dialysis resident had an appropriate ambulation device for optimizing safety upon their return from dialysis. Completed on 7/31/2023. 3. Nursing Administration completed 100% education to all CNA(s) and Licensed Nursing Staff on appropriate ambulation devices and transferring residents upon completion of dialysis to optimize resident's safety. The DON and/or Designee completed the training with licensed nursing staff, CNA and licensed staff on 7/31/2023. 4. DON or designee will complete observation audits on the use of dialysis chairs and appropriate ambulation devices used post dialysis treatment. Audits will be completed weekly x 4 weeks on all in house residents with dialysis chairs for treatment in the dialysis den. Aggregate findings will be analyzed, and any adverse findings immediately corrected. Findings and any applicable corrections will be presented and recorded in the monthly Quality Assurance and Performance Improvement (QAPI) meeting. Facility Administrator will be responsible for ensuring compliance. 5. Completion Date: 8/7/2023 On 11/28/23 at approximately 10:15 AM a chair designated as only for dialysis was observed in the hallway unoccupied. An interview was conducted with CNA #2 to determine if the chair could be utilized for another resident who resided on the hall since it was unoccupied. CNA #2 stated the chair was put there for Resident #1, although he was transferred to the hospital earlier that morning. CNA #2 further stated that the chair could only be utilized by a resident on their way to dialysis, during dialysis, or returning from dialysis. CNA #2 acknowledged the information was based on education that all nursing staff received based on the PIP after Resident #1 experienced a fall from a dialysis-only chair. On 11/28/23 and 11/29/23 observations were made of seven residents identified to use a specialty chair for dialysis. No observations were made of any of the seven residents using a dialysis chair outside of the dialysis den except during the process of transferring to or from a leisure device (chair or bed) deemed safe for the individual which supported the facilitty's PIP. On 11/29/23 at 12:15 PM, a final interview was conducted with the Administrator, Director of Nursing, and Regional Director of Clinical Services. It was determined that the facility implemented its Performance Improvement Plan, and there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance at the time of the current survey for the regulatory requirement, F-689.

Based on observations, resident interview, and staff interview, the facility staff failed to maintain a clean comfortable homelike environment for 1 of 50 residents (Resident #273), in the survey sample. The findings included: Resident #273 was originally admitted to the facility 6/1/2023 after an acute care hospital stay. The resident discharged from the facility on 6/21/23. The diagnoses included; a urinary tract infection (UTI), status post a kidney transplant and kidney stones. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/7/2023 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #273's cognitive abilities for daily decision making were intact. On 6/20/23 at approximately 1:53 p.m. an interview was conducted with Resident #273 in her room. The resident was reclined in on her bed, talking about the events which brought her to the facility and the plan for her to be discharged home 6/21/23 at 3:00 p.m. The resident stopped mid-sentence to ask the surveyor if she saw the gnats in her room. The resident stated she needs to drink a lot of water to aid in passing the kidney stones but the gnats go down the straw into her water so she doesn't always have water to drink. Resident #273 also stated the gnats were in her room when she was admitted to present time. The resident also said when she removes the top from her meal tray she has to fight the gnats off to consume the meal. The resident further stated what is homelike about that. An interview was conducted with the Director of Maintenance on 6/23/23 at approximately 12:15 p.m. The Director of Maintenance stated they had a problem with gnats but thought it was no longer a concern. He also stated the gnats were associated to the resident having flowers and plants in the facility and he thought if they keep them out the problem would be totally resolved. The Director of Maintenance stated, I asked the pest control company come in today (6/23/23) because he was asked today about the gnat situation in the facility. The pest control technician used a special aerosol was gnats today and prior to that he believes the special aerosol was used last month. Over the four days of the survey (6/20/23 - 6/23/23) the survey team identified gnats throughout the facility including the conference room. On 6/23/23 at approximately 2:05 p.m., the above findings were shared with the Administrator, Director of Nursing, a Corporate Consultant, and the Regional [NAME] President of Operations. An opportunity was offered to the facility's staff to present additional information but no additional information was provided, and no further concerns were voiced.

Based on interview, record review, document review and facility policy review, the facility failed to protect seven out of seven residents (Resident (R) 71, R2, R64, R324, R225, R63, R56) reviewed for abuse, specifically the misappropriation of resident's property out of a total sample of 50 residents. This failure has the potential for misappropriation of property for other residents. Findings included: Review of the facility policy, Virginia Resident Abuse Policy dated 10/03/2022 (sic), revealed, Policy: This Facility will not tolerate . misappropriation of resident property by anyone. It is the facility's policy to investigate all allegations, suspicions and incidents of .misappropriation of resident property .Procedure: 7) Investigate: Once the Administrator and DON (Director of Nursing) are notified, an investigation of the allegation or suspicion will be conducted .The person investigating the incident should generally take the following actions: i. Interview the resident, the accused, and all witnesses . c. Documentation. Evidence of the investigation should be documented. 8) Reach a Conclusion: After completion of the investigation, all of the evidence should be analyzed, and the Administrator (or his/her designee) will make a determination regarding whether the allegation or suspicion is substantiated, and, for Injuries of Unknown Source, a determination regarding the probable source of the injury. 1. Review of R71's undated Admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R71 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included malignant neoplasm of lower lobe right lung, atrial fibrillation (irregular heartbeat), congestive heart failure, vascular dementia, cerebral infarction (stroke). Review of the facility's investigation revealed an unnamed and undated document that indicated R71 was missing 22 oxycodone tablets. Review of R71's EMR under the Orders tab revealed a Physician Order for oxycodone-acetaminophen tablet 5-325mg (milligram), give 1 tablet by mouth every 12 hours for RA (rheumatoid arthritis) pain, start 07/12/22. 2. Review of R2's undated Admission Record, located in the EMR under the Profile tab revealed R2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified intestinal obstruction, major depressive disorder, chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity cerebral infarction (stroke). Review of the facility's investigation revealed an unnamed and undated document that indicated R2 was missing 23 hydrocodone tablets. Review of R2's EMR under the Orders tab revealed a Physician Order for hydrocodone-acetaminophen tablet 5-325mg, give 1 tablet by mouth every 12 hours as needed for chronic back pain, start 10/17/22. 3. Review of R64's undated Admission Record, located in the EMR under the Profile tab revealed R64 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included aphasia (disorder affecting communication) following cerebral infarction (stroke), malignant neoplasm of left breast, epilepsy. Review of the facility's investigation revealed an unnamed and undated document that indicated R64 was missing 9cc (cubic centimeters) liquid morphine. Review of R64's EMR under the Orders tab revealed a Physician Order for morphine sulfate 100mg CR (prolong release), give 0.5 ml (milliliter) by mouth every 3 hours as needed for pain, give sublingually for moderate to severe pain, start 10/21/22. 4. Review of R324's undated Admission Record, located in the EMR under the Profile tab revealed R324 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute respiratory failure with hypoxia (in sufficient oxygen levels) tracheostomy, gastrostomy. Review of the facility's investigation revealed an unnamed and undated document that indicated R324 was missing 275cc liquid oxycodone. Review of R324's EMR under the Orders tab revealed a Physician Order for oxycodone hcl (hydrochloride) solution 5mg/5ml, give 5ml via PEG (percutaneous endoscopic gastrostomy) tube every 6 hours as needed for pain, start 11/29/22. 5. Review of R225's undated Admission Record, located in the EMR under the Profile tab revealed R225 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included congestive heart failure, chronic kidney disease, chronic pain, acute respiratory failure with hypoxia. Review of the facility investigation revealed an unnamed and undated document revealing R225 was missing 10 oxycodone tablets. Further review of R225's EMR under the Orders tab revealed R225 was ordered oxycodone-acetaminophen tablet 5-325mg, give 1 tablet by mouth every 4 hours as needed for moderate to severe pain, start 12/07/22. 6. Review of R63's undated Admission Record, located in the EMR under the Profile tab revealed R63 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, major depressive disorder, morbid obesity, dementia, asthma, adjustment disorder. Review of the facility's investigation revealed an unnamed and undated document revealing R63 was missing 144 Percocet tablets. Further review of R63's EMR under the Orders tab revealed a Physician Orders that indicated Percocet tablet 5-325mg (oxycodone-acetaminophen), give 1 tablet by mouth every 6 hours as needed for pain, start 10/31/22. 7. Review of R56's undated Admission Record, located in the EMR under the Profile tab revealed R56 was admitted to the facility on [DATE] with diagnoses which included nontraumatic intracerebral hemorrhage, dementia, congestive heart failure, chronic obstructive pulmonary disease. Review of the facility investigation revealed an unnamed and undated document that indicated R56 was missing 102 Percocet tablets. Further review of R56's EMR under the Orders tab revealed R56 was ordered Percocet tablet 5-325mg, give 1 tablet by mouth every 8 hours as needed for jaw pain, start 10/21/21. In an interview on 06/22/23 at 3:30 PM, the Regional [NAME] President of Operations (RVPO) stated, on 01/02/23 a nurse reported a medication card of Percocet (an opioid pain medication) was missing from the medication cart. As a result of this discovery a full facility audit was performed, and additional medications were discovered to be missing. A full investigation was carried out, staff were interviewed, and residents were given head to toe assessments. All affected residents were assessed for pain, no residents were found to be in distress or reporting signs or symptoms of pain. No resident was found to have missed any doses of pain medication and the missing medications were replaced. Suspected staff provided written statements and have resigned from the facility. Agency staff suspected have not returned to the facility. The cameras in the facility did not work so there was no video evidence to review. There have been previous incidents of missing medication in the facility and no suspect has been identified after the investigations were completed. The police were notified along with other appropriate agencies. Increased audits of medications are being conducted. Review of the facility incident investigation confirmed the incident occurred.

Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to send a copy of the Resident's Care Plan to include their goals for 1 of 50 residents (Resident #324) after being transferred and admitted to the hospital on 12/10/22. The findings included: Resident #324 was originally admitted to the nursing facility on 04/02/22. Diagnosis for the resident included but are not limited to Gastrostomy and Trachoestomy. The most recent Minimum Data Set (MDS - an assessment protocol) a significant change with an Assessment Reference Date (ARD) of 02/23/23 coded Resident #324 with a 10 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. The Discharge MDS assessments was dated for 12/10/22 - discharge return anticipated. Resident #324 was readmitted to the nursing facility on 12/22/22. A review of Resident #324's clinical record indicated the resident was transferred to the local hospital on 12/10/22 related to clogged G-tube. On 06/23/23 at approximately 12:46 p.m., an interview was conducted with License Practical Nurse (LPN) #6. She stated she sent Resident #324 out to the hospital on 12/10/22 for a clogged G-tube. After the LPN reviewed the resident's clinical record, she stated she would get back to the surveyor related to the resident's care plan being sent upon transfer or shortly after. On the same day at approximately 1:11 p.m., an interview was conducted with the Director of Nursing. She stated LPN #6 informed her she was unable locate in the resident's clinical record that Resident #324's person-centered care plan was sent when discharged and admitted to the hospital on 12/10/22. The DON stated if the resident's clinical record did not indicate the care plan was ever sent when discharge or shortly after, then the care plan was never sent to the receiving provider. On 06/23/23 at 2:06 p.m., the Administrator, Director of Nursing (DON) and Regional Director of Clinical Services Nursing were informed of the above findings. The DON stated the purpose of sending the residents care plan is for the receiving provider to maintain continuity of care. Definitions -A gastrostomy feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach (https://medlineplus.gov). -A tracheostomy is surgery to create a hole in your neck that goes into your windpipe. If you need it for just a short time, it will be closed later. Some people need the hole for the rest of their life. The hole is needed when your airway is blocked, or for some conditions that make it hard for you to breathe. You may need a tracheostomy if you are on a breathing machine (ventilator) for a long time; a breathing tube from your mouth is too uncomfortable for a long-term solution. The tracheostomy provides a way for your health care providers to gradually remove the ventilator if possible (https://medlineplus.gov).

Based on record review, interview, and facility policy review, the facility failed to provide evidence that one of two residents (Resident (R) 102) reviewed for hospital transfers, out of a total sample of 50 residents, documentation that the resident and/or the resident representative were provided a written notice of transfer when the residents were transferred to the hospital. Findings included: Review of the facility policy Resident Discharge/Transfer Letter Policy, dated 04/19/2023 (sic), revealed, Policy: The Facility will complete discharge letters appropriately and according to all federal, state, and local regulations. Procedure: .D) Discharge notices must have the following components: 1. The reason for discharge/transfer, to include appropriate verbiage listed above. 2. The effective date of transfer/discharge. 3. The location to which the resident is transferred/discharge, this must be a specific address which has accepted the resident and is an appropriate location. 4. A statement that the resident has the right to appeals the action to the state. 5. The name, address, and telephone number of the Local and State long term care ombudsman. 6. The mailing address and telephone number of agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Assistance and [NAME] of Rights Act. 7. The mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. E) Social Service or designee will assure the original discharge/transfer letter is given to resident or guardian/sponsor, if applicable. 1. Copies will be sent to the Department of Health, Ombudsman Office and filed in the business file and/or scanned into the electronic chart with administrator/designee signature, with the certified receipt if applicable. 2. For emergency transfers, one list can be sent to the Ombudsman at the end of the month. F) Social service of designee will document in the chart all discharge/transfer reasons, any notices given to the resident or the guardian/sponsor, and discharge planning. Review of R102's undated Admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R102 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute respiratory failure, anxiety disorder, dependence on respirator (ventilator) status, atrial fibrillation, end stage renal disease, morbid obesity, gastrostomy, tracheostomy status. Review of the EMR Progress Notes, located under the Notes tab, revealed an Alert note dated 03/03/23 While in dialysis, resident voiced that he was having chest pain and sob [shortness of breath]. Resident was taken back to his room. While transferring resident to his room, resident skin color noted to be pale, and lips were cyanotic . By the time staff attempted to assist resident with transferring to his bed, Resident became unresponsive . 911 was called. Resident was transported over to Sentara [NAME] (hospital).Further review of the EMR Progress Notes revealed a respiratory therapy note, dated 03/08/23, documented R102 was readmitted to the facility from the hospital. Further review of the record revealed no documentation that written notice of transfer was provided to the resident and/or the resident's representative. In an interview on 06/23/23 at 10:30 AM, the Administrator stated, Residents and their representatives are only given verbal notifications of resident transfers, and nothing is provided to them in writing.

Based on staff interviews, facility documentation review and clinical record review the facility staff failed send a copy of the Bed-Hold policy upon discharge/transfer for 1 of 50 resident's (Resident #324) that was transferred to the local hospital on 12/10/22. The findings included: Resident #324 was originally admitted to the nursing facility on 04/02/22. Diagnosis for the resident included but are not limited to Gastrostomy and Trachoestomy. The most recent Minimum Data Set (MDS - an assessment protocol) a significant change with an Assessment Reference Date (ARD) of 02/23/23 coded Resident #324 with a 10 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. The Discharge MDS assessments was dated for 12/10/22 - discharge return anticipated. Resident #324 was readmitted to the nursing facility on 12/22/22. A review of Resident #324's clinical record indicated the resident was transferred to the local hospital on 12/10/22 related to clogged G-tube. On 06/23/23 at approximately 12:46 p.m., an interview was conducted with License Practical Nurse (LPN) #6. She stated she sent Resident #324 out to the hospital on 12/10/22 for a clogged G-tube. After the LPN reviewed the resident's clinical record, she stated she would get back to the surveyor related to the Bed-Hold policy being sent when transferred. On the same day at approximately 1:11 p.m., an interview was conducted with the Director of Nursing. She stated LPN #6 informed her she was unable locate in the resident's clinical record the Bed-Hold Policy was sent when discharged to the hospital on 12/10/22. The DON stated if the resident's clinical record did not indicate the Bed-Hold policy was ever issued to the resident and or their representative on the day of discharge, then the Bed-Hold policy was never provided. On 06/23/23 at 2:06 p.m., the Administrator, Director of Nursing and Regional Director of Clinical Services Nursing were informed of the above findings. No further information was provided prior to exit. The facility policy titled Bed Hold Notice stated the notice is to be provided to the resident and his/her representative at the time of transfer. In the case of an emergency, the paperwork should be provided within 24 hours. Definitions -A gastrostomy feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach (https://medlineplus.gov). -A tracheostomy is surgery to create a hole in your neck that goes into your windpipe. If you need it for just a short time, it will be closed later. Some people need the hole for the rest of their life. The hole is needed when your airway is blocked, or for some conditions that make it hard for you to breathe. You may need a tracheostomy if you are on a breathing machine (ventilator) for a long time; a breathing tube from your mouth is too uncomfortable for a long-term solution. The tracheostomy provides a way for your health care providers to gradually remove the ventilator if possible (https://medlineplus.gov).

Based on staff interview and clinical record review the facility staff failed to ensure a resident received a comprehensive Minimum Data Set (MDS) assessment not less than once every 12 months, within 366 days for 1 of 50 residents (Resident #41), in the survey sample. The findings included: Resident #41 was originally admitted to the facility 5/120/21 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included a seizure disorder, TBI, schizophrenia disorder, and high blood pressure. The quarterly MDS assessment with an assessment reference date (ARD) of 1/24/23 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired for daily decision making. During a review of the facility task, Resident assessments triggered Resident #41 for not having a Minimum Data Set (MDS) assessment completed for over 120 days. A review of completed MDS assessment for the resident revealed the following quarterly MDS assessments were completed 1/24/23, 10/29/22, 7/29/22 and a comprehensive MDS assessment was dated 4/28/22 therefore a comprehensive MDS assessment was due April 2023 because each resident must receive a comprehensive Minimum Data Set (MDS) assessment not less than once every 12 months, within 366 days. The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless a Significant Change in Status Assessment or a Significant Correction to Prior Comprehensive Assessment has been completed since the most recent comprehensive assessment was completed. Its completion dates (MDS/Care Area Assessment(s)/care plan) depend on the most recent comprehensive and past assessments ' ARDs and completion dates. (CMS's RAI Version 3.0 Manual, Chapter 2 Page 2-21) An interview was conducted with the MDS Coordinator on 6/22/23 at approximately 5:00 p.m. The MDS Coordinator stated after reviewing it was determined that Resident #41's MDS assessment wasn't completed timely and a new MDS assessment had been opened since it was brought to her attention On 6/23/23 at approximately 2:05 p.m., the above findings were shared with the Administrator, Director of Nursing, a Corporate Consultant, and the Regional [NAME] President of Operations. An opportunity was offered to the facility's staff to present additional information, but none was provided, and no other concerns were voiced from them.

Based on information gleamed during the closed record review and staff interview the facility staff failed to complete a Death in Facility tracking record for Resident #47. Resident #47 was originally admitted to the facility [DATE] after an acute care hospital stay. The current diagnoses included chronic respiratory failure, a seizure disorder, mini stroke and diabetes. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #47's cognitive abilities for daily decision making were intact. The closed record was categorized as hospitalization . A review of the discharge MDS revealed it was coded discharged return not anticipated. During the review of the clinical record a nurse's note date [DATE] at 4:50 a.m. read, the resident was transferred from the facility to the emergency department of a local hospital. Another nurse's note dated [DATE] at 5:31 a.m. read, a nurse telephoned the hospital for information regarding Resident #49 and was told by the hospital personnel that the resident expired at 5:12 a.m., in the emergency department. An interview was conducted with the MDS Coordinator on [DATE] at approximately 5:00 p.m. The MDS Coordinator stated she gained additional information about Resident #47's status and she determined the resident was not admitted to the hospital therefore the Death in facility tracking record should have been completed instead of a discharge assessment return not anticipated. Death in Facility refers to when the resident dies in the facility or dies while on a leave of absence (LOA) (see LOA definition). The facility must complete a Death in Facility tracking record. No Discharge assessment is required. (CMS's RAI Version 3.0 Manual, Chapter 2 Page ,d+[DATE]) Leave of Absence (LOA), which does not require completion of either a Discharge assessment or an Entry tracking record, occurs when a resident has a: Temporary home visit of at least one night; or Therapeutic leave of at least one night; or Hospital observation stay less than 24 hours and the hospital does not admit the resident. (CMS's RAI Version 3.0 Manual, Chapter 2 Page ,d+[DATE]) On [DATE] at approximately 2:05 p.m., the above findings were shared with the Administrator, Director of Nursing, a Corporate Consultant, and the Regional [NAME] President of Operations. An opportunity was offered to the facility's staff to present additional information, but none was provided and no concerns were voiced from them.

Based on staff interview, and a clinical record review the facility's staff failed to develop a person-centered comprehensive care plan to include a seizure disorder for 1 of 50 residents (Resident #27), in the survey sample. The findings included: Resident #27 was originally admitted to the facility 4/7/23 after an acute care hospital stay. The resident was discharged to a local hospital on 5/30/23 and returned to the facility on [DATE]. The current diagnoses included chronic respiratory failure, status post a subdural hematoma, a seizure disorder and pressure ulcers. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/13/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 3 out of a possible 15. This indicated Resident #27's cognitive abilities for daily decision making were severely impaired. A review of the clinical record revealed a nurse's noted dated 5/30/23 at 2:26 p.m. It read an order was received from the physician to send Resident #27 to a local emergency room for seizures, altered mental status, a rapid heart rate and fever. The resident's vitals were as follows: blood pressure 150/85, heart rate 127, and temperature 100.8. The hospital's discharge summary dated 6/8/23 read the resident had a past medical history significant for a seizure disorder and she was maintained on Keppra (an anticonvulsive). The hospital's discharge summary further read the resident was sent to the emergency room after staff witnessed seizure-like activity at the facility and the emergency room staff noted that she was actively seizing. The resident was treated with intravenous (IV) Ativan and a loading dose Keppra unsuccessfully therefore IV propofol was started with cessation of the seizure activity. A review of the physician's order summary revealed the resident was receiving Levetiracetam oral Tablet 750 MG (Levetiracetam), give two tablets via G-Tube two times a day for seizures. A review of the active care plan revealed there was not a seizure disorder care plan to ensure safety during and after seizures, preventing injury, and minimizing the frequency and severity of seizures through appropriate medication management and caregiver education. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 6/22/23 at approximately 1:36 p.m. LPN #1 stated it is the responsibility of the nursing staff to keep each resident's care plan updated and a care plan is necessary to define how to care for the resident. On 6/23/23 at approximately 2:05 p.m., the above findings were shared with the Administrator, Director of Nursing, a Corporate Consultant, and the Regional [NAME] President of Operations. An opportunity was offered to the facility's staff to present additional information, but none was provided and no concerns were voiced from them.

Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to revise the resident's person-centered care plan to include the application and removal of a right leg immobilize for 1 of 50 residents (Resident #75), in the survey sample. The findings included: Resident #75 was originally admitted to the facility 03/29/22. Diagnosis for Resident #75 included but not limited to difficulty in walking and muscle weakness. The most recent Minimum Data Set (MDS - an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 05/24/23 coded Resident #75 with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. On 06/22/23 at approximately 11:33 a.m., Resident #75 observed sitting in her wheelchair with immobilize to right knee. On the same day at 4:05 p.m., right knee leg brace remained in place. Resident #75 observed sitting in her wheelchair on 06/22/23 at 11:33 a.m., with right knee immobilizer in place. The resident stated she always wears the brace when out of bed. She stated the immobilizer is applied by the Certified Nursing Assistant (CNA), therapy but on occasion, she will apply the knee immobilizer. She stated she has worn a brace since being admitted to the facility in March 2022. A review of Resident #75's care plan did not include the wear of a right leg/knee splint/immobilizer. The Director of Nursing (DON) was interviewed on 06/23/23 at 1:00 p.m. She stated Resident #75's person-centered care plan should have been revised to include the use of right knee device. On 06/23/23 at 2:06 p.m., the Administrator, Director of Nursing and Regional Director of Clinical Services Nursing were informed of the above findings. No further information was provided prior to exit. The facility policy titled Splint Issuance policy revised 03/11/22. It is the facility's policy that splints shall be issued or fabricated with a provider's order and therapist must evaluate to determine need for splint, fit and issuance. -Procedure: 2. Patient splint schedule will be communicated to the multidisciplinary team and documented in the care plan. Comprehensive Care Planning revised 07/19/19. It is the facility policy for the interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements and on an as needed basis.

Based on observation, staff interview, and clinical record review the facility's staff failed to ensure appropriate care and services were provided to prevent/reduce complications while utilizing an indwelling catheter for 1 of 50 residents (Resident #27), in the survey sample. The findings included: Resident #27 was originally admitted to the facility 4/7/23 after an acute care hospital stay. The resident was discharged to a local hospital on 5/30/23 and returned to the facility on [DATE]. The current diagnoses included chronic respiratory failure, status post a subdural hematoma, a seizure disorder and pressure ulcers. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/13/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 3 out of a possible 15. This indicated Resident #27's cognitive abilities for daily decision making were severely impaired. In section H0100 of the MDS assessment the resident was coded for utilizing an indwelling catheter. During the tour on 6/20/23 at approximately 1:25 p.m., Resident #27's indwelling catheter's bedside drainage bag was observed resting on the floor, again on 6/21/23 at approximately 12:15 p.m., the indwelling catheter's bedside drainage bag was resting on the floor and on 6/23/23 at approximately 1:35 p.m., an observation was made with Registered Nurse #1 (RN) of Resident #27's indwelling catheter bedside drainage bag resting on the floor. RN #1 donned a pair of gloves, adjusted the bed so the catheter drainage bag was no longer resting on the floor. RN #1 put the drainage bag inside a privacy cover and stated he would educate staff to ensure all catheter drainage bags are emptied prior to weighing the bag down and to make sure the drainage bag didn't rest on the floor. On 6/23/23 at approximately 2:05 p.m., the above findings were shared with the Administrator, Director of Nursing, a Corporate Consultant, and the Regional [NAME] President of Operations. An opportunity was offered to the facility's staff to present additional information and the Director of Nursing stated they had begun educating the staff regarding best practices when use of an indwelling catheter is necessary. The Centers for Disease Control recommendations to maintain unobstructed urine flow for an individual utilizing an indwelling catheter; Maintain the bag below the level of the bladder. Ensure that the bag is emptied prior to transport. Use a catheter securement device to anchor the catheter. Keep the urine bag off the floor. (https://www.cdc.gov/infectioncontrol/pdf/strive/CAUTI104-508.pdf)

Based on observations, staff interview, and clinical record review, the facility staff failed to ensure staff reviewed the risks and benefits of bed rail use with the Resident and/or Resident Representative prior to installation, provide documentation that the facility staff attempted alternatives or that they obtained consent for the use of bed rails prior to use for 1 of 50 residents (Resident #27), in the survey sample. Findings include: Resident #27 was originally admitted to the facility 4/7/23 after an acute care hospital stay. The resident was discharged to a local hospital on 5/30/23 and returned to the facility on [DATE]. The current diagnoses included chronic respiratory failure, status post a subdural hematoma, a seizure disorder and pressure ulcers. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/13/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 3 out of a possible 15. This indicated Resident #27's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring total care of two or more people with bed mobility, transfers, locomotion, dressing, eating, toileting, personal hygiene and bathing. During the tour on 6/20/23 at approximately 1:25 p.m., Resident #27 was observed in bed with the head of the bed at approximately 45 degrees, bilateral bed rails were attached to the bed and in an upright position and a fall mat was on the floor on the resident's right side. The resident didn't respond when spoken to and there was no identified body movement. On 6/21/23 at approximately 12:15 p.m., the resident was again observed in bed facing the window, with bilateral bed rails in an upright position. On 6/23/23 at approximately 1:35 p.m., an observation was made with Registered Nurse #1 (RN) of Resident #27 in bed with bed rails were attached to the bed and in an upright position. The active care plan dated 4/25/23 had a problem which read resident has an ADL self care performance deficit related to disease process. The interventions included provide two person staff assistance with repositioning and turning in bed and provide two person assistance with transfers daily. There was not any care plan documentation for use of bed rails. A review of the clinical record failed to reveal an assessment for use of bed rails, neither was there documentation that staff reviewed the risks and benefits of bed rail use with the Resident and/or Resident Representative prior to installation of the bed rails, or documentation that the facility staff attempted alternatives prior to use of bed rails use or that they obtained consent for the use of bed rails prior to use. An interview was conducted with the Director of Nursing on 6/23/23 at approximately 11:40 a.m. The Director of Nursing stated there was not a side rail assessment, risk and benefit information provided to the Resident and/or Resident Representative, or documentation of alternative attempted prior to use of the bed rails and there was not a signed consent for bed rails. On 6/23/23 at approximately 2:05 p.m., the above findings were shared with the Administrator, Director of Nursing, a Corporate Consultant, and the Regional [NAME] President of Operations. An opportunity was offered to the facility's staff to present additional information. They provided no additional information and voiced no further concerns.

Based on observations, resident interview, and staff interview, the facility staff failed to maintain an effective pest control program so that the facility was free of gnats which was voiced by 1 of 50 residents (Resident #273), in the survey sample. The findings included: Resident #273 was originally admitted to the facility 6/1/2023 after an acute care hospital stay. The resident discharged from the facility on 6/21/23. The diagnoses included; a urinary tract infection (UTI), status post a kidney transplant and kidney stones. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/7/2023 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #273's cognitive abilities for daily decision making were intact. On 6/20/23 at approximately 1:53 p.m. an interview was conducted with Resident #273 in her room. The resident was reclined in on her bed, talking about the events which brought her to the facility and the plan for her to be discharged home 6/21/23 at 3:00 p.m. The resident stopped mid-sentence to ask the surveyor if she saw the gnats in her room. The resident stated she needs to drink a lot of water to aid in passing the kidney stones but the gnats go down the straw into her water so she doesn't always have water to drink. Resident #273 also stated the gnats were in her room when she was admitted to present time. The resident also said when she removes the top from her meal tray she has to fight the gnats off to consume the meal. The resident further stated what is homelike about that. An interview was conducted with the Director of Maintenance on 6/23/23 at approximately 12:15 p.m. The Director of Maintenance stated they had a problem with gnats but it is no longer a concern. He also stated the gnats were associated to the resident having flowers and plants in the facility and he thinks if they keep them out the problem will be totally resolved. The Director of Maintenance stated, I asked the pest control company come in today (6/23/23) because he was asked today about the gnat situation in the facility. The pest control technician used a special aerosol was gnats today and prior to that he believes the special aerosol was used last month. Over the four days of the survey (6/20/23 - 6/23/23) the survey team identified gnats throughout the facility including the conference room. On 6/23/23 at approximately 2:05 p.m., the above findings were shared with the Administrator, Director of Nursing, a Corporate Consultant, and the Regional [NAME] President of Operations. An opportunity was offered to the facility's staff to present additional information but no additional information was provided, and no further concerns were voiced.

Based on a complaint investigation, observations, staff interviews and facility document review the facility staff failed to ensure a clean, comfortable, homelike environment for 1 of 6 residents in the survey sample, Resident #1. The facility staff failed to ensure the floor in Resident #1's room was free from dried, sticky tube feeding spillage. The findings included: Resident #1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to; [CONDITION(S)] with Ventilator Dependence, Gastrostomy Tube (feeding tube), and [CONDITION(S)]. The most recent Minimum Data Set (MDS) was a quarterly with an Assessment Reference Date (ARD) of 6/4/22. The Brief Interview for Mental Status was not completed due to the resident being comatose. Under Section K Swallowing and Nutritional Status, Resident #1 was coded as receiving 51% or more of total calories via tube feeding. On 6/28/22 at 11:30 a.m. Resident #1's room was inspected. While walking into the room and around to the left side of the bed a large amount of a sticky substance was noted on the floor. This surveyors shoes were sticking to the floor with each step. Under and on the base of Resident #1's tube feeding pole there was a large amount of tube feeding spillage observed. While in the Resident's room Respiratory Therapist #2 entered the room and stated, This floor is sticky, my shoes are sticking. On 6/28/22 at 2:45 p.m. Resident #1's room was inspected again. The floor was still sticky and the tube feeding spillage continued to be present under and on the tube feeding pole. On 6/29/22 at 10:00 a.m. Resident #1's room was inspected. The floor remained sticky and there was tube feeding spillage still present on the floor and the tube feeding pole. On 6/28/22 at 2:15 p.m. an interview was conducted with Housekeeper #1 Resident #1's room. Housekeeper #1 stated, I wipe down the bedrails daily because the tube feeding gets spilled on it. The nurses spill stuff on the floor al the time. I usually mop his (Resident #1's) floor two times a day because he always has sticky stuff on the floor. On 6/29/22 at 3:30 p.m. this surveyor and the Director of Housekeeping walked to Resident #1's room. The Director of Housekeeping was shown the tube feeding spillage that was on the tube feeding pole and on the floor. The Director of Housekeeping stated, I see the tube feeding. We need to move the pole and mop under it and wipe the pole down. I will get it taken care of and make sure my staff are aware from now on. The facility policy titled General/Routine Environmental Cleaning and Disinfection Policy last revised 3/12/20 was reviewed and is documented as follows: Policy: Proper cleaning and disinfecting of environmental surfaces is necessary to break the chain of infection. Cleaning refers to the removal of visible soil from surfaces through the physical action of scrubbing with detergents/surfactants and rinsing with water. B. Household surfaces should be cleaned on a regular basis, when spills occur, and when surfaces are visibly soiled. On 6/29/22 at 5:21 p.m. a pre-exit debriefing was conducted with the Administrator and the Director of Nursing where the above information was shared. The Administrator stated, Floors are to be mopped daily and all spills are to be immediately cleaned up and housekeeping notified. Prior to exit no further information was shared. Complaint deficiency

Based on staff interviews, clinical record review, documentation review and the facility policy, the facility staff failed to meet professional standards of quality and provide an ongoing assessment and monitoring after an unwitnessed fall for 5 of 23 residents (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #23) in the survey sample. The findings included: 1. Resident #1 was admitted to the nursing facility on 11/03/15. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's Minimum Data Set (MDS - an assessment protocol) an annual with an Assessment Reference Date (ARD) of 08/12/21 coded Resident #1 Brief Interview for Mental Status (BIMS) with a 13 out of a possible score of 15 indicating no cognitive impairment. The MDS coded Resident #1 independent with no supervision or physical setup from staff with bed mobility, transfer, dressing, toilet use, personal hygiene and bathing for Activities of Daily Living (ADL) care. The care plan identified Resident #1 with an unwitnessed fall on 11/20/19 without any apparent injuries. The goal set for the resident by the staff to be without complications related to fall. Some of the interventions/approaches the staff would use to accomplish this goal offer assistance to the resident with toileting prior to going to bed and Occupational Therapy (OT) to evaluate. The Fall Risk assessment dated [DATE] assessed the residents score as a 12. A score of 10 or more indicates a High Risk for falls. Review of the clinical nurse's notes evidenced an entry dated 11/20/19 at 10:29 p.m. The nurse documented she heard a scream from the resident's bathroom (door was closed) .this nurse opened the bathroom door observed the resident on the floor lying on her right side. Vital signs (VS): (BP) 115/67, (P) 67, (R) 22, (T) 98.5, and oxygen saturation 99% on room air. The resident did not complain of pain, able to move extremities without difficulty. The clinical note also included the following recommendations: continue to monitor and post fall process per protocol. Review of Resident #1's clinical record revealed neurological assessment was initiated and started on 11/20/19 at approximately 10:30 p.m., related to an unwitnessed fall. The frequency of neurological assessments was scheduled for every 15 minutes x 4; then every 30 minutes x 4; then every 1 hour x 4; then every 4 hours x 4; then every 8 hours x 7 then stop. The clinical record revealed during the every 8 hours x 7 neurological assessments, Resident #2 was only assessed 4 times out of the 7 assessments. 2. Resident #2 was admitted to the nursing facility on 07/18/19. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's Minimum Data Set (MDS - an assessment protocol) a quarterly with an Assessment Reference Date (ARD) of 10/03/20 coded Resident #2 Brief Interview for Mental Status (BIMS) with a 12 out of a possible score of 15 indicating moderate cognitive impairment. The MDS coded Resident #2 supervision with setup help only with bed mobility, transfer, dressing, eating and toilet use, supervision with limited assistance of one with personal hygiene and independent with no supervision with bathing for Activities of Daily Living (ADL) care. The care plan identified Resident #2 with an unwitnessed fall on 11/07/19 without any apparent injuries. The goal set for the resident by the staff was that the resident will be free from complications. One of the interventions/approaches the staff would use to accomplish this goal was to encourage resident to use call light if assistance is needed. The Fall Risk assessment dated [DATE] assessed the residents score as a 6. Another assessment was completed on 11/07/19 assessed the residents score as a 12. A score of 10 or more indicates a High Risk for falls. Review of the clinical nurse's notes evidenced an entry dated 11/07/19 at 2:35 p.m. The nurse documented Resident #2 was observed with her hands and knees on the floor. The clinical note indicated that the fall was an unwitnessed fall and the resident said she was trying to go bed. The resident's hands, knees or any other part to the body assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The note revealed resident did not complain of pain andwas able to move extremities without difficulty. The clinical note also included neuro checks in progress as ordered. Review of Resident #2's clinical record revealed neurological assessment was initiated and started on 11/07/19 at approximately 2:30 p.m., related to an unwitnessed fall. The frequency of neurological assessments was scheduled for every 15 minutes x 4; then every 30 minutes x 4; then every 1 hour x 4; then every 4 hours x 4; then every 8 hours x 7. The clinical record documented Resident #2 was only assessed once out of the every 4 hours x 4 assessments and was never assessed during the 8 hours x 7 assessments. 3. Resident #3 was originally admitted to the nursing facility on 02/05/14. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's Minimum Data Set (MDS - an assessment protocol) an quarterly with an Assessment Reference Date (ARD) of 07/13/21 coded Resident #3 Brief Interview for Mental Status (BIMS) a 03 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognitive skills for daily decision-making. The MDS coded the resident total dependence of one with bathing, extensive assistance of one with bed mobility and toilet use, activity only occurred with one assist with with transfer and dressing. Under section G-0400 (Functional limitation in Range of Motion (ROM) was coded for impairment on both side to bilateral lower extremities. The care plan identified Resident #3 with an unwitnessed fall on 11/26/19 without any apparent injuries. The goal set for the resident by the staff was that the resident will be free from complications. One of the interventions/approaches the staff would use to accomplish this goal was to encourage resident to use call light if assistance is needed. The Fall Risk assessment dated [DATE] assessed the residents score as a 14. A score of 10 or more indicates a High Risk for falls. Review of the nurse's notes evidenced an entry dated 11/26/19 at 6:47 a.m. The nurse documented Resident #3 was observed on the floor at 6:30 a.m., (VS) (BP) 138/68, (P) 76, (R) 18. The nurse's note indicated the resident woke up and was on the floor, Review of Resident #3's clinical record revealed neurological assessment was initiated and started on 11/26/19 at approximately 6:30 a.m., related to an unwitnessed fall. The frequency of neurological assessments was scheduled for every 15 minutes x 4; then every 30 minutes x 4; then every 1 hour x 4; then every 4 hours x 4; then every 8 hours x 7. The clinical record documented Resident #3 was only assessed twice during the every 4 hours x 4 assessments, and was never assessed during the every 8 hours x 7 assessments. 4. Resident #4 was originally admitted to the nursing facility on 11/23/19. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4's Minimum Data Set (MDS - an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 07/25/21 coded Resident #4's Brief Interview for Mental Status (BIMS) a 03 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognitive skills for daily decision-making. The care plan identified Resident #4's with an unwitnessed fall on 12/23/19 without any apparent injuries. The goal set for the resident by the staff was that the resident will be free from pain related to fall. One of the interventions/approaches the staff would use to accomplish this goal was to place Dycem in the resident's wheelchair. The Fall Risk assessment dated [DATE] assessed the residents score as a 11. A score of 10 or more indicates a High Risk for falls. Review of the clinical nurse's note evidenced an entry dated 12/23/19 at 6:02 p.m. The nurse documented the Certified Nursing Assistant (CNA) informed her that Resident #4 had an unwitnessed fall in the activity room. The nurse note indicated that the resident fell from her wheel chair and was lying flat on the floor with her eyes open. The resident did not complain of any pain. (VS): (BP) 169/91, (P) 101, (R) 18, (T) 96.6, and oxygen saturation 89 on room air. The note documented Resident #4 has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's clinical record revealed neurological assessment was initiated and started on 12/23/19 at approximately 5:00 p.m., related to an unwitnessed fall. The frequency of neurological assessments was scheduled for every 15 minutes x 4; then every 30 minutes x 4; then every 1 hour x 4; then every 4 hours x 4; then every 8 hours x 7. The clinical record revealed during the every 8 hours x 7 assessments, only one of the assessments were completed. 5. Resident #23 was admitted to the nursing facility on 09/19/19. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #23's Minimum Data Set (MDS - an assessment protocol) a significant change with an Assessment Reference Date (ARD) of 12/27/19 coded Resident #23 Brief Interview for Mental Status (BIMS) scored a 99 indicating short and long term memory problems and with severe cognitive impairment - never/rarely made decisions. The MDS coded Resident #23 total assistance of two with bed mobility, dressing, eating, toilet use personal hygiene and bathing for Activities of Daily Living (ADL) care. The care plan identified Resident #23 with an unwitnessed fall on 11/20/19 without any apparent injuries. The goal set for the resident by the staff to be without complications related to fall. Some of the interventions/approaches the staff would use to accomplish this goal is to offer assistance to the resident with toileting prior to going to bed and Occupational Therapy (OT) to evaluate. The Fall Risk assessment dated [DATE] assessed the residents score as a 18. A score of 10 or more indicates a High Risk for falls. Review of the nurse's note evidenced an entry dated 11/21/19 at 3:25 p.m. The nurse documented the Certified Nursing Assistant (CNA) informed her on the same day at 2:45 p.m., that Resident #23 was lying on floor mats on the right side of the bed; no apparent injuries noted. (VS): (BP) 137/68, (P) 82, (R) 18, (T) 97.7 and oxygen saturation 97% on room air. Review of Resident #23's clinical record revealed neurological assessment was initiated and started on 11/21/19 at approximately 3:00 p.m., related to an unwitnessed fall. The frequency of neurological assessments was scheduled for every 15 minutes x 4; then every 30 minutes x 4; then every 1 hour x 4; then every 4 hours x 4; then every 8 hours x 7. The clinical record revealed during the every 8 hours x 7 assessments, none of the assessments were completed. An interview was conducted with the Director of Nursing (DON) on 09/10/21 at approximately 9:45 a.m. The DON stated, The expectations is for the nurse's to complete the entire neurological assessment as it appears in Point Click Care (PCC). On 09/10/21 at approximately 4:20 p.m., a pre-exit meeting was held with the Administrator, Director of Nursing, Regional Nurse Consultant and Education Specialist. No additional information was provided. The facility's policy titled Fall Prevention and Management Policy - revision date 12/09/19. Residents will be assessed for fall risk(s) on admission, quarterl, after any falls, and as needed. The facility's policy titled Neurological Checks Policy - revision date 05/27/21. Polivy: Neurological checks are indicated to monitor for potential irregularities in neurological status in the event of know or unknown head trauma as the result of a resident event, change in resident condition, or physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Procedure (General Guidelines) A.) An initial neurological check will be performed by a licensed clinician for all residents who have sustained a witnessed, unwitnessed, alleged, or suspected head trauma following an unusual occurrence or change in resident neurological condition. B.) The neurological check assessment in the electronic health record will be initiated to trigger the periodic checks and to document the results of the neurological checks. Unless otherwise ordered by the physician, the frequency of neurological assessments will be: every 15 minutes x 4; then every 30 minutes x 4; then every 1 hour x 4; then every 4 hours x 4; then every 8 hours x 7. C.) Elements to be assessed: level of consciousness, mental status, ability to communicate, movement/coordination, reflexes, changes in behavior and vitals signs: (BP, pulse and respirations). Complaint deficiency

Based on staff interview, clinical record review and facility document review, it was determined that facility staff failed to conduct an initial wound assessment to a sacral pressure ulcer upon admission; identify wounds to the right and left ischium prior to an advanced stage; AND failed to conduct complete and accurate weekly wound assessments from 12/4/20 through 12/30/20 that led to the deterioration of both the left and right ischium which constitutes harm for one of eight sampled residents, Resident #8. The findings included: Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #8's most recent MDS (Minimum data set) was a discharge assessment with an ARD (Assessment Reference Date) of 1/7/21. Resident #8 was coded in Section B as being in a persistent Comatose state. Resident #8 was coded as requiring total dependence on all ADLS (Activities of Daily Living) from staff. Resident #8 was documented in Section H (Bladder and Bowel) as always being incontinent of bowel and having a Foley catheter. Review of Resident #8's care plan dated 10/12/20 revealed the following skin preventative interventions were put into place: - Administer treatments as ordered and monitor for effectiveness. - Assess/document/report to MD (Medical Doctor) PRN (As needed) changes in skin status. - Assess/record/monitor wound healing per routine. - Educate the family/and/or caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. - Inform the family/and/or caregivers of any new area of skin breakdown as needed. - Medications/supplements/etc. to promote wound healing per orders - The resident requires LAL (Low Air Loss) mattress on bed to help promote wound healing and help prevent further skin breakdown. Review of Resident #8's POS (Physician order [REDACTED].#8 was placed on the following skin preventative measures: -Turn and Reposition Q (every) 2 hours as tolerated while in bed. This order was discontinued on 1/8/21. -Pro-Stat Liquid (Protein) Give 30 mls (milliliters) via Pe[DEVICE] two times a day for wound care. This order was discontinued on 10/27/20. -ProMod Liquid (Protein) Give 30 ml via peg two times a day for wound care. This order was initiated on 10/31/20 and discontinued on 11/4/20. -Zinc Capsule 220 MG (milligrams) Give 1 tablet via Peg Tube daily. This order was initiated on 11/1/20 and discontinued on 11/7/20. -Pro-STAT BID (Two times a day). This was initiated on 11/4/20 and discontinued on 1/8/21. -[MEDICATION NAME] Acid (Vitamin C) 250 mg Tablet Give 1 tablet daily for supplement. This order was initiated on 11/1/20 and discontinued on 1/8/21. Further review of Resident #8's clinical record revealed that Resident #8 was discharged from the facility on 10/27/20 for Respiratory distress. The following note was documented on 10/27/20 at 9:00 a.m.: Upon morning assessment (sic) patient was found to respiratory distress .Diminished breath sound at the bases with scattered Rhonchi .Was unable to get O2 saturation to stabilize (sic) and patient remained [MEDICAL CONDITION] (high pulse). Spoke with PA (Physician Assistant) who said to send out 911 . The next nursing note documented on 10/27/20 at 3:40 p.m. documented the following: Resident admitted to (Name of hospital) [MEDICAL CONDITION]. Sister notified. Resident #8 was admitted back to the facility on [DATE]. The hospital discharge instructions dated 10/31/20 documented Resident #8 as having a stage three (1) pressure ulcer to his sacral area. The following was documented in an admission note dated 10/31/20, Patient arrived at facility at 1935 (7:35 p.m.) via stretcher with medical personal. Patient's eyes open and nonverbal, unable to assess due to condition. Vitals stable and patient is afebrile with no signs or symptoms of pain .Ulcer present on sacral area with, [MEDICATION NAME] (dressing) (sic) present which was cleaned with NS (normal saline). There was no evidence of any initial measurements or description of Resident #8's sacral wound upon admission to the facility. There was no evidence of a treatment put into place on the physician order [REDACTED]. However, there was a note by the physician on 11/3/20 that documented in part, the following: appropriate ointment and dressing to the sacral [MEDICAL CONDITION], wound care consult. The first documented assessment on Resident #8's sacral wound was by the wound care physician on 11/6/20 (One week later). The following was documented: Pressure .unstageable (2) .Length: 9 Width: 7 Depth: 0 .Sanguineous Drainage .Scant drainage .Wound bed appearance: slough . santyl, Dakin's, skin prep, border gauze. Further review of Resident #8's November 2020 TAR (Treatment Administration Record) revealed staff were completing the above orders for his sacral wound recommended on 11/6/20. Review of Resident #8's pressure ulcer notes revealed that Resident #8 had also developed an unstageable pressure ulcer to his right ischium as well as a stage three to his left ischium on 11/29/20. There was no evidence of any previous documented skin alterations to these areas prior to an advanced stage. The following wound notes documented by the wound care physician were documented: Left ischium .stage 3 .Length (cm) (centimeters): 4, Width: 5, Depth: 0.2 .Drainage Type: Serosanguinous, Drainage: Moderate, Wound bed appearance: Pink .Treatment: santyl, Dakin's, cover. Unstageable due to necrosis to the right ischium .4.5 x 3.5 x not measurable .The wound is in a (sic) [MEDICAL CONDITION] stage and unable to progress to a healing phase because of the presence of biofilm .Surgical Debridement Procedure .Dakin's solution apply once for 30 days; Santyl apply once daily for 30 days. Review of Resident #8's clinical record revealed the next visit from the wound care physician was on 12/3/20. Resident #8's sacrum, right and left ischium were assessed. The following was documented: Stage 4 pressure (3) wound sacrum .7 x 5 x 2.5 cm (centimeters) .Santyl apply once daily for 26 days; Dakin's solution apply once daily for 26 days; ¼ strength Dakin's moistened gauze . Stage three of the left ischium .6 x 4 x 0.2 cm .Santyl apply once daily for 26 days; Dakin's solution apply once daily for 26 days . Unstageable due to necrosis (dead tissue) right ischium .5 x 4 x not measurable cm . Dakin's solution apply once daily for 26 days; Santyl apply once daily for 26 days . Review of Resident #8's clinical record failed to evidence any further complete weekly wound assessments on the above wounds including measurements; descriptions and stages until 12/30/20. (For 26 days). A physician progress notes [REDACTED].My PA is also seen in and agrees with this sacral wounds seem to be improving according to the nursing staff that work with it .sacral [MEDICAL CONDITION] do not look infected .sacral ulcers; still about 2.5 cm on each gluteal area with no surrounding [MEDICAL CONDITION] or abscess. Wound care team will follow them show slight improvement. The above note failed to document which gluteal ulcer the physician was referring to and failed to document complete wound measurements, descriptions, and stages of Resident #8's sacral, right and left ischium pressure ulcers. A physician progress notes [REDACTED].had multiple sacral wounds . They were doing bathing so I was able to evaluate all of his wounds for the first time in a while He has multiple wounds on his sacral area none of them look secondarily infected . he has several sacral [MEDICAL CONDITION]. The right-side buttocks as a large eschar which is unstageable left side is deeper as is the superior one these are both dressed and packed they just been cleaned of the nurses remove the dressings to show me. There's no secondary infection no foul odor they look well cared for . multiple decubitus ulcers were evaluated today. All are well cared for the wound care team is seeing the patient. I'll leave issues of debridement up to them. I don't think any of them need antibiotics at this stage. The above note from the Medical Director again failed to document a complete description off all wounds including stages of the left ischium and the sacral ulcer as well as measurements of all three wounds. On 12/30/20 it was documented that Resident #8's right ischium wound was draining foul smelling drainage. The following nursing note was documented: .PRN (as needed) treatment done to sacrum, left and right ischium, wound on right ischium is draining heavily with foul smelling drainage, CM (Clinical Manager) notified . On 12/30/20 the following note by the physician assistant documented in part, the following: On examination, there is a large communicating unstageable wound of the right buttock traversing anteriorly into the perineum. There is a significant amount of necrotic eschar covering the wound. The area around the wound is swollen and palpable. A small hole noted at the edge of eschar on the buttock noted to be draining a small amount of foul smelling green discharge. I inserted my finger into the hole to widen the aperture and could palpate bone. With my hands, I expressed a copious amount of malodorous discharge from the wound defect, estimated 100 to 150 mL altogether. There is no surrounding [DIAGNOSES REDACTED] (swelling) or warmth. No streaking noted. The chronic stage IV wound of the low back/sacrum actually appears to be healing well, with beefy red wound bed, no discharge or bleeding, no swelling or warmth. Unit manager and DON (Director of Nursing) were notified of this significant change. I also contacted (Name of wound care physician) and discussed my findings. She will be coming tomorrow for weekly wound rounds. (She has not been able to come into the facility since 12/7 secondary to COVID-19 outbreak). She advised against starting any antibiotics until she can assess. Wound cultures were obtained and will be sent out in the morning. Labs will also be repeated in the morning. Nursing staff was made aware. Wound care orders were also updated to include Santyl ointment and Dakin's- soaked gauze . I also spent a good deal of time discussing nutritional status with the dietitian. The patient has appeared more cachectic of late but has not been waived since December 4. I asked nursing staff to weigh him tomorrow. Most recent [MEDICATION NAME] (plasma protein) remained low at 2.8. Dietitian has recommended adjusting his TF tube feed) a higher-protein formula and continuing pro-stat 30 mL three times daily. He is already receiving vitamin C . On 12/30/20 the Physician Assistant also ordered a Complete Metabolic Panel (Complete Metabolic Panel) that showed Resident #8's [MEDICATION NAME] (protein) level to be low at 2.2. (Normal Range: 3.5-5.7). Based on the above [MEDICATION NAME] level the dietician recommended the following on 12/31/20: RD (Registered Dietician) recommend and discussed with NP change .1) Impact Peptide (4) 1.5 cc/hr x 22 hours with Prostat BID (two times a day) .Will provide L-[MEDICATION NAME] (amino acid) to help with wound management . Review of the January 2020 MARS (Medication Administration Record) revealed the above dietary orders were implemented starting 1/1/20. The next note dated 1/1/20 by the Medical Director documented the following: HPI: extremely complex extremely ill patient is been followed closely by my partner. She's been in contact with the wound care doctor who unfortunately is not been able to come in to see this patient for some time. (Name of charge nurse) the charge nurse has done wound rounds on this patient with me and will do full wound rounds on this patient today .They all are foul-smelling and appear to be getting worse . The wound care Dr. has specified to my PA to not start antibiotics until she saw the patient but after texting back and forth with her today and telling the wound care Dr. patient's wounds were becoming more foul-smelling with discharge we are starting antibiotics at her recommendation. Starting's [MEDICATION NAME] that should cover most everything including anaerobes. Starting a midline or PICC line . Review of Resident #8's POS (Physician order [REDACTED].#8 was started on [MEDICATION NAME] Solution (antibiotic) Reconstituted 3.3.75 GM- 1 dose every 6 hours for Decubitus ulcer for 10 days. On 1/1/21 it was documented that right ischium wound had deteriorated and had increased in size. The following assessment was documented: Note Text: Wound type is pressure. Stage: unstageable Wound Location right lower ischium/buttock Length (cm) 11 Width (cm) 11 Depth (cm). Area is in house acquired .Skin impairment was not present on admission .Drainage type: Purulent Drainage Heavy Drainage Wound bed appearance is Yellow Wound bed appearance is Necrotic Wound bed has Slough Strong odor Periwound appearance is Necrotic/Black .Wound is deteriorating. On 1/1/21 it was determined that the left ischium; that was once a Stage 3 on 12/4/20 had deteriorated to an unstageable pressure ulcer and had increased in size. The following was documented: Wound type is pressure. Stage: unstageable/dti Wound Location left lower (sic) ischium/buttock Length (cm) 8 Width (cm) 4 Depth (cm). Area is in house acquired. Skin impairment was not present on admission. Further review of Resident #8's clinical record showed no decline to his Stage IV sacral wound on 1/1/21. Review of Resident #8's clinical record revealed that the wound care physician had evaluated Resident #8's wounds on 1/7/20 (the day of Resident #8's discharge). The following in part, was documented for the right and left ischium: Unstageable due to necrosis of the left ischium .7 x 7 x not measurable . This wound is in an [MEDICAL CONDITION] stage and is unable to progress to a healing phase because of the presence of biofilm. Wound progress: Deteriorated .Surgical excisional debridement procedure . Unstageable due to necrosis of the right ischium .14.0 x 11.0 x not measurable .wound deteriorated .Purulent drainage coming out of wound, large flap of tissue debrided- left with exposed bone .Will likely need six weeks of antibiotics for clinical osteo[DIAGNOSES REDACTED] (Inflammation/Infection of Bone). Will discuss with PA (physician's assistant). On 1/7/21 it was documented that Resident #8's had been sent out to the hospital for a worsening pressure ulcer of his posterior head that had been followed by neurosurgery. Resident #8 was also sent out for worsening [MEDICAL CONDITION]. On 2/3/20 at 10:08 a.m., an interview was conducted with RN (Registered Nurse) #1, the clinical manager on the 400 hall. When asked who was responsible doing weekly wound measurements, RN #1 stated that the wound care physician usually made rounds on the residents with wounds. When asked if LPNs and RNs could stage wounds, RN #1 stated that they could. When asked if nurses should be conducting weekly wound assessments when the wound care physician was not available or present, RN #1 stated that they should. When asked the purpose of weekly wound measurements, RN #1 stated that weekly wound measurements were a way to monitor wounds to see if wounds were improving, getting worse, if treatments need to be changed etc. RN #1 stated that nurses also conducted biweekly skin assessments and should be documenting any new area of skin breakdown. When asked the process if a nurse or certified nursing assistant identifies a new skin area and a new skin area upon admission, RN #1 stated that she expected staff to assess the area, notify her as the unit manager, and initiate a treatment. RN #1 then stated they would also obtain a wound consult from the wound care physician. When asked why nursing staff were not conducting weekly wound assessments on Resident #8 ' s wounds after 12/4/20; RN #1 stated, I can ' t answer that, I was out sick. RN #1 stated that she had come back on 1/1/21 and did a sweep of the entire unit. When asked if Resident #8 ' s right and left ischium had deteriorated from the previous assessment dated [DATE]; RN #1 stated, Yes, ma ' am they really increased in size. When asked what she saw to the left and right ischium on 1/1/21; RN #1 stated that the left ischium did not have an odor, but that the right one appeared to be infected. When asked if the lack of wound assessments from 12/4/20 through 12/30/20 caused the wounds to the left and right ischium to deteriorate, RN #1 stated, That's a tough call. We try to stay diligent with wound care. When asked if Resident #8's sacral wound was assessed upon admission; RN #1 could not recall. When asked if wounds should be assessed upon admission to the facility, RN #1 stated that they should. When asked if it were probable that Resident #8 could develop an unstageable to his right ischium and a stage three to his left ischium overnight; as his skin assessment directly prior to 11/29/20 (the day the wounds were identified at an advanced stage) showed no new areas; RN #1 stated, Yes, Ma ' am. He has a neurological deficit from a [MEDICAL CONDITION], so his blood flow is not concentrating on wound healing. RN #1 proceeded to say that his body was focused on keeping his heart pumping and lungs breathing. On 2/3/21 at 11:11 a.m., an interview was conducted with ASM (Administrative Staff Member) #3, the Medical Director. When asked if he could tell me about Resident #8 ' s wounds, ASM #3 stated, I can ' t tell you much. ASM #3 then stated that the wound care specialist is the practitioner who evaluates all wounds, that he will just do a brief overview of the wounds to look for signs of infection. ASM #3 stated that Resident #8 ' s sacral wounds were Bad all along but could not go into detail about the status of each wound. On 2/3/21 at 2:38 p.m., an interview was conducted with the ASM #4, the Wound Care Physician. When asked why she last saw Resident #8 on 12/4/20; ASM #4 stated that there was a COVID outbreak in the building and that she was considered a high-risk exposure to COVID-19. When told ASM #4 that weekly wound assessments could not be found for Resident #8 after 12/4/20 to his right and left ischium and sacral area until 1/1/21; ASM #4 stated, Absolutely, they drop off. When asked if she expected nursing staff to continue to do weekly wound measurements when she cannot go into a building; ASM #4 stated that she first expected staff to be available to do telemedicine rounds with her. ASM #4 stated that she could not get staff to make rounds with her via telehealth during the time she was out. ASM #4 stated that she was not able to go back into the facility until 1/7/21, when the outbreak was under control. ASM #4 confirmed that Resident #4 ' s left ischium had deteriorated to an unstageable and the right ischium wound had necrotic tissue as well as purulent drainage and had increased significantly in size. ASM #4 stated that it was not unusual for Resident #8's wounds to continue to deteriorate after 12/30/20 when the infection was identified. ASM #4 stated that once a resident has an infection of that magnitude it was not uncommon for more wounds to pop up. ASM #4 stated however that prior to 12/30/20, she was not sure how his infection was first identified when copious amount of drainage was coming from his right ischium. ASM #4 stated that even though Resident #8 had a poor prognosis; the degree of his wound decline was significant. ASM #4 stated that she was not sure how his right and left ischium declined to that point. On 2/3/21 at 4:00 p.m., an interview was conducted with ASM #1, the Administrator and ASM #2 the DON (Director of Nursing). When asked if they had a COVID-19 outbreak in December 2019, ASM #2 stated that they did. When asked if physicians were not allowed in the facility at that time, ASM #2 stated that all physicians were allowed and could also do telehealth. When asked if staff were not available to ASM #4, the wound care physician to make rounds on wound patients during the outbreak, ASM #1 and ASM #2 stated that staff were available to her, but that she only wanted to round with just one nurse for continuity of care. ASM #1 stated that the wound care physician could have rounded with the nurses assigned to the patients she needed to evaluate. On 2/4/21 at 8:50 a.m., an interview was conducted with LPN (Licensed Practical Nurse) #2, a nurse who frequently worked with Resident #8, and who initially saw his right ischium wound infected on 12/30/20. LPN #2 stated that she had worked with Resident #8 in the beginning of December and was then moved to work the COVID unit. LPN #2 stated that when she returned on 12/30/20 to work with Resident #8, she had received report from the 11-7 shift nurse that his sacral wounds were getting bad. LPN #2 stated that the night shift nurse had told her that she alerted the physician but could not confirm if this really happened. LPN #2 stated that had alerted the clinical manager (RN #1) of what was reported to her, and that she wanted to assess the wound with the clinical manager. LPN #2 stated that she had to remind the clinical manager about 3-4 times that she needed assistance with assessing wounds. LPN #2 was then told by the clinical manager that they can Just look at them tomorrow. LPN #2 stated that Resident #8's wounds were not bad in the beginning of December, so she didn't feel right leaving the assessment for another day. LPN #2 stated that she asked a CNA (Certified Nursing Assistant) to help her with turning Resident #8. LPN #2 stated on her assessment she found one of the wounds draining a foul-smelling drainage. LPN #2 stated that she could not recall which wound was draining at that time. LPN #2 stated that both areas to the right and left ischium also looked bigger. LPN #2 stated that the wounds appeared to have significantly declined from when she had seen them last. LPN #2 stated that she was concerned when she had seen his wounds. When asked if she did a complete wound assessment by measuring each wound and documenting a description of each wound on 12/30/20; LPN #2 stated that she did not. When asked if nurses were supposed to conduct weekly wound assessments for residents with wounds, LPN #2 stated that the wound care physician made all the wound rounds and that after COVID-19 outbreak, it was not clear who was supposed to be making wound rounds. LPN #2 stated that she had notified the Physician Assistant who had also seen Resident #8 on 12/30/20. LPN #2 stated that Antibiotics were ordered via a PICC line. LPN #2 stated that the line was placed, and an x-ray had to be obtained to verify the placement. LPN #2 stated that the PICC had to be reinserted as it was not properly placed. LPN #2 stated that Resident #8 did not receive his antibiotics for a few days after the infection was identified, due to the issues with the PICC line. When asked the purpose of doing weekly wound rounds, LPN #2 stated that the purpose of assessing each wound on a weekly basis was to see if the wound was improving, deteriorating, or to see if treatment needs to be changed. LPN #2 could not recall Resident #8's sacral wound upon admission. LPN #2 could also not recall if Resident #8 had any skin issues to his right and left ischium prior to being found at an advanced stage. On 2/4/21 at 11:43 a.m., an interview was conducted with CNA (Certified Nursing Assistant) #2, a CNA who worked the day shift on 11/27/20 and 11/28/20 prior to Resident #8 ' s right and left ischium wound being found at an advanced stage. When asked how often staff turn and reposition residents, CNA #2 stated that she will turn and reposition every two hours. CNA #2 stated that it might be three hours if the day is busy. When asked the process if she were to find a new skin area on a resident, CNA #2 stated that she would report any new skin alterations to the nurse on duty. When asked when she would look at resident's skin, CNA #2 stated with bathing, dressing and turning. CNA #2 could not recall seeing a skin area to Resident #2 ' s right and left ischium on 11/27/20 and 11/28/20. On 2/4/21 at approximately 12:00 p.m., an interview was conducted with CNA #3, a CNA who worked 7p to 7 am on 11/27/20 and 11/28/20. CNA #3 stated that she worked with Resident #8 almost every day. When asked the process if she were to identify a new skin area, CNA #3 stated that she would immediately notify the supervisor. CNA #3 could not recall seeing any skin areas to Resident #8 ' s right and left ischium during that time. CNA #3 stated all that she could recall was the pressure that was bandaged up to his sacral area that was present on admission. The nurse who did a skin assessment on Resident #8 on 11/28/20; the day before his wounds were identified at an advanced stage was attempted to be reached for an interview on 2/4/21 at 9:10 a.m. and 11:21 a.m. She could not be reached. On 2/4/21 at approximately 1:00 p.m., further interview was conducted with ASM #4, the wound care physician. When asked if it were probable that Resident #8 could develop an unstageable to his right ischium and a stage three to his left ischium overnight; as his skin assessment directly prior to 11/29/20 (the day the wounds were identified at an advanced stage) showed no new areas of skin breakdown, ASM #4 stated, We all know it didn't come up at that stage. ASM #4 then stated there were probably skin areas to Resident #8 ' s right and left ischium prior to the advanced stage and it may not be clearly documented. ASM #4 stated that she was sure if she looked through his chart, she would be able to find something before each area turned to an advanced stage. ASM #4 was then told that nothing was documented to Resident #8 ' s right and left ischium prior to an advanced stage. ASM #4 stated, Give them (the facility) a chance to present something. It would be unusual for him to develop those areas at an advanced stage. ASM #4 stated that even with Resident #8 ' s poor prognosis it would be unusual for him to develop those wounds at an advanced stage. ASM #4 clarified again that after his infection was identified on 12/30/20; then she could believe new wounds could pop up quickly at an advanced stage. ASM #4 stated recently, in January of 2021 she had attended a meeting to discuss pressure ulcers in the facility and how to improve care. ASM #4 stated that she now has a designated wound care nurse to make rounds with her. ASM #4 stated that she has seen improvement in the facility with pressure ulcers. On 2/4/21 at 2:16 p.m., further interview was conducted with ASM #1 and ASM #2. When asked if she expected nursing staff to conduct weekly wound assessment on residents with wounds if the wound care physician is not available to assess, ASM #2 stated, Yes. When asked the purpose of the weekly wound assessments, ASM #2 stated that the purpose was to determine if the wound got bigger, improved or needed a change in treatment. This writer expressed concerns with Resident #8's pressure ulcer. When asked if all nurses, even LPNS can assess and stage wounds, ASM #2 stated that they can. ASM #1 stated that the facility was working on a solution for better continuity of wound care such as having one dedicated wound nurse to make wound rounds with the wound care physician. ASM #1 and ASM #2 were made aware of the concern for harm at this time. On 2/4/21 at 2:34 p.m., ASM #2 presented this writer a POC (Plan of Correction) for pressure ulcers. The following was documented: Problem 1-15-2021 Weekly Wound Documentation of wound measurements. Corrective Action for affected residents: A review of current residents with orders for pressure injury care: wounds were assessed and documented in the medical record 1-21-21 with assistance from the wound physician. How will the facility identify other like residents that have the potential to be affected and what corrective action will be done: Licensed nurses completed the facility skin assessments no new areas identified 1-18-21. Care plans were reviewed and updated if indicated. Residents will continue to have biweekly skin assessments completed and daily review of clinical alerts by licensed nurse. What will you do to prevent this from reoccurring or what systemic change will you implement: 1/11/21 a Wound nurse designated to provide consistency for residents with wounds. Licensed nurses were re-educated on Pressure area prevention and management policy with emphasis on completing weekly wound assessments which includes but not limited to obtaining measurements, a description of the wound bed, surrounding tissue, odors, drainage and that status of the wound. Education completed by the DON/Designee on 1/19/21. Wound physician attending weekly wound meeting beginning 1/27/21. How will you monitor and maintain ongoing compliance: Clinical manager/designee will conduct weekly audits x 4. Audit to include that wound assessment completed, skin assessments completed by licensed nurse, treatment orders in place, care plan reviewed and notification to responsible parties and physician. Audit to include residents with existing wounds and newly identified wounds. Weekly wound log reviewed by the Regional Director of Clinical Services. AD HOC (Needed) QAPI (Quality Assurance and Performance Improvement) meeting held on 1/25/21 to review identified concern and plan. Review of the facility's policy titled, Pressure Ulcer Prevention and Treatment Policy, documents in part, the following: Residents admitted with existing pressure injuries will receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection. New pressure injuries will not develop unless the individual's clinical condition demonstrates that they were unavoidable. A. Assessment: Residents will be assessed for pressure injury risk on admission, quarterly, and with significant changes of condition using the Braden Scale for Predicting Pressure Ulcer Risk. Wound identified will be assessed initially and at least weekly thereafter, until closed, to include the following elements: Location and stage Size (perpendicular measurements of the greatest extent of length and width of the ulceration), depth and the presence, location and extent of any undermining or tunneling/sinus tract; Exudate, if present: type: (such as purulent/serous), color, odor and appropriate amount; Pain, if present: nature and frequency (e.g., whether episodic or continuous); Wound bed: Color and Type of tissue/character including evidence of healing (e.g., granulation tissue, maceration) as appropriate; Appearance of surrounding tissue; Any evidence of infection If a PU/PI (Pressure Ulcer/Pressure Injury fails to show some evidence of progress toward healing within 2-4 weeks, the area and the resident's overall condition will be reassessed. B. Treatment: Pressure Injuries Identified will be documented and orders obtained from providers for treatment. C. Monitoring: At least weekly (and more when indicated by wound complications or changes in wound characteristics), an evaluation of the PU/PI will be documented. At a minimum documentation will include all elements listed in Section A. D. The facility will notify family/resident representatives and the provider of any newly acquired or worsening pressure injuries and any changes in treatment(s). On 2/4/21 at 4:38 p.m., ASM #1 presented this writer documents from Resident #8's hospital stay dated 10/4/20 that documented in part, the following: Palliative life expectancy less than 6 months. Neurosurgery note cites prognosis grim .improving respiratory status patient is being discharged back in fair condition to skilled nursing facility but at high risk for recurrent admission and poor long

Based on family interview, staff interview, clinical record review and facility document review, it was determined that facility staff failed to clarify the use of a helmet upon admission for one of 8 sampled residents, Resident #8 that led to the reopening of a pressure ulcer* to his posterior head and an abrasion to his forehead and nose. The findings included: Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #8's most recent MDS (Minimum data set) was a discharge assessment with an ARD (Assessment Reference Date) of 1/7/21. Resident #8 was coded in Section B as being in a persistent Comatose state. Resident #8 was coded as requiring total dependence on all ADLS (Activities of Daily Living) from staff. Resident #8 was documented in Section H (Bladder and Bowel) as always being incontinent of bowel and having a Foley catheter. Review of Resident #8's clinical record revealed that he was admitted to the facility on [DATE] with a stage three pressure ulcer to the back of his head. The following skin note was documented: Resident arrived via medical transportation from (Name of hospital) with recent significant head trauma .Stage 3 (1) to rear of head, 2.5 x1.5x 0.3 (centimeters) present on admission . Helmet for head protection from flap, no skull to right side of head. surgical incision well healed. PA (Physician Assistant) validated skin check and all medications as per discharge summary . Review of Resident #8's hospital discharge orders dated 10/12/20, failed to evidence orders for the use of his helmet. Review of Resident #8's clinical record failed to evidence that facility staff had clarified the use of his helmet upon admission. Resident #8's care plan dated 10/12/20 documented the following: Resident is required to wear a helmet. There was no further instruction on when Resident #8 should be wearing the helmet and when the helmet should be removed. Review of Resident #8's weekly wound assessments revealed the wound to Resident #8's posterior head had healed on 11/5/20. Review of Resident #8's skin assessments revealed that Resident #8's posterior head wound had opened back up on 11/24/20. The following was documented in a weekly wound note: unstageable (2) .posterior head .2 x 2 cm .date wound identified 11/24/20 .CA (Calcium Alginate) (treatment) off load with foam . re opening from previous admission . I spoke with residents RP (responsible party) his sister about the area on his posterior head re-opening. left note to DR. (Doctor) and wrote order for treatment. Review of Resident #8's November 2020 TAR (Treatment Administration Record) revealed that staff were documenting that they were implementing the above order for his head pressure ulcer. Review of Resident #8's clinical record revealed that he obtained a hematoma to his forehead due to his helmet on 11/28/20. The following note was documented: Occurrence Details: a hematoma was discovered when restorative went to do his arm braces. she came to get me, and he has a knot in the middle of his forehead with a scratch in the center. It appeared to have been an abrasion to me . I left a note for the DR. (Doctor) to see him on Monday. Immediate Intervention: measure, place a cold compress for 20 minute intervals which is helping with the swelling. A nursing note dated 11/30/20 documented the following: noted to have scab to front forehead, potentailly caused by helmet necessary to protect brain from MVA (Motor Vehicle Accident) in August 2020. MD notified sister notified. Small scab to bridge of nose, potentially from helmet as well . A physician's note dated 11/30/20 documented in part, the following: Previously healed stage III pressure ulcer of occiput scalp has worsened. Nursing staff was not utilizing foam cushion inside of helmet. Now has large unstageable pressure wound of occipital scalp with overlying eschar, as well as small DTI (Deep Tissue Injury) on frontal region of scalp/forehead. Wound care orders have been updated, and (Name of wound care physician) had been notified and will be assessing on Thursday . Review of Resident #8's clinical record revealed that the wound care physician had seen Resident #8's posterior head on 12/3/20. The following was documented: Unstageable due to necrosis of the posterior head .3.5 x 7.5 x not measurable .12/3 would recommend notifying neurosurgery; since its at the end of the incision line and with the craniectomy, there is concern for open wounds that would be exposed .Dakins solution apply once daily for 30 days: ¼ strength dakins solution . A nursing note dated 12/4/20 documetned the following: Spoke with resident sister she is concerned that resident is wearing his helmet while in bed. as per sister resident should only be wearing his helmet when out of bed. Will communicate with MD as per sister wishes. A note from the physician's assistant dated 12/9/20 documented in part, the following: .I have asked nursing staff to remove his helmet as I see no clinically utility for wearing constantly, and I belive its causing more harm than good as now he has two wounds associated with wearing it. A note dated 12/10/20 from the physcian's assistant documented in part, the following: .Unstageable wound of scalp appears to be healing better since his protective helmet was taken off 2 days ago .I spoke with sister/POA today .She confirms that indeed he was not supposed to wear his protective helmet continuously, only during medical transport or if he is having [MEDICAL CONDITION] activity . Review of Resident #8's clinical record revealed that Resident #8 had an appointment with neurosurgery on 12/14/20 for his posterior head wound. The following recommendations were given: [MEDICATION NAME] Cream 1% (percent) (treatment) apply to rear of head topically every shift for Pressure Ulcer foam dressing to support. A physician progress notes [REDACTED]. had multiple sacral wounds and the scalp pressure wound. The scalp wound was evaluated by neurosurgery at the request of the wound care doctor. This is because it was close to where he had skull removal. This is done better since we took the foam helmet off. He had no signs of any [MEDICAL CONDITION] does not need the protective helmet anymore . On 2/3/20 at 10:08 a.m., an interview was conducted with RN (Registered Nurse) #1, the clinical manager on the 400 hall. When first asked about Resident #8's pressure ulcer to his posterior head, RN #1 stated that Resident #1 had been admitted to the facility with either a stage 2 or 3 to the back of his head. RN #1 stated that she could not remember. When asked if there were any instructions on how to utilize the helmet; such when to take off the helmet and how long to leave it on, RN #1 stated that she did receive any instructions from the hospital on when to use the helmet. When asked how nursing staff were utilizing the helmet, RN #1 that nursing staff always left the helmet on except for during skin checks and bathing. When asked if the use of his helmet should have been clarified prior to his head wound re-opening; RN #1 stated, I am sure if (Name of PA) or (Name of Physician) had a concern, they would clarify. When asked if there should be directions on the resident's care plan on how to utilize the helmet and when to remove the helmet, RN #1 stated that she would not necessarily see this information on a care plan because it was nursing judgement to remove the helmet during hygiene and skin checks. When asked the purpose of the care plan, RN #1 stated that the purpose of the care plan was to give direction and expectations for nursing care. When read RN #1 the above note that the PA had written on 11/30/20 regarding nursing staff not utilizing foam for Resident #8's helmet, RN #1 stated that staff were utilizing the foam; that she wasn't sure why the PA had written that staff were not using the foam. RN #1 stated that since Resident #1 had a previous history of skin breakdown in that area, that it was more likely to reopen, especially since it was not easy to turn and reposition his head due half his skull missing. RN #1 then stated that staff were also utilizing the black foam until Resident #8 was seen by neurosurgery and a green foam was recommended. On 2/3/21 at 1:36 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #3, a nurse who frequently worked with Resident #8. When asked how Resident #8 was supposed to wear his helmet, LPN #3 stated that Resident #8 was supposed to wear it at all times. When asked if there should be an order for [REDACTED].#3 stated it was removed during bathing and skin checks. When asked if she expected directions on how to utilze the helmet be on the the care plan, LPN #3 stated that she didn't know if she would check the care plan but she would clarify orders with the MD (medical doctor) if there was no clear directions on how to utilize the helmet. On 2/3/21 at 3:53 p.m., an interview was conducted with ASM #5, the (Physician's Assistant). When asked about the use of Resident #8's helmet, ASM #5 stated that the in the beginning she was told that Resident #8 was supposed to wear the helmet continuously. ASM #5 stated that it seemed odd, but that Resident #5 had extensive trauma to the brain. ASM #5 stated that Resident #8 was admitted with a stage three wound to the posterior head. ASM #5 stated that the wound had healed at one point and then opened back up. ASM #5 stated that staff were then instructed to utilize black foam inside the helmet to offload pressure off the posterior head wound. ASM #5 then stated that staff stopped utilizing the black foam because offloading pressure to the back of the head, was then causing pressure to the front of Resident #8's head. ASM #5 stated that Resident #8 ended up getting an abrasion to his forehead due to offloading pressure to the back of his head. When asked if the wound to Resident #8's posterior head was caused by staff not utilizing the black foam per her note on 11/30/20; ASM #5 stated that she had originally thought that was the case and then realized the order was not in place until after the wound had developed and then she had found out the black foam was causing more harm than good. ASM #5 stated that she should have written a clarification note. ASM #5 stated that after the abrasion had occurred, she made the decision to call neurosurgery and to clarify the use of the helmet. ASM #5 stated that the wound care physician also wanted Resident #8 to be seen by neurosurgery due to his posterior head wound being close to the incision line and digging into the dura matter. ASM #5 stated that several appointments were made that ended up being canceled by the Neurosurgeon's office. ASM #5 stated that Resident #8 ended up going to neurosurgery on 12/14/20. ASM #5 stated that neurosurgery recommended [MEDICATION NAME] with green foam to the posterior head wound. ASM #5 stated that Neurosurgery never clarified the use of his helmet at that appointment and that after several attempts, she got in touch with the surgeon who stated, Wear it or not wear it- whatever. ASM #5 stated that she also talked to the RP (Resident #8)'s sister who stated that Resident #8 was only supposed to be wearing the helmet during transport or if he starts showing [MEDICAL CONDITION] activity. ASM #5 stated that she then decided to remove the helmet unless he was being transported. When asked who made her aware that Resident #8 was supposed to wear the helmet continuously when he was first admitted , ASM #5 stated that she was told EMS (Emergency Medical Staff) had told the nursing staff that he was supposed to always wear the helmet. When asked if she expected staff to clarify the use of the helmet sooner, such as upon admission, ASM #5 stated, Sure, I expect staff to call and clarify. ASM #5 then stated that when Resident #8 developed the abrasion to his forehead, she went through his chart and could not find any admission orders [REDACTED]. ASM #5 stated that there was no real urgency to clarify the use of the helmet unit his wound had opened back up. ASM #5 stated that Resident #8's head wound started healing up nicely after the helmet was removed until sometime in January, in a matter of days, the head wound had significantly increased in size. ASM #5 stated that her and the wound care physician decided to send the resident out to the hospital due to fluid that was found to his posterior head wound. ASM #5 stated that they were afraid the fluid was from the brain. On 2/4/21 at 11:43 a.m., an interview was conducted with CNA (Certified Nursing Assistant) #2, a CNA who frequently worked with Resident #8. When asked if she ever worked with Resident #8 when he was wearing his helmet, CNA #2 stated the thought by the time the resident was on her assignment, that he only had the bandage to his posterior head. When asked how she would know how to utilze the helmet if their were no clear instructions, CNA #2 stated, I would just get the nurse. On 2/4/21 at 12:00 p.m., an interview was conducted with CNA #3, another CNA who frequently worked with Resident #8. When asked how Resident #8 utilized his helmet, CNA #3 stated that Resiident #8 always had to have it in place, that she was told never to remove the helmet. CNA #3 also stated that she never removed the helmet during bathing. CNA #3 stated that she was always told not to touch his head. On 2/4/21 at 2:29 p.m. an interview was conducted with ASM #1 (Administrative Staff Member), the Administrator and ASM (Administrative Staff Member) #2, the DON (Director of Nursing). ASM #1 and ASM #2 were made aware of the above concern. ASM #1 then stated that not all orders get clarified upon admission and that the PA had clarified the use of Resident #8's helmet with neurosurgey. This writer informed ASM #1 that clarification was not done until after Resident #8's posterior wound had reopened and he obtained an abraison to his forhead and nose. It was requested that the facility send any evidence that the PA or any other nursing staff had clarifed the use of his helmet prior to his skin breakdown. On 2/4/21 at 4:56 p.m., further interview was conducted with ASM #2. When asked who was responsible for reconciliation of medications upon admission, ASM #2 stated the nurse doing the admission was responsible for entering the orders and that the unit manager went behind and reconciled medications. ASM #2 stated that she would have expected her staff to clarify the use of his helmet and when to remove etc When asked if there should be an order for [REDACTED]. No further information was presented prior to exit. Facility policy titled, Physician's Orders did not address the above concerns. The following information was obtained from National Pressure Ulcer Advisory Panel website at http://www.npuap.org/pr2.htm. *Pressure Ulcer- A pressure ulcer is localized damage to the skin and underlying soft tissues usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer that may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear also be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of soft tissue. (1) Stage Three Pressure Ulcer - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. (2) Unstageable Pressure Ulcer- Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Based on staff interview and clinical record review, the facility staff failed to notify a representative of the Office of the State Long-Term Care Ombudsman of discharges to the hospital for 6 residents (Residents #63, #27, #71, #61, #37 and #62) of 43 residents in the survey sample. This deficiency is cited as Past Non-Compliance. The findings included: On 12/12/19 at approximately 3:13 PM an interview was conducted with the Corporate Nurse Consultant concerning the above. She stated, Ombudsman notification will fall under our past non compliance. A document was received shortly thereafter concerning discharge notices not being sent to the local state ombudsman by the previous director of social services for (MONTH) or October. Corrective Action: The discharge notices will be sent to the ombudsman for those not previously sent. The Ombudsman was notified and he did confirm that he had not received notices for the past couple of months, but said that he is fine with us sending over a spread sheet monthly. How will the facility identify other like residents that have the potential to be affected and what corrective action will be done? An audit was completed of past residents to see if the notices were sent, those not sent are being sent to the ombudsman. What will you do to prevent this from reoccurring or what systematic change will you implement? The spread sheet will be reviewed monthly. How will you monitor and maintain ongoing compliance? The discharge spreadsheets will be reviewed in the monthly QAPI meeting to ensure they are being completed. QAPI: The issue was discussed on 12/06/19 as the new director of social services discovered that the notices had not been sent for the previous months. 1. Resident #63 was originally admitted to the facility on [DATE]. Resident #63 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. On 12/11/2019 at approximately 5:02 p.m., an interview was conducted with the Director of Social Services and when he was asked if the Ombudsman was notified of Resident #63's discharge to the hospital on [DATE], the Director of Social Services stated, I've only been here in this position for about two weeks and I contacted the previous Social Worker concerning discharge notices and she stated that she had faxed the list of residents who had been discharged in (MONTH) and (MONTH) to the Ombudsman but she did not have confirmation that they were sent to the Ombudsman. Going forward I will obtain confirmations when the Ombudsman is made aware of discharges. The Administrator, Director of Nursing and Regional Director of Clinical Services was informed of the finding on 12/12/2019 at 6:55 p.m. at the pre-exit meeting. The facility did not present any further information about the finding. 2. Resident #27 was admitted with [DIAGNOSES REDACTED]. Resident #27 was discharged to the hospital on [DATE]. There were no clinical records indicating the facility staff contacted the State Long Term Care Ombudsman of the discharge. During an interview on 12/11/19 at 11:10 [NAME]M. with the facility's Social Worker, he stated, The facility had not contacted the State Long Term Care Ombudsman regarding discharge to the hospital for Resident #27. 3. Resident #71 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. The Discharge MDS assessment was dated for 08/15/19 - discharged with return anticipated. On 08/15/19, according to the facility's documentation, Resident #71 was sent to the local emergency room (ER). Resident picked up at 6:05 PM and daughter notified right after. On 12/12/19 an interview was conducted with the facility Director of Social Services (Other Staff #1). He stated that Resident #71's name was not on the list that was sent out to the local ombudsman. A pre-exit meeting was held with the Administrator, Director of Nursing and Corporate Nurse Consultant on 12/12/19 at approximately 3:05 p.m. No further comments were made. 4. Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #61's clinical record revealed that she was transferred to the hospital on [DATE]. There was no evidence that the long term care ombudsman was made aware of this transfer on 8/9/19. Review of Resident #61's clinical record revealed that she had been transferred to the hospital for a second time on 11/23/19. There was no evidence that the long term care ombudsman was made aware of this transfer on 11/23/19. On 12/11/19 at 3:36 p.m., an interview was conducted with OSM (other staff member) #1, the Director of Social Work. When asked who was responsible for notifying the long term care ombudsman when a resident is sent out to the hospital for an acute care transfer, OSM #1 stated that the social worker was responsible for notifying the long term care ombudsman on a monthly basis of all discharges including acute transfers to the hospital. OSM #1 stated that he had only been employed with the facility for approximately two weeks. OSM #1 stated he was also in training the first week. OSM #1 stated that the only list of discharges he could find from the previous social worker was from (MONTH) of 2019. On 12/11/19 at 4:51 p.m., OSM #1 confirmed that he could find evidence that the long term care ombudsman was notified when Resident #61 was sent to the hospital on [DATE] and 11/23/19. On 12/12/19 at the pre-exit meeting (6:55 p.m.) ASM (administrative staff member) #1, the Administrator, ASM #2, the DON (Director of Nursing) and ASM #3, the Regional Director of Clinical Services were made aware of the above concerns. No further information was presented prior to exit. 5. Resident #37 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #37's clinical record revealed that she was sent out to the hospital on [DATE]. There was no evidence that the long term care ombudsman was made aware of this transfer on 9/19/19. On 12/11/19 at 3:36 p.m., an interview was conducted with OSM (other staff member) #1, the Director of Social Work. When asked who was responsible for notifying the long term care ombudsman when a resident is sent out to the hospital for an acute care transfer, OSM #1 stated that the social worker was responsible for notifying the long term care ombudsman on a monthly basis of all discharges including acute transfers to the hospital. OSM #1 stated that he had only been employed with the facility for approximately two weeks. OSM #1 stated he was also in training the first week. OSM #1 stated that the only list of discharges he could find from the previous social worker was from (MONTH) of 2019. On 12/11/19 at 4:51 p.m., OSM #1 confirmed that he could find evidence that the long term care ombudsman was notified when Resident # 37 was sent to the hospital on [DATE]. On 12/12/19 at the pre-exit meeting (6:55 p.m.) ASM (administrative staff member) #1, the Administrator, ASM #2, the DON (Director of Nursing) and ASM #3, the Regional Director of Clinical Services were made aware of the above concerns. No further information was presented prior to exit. 6. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #62's transfer and admission to the hospital on [DATE]. Resident #62 was originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Discharge MDS assessments was dated for 08/11/19 - discharged with return anticipated. An interview was conducted with the Director of Social Worker (DSW) on 12/11/19 at approximately 10:00 a.m. He said that he has only been employed at the facility for 2 weeks. The DSW stated, I have search the entire Social Worker's office and I am unable to provide evidence that the Ombudsman was notified of Resident #62's transfer to the hospital on [DATE]. A briefing was held with the Administrator, Director of Nursing and Regional Director of Clinical Services on 12/12/19 at approximately 6:53 p.m. The facility did not present any further information about the findings. The facility's policy titled Discharge or Transfer Letter Policy (Revised (MONTH) 5, (YEAR)). -Policy: The facility will complete discharge letters appropriately and according to all federal, state, and local regulations. -Procedure include but not limited to: E. Social Service or designees will assure the original letter is given to resident or guardian/sponsor, if applicable. -Copies will be sent to Department of Health, Ombudsman Office and filed in the business file and/or scanned into Point[NAME]Care (PCC) documents tab with administrator/designees signature. -For emergency transfers, one list can be sent to the Ombudsman at the end of month.

Based on observation, staff interviews, and review of the facility's policy, the facility staff failed to ensure food was stored under sanitary conditions. The finding included; On 12/10/19 at approximately 10:50 AM an initial tour of the kitchen was conducted with the Food Service Director (FSD). The following was observed during the tour: Located in the walk-in freezer-one opened and not sealed 5 lb. bag (1/2 full) of Chicken tenders with no opened date listed. Located in dry storage one opened bag of Brown Sugar (1/2 full) with no opened date. Located in the kitchen on the shelf was one bag of Red Raspberry Gelatin dessert mix. (1/4 mix left in bag) and one opened bag of[NAME]auce with no opened date listed. Located in the reach in freezer was one opened, unsealed, and unlabeled bag of frozen vegetables with no opened date. Located in the reach in freezer was a 2 lb opened (sealed) brown bag of french fries with no opened date. The bag was not labeled with what the product was. One opened, 12 ounce bag of dry gravy mix (1/4 full) with no opened date. Policy: Storage of Refrigerated Foods. Date Reviewed: 2/19/19. Date Revised: 2/19/19. Refrigerated items must have a label showing the name of the food and date it should be consumed, or discarded. On 12/11/19 at approximately 5:10 PM an interview was conducted with the Food Service Director (FSD) concerning the opened items listed above. She was asked what should have been done concerning the unlabeled/undated foods? She stated, They should have been labeled with an opened date. A pre-exit meeting was held with the Administrator, Director of Nursing and Corporate Nurse Consultant on 12/12/19 at approximately 3:05 p.m. No further comments were made.

Based on observation and staff interviews the facility staff failed to protect resident from public view during care for 1 resident (Resident #2), of 43 residents in the survey sample. The facility staff failed to ensure Resident #2's privacy was maintained during [MEDICAL CONDITION] care. The findings included: Resident #2 was originally admitted to the facility on [DATE]. [DIAGNOSES REDACTED].*[MEDICAL CONDITION], Ventilator and Persistent Vegetative State. Resident #2's Minimum Data Set (MDS-an assessment protocol), a quarterly assessment with an Assessment Reference Date of 09/09/19, coded Resident #2 requiring total dependence of two with dressing, bed mobility, bathing, and toilet use, total dependence of one with hygiene and eating. On 12/12/19 at approximately 8:30 a.m., the Respiratory Therapist (RT) performed [MEDICAL CONDITION] care with two surveyors present. While [MEDICAL CONDITION] care was being provided on Resident #2's, the privacy curtain was not pulled nor was her door closed to provide privacy. The RT performed [MEDICAL CONDITION] care as follows: -Removed gauze from around trach, removed [MEDICAL CONDITION], inner [MEDICAL CONDITION], gloves removed then washed her hands. -RT left the room, remove a split gauze from the treatment cart, came back into the room; door remained open and curtain still not pulled for privacy. -Washed hands, donned a new pair of gloves, cleaned [MEDICAL CONDITION] with wet saline gauze. -Placed a new split gauze around Resident #2's trach. -Suctioned Resident #2, gloves removed, hands washed. -Applied new gloves; listen to breathe sounds, then position Resident #2's head for comfort. During the [MEDICAL CONDITION] care procedure, the resident could be viewed by anyone walking past the doorway because the privacy curtain was not pulled and the door was left opened. On 12/12/19, immediately following [MEDICAL CONDITION] care, the RT was asked, Should the door be closed or the curtain pulled while [MEDICAL CONDITION] on Resident #2 she replied, Yes, I should have closed the door or pulled the curtain. The RT was asked, What is the purpose for pulling the curtain or closing the door while providing [MEDICAL CONDITION] care on (Resident #2), she replied, Normally, we do pull the curtain for privacy. An interview was conducted with Director of Nursing (DON) and Regional Director Vice President of Operations on 12/12/19 at approximately 2:01 p.m. The DON said the therapist should have pulled the curtain and close the door as necessary to provide dignity and privacy of the resident. A briefing was held with the Administrator, Director of Nursing and Regional Director of Clinical Services on 12/12/19 at approximately 6:53 p.m. The facility did not present any further information about the findings. The facility's policy titled Resident's Privacy (Revised 04/2015). -Purpose: All personnel will provide resident privacy to the maximum extent possible, in order to maintain the privacy of their bodies. -Procedure include but not limited to: -Residents shall be examined and treated in a manner that maintains the privacy of their bodies. -A closed door, drawn curtain, or both, shield the resident from passersby, as well as their roommate. -Resident's should be draped and dressed appropriately at all times to avoid exposure of embarrassment. -Privacy is also maintained during toileting, bathing, and other activities of personal hygiene. -Protecting the resident's privacy is a very important aspect of resident care and a right guaranteed by the Resident's Bill of Rights. Definitions: -[MEDICAL CONDITION] is a hole that surgeons make through the front of the neck and into the windpipe (trachea). A [MEDICAL CONDITION] is placed into the hole to keep it open for breathing (Mayoclinic.com). -Ventilator is a machine that supports breathing. Ventilators: Get oxygen into the lungs, remove carbon [MEDICATION NAME] from the body (Carbon [MEDICATION NAME] is a waste gas that can be toxic), help people breathe easier and breathe for people who have lost all ability to breathe on their own (nih.gov). -Persistent Vegetative State is a person with overwhelming damage to the cerebral hemispheres commonly pass into a chronic state of unconsciousness (ie, loss of self-awareness) called the vegetative state. When such cognitive loss lasts for more than a few weeks, the condition has been termed a persistent vegetative state, because the body retains the functions necessary to sustain vegetative functions (nih.gov).

Based on clinical record review, staff interviews, facility documentation review, and in the course of a complaint investigation, the facility staff failed to ensure residents entering the facility did not develop pressure ulcers unless they were unavoidable, or those residents that did develop them received the necessary treatment to promote healing, prevent infection and prevent new ulcers from developing for 3 out of 61 residents (R#18,#72 and #576) in the survey sample. 1. For Resident #18, the facility staff failed to accurately assess, treat, and monitor a sacral pressure ulcer that was incorrectly identified as a Stage I pressure ulcer upon readmission to the facility on [DATE]. Review of hospital discharge paperwork revealed identification of an unstageable sacral pressure ulcer upon hospital discharge. No treatment had been initiated prior to the pressure ulcer being later identified as an unstageable pressure ulcer by the facility staff, which required surgical intervention resulting in harm. In addition, Resident #18 acquired a DTI (Deep Tissue Injury) to the right plantar area of his foot on 12/27/17. 2. For Resident #72, the staff failed to identify a wound on the plantar surface of the left foot until it was 45% eschar (hard black dead tissue) and found by surveyors during wound care observations, due to observed exudate on the foot of the bed. The wound doctor was present, and unable to stage the wound. 3. For Resident #576, the facility staff failed to identify 9 unstageable wounds (4 of the 9 had slough and eschar present) until they were all found at one time on 11-6-17 during wound rounds with the wound nurse. The findings included: 1. Resident #18 was originally admitted to the nursing facility on 11/9/17 with [DIAGNOSES REDACTED]. The resident was seen in the Emergency Department (ED) on 11/10/17 and readmitted on [DATE]. Resident #18 was readmitted to the nursing facility on 12/5/17 with a sacral pressure ulcer assessed as a *Stage I. In addition the facility staff failed to assess the wound every 7 days per facility protocol until 13 days later at which time the wound had progressively worsened and ultimately led to wound management by a specialized wound care physician. All of the aforementioned issues constituted harm for Resident #18. Minimum Data Set (MDS) assessment analysis: The MDS assessment in effect at the time of Resident #18 initial, first entry dated 11/9/17 indicated no skin issues. In correlation with this MDS assessment, the hospital discharge summary dated 11/9/17 also indicated no skin issues. The discharge MDS assessment dated [DATE] with return anticipated, one day in the building, the resident was assessed to have one *Stage II pressure ulcer. Resident #18 was coded with short and long term memory problems and severely impaired in the skills for daily decision making. The resident was non-verbal and not able to understand staff. The resident was totally dependent on one staff for all activities of daily living (ADL). The hospital wound care notes dated 11/23/17 indicated the resident's sacral ulcer progressed to a *Stage 3 and on 12/3/17 the hospital wound care notes indicated the pressure ulcer had further progressed to 4x3 centimeter unstageable, open with slough (soft adherent necrotic tissue). The resident was readmitted to the nursing facility on 12/5/17. The Admission MDS assessment with an assessment reference date of 12/12/17 indicated the resident had a one Stage 1 sacral pressure ulcer. The facility admission nursing note entered by Licensed Practical Nurse (LPN) #6 dated 12/5/17 indicated Resident #18 had one Stage I pressure ulcer 2 cm by 1 cm. The significant change in status MDS assessment dated [DATE] assessed the resident as having two pressure ulcers: one unstageable pressure ulcer with slough and/or eschar (hard black necrotic tissue), as well as one unstageable deep tissue injury (DTI). The quarterly MDS assessment dated [DATE] and the quarterly MDS assessment dated [DATE] assessed Resident #18 as having one Stage IV pressure ulcer. During an interview with the facility MDS coordinator and the Regional Corporate MDS coordinator on 6/26/18 at 3:00 p.m., they stated they get their information from the nurse's notes in order to complete the MDS and although they felt the most recent MDS's dated 3/26/18 and 6/18/18 were accurate representations of Resident #18 current sacral wound, the admission nurse's note assessment of the sacral wound as a Stage I was not accurate, thus the 12/12/17 MDS assessment was not an accurate assessment of the sacral wound. They stated they follow through with care planning based on the MDS assessment. The re-admission nursing assessment dated [DATE] scored the resident with a 6 on the Braden Scale Pressure Sore Risk assessment which indicated the resident was at very high risk for the development of pressure ulcers. The care plan dated 12/14/17 indicated the resident had a Stage I pressure ulcer and the goal set by the staff for the resident was that it would decrease over the review period (3/12/18). Some of the interventions to accomplish this goal include assess and record the size of the ulcer, perform a complete assessment and record, perform nutritional screening and assessment and to implement the protocol for Stage I pressure ulcer and was at risk for having pressure ulcers. The nursing staff were to use pillows and or wedges to reduce pressure on heels and pressure points, and turn and position, as well as a pressure reducing mattress (standard mattress for all residents) and pad when sitting. The nursing staff would also check skin for redness, skin tears, swelling or additional breakdown. The resident was incorrectly care planned in the area of actual alteration in skin integrity and should have been care planned for an unstageable pressure ulcer to the sacrum. The facility pressure ulcer protocol was reviewed and included: Stage I pressure: turn/reposition/offload, use personal cleanser, skin barrier cream and no dressing, Prostat (protein supplement to increase wound healing) 30 ml daily not ordered). Unstageable pressure ulcer protocol could include the following: -Without foul odor-apply/pack with hydrogel moistened sterile [MEDICATION NAME] into wound as the topical treatment covered with sterile 4x4 or ABD's secured with retention tape and cover with transparent film. -With foul odor-pack with 1/4 Dakins moistened Kerlix into the wound bed-packing into undermining/tunneling if present and cover with the same dressing as without foul odor. All Stage III and above pressure ulcers require Prostat AWC 30 ml BID, labs (CBC, CMP, Pre-[MEDICATION NAME]), low air loss mattress. The resident was not ordered Prostat until after the wound care specialist physician evaluated the resident. The [MEDICATION NAME] level per COWCN recommendations collected on 1/29/18 was 23 (20-40=normal range). The [MEDICATION NAME] level per COWCN recommendations collected on 1/29/18 was 3.4 (3.5-5.0=normal). The LPN #6 that assessed Resident #18's sacral area upon readmission to the nursing facility on 12/5/17 was interviewed on 6/28/18 at 12:10 p.m. She reviewed her nursing note entry and checked the time of the assessment to be 9:30 p.m., and stated she was called over to the unit to admit the resident and possibly did a quick sweep and did not take the time she should have because they were so busy. She said she followed the facility's skin care protocol and did not implement any treatment other than skin barrier cream and turning and positioning. She reviewed the hospital skin assessment and wound care notes and stated there was no way the pressure ulcer would have been a Stage I and reiterated how busy she was admitting a patient at 9:30 p.m. She added she did not have the resident anymore after the admission, which was verified through review of subsequent nurse's notes to be an accurate statement. She stated total body weekly skin assessments should have captured further assessments of the area and any treatment changes, plus Certified Nursing Assistants (CNA) should have passed on to the licensed nurse if there were any problems with the skin. LPN #6 stated she had extensive training on pressure ulcer assessment prevention and treatment, as well as the Skin Dyad Program with wound care protocols. The LPN added that the wound care nurse should have come behind her and looked at the resident's skin. There was not wound care nurse assessment documented at the time of LPN #6's assessment. The next weekly assessment to be completed by the licensed nurse for would have been 12/12/17, which was not completed for Resident #18. A weekly wound assessment was completed by LPN #7 12/17/17 where it was documented in the nurse's notes that the CNA informed her of a blister on the resident's right lower leg and it was at that time she completed a full body assessment and documented an unstageable sacral ulcer. This LPN was interviewed about this assessment on 6/22/18 at 12:05 p.m. She stated she was not made aware of the unstageable sacral area, but once she assessed it as unstageable she would have initiated the pressure ulcer protocol for unstageable pressure ulcer, but called the physician to inform him of the condition of the sacral ulcer. She stated he gave the following order daily cleanse sacral area with normal saline, apply *Santyl (topical debridement ointment), and cover with *Mesalt (Sodium Chloride Impregnated Gauze) and *Allevyn (an adhesive dressing to support moist wound healing). This was the first treatment to the sacral pressure ulcer since admission on 12/5/17, 13 days later. The CW[NAME]N RN (Certified Wound Ostomy Continence Nurse Registered Nurse) makes her first assessment of the sacral pressure ulcer on 12/27/17, as unstageable, unable to gage the depth due to amount of slough in wound bed, 90% adherent slough, 10% smooth red nongranulating tissue. A right plantar *DTI (Deep Tissue Injury) was identified, deep purple intact skin, as well as the right calf reabsorbing serous blister, as well as a excoriation of the left ear with skin prep treatment daily and as needed. The CW[NAME]N RN changed the order on 12/27/17 to the sacral pressure ulcer to a more aggressive treatment to cleanse the area with normal saline, apply [MEDICATION NAME] to peri-wound, apply nickel thick Santyl, cover with 4x4/*ABD (abdominal pad dressing), secure with tape (skin prep where tape will be applied) daily and as needed. (MONTH) cover with opsite as needed. The wound care nurse set up recommendations for a low air loss mattress which was indicated for residents with advanced stage wounds Stage III or greater. [MEDICATION NAME] and [MEDICATION NAME] levels (nutritional metrics) were ordered, bed extension was set up with the maintenance department. The CW[NAME]N RN documented that she educated the nursing staff on the importance of repositioning and preventing pressure ulcers. The CW[NAME]N RN was not available for interview and no longer worked for the facility. Prior to the wound care nurse evaluating the resident's wounds there were no weekly skin condition progress notes. There were no weekly skin assessments, per review of the clinical record, 7 days later on [DATE], (YEAR), [DATE], (YEAR). The resident was admitted to the local hospital on [DATE] for a planned procedure and readmitted to the nursing facility on 1/23/18. On 1/25/18 the wound care regimen was changed again to even a more aggressive treatment due to to continued deterioration of the sacral wound, now 100% slough in the wound bed with undermining and peri wound with excoriation. *Dakin's solution 1/4 topical two times a day starting 1/24/18 with *Calmaseptine to peri-wound, nickel thick Santyl to wound bed, pack with 1/4 Dakins moistened gauze, cover with 4x4/ABD, secure with tape (skin prep wherever tape will be). *Dakin's solution is a type of hypochlorite solution. It is made from bleach that has been diluted and treated to decrease irritation. Chlorine, the active ingredient in Dakin's solution, is a strong antiseptic that kills most forms of bacteria [MEDICAL CONDITION] (http://www.webmd.com/drugs/2/drug- /dakin's-misc/details). *Calmaseptine Ointment to Prevent & Heal Skin Irritations. A moisture barrier that prevents & helps heal skin irritations (https://www.webmd.com/drugs/2/drug-3614/[MEDICATION NAME]-topical/details). A wound consult was ordered for the wound specialist to evaluate and treat on 2/2/18 per the CW[NAME]N RN on her next visit to the facility. The CW[NAME]N RN recommended the same treatment until evaluation by the wound specialist. The CW[NAME]N RN documented that she re-educated the staff on the importance of packing the wound and re-educated the staff on the use of repositioning tools to offload wound location and prevent further breakdown. The wound care specialist physician evaluated the sacral wound on 2/5/18 and assessed the wound as unstageable necrosis 7.5 cm x 3.5 cm x (depth but not able to measure). The wound bed exhibited 50% black necrotic tissue (eschar) and 40% devitalized necrotic tissue, and 10% skin. the wound was surgically debrided of devitalized and necrotic tissue. The orders were unchanged to the sacral wound and she would re-evaluate on 2/8/18. She added on 2/5/18 to document skin assessments. Starting 2/12/18 skin inspections were placed on the Treatment Administration Records (TAR) and noted to be signed off as completed by the licensed nurse for Resident #18 every 7 days. (MONTH) 12, (YEAR) was signed off and not signed off as completed on 2/19/18. The next skin inspection signed off as completed was dated 2/26/18. The TAR indicated a scheduled skin assessment was not signed off as completed on 4/9/18. The wound was surgically debrided again on the wound care specialist's visits, 2/8/18, 2/15/18, 2/22/18, 3/1/18 (added a *wound vac with the primary wound care three times a week). On 3/15/18, the primary wound bed treatment remained unchanged with continuation of the wound vac. On 3/29/18, the primary wound care was changed to add [MEDICATION NAME], Santyl and Dakins moistened gauze to the wound bed daily for 14 days covered with a foam dressing. On 4/5/18, the primary wound care was continued as the order of 3/29/18, for 30 days. The wound care specialist evaluated the wound on 4/12/18, 4/19/18, 4/26/18 with surgical debridement. On 5/3/18 the Dakins solution and [MEDICATION NAME] was discontinued and *Calcium Alginate was ordered daily for 30 days and the Santyl remained. On 5/10/18 the primary wound care remained the same with debridement but scheduled to be performed twice a day. The wound VAC was reestablished on 5/24/18 to be changed twice a week and the primary wound care treatment to 1/4 Dakins solution-apply Santyl and Dakins moistened gauze in wound bed, also twice a week with wound VAC change. The primary wound care and wound VAC continued at the next evaluation dated 5/31/18 and 6/7/18. The wound was surgically debrided on 6/14/18 with unchanged primary wound care treatment. On 6/20/18 at 12:15 p.m., the sacral wound care observation was made conducted by the wound specialist physician, assisted by the North 4 Unit Manager RN#1. The wound care specialist stated that she was not going to let the wound go until it was healed. She stated the wound was not accurately assessed from the beginning, wound assessments were not being performed by the nursing staff as they should have been which was one of the reasons she stated she stopped treating residents in the facility. She indicated the condition of Resident #18's wound was avoidable. She stated a certain physician persuaded her to reconsider treating the complicated wounds and Resident #18 was one of the most challenging wounds she took on when coming back to the facility. When asked about the wound care protocols and how effective they were she answered, The nurses get what they need right at the time, if assessments are appropriate. I am not in agreement with them 100% of the time and probably 85% of them may be followed, but residents are not recipes and one protocol for a wound type does not fit all. After initiation of the protocol, they wound should be assessed every 7 days and the physician informed of improvement or deterioration. She continued to say that Resident #18's wound was clean with no tunneling and the current progress was a win for us. The wound was observed with a slight odor, but no obvious drainage and measured by the wound care specialist physician as 3.3 cm x 2.8 x 1.2 depth. The treatment observed included 1/4 Dakins solution-apply Santyl and Dakins moistened gauze in wound bed, with wound VAC change (PICO Brand). The UM RN #1 stated the resident was readmitted to the nursing facility on 12/5/17 with an unstageable wound and the wound was never a Stage I at that admission. She stated wound care assessments had been a problem, but they were working on consistency for all licensed nurse in the performance of wound assessments. On 6/21/18 at 3:54 p.m., an interview was conducted with the Administrator, DON#1, DON #2 and Director of Operations. The above findings were shared with the group regarding failure to correctly assess Resident #18's wound upon readmission 12/5/18 and implement appropriate treatment protocol, thus wound deterioration was the outcome followed by many painful and aggressive treatments. The Administrator and DON #1 were not aware of LPN#6 inaccurate assessment of the sacral wound. It was shared that the inaccuracy led to an inaccurate MDS, as well as an inaccurate care planning. The Administrator stated they did not complete any individual Resident wound investigations, but recognized assessments were not being documented. It was shared with the group that Resident #18 situation was not the result of poor documentation, but the lack of care and services per the facility's wound care protocols, polices and the facility's educational curriculum on prevention and treatment of [REDACTED]. On 6/25/18 at 12:20 p.m., during an interview with DON #2, who was assisting DON #1 with reviewing issues and locating documents stated she was not able to find any skin assessments completed by the licensed nurses for Resident #18 other than the ones completed by the COWCN when she initiated review of the wound on 1/25/18. She stated she could not locate any of them afterwards, although it was signed off intermittently that they had been completed by the licensed nurses. The nurse's notes did not reflect skin assessments even after areas had been identified. The most consistent assessments were done by the wound care specialist after she took over care of the wound on 2/5/18. During investigation of the wound with the surveyor, DON #2 stated, I see where this is going in comparison to the hospital wound care notes on 12/3/18 and I agree there was an inaccurate admission assessment of the wound when he was re-admitted on [DATE] with failure to implement appropriate wound care protocol for an advanced stage pressure ulcer. The facility's policy and procedures titled Guidelines for Skin Integrity dated 3/6/17 indicated the following: -Licensed nurse would measure, stage using the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, describe and document all identified impaired skin integrity and surrounding skin areas. -Initiate the Wound Care Protocol for all identified skin impairments. -Complete the Unavoidable Pressure ulcer documentation assessment in Vision on all high-risk residents at time of identification (Clinical Manager and/or DON). -Initiate the Weekly Skin Condition Progress Report (embedded in the initial nursing assessment ) for residents with identified skin impairments and will be continued weekly. -Weekly skin assessments to be completed on ALL residents through the assessment widget. Residents with skin impairment will have BOTH Weekly Skin Inspection Assessment and Weekly Skin Condition Progress reports completed. -All alterations of skin are re-evaluated for healing progress. If not progressing, notify Clinical Manager/DON and physician for review and recommendations for skin care orders and/or additional treatments. If wound is progressing re-new existing order every 14 days. If wound is not progressing and current treatment continues, discuss with physician and provide documentation to support rational. -Care plans must identify separately existing skin integrity areas and must include their own goals and interventions. -The wound care specialist team will make recommendations regarding wound care, however, the facility is responsible for ongoing care, follow-up, care, notification to the physician, all documentation and referrals as needed. On 6/28/18 at 3:35 p.m., the aforementioned issues were re-shared during a debriefing with the Administrator, Director of Operations and Director of Nursing (DON). No further information was provided prior to exit. *Category/ Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed (National Pressure Ulcer Advisory Panel/NPUAP www.npuap.org). *Category/ Stage I is Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin (National Pressure Ulcer Advisory Panel/NPUAP www.npuap.org). *Category/Stage II: Partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. Bruising indicates deep tissue injury (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/) *Category/Stage III: Full thickness skin loss: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/). *DTI (Deep Tissue Injury) - depth unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment (National Pressure Ulcer Advisory Panel/NPUAP www.npuap.org). *ABD Pads measure 5 x 9 and feature a soft non-woven outer layer that wicks fluid to a cellulose center that prevents pooling. Often referred to as abdominal pads, ABD pads are also known as trauma pads. The ABD stands for Army Battle Dressing and are used when high absorbency is required to handle heavy draining wounds or large wounds. This sterile ABD pad has a thick layer that absorbs and disperses fluids laterally to prevent pooling. The hydrophobic back impedes strike through and all the edges are sealed (http://www.hightidehealth.com/medline-abdominal-abd-pads-5x9-sterile.html#sthash.q0Yr4mtb.dpuf) *Santyl ([MEDICATION NAME]) This product is used to help the healing [MEDICAL CONDITION] skin ulcers. [MEDICATION NAME] is an enzyme. It works by helping to break up and remove dead skin and tissue. This effect may also help to work better and speed up your body's natural healing process (http://www.webmd.com/drugs/2/drug-9489/santyl-topical/details). *Mesalt Sodium Chloride Impregnated Gauze helps stimulate the cleansing of moist necrosis (slough) in draining infected wounds. Upon contact with wound moisture, sodium chloride is released (https://www.woundsource.com/product/mesalt-sodium-chloride-impregnated-gauze). *Alleyvn adhesive, with its unique triple layer formation, has been designed to achieve this combination to ensure optimal fluid handling to support moist wound healing1. Alleyvn adhesive is an economically-efficient2 dressing specifically designed to manage chronic or acute exuding wounds (http://www.smith-nephew.com/key-products/advanced-wound-management/allevyn/allevyn-adhesive/). *Wound V.A.C. therapy for wounds promotes wound healing through Negative Pressure Wound Therapy (NPWT). By delivering negative pressure (a vacuum) at the wound site through a patented dressing, this helps draw wound edges together, remove infectious materials and actively promote granulation (http://www.kci1.com/KCI1/vactherapy) *Calcium Alginate dressings are used primarily for the granulating phase of wound repair. They are made from alginate, a derivative of seaweed (https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/calcium-alginate). 3. For Resident #72, the staff failed to identify a wound on the plantar surface of the left foot until it was 45% eschar (hard black dead tissue) and found by surveyors during wound care observations, due to observed exudate on the foot of the bed. The wound doctor was present, and unable to stage the wound. Resident #72 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #72's most recent Minimum Data Set (an assessment protocol) was a quarterly assessment, with an Assessment Reference Date of 5-3-18. The MDS coded Resident #72 as alert, oriented to person, place, time and situation, with no cognitive impairment. The Minimum Data Set further coded Resident #72 as being totally dependent, on 1-2 staff members for all Activities of Daily Living care. The Resident was coded as at risk for skin breakdown, and having currently, 2 acquired wounds, while in the facility. They were; (1) unstageable deep tissue injury on the right buttock, and (2) a stage 3 wound on the lower right leg shin. On initial tour of the facility on 6-19-18 at approximately 11:30 a.m. Resident #72 was interviewed and observed. The Resident was laying in a Clinitron Bed which is a specialty skin pressure removal bed used for individuals with skin breakdown from pressure. The bed is constantly filled with blowing air which moves tiny soft beads inside the mattress creating a floating sensation for the user, and no steady pressure point on the body of a user. The Resident's feet were uncovered and were noted to be propped on a pillow. The mattress was covered with 2 sheets, and had a border around it which resembled the bumper rail around a billiards or pool table, which set up above the mattress approximately 4-6 inches. With the Resident's calves elevated on the pillow, it allowed the Resident's heels to lie directly on the bumper which was harder than the mattress, and forced the soles of the Resident's feet against the hard plastic foot board of the bed. Brown yellow and tan spots of creamy drainage were noted on the bumper of the mattress in the foot area. On the floor, against the wall at the foot of the bed was a pile of 2-3 foam wedges, and 2-3 pillows, which the Resident stated were to position him with while he was in bed. These positioning devices were also stained with the same color drainage observed to be on the bumper at the foot of the bed. The Resident was asked if he was comfortable with his feet pushed against the foot board, and he responded that he slid down in the bed often, and had to wait for nurses to pull him up. He stated he loved the bed, however, needed to be pulled up to get his feet right every couple hours. A review of Resident #72's clinical record was conducted during the survey. The review revealed documents titled Skin. The Director of Nursing (DON) provided these records and stated these are the (MONTH) and (MONTH) (YEAR) weekly skin checks, these are all we have. The documents revealed skin assessments completed by nursing staff on (MONTH) 1, 7, 14, 21, 28, and 6-18-18. No skin checks were completed from 5-28-18 through 6-18-18. The documents revealed the following; 5-1-18 - 2 different wounds right lower leg, no open [MEDICAL CONDITION] on the foot. No preventative, or protective foot care. 5-7-18 - DTI (deep tissue injury) right buttock, 3 areas right lower leg, no open [MEDICAL CONDITION] on the foot. No preventative, or protective foot care. 5-14-18 - DTI (deep tissue injury) right buttock, 3 areas right lower leg, no open [MEDICAL CONDITION] on the foot. No preventative, or protective foot care. 5-21-18 - DTI (deep tissue injury) right buttock, 2 areas right lower leg, no open [MEDICAL CONDITION] on the foot. No preventative, or protective foot care. 5-28-18 - DTI right buttock, and right lower leg, no open [MEDICAL CONDITION] on the foot. No preventative, or protective foot care. 6-18-18 - Blister right elbow, right lower leg wound. No preventative, or protective foot care. Nursing progress notes were reviewed and revealed no wound had been identified on the bottom (sole) or plantar surface of the left foot. A nutrition assessment was ordered on 5-24-18 to be completed by the Registered Dietician. The nutrition assessments were reviewed, and the most recent assessment was completed (MONTH) (YEAR). The DON was asked to produce the (MONTH) nutrition assessment, she stated there was none. The current care plan starting 5-8-18 was reviewed and revealed an intervention which read (Resident name) has a Clinitron Air Mattress, ensure air mattress is inflated and operating appropriately. Goal date 7-31-18. No instruction was given in the care plan as to how the bed should be used, what settings should be maintained, what linens could be used, if any, and if other positioning devices should be used with the bed. No direction was given as to use of the bed. Interventions for Floating of legs and heels remained on the care plan, and had not been removed/revised when the Clinitron bed was installed. No foot wound was documented in the care plan. The treatment nurse and Wound doctor were asked if they had been trained on the use of the bed, and they both stated no, however, they stated that the Hill ROM representative came and set up the bed, and if they had a problem the representative would come out and fix it. They were asked what the representatives response time to their call for help would be, and they stated they were unsure. The treatment nurse, and Administrator were asked for the manufacturers instructions guide for use of the bed. The Administrator delivered a 2 page flyer printed from the Hill ROM computer site on 6-21-18, and stated this is all we have. The flyer did not explain how to use the bed. Research of the Clinitron bed was conducted by the surveyor online, on the Hill ROM eLearning site and revealed that only one bed shee

Based on observation, staff interviews, closed record review, and in the course of a complaint investigation, the facility staff failed to ensure 2 residents (Resident #477 and #14) of 61 residents in the survey sample was free from accidents. Resident #477 sustained harm after the application of a hot compress resulted in second [MEDICAL CONDITION] the facility staff failed to ensure the Resident #14's mobility wheel chair was in safe operating condition. 1. Resident #477 sustained second [MEDICAL CONDITION] a hot compress was applied to his left hand. (A second degree burn is described according to the University of Rochester Medical Center as: the epidermis or top layer of skin appears red, and blistered and my be painful and swollen). 2. For Resident #14, the wheel chair had torn arms, a torn seat, and a torn back rest. Findings included: Resident #477 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #477 sustained second [MEDICAL CONDITION] his left hand after CNA #1, under the direction of LPN #2, applied a hot compress to his hand. A care plan for Resident #477 was revised on 11/18/17 which included: Problems: Transfers - Resident #477 is totally dependent on the staff. Goals: Resident #477 will be out-of-bed daily (as tolerated) transfers will be conducted by the staff (transfer boards/lifts) as required. Interventions - Resident #477 to be out of bed in chair PRN (as needed), transfer using the transfer board PRN. Problem: Personal Hygiene - Resident #477 requires assistance. Goal: Resident #477 will have oral hygiene, hair combed, and other personal hygiene needs met daily. Intervention: Complete personal hygiene and encourage patient to complete what he can. Problem: Bathing - Resident #477 is totally dependent on the staff. Goal: Resident #477 will be bathed/showered by the staff over the next 90 days. Interventions: Bathe/shower PRN. Problem: [MEDICAL CONDITION] the fifth, fourth, and third fingers. Goals: No complications related to blisters within the next 30 days. Intervention: Apply appropriate treatments as per orders, Assess areas and report and s/s of infection to MD. An Admission MDS 3.0 (Minimum Data Set) assessment for Resident #477 was dated 6/20/2017 which included coded with a BIMS (Brief Interview for Mental Status) score of 15, indicating cognitively intact. Resident #477's ADL (Activities of Daily Living) status was coded as total dependence upon staff for Transfers, and needing extensive assistance for self-performance and assistance of 1 -2 staff for Bed mobility, Dressing, Eating, Toilet use, and Personal hygiene. Resident #477 was documented as being seen by Physical Therapy and Occupational Therapy. Functional Status is coded as limited range of motion, impaired on both sides to his upper and lower extremities. A Quarterly MDS 3.0 assessment was completed for Resident #477 on 9/8/17. ADL coding reflected Resident #477 required extensive assistance for self-performance and assistance from 1 staff member for bed mobility and transfers. Resident #477 was totally dependent for self-performance and assistance of 1 staff member for Dressing, Eating, Toilet use, and Personal Hygiene. Functional Status is coded as limited range of motion, impaired on both sides to (his) upper extremities. A complaint investigation was conducted regarding the burn sustained by Resident #477. The complaint documented that the resident complained of pain to his left hand. He requested a warm compress. The CNA (certified nursing assistant) heated a washcloth in the microwave and placed it in a plastic bag and applied it to the resident's (#477) hand. The resident sustained [REDACTED]. He was sent to the hospital for evaluation and treatment. On 6/21/18 at 1:00 PM a review of the facility document titled Incident Abstract Report related to the burn injury was completed. The report was dated 10/31/17 and documented Event Description Nursing issues: heating pad protocol, catheter care, personal care, The report asks the question did the deviation reach the patient to which Y Yes - Reached Patient was documented. On 6/21/18 at 16:00 (4:00 PM) a documentation review for Resident #477's emergency room visit which took place on 10/30/17 at 9:25 PM was conducted. The chief complaint was listed as thermal burn and pain scale was reported as a 7 (0 = no pain and 10 = the worst pain) and his pain was described as constant and sharp. The [DIAGNOSES REDACTED]. The emergency room nurse documented Pt (patient) came by rescue (ambulance) from (facility name), pt reports his hand was burnt by putting a towel in the microwave and then in a plastic bag, then it was placed on his hand. On 06/22/18 at 2:11 PM a closed record review for Resident #477 was conducted. A nurse's note written on 10/28/17 at 6:49 AM stated the resident (#477) complained about pain in his left hand. On 6/22/18 at 2:30 PM a review of the physician's orders [REDACTED].#477's hand prior to application. On 6/22/18 at 3:00 PM a nurses note written on 10/30/17 at 4:50 PM documented Measurements for blisters: Left index finger (second digit) 2.5 cm x 1.7 cm Left middle finger (third digit) 4.7 cm x 4.5 cm Left ring finger (fourth digit) 1.3 cm x 1 cm Left pinky finger (fifth digit) 2 cm x 1.9 cm All blisters are fluid filled and intact. Pain at site. Opsite (dressing/bandage) remains over the blisters. On 06/25/18 at 09:58 AM a review of Resident #477's clinical record noted he had an office visit on 11/3/17 for a surgical procedure to debride (removal of dead tissue) the burn on his left hand. The physicians note stated Resident #477 has scant movement of his bilateral hands and fingers. He does have a 1% total body surface area deep partial-thickness burn involving the dorsal aspect of his second, third, fourth and fifth fingers. There is a large bullae (blister) present over each one of these areas that was excised off (removed) with suture scissors, cleansed and [MEDICATION NAME] Ag (dressing) was applied. On 6/25/18 at 1:42 PM an attempt was made to call LPN #2 (licensed practical nurse) who was caring for Resident #477 on the date of the burn injury with a message left. On 6/25/18 at 4:50 PM a telephone interview was conducted with CNA #1 who was caring for Resident #477 on 10/28/17. He stated the LPN #2 told him to apply heat to Resident #477's left hand. CNA #2 stated he heated a wet washcloth in the microwave oven for 30 seconds and placed the cloth in a plastic bag, and he placed a towel on Resident #477's hand. CNA #1 was asked if he had been trained in the use of heat for residents and he stated he had not. When asked what prompted him to apply the hot pack to Resident #477 he stated the nurse told me to do it, I just do what she tells me to do. I had done it couple of times before. CNA #1 was asked if he was aware that Resident #477 had very limited movement in his upper extremities which made it more difficult for him to move away from the hot washcloth. CNA #1 stated he was aware that Resident #477 has limited movement in his hands and arms. On 6/26/18 at approximately 1:00 PM a second attempt to call LPN #2 was made and a message was left for her to return the call. No return call were received prior to the end of the survey. On 6/26/18 at 1:51 PM an interview was conducted with RN #1 in regard to LPN #2. RN #1 confirmed that she authored disciplinary action and termination for LPN #2 related to her failure to follow facility policy. When asked specifically what LPN #2 had failed to do RN #1 responded that it is against policy to put any wet item into the microwave and then apply it to a patient. Only food goes into the microwave. RN #1 further explained that there is a sticker on the all the microwaves about what can be put into the microwave. RN #1 confirmed that the warning sticker has been on the microwaves since she started employment at the facility in (MONTH) of (YEAR), 2 months prior to the burn injury to Resident #477. During the same interview RN #1 was asked what actions she would have expected to take place if a warm compress was indicated for a resident. RN #1 responded that the nurse should have notified the physician about what was going on with the resident. RN #1 stated that if an order had been obtained for a warm compress from the physician we could have gone to the hospital to get a real heat pack instead of a washcloth. RN #1 added that LPN #2 should not have instructed CNA #1 to apply the heat, and that CNA #1 needed to question anything he is asked to do if he has a concern about being correct or not company policy. RN #1 was asked if the application of heat was within the scope of practice for a CNA she state no, it is not, the LPN should never have instructed him to do that. On 6/26/18 at 1:55 PM an observation of the microwave ovens behind the nurse's station on Units 1, 3, and 4 noted each had a red sticker prominently placed on the microwave door which measured approximately 4 inched square. The red sticker reads: Microwave is for heating food and drinks only. Please DO NOT heat any medical supplies in this microwave. Those actions have the potential to burn our patients. On 6/26/18 at 4:02 PM an interview was conducted with PT (physical Therapist) (other staff) #4 about Resident #477's burn. PT #4 was asked if Resident #477 had been assessed for the use of heat as a therapeutic treatment and he stated he had assessed him as safe for use of the hydroculator (warming machine) pads used by therapy personnel. PT #4 stated the temperature in the hydroculator is set to be between 130-140 degrees and the use of 4 layers of towels is standard to protect the resident's skin from burns. He further stated that the skin under the towels should be checked within 2 minutes to assess effectiveness and the patient's skin should be supervised. PT #4 was asked if nursing had been instructed on how to use the hydroculator warming machine and pads and he said no. On 6/27/18 at 1:00 PM an interview with the administrator was conducted to review the complaint. She stated that she was unfamiliar with the incident because she was new at the facility. On 6/27/18 at 4:10 PM an interview was conducted with the DON (Director of Nursing) RN #2. When asked what her expectation of the nursing staff if warm compress was indicated for a resident to which she replied if someone needs heat we would call the doctor to clarify the order. Now we have disposable hot packs. When asked if staff had been trained on the application of warm compresses she stated the staff has now been in serviced. On 6/28/18 at 2:00 PM a review of Policy # 301a - Employee Conduct Procedure Policy noted: Examples of Critical Violations in part listed violation of organizational or departmental policy, procedure and/or practice. The facility failed to ensure one resident (#477) of 58 residents in the survey sample was free from accidents which caused harm after the application of a hot compress resulted in second degree burns. COMPLAINT DEFICIENCY 2. Resident #14 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #14's most recent Minimum Data Set (an assessment protocol) was an annual assessment, with an Assessment Reference Date of 6-8-18. The MDS coded Resident #14 as alert, oriented to person, place, time and situation, with no cognitive impairment, no memory impairment, and no behavior problems. The Minimum Data Set further coded Resident #14 as needing only supervision, or otherwise independent for Activities of Daily Living care. The Resident was coded as at risk for skin breakdown, and currently having no wounds. On initial tour of the facility on 6-19-18 at approximately 11:40 a.m. Resident #14 was interviewed and observed. The Resident was sitting on her bed wiping a small scrape on her arm with a paper napkin. The napkin had a small smear of blood on it. The Resident was asked what happened to her arm, and she complained that she had scratched her arm on the wheel chair because the arm rests were so torn. The surveyor observed the chair which had worn so thin on the seat, that the threads inside the leather covering were exposed and the seat was splitting in the center. The arms were torn as well as the back of the chair. Resident #14 was asked how long the chair had been that way, and she stated she didn't remember, however she stated she had been asking for a new one for about a year (since last summer), and no one would give her one. On 6-20-18 at approximately 4:00 p.m., the Administrator and Director of Nursing (DON) were made aware of the condition of the wheel chair and asked why the Resident was using an unsafe mobility device. The Administrator stated that the Resident was Private Pay and would have to buy her own wheel chair. On 6-21-18 the Administrator stated they had given Resident #14 a wheel chair that was in good repair and safe, and that the Resident stated she liked the new wheel chair. On 6-22-18 the Resident was seen in the wheel chair which appeared to be in good repair and safe. No further information was requested or received.

Based on observation, staff interview, facility document review, and closed record review the facility staff failed for one (Resident #477) of 61 residents in the survey sample, to assess, prevent, and treat a penile injury caused by an indwelling catheter which resulted in a 2 cm (centimeter) split to the meatus (opening) of Resident #477's penis resulting in harm. For Resident #477, the facility staff failed to prevent an indwelling Foley catheter related injury. Findings included: Resident #477 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Admission MDS 3.0 (Minimum Data Set) assessment for Resident #477 was dated 6/20/2017. The MDS coded Resident #477 with a BIMS (Brief Interview for Mental Status) score of 15, indicating cognitively intact. Resident #477's ADL (Activities of Daily Living) status was coded as total dependence upon staff for Transfers, and needing extensive assistance for self-performance and assistance of 1 -2 staff for Bed mobility, Dressing, Eating, Toilet use, and Personal hygiene. The MDS coded Resident #477 as having an indwelling catheter in his bladder. Resident #477 was documented as being seen by Physical Therapy and Occupational Therapy. Functional Status is coded as limited range of motion, impaired on both sides to his upper and lower extremities. A Quarterly MDS 3.0 assessment was completed for Resident #477 on 9/8/17. ADL coding reflected Resident #477 required extensive assistance for self-performance and assistance from 1 staff member for bed mobility and transfers. Resident #477 was totally dependent for self-performance and assistance of 1 staff member for Dressing, Eating, Toilet use, and Personal Hygiene. Functional Status is coded as limited range of motion, impaired on both sides to his upper extremities. The use of an indwelling catheter was coded on the MDS. A care plan for Resident #477 was revised on 11/18/17 which included: Problems: Transfers - Resident #477 is totally dependent on the staff. Goals: Resident #477 will be out-of-bed daily (as tolerated) transfers will be conducted by the staff (transfer boards/lifts) as required. Interventions - Resident #477 to be out of bed in chair PRN (as needed), transfer using the transfer board PRN. Problem: Personal Hygiene - Resident #477 requires assistance. Goal: Resident #477 will have oral hygiene, hair combed, and other personal hygiene needs met daily. Intervention: Complete personal hygiene and encourage patient to complete what he can. Problem: Bathing - Resident #477 is totally dependent on the staff. Goal: Resident #477 will be bathed/showered by the staff over the next 90 days. Interventions: Bathe/shower PRN. Problem: At risk for infection related to indwelling catheter. Goal: Resident #477 will remain free of urinary tract infection during period of catheterization. Intervention: Change drainage bag, Clean around catheter with soap and water, keep tubing below level of the bladder and free of kinks and twists, Record output per shift, Report any sign of infection. Problem: Skin opening of head/shaft of penis related to Foley catheter. Goals: Open area decreases in size within 30 days. Interventions: Assess area and report any s/s (signs and symptoms) of infection to MD. Keep skin clean and dry. The care plan prior to the wound included the above information except the penile skin opening. On 06/21/18 at 10:25 AM a review of the closed medical record was conducted. A nurse's note dated 10/23/17 at 12:03 AM documented Resident (#477) stated he would like to see the nurse practitioner about having his Foley removed he is concerned about long term use complications of penile erosion. A nurse's note written on 10/25/17 at 2:15 PM noted Resident (#477} is requesting to see his MD and message left at his office and in the MD book at the station. A Nurse's note dated 10/26/17 at 12:36 PM documented Dr. (redacted for privacy) saw resident (#477) at approx. 8 am this morning about concerns of penis tear. MD examined resident and told him the penis was not a tear, there was no trauma. The area beneath the penis he was talking about is caused by prolonged Foley catheter use and since resident has his concerns MD asked for the resident to be seen by urologist. Appointment was made and resident made aware and asked (family member) to be notified and she will meet resident at his appointment. A noted a nurse's notes written on 10/27/17 at 4:31 PM which documented tear on head of the penis underneath foley catheter. Skin opening r/t (related to) foley cath measuring 0.4cm x 2cm (centimeters). The doctor was notified, steri strips were applied and the resident was sent to the urologist. On 6/21/18 at 1:00 PM a review of the resident medical record noted a skin sheet dated 10/31/17 documented the penile erosion (split/tear in the head of the penis) measured 2 cm x 2 cm. On 6/21/18 at 3:00 PM Administrative RN #3 was asked about the expectation for staff to use an anchor to secure the Foley catheter tubing to prevent injury she stated it's already a part of our expected process. This was a performance issue by staff. A physician's orders [REDACTED]. On 6/25/18 at approximately 2:00 PM an Incident Abstract Report was reviewed. The report was dated 10/27/17 and noted Open area to head / shaft of penis r/t (related to) foley cath. Measuring 0.4cm x 2.8cm x 2cm. Serous sanguineous drainage. No odor. Urology f/u (follow up appointment) on Monday. The primary cause was listed as Device Related (Foley catheter). On 6/25/18 at 3:45 PM a phone call was placed to the LPN #3 who first documented the penile injury to Resident #477. LPN #3 is no longer employed by the facility. A message was left for her to return the call. On 06/26/18 at 10:15 AM a record review noted Resident #477 had a urology appointment on 10/30/17. The physicians noted in his progress note discussion repair of erosion (split penis). Further erosion can be prevented by eliminating traction (pulling due to having the tubing not secured i.e. to the leg) on catheter. Catheter must be off traction and loose at all times. On 6/26/18 at 2:00 PM a second attempt to reach LPN #3 by phone regarding the documentation of Resident #477's penile injury. A second message was left with instructions to return the call. No return call was received prior to the end of the survey. On 6/26/18 at 4:10 PM an interview was conducted with the DON (Director of Nursing) Administrative RN #2 about the use of anchoring devices to secure Foley catheter tubing to prevent injury. The DON stated the Foley catheter kit comes with the anchor in the package, there was no reason it was not applied. I set up a urology appointment the next day. On 6/26/18 at 4:30 PM the facility procedure for Urinary Catheter, Indwelling (Foley): Inserting in the Adult Male Patient includes: Secure the catheter and tubing to prevent movement and traction against the urethra (opening at the tip of the penis) that could damage urethral tissue. Typically the catheter is strapped to the patient's inner thigh using a commercial tube holder. Allow for enough slack in the drainage tubing so the patient can move his thighs without pulling the catheter.

Based on observation, staff interviews, clinical record review and facility document review the facility staff failed to provide the necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing for 1 of 29 residents in the survey sample, Resident #9. The facility staff failed to provide appropriate monitoring for Resident #9 who was at risk for pressure ulcer development. The facility staff failed to identify the resident had developed a right ischial (the lower portion of the hip bone) pressure ulcer until it had advanced to a stage III. Furthermore, the prevention intervention of weekly skin assessments conducted on 12/8/16, 12/29/16, 1/5/17, 1/12/17 and 1/19/17 were not thorough and were inaccurate. On 12/23/16 an advanced stage III (1) pressure ulcer (2) to the right ischial was initially identified by the wound care specialist during a routine wound care assessment. The ischial pressure ulcer measured 4.5 cm (centimeters) x 1.5 cm x 0.2 cm. with light sero-sanguinous drainage, and presented with 15% yellow necrotic (dead) tissue that required surgical excisional debridement (3). The findings included: Resident #9 was admitted to the facility on [DATE] and a current readmission on 12/6/16. [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) an annual with an assessment reference date of 12/13/16 coded the resident as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition was intact. The resident required extensive assistance of one staff for bed mobility, and personal hygiene. The resident was dependent on staff for transfers and bathing. Under Section M. Skin Condition the resident was assessed as having a stage III pressure ulcer and a stage II pressure ulcer. The resident was incontinent of bowel and had an indwelling Foley catheter (a tube placed into the bladder to drain urine). A hospital skin sheet for Resident #9 with a diagram of a body dated 12/5/16 was reviewed. The skin sheet annotated the resident had an open wound on the left outer ankle with nonblanchable redness, and an open area with nonblanchable redness around on the residents sacrum/coccyx area (based on the picture). The registered nurse (RN) unit manager for 2 South was interviewed on 1/25/17 at 10:15 a.m. She documented on 12/7/16, Resident noted with a stage 2 ulcer to right ischium with excoriation and reddened areas. tx (treatment) implemented .Resident has Triad ordered for excoriated areas . The RN unit manager was asked if the resident had a stage 2 pressure ulcer to the right ischium as there were no Weekly Skin Assessment Progress Reports found in the clinical record from 12/6/16 through 1/25/17 for this ulcer. She stated, I'm not sure it was a stage 2 pressure ulcer, he came back from the hospital with MASD (4), it was probably MASD (Moisture Associated Skin Damage). She further stated that she had requested the wound care specialist to assess the area on 12/9/16. She stated the wound care specialist assessed the resident's skin and verbalized to her that there was no pressure ulcer on the right ischium/ buttocks. A stage II should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD). National Pressure Ulcer Advisory Panel (NPUAP) The wound care specialist physical exam dated 12/9/16 indicated the resident's buttock area was normal. The RN unit manager was asked about the stage III pressure ulcer to the right ischium on 1/25/17 at 10:15 a.m She stated, It was discovered during wound rounds with (name of wound care specialist). The RN unit manager stated she would have expected the wound to have been identified by the certified nurse aides who provide daily baths and incontinent care or during the weekly skin assessments. The Braden Scale Pressure Ulcer Risk assessment dated [DATE] evidenced the resident scored a 12. This indicated the resident was at high risk for pressure ulcer development. The comprehensive plan of care effective 12/22/2016 to present identified the resident was at risk for further developing pressure ulcers. The goal was the resident will remain free of further developing pressure ulcer(s) over the next 90 days, target date 2/22/17. Interventions listed to achieve the goal included the following; check skin for redness, skin tears, swelling, or pressure areas. report any signs of skin breakdown, use pillows, pads, or wedges to reduce pressure on heals and pressure points, turn/reposition . The Wound Care Specialist Evaluation dated 12/23/16 read, in part: At the request of (name of attending physician), this (age and gender) was seen and evaluated today presents with a stage 3 pressure wound of the right ischium of at least 1 days duration. Etiology: Pressure. The wound measured 4.5 cm (centimeters) x 1.5 cm x 0.2 cm. with light sero-sanguinous drainage, 15% yellow necrotic (dead) tissue (5), 50% granulation tissue (6), skin 35%. Procedure: Surgical excisional debridement of subcutaneous tissue. Dressing: Santyl (a [MEDICATION NAME] ointment) and calcium alginate dressing (a type of dressing that forms into a gel when it comes into contact with liquid) once a day. The Wound Care Specialist Evaluation dated 1/6/17 read, in part: Stage 3 pressure wound of the right ischium resolved on 1/6/17. Further investigation evidenced the prevention intervention of weekly skin assessments conducted on 12/8/16, 12/29/16, 1/5/17, 1/12/17 and 1/19/17 were not thorough and or inaccurate as follows: 1. On 12/8/16, two days after readmission, the skin assessment identified the resident had one pressure ulcer located on the left ankle. Under other [MEDICAL CONDITION], other wounds, or other skin problems the nurse checked, No. The clinical record evidenced the resident had been assessed with [REDACTED]. 2. The 12/29/16 skin assessment identified the resident had one pressure ulcer to the right ischium. The assessment failed to capture the left ankle pressure ulcer that was still present. 3. The 1/5/17 skin assessment identified the resident had one pressure ulcer to the right ischium. The assessment failed to capture the left ankle pressure ulcer that was still present. 4. The 1/12/17 skin assessment identified the resident had one pressure ulcer to the right ischium. The right ischium pressure ulcer had resolved on 1/6/17. The assessment failed to capture the left ankle pressure ulcer that was still present. 5. The 1/19/17 skin assessment identified the resident had one pressure ulcer to the right ankle, this was incorrect, the ulcer was on the left ankle. The failure to provide a thorough and accurate assessment as evidenced by the above weekly skin assessments was presented to the RN 2 South unit manager on 1/25/17 at 10:15 a.m. The following morning on 1/26/17 at 10:10 a.m., the RN 2 South unit manager stated she had spoken with the night shift nurse (licensed practical nurse #10) who had conducted the weekly skin assessments for Resident #9. The nurses response was that she must have been sleepy and made mistakes. The unit manager stated the nurse was provided education this morning on wound care and skin assessment. She stated the nurse was receptive to the education. Following this education, the RN unit manager had the nurse perform a head to toe skin assessment on a resident. The RN unit manager stated the nurse had made a couple of mistakes during the assessment. An attempt to contact and interview LPN #10 was made on 1/26/17 at 1:50 p.m., a message was left. The nurse did not make a return phone call. A dressing change observation of the left ankle and inspection of the resident's sacral/ buttock area was conducted on 1/26/17 at 12:45 p.m. The RN unit manager assisted the licensed practical nurse. The resident was observed to have a diffuse area of [DIAGNOSES REDACTED] (redness) and discoloration with three small areas of broken skin which appeared to be MASD. The nurse cleansed the area with dermal wound cleanser, applied Solosite gel (a hydrogel wound dressing with preservatives) to the open areas, applied skin prep to surrounding skin and covered with an Allevyn dressing. This treatment was started 1/25/17. The above findings was shared with the Director of Nursing (DON) on 1/26/17 at 4:45 p.m. The DON stated she would have expected the stage III ischial pressure ulcer to have been identified during daily skin care or during the weekly skin inspections by the licensed nurse. She further stated that, this is one of the areas that we are definitely working on .filling out the weekly skin assessments is one of them . At approximately 6:00 p.m., the DON provided additional information. An Ad Hoc QAPI (Quality Assurance Performance Improvement) plan dated 12/12/16. One of two Identified Opportunity for Improvement/ Deficient Practice was F 314. It read, in part: The IDT (Interdisciplinary) team has identified an opportunity to promote the highest quality of care and services by validating adherence to the established practice standards for Skin Integrity and Wound Management. The DON/Designee will provide education to the nursing staff regarding the established practice standards that govern promoting and maintaining Skin Integrity, Wound Prevention and Wound Management. Education will be conducted during Dec TEA Time. One of the sign in sheets evidenced the night shift nurse (LPN#10's) signature of attendance for this education on 1/12/17. According to the DON all education would be completed by 2/2/17. The Ad Hoc QAPI plan did not include a date of compliance. When asked by two inspectors on speaker phone at approximately 6:45 p.m. the date of compliance, the DON stated, February 24, 2017. Shortly after this during a meeting with the survey team, the DON signed page 2 of the Ad Hoc QAPI with the date of compliance as 1/26/17. No additional information was provided prior to exit. A complete assessment is essential to an effective pressure ulcer prevention & treatment program. A comprehensive individual evaluation helps the facility to: o Identify the resident at risk of developing pressure ulcers, the level & nature of risk(s); & o Identify the presence of pressure ulcers. It is, therefore, important for clinical staff to regularly conduct thorough skin assessments on each resident who is at risk for developing pressure ulcers. *Policies & Definitions: The facility policy titled Pressure Ulcer Prevention, revision date 6/23/16 read, in part: Policy Statement-To prevent development of pressure ulcers. Weekly skin inspections are conducted and documented on all residents by licensed staff. *Monitoring - At least daily, staff should remain alert to potential changes in the skin condition & should evaluate & document identified changes. NPUAP (National Pressure Ulcer Advisory Panel). COMPLAINT DEFICIENCY (1) Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. (NPUAP) (2) Pressure Ulcer - A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). National Pressure Ulcer Advisory Panel (NPUAP) (3) Debridement - Debridement is the removal of devitalized/necrotic tissue & foreign matter from a wound to improve or facilitate the healing process. Various debridement methods include: Sharp or surgical debridement refers to removal of foreign material or devitalized tissue by a surgical instrument. (NPUAP) (4) MASD-Moisture Associated Skin Damage is a result of skin damage caused by moisture rather than pressure. It is caused by sustained exposure to moisture which can be caused, for example, by incontinence, wound exudate (drainage) and perspiration. RAI (Resident Assessment Instrument) Manual. (5) Necrotic (dead) or devitalized tissue that has lost its usual physical properties & biological activity. NPUAP (6) Granulation tissue is the pink-red moist tissue that fills an open wound, when it starts to heal. It contains new blood vessels, collagen, fibroblasts, & [MEDICAL CONDITION] cells. NPUAP

Based on observations, resident interview, staff interview, facility documentation review, clinical record review, the facility staff failed to prevent and to treat pressure ulcers for four (4) residents (Resident #17, #11, #10, #9) of a 43 resident survey sample which constituted harm for all four (4) residents which resulted in Sub-Standard Quality of Care. The findings included: 1. For Resident #17, the faciity staff failed to provide medical treatment for [REDACTED]. On 8/14/15 it was an unstageable Pressure Ulcer due to Necrotic Tissue, causing harm. 2. For Resident #11, the facility staff failed to identify a pressure ulcer to Resident #11's left index finger before it reached an advanced stage which constitutes harm. 3. For Resident #10, the facility staff failed to identify a Stage III right ankle pressure ulcer prior to it developing to an advanced stage on 9/25/15, which constitutes harm. 4. For Resident #9, the facility staff failed to identify a pressure ulcer to the right heel before it reached an advanced stage III and failed to follow physicians orders to float heels resulting in harm. The findings included: 1. Resident #17 was originally admitted to the facility on [DATE], readmission on 07/17/15, readmission on 07/24/15 and readmitted on [DATE]. [DIAGNOSES REDACTED]. The resident also has been on a Vegan (excludes all meat and animal products including milk and dairy and no soy) for [AGE] years. Review of the resident's clinical record noted the most recent comprehensive MDS (minimum data set-an assessment protocol) was a Significant Change with an ARD (assessment reference date) of 11/23/15. The resident's BIMS (brief interview for mental status) score was coded a 15 which indicated the resident was cognitively intact. Further review of the record revealed the resident was totally dependent on one staff member for toileting, personal hygiene and bathing. The resident was coded as requiring extensive assistance of one staff member for bed mobility and eating. The resident was also coded as having a condom catheter for urine control and was incontinent of bowel. It was further noted under Section M-Skin Conditions that the resident was at high risk for developing a pressure and at the time of the assessment had a Stage IV at present and had also been present on his re-admission to the facility from the hospital on [DATE]. Review of the resident's clinical record noted that he had been admitted to the hospital on [DATE] for evaluation, due to low blood pressure, desating oxygen levels and having an elevated temperature of 102 degrees F (Fahrenheit). Review of the resident's discharge summary dated 07/15/15, revealed that the resident had [DIAGNOSES REDACTED]. The resident was not discharged back to the facility until 07/17/15. Review of the hospital notes dated 07/10/15, revealed that when the resident had been transferred from ICU (intensive care unit) to the medical floor the resident was noted to have a Stage II pressure ulcer to his coccyx and [MEDICATION NAME] treatment was in place. No additional information could be obtained from the hospital regarding the status of the resident's Stage II pressure ulcer to his coccyx, if it had been resolved or if further treatment was required. On his readmission to the facility on [DATE], Resident #17 was placed on a specialized unit due to his need for RT (respiratory therapy) and specialized [MEDICAL CONDITION] care. The resident had an upgraded mattress as all on the specialized unit have on their beds. The resident was also repositioned every two hours which is documented in the resident's clinical record. RD (registered dietician) also did an assessment and had multiple interviews with the resident regarding his Vegan diet. Supplements were added daily as well as being repositioned every two hours. The resident's spouse agreed to bring in the resident's meals from home knowing his likes and dislikes until the facility was able to have a wider selection of foods the resident could choose from. The resident also received preventative perineal care after every incontinent episode of bowel in addition to a moisture barrier to his coccyx area every shift which was documented in the resident's clinical record. No formal nursing admission had been done on the resident's return from the hospital. Review of the nursing notes on 07/17/15, revealed that when the resident had been readmitted his skin was intact. Review of Daily Skilled Nurse's Note/Med Spec dated 08/04/15, noted that the resident had a pressure ulcer, but assesment or description included. No formal wound assessment could be located in the resident's clinical record. Review of the August 2015 TAR (treatment administration record) revealed that weekly skin inspections to be done on the day shift starting 07/20/15, had been signed off as done on 08/04/15, 08/11/15, 08/18/15 and 08/25/15. The inspections were signed as done but no documentation of the assessment of the resident's skin status could be found in the record. Review of the August MAR (medication administration record) revealed an order dated 08/13/15: Polymim foam dressing to sacral wound every 2 days and PRN (as needed). Review of the August TAR noted that the aforementioned treatment did not start until 08/15/15 and had been signed off as being done by the facility staff on 08/15/15, 08/17/15, 08/19/15, 08/21/15 and 08/25/15. Review of the August MAR indicated [REDACTED]. A Wound Care Specialist Initial Evaluation dated 08/14/15 noted: The resident presents with an unstageable (due to necrosis) of the sacrum of at least 1 days duration. Wound Size L-4.5 cm. (centimeters) x W (widith) -8.5 cm. D (depth) -not measurable due to necrosis. Assessment & Plan: Discontinue: Foam Every Two Days. Add: Santyl-Once Daily. A Wound Care Specialist Evaluation dated 08/21/15 noted: The resident presents with a stage 3 pressure wound of the sacrum of at least 7 days duration. Wound Size L-2.8 cm. x W-1.0 cm x D-0.2 cm. Procedure: Surgical excisional debridement of subcutaneous tissue. Discontinue Santyl-Once Daily. Add: Foam-every two days and PRN. A Wound Care Specialist Evaluation dated 08/31/15 noted: The resident presents with a stage 3 pressure wound of the sacrum of at least 17 days duration. Wound Size L-4.5 cm. x D-6.0 cm. x 0.2 cm. Discontinue: Foam-Every two days and PRN Add: Santyl-Once Daily. An interview was conducted on 3/28/16 at apporoximately 12:15 p.m. with LPN #11. She stated, When he was first admitted and he had [MEDICAL CONDITION] cervical collor, he preferred to tell us how he was to be positioned and where his pillows were to be placed. If he didn't like you, he wouldn't let you do anything. Resident #17 was observed 3/25/16 at 9:12 a.m., 3/25/16 at 12:07 p.m., 3/25/16 at 4:15 p.m. and 3/28/16 at 8:15 a.m. in bed with the head of the bed elevated, wound vac to sarcum and an air mattress in place on bed. Resident #17's care plan dated 8/5/15 to 12/02/15 documented: At risk for pressure ulcer: Perform nutrional screening. Adjust diet/supplements as indicated to reduce the risk of skin breakdown - dietary Impaired bed mobility: Use pilows. pads, or wedges to reduce pressure on heels and pressure ooints. Resident #17 is to be turned side to side as needed no greater than 30 degrees with appropriate positioning devices to relieve pressure and provide comfort and support At risk for altered nutrition as related to poor skin integrity and risk for skin breakdown/pressure AEB (as evidenced by) pressure ulcers Pressure Ulcer r/t (related to) immobility AEB Stage 4 to sacrum, Wound vac Therapy begun 2/1/16. 2. Resident #11 was admitted to the facility on [DATE] with a readmission note of 1/26/16. At the time of the survey the resident was [AGE] years old. The resident's [DIAGNOSES REDACTED]. The resident's 1/6/16 quarterly minimun data set (MDS) described the resident as being at risk for the development of pressure areas. The resident's 2/01/16 significant change MDS evidenced the resident was not understood and did not understand others, with severe long and short term memory loss. Resident #11 required assistance with all activities of daily living. The nursing note on 1/9/16 evidenced, nurse went to clean inside or (sic) resident left contracted hand when she noted resident hand to have a pressure ulcer to the inside of her left index finger where the thumb presses on. the area is open with 100% granulation and measures 2.0 cm X 2.0 cm X 0.2 cm. Resident does complain of pain to the hand. MD notified. The MDS manual instructs that granulating tissue (pink or red tissue with shiny, moist, granular appearance) is not present in a Stage II, as granulating tissue represents a full thickness of skin (dermis) loss to underlying tissue. The MDS identifies full thickness tissue loss as a Stage III. On 1/21/16 the resident was sent to the hospital with pneumonia and returned on 1/27/16. On 1/31/16 the resident was referred to the wound physician who identified the left finger wound as a Stage IV. Under the 2/1/16 MDS skin condition (Section M) evidenced the resident had one or more unhealed pressure areas. The stage was identified as unstagable. The measurements were 1.2 centimeters (cm) X 1.1 cm with a depth of 0.3 cm. The MDS defines unstagable as a wound that due to the presence of eschar or slough the wound bed is not visible. The MDS defines a Stage IV as, Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. The MDS identifies eschar as, brown, black, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin. Unit I did not have a unit manager but RN #6 was identified as helping the DON cover the unit pending the position being filled. On 2/23/16 RN #6 was interviewed. RN #6 stated the resident's Stage IV on the left index finger was healed. The area had been caused by the resident's thumb overlapping the index finger causing pressure. The RN was requested to describe the area when found. She stated that white was visible when the wound was discovered and identified it as tendon. RN #6 stated the left ring finger also digs into the resident's palm, it is now red and a 4 x 4 gauze was placed in between the thumb/index finger and between the ring finger and palm. RN #6 stated the resident would remove a hand roll from her hand. On 3/23/16 at 4:55 p.m., LPN #8 accompanied the surveyor into Resident #11's room to observe her hand. The LPN stated she had been pulled from another unit so she was not familiar with the resident. The LPN was unable to separate the thumb from the finger as the resident was pulling away, the LPN stopped. There was a gauze between the ring finger and palm but nothing between the thumb and finger. On 3/24/16 (12:05 pm) the resident was observed in bed, there was no gauze in the resident's left hand. On 3/24/16 (1:30 pm) two surveyors observed the resident's hand. LPN #9 accompanied the surveyors. LPN #9 stated she was the one who had first discovered the pressure area. LPN #9 stated the tendon was clearly visible. When asked how they healed the wound since the resident's thumb still curled over the index finger. LPN #9 stated we used Allevyn a brand name for a padded dressing that has adhesive around the edges. LPN #9 stated the resident did sometimes remove the Allevyn but for the most part left it in place. But, she (the nurse ) had been informed that the Allevyn was too expensive to be used as a preventive measure. The LPN commented that the area was likely to breakdown again. RN #6 and I have done some brain storming. The resident's thumb and index finger were noted to be misshapen. The thumb was flattened and the index finger had a depressed area from constant pressure/contact with the thumb. The LPN was able to separate the thumb and finger by 3/4 to an inch. The resident immediately clenched them back together when the nurse released the digits. The LPN stated as far as she was aware there was not an Occupation Therapy referral for a possible positioner. Review of the Treatment Administration Record evidenced the Alleyn was started 1/9/16, and changed every day. The treatment continued but on 1/29/16 Kerlix (gauze bandage) was added to be wrapped around the dressing and hand. The resident's care plan in place from 10/21/15 to 2/10/16 was reviewed for interventions for the prevention of pressure areas. The care plan evidenced, Actual contracture of in left hand The goal was the resident will not develop further contractures and will have pain management through 90 days. The interventions were to administer medications, monitor for side effects and and effectiveness of medications, range of motion to resident's tolerance, frequent position changes and encourage resident to exercise. The residents current care plan was also reviewed and had not included any interventions to prevent the pressure ulcer. This was discussed with RN #6, on 3/25/16 at approximately 3: 30 pm. RN #6 stated that they are now using a hand roll and Allevyn on the resident's hand. RN #6 stated that the hand roll was found in the resident's closet and that it had been used at one time. RN #6 reviewed the care plan and stated it was not addressing the resident's need for pressure reduction to the left thumb and finger. RN #6 stated the intervention of range of motion was not appropriate as the resident's left hand could not be separated enough and it would be too painful for the resident, you can't get her hand open to do that. The resident was observed on 3/28/16 10:40 am and 3/29/16 approximetely 3 pm with the Allevyn between thumb and finger and a hand roll in her palm. 3. The facility staff failed to identify a Stage III right ankle pressure ulcer prior to it developing to an advanced stage on 9/25/15 for Resident #10, which constitutes harm. Resident #10 was a [AGE] year old admitted to the facility initially on 12/2/12 and readmitted on [DATE]. Resident #10's [DIAGNOSES REDACTED].*Diabetes Mellitus, *Gastrostomy Tube, *Contractures, and *Dementia. *Stage III Pressure Ulcer: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Definition derived from the Minimum Data Set (MDS) Assessment-Version 3.0 *Diabetes Mellitus: a complex disorder of carbohydrates, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion by the beta cells of the pancreas or resistance to insulin. *Gastrostomy Tube ([DEVICE]): surgical creation of an artificial opening into the stomach through the abdominal wall to prevent malnutrition. *Contractures: an abnormal, usually permanent condition of a joint, characterized by flexion and fixation. *Dementia: a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses. The above definitions were derived from Mosby's Dictionary of Medicine, Nursing, and Health Professions 8th Edition. The most recent Minimum Data Set (MDS) assessment was a Quarterly assessment with an Assessment Reference Date (ARD) of 2/16/16 with a Brief Interview for Mental Status (BIMS) indicating that the resident is rarely or never understood. Resident #10 was also coded to have long and short term memory problems and is severely impaired in cognitive skills for daily decision making. Under functional status Resident #10 is totally dependent with one person physical assist for bed mobility, dressing, eating, bathing and personal hygiene. Under functional limitation in range of motion the resident is coded having upper and lower extremity impairment. Under skin conditions Resident #10 is coded as follows: Number of Stage 2 pressure ulcers=1, Number of these Stage 2 pressure ulcers that were present upon admission/reentry=0, Date of oldest Stage 2 pressure area=2/16/16, Number of Stage 3 pressure ulcers=1, Number of these Stage 3 pressure ulcers that were present upon admission/reentry=0, Dimensions of Unhealed Stage 3 Pressure Ulcer=1.5 cm (centimeters) pressure ulcer length X 2.0 cm pressure ulcer width X 0.2 cm pressure ulcer depth, Most severe tissue type for any pressure ulcer=4 Eschar-black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin. Under skin and ulcer treatments the following interventions are codes: pressure reducing device for chair, pressure reducing device for bed, nutrition or hydration, pressure ulcer care, application of nonsurgical dressings, and application of ointments/medications. Resident #10's Comprehensive Care Plans were reviewed in the following sequence: Annual 9/3/15-12/3/15, Quarterly 12/3/15-2/25/16, and Current Quarterly 2/25/16-present. The Annual Care Plan dated 9/3/15-12/3/15 documented in part: Problems: Resident #10 at risk of pressure ulcer. Goals: Resident #10 will remain free of skin breakdown over the next 90 days. Interventions: Check for redness, skin tears, swelling,or pressure areas. Report any signs of skin breakdown. There was no entry indicating that Resident #10 had developed a Stage III pressure ulcer on 9/25/15, and no documentation of any interventions or treatments that had been started. The Quarterly Care Plan dated 12/3/15-2/25/16 documented in part: Problems: Resident #10 at risk of pressure ulcer. Goals: Resident #10 will remain free of skin breakdown over the next 90 days. Interventions: Check for redness, skin tears, swelling,or pressure areas. Report any signs of skin breakdown. The Current Quarterly Care Plan dated 2/25/16-Present documented in part: Problems: Resident #10 is at risk for further pressure ulcers and other non pressure skin breakdown related to incontinence, immobility, contractures. Goals: Resident #10 will remain free of skin breakdown over the next 90 days. Interventions: Check for redness, skin tears, swelling,or pressure areas. Report any signs of skin breakdown. Treatments per MD (doctor orders. Problems: Stage 3 pressure ulcer right ankle. Stage 2 pressure ulcer right upper medial foot. Goals: The size of ulcer will decrease with evidence of healing over the next 90 days. Interventions: Assess and record the size (Length X Width X Depth), amount and characteristics of exudates, and pain status. Perform complete skin assessment and record. Provide care according to the protocol for Stage 3 and Stage 2 Pressure Ulcers. Off loading boots at all times. Float heels intermittently when in bed. The facility staff was asked for all Braden Scales For Predicting Pressure Sore Risk that had been completed on Resident #10 in 2015 and 2016. Only one Braden Scale was completed in the 2015-2016 time frame for Resident #10 and it was dated 6/30/15. Resident #10's Braden Scale Score on 6/15/15 was a 12 indicating that the resident was HIGH RISK. On 3/25/16 at approximately 12:20 p.m. an interview was conducted with the Quality Management Nurse Consultant who was asked if the facility had done a new Braden Scale on Resident #10 when the new Stage 2 and Stage 3 pressure ulcers were were identified. The Quality Management Nurse Consultant stated, Evidently not, no we didn't do it. Resident #10's Physician order [REDACTED]. The following dated orders documented in part: 1/5/15- Off loading boots at all times. 4/29/15- High Risk for Skin Breakdown/Pressure Ulcer Prevention Protocol. 4/29/15- Float heels intermittently when in bed. 9/25/15- Left Great Toe and Left Plantar foot wounds: Poly Mem dressing every 2-3 days until healed. 9/25/15- Right Ankle wound: Cleanse daily with wound cleanser. Apply Santyl/Alginate to wound daily. Cover with dressing daily and PRN (as needed). 12/31/15- Weekly Skin Assessments with vitals. A review of Resident #10's Weekly Skin Assessments was completed. The Weekly Skin Assessments documented in part: Does this patient have a Pressure Ulcer? 9/8/15- No 9/15/15-Yes, Location-open area to left great toe. 9/22/15- NO WEEKLY SKIN ASSESSMENT AVAILABLE 9/30/15- Yes, Location-open area to left great toe. 10/6/15- NO WEEKLY SKIN ASSESSMENT AVAILABLE 10/13/15- NO WEEKLY SKIN ASSESSMENT AVAILABLE 10/20/15- NO WEEKLY SKIN ASSESSMENT AVAILABLE 10/27/15- No 11/3/15- NO WEEKLY SKIN ASSESSMENT AVAILABLE 11/10/15- No 11/17/15- NO WEEKLY SKIN ASSESSMENT AVAILABLE 11/24/15- NO WEEKLY SKIN ASSESSMENT AVAILABLE 12/1/15- NO WEEKLY SKIN ASSESSMENT AVAILABLE 12/7/15- Yes, Location right foot. 12/15/15- NO WEEKLY SKIN ASSESSMENT AVAILABLE 12/22/15- Yes, Location right ankle. 12/29/15- NO WEEKLY SKIN ASSESSMENT AVAILABLE 1/5/16- NO WEEKLY SKIN ASSESSMENT AVAILABLE 1/12/16- NO WEEKLY SKIN ASSESSMENT AVAILABLE 1/19/16- NO WEEKLY SKIN ASSESSMENT AVAILABLE 1/29/16- NO WEEKLY SKIN ASSESSMENT AVAILABLE 2/2/16- NO WEEKLY SKIN ASSESSMENT AVAILABLE 2/9/16- NO WEEKLY SKIN ASSESSMENT AVAILABLE 2/16/16- NO WEEKLY SKIN ASSESSMENT AVAILABLE 2/23/16- NO WEEKLY SKIN ASSESSMENT AVAILABLE 3/1/16- Yes, Location right ankle 3/9/16- Yes, Location right ankle 3/16/16- Yes, Location right ankle From 9/8/15 though 3/16/16 Resident #10 had 18 Weekly Skin Assessments that were unaccountable for. Resident #10's Wound Care Specialist Evaluations which were completed weekly by the Wound Care Physician were reviewed. The Wound Care Specialist Evaluations documented in part: Physical Exam 9/11/15: Stage 2 Pressure Wound of the Left, First Toe, Etiology: Pressure, Dressing: Foam-Every Three Days and PRN, Recommendation: Off-Load Wound, Reposition per facility protocol. 9/18/15: Stage 2 Pressure Wound of the Left, First Toe, Etiology: Pressure, Dressing: Foam-Every Three Days and PRN, Recommendation: Off-Load Wound, Reposition per facility protocol. 9/25/15: Stage 2 Pressure Wound of the Left, First Toe, Etiology: Pressure, Dressing: Foam-Every Three Days and PRN, Recommendation: Off-Load Wound, Reposition per facility protocol. Stage 2 Pressure Wound of the Left, Plantar Foot, Etiology: Pressure, Dressing: PolyMem and Foam every three days, Recommendation: Off-Load Wound, Reposition per facility protocol. Stage 3 Pressure Wound of the Right Ankle, Etiology: Pressure, Wound Size: 1.2 cm x 1.4 cm x 0.2 cm (centimeters), Thick Adherent Black Necrotic (Eschar): 10%, Yellow Necrotic: 10%, Granulation Tissue: 80%, Dressing: Santyl- Once daily, Recommendation: Off-Load Wound, Reposition per facility protocol. The Wound Care Physician's weekly Wound Care Specialist Evaluations were available and complete, the last evaluation available was on 3/18/16 which documented in part: Stage 3 Pressure Wound of the Right Ankle, Etiology: Pressure, Duration greater than 166 days, Wound Size: 0.6 cm. x 0.8 cm. x 0.2 cm., Yellow Necrotic: 5%, Granulation: 95%, Dressing: Santyl- Once daily, Recommendation: Off-Load Wound, Reposition per facility protocol. On 3/24/16 at 5:00 p.m. an interview was conducted with the Wound Care Physician. The Wound Care Physician was asked what was the stage of Resident #10's right ankle pressure when it was first identified. The Wound Care Physician stated, The right ankle was first identified at a Stage 3. Surveyor asked, Is it a pressure area? The Wound Care Physician stated, It is absolutely from pressure, those wounds are not diabetic ulcers. My perspective is that she favors the right side, so she needs to be off-loaded and use the prevalon boots. I want both interventions in place. She should be off-loaded all the time completely, no pressure at all. There should be dead space between the prevalon boot and the bed. The wounds are healing, they are not diabetic ulcers. On 3/22/16 at 4:35 p.m. Resident #10 was observed lying in bed with the prevalon boots on but the resident's boots were touching the bed, the heels were not being floated. On 3/23/16 at 10:30 a.m. Resident #10 was again observed lying in bed positioned on the right side. The resident's prevalon boots were on bilateral feet; however, the heels were not being floated causing direct pressure on the Stage 3 right ankle pressure area. On 3/23/16 at 12:45 p.m. after the completion of a wound care observation Resident #10's prevalon boots were reapplied but the heels were not floating; they remained touching the bed. Also, prior to the beginning of the wound care observation LPN #1 was asked what was the stage of Resident #10's right ankle when it was first identified. LPN #1 stated, We found the right ankle at a Stage 3. On 3/24/16 at 11:20 a.m. Resident #10 was observed lying in bed on her right side with the prevalon boots on but the heels were not floating. The left prevalon boot was positioned on top of the right prevalon boot with the right ankle making contact with the bed. The facility policy titled Physician Approved Pressure Ulcer-Prevention Orders/Protocol not dated, documented in part: All Residents 3. All Residents are assessed for pressure ulcer risk on admission; weekly times four weeks, then quarterly, with significant change and annually using the Braden scale. Re-evaluate if a pressure ulcer is identified. 6. Weekly skin inspections. 8. Develop patient-specific written care plan for pressure ulcer prevention. If Braden score is 14 or less add: 12. Suspend heels when in bed intermittently. The facility policy titled Pressure Ulcer Prevention revised 11/12/16 documented in part: Policy Statement: To prevent development of pressure ulcers. *All Residents are assessed for pressure ulcer risk on admission, every week times 4 after admission, quarterly, with significant change and annually using the Braden scale. *Weekly skin inspections are conducted and documented on all residents by licensed staff. *Complete weekly skin inspection form. *Turning and repositioning frequency is dependent on resident assessment and chart on TAR (Treatment Administration Record). *Pressure ulcer prevention order set is implemented based on need. On 3/24/16 at approximately 4:40 p.m. a pre-exit conference was held with the Administrator, the Director of Nursing, and the Quality Management Nurse Consultant and the above findings were shared. The Director of Nursing was asked, At what stage would you have expected your nursing staff to identify Resident #10's right ankle pressure ulcer? The Director of Nursing stated, During the skin assessments, when it was pink or red and blanchable. At a Stage 1, so we could start prevention.' Prior to exit no further information was shared by the facility. #4. For Resident #9, the facility staff failed to identify a pressure ulcer to the right heel before it reached an advanced stage III and failed to follow physicians orders to float heels resulting in harm. Resident #9 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #9's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date (ARD) of 09/07/2015 coded Resident #9 with severely impaired cognitive skills for daily decision making. In addition, the MDS coded Resident #9 requiring total dependence on staff for Activities of Daily Living. Resident #9's MDS with an ARD of 09/07/2015 Section M: Skin Conditions coded Resident #9 at risk of developing pressure ulcers with no current ulcers present. A review of Resident #9's clinical record was conducted during the survey. A clinical note written by LPN #2 on 2/16/16 at 7:13 pm read: writer advised by CNA (certified nursing assistant) identified an open area to the right heel. Pressure ulcer noted stage 3. Wound bed noted as beefy red, surrounding area macerated and white. 5% slough noted. Wound measures 1.5 cm (centimeters) in length, 1.0 cm in width and .1 cm in depth. The treatment ordered, Solosite to wound bed and covered with foam dressing. The wound was reported to the MDS coordinator RN #4 and clinical supervisor RN #1. An additional note was made on 2/16/2016 at 7:21 pm that the family was notified and on 2/16/2016 at 7:24 the doctor was notified with a message to call back with orders for wound care and wound consult if appropriate. On 2/18/2016 at 7:32 am a note was added to the clinical record by the clinical supervisor RN #1 which read, Note for 2/17/2016. Reassessed the resident's left heal pressure ulcer wound. The site had bright red blood. Area measured 3.5 x 4.0 x 0.1 cm presenting as stage two. Surrounding wound bed with 5% maceration. Wound bed has 100% granulation. MD and RP (responsible party) were notified. Will continue the same treatment. Prevalon boots to bilateral feet. No facial grimacing during the procedure. The National Pressure Ulcer Advisory Panel redefined the definition of a pressure ulcer and the stages of pressure ulcers in 2007 to include but not limited to the definition of a stage II pressure ulcer: partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open /ruptured serum filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising (bruising indicates deep tissue injury). This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. According to the National Pressure Ulcer Advisory Panel the definition of a stage III pressure ulcer is Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer may varies by anatomical location. According to Minimum Data Set (MDS) Version 3.0 the term granulation tissue is defined as pink or red tissue with shiny, moist, granular appearance and slough is yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous. According to the facility documentation Pressure Ulcer Monitoring sheet for the month of March 2016, Resident #9 was identified with an acquired stage III pressure ulcer to the right heel on 2/16/16 and the treatment was calcium alginate and santyl (debridement agent) QD (every day), Prevalon boots. The description on the Pressure Ulcer Monitoring sheet measured Resid

Based on clinical record reviews, staff interviews, and review of facility policies, it was determined the facility failed to adequately identify, keep systems functioning properly as well as implement necessary action plans to assure the provisions of quality care for the residents. The Quality Assessment and Assurance (QA&A) committee failed to identify quality deficiencies in the areas of Pressure Sores F314 and Sufficient Nurse Staffing F353. The findings included: On 3/26/16 at 11:35 a.m., the QA&A interview was conducted with the Administrator and Director of Nursing (DON). The Administrator stated the Quality Assurance QA&A committee meets monthly and was composed of himself, the DON, Medical Director, Director of Social Services, Food Service Director (FSM), Director of Maintenance, Staff Development Coordinator, Activities Director, Rehabilitation Manager, Pharmacist, the Clinical Managers and the Administrative Assistant who records the minutes. The Administrator stated each month all participate except the Pharmacist, may miss some meetings. The Administrator further stated during the interview that it was the company's way of operation to have the QA&A committee meeting monthly instead of quarterly and he felt it was a good idea because it encouraged them to take a good look at various indicators and act upon them expeditiously. He stated any of the above mentioned personnel as well as other facility employees, residents and staff can submit concerns to be addressed by the QA&A committee and the QA&A committee can develop a plan to resolve any concern affecting the facility's operation. The Administrator stated pressure ulcers had been a concern and they now had them under control. He stated pressure ulcers are all green (where they wanted them to be). He looked at the Quality Measure Report/Casper Report and pointed to new/worse pressure ulcer quality measure; it was now in the 62 percentile compared with the Group National Percentile. The Administrator stated they now had a wound care physician in the facility weekly and a successful system in place to prevent wounds and to identify skin problems early. The wound care program began with the certified nursing assistants reporting any areas of concern to the charge nurse, the charge nurse was to initiate treatment and document the skin concern for follow-up by the Clinical Manager. Other interventions included weekly skin assessments by the charge nurses, completion of the skin risk assessment at intervals as specified, consulting the wound care physician upon recommendations of the primary care physician and accurate coding on the Minimum Data Set assessment hence, the Casper report would provide accurate information. All four residents in F314 (Resident #s 17, 11, 10 and 9) were listed on the Caspers as within the 96% for high risk for pressure ulcers. The QA&A committee failed to address the Hi-risk Pressure Ulcer quality measure for long stay residents. The facility scored 96 percentile compared with the national percentile on the Casper Report and had 20 residents with hi-risk. The Administrator stated he only reviewed the new/worse quality measure not the Hi-risk quality measure. During the survey four (4) compliant residents were recognized with pressure ulcer not identified by the staff until they were at an advance stage (stage 3 or more). An MDS was coded with granulation tissue but classified as a stage 2. The MDS manual and National Pressure Ulcer Advisory Panel specifically states a stage 2 pressure ulcer cannot have granulation tissue therefore; the MDS was not coded correctly. (CMS's RAI Version 3.0Manual, page M-24). The MDS coordinator stated this was the information provided by the Clinical Manager who assessed the wound. Other non-functioning components pertinent to having an effective wound care program were many weekly skin assessments, skin risk assessments and nurse admission assessments were not completed. Only 1 of 4 units had a fulltime Clinical Manager. The Clinical Manager is the individual responsible to follow-up on identified skin conditions and ensures the program on their respective unit was operational. The facility's Nurse Staffing was also addressed during the QA&A interview. The Administrator and DON stated the QA&A process can address nurse staffing. They both stated staffing looked good on paper but the lack of staff is a result of many call outs. The DON stated a program was instituted 8 weeks ago where current staff could sign up for additional shifts. Another effort to address staffing was they had participated in several job fairs to recruit staff and conducted an onsite job fair. The mentorship was changed because there were mentors who discouraged newly hired employees. The Administrator and DON were asked to share information regarding the staffing on the evening of 3/24/16. One unit was identified by the surveyors as not having licensed nurses to relieve the licensed nurse leaving from the previous shift. This resulted in only 1 licensed nurse caring for the entire unit. A resident experiencing pain was unable to obtain medication, 8 residents received their dinner meal prior to have ordered finger stick blood sugars obtained and family members were complaining because a resident needed assistance with toileting hygiene. The DON simply said people did not show up. The Administrator shared with the survey team on 3/26/16 at approximately 11:00 a.m. that authorization for interim staff had been received and he expected the individuals to begin working within 14 days. The Administrator stated it can take up to 3 months to get newly hired staff on board to work. At the conclusion of the QA&A interview with the Administrator and DON on 3/26/16 at approximately 11:35 a.m., they both stated they had access to the above information and neither had presented it to the QA&A committee or had initiated action plans to address pressure ulcers or nurse staffing.

Based on observations, resident interview, staff interviews, clinical record reviews, facility document reviews and during the course of complaint investigations the facility staff failed to provide the necessary care and services to promote and maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, for 11 residents out of 43 residents in the survey sample, Residents #21, #41, #32, #21, #20, #29, #33, #34, #31, #30 and #9. 1. The facility staff failed to provide effective pain management for Resident #21 resulting in harm. In addition for Resident #21, the facility staff failed to provide IV (intravenous) antibiotics and post surgical wound care as ordered by the physician, and failed to obtain effective treatment for [REDACTED]. 2. The facility staff failed to provide surgical wound care and administer IV antibiotics as ordered by the physician for Resident #41. 3. The facility staff failed to follow physician's orders and obtain Finger Stick Blood Sugar (FSBS)/accuchecks before meals at 4:30 p.m. with sliding scale insulin for Resident #32. 4. The facility staff failed to follow physician's orders and obtain Finger Stick Blood Sugar (FSBS)/accuchecks before meals with sliding scale insulin at 4:30 p.m. and 5:00 p.m. medications (*[MEDICATION NAME] and *Psysillium) for Resident #21. 5. The facility staff failed to follow physician's orders and obtain Finger Stick Blood Sugar (FSBS)/accuchecks before meals with sliding scale insulin at 4:30 p.m. and administer routine insulin at 5:00 p.m., for Resident #20. 6. The facility staff failed to follow physician's orders and obtain Finger Stick Blood Sugar (FSBS)/accuchecks with sliding scale insulin before meals and routine medications (*[MEDICATION NAME]/Sevelamer [MEDICATION NAME] F/C 800 mg (3 tabs), both scheduled at 5:00 p.m., for Resident #29. 7. The facility staff failed to follow physician's orders and obtain Finger Stick Blood Sugar (FSBS)/accuchecks before meals and administer routine insulins for Resident #33, as well as administer other oral medication due at 5:00 p.m. 8. The facility staff failed to follow physician's orders and obtain Finger Stick Blood Sugar (FSBS)/accuchecks with sliding scale insulin before meals at 4:30 p.m. and administer routine insulin, also due at 4:30 p.m., for Resident #34. 9. The facility staff failed to follow physician's orders and obtain Finger Stick Blood Sugar (FSBS)/accuchecks before meals, as well as administer other oral medication due at 5:00 p.m. for Resident #31. 10. The facility staff failed to obtain Resident #30's Accucheck at 4:30 p.m. per physician's orders. The blood sugar history records indicated the staff obtained the blood sugar at 6:05 p.m., but recorded a reading of 324 on 3/24/16 in the 4:30 p.m. box on the Medication Administration Record (MAR). In addition, the 4:30 p.m. scheduled Humalog 2 units before meals was not administered until 6:05 p.m., after the resident consumed the evening meal. 11. The facility staff failed to provide pain management for Resident #9 when the resident was identified as exhibiting pain during a treatment. The findings include: 1. The facility staff failed to provide effective pain management for Resident #21's acute pain, resulting in harm. Resident #21 was admitted to the facility at 8:00 p.m., Sunday 1/24/16 following a hospitalization for surgical incision and drainage (I&D) with resection of a toe due to a [MEDICAL CONDITION] related to osteo[DIAGNOSES REDACTED] (a bone infection) on 1/19/16, with subsequent left foot skin graft on 3/15/16. The resident was admitted for IV (intravenous) antibiotics, wound care, physical and occupational therapy. The admission MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of 1/31/16 evidenced the resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident's cognition was intact. Section J. Health C Pain Assessment Interview evidenced the resident had experienced occasional pain, with intensity of severe, that limited day-to-day activity. Section M. Skin Conditions evidenced the resident had a surgical wound to a foot and was receiving wound care to include dressings. Section O. Special Treatments, Procedures, and Programs coded the resident as receiving IV medications while a resident. A comprehensive Care Plan had not been developed based on an admission MDS ARD of 1/31/16. An Interim Care Plan dated 1/27/16 evidenced the facility failed to include the resident's need for comfort related to actual or potential pain symptoms due to the resident's stated pain to the post operative wound site. On 3/23/16 at 5:30 p.m., the resident requested to speak to a surveyor. At this time an interview was conducted with the resident. The resident expressed concerns over the lack of care and services provided since admission and her safety due to the care. Resident #21 stated the facility did not provide effective pain management for the first two days following admission to the facility. She stated, .I was not able to get any sleep at all due to my pain .I had surgery and they removed two bones and ligaments, my bone was infected .I kept saying the [MEDICATION NAME] was not working for two days .they would not give me anything stronger than [MEDICATION NAME] .I was in pain, I kept saying what do I have to do to get you all to understand .at first the nurse said my birth date was wrong and that is why pharmacy would not fill the prescription .then they said I was allergic to [MEDICATION NAME] .which I am not, it makes me itch and at the hospital they gave it to me with an [MEDICATION NAME] .by the morning I was livid .that's when (name of unit 3 manager), the administrator and (name of the director of nursing) came into my room and apologized .after that they (the unit 3 nurse manager) gave me a dose of liquid [MEDICATION NAME] around 9:00 a.m., it knocked me out, I slept until 6:00 p.m., . my pain came back and I asked for some more [MEDICATION NAME] and they told me it had not come in from the pharmacy, they gave me Tylenol. Resident #21 was asked what her pain goal level was, and stated, I can handle a lot of pain .my goal would be a five to five and a half on a scale of one to ten .for those two days my pain was a ten out of a ten .It made me feel depressed, like nobody was listening to me .I was yelling at the nurse .I couldn't sleep well, I was literally trembling .I wasn't eating much. The clinical record notes were reviewed, the nurse documented the following, in part: 1/27/16 at 1:48 a.m., .client c/o (complains of) pain/discomfort attempted to administer [MEDICATION NAME] client refused: client stated [MEDICATION NAME] does not work. at this time I called pharmacy spoke with the pharmacist she stated, I need clarification for the prescription ([MEDICATION NAME]) .called (name of attending physician) @ (at) 0126 am message box full. Redirected client and she took two [MEDICATION NAME] .called (name of attending physician) @ 0147 am message box full . Clinical record notes dated 1/27/16 at 9:27 a.m., documented by the unit 3 nurse manager, read, in part: Resident complaint of left leg pain. She has orders for [MEDICATION NAME] and she has been refusing stating it is not strong enough for her pain. MD gave orders for [MEDICATION NAME] on 1/26/16. The order was discontinued {sic} allergy to [MEDICATION NAME]. The night nurse called MD and received orders for [MEDICATION NAME]. This nurse called the MD and received orders to give [MEDICATION NAME] sulfate liquid now and [MEDICATION NAME] tablet as needed. Pharmacy notified of the new orders to send the medications. [MEDICATION NAME] sulfate liquid now order pulled from emedstart (pharmacy electronic storage box). Clinical record notes dated 1/27/16 at 10:43 p.m., documented by the unit 3 nurse manager, read, in part: .At about 10:00 pm she asked for pain medication. Medication had not arrived from pharmacy ([MEDICATION NAME]). Pharmacy informed this nurse this morning that medication will arrive before 10:00 pm. Resident was medicated with PRN (as needed ) Tylenol . Clinical record noted dated 1/28/16 at 12:32 a.m., documented by the night nurse, read, in part: .client c/o pain/discomfort pain level 10/10 received [MEDICATION NAME] sulfate tabs 15 mg (milligrams) via po (by mouth) and pain subside {sic} pain level at 2/10 . The Medication Administration Record (MAR) for January 2016 was reviewed and evidenced the resident was administered [MEDICATION NAME] 800 mg one tablet three times a day starting on 1/25/16. The [MEDICATION NAME] was scheduled and administered at 6 am, 2 pm and 10 pm. It was discontinued on 1/26/16. The MAR for January 2016 evidenced the resident was administered the following for pain management: 1. On 1/26/16 at 00:21 (12:21a.m.) a.m., [MEDICATION NAME] 50 mg (1-2) tabs was administered for a pain level of 6/10 at 01:21 a.m., effective. 2. On 1/27/16 at 22:46 (10:46 p.m.) p.m., Tylenol Extra Strength 500 mg one tablet administered, pain level was not documented, at 23:46 (11:46 p.m.)., effective. On 3/23/16 at 7:40 p.m., the unit 3 manager was interviewed. The unit manager was asked about the resident's pain and stated, She (the resident) was in severe pain, she said the [MEDICATION NAME] was not effective .the night nurse called the doctor; his mail box was full .she was able to get an order right before she left in the morning. I called the doctor that morning and got an order for [REDACTED]. She was asked if the resident had filed any grievances concerning her pain management. The unit manager stated, Yes. A Customer Communication Form (grievance form) was provided to this inspector by the Administrator. The form dated 1/27/16 was filled out by the unit 3 nurse manager. The form read under Comments/Concerns: Did not receive stronger pain medication since admission. Breakdown of communication between nursing and pharmacy per patient. Investigation: There was a delay on pharmacy calling the unit to inform them of contraindication of [MEDICATION NAME] that was ordered on [DATE]. Resolution or Final Outcome: New orders received to give [MEDICATION NAME] sulfate liquid 10 ml (milliliters) now. [MEDICATION NAME] 15 mg Q (every) 6 hrs (hours) PRN (as needed) ordered. Resident medicated @ 9:30 am and stated while this nurse was in the room that she was feeling its effect. The form was signed by both the unit manager and the Administrator. 1b. The facility staff failed to provide IV antibiotics as ordered by the physician for Resident #21. The resident received IV antibiotics via a PICC line to the right arm (peripherally inserted central catheter). Resident #21 was admitted to the facility on [DATE] for post operative care of an infected bone in the left foot. The Infectious Disease physician ordered IV antibiotics of [MEDICATION NAME] one gram every eight hours and Meropenem one gram IV every eight hours for forty-two days for the treatment of [REDACTED]. On 3/23/16 at 5:30 p.m., an interview was conducted with the resident. The resident expressed concerns about the lack of care and services provided since admission and her safety due to the care. Resident #21 stated when she was receiving IV antibiotics the nursing staff would leave the empty IV container hanging for extended periods of time after it had infused and this limited her ability to move about. The resident also stated the staff failed to administer the IV antibiotics as ordered. She stated she expressed this to the infectious disease physician who then changed the IV antibiotic and scheduled it to be given once a day. The IV antibiotic order was changed on 2/22/16 to Ivanz 1 gram once a day for twelve days, scheduled to be administered at 9:00 p.m. The Medication Administration Record evidenced that on 2/27/16 the 9:00 p.m., IV Ivanz was not administered. As a result the IV was extended an additional day. Review of the clinical record evidenced the resident was no longer receiving IV antibiotics. On 3/23/16 at 7:40 p.m., the unit 3 manager was interviewed. The unit manager was asked about the omission of the IV antibiotic on 2/27/16. She stated, Yes, the resident was on leave of absence that evening and returned at 7:30 p.m. The nurse did not administer the scheduled 9:00 p.m., antibiotic, stating, I am not sure why. She stated as a result the IV antibiotic was extended an additional day to ensure the resident received the full course of the IV antibiotic therapy. The unit manager stated this was brought to her attention by the resident on 2/29/16. A Customer Communication Form (grievance form) dated 2/29/16 filled out by the unit three nurse manager read, in part: Comments/Concerns: IV ABT (antibiotic) not administered on 2/27/16. Resident stated she was out of the facility that day and returned at 7:30 pm. Investigation: MAR checked for signature for 2/27/16. There was no signature by the nurse who worked on 2/27/16 on 3-11 shift. Further review of the clinical record for February 2016 evidenced there was no signature by the nurse; indicating the IV antibiotics were not administered on the following dates: 1. [MEDICATION NAME] one gram 2/2/16 at 9:00 p.m., 2/7/16 at 12:30 p.m., 2/15/16 at 9:00 p.m., and 2/20/16 at 9:00 p.m. 2. Meropenem one gram 2/1/16 at 2:00 p.m., 2/7/16 at 2:00 p.m., and 2/15/16 at 10:00 p.m. 1c. The facility staff failed to provide post surgical wound care as ordered by the physician. An order dated 1/25/16 directed the staff to apply wound VAC therapy to the resident's post surgical foot wound and change it every three days (there were no settings on this order). A wound VAC is a negative pressure wound therapy. It is a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds. The therapy involves the controlled application of sub-atmospheric pressure to the local wound environment, using a sealed wound dressing connected to a vacuum pump. On 3/23/16 at 5:30 p.m., an interview was conducted with the resident. The resident expressed concerns for her safety due to the lack of care provided. The resident stated that the staff failed to change the wound VAC every three days as ordered, she stated some days the nurses did not know how to change it and therefore it did not get done. The wound VAC has been discontinued. Review of the TAR (Treatment Administration Records) for February 2016 evidenced the wound VAC was not changed as ordered on the following dates: 2/16/16, 2/18/16, 3/3/16, 3/5/16 and 3/10/16. The wound care order was changed on 3/13/16 to cleanse the wound with normal saline, apply a wet to dry dressing and kerlix daily for three days. Review of the TAR (Treatment Administration Records) for February 2016 evidenced the wet to dry dressing was not changed on 3/13/16. On 3/23/216 at 7:40 p.m., an interview was conducted with the Social Worker (SW). She stated the resident had expressed concerns for her safety due to lack of care and requested a transfer to another facility. The Social Worker stated the resident did state that the wound VAC dressing changes were not, being consistently done or correctly, and she later found out that one of the nurses did not have the correct wound VAC dressing size. 1d. The facility staff failed to assess and obtain effective treatment for [REDACTED].#21, subsequently the resident was taken to the emergency room by a family member for evaluation and treatment. On 3/23/16 at 5:30 p.m., the resident was observed in a wheelchair sitting outside the residents room doorway. The resident requested to speak to an inspector. At this time an interview was conducted with the resident. The resident expressed concerns about the lack of care and services provided since admission and her safety due to the care. The resident stated, When I first came in I was on a medication for a UTI and it changed my urine orange ([MEDICATION NAME]), I still had complaints of itching down there (vaginal area) .I didn't get anything for the itching for a couple weeks .it was after a care plan meeting around February 8th .I told them at that time what was going on .they got a prescription for [MEDICATION NAME] a one time pill .I was still itchy the nurse said it would take three to five days to work .another two weeks went by and I just couldn't take it anymore .one of the nurses said they faxed they doctor and he never responded .I was suffering .my daughter came in one day from work and told me that I can't stand to see you suffering any longer and took me to the emergency room . I was given a [MEDICATION NAME] (an antifungal cream) prescription there, I filled the prescription on my way back to the facility and the nurses kept it in the cart. I would have to go to them and ask for it. The resident was asked if the staff had assessed her for a vaginal yeast infection prior to her going to the emergency room , she stated, No. The clinical record notes dated 2/10/16 read, in part: She was started on [MEDICATION NAME] . No additional information as to why the resident was started on the [MEDICATION NAME] followed. The clinical record notes dated 2/20/16 at 3:50 p.m., read, in part: Resident complains of urethral pain and right flank pain. Resident refused straight catheterization for urine specimen for culture and sensitivity. Stated she was going to the emergency room , and her daughter was driving her as she believes she has a UTI . Review of the emergency room notes dated 2/20/16 read, in part: Reports vaginal itching x 2 weeks. Onset of burning and soreness in urethra x 2 days with right sided abdominal pain. Also reporting urgency and frequency. The resident was worked up for a UTI (urinary tract infection)the urinalyses was negative, CT of the abdomen/pelvis were negative, a vaginal swab was obtained, and lab work. The resident was diagnosed with [REDACTED]. The clinical record notes dated 2/21/16 at 1:06 a.m., read, in part: client returned from ER .client received order of [MEDICATION NAME] r/t (related) to yeast infection d/t (due to) ABT (antibiotics) . The nurse who documented on 2/20/16 at 3:50 p.m., was interviewed on 3/28/16 at approximately 1:00 p.m. She stated the resident was complaining of pain and thought it might be from a UTI (urinary tract infection). The nurse stated she remembered trying to call the physician for an order but he did not respond to her call. She stated she then notified the north 4 unit manager. She was instructed by the unit manager to obtain a urine specimen and then start the resident on [MEDICATION NAME]. The nurse was asked if this was a physician standing order, she stated she did not know but followed the unit managers instructions. The resident refused the straight cath for the urine sample and instead went to the emergency room . The nurse stated she remembered the resident did have the [MEDICATION NAME] inside the medication cart and would ask the nurses for it. The MAR evidenced an order entry for [MEDICATION NAME] 100 mg (milligrams) three times a day for three days, dated 2/20/16. [MEDICATION NAME] is used to treat pain, burning, increased urination, and increased urge to urinate. These symptoms are usually caused by infection, injury, surgery, catheter, or other conditions that irritate the lower urinary tract. [MEDICATION NAME] will treat the symptoms of a urinary tract infection, but this medication does not treat the actual infection. Do not use [MEDICATION NAME] for longer than 2 days unless your doctor has told you to. The MAR evidenced an order entry for [MEDICATION NAME] (an antifungal) 150 mg one time daily for one day starting 2/9/16, and the same order on 2/10/16. The resident was administered both doses. The MAR and the physician orders did not evidence an order entry for the [MEDICATION NAME] as prescribed by the ER physician. Further investigation evidenced a faxed communication sheet sent to Resident #21's attending physician (the medical director) dated 2/11/16. The fax read, in part: Subject: Topical for burning sensation? Notes: (Resident name and room number) has a request for a topical cream to relieve the burning sensation of her vaginal area. She is extremely uncomfortable, what would you like to prescribe? Please respond with any new orders? There was no physician response found in the clinical record addressing this fax reporting the resident's symptoms and need for treatment. A copy of all physician standing orders/protocols was requested. A stack of standing orders/protocols was provided to the inspector for review. The inspector was told there were no other standing orders/protocols. This stack did not contain a standing order/protocol for the treatment of [REDACTED]. On 2/26/16 the attending physician documented, in part: .pt (patient) has persistent UTI she was previously treated with [MEDICATION NAME] but symptoms persisted, family took her to the ER (emergency room ) and she was prescribed [MEDICATION NAME] b/c (because) [MEDICATION NAME] was insufficient symptoms has since resolved . 2. The facility staff failed to provide surgical wound care and intravenous (IV) antibiotics per physician's order for Resident #41. Resident #41 was admitted to the nursing facility on 3/18/16 at 5:00 p.m. with [DIAGNOSES REDACTED].*osteo[DIAGNOSES REDACTED] of left foot, diabetes mellitus (DM), *gangrene and [MEDICAL CONDITION] of left lower leg [MEDICAL CONDITION] (systemic infection) *[DIAGNOSES REDACTED] is an infection in a bone. Infections can reach a bone by traveling through the bloodstream or spreading from nearby tissue. Infections can also begin in the bone itself if an injury exposes the bone to germs (www.mayoclinic.org/diseases-conditions/osteo[DIAGNOSES REDACTED]/basics/definition/CON- 518). *Gangrene refers to the death of body tissue due to a lack of blood flow or a bacterial infection. Gangrene most commonly affects the extremities, including your toes, fingers and limbs (www.mayoclinic.org/diseases-conditions/gangrene/basics/definition/con- 120). *[MEDICAL CONDITION] (sel-u-LIE-tis) is a common, potentially serious bacterial skin infection. [MEDICAL CONDITION] appears as a swollen, red area of skin that feels hot and tender. It can spread rapidly to other parts of the body (www.mayoclinic.org/diseases-conditions/[MEDICAL CONDITION]/basics/definition/CON- 471). Resident #41 was to recently admitted to have a Minimum Data Set (MDS) completed. Resident #41 was to recently admitted to have a completion of a care plan, thus physician's orders and nursing assessments directed care for the resident. The Nursing Admission assessment dated [DATE] assessed the resident to have no cognitive deficits and was responsive, communicative and oriented to person, place and time. Resident #41 had physician's orders dated 3/19/16 at 2:53 p.m. for *Ivanz SDV 1 gram (1 g) vial (EA) intravenous (IV) for Wound/Bone/Sepsis infection of left foot. The resident received the first dose in the facility on 3/19/16 at 9:00 p.m. The clinical record revealed two consecutive doses were missed on 3/24/16 and 3/25/16 with no recorded justification as to why the IV was not administered. *Ivanz SDV/Ertapenem injection is an antibiotic used to treat certain serious infections, including diabetic foot infections, that are caused by bacteria. It works by killing bacteria. The injection is to be used the same time(s) every day. Use ertapenem injection until you finish the prescription, even if you feel better. If you stop using ertapenem injection too soon or if you skip doses, your infection may not be completely treated and the bacteria may become resistant to antibiotics(www.nlm.nih.gov/medlineplus/druginfo/meds/a 1.html). An interview with the resident on 3/28/16 at approximately 2:00 p.m. revealed that the nursing staff did not perform his dressing change to the left foot surgical wound every other day as ordered and he had to personally call the physician to inform him; in addition to the omission in administration of the IV antibiotic on 3/24 and 3/25/16. On 3/29/16 at 10:40 a.m., an interview was conducted with the Director of Nursing (DON) and the Unit Four Registered Nurse (RN) Manager. They stated two sets of orders were put in the system for the dressing change to the left foot surgical wound, one for wound care every seven days and one for wound care every other day. They stated the resident had the dressing change completed on Friday by the physician before he left the facility. There was no explanation as to why the two conflicting orders were not clarified, but the resident knew the dressing change was every other day. The resident called the physician on Monday (3/21/16) to complain that his dressing change had not been done and the physician came in to complete the dressing change herself. Apparently, the resident called again on 3/25/16 to complain his dressing changes were not being done and the physician lodged an official complaint on 3/25/16. It was not until 3/28/16 that the surgical wound care order was corrected to every two days on day shift. Resident #41 was signed off on 3/28/16 to have received surgical wound care to the left foot and scheduled for the next dressing change on 3/30/16. The DON and Unit Four Manager stated they did not know how both orders were transcribed with conflicting wound care treatment times, but the nurses should have clarified immediately which one should have been implemented. During the above interview, the DON and Unit Four Manager stated the IV antibiotics were in the facility to be administered, but no explanation as to why they were not given because the nurse involved had not been scheduled to work since the errors were identified. The physician's official complaint 3/25/16 indicated she did not mind coming in after hours on Monday and did not mind going above and beyond, but when the resident called her again about failure to have treatment done, she thought it was understood the reason the resident was in the nursing facility was for antibiotics and care of his surgical site. The facility's policy and procedure entitled Verification of Orders dated 5/14/13 indicated nurses were to verify accuracy of orders on Medication Administration Record (MAR) and the Treatment Administration Record (TAR) by comparing to the orders. Also, verify accuracy of transcription by comparing order to the MAR and/or TAR. 3. The facility staff failed to follow physician's orders and obtain Finger Stick Blood Sugar (FSBS)/accuchecks before meals at 4:30 p.m. with sliding scale insulin for Resident #32. Resident #32 was admitted to the nursing facility on 11/13/12 with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment dated [DATE] coded the resident with a score of 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated he was cognitively intact in the skills needed for daily decision making. Resident #32 was assessed to have diabetes that required insulin injections. The care plan dated 1/30/16 identified Resident #32 was at risk for [DIAGNOSES REDACTED] and [MEDICAL CONDITION] related to Diabetes Mellitus. The goal the staff set for the resident was that he would have no effects from [DIAGNOSES REDACTED]/[MEDICAL CONDITION]. Some of the interventions the staff would implement to accomplish this goal included monitor accuchecks per physician's order and notify the physician as needed. The licensed nurses were the responsible discipline to implement this intervention. Resident #32 had physician's orders dated 8/1/15 for Stick Blood Sugar (FSBS)/accuchecks before meals at 4:30 p.m. with sliding scale insulin. On 03/24/16, at approximately 7:03 p.m. the Licensed Practical Nurse (LPN) #10 took over the medication cart to began passing medications. The LPN stated she called early in the morning to inform the unit, she would not be working, but received phone calls asking where she was. The Director of Nursing (DON) stated she did not know Licensed Practical Nurse (LPN) #10 was not scheduled to work at 3:00 p.m. and there was no one assigned on the cart to administer any medications that may have been scheduled from 3:00 p.m. to 7:00 p.m. to also include FSBS/accuchecks, thus no accucheck was obtained to determine if the resident required sliding scale insulin and the resident had already eaten the evening meal. There were no nurse's notes or entries on the Medication Administration Record (MAR) to indicate the accuchecks were not done, nor was there any evidence the physician was called and informed of the same. The DON stated the physician should have been called and informed of the failure to obtain accuchecks and administer medications, as well as completion of a medication error report and incident report, which was not done. 4. The facility staff failed to follow physician's orders and obtain Finger Stick Blood Sugar (FSBS)/accuchecks before meals with sliding scale insulin at 4:30 p.m. and administer 5:00 p.m. medications (*[MEDICATION NAME] and *Psysillium) for Resident #21. *[MEDICATION NAME] is used to treat high blood pressure and heart failure (http://www.webmd.com/drugs/2/drug-5574/carvedilol-oral/details). *[MEDICATION NAME] is used to treat constipation. It increases the bulk in your stool, an effect that helps to cause movement of the intestines (http://www.webmd.com/drugs/2/drug-797/[MEDICATION NAME]-oral/details). Resident #21 was admitted to the nursing facility on 1/24/16 with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Admission assessment dated [DATE] coded the resident with a score of 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated she was cognitively intact in the skills needed for daily decision making. Resident #21 was assessed to have diabetes that required insulin injections. The care plan dated 2/5/16 identified Resident #21 was at risk for [DIAGNOSES REDACTED] and [MEDICAL CONDITION] related to Diabetes Mellitus. The goal the staff set for the resident was that she would have no effects from [DIAGNOSES REDACTED]/[MEDICAL CONDITION]. Some of the interventions the staff would implement to accomplish this goal included monitor accuchecks per physician's order and notify the physician as needed. The licensed nurses were the responsible discipline to implement this intervention. The resident was also care planned for high blood pressure. The goal set by the staff for the resident indicated the resident would have no adverse effects from hyper/[MEDICAL CONDITION]. Some of the interventions the staff would implement to accomplish this goal included to administer medication per physician's order and to notify the physician as needed. Resident #21 had current physician's orders dated 1/26/16 for FSBS/accuchecks at 4:30 p.m. before the evening meal, [MEDICATION NAME] 6.25 milligrams (mg) at 5:00 p.m., [MEDICATION NAME] Fiber 0.52 gram (1 capsule) at 12:00 p.m. and 6:00 p.m. On 03/24/16, at approximately 7:03 p.m. the Licensed Practical Nurse (LPN) #10 took over the medication cart to began passing medications. The LPN stated she called early in the morning to inform the unit, she would not be working, but received phone calls asking where she was. The Director of Nursing (DON) stated she did not know Licensed Practical Nurse (LPN) #10 was not scheduled to work at 3:00 p.m. and there was no one on the cart to administer any medications that may have been scheduled from 3:00 p.m. to 7:00 p.m. to also include FSBS/accuchecks, and the [MEDICATION NAME] and [MEDICATION NAME] Fiber, which were omitted. She stated because there was no one assigned to the cart from 3:00 p.m. to 7:00 p.m., thus no accucheck was obtained to determine if the resident required sliding scale insulin and the resident had already eaten her evening meal. There were no nurse's notes or entries on the Medication Administration Record (MAR) to indicate the accuchecks were not done or medications were not administered, nor was there any evidence the physician

Based on information obtained during a complaint investigation, family interview, staff interviews, clinical record review, and review of the facility's policy the facility staff failed to provide supervision and interventions to prevent accidents and elopement for 3 of 43 residents in the survey sample (Resident #24, #39 and #7) 1. The facility staff failed to implement fall prevention strategies and to provide necessary supervision to prevent a fall resulting in a fracture and debilitating pain for Resident #24. The outcome of this fall constituted harm for Resident #24. 2. The facility staff failed to provide adequate supervision to Resident #39 to prevent elopement from the facility. Resident #39 eloped from the facility and was found approximately 0.4 miles away at a convenience store. 3. The facility staff failed to provide adequate supervision to Resident #7 to prevent elopement from the facility. The findings included: 1. Resident #24 was originally admitted to the facility 9/7/16 for rehabilitation therapy after a fall at home resulting in a left closed femur neck fracture. The resident was discharged on [DATE] after sustaining a closed lumbar 1 vertebra fracture after a fall in the nursing facility on 10/2/15. Resident #24 [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/14/15 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #24 cognitive abilities for daily decision making were intact. Resident #24 was coded unsteady moving from a seated position to a standing position, activity did not occur walking, turning around and facing the opposite direction, moving on and off the toilet and unsteady with surface-to-surface transfers. The resident was also assessed to need extensive assistance of 1 person with transfers, unable to walk, total assistance with dressing and bathing, and requiring limited assistance with personal hygiene and eating. The resident was coded as having an indwelling catheter and occasionally incontinence of bowels. The resident was not coded on the MDS assessment with behavioral symptoms/problems or indicators of delusions, psychosis, physical, verbal or behavioral symptoms towards others, and she did not reject care. A facility Fall Risk Assessment was not completed for Resident #24 upon admission or anytime doing the 25 day stay. The facility's policy entitled Fall Prevention Program - Assessment and Care Planning with a revision date of 10/4/13 read a Fall Risk Assessment is to be completed within 24 hours following admission. An interim care plan will be instituted for residents determined to be at-risk on admission. Residents assessed at high risk will have a yellow armband . All residents who have fallen will have Fall Prevention interventions placed on their care plan. Individualized care plan interventions will be implemented for residents found to be at high risk for falls, through Fall Risk Assessment or MDS. The care plan with an effective date of 9/21/15 identified as a problem; at risk for falls related to impaired mobility. The goal (resident name) will demonstrate the ability to ambulate/transfer without fall related injuries over the next 90 day review period. The approaches listed to achieve the goal were listed as; keep areas free of obstructions to reduce the risk of falls or injury. Place call bell/light within easy reach. Remind (resident name) to call for assistance before moving from bed to chair and from chair to bed. Respond promptly to calls for assistance to the toilet. Use alarm to monitor attempts to rise. Footwear will fit properly and have non-skid soles. Provide reminders to use ambulation and transfer assist devices. Review of the clinical record revealed on 9/8/15 a nurses' note written at 1:46 a.m., stating the family member (daughter in law) reported to the facility's staff the resident had sun downers and would become a little confused. The staff documented the resident became very confused, repeatedly yelled out for help and stating she did not want to be alone, then called 911. Another nurses' note dated 9/13/15 indicated the resident continued with periods of confusion and was now incontinent of bladder and sometimes bowels. The clinical record further revealed a nurses' note dated 9/19/15 written at 3:42 a.m., which stated Resident #24 was requesting the bedpan and the staff was aiding to transfer her from bed to the bedside commode for elimination. Another nurses' note dated 9/24/15 at 7:16 p.m., stated the resident was diagnosed with [REDACTED]. On 9/27/15 at 3:37 p.m., a nurses' note stated the resident is now continent of her bowels and bladder but requires assistance of 1-2 staff to the bedside commode or to get out of bed. Review of the Physical therapist note dated 10/5/15, revealed Resident #24 was discharged from physical therapy on 10/1/15 to travel back home with family because maximum potential with skilled services had been reached. At the time of Resident #24 discharge she was capable of walking 100 feet with contact guard assistance and rest breaks. The physical therapist documented on 9/29/15 the resident had a high risk for falls. On 10/2/15 a nurses' note written at 7:01 a.m., states found resident on the floor in room. Resident states she was trying to use the bedside commode without assistance. She did not use the call bell to inform staff. Resident stated she hit her head on the bed adjacent to her. Complained of back and head hurting. Resident has not been moved, awaiting medical transport. Vital signs blood pressure 175/75, pulse 75, respirations 22, temperature 97.8 oral, oxygen saturation 87%. Another nurses' note dated 10/2/15 7:04 a.m., stated in the hallway up from (room number), heard a yell then a thump, entered room and found resident on the floor, lying on her back. She was alert, but confused to time and date. Asked if she was in pain, she stated my spine hurts. Supervisor present and several nurses. Roommate said resident hit her head on the bed. Examined head, no bruising or tenderness noted. Resident not moved, for safety reasons. Did note bed in low position and resident had removed entire alarm system and put in chair. Physician called and 911 called. Another nurses' note dated 10/2/15 at 7:16 a.m. stated, 911 in to transfer via stretcher. Resident verbal and alert. A nurses' note dated 10/2/15 at 7:46 a.m., stated the physician and family were updated. An incident report with an event date of 10/2/15 stated entered room, found resident lying on her back. Alert but confused. Complained of spinal pain. Able to move arms. Supervisor called. The incident report with an event date of 10/2/15 further revealed; Preliminary cause; impulsive, non-compliant, Patient severity index; minor injury, Primary injury; pain- no physical harm. Review of the 10/2/15 hospital emergency room physician documentation revealed Resident #24 was seen for a fall. The resident reported she had to use the bathroom and became tired waiting for the nurse to come help her therefore; she walked to the bedside commode. The resident stated her sock got caught on the rug/mat causing her to trip and fall backwards landing on her bottom. The resident reported hitting her head on the bed, denied loss of consciousness but complained of pain to her low back and left hip. The resident was diagnosed with [REDACTED]. Percocet (a narcotic pain medication) was prescribed for pain and the resident was discharged because she and the family stated they had flights to another state in 2 days. *A closed fracture is a broken bone that does not penetrate the skin. *Lumbar vertebras are located in the lower back and support most of the upper body's weight. The lumbar vertebras are most vulnerable to spinal conditions that can cause chronic and debilitating pain. The nurses' note dated 10/2/15 at 7:09 p.m. stated the resident returned to the facility from the emergency department of a local hospital on a stretcher. The nurse stated the social worker and family member stated the resident was leaving the facility today instead on tomorrow. Discharge orders were received and the resident was given all medications for the week. The resident did not exhibit signs of distress or pain and was wheeled out the facility by the family and placed in the car. A telephone interview was conducted with the emergency contact/family member on 3/24/16 at approximately 12:45 p.m. The family member stated she had been informed on 9/30/15 by the physical therapist the resident had been getting confused and was observed out of bed grabbing furniture to get to the bedside commode therefore the family member requested the staff use a bed alarm to keep the resident safe for the next 2 days. The resident was scheduled to be discharged on [DATE]. The family member stated during visits with Resident #24, she noted the facility was always short of staff and it sometimes took the staff 30 minutes to respond to the resident's call bell. *An alarm device alerts the staff; by sounding if the resident forgets to call for assistance with transfers. The family stated on 10/2/15 between 7:00 a.m. and 7:10 a.m. she received a call from the nursing facility stating Resident #24 had fallen in her room and was being transported to a local emergency room . The family member stated she came to the nursing facility to ask the staff and Unit 4 Manager how did the fall occur and they responded the resident had been taking the clip bed alarm off her shirt. The family member stated she asked the facility staff why did they not attempt another intervention and they did not respond to the question. Resident #24 family member stated prior to the 10/2/15 fall the resident was able to sit in a wheelchair without pain, aid with transfers on and off the bedside commode, walk with the therapist/staff and participate in her daily care. She further stated after the 10/2/15 fall the resident was unable to sit, walk or lie down without severe debilitating pain and the resident often cried because the pain was often so severe. The family member stated narcotic pain medications were required to achieve some comfort but not eliminate the pain. The family member further stated the pain after the fall resulting in the lumbar 1 vertebra fracture required a delay in resumption of therapy sessions. The family member stated the in home therapy had to be put on hold for 2 weeks while some degree of pain control was being accomplished. The family member stated it was 6 weeks before the resident was able to tolerate sitting again without use of narcotic pain medication. An interview was conducted with the Unit 4 Manager on 3/26/16 at approximately 2:20 p.m. The Unit 4 Manager stated Resident #24 was found lying on the floor at 6:55 a.m. The Unit 4 Manager also stated Resident #24 was utilizing a clip type alarm because the family requested an alarm as there had been reports of the resident transferring herself without assistance. The Unit 4 Manager stated Resident #24 was known to repetitively remove the alarm but no other interventions had been instituted at the time of the fall. The Unit 4 Manager stated usually when the alarm system was deemed ineffective for a fall risk resident the individual would be moved closer to the nurses' station for more frequent monitoring by the staff but for some reason this did not occur neither were more effective interventions institute to prevent further falls for the resident. An interview was conducted with the Director of Nursing (DON) on 3/28/16 at approximately 4:20 p.m., when it was discovered a Nursing admission assessment had never been completed for Resident #24. The DON stated the assessment was likely not completed because there was not sufficient staff to perform the duty. The DON stated the nursing admission assessment is a valuable tool in determining care needs for the resident. The DON stated the nursing admission assessment aids the staff in determining potentials for pain, skin breakdown, elimination needs, incontinence care, elopement risk and aids in development of an individual pall prevention program and necessary care planning interventions. The DON further stated she was aware the nursing admission assessments were not being completed but no action plan had been developed to ensure this would not continue to be a facility practice. During the interview with the Director of Nursing (DON) on 3/26/16 at approximately 4:20 p.m., the DON was asked to provide information on how the admission nursing assessment could have benefited Resident #24. The DON stated completing the nursing admission assessments would have alerted the staff the resident was a high fall risk resident and prompt them to respond quickly to calls for assistance, encourage increased monitoring and frequent reinforcement of using the call bell to contact the staff. Review of the call bell activity for Resident #24 bed revealed on the day of the fall 10/2/16, the resident had called at 12:44 a.m. and the call bell was not answered for 16:08 minutes, another call was made at 3:33 a.m. and the staff responded 10:15 minutes later, the resident called again at 5:42 a.m. and waited 7:58 minutes for assistance, at 5:58 the resident called and staff responded within 3:54 minutes , another call was made at 6:03 a.m. and staff responded in 4:41 minutes. There were no further calls from that bed until 14:08. There was no call logged for the time of the fall at approximately 6:55 a.m. on 10/2/15. The above information was shared with the Administrator, Director of Nursing and Corporate Representative on 3/29/16 at approximately 4:00 p.m. The facility staff did not offer any additional information prior to the survey team's exit. 2. The facility staff failed to ensure supervision was maintained and assistance devices were in place to prevent elopement from the facility for Resident #39. Resident #39 was admitted to the nursing facility on 1/12/16. The resident was admitted to a local acute care hospital and readmitted to the facility on [DATE]. Resident #39 [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/7/16 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #39 cognitive abilities for daily decision making were intact. The assessment states the resident is feeling down, depressed or hopeless 2-6 days over a 14 day period and has no behavior problems. The resident requires limited assistance of 1 with transfers and walking. He is coded as not steady moving from a seated position to standing, walking, turning around while walking, moving on and off the toilet and from surface to surface. The resident requires supervision only with bathing, limited assistance with personal hygiene and toileting but extensive assistance with dressing because of hand contractures and left hemiparesis. The elopement risk assessment dated [DATE] was completed with the resident only because no family accompanied him to the facility. The risk assessment indicated the resident was not an elopement risk. A clinical note dated 1/13/16 at 6:10 p.m., stated the facility staff offered a wander guard bracelet (a device that sounds an alarm when a wandering resident walks outside the building) to Resident #39 even though the information provided by the resident indicated it was not necessary. The 1/13/16 clinical note further stated the staff explained the importance of the device to the resident but he declined use of the wander guard bracelet and promised not to leave or go out the door. A clinical note dated 1/15/16 at 11:35 a.m., stated the resident left the facility without notifying staff. He went to (name of the convenience store). Resident assessed by nurse, Registered Nurse and Director of Nursing (DON) and found to be alert and oriented x4. The resident was without injury. Resident agreed to use of a wander guard. The wander guard was placed on his left ankle. Resident was instructed on the sign out policy and importance of staff being notified when he was going on leave of absence. Another clinical note date 1/15/16 at 1:53 p.m., stated the resident walked to (name of the convenience store) stated he was going to the bank to cash his money. Resident returned to the facility alert oriented x4, knew what he did was wrong. Accepted to have wander guard placed for his safety. Son notified and made aware. The care plan dated 3/16/16; stated the resident had a potential for injury related to wandering/elopement. 1/15/16 walked to (name of the convenience store) without notifying staff. On 2/29/16 the resident walked to the facility's entrance to look for his son. No further episodes of exit seeking behavior. Resident was told when his cardiac monitoring was completed his need for the wander guard would be reviewed. The care plan goal stated; Resident will have no injury and will not wander from unit or out the facility on a daily basis for 90 days. The care plan interventions were; Provide diversional activities. Approach calmly and attempt to redirect into appropriate areas of the facility. Wander guard per physician's order. Check for placement every shift and functioning every week. Monitor whereabouts at all times. Adapt environment as needed so resident can identify own room and belongings. Encourage activity attendance. Monitor for signs and symptoms of over tiring and encourage rest periods. Assess for need that may have initiated wandering. Attempt to anticipate needs as indicated. Have picture and accurate description readily available in case resident leaves the facility. Notify appropriate persons and initiate search. Notify physician and Responsible Party as needed. On 3/28/16 at 6:00 p.m., the resident's elopement route was reviewed by the surveyor. Observation of the route revealed the resident walked a road with 2 lanes through a residential area where the speed limit was 25 miles per hour. Traffic was very heavy at the (name of the convenience store) and a busy 4 lane highway with 4 directions of traffic was 0.1 mile away. According to a weather site for the area, the high temperature on 1/15/16 was 59 degrees. An interview was conducted with the Director of Nursing on 3/28/16 at approximately 4:15 p.m. The DON stated she was informed at approximately 7:00 a.m. on 1/15/16 by the Maintenance man that he saw Resident #39 at the (name of the convenience store). The DON stated she drove to the (name of the convenience store) talked with the resident, encouraged him to get in her vehicle and she returned him to the facility without incident or injury. The DON stated she did not complete an investigation or report the incident to the state agency because he had no physician order which stated he could not leave the facility at will. The DON was asked why did she go get the resident, have a wander guard bracelet applied to his left leg, have a new elopement assessment completed for the resident and an elopement care plan initiated if his leaving the facility was not considered an elopement. The DON again stated Resident #39 could leave at will because there was no physician order stating he could not. A telephone interview was conducted with Licensed Practical Nurse (LPN) #199 on 3/29/16 at approximately 12:30 p.m. LPN #199 stated on 1/15/16, she observed Resident #39 in his room at approximately 7:00 a.m. and administered his medications to him at approximately 9:00 a.m. LPN #199 stated after breakfast the resident was observed sitting near the water fountain for a short while then he stated he was going to activities at approximately 10:00 a.m. LPN #199 stated that was the last time she saw the resident prior to a Certified Nursing Assistant (CNA) bringing the Resident to her and informing her the resident was just brought back from the (name of the convenience store). LPN #199 stated she assessed the resident and charted what she knew about the event in the clinical notes. LPN #199 stated she was not informed who saw the resident at the (name of the convenience store) or who brought him back to the facility. LPN #199 stated the DON and RN also assessed the resident and initiated use of a wander guard. An interview was conducted with CNA #200 on 3/29 16 at approximately 12:45 p.m. CNA #200 stated she was caring for Resident #39 on 1/15/16, the day of the elopement. CNA #200 stated the resident was unsteady when walking and required use of a cane because of weakness on one side. CNA #200 also stated most of the resident's hygienic care was provided by her. She stated the resident was dressed in pants, a shirt and a hoodie and she last saw the resident sitting in his room at approximately 10:30 a.m. CNA #200 stated at approximately 12:00 noon she was informed by LPN #199 that Resident #39 was seen at the (name of the convenience store) and brought back to the facility. CNA #200 said LPN #199 gave her no new instructions for caring for Resident #39. An interview was conducted with the Palliative Care Nurse Practitioner (NP) on 3/29/16 at approximately 1:30 p.m. The NP stated the resident was enrolled in the Palliative Care program for symptom management on the same day he left the facility unescorted. The NP also stated based upon clinical judgement Resident #39 was not a candidate for a leave of absence with a responsible person accompanying him. The NP stated the Resident had been residing at the facility only 2 days, had cardiac concerns and an unsteady gait with left side weakness. Another interview was conducted with the DON on 3/29/16 at approximately 2:45 p.m. After further questioning by the surveyor the DON stated she did not pick the resident up from the (name of the convenience store) a little after 7:00 a.m. on 1/15/16. The DON stated it was later in the day based on nurses' notes she had reviewed. The DON further stated she did not document on the event. The facility's policy and procedure entitled 'Adverse Events' with a revision date of 1/13/15 states the definition of an Adverse Event is any event that has caused (or potential to cause) harm to staff, resident and/or Sentara Health Care. The policy further states examples of adverse events are elopement; occurs when a resident leaves the premises or safe area without authorization and/ or the necessary supervision to do so and under circumstances that place the Resident's health, safety, or welfare at risk. Under 'Investigation' the policy states a thorough investigation of the event is conducted and documented by the Administrator and Director of Nursing. The above information was shared with the Administrator, Director of Nursing and Corporate Representative on 3/29/16 at approximately 4:00 p.m. The facility staff did not offer any additional information prior to the survey team's exit. 3. The facility staff failed to provide adequate supervision for Resident #7 to prevent elopement from the facility. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. The facility staff failed to provide supervision to prevent elopement. A Quarterly Minimum Data Set ((MDS) dated [DATE] assessed this resident as being able to understand and makes self understood with clear comprehension. This resident was assessed as having scored an 11 on the Brief Interview Mental Status (BIMS) assessment indicating moderate cognitive impairment. This resident was not assessed as having wandering behaviors. An Elopement Risk Assessment was performed on 1/27/16 at 2:57 P.M. The assessment indicated: Applicable Diagnosis-Schizophrenia. The resident has attempted to leave a residence or other place unescorted that places him/her in danger. (Yes). The resident is cognitively impaired with poor decision-making skills (i.e. intermittent confusion, cognitive deficits or disoriented all the time) and independently ambulatory. (Yes). The resident has a history of elopement. (No). The resident is on medication to manage the wandering behavior. (No). There has been a recent change in this medication. (No). Resident has verbalized intent to leave facility. (Yes) The resident is wandering/seeking to find spouse or family. (No) The resident is wandering aimlessly. (No). The resident is actively exhibiting exit-seeking behavior. (Yes). Comment on wandering behavior: Resident has been leaving facility unsupervised and not notifying staff. Resident has been rolling in wheelchair down (sic) street to nearby store. Resident #7 was observed throughout the survey walking from one unit to the other and participating in smoking activities. A Care Plan dated 10/8/15 indicated: Short term memory impaired-unable to recall after 5 minutes. Interventions- maintain consistent routine, introduce changes slowly to reduce confusion. Provide direct guidance when resident is unable to follow through with instructions. A Care Plan dated 3/18/16 indicated: Potential for injury related to wandering/elopement- Intervention Provide diversional activities; wander guard per MD order; monitor whereabouts at all times hourly check in. A Social Services Progress Note dated 12/23/15 indicated: Resident is A+Ox3 (alert and oriented times 3) and able to effectively communicate his needs. He is very pleasant and cooperative with care. He does have a history of being non-compliant with dietary restrictions. Resident has family that is actively involved in his care. He serves as a great advocate on his behalf. The plan is for resident to remain LTC (long term care) due to his need for supervision and assistance with ADL'S. A Nursing note dated 1/26/16 at 9:52 A.M. indicated: Resident is (sic) verbal abusive cussing at staff and calling them out of name. A Nursing note dated 1/26/16 at 11:54 A.M. indicated: Resident had dried blood on left elbow and was asked what happened? Resident stated it happened in the courtyard when he was outside drinking. This nurse cleaned elbow and noticed a small scratch in place. This nurse asked resident if he had anything besides his meds and resident stated yes I had, wine, beer, and (sic) (illicit drugs). Nurse called MD (medical doctor) and notified him that resident was acting erratically and needed to be evaluated at ER (emergency room ) for possible drug toxicity. MD gave order for ER to evaluate for possible drug toxicity and once resident is stabilized medically to send resident for a psych evaluation. Nursing note dated 1/26/16 at 2:36 P.M. indicated: Psych evaluator stated resident is very cooperative and no danger to himself or others and does not meet the criteria to be TDO (Temporary Detaining Order), and resident is not willing to check himself in for mental help. Nurse stated resident stated he was going to come back to facility and chill. Nursing note dated 1/27/16 at 7:18 A.M. indicated: Resident slept until 5 this morning. Woke up and start rolling himself towards the court yard. Noted resident hard to redirect. Blood sugar this morning 252 coverage given. At 6 A.M. morning staff spotted Resident #7 rolling back to the facility from local store. 11-7 staff encourage and re-directed resident back inside. Resident keep refusing. Nursing note dated 1/27/16 at 2:42 P.M. indicated: Resident left building once again today in wheelchair headed to store. This nurse received call from front desk and went up to the desk and saw resident rolling down street in wheelchair. Nurse called out to resident and he turned around and came back to facility. Resident states he was going to get cigarettes and this nurse made it perfectly clear to resident on several occasions that he is not to leave facility without notifying staff and how dangerous it is for him to be on the road alone. Social worker and POA (power of attorney) are aware that resident left building again and at the request of the POA and social worker, MD was called and a wanderguard and outpatient Psych evaluation and med adjustment were ordered. Wanderguard placed on left ankle and explained to resident. An Incident Abstract Report dated 1/27/16 indicated: Facility employee reported to this writer via telephone that this resident was seen at local store without supervision or acknowledgement by the nurse on duty. Responsible Party made aware and Director of Nursing (DON) notified. Returned without any obvious injury. Nursing note dated 1/27/16 at 7:24 P.M. indicated: Resident attempted to leave facility this evening at approx 1600 (4:00 pm). received call from lobby front desk stating, resident attempted to leave facility, but was unable due to having wanderguard. Receptionist stated that resident proceeded to walk to door alarm system and enter in code to unlock door. Attempt was successful and resident was stopped by staff. Resident stated he was leaving to 'Hit the streets' and engage in illegal activities. Resident was counseled by this nurse regarding his safety and the reasoning for the wanderguard. Resident did not seem to be content about the new device and stated the facility has him on 'house arrest.' Attempted to reassure resident the device is for his safety. Device is currently on left ankle. Nursing note dated 1/27/16 at 10:27 P.M. indicated: This nurse received notice that resident eloped from building and was seen at local store drinking beer and smoking. This nurse arrived at (name of store) and witness resident drinking and smoking. DON and POA were notified. Another facility employee saw incident and assisted with leading resident back to facility. Resident left building and entered door code himself. Will inform oncoming shift. No injury noted to resident. Nursing note dated 1/29/16 at 1:53 P.M. indicated: Resident was placed on hourly monitoring sheet per DON. Sheets must be signed every hour after laying eyes on patient. Resident has been directed by MD not to leave facility at all. Nursing note dated 1/30/16 at 8:09 A.M. indicated: During med pass the Maintenance Director stated that he saw Resident #7 at local store and brought him back to the facility. During an interview on 3/24/16 at 11:06 A.M. with the Maintenance Director he stated, resident #7 was found at the local store down the street from the facility. When asked how did the resident know the code, he stated, I think he was watching as other staff and family members were going and coming. The Maintenance Director was asked if the code had been changed and he stated, Yes. A Missing Resident Policy, as provided by Administrator, indicated: Should an employee observe a resident attempting to leave the premises, he/she should attempt to prevent the departure; obtain assistance from other staff members in the immediate vicinity and inform Charge Nurse that a resident is attempting to leave the premises. During an interview on 3/24/16 at 1:15 P.M. with the Administrator he stated, we were finally able to get Resident #7 sent out for a psych eval and in-house services. The facility staff failed to provide Resident #7 with supervision to prevent elopement from the facility. Complaint Deficiency

Based on observation, staff interview, clinical record review, and facility document review it was determined that the facility staff failed to ensure the environment was free of accident hazards for 1 of 15 residents in the survey, Resident #108, resulting in immediate jeopardy and substandard quality of care. Facility staff failed to ensure that a "E" 2000 PSI oxygen cylinder was safely secured and not creating a probability of serious harm. Immediate Jeopardy (IJ) was called based on observations of the oxygen cylinder left standing against the wall in Resident #108's room and not in a "E-tank" holder making it a serious environmental danger and hazard. Immediate Jeopardy (IJ) was called on 11/4/14 at 12:40 PM. Based on review and acceptance of the Plan of Correction (POC), the Immediate Jeopardy (IJ) was removed on 11/4/14 at 4:10 PM. After removal of the immediate jeopardy, the scope and severity was lowered to a level 2, isolated. The findings include: Resident #108 was a [AGE] year old female readmitted to the facility on [DATE]. Review of Resident #108's clinical record indicated [DIAGNOSES REDACTED]. Resident #108's most recent MDS (Minimum Data Set) was a quarterly dated 10/4/14. Resident #108 was coded 5 out of possible 15 on the Brief Interview for Mental Status (BIMS) indicating she was severely impaired in cognitive skills for daily decision making. Resident required extensive assistance with all activities of daily living (ADL's). Resident #108's most recent plan of care on the clinical record evidenced that the resident was care planned with interventions for decision making and required extensive assistance with all activities of daily living (ADL's). On 11/4/14 at 11:15 AM during initial rounds an unsecured "E" 2000 PSI oxygen cylinder was found standing by the wall in Resident #108's room. The oxygen cylinder was not stored secured in a "E-tank holder", and created a probability of serious harm. Observations of the unsecured oxygen cylinder was evidenced to be full of oxygen as determined by the green rubber label on the neck of the cylinder and oxygen being released when the release valve was placed in the "On" position. Surveyors made observations at 11/14/14 at 12:30 PM, 12:50 PM and at 1:15 PM. The unsecured oxygen cylinder was in plain view sight upon entering the resident's room. The resident was in bed and appeared to be asleep. A complete tour of the facility was completed by the surveyors and an audit of 100 percent of residents with the use of oxygen and no other oxygen cylinder hazards were evidenced. The State office was notified at 12:30 PM of the " IJ " status. The facility Administrator and Director of Nursing was advised of the "IJ" status at 12:40 PM. A facility investigation was initiated by the Administrator and Director of Nursing and the unsecured oxygen cylinder was removed from the resident's room. The Director of Nursing (DON) stated that the nursing staff should have observed the oxygen cylinder which was right out in plain sight standing against the wall unsecured when staff entered the room. The DON stated that the oxygen cylinder was left in the room by a contracted agency providing services. Review of the facilities' policy on " Storage of Hazardous Materials" with a revision date of 6/11/13 evidenced the following: It is the policy to establish guidelines for the proper storage of all hazardous materials. Flammable liquids, combustible gases will not be stored in areas where intense heat or open flame devices could ignite such matter. Oxygen cylinders are stored in upright position and keep in " E-tank holder " . The facility Administrator presented a plan of correction at 3:22 PM which was not accepted due to all required elements of a plan of correction was not evidenced. The State office was notified at 3:35 PM. At 4:10 PM the facility Administrator presented an acceptable plan of correction with an allegation of compliance (AOC) of 11/6/14 which re-evaluated the corrective measures to ensure the situation was corrected. The Immediate Jeopardy (IJ) was removed at this time. The submitted Corrective Action Plan included: 1. The immediate removal of the oxygen cylinder with placement in the secure oxygen room in a "E-tank" holder. 2. A facility wide inspection for other oxygen hazards in which none were found. 3. Administration acknowledged that residents and facility staff was evidenced to could have been affected by the deficient practice. 4. The Medical Director was notified, interventions were put in place with facility wide training of all nursing staff. 5. The Allegation of Compliance (AOC) was evidenced to be 11/6/14. All other non nursing staff was updated on the new interventions. The State office was notified. Guidance was provided at www.premierhealthcare.com with interpretation of the guidelines for Life Safety: "Oxygen cylinders store gaseous oxygen under a very high pressure (2,000 psi-pounds per square inch). Oxygen cylinders must be stored in a rack or stand and empty cylinders must be stored away from full cylinders" Additionally, guidance was provided by Joint Commission at www.jointcommission. org, "It may be impractical for some organizations to have piped nonflammable medical gases, so they may provide these gases in freestanding cylinders of various sizes. All freestanding cylinders must be stored in a rack, a cart, or another enclosure to protect them. Unsecured cylinders could fall, breaking the valve and possibly resulting in a rapid release of the gas, propelling the cylinder and turning it into a dangerous projectile."

2 Based on observation, staff interview, clinical record review, and facility document review it was determined that the facility staff failed to ensure the environment was free of accident hazards for 1 of 15 residents in the survey, Resident #108, resulting in immediate jeopardy and substandard quality of care. Facility staff failed to ensure that a E 2000 PSI oxygen cylinder was safely secured and not creating a probability of serious harm. Immediate Jeopardy (IJ) was called based on observations of the oxygen cylinder left standing against the wall in Resident #108's room and not in a E-tank holder making it a serious environmental danger and hazard. Immediate Jeopardy (IJ) was called on 11/4/14 at 12:40 PM. Based on review and acceptance of the Plan of Correction (POC), the Immediate Jeopardy (IJ) was removed on 11/4/14 at 4:10 PM. After removal of the immediate jeopardy, the scope and severity was lowered to a level 2, isolated. The findings include: Resident #108 was a [AGE] year old female readmitted to the facility on [DATE]. Review of Resident #108's clinical record indicated [DIAGNOSES REDACTED]. Resident #108's most recent MDS (Minimum Data Set) was a quarterly dated 10/4/14. Resident #108 was coded 5 out of possible 15 on the Brief Interview for Mental Status (BIMS) indicating she was severely impaired in cognitive skills for daily decision making. Resident required extensive assistance with all activities of daily living (ADL's). Resident #108's most recent plan of care on the clinical record evidenced that the resident was care planned with interventions for decision making and required extensive assistance with all activities of daily living (ADL's). On 11/4/14 at 11:15 AM during initial rounds an unsecured E 2000 PSI oxygen cylinder was found standing by the wall in Resident #108's room. The oxygen cylinder was not stored secured in a E-tank holder, and created a probability of serious harm. Observations of the unsecured oxygen cylinder was evidenced to be full of oxygen as determined by the green rubber label on the neck of the cylinder and oxygen being released when the release valve was placed in the On position. Surveyors made observations at 11/14/14 at 12:30 PM, 12:50 PM and at 1:15 PM. The unsecured oxygen cylinder was in plain view sight upon entering the resident's room. The resident was in bed and appeared to be asleep. A complete tour of the facility was completed by the surveyors and an audit of 100 percent of residents with the use of oxygen and no other oxygen cylinder hazards were evidenced. The State office was notified at 12:30 PM of the IJ status. The facility Administrator and Director of Nursing was advised of the IJ status at 12:40 PM. A facility investigation was initiated by the Administrator and Director of Nursing and the unsecured oxygen cylinder was removed from the resident's room. The Director of Nursing (DON) stated that the nursing staff should have observed the oxygen cylinder which was right out in plain sight standing against the wall unsecured when staff entered the room. The DON stated that the oxygen cylinder was left in the room by a contracted agency providing services. Review of the facilities' policy on Storage of Hazardous Materials with a revision date of 6/11/13 evidenced the following: It is the policy to establish guidelines for the proper storage of all hazardous materials. Flammable liquids, combustible gases will not be stored in areas where intense heat or open flame devices could ignite such matter. Oxygen cylinders are stored in upright position and keep in E-tank holder . The facility Administrator presented a plan of correction at 3:22 PM which was not accepted due to all required elements of a plan of correction was not evidenced. The State office was notified at 3:35 PM. At 4:10 PM the facility Administrator presented an acceptable plan of correction with an allegation of compliance (AOC) of 11/6/14 which re-evaluated the corrective measures to ensure the situation was corrected. The Immediate Jeopardy (IJ) was removed at this time. The submitted Corrective Action Plan included: 1. The immediate removal of the oxygen cylinder with placement in the secure oxygen room in a E-tank holder. 2. A facility wide inspection for other oxygen hazards in which none were found. 3. Administration acknowledged that residents and facility staff was evidenced to could have been affected by the deficient practice. 4. The Medical Director was notified, interventions were put in place with facility wide training of all nursing staff. 5. The Allegation of Compliance (AOC) was evidenced to be 11/6/14. All other non nursing staff was updated on the new interventions. The State office was notified. Guidance was provided at www.premierhealthcare.com with interpretation of the guidelines for Life Safety: Oxygen cylinders store gaseous oxygen under a very high pressure (2,000 psi-pounds per square inch). Oxygen cylinders must be stored in a rack or stand and empty cylinders must be stored away from full cylinders Additionally, guidance was provided by Joint Commission at www.jointcommission. org, It may be impractical for some organizations to have piped nonflammable medical gases, so they may provide these gases in freestanding cylinders of various sizes. All freestanding cylinders must be stored in a rack, a cart, or another enclosure to protect them. Unsecured cylinders could fall, breaking the valve and possibly resulting in a rapid release of the gas, propelling the cylinder and turning it into a dangerous projectile.

Based on observations, clinical record review, staff and family interview and facility documentation, the facility staff failed to notify the physician of a change in condition for 1 of 10 residents (Resident #3) in the survey sample. Resident #3's physician was not informed of an antibiotic that was resistant to treatment for [REDACTED]. The resident was subsequently admitted to the ICU with a primary [DIAGNOSES REDACTED]. The findings include: Resident #3 was admitted to the nursing facility on 2/19/13 with [DIAGNOSES REDACTED]. The resident was discharged to a local hospital on [DATE] and did not return to the nursing facility. The most recent Minimum Data Set (MDS) assessment dated [DATE] coded Resident #3 with a score of 13 (cognitively intact in the skills for daily decision making) on the Brief Interview for Mental Status (BIMS). The resident required extensive assistance from one staff for bed mobility, transfers from one surface to the next and dressing. She was assessed totally dependent on one staff for toilet use and bathing. The resident was functionally limited in range of motion (ROM) on both sides in upper and lower extremities. Resident #3 had an indwelling urinary catheter and was always incontinent of bowel. The resident's weight was 186 pounds (LB). The MDS coded the resident with one Stage 2 pressure ulcer with granulating tissue 1.4 centimeters (cm). The care plan dated 8/19/14 identified the resident was on an antibiotic related to a current Urinary Tract Infection [MEDICAL CONDITION]. The goals the staff set for the resident was the resident would tolerate the antibiotic without signs and symptoms of adverse reaction during the next 7 days and the resident's UTI would be treated and improve without complications during those 7 days. Some of the approaches the staff would use to accomplish this goal included monitor for decreased functional ability, weakness and fatigue, monitor percentage (%) of meals consumed every shift and report any changes in condition to the medical doctor. During a clinical record review, a physician's orders [REDACTED]. The Lab results dated 8/19/14 for 6:00 AM indicated the resident had an abnormal urine culture and the organism was resistant to one antibiotic, Cipro. A physician's orders [REDACTED]. On 9/12/14 at 1:55 PM, an interview was conducted with the Nurse Practitioner (NP). She stated she was in the facility all day on 8/19/14 seeing residents and at the time she saw Resident #3 she only saw a previous UA/C&S that was dated as resulted 8/17/14 and initialed it indicating to have seen the results and faxed to the resident's physician. She stated the C&S results indicated the resident was not resistant [MEDICATION NAME] she ordered the antibiotic to be given twice a day for 7 days based on the report she saw in the clinical record. She stated if the 8/19/14 results were on the fax machine waiting to be filed on the clinical record and a nurse saw them, she expected the nurse to look at the report let her know the results and she would have changed the antibiotic to an appropriate one to effectively treat the UTI. She stated she was in the building all day and she was available by phone. She stated it may be because there was no unit manager on the unit that things are missed. She stated as a rule, when she sees a lab/X-ray report she initials at the bottom of the report that she saw it. She stated there was no initial at the bottom of the 8/19/14 6:00 AM U/A/C&S lab report. The attending physician/Medical Director joined the interview along with the NP at 2:35 PM. He reviewed the labs on the clinical record and stated the lab requested a new specimen be submitted for the U/A and C&S on 8/13/14, which was collected on 8/15/14 and resulted on 8/17/14 [MEDICATION NAME] sensitive to the organism. He further saw that a repeat urine sample was collected on 8/16/14, verified on 8/18/14 and final results available on 8/19/14. He stated he was not made aware of the final results of 8/19/14 and if he had them or had known about them he would have immediately changed the antibiotic. During the aforementioned interview, the complaint allegations regarding the resident's physical decline until the family sending the resident out on 8/23/14 via 911 was reviewed with him. He stated he had several conversations with the family about the sacral pressure ulcer and their concerns about wanting the resident sent out to the ED to have the wound evaluated. He said he told them he felt it was not necessary to have her sent out specifically for a wound evaluation and would set up a wound clinic appointment to address the wound issues. He stated the family seemed to be okay with the plan and he wrote progress notes regarding their conversations about the pressure ulcer and the consult with the wound clinic. He stated he wrote an order on 8/19/14 to have the resident seen by the wound clinic. During the interview, it was shared with the physician that the complainant alleged Resident #3 was steadily declining especially from 8/19/14 to 8/23/14 with altered mental status, lethargy and not eating at all and the nursing staff telling the complainant, he refused to send the resident out to the hospital. He stated the nursing staff did not make him or his NP aware of these other areas of decline other than the wound issues. He said, "I would have never said under no circumstances send the resident out to be evaluated in the ED for anything. If she were having increased lethargy, altered mental status and now that I know she had been on an inappropriate antibiotic, which I was not told about, I would have sent her out to the ED earlier than 8/23/14." He reviewed the nurse's notes and voiced concern about the nurse's notes on 8/22/14 and 8/23/14 about the resident's decline and documentation that indicated and assumed he not wanting to send the resident out to the ER for other physical problems other than the wound issue. He asked to talk to the Administrator and the DON. On 9/12/14 at 3:15 PM, an interview was conducted with the Administrator that was covering for the facility's Administrator who was out of town, the facility's DON, a DON from another facility and the facility's ADON. The physician shared his concern that he was not informed about the obvious change in the resident's condition other than the wound from 8/19/14 to the family sending her out 911 on 8/23/14. He stated he was especially concerned with how the nurse wrote a note on 8/22/14 at 3:00 PM assuming he "globally" meant the resident could not be sent to the hospital for any reason. The physician further said not sending the resident to the ED was only in regards to the wound, which he had addressed with the family with follow/up at the wound clinic. He stated he was not aware of the 8/19/14 U/A C&S results indicating the resident was on the [MEDICATION NAME] was having no positive effect on treating the current UTI with the resident getting sicker day by day. He stated, "If I was told she was listless, lethargic, not eating anything at all, no urine output, nasty urine with blood, distended abdomen, I would have had her sent out. No physician would have said not to send her out under any circumstances." When the Physician left the room at 3:30 PM, the DON stated there had been lots of turn over on S1 and they were looking for a Unit Manager for that unit. She said, "This is appalling. I can see his upsetness and the concerns from the family are justifiable." The nurses notes were not all inclusive for documentation regarding the resident's change in condition. Some of them are chronicled as follows from 8/15/14 to discharge 8/23/14: From 8/15/14 to 8/18/14 there were no nurse's notes for any shift and only one on 8/19/14 at 7:30 PM, which indicated a new order for antibiotic and the Power of Attorney (POA) was made aware. On 8/20/14 for 7/3 a note was written by Licensed Practical Nurse (LPN) # 3 indicating the physician had written an order for [REDACTED]. was very poor and ordered Glucerna shakes 240 cubic centimeters (cc) with every meal and will continue to monitor. There were no further nurses notes on 8/20/14 for the 3/11 or 11/7 shift in light of the above need to monitor by nursing due to a change in condition, as well as the concerns voiced by the resident's daughter. Two nurse's note were written by the 11/7 nurse (LPN #1)who was leaving on 8/21/14 at 7:45 AM and 7:55 AM. The 7:45 AM note was a late entry and indicated the Certified Nursing Assistant (CNA) told her the resident had no output in the Foley bag. She indicated she flushed it with 60 cc of normal saline and 100 cc returned with sediment and blood. The CNA stated the resident had an extra large bowel movement, but no further description documented. It was documented a note was sent to the MD informing him of the change in the resident's behavior along with the decrease food and fluid intake and increase lethargy the past few days. This note was not made available to this writer during the survey. The nurse's note indicated the DON was made aware, along with the status of the wound. The 7:55 AM note indicated the previous shift nurse (3/11 on 8/20/14) told her the resident had difficulty swallowing her meds, but she did not have the same issue on her shift. LPN #1 documented the resident's stomach was distended, the resident was currently on an antibiotic for a UTI and monitoring would continue. On 8/21/14 at 7:15 AM, Acting S1 Unit Manager/AADON documented the resident was on an antibiotic for UTI without signs and symptoms of adverse reaction and that they would continue to monitor. On 8/22/14 at 3:00 PM (7/3 shift nurse), LPN #10 documented the family had concerns about "how the resident was looking" and they wanted her sent out to the ED for further evaluation. The LPN documented she spoke with the physician and he stated that he talked with the family and the resident was not being sent out. She documented the physician stated if they wanted the resident sent out to the ER for them to call 911 themselves and if any questions to call him. There were no nurse's notes to reflect monitoring for 8/22/14 for the 3/11 shift and the 11/7 shift in light of a progressing decline in the resident's health status and the family's concern about "how the resident was looking". On 8/23/14 at 11:47 AM, LPN #10 documented the family members called 911 to have resident sent to the ER for further evaluation and she left a message for the physician to notify him of the situation. On 9/12/14 at 4:45 PM, an interview was conducted with LPN #10 who had documented on 8/22/14 (Friday) at 3:00 PM and on 8/23/14 at 11:47 AM. She stated 8/22/14 was her weekend to work and the family approached her about the change in the resident that they noticed Tuesday (8/19/14) and Wednesday (8/20/14). She said besides their concern about the pressure ulcer, they told her the resident was lethargic, somewhat unresponsive, the urine had thick sediment with blood in the tubing and not much urine in the Foley drainage bag, tarry stools and she was not eating. She said she was told the resident was lethargic during report from the night nurse (LPN #1). She said she found the resident to be in the same condition as described by the family. She said the family wanted the resident sent to the ER and she told them she would talk to the physician. LPN #10 said she told the physician on 8/22/14 because he was in the building about the family's concerns and her assessment of the same. She stated the physician told her the resident was not to be sent out under no circumstances and she relayed that to the family. She stated she had started the process to send the resident out via regular medical transport and canceled after the physician told her not to send the resident to the ER. When asked if she knew the resident was on an antibiotic that was resistant to the type of infection she had she responded; "I knew she was [MEDICATION NAME] was resistant to the organism in the urine, but I didn't tell him anything. I thought he knew what he wanted to treat her with. The lab results for 8/19/14 were on the record." LPN #10 further stated on 8/23/14 when she came back to work for 7/3, the resident was worse than the previous day and she didn't call the physician based on her understanding he was not going to give her an order to send the resident for further evaluation at the ER, so the family called 911. On 9/12/14 at 5:10 PM, the attending physician joined the interview with the LPN #10. The LPN stated to the physician she told him on 8/22/14 the resident had a change in her mental status, she was lethargic, the Foley was not draining any urine and he stated not to send the resident to the ER. The Physician stated to her he was referring to the wound situation only and she did not tell him about the other elements of the resident's change in condition. He stated he never got a note, fax or a call about the resident's change in condition nor did he or the NP see the 8/19/14 lab results or informed about [MEDICATION NAME] resistant to the organism in the resident's urine on 8/19/14. He stated, "You all have sent residents out before for even less than what this resident was experiencing, why didn't you or the previous shift nurses go on and send her out. No one on this unit uses critical thinking skills at all. I was never saying not to send her out under no circumstances and to use that globally. You took the statement about not sending her out for the wound to mean not sending her out for anything. Furthermore, you did not tell me about her mental status changes, the lack of urine and appearance of the urine, no intake and tarry stools." On 9/12/14 at 5:30 PM, the DON joined the interview with the physician and LPN #10. The DON asked LPN #10 did she specifically tell the physician about the change in the resident's condition besides the wound issues. LPN #10 responded, "No I didn't, but why aren't you concerned about the other nurses that did not tell him she was getting sicker and was lethargic." The DON stated to LPN #10 she was only responsible for her assessment and her nurse's notes. The physician stated when he called the family and found out the resident was admitted to the ICU [MEDICAL CONDITION], was on an inappropriate antibiotic he was livid and taken back because he would have not hesitated to give to order to send her out. He stated with the resident not eating or drinking, not voiding, not as responsive, having tarry stools, as well as their knowledge of a lab result with a resident on the wrong antibiotic; 24 hours of that kind of decline would was warranted her to have been sent out. LPN #10 then recanted that she did not tell him about the change in condition and said, "Oh, I did tell you everything and that my call was not for the wound and you told me not to send her out." The DON said, "Which is it? you told him, you did not share the information, or now back to you told him. You need to stick to one story." An interview was conducted with LPN #3 who documented on 8/20/14 and 8/21/14 for the 7/3 shift. She stated the pressure ulcer was getting worse from the time she last saw it and she informed the S1 Acting Unit Manager/ADON. She stated the CNAs told her the resident was having tarry stools, appetite was getting poorer and she was not herself. She stated she got an order for [REDACTED]. She stated she did not receive a report from the 11/7 nurses about altered mental status or lethargy and again thought it was due to no one knowing anyone's baseline because they were not the regular nurses. She said the 3/11 and 11/7 nurses were either pulled from other units or they were pool staff and they don't know the resident or that there was a change in their status. She stated it was reported to her on 8/21/14 when she came on, the resident had no urine output so she had the 11/7 nurse, LPN #1 to irrigate the Foley catheter. According to the LPN she knew there was a repeat U/A/C&S because the first one grew out too many organisms and heard the NP put the resident on the wrong antibiotic, Cipro, and based on the final results the organism was resistant to it. She was not able to say when or why none of this information was relayed to the NP or the physician. On 9/15/14 at 11:40 AM, an interview was conducted with the previous S1 Unit Manager/ADON. She stated she was still working for the corporation, but transferred to another nursing facility as of 8/22/14. She reviewed the labs during this interview and said this was the first time she was aware the resident was on an antibiotic that was resistant to the organism growing in the resident's urine. She stated she saw where the NP wrote the order and she made sure it was available from the pharmacy. She said she remembered calling the RP's cell on 8/19/14 and she calling the desk back immediately, at which time I told her the resident had a UTI and was being treated with an antibiotic. She stated the most recent lab dated 8/19/14 6:00 AM printed out automatically from the lab on the fax machine. The date on the report meant the lab was available for view on 8/19/14 at 6:00 AM. She said the expectation is from the fax machine, the nurse would look at it, call the physician and let him know regardless of questioning if he knew the results or not by leaving a message for him to call you back to personally give him the results or fax him the results. The S1 Unit Acting Unit Manager/ADON at the time continued to say, she had gotten an order on 8/20/14 for Glucerna because LPN #3 was concerned the resident was not eating well and knew the wound was not improving. She stated the licensed nursing staff staff was supposed to complete a SBAR (Situation, Background, Assessment and Recommendation) report related to a change in condition/clinical variances and communicate the information to the physician. She stated there were no SBAR reports from any of the nurses. She said the CNAs were to complete a Stop and Watch report for any concerns they have and give it to the licensed nurse. She said to her knowledge there were no Stop and Watch reports from the CNAs. She said with regard to rounding on residents, the licensed nurses make rounds on the odd hours and the CNAs every two hours, which should pick up any decline and changes in the resident condition. When asked during the interview if the unit was short of staff to properly make those rounds and on going monitoring for changes in condition, as well as ongoing monitoring for worsening of an existing medical problem; she stated, "Staffing is a challenge and that is all I am going to say." She stated the 24 hour Change of Status report was filled out by a licensed nurse and supposed to be a nursing shift to shift communication documentation tool for residents with the need to monitor specific concerns to include a changes in medical condition. The 24 hour report dated 8/20/14 for the 11/7 shift indicated the resident was [MEDICATION NAME] mg twice a day (BID) for 7 days. On 8/21/14 the 24 hour report for the 11/7 shift documented the resident's Foley catheter was flushed with 60 cc of normal saline and 100 cc urinary return. On 8/22/14 the 24 hour report for the 11/7 shift noted the resident had a change in behavior, lethargy, decrease in food intake and she was on day 3 of a 7 day antibiotic. On 8/23/14 the 24 hour report for the 11/7 shift indicated close monitoring was needed for lethargy, decreased food and water intake. All of the aforementioned documentation on the 11/7 24 hour report indicated the information was recorded in the nurse's notes. On 8/23/14 for the 7/3 shift, the 24 hour report indicated the resident was sent to the ER per family with a [DIAGNOSES REDACTED]. On 9/13/14 at 12:15 AM, an interview was conducted with LPN #1 who documented on the 24 hour report for 11/7 shift 8/20-23/14, as well as in the nurse's note on 8/21/14. She stated the 3/11 nurse on 8/20/14 told her the resident was having problems taking her medications and she had no urine output with thick creamy sediment in the Foley tubing. She said the resident had taken her medications for her and she found the Foley catheter was clogged with sediment; she flushed it and had minimum return. She stated on 8/21/14, 8/22/14 and morning of 8/23/14, she found the resident to be progressively lethargic, not her friendly self, eyes looking glazed and the CNAs were concerned. She stated, "I told the ADON who came on at 7:30 AM to keep a close eye on her and I didn't call the physician, but wrote a note to be faxed to the doctor that she was not doing well and he needed to be aware. I wasn't aware the resident was on an antibiotic that was resistant to the bug in her urine. I guess that's why she wasn't getting better." The note written by the nurse was not located during the survey and the doctor had already stated he was not made aware of the resident's progressive change in condition, apart from the poor healing pressure ulcer. Resident #3's primary CNA (#5) on the 7/3 shift was interviewed on 9/15/14 at 2:25 PM. She stated the resident had been able to feed herself, but towards the end she wasn't able to and had stopped eating. She stated the urine in the Foley catheter was very cloudy and the output was very low and she had remembered her having dark stools. She said the family was very upset and wanted the resident sent out, but LPN #10 stated the physician refused to let the resident go out to the ER so the family sent her via 911. She said she did not fill out a Stop and Watch form based on the changes she saw in the resident because on day shift everyone knew she was not doing well. The CNA stated the resident's grandson was upset when he saw the resident not responsive to him and told the one of the resident's daughters and she talked to the daughter on the phone, who was the RP, and they decided to send her out 911 regardless of what LPN #10 said the physician said. CNA #5 said the family told her the resident was not coming back. Another CNA (#1) was interviewed on 9/15/14 at 3:00 PM. She stated she worked the whole week before the resident went to the ER. She said she knew the family was not happy because the resident was less responsive and wanted the resident to go out Thursday (8/21/14) and Friday (8/22/14). She stated it was the resident's second daughter (not the RP) that contacted the RP and they decided to send the resident out by 911. The facility was not able to identify all the licensed nurses who worked on the 3/11 shift on 8/19-22/14, but was able to provide a contact number for one of them, LPN #11. The LPN was interviewed on 9/16/14 at 4:35 PM. She stated she was not fully familiar with the resident and when she came on, no one told her anything about the resident because they were so short of staff, she just got the assignment and started passing meds. She stated she remembered she was on antibiotics and seemed very tired. She stated she did not chart any of the days she worked the 3/11 shift, but should have because the resident was on an antibiotic and had a UTI along with being very tired looking. A telephone interview was conducted with Resident #3's RP on 9/16/14 at 11:00 AM. She stated she was informed the pressure ulcer was not healing and had spoken to the physician about the plan to send the resident to the wound clinic, but was equally concerned about the resident's steady decline in her mental status from 8/19-23/14 and she was becoming less responsive, weak and not able to eat and looked bad. She stated she had found food pocketed in the resident's mouth because she was just too weak to chew her food and felt the CNAs should have not left food in her mouth. She stated she was unable to see the resident from 8/21/14 on because of a planned surgical procedure and left her sister to make visits and communicate with her. The RP voiced concerns about the appearance of the urine in the Foley catheter tubing for a week prior to 8/19/14, but especially on 8/19/14 which was observed by herself, her sister and her son with a clay colored sludge like substance. She stated over the next two days more sediment formed yellow and "bubbly-like". She stated she was concerned that treatment for [REDACTED]. The RP continued to say she was concerned about the resident not eating anything and too weak to eat on the 8/20/14 and 8/21/14 and was told by the nurses [MEDICATION NAME] time to work. She stated on 8/22/14 she called the secretary on the S1 unit and told her to get the resident ready to send to the ER. She said by the time her sister got to the facility, LPN #10 had called her to let her know, the physician refused to send her out and he said [MEDICATION NAME] time to work. The RP stated her sister was at the S1 desk and overheard LPN #10 tell her the physician was not going to sign off on sending the resident to the hospital and canceled the medical transport company. The RP stated LPN #10 said the vital signs were good and the resident was eating and she was alert and responsive. During the interview with the RP, she further stated on 8/22/14, her son looked in on the resident and found her virtually unresponsive and could not rouse her. She stated when her sister arrived she found her more confused than the following day. She said LPN #10 told her sister under no circumstances would the physician let the resident go to the hospital because they would be doing the same thing the facility would do. She said it was reported to her by her sister, the Foley bag had no urine in it and the nurse was not successful when she tried to irrigate it, with no urine return. It was at this visit, she stated her sister found food pocketed in the resident's cheek and she feared the resident would aspirate. She stated LPN #10 told her the physician had said if she wanted the resident to be sent to the ER, they would have to do it themselves, so she instructed her sister to call 911. According to the Emergency Medical Services (EMS)/911 records, they were on the scene on 8/23/14 at 11:50 AM. The provider impression of the resident was Altered Level of Consciousness, unable to answer questions, lethargic and weak, oxygen saturation level was 87 % (normal= (95-100%)http://www.mayoclinic.org/symptoms/hypoxemia/basics/definition/sym- 930 The local hospital ED notes indicated the resident arrived on 8/23/14 at 12:48 PM. Upon physical exam, the resident moaned to painful stimuli, but wasn't consistent with answering questions and occasionally answered 'yes ma'am' (sic). UA/C&S, and other labs were drawn. The resident was admitted to the ICU. Results of specimens revealed the resident had been treated with an inappropriate antibiotic and appropriate antibiotics were started via a central line, as well as intravenous fluids to treat dehydration. Primary [DIAGNOSES REDACTED].=normal) with [MEDICAL CONDITION] and [MEDICAL CONDITION], toxic grade 3 due [MEDICAL CONDITION]/UTI. The resident was having loose stools with a drop in Hemoglobin and Hematocrit (H/H) and the [MEDICATION NAME] surgeon diagnosed acute Gastrointestinal (GI) bleed due to esophagitis/ulcers with blood [MEDICAL CONDITION] and surgical intervention. Oxygen and respiratory treatments were initiated to treat shortness of breath. The pressure ulcer was addressed with surgical debridement and wound treatments. Her nutritional status was addressed with swallowing evaluations and therapeutic dietary changes. The resident was eventually discharged to the step down unit and discharged on [DATE] to another nursing facility. On 9/16/14 at 7:00 PM, the aforementioned issues and the complaint allegations were reviewed with the Administrator, a second support Administrator, the DON, ADON and the Director of Clinical operations. No further information was provided including any investigation of why the resident was ordered an antibiotic when resistant to treatment. The facility's policy entitled Laboratory services dated 1/11/11 indicated laboratory results will be reviewed by a licensed nurse and relayed to the attending physician. The physician would be notified of abnormal results within 24 hours of receipt of the results. Physician response will be noted in the resident's clinical record. The facility's policy and procedure entitled Catheter: Urinary-care/Maintenance dated 7/13/10 indicated if drainage is inadequate, check tubing and/or irrigate catheter, if in physician's orders [REDACTED]. If drainage ceases report to nurse supervisor. Notify physician if drainage remains inadequate for more than one hour. Abnormal urine characteristics are to be reported to the team leader immediately and documented in the clinical record. Notify physician immediately of adverse reactions. The facility's policy and procedure entitled Notification of Changes in Condition dated 10/12/10 indicated the resident's physician would be consulted by the nurse on duty when a significant change in the resident's physical, mental or psychosocial status (i.e., deterioration in health, mental or psychosocial status is either life threatening conditions or clinical complications). The policy further indicated the nurse on duty would notify the physician when there is a need to alter treatments significantly (i.e., a need to discontinue an existing treatment due to adverse consequences, or to commence a new form of treatment). COMPLAINT DEFICIENCY

Based on a complaint investigation, clinical record reviews, staff and family interview and facility documentation, the facility staff failed to ensure the necessary care and services were provided to attain the highest practicable physical well-being for 2 of 10 residents (Resident #3 and #1) in the survey sample. 1. Resident #3 had a Urinary Tract Infection [MEDICAL CONDITION] and was being treated with an antibiotic that was resistant to the offending organism. The resident continued to decline and facility staff failed to promptly intervene for a recognized change in her mental and physical status. The family initiated transfer to the local Emergency Department (ED) where the resident was admitted and spent several days in the Intensive Care Unit (ICU) diagnosed with [REDACTED]. 2. The facility staff failed to ensure a physician's orders [REDACTED].#1. The findings include: 1. Resident #3 was admitted to the nursing facility on 2/19/13 with [DIAGNOSES REDACTED]. The resident was discharged to a local hospital on [DATE] and did not return to the nursing facility. The most recent Minimum Data Set (MDS) assessment dated [DATE] coded Resident #3 with a score of 13 (cognitively intact in the skills for daily decision making) on the Brief Interview for Mental Status (BIMS). The resident required extensive assistance from one staff for bed mobility, transfers from one surface to the next and dressing. She was assessed totally dependent on one staff for toilet use and bathing. The resident was functionally limited in range of motion (ROM) on both sides in upper and lower extremities. Resident #3 had an indwelling urinary catheter and was always incontinent of bowel. The resident's weight was 186 pounds (LB). The MDS coded the resident with one Stage 2 pressure ulcer with granulating tissue 1.4 centimeters (cm). The care plan dated 8/19/14 identified the resident was on an antibiotic related to a current Urinary Tract Infection [MEDICAL CONDITION]. The goals the staff set for the resident was the resident would tolerate the antibiotic without signs and symptoms of adverse reaction during the next 7 days and the resident's UTI would be treated and improve without complications during those 7 days. Some of the approaches the staff would use to accomplish this goal included monitor for decreased functional ability, weakness and fatigue, monitor percentage (%) of meals consumed every shift and report any changes in condition to the medical doctor. During a clinical record review, a physician's orders [REDACTED]. The lab results dated 8/19/14 for 6:00 AM indicated the resident had an abnormal urine culture and the organism was resistant to one antibiotic, Cipro. A physician's orders [REDACTED]. On 9/12/14 at 1:55 PM, an interview was conducted with the Nurse Practitioner (NP). She stated she was in the facility all day on 8/19/14 seeing residents and at the time she saw Resident #3 she only saw a previous UA/C&S that was dated as resulted 8/17/14 and initialed it indicating to have seen the results and faxed to the resident's physician. She stated the C&S results indicated the resident was not resistant [MEDICATION NAME] she ordered the antibiotic to be given twice a day for 7 days based on the report she saw in the clinical record. She stated if the 8/19/14 results were on the fax machine waiting to be filed on the clinical record and a nurse saw them, she expected the nurse to look at the report let her know the results and she would have changed the antibiotic to an appropriate one to effectively treat the UTI. She stated she was in the building all day and she was available by phone. She stated it may be because there was no unit manager on the unit that things are missed. She stated as a rule, when she sees a lab/X-ray report she initials at the bottom of the report that she saw it. She stated there was no initial at the bottom of the 8/19/14 6:00 AM U/A/C&S lab report. The attending physician/Medical Director joined the interview along with the NP at 2:35 PM. He reviewed the labs on the clinical record and stated the lab requested a new specimen be submitted for U/A and C&S on 8/13/14, which was collected on 8/15/14 and resulted on 8/17/14 [MEDICATION NAME] sensitive to the organism. He further saw that a repeat urine sample was collected on 8/16/14, verified on 8/18/14 and final results available on 8/19/14. He stated he was not made aware of the final results of 8/19/14 and if he had them or had known about them he would have immediately changed the antibiotic. During the aforementioned interview, the complaint allegations regarding the resident's physical decline up until the family sending the resident out on 8/23/14 via 911 was reviewed with him. He stated he had several conversations with the family about the sacral pressure ulcer and their concerns about wanting the resident sent out to the ED to have the wound evaluated. He said he told them he felt it was not necessary to have her sent out specifically for a wound evaluation and would set up a wound clinic appointment to address the wound issues. He stated the family seemed to be okay with the plan and he wrote progress notes regarding their conversations about the pressure ulcer and the consult with the wound clinic. He stated he wrote an order on 8/19/14 to have the resident seen by the wound clinic. During the interview, it was shared with the physician that the complainant alleged Resident #3 was steadily declining especially from 8/19/14 to 8/23/14 with altered mental status, lethargy and not eating at all and the nursing staff telling the complainant, he refused to send the resident out to the hospital. He stated the nursing staff did not make him or his NP aware of these other areas of decline other than the wound issues. He said, "I would have never said under no circumstances send the resident out to be evaluated in the ED for anything. If she were having increased lethargy, altered mental status and now that I know she had been on an inappropriate antibiotic, which I was not told about, I would have sent her out to the ED earlier than 8/23/14." He reviewed the nurse's notes and voiced concern about the nurse's notes on 8/22/14 and 8/23/14 about the resident's decline and documentation that indicated and assumed he not wanting to send the resident out to the ER for other physical problems other than the wound issue. He asked to talk to the Administrator and the DON. On 9/12/14 at 3:15 PM, an interview was conducted with the Administrator that was covering for the facility's Administrator who was out of town, the facility's DON, a DON from another facility and the facility's ADON. The physician shared his concern that he was not informed about the obvious change in the resident's condition other than the wound from 8/19/14 to the family sending her out 911 on 8/23/14. He stated he was especially concerned with how the nurse wrote a note on 8/22/14 at 3:00 PM assuming he "globally" meant the resident could not be sent to the hospital for any reason. The physician further said not sending the resident to the ED was only in regards to the wound, which he had addressed with the family with follow/up at the wound clinic. He stated he was not aware of the 8/19/14 U/A C&S results indicating the resident was on the [MEDICATION NAME] was having no positive effect on treating the current UTI with the resident getting sicker day by day. He stated, "If I was told she was listless, lethargic, not eating anything at all, no urine output, nasty urine with blood, distended abdomen, I would have had her sent out. No physician would have said not to send her out under any circumstances." When the Physician left the room at 3:30 PM, the DON stated there had been lots of turn over on S1 and they were looking for a Unit Manager for that unit. She said, "This is appalling. I can see his upsetness and the concerns from the family are justifiable." The nurses notes were not all inclusive for documentation regarding the resident's change in condition. Some of them are chronicled as follows from 8/15/14 to discharge 8/23/14: From 8/15/14 to 8/18/14 there were no nurse's notes for any shift and only one on 8/19/14 at 7:30 PM, which indicated a new order for antibiotic and the Power of Attorney (POA) was made aware. On 8/20/14 for 7/3 a note was written by Licensed Practical Nurse (LPN) # 3 indicating the physician had written an order for [REDACTED]. was very poor and ordered Glucerna shakes 240 cubic centimeters (cc) with every meal and will continue to monitor. There were no further nurses notes on 8/20/14 for the 3/11 or 11/7 shift in light of the above need to monitor by nursing due to a change in condition, as well as the concerns voiced by the resident's daughter. Two nurse's note were written by the 11/7 nurse (LPN #1)who was leaving on 8/21/14 at 7:45 AM and 7:55 AM. The 7:45 AM note was a late entry one and indicated the Certified Nursing Assistant (CNA) told her the resident had no output in the Foley bag. She indicated she flushed it with 60 cc of normal saline and 100 cc returned with sediment and blood. The CNA stated the resident had an extra large bowel movement, but no further description. It was documented a note was sent to the MD informing him of the change in the resident's behavior for the resident along with the decrease food and fluid intake and increase lethargy the past few days. This note was not made available to this writer during the survey. The nurse's note indicated the DON was made aware, along with the status of the wound. The 7:55 AM note indicated the previous shift nurse (3/11 on 8/20/14) told her the resident had difficulty swallowing her meds, but she did not have the same issue on her shift. LPN #1 documented the resident's stomach was distended, the resident was currently on an antibiotic for a UTI and monitoring would continue. On 8/21/14 for 7/3, LPN #3 documented the condition of the pressure ulcer and that the DON and Acting S1 Unit Manager/Acting Assistant DON (AADON) were aware. On 8/21/14 at 7:15 AM, Acting S1 Unit Manager/AADON documented the resident was on an antibiotic for UTI without signs and symptoms of adverse reaction and that they would continue to monitor. On 8/21/14 at 1:30 PM, the Acting S1 Unit Manager/AADON documented a complete assessment of the resident's pressure ulcer and at 1:37 PM, documented wound clinic appointment day and time. On 1:39 PM, she documented about an order for [REDACTED]. There were no nurse's notes monitoring the residents condition on 8/21/14 for the 3/11 shift or the 11/7 shift. On 8/22/14 at 3:00 PM (7/3 shift nurse), LPN #10 documented the family had concerns about "how the resident was looking" and they wanted her sent out to the ED for further evaluation. The LPN documented she spoke with the physician and he stated that he talked with the family and the resident was not being sent out. She documented the physician stated if they wanted the resident sent out to the ER for them to call 911 themselves and if any questions to call him. There were no nurse's notes to reflect monitoring for 8/22/14 for the 3/11 shift and the 11/7 shift in light of a progressing decline in the resident's health status and the family's concern about "how the resident was looking". On 8/23/14 at 11:47 AM, LPN #10 documented the family members called 911 to have resident sent to the ER for further evaluation and she left a message for the physician to notify him of the situation. On 9/12/14 at 4:45 PM, an interview was conducted with LPN #10 who had documented on 8/22/14 (Friday) at 3:00 PM and on 8/23/14 at 11:47 AM. She stated 8/22/14 was her weekend to work and the family approached her about the change in the resident that they noticed Tuesday (8/19/14) and Wednesday (8/20/14). She said besides their concern about the pressure ulcer, they told her the resident was lethargic, somewhat unresponsive, the urine had thick sediment with blood in the tubing and not much urine in the Foley drainage bag, tarry stools and she was not eating. She said she was told the resident was lethargic during report from the night nurse (LPN #1). She said she found the resident to be in the same condition as described by the family. She said the family wanted the resident sent to the ER and she told them she would talk to the physician. LPN #10 said she told the physician on 8/22/14 because he was in the building about the family's concerns and her assessment of the same. She stated the physician told her the resident was not to be sent out under no circumstances and she relayed that to the family. She stated she had started the process to send the resident out via regular medical transport and canceled after the physician told her not to send the resident to the ER. When asked if she knew the resident was on an antibiotic that was resistant to the type of infection she had she responded; "I knew she was [MEDICATION NAME] was resistant to the organism in the urine, but I didn't tell him anything. I thought he knew what he wanted to treat her with. The lab results for 8/19/14 were on the record." LPN #10 further stated on 8/23/14 when she came back to work for 7/3, the resident was worse than the previous day and she didn't call the physician based on her understanding he was not going to give her an order to send the resident for further evaluation at the ER, so the family called 911. On 9/12/14 at 5:10 PM, the attending physician joined the interview with the LPN #10. The LPN stated to the physician she told him on 8/22/14 the resident had a change in her mental status, she was lethargic, the Foley was not draining any urine and he stated not to send the resident to the ER. The Physician stated to her he was referring to the wound situation only and she did not tell him about the other elements of the resident's change in condition. He stated he never got a note, fax or a call about the resident's change in condition nor did he or the NP see the 8/19/14 lab results or informed about [MEDICATION NAME] resistant to the organism in the resident's urine on 8/19/14. He stated, "You all have sent resident's out before for even less than what this resident was experiencing, why didn't you or the previous shift nurses go on and send her out. No one on this unit uses critical thinking skills at all. I was never saying not to send her out under no circumstances and to use that globally. You took the statement about not sending her out for the wound to mean not sending her out for anything. Furthermore, you did not tell me about her mental status changes, the lack of urine and appearance of the urine, no intake and tarry stools." On 9/12/14 at 5:30 PM, the DON joined the interview with the physician and LPN #10. The DON asked LPN #10 did she specifically tell the physician about the change in the resident's condition besides the wound issues. LPN #10 responded, "No I didn't, but why aren't you concerned about the other nurses that did not tell him she was getting sicker and was lethargic." The DON stated to LPN #10 she was only responsible for her assessment and her nurse's notes. The physician stated when he called the family and found out the resident was admitted to the ICU [MEDICAL CONDITION], was on an inappropriate antibiotic he was livid and taken back because he would have not hesitated to give to order to send her out. He stated with the resident not eating or drinking, not voiding, not as responsive, having tarry stools, as well as their knowledge of a lab result with a resident on the wrong antibiotic; 24 hours of that kind of decline would was warranted her to have been sent out. LPN #10 then recanted that she did not tell him about the change in condition and said, "Oh, I did tell you everything and that my call was not for the wound and you told me not to send her out." The DON said, "Which is it? you told him, you did not share the information, or now back to you told him. You need to stick to one story." An interview was conducted with LPN #3 who documented on 8/20/14 and 8/21/14 for the 7/3 shift. She stated the pressure ulcer was getting worse from the time she last saw it and she informed the S1 Acting Unit Manager/ADON. She stated the CNAs told her the resident was having tarry stools, appetite was getting poorer and she was not herself. She stated she got an order for [REDACTED]. She stated she did not receive a report from the 11/7 nurses about altered mental status or lethargy and again thought it was due to no one knowing anyone's baseline because they were not the regular nurses. She said the 3/11 and 11/7 nurses were either pulled from other units or they were pool staff and they don't know the resident or that there was a change in their status. She stated it was reported to her on 8/21/14 when she came on, the resident had no urine output so she had the 11/7 nurse, LPN #1 to irrigate the Foley catheter. According to the LPN she knew there was a repeat U/A/C&S because the first one grew out too many organisms and heard the NP put the resident on the wrong antibiotic, Cipro, and based on the final results the organism was resistant to it. She was not able to say when or why none of this information was relayed to the NP or the physician. On 9/15/14 at 11:40 AM, an interview was conducted with the previous S1 Unit Manager/ADON. She stated she was still working for the corporation, but transferred to another nursing facility as of 8/22/14. She reviewed the labs during this interview and said this was her first time she was aware the resident was on an antibiotic that was resistant to the organism growing in the resident's urine. She stated she saw where the NP wrote the order and she made sure it was available from the the pharmacy. She said she remembered calling the RP's cell on 8/19/14 and she calling the desk back immediately, at which time I told her the resident had a UTI and was being treated with an antibiotic. She stated the most recent lab dated 8/19/14 6:00 AM printed out automatically from the lab on the fax machine. The date on the report meant the lab was available for view on 8/19/14 at 6:00 AM. She said the expectation is from the fax machine, the nurse would look at it, call the physician and let him know regardless of questioning if he knew the results or not by leaving a message for him to call you back to personally give him the results or fax him the results. The S1 Unit Acting Unit Manager/ADON at the time continued to say, she had gotten an order on 8/20/14 for Glucerna because LPN #3 was concerned the resident was not eating well and knew the wound was not improving. She stated the licensed nursing staff staff was supposed to complete a SBAR (Situation, Background, Assessment and Recommendation) report related to a change in condition/clinical variances and communicate the information to the physician. She stated there were no SBAR reports from any of the nurses. She said the CNAs were to complete a Stop and Watch report for any concerns they have and give it to the licensed nurse. She said to her knowledge there were no Stop and Watch reports from the CNAs. She said with regard to rounding on residents, the licensed nurses make rounds on the odd hours and the CNAs every two hours, which should pick up any decline and changes in the resident condition. When asked during the interview if the unit was short of staff to properly make those rounds and on going monitoring for changes in condition, as well as ongoing monitoring for worsening of an existing medical problem; she stated, "Staffing is a challenge and that is all I am going to say." She stated the 24 hour Change of Status report was filled out by a licensed nurse and supposed to be a nursing shift to shift communication documentation tool for residents with the need to monitor specific concerns to include a changes in medical condition. The 24 hour report dated 8/20/14 for the 11/7 shift indicated the resident was [MEDICATION NAME] mg twice a day (BID) for 7 days. On 8/21/14 the 24 hour report for the 11/7 shift documented the resident's Foley catheter was flushed with 60 cc of normal saline and 100 cc urinary return. On 8/22/14 the 24 hour report for the 11/7 shift noted the resident had a change in behavior, lethargy, decrease in food intake and she was on day 3 of a 7 day antibiotic. On 8/23/14 the 24 hour report for the 11/7 shift indicated close monitoring was needed for lethargy, decreased food and water intake. All of the aforementioned documentation on the 11/7 24 hour report indicated the information was recorded in the nurse's notes. On 8/23/14 for the 7/3 shift, the 24 hour report indicated the resident was sent to the ER per family with a [DIAGNOSES REDACTED]. On 9/13/14 at 12:15 AM, an interview was conducted with LPN #1 who documented on the 24 hour report for 11/7 shift 8/20-23/14, as well as in the nurses note on 8/21/14. She stated the 3/11 nurse on 8/20/14 told her the resident was having problems taking her medications and she had not urine output with thick creamy sediment in the Foley tubing. She said the resident had taken her medications for her and she found the Foley catheter was clogged with sediment, she flushed it and had minimum return. She stated on 8/21/14, 8/22/14 and morning of 8/23/14, she found the resident to be progressively lethargic, not her friendly self, eyes looking glazed and the CNAs were concerned. She stated, "I told the ADON who came on at 7:30 AM to keep a close eye on her and I didn't call the physician, but wrote a note to be faxed to the doctor that she was not doing well and he needed to be aware. I wasn't aware the resident was on an antibiotic that was resistant to the bug in her urine. I guess that's why she wasn't getting better." The note written by the nurse was not located during the survey and the doctor had already stated he was not made aware of the resident's progressive change in condition, apart from the poor healing pressure ulcer. Resident #3's primary CNA (#5) on the 7/3 shift was interviewed on 9/15/14 at 2:25 PM. She stated the resident had been able to feed herself, but towards the end she wasn't able to and had stopped eating. She stated the urine in the Foley catheter was very cloudy and the output was very low and she had remembered her having dark stools. She said the family was very upset and wanted the resident sent out, but LPN #10 stated the physician refused to let the resident go out to the ER so the family sent her via 911. She said she did not fill out a Stop and Watch form based on the changes she saw in the resident because on day shift everyone knew she was not doing well. The CNA stated the resident's grandson was upset when he saw the resident not responsive to him and told the one of the resident's daughters and she talked to the daughter on the phone, who was the RP, and they decided to send her out 911 regardless of what LPN #10 said the physician said. CNA #5 said the family told her the resident was not coming back. Another CNA (#1) was interviewed on 9/15/14 at 3:00 PM. She stated she worked the whole week before the resident went to the ER. She said she knew the family was not happy because the resident was less responsive and wanted the resident to go out Thursday (8/21/14) and Friday (8/22/14). She stated it was the resident's second daughter (not the RP) that contacted the RP and they decided to send the resident out by 911. The facility was not able to identify all the licensed nurses who worked on the 3/11 shift on 8/19-22/14, but was able to provide a contact number for one of them, LPN #11. The LPN was interviewed on 9/16/14 at 4:35 PM. She stated she was not fully familiar with the resident and when she came on, no one told her anything about the resident because they were so short of staff, she just got the assignment and started passing meds. She stated she remembered she was on antibiotics and seemed very tired. She stated she did not chart any of the days she worked the 3/11 shift, but should have because the resident was on an antibiotic and had a UTI along with being very tired looking. A telephone interview was conducted with Resident #3's RP on 9/16/14 at 11:00 AM. She stated she was informed the pressure ulcer was not healing and had spoken to the physician about the plan to send the resident to the wound clinic, but was equally concerned about the resident's steady decline in her mental status from 8/19-23/14 and she was becoming less responsive, weak and not able to eat and looked bad. She stated she had found food pocketed in the resident's mouth because she was just too weak to chew her food and felt the CNAs should have not left food in her mouth. She stated she was unable to see the resident from 8/21/14 on and left her sister to make visits and communicate with her. The RP voiced concerns about the appearance of the urine in the Foley catheter tubing for a week prior to 8/19/14, but especially on 8/19/14 which was observed by herself, her sister and her son with a clay colored sludge like substance. She stated over the next two days more sediment formed yellow and "bubbly-like". She stated she was concerned that treatment for [REDACTED]. The RP continued to say she was concerned about the resident not eating anything and too weak to eat on the 8/20/14 and 8/21/14 and was told by the nurses [MEDICATION NAME] time to work. She stated on 8/22/14 she called the secretary on the S1 unit and told her to get the resident ready to send to the ER. She said by the time her sister got to the facility, LPN #10 had called her to let her know, the physician refused to send her out and he said [MEDICATION NAME] time to work. The RP stated her sister was at the S1 desk and overheard LPN #10 tell her the physician was not going to sign off on sending the resident to the hospital and canceled the medical transport company. The RP stated LPN #10 said the vital signs were good and the resident was eating and she was alert and responsive. During the interview with the RP, she further stated on 8/22/14, her son looked in on the resident and found her virtually unresponsive and could not rouse her. She stated when her sister arrived she found her more confused than the following day. She said LPN #10 told her sister under no circumstances would the physician let the resident go to the hospital because they would be doing the same thing the facility would do. She said it was reported to her by her sister, the Foley bag had no urine in it and the nurse was not successful when she tried to irrigate it, with no urine return. It was at this visit, she stated her sister found food pocketed in the resident's cheek and she feared the resident would aspirate. She stated LPN #10 told her the physician had said if she wanted the resident to be sent to the ER, they would have to do it themselves, so she instructed her sister to call 911. According to the Emergency Medical Services (EMS)/911 records, they were on the scene on 8/23/14 at 11:50 AM. The provider impression of the resident was Altered level of Consciousness, unable to answer questions, lethargic and weak, oxygen saturation level was 87 % (normal= (95-100%)http://www.mayoclinic.org/symptoms/hypoxemia/basics/definition/sym- 930 The local hospital ED notes indicated the resident arrived on 8/23/14 at 12:48 PM. Upon physical exam, the resident moaned to painful stimuli, but wasn't consistent with answering questions and occasionally answered 'yes ma'am' (sic). UA/C&S, and other labs were drawn. The resident was admitted to the ICU. Results of specimens revealed the resident had been treated with an inappropriate antibiotic and appropriate antibiotics were started via a central line, as well as intravenous fluids to treat dehydration. Primary [DIAGNOSES REDACTED].=normal) with [MEDICAL CONDITION] with [MEDICAL CONDITION] and [MEDICAL CONDITION], toxic grade 3 due [MEDICAL CONDITION]/UTI. The resident was having loose stools with a drop in Hemoglobin and Hematocrit (H/H), and the [MEDICATION NAME] surgeon diagnosed acute Gastrointestinal (GI) bleed due to esophagitis/ulcers with blood [MEDICAL CONDITION] and surgical intervention. Oxygen and respiratory treatments were initiated to treat shortness of breath. The pressure ulcer was addressed with surgical debridement and wound treatments. Her nutritional status was addressed with swallowing evaluations and therapeutic dietary changes. The resident was eventually discharged to the step down unit and discharged on [DATE] to another nursing facility. On 9/16/14 at 7:00 PM, the aforementioned issues and the complaint allegations were reviewed with the Administrator, a second support Administrator, the DON, ADON and the Director of Clinical operations. No further information was provided. The facility's policy and procedure entitled Emergency Rescue Services dated 4/13/10 indicated emergency rescue services would be called as ordered by the physician, or when assessed as needed by a licensed nurse. The facility's policy and procedure entitled Nursing Staff-responsibilities dated 1/11/11 indicated sudden changes in resident health status and emergencies would be properly identified and managed in a timely manner. The facility's policy entitled Laboratory services dated 1/11/11 indicated laboratory results will be reviewed by a licensed nurse and relayed to the attending physician. The physician would be notified of abnormal results within 24 hours of receipt of the results. Physician response will be noted in the resident's clinical record. The facility's policy and procedure entitled Catheter: Urinary-care/Maintenance dated 7/13/10 indicated if drainage is inadequate, check tubing and/or irrigate catheter, if in physician's orders [REDACTED]. If drainage ceases report to nurse supervisor. Notify physician if drainage remains inadequate for more than one hour. Abnormal urine characteristics are to be reported to the team leader immediately and documented in the clinical record. Notify physician immediately of adverse reactions. 2. Resident #1 was originally admitted to the facility 4/8/14 and was readmitted [DATE] after an acute hospital stay. The current [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/22/14 coded the resident at section B0100 as being is a persistent vegetative state therefore the cognitive section was not completed. In section "H" (Bladder and Bowel) the resident was coded as having an indwelling catheter. On 9/15/14 at 5:30 P.M. Physician orders [REDACTED].#1. The physician's orders [REDACTED]. Discontinue Foley catheter. Monitor intake and output. If no urine output please get bladder scan. If patient has [MEDICAL CONDITION] please replace Foley. Also on 9/15/14 at 5:30 P.M. the nurses' notes from 9/13/14 through 9/15/14 were reviewed. They consisted of no documentation which stated the indwelling catheter had been removed or how Resident #1 was voiding since removal of the indwelling catheter. On 9/15/14 at 5:50 P.M. Resident #1 was observed in bed with the eyes open and resting quietly. Resident #1 did not respond in any manner to

Based on observation, resident interview, facility documentation and clinical record review, the facility staff failed for 2 residents in a survey sample of 29 residents, (Resident #3 and Resident #7) to assess, document and treat pressure wounds resulting in harm. 1. Resident #3 failed to have two unable to stage (UTS) wounds identified and treated, wound care treatment was unchanged for over 8 weeks despite wound deterioration ie, left heel progressed from a stage 1 to UTS, the sacrum deteriorated from 2.5cm X 2.6 X 0.2 on admission to 4.0 X 3.0 X 1.0 with undermining currently. A low air loss or alternating pressure mattress was not used. In addition, the nurse's hands were not washed between gloving. 2. For Resident #7, the facility staff failed to A) Identify a pressure ulcer to the back of the head before it reached a stage III, B) Develop interventions for the prevention of pressure ulcers to the back of the head, and C) Perform wound care for pressure ulcers to the back of the head in a manner to prevent the spread of infection. The findings included: 1. Resident #3 was admitted to the facility 12/19/13. [DIAGNOSES REDACTED]. Resident #3's most recent MDS (minimum data set) with an ARD (assessment reference date) of 12/26/13 was coded as a 5 day admission assessment. Resident #3 was coded as having a BIMS (brief interview of mental status) score of "13" out of a possible 15, or no cognitive impairment. Resident #3 was also coded as requiring extensive to total assistance of one or two staff members to perform activities of daily living, such as bed mobility. Resident #3 was coded as being at risk for the development of pressure ulcers and pressure ulcers were coded on the admission MDS assessment as being two stage 1's, one stage 2 and an unable to stage sacral wound. The Minimum Data Set 3.0 defines the four stages of pressure ulcers. "STAGE I Intact skin with non-blanchable redness of a localized area usually over a bony prominence. STAGE II Partial thickness of skin loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact blister. STAGE III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. STAGE IV Full thickness loss with exposed bone, tendon or muscle. Slough or eschar may be present on some part of the wound bed. Often includes undermining or tunneling." The MDS also included pressure ulcers that are unstagable due to coverage of the wound bed by slough and/or eschar. Slough is defined as yellow or white tissue that adheres to the ulcer bed in strings or thick clumps or is mucinous. Review of the clinical record and wound tracking revealed the following: Left heel: admission: 12/19/13: "reddened" stage1 12/31/13: no measurements, skin prep added 12/23/13 with Prevalon boots 1/7/14: No measurements 1/14/14: No measurements 1/21/14: No measurements. "Became UT'S" per wound nurse. 1/28/14: No measurements 2/4/14: 3.0 cm (centimeters) X 2.0 (dark) UT'S, skin prep and [MEDICATION NAME] (adhesive dressing) 2/11/14: 4.5 X 5.0 UTS, same treatment 2/18/14: refuses to be assessed 2/25/14: 2.5 X 2.0 (dark/flat), same treatment 3/4/14: 4.0 X 3.5, UTS, same treatment Right heel: Admission: Reddened, stage 1 12/31/13: No measurements, Skin prep added 12/23/13 with Prevalon boots 1/7/14: No measurements 1/14/14: No measurements 1/21/14: No measurements 1/28/14: No measurements 2/4/14: 1.0 X 1.5 (dark) 2/11/14: 3.5 X 3.0, skin prep and [MEDICATION NAME], not staged 2/18/14: Refused to be assessed 2/25/14: 2.0 X 1.6, not staged 3/4/14: 2.0 X 1.6 Sacrum: admission: 2.5cm X 2.6 X 0.2 (depth), UTS, [MEDICATION NAME] gel, dressing 12/24/13: 3.0 X 2.5. 40 % slough (dead tissue) 30 % necrosis (dead tissue), treatment changed to Santyl and adhesive dressing 12/31/13: 3.0 X 2.5 1.0 with 50% slough 20 % eschar. No change in treatment 1/7/14: 3.5 X 3.0 X 1.0 with 60 % slough. No change in treatment 1/14/14: 3.2 X 2.5 X 1.0 with 60 % slough. No change in treatment 1/21/14: 3.0 X 3.0 X 1.0 with 70 % slough. No change in treatment 1/28/14: 3.5 X 2.5 X 1.0 with 70 % slough. No change in treatment 2/4/14: 3.5 X 2.5 X 1.0 with 70 % slough. No change in treatment 2/11/14: 4.0 X 3.0 X 1.0. No change in treatment 2/18/14: Refused to be assessed 2/25/14: 4.0 X 3.0 X 2.0. No change in treatment 3/4/14: 4.0 X 3.0 X 1.0 with undermining. Treatment changed to Santyl with [MEDICATION NAME] dressing. Mid back: Admission: 1.0 cm X 0.9. Replicare dressing 12/24/13: 1.0 X 1.0. Treatment changed to Santyl with adhesive dressing. Did not stage 12/31/13: 0.8 X 1.5, stage 3. 1/7/14: 1.0 X 1.5 not staged 1/14/14: 0.8 X 1.0, not staged 1/21/14: 2.5 X 1.0. Now has two areas. No treatment for [REDACTED]. 1/28/14: 2.5 X 2.5 X 1.0. No change in treatment 2/4/14: 2.0 X 2.5. No change in treatment. Second area 0.5 X 0.5, no treatment. 2/11/14: 2.0 X 2.5. No change in treatment 2/18/14: Refused to be assessed 2/25/14: 1.5 X 2.5, stage 3. No change in treatment 3/4/14: 1.0 X 2.0, stage 3, changed to Allevyn and Santyl. On 3/5/14 at 11:30 AM, wound care was observed by LPN (licensed practical nurse) A. The resident was turned to her side, and the midback dressing (dated 3/4/14) was removed. Gloves were changed, hands were not washed between gloving. Area has slough, with dark edges. The area was cleansed with NS (normal saline) and Santyl and a [MEDICATION NAME] dressing was applied. A dressing was present on the left upper buttocks. The dressing was removed, and an UTS (per LPN A) wound approximately 2.0 to 2.5 cm area was revealed. LPN (A) stated, "That is new, it is dark." The area was cleansed with NS and an adhesive dressing was applied. There was no order to treat this wound, nor had it been identified prior to treatment. The sacral dressing was then removed, the gloves were changed, but no hand cleaning was done with regloving. The wound was covered with tough, tan appearing slough with some stringy slough at the wound edges. The area was approximately 5.0 to 5.5 cm in diameter. There was undermining present. The area was cleansed with NS, and Santyl and [MEDICATION NAME] dressing was applied. Gloves were changed, but hands were not washed. The left heel dressing was removed. Gloves were changed, but the hands were not washed. An open area approximately 2 cm was revealed with dark edges. The area was cleansed and an Allevyn dressing applied. The right heel dressing was removed. Gloves were changed and the hands were not washed prior to regloving. An UTS area was revealed, and an Allevyn dressing was applied. It was noted on the left outer foot adjacent to the small toe, a dark, blackened area of approximately 0.5 cm. This area was not identified or treated. On 3/5/14 at 12:15 PM, LPN (A) stated, "I do not see a treatment order for this wound (found on left upper buttocks). It is not on the tracking from yesterday." Review of the 3/4/14 weekly skin inspection revealed the following: "open area mid back, open area with Tx (treatment) sacral area, red heels with Tx in place." Pressure relief surface type: Rest Q matt. The unable to stage wound on the upper left buttocks and the unable to stage wound on the left outer foot were not documented. On 3/5/14 at 6:10 PM, the Administrator and DON (director of nursing) were notified of above findings and of potential harm level finding. On 3/6/14 at 10:45 AM, LPN (B) was asked as to what kind of mattress the resident was on. She stated, "She is on a "Rest Q mattress, but we can order an overlay. This should be done on admission." She went on to state, "She is not on a specialty mattress." On 3/6/14 at 10:50 AM, an interview was conducted with LPN (B), who does the weekly wound tracking. The tracking was reviewed, and the heel areas were noted to be blank as to stage. LPN (B) pulled out her pen and was going to fill in the stages. The nurse was told she could not alter the records after the fact. LPN (B) was asked when she would consider changing the wound treatment. LPN (B) stated, "I would change the treatment if it is a big change." She went on to state, "If I didn't write an order, the treatment wasn't changed." LPN (B) also stated, "The area on her back was a new area, an abrasion from her pad." She went on to state that" the wound was identified on 3/4/14" and she put a dressing on it, but hadn't recorded it on her tracking or written an order yet. On 3/6/14 at 11:15 AM, LPN (A) and LPN (B) entered the resident's room to look at the left outer foot. LPN (B) stated, "It looks like a little eschar is there." LPN (A) stated, I did not see it yesterday." Review of the care plan dated 1/1/14 revealed under the heading of Impaired skin integrity to include: "Pressure relief mattress, daily skin inspection during care for redness, blistering irritation, Prevalon boots, turn and reposition every 2 hrs and use drawsheet to turn and reposition to prevent shearing. Review of "Physician Approved Pressure Ulcer /Wound Orders" revealed for stage 2 or stage 3 pressure ulcers contained the following: "Evaluate progress weekly. If no improvement after two weeks, consider another treatment choice." Under Pressure Ulcer Support Surface Matrix", Resident's with multiple stage 2's or stage 3-4, gave the options for an Alternating pressure/ low air loss mattress. On 3/6/14 at approximately 2:00 PM, the DON stated, "Rest Q mattresses are alternating pressure mattresses." Information was provided to the teamleader the next day. The Rest Q mattress is a "Pressure redistribution mattress." Information was provided as of 3/7/14 the resident was on a low air loss pressure relief mattress. 2. For Resident #7, the facility staff failed to A) Identify a pressure ulcer to the back of the head before it reached a stage III, B) Develop interventions for the prevention of pressure ulcers to the back of the head, and C) Perform wound care for pressure ulcers to the back of the head in a manner to prevent the spread of infection. A) Resident #7 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #7's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 01/21/2014 coded Resident #7 in a persistent vegetative state. In addition, the Minimum Data Set coded Resident #7 requiring total dependence, on staff, for Activities of Daily Living care. A review of Resident #7's clinical record was conducted during the survey. The review showed a document titled " Weekly Skin Condition Progress Report... R(ight) Occipital. " The report read that on 09/03/2013 Resident #7 had a right occipital (related to the back part of head or skull) wound that was present on re-admission. The report read that on 10/29/2013 the wound had closed. The review showed a nursing note dated 01/24/2014. The note read, " Open area to back of head (center of area). " The review showed a document titled " Pressure Ulcer Monitoring Form " dated 01/28/2014. The form read that Resident #7 had a mid lower occiput (back part of head or skull) and a mid upper occiput wound that were at stage III's. The form read that on 01/28/2014 the lower area measured 3 by 3 centimeters and the upper area measured 1 by 0.8 centimeters. An interview was conducted with Licensed Practical Nurse-B (LPN-B) on 03/06/2014 at approximately 11:23 a.m. LPN-B is responsible for tracking pressure ulcers on Resident #7's unit. LPN-B stated that Resident #7's back of the head wounds were pressure ulcers and that they were found at a stage III. LPN-B stated that Resident #7 has a history of pressure ulcers on the back of the head. An interview was conducted with the Director of Nursing on 03/05/2014 at approximately 5:15 p.m. The Director of Nursing stated that pressure ulcers should not be found at a stage III. B) A review of Resident #7's care plan, that was in effect prior to 01/24/2014, was conducted. The care plan showed no interventions for the prevention of pressure ulcers to the back of the head. An interview was conducted with the Director of Nursing on 03/07/2014 at approximately 11:34 a.m. The Director of Nursing stated that Resident #7's care plan (that was in effect prior to 01/24/2014) did not contain interventions for the prevention of pressure ulcers to the back of the head. C) On 03/06/2014 at approximately 10:55 a.m. a wound care observation for Resident #7's pressure ulcers to the back of the head, was conducted with Licensed Practical Nurse-A. During the wound care observation, LPN-A changed her gloves at least four times. However, LPN-A did not wash her hands in-between glove changes. The " Morbidity and Mortality Weekly Report ", Centers for Disease Control and Prevention, March 25, 2002, reads, " Recommendations ... 1. Indications for handwashing and hand antisepsis... J. Decontaminate hands after removing gloves." Additionally, it read, "The following caveats regarding use of gloves by HCWs (Health Care Workers) must be considered. Personnel should be informed that gloves do not provide complete protection against hand contamination. Bacterial flora colonizing patients may be recovered from the hands of <30% of HCWs who wear gloves during patient contact. Further, wearing gloves does not provide complete protection against acquisition of infections caused by [MEDICAL CONDITION] virus and [MEDICAL CONDITION] simplex virus. In such instances, pathogens presumably gain access to the caregiver's hands via small defects in gloves or by contamination of the hands during glove removal." The facility administration was informed of the findings during a briefing on 03/07/2014 at approximately 10:47 a.m. The facility did not present any further information about the findings. COMPLAINT DEFICIENCY

Based on observation, clinical record review, staff interview and review of facility policy, facility staff failed to provide physician ordered treatment to a newly developed to treat a Stage II wound until it had deteriorated and became unstagable for 1 of 25 residents in the survey sample, Resident #14. The findings included 1. Resident #14 entered the facility without pressure ulcers on her sacrum/buttock area. An open area was identified on 12/12/12 and a treatment was initiated. The treatment was stopped on 12/19/12, restarted on 1/1/2013 and changed on 1/2/2013. From 12/19/2012 to 1/2/2013 the wound area deteriorated from an open area 1.5 X 1.5 to 3 X 5.5 covered with 100% slough (necrotic or dead tissue) and a dark area in the center. Resident #14 was admitted to the facility from the hospital on [DATE]. She was [AGE] years old and had [DIAGNOSES REDACTED]. The resident also had an unstagable area to her left heel. Resident #14 was incontinent of bowel and bladder per the admission assessment (MDS) with a reference date of 12/10/2012. On 12/12/12 an open area was identified on Resident #14's sacrum area and according to a nursing note of that date a treatment was started per the physician 's standing orders. The order was written and faxed to the physician. "Cleanse Sacral area with normal saline, apply [MEDICATION NAME] ointment cover with dry dressing q (each) day and prn (as needed) for 7 days or until healed." This order was transcribed to the Treatment Administration Record (TAR). On 12/13/12 Resident #14 is seen by the FNP #1 (Family Nurse Practitioner) who documented, "She has an open area to her sacrum.... which is red is 1.5 X 1.5, it is cleansed with DWC (dermal wound cleaner). [MEDICATION NAME] will be applied and adhesive dressing. Review of the TAR evidenced that on 12/19/2012 the order was changed and no additional treatments of the [MEDICATION NAME] were completed. There was no corresponding physician order [REDACTED]. Review of the clinical record did not reveal a new physician's orders [REDACTED].. Review of the January 2013 TAR evidenced the order was carried over on the TAR and completed on 1/1/2013. It showed a new order starting on 1/3/2013. Review of the weekly wound sheets evidenced that on 12/13/2012 the wound was described as above. On 12/20/12 the wound was 1.8 X 1.6 and described as pink/red without slough although the wound sheet had an area to mark to indicate the stage of the ulcer the area had been left blank across the sheet. On 12/27/2012 the wound was described as 2.6 X .5 with pink red edges. Although not staged the wound as documented would match the Stage II definition below. The Minimum Data Set 3.0 defines the four stages of pressure ulcers. STAGE I Intact skin with non-blanchable redness of a localized area usually over a bony prominence. STAGE II Partial thickness of skin loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact blister. STAGE III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. STAGE IV Full thickness loss with exposed bone, tendon or muscle. Slough or escar may be present on some part of the wound bed. Often includes undermining or tunneling. The MDS also includes pressure ulcers that are unstagable due to coverage of the wound bed by slough and/or eschar. Slough is defined as yellow or white tissue that adheres to the ulcer bed in strings or thick clumps or is mucinous. On 1/3/2013 the sacral wound is described on the wound sheet as 3 X 5.5 100% slough with a dark area in the center. Review of the January 2013 TAR evidenced that the Bacitricin treatment was done on 1/1/2013 and changed on 1/2/2013 to "clean sacrum with DWC, apply Santyl with clean dry dressing daily and prn." Santyl is a chemical debridement agent used to clear the slough from a wound. On 1/2/2013 FNP #2 described the wound as "sacrum 8 x 8 x 0.01, has 3 areas of sloughing approximately 40% with blanching." Under Assessment and Plan was Sacral decubitus stage III ulcer. We will change the treatment to Santyl, also the patient does qualify for a bed change." FNP #documented on 1/3/2013, "She has open areas to her sacrum which includes 2 open areas measuring 3 x 5.5. They are 100% slough". On 1/31/2013 at 2 p.m.the above was discussed with the Unit Manager from I South. She stated she would research the issue and get back to the surveyor. At 3 p.m. the UM was interviewed again and stated it was an "error in documentation", instead of writing healed the nurse just discontinued the order, "its the only thing I could figure." The surveyor then showed the UM the wound sheet and she stated it could just have been a Stage I, "see there is no depth filled out." The surveyor then pointed to the wound sheet again to show that the wound stage had not been completed across the sheet, the UM stated "I see what you mean." Following this interview the nurse identified as writing "changed" on the order was interviewed. LPN #4 stated she wrote that there was an order change but they could not find it and maybe it was on another sheet of a TAR that might be missing. She remembered that the treatment was being done on the 3-11 shift and they thought it would be better to monitor the wound on the day shift. The new order and the TAR had not been found but they would keep looking. On 2/1/2013 FNP #1 was interviewed, she stated that she was in the building on 12/20/2012 but checked her notes and she did not see the resident. FNP #1 continued that occasionally not all resident are seen every week on wound rounds that some might already be up and dressed with dressing change completed or out of the building. She could not say why Resident #14 was not seen on wound rounds on 12/20/12. FNP #1 stated it was a half day for her so she only saw 5 residents. FNP #1 stated she was not in the building on 12/27/12 or on 1/2/2013. FNP #2 saw the resident on 1/2/2013 and the difference in the size of the wound was that FNP #2 was measuring from one side of the buttocks to the other when in reality it was two small areas on either side of the "crack." FNP #1 stated she saw it the following day and put the measurements in her note. (FNP #2 was on vacation and unavailable for interview) When asked about the change in the wound FNP #1 stated if they had called her with the changes she would have changed the order when slough started to appear. She added that the biggest difference in the wound healing presented after the Foley was placed. The Foley was placed on 1/16/2013, at that time the wound was 50% slough and measured 2 x 4 cm. and scissors were used to cut away slough. On 1/24/2013 the wound measured 2 x 4.3 with 20% slough. On 2/1/2013 (approximately 10:30 a.m. ) another surveyor observed the wound. On the right buttocks the area was irregularly shaped with a pink wound bed and a scant amount of slough. A smaller area was noted on the left buttocks, the wound bed was pink. The wound showed evidence of healing after Santyl treatments were started. On 2/1/2013 the Administrator and Director of Nurses were interviewed and asked to provide any additional information they might have on Resident #14. The Administrator stated that his staff was telling him the wound was being treated and he had no reason not to believe them, he thought it was a documentation problem.

Based on a complaint investigation, clinical record review, staff interviews and facility documentation review, the facility staff failed to provide the necessary care for 1 of 8 residents (R#7) in the survey with a gastrostomy tube (GT). A GT is placed in an opening into the stomach to provide feeding, fluids and/or medication. The facility staff failed to provide consistent care, assessment and monitoring for Resident #7's GT site to prevent adverse complications. The findings included: Resident #7 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident resided on the North III unit. On 9/3/11, Resident #7 was discharged to the local emergency room and admitted to the hospital and did not return to the nursing facility. The Minimum Data Set (MDS) assessment dated [DATE] was a quarterly and coded Resident #7 with short and long term memory and severely impaired in the skills needed for daily decision making. The resident was totally dependent on one staff for ADL's. The MDS coded the resident for a [MEDICAL CONDITION], feeding tube (all nutritional support to include fluids was through the feeding tube). The care plan dated 6/7/11 identified the resident had a feeding tube and was also at risk for fluid volume imbalance. The resident was dependent on staff for Activities of Daily Living (ADL). The goal of the staff was that the resident would have a properly functioning feeding tube and to promote adequate hydration through the next review. Some of the approaches the staff would implement to accomplish this goal included clean around feeding tube daily, check for tube position and patency, irrigate as ordered and needed, administer tube feeding nutrition/fluids/hydration via feeding tube per physician's current orders and report complications. The care plan also indicated nursing would perform daily skin inspections during care for redness, blistering or irritation. Physician orders [REDACTED].#7 to the local Emergency Department (ED) due to purulent drainage and larvae discovered at the GT site to rule out infection. Upon review of the ED documentation dated 9/3/11, Resident #7 arrived in the ED at 1:38 pm. The ED physician's assessment of the GT indicated the following: "PEG (percutaneous [MEDICAL CONDITION] gastrostomy-term used interchangeably with GT) site in LUQ (left upper quadrant), there is foul pus noted with visible maggots." The abdomen was assessed distended and tenderness was present. The ED notes indicated the resident was unable to communicate, but appeared to be in pain. The primary diagnosis/chief complaint was complicated wound infection, mechanical complication of gastrostomy and the secondary [DIAGNOSES REDACTED]. A triple lumen central line was inserted at 5:50 pm to necessitate fluids. The resident was admitted to the hospital for ongoing medical management. The hospital admission history and physical (a second physician) dated 9/3/11 at 4:13 pm indicated the resident's the PEG tube was non-functional with maggots growing around and imbedded about and in the PEG site. The wound was identified as a "maggot infected wound ". Resident #7 was evaluated in the hospital by a Digestive and Liver Disease Specialist (a third physician) on 9/3/11 at 7:40 pm. The Gastrointestinal (GI) specialist indicated the PEG site infection with maggot infestation. A [MEDICAL CONDITION] (NG) tube (a tube that enters the stomach inserted through the nares) was inserted for feedings and medication administration with plans to replace the PEG once the infection had cleared. He was kept nothing by mouth (NPO) as prior to admission. The current PEG was left in place to prevent PEG tract closure. An abdominal CT revealed cellulitic (swelling, inflammation caused by bacterial infection-ncbi.nlm.nih.gov) changes. Treatment included topical therapy to the PEG site with alcohol soaked gauze to kill the maggots and removal of them. The wound ostomy/ET Nurse was consulted on 9/4/11 to implement skin/wound/ostomy pressure ulcer protocol. The PEG was replaced by the GI specialist on 9/5/11 and determined to be functional. Bactrim DS 160-800 milligrams (mg) via feeding tube twice daily for 7 days covering for the possibility of [MEDICAL CONDITION] (MRSA).[MEDICAL CONDITION] is a staph infection that resists many antibiotics. The resident was discharged from the hospital on [DATE]. The discharge summary in relation to the admitted [DIAGNOSES REDACTED]. Bactrim DS 40-200 mg/5 milliliters (ml) suspension continued via feeding tube twice daily for 6 days. Special ostomy care included [MEDICATION NAME] AG (antimicrobial silver dressing to a wound where there in infection or increased risk of infection-[MEDICATION NAME].com) 2x2 around PEG site and change every 3 days. Resume prior tube feeds. Resident #7 had physician orders [REDACTED]. Other orders involving the GT dated 9/17/08 included check placement every shift; 5/12/10 check GT balloon every Sunday, reinstall water if necessary; 9/17/08 check residuals of tube feeding every 6 hours (6a/12p/6p/12mn); 9/17/08 flush PEG with 200 cc water every 6 hours (6a/12p/6p/12mn) in addition to 25 cubic centimeter (cc) of water via the Quantum pump; 1/14/09 [MEDICATION NAME] tube feeding 1.5 at 50 cc/hr via PEG tube from noon till 6 am (18 hours); and, water between 9 different medications administered via the GT. The following interviews were conducted with the facility staff: On 9/8/11 at 11:30 am an interview was conducted with the North III Registered Nurse (RN #3) supervisor. She stated she was called to the room by LPN #1, who was assigned to Resident #7 on 9/3/11 for the 7/3 shift. She stated LPN #1 was not able to obtain placement of the GT prior to administering morning medications. She said the drain sponge was turned over to the side of the GT and upon inspection larvae "too numerous to count" was found outside and inside the GT site. She stated the drain sponge was saturated with purulent foul smelling drainage and she notified the physician on call of her findings. The physician ordered the resident to be sent to the local ED for evaluation of the condition of the GT site and to rule out infection. RN#3 said she took a cotton tipped applicator to closely examine the drainage "that moved" and placed some of it on a paper towel. She stated, "The same drainage on the drain sponge was coming out of the stoma, as well as crusted old drainage observed in and around the GT and on the drain sponge. It did not look like the site had been cared for in a few days." She said she checked the Treatment Administration Record (TAR) and discovered that the dressing may not have been changed in two days; there was a physician's orders [REDACTED]. RN#3 stated, "I did not see any flies on 9/3/11 and just saw this as a nasty and deplorable GT. In my opinion, the condition of this GT site was because the nursing staff failed to adequately assess, monitor on every shift, and report any signs and symptoms of infection, as well as clean and change the drain sponge every day and/or as needed. The fly was just drawn to the nasty drainage from an infected GT site. Because you do something every shift with the tube, there is an opportunity to assess for any problems and I don't think that was done based on the condition of the GT site." She also stated, "I had never seen anything like that before. If you had seen that, you would be done! I have chills, just talking about it." RN #3 said she notified the physician and manager on call who notified the Quality Manager (QM). The QM was filling in for the Interim Director of Nursing. The QM called her and instructed her to have each assigned licensed nurses to check all PEG sites. She stated until interviewed by this writer, she had not been interviewed by anyone or asked to provide any statements about her findings. She stated on 9/2/11 there was a circle around the initials in the spot where the PEG site was to be cleaned and drain sponge changed. She said the circle around the initials indicated it was not done, but the nurse did not indicate on the TAR or in the nurse's notes why the treatment was not provided to the resident. She stated she thought there was another day it was not changed, but she was sure the nurse failed to provide care for it on 9/2/11. In addition, she said the PEG was assessed unusable and; therefore, resident was not able to receive water flushes, water during medication administration or the scheduled tube feedings. She stated she did not hear what the outcome was, but heard the Responsible Party (RP) did not want the resident to return to the nursing facility. On 9/8/11 at 1:00 pm the Administrator stated he saw issue as a fly problem on 9/3/11 because they found larvae on the resident that day and recorded flies that day on Unit III. He stated he started the investigation after he returned from vacation on 9/6/11. He said he knew it only took 1-2 hours after the fly landed on a host for the larvae to erupt and he had some professional information to support this fact. He stated he had the Pest control company come on 9/7/11 to do an inspection of the facility and they were going to put together a proposal for an added program for fly control. He stated he left any clinical aspects to the QM who was covering for the Interim Director of Nursing (IDON) while he was on leave. On 9/8/11 at 3:30 pm, and interview was conducted with the QM. She stated she received a call from the Administrator on 9/3/11 simultaneously when the Manager on call called telling her the "GT is clogged and it was larvae". She said the physician was in the building and had gone to see the site and sent the resident out to the ED because the tube was clogged and to evaluate infection from the larvae. She stated, "I heard it from somebody that it was not purulent drainage, but just brown drainage and no infection." She said, "The family came for a care conference on 9/6/11 and the RN (#2) in charge of the care conference said the family did not want the resident to come back, but they did not say why they didn't want him to come back." The QM said she ordered a 100% larvae check of all PEG sites and further said, "The problem was that on 9/3/11 a fly deposited larvae at the PEG site." She stated flies were typically drawn to drainage, garbage and obnoxious stuff and it took only 1-2 hours after contact for the larvae to show up. She stated on 9/6/11, she noticed the dressing had not been changed for 2 days prior to going out to the ED and she instructed the North III RN Unit Manager (UM) to contact the nurse in question to see if she completed the PEG site dressing change and if so she needed to sign off on the treatment. The UM entered the room during interview with the QM. The UM stated she called the nurse and had her come in on 9/7/11 to sign for the day she said she did the dressing change, but no documentation was recorded on the flip side of the TAR or in the nurse's notes as a late entry. The UM stated she understood the problem with R#7's PEG site was due to a facility fly problem on 9/3/11. During the above interview, the UM said, "On yesterday (9/7/11) I gave in-services to the nurses on cleaning the peg site and how frequently it should be done." When asked to show in-service content and original sign in sheets, she brought documentation about "Charting-C.N.A. and LPN's must sign for all work you have done on each patient every shift. If this does not improve, first I will in-service, second a written warning -under code of conduct." Six signatures were notes (2 LPN's and 4 C.N.A.'s). The UM stated, "This is all I have, obviously I covered the care of PEG tube, but clearly it's not written here! This is all I have to show I in-serviced the nurses. I have not done any official in-servicing." The UM could not explain why she in-serviced C.N.A.'s on a procedure (Peg site assessment and care) that was not within their scope of practice. On 9/8/11 at 3:50 pm, an interview was conducted with LPN #1. She stated she was assigned to care for the resident on 9/3/11 for the 7/3 shift. She said she was unable to check placement by pushing air through the GT prior to administering morning medications scheduled for 9:00-10:00 am. She stated, "I asked another nurse (LPN#2's name) to help her figure out why the tube was clogged and when she removed the dressing she showed me the larvae at the PEG site. I ended up talking to (RN#3's name) the supervisor and she showed me how to send the patient out to the ED." She said she has not been interviewed by the administrative staff or had had a discussion about the resident's PEG tube, and; the first time was with this writer. She stated, "Honestly, I have no idea what the problem was." On 9/8/11 at 10:30 am, an interview was conducted with LPN #2. She stated she was one of the nurse's in charge on Unit III 9/3/11 for the 7/3 shift. She said when she came to the room she was unable to flush the GT and saw drainage though the drain sponge. She stated, "When I removed the drain sponge and turned it facing up, at the corner of my eye, I saw maggots on the drain sponge and upon further assessment, I saw them coming from out of the GT site and detected an odor." She stated she observed old dry crusty brown drainage on the drain sponge and at the GT site. She said she would normally see a small amount of drainage at the site, but it never saw drainage soaked through and never odor. During the above interview with LPN #2, she stated assessment of anyone with a PEG tube included noting the drainage, color and odor, redness, swelling and pain upon touch to the site and whether the tube was patent. She said Resident #7 was not able to speak, but able to nod his head for yes or no. She stated if she had not been able to clean and dress the site she would pass this information on to the next shift. LPN#2 said she had not been interviewed nor the issue addressed about the aforementioned problem with R#7's GT by the administrative staff. On 9/8/11 at 3:00 pm the Administrator presented the "Action Plan to enhance workflow processes to reduce flies on the unit." On 9/8/11 at 3:05 pm, the Interim Director of Nursing (IDON) toured with this writer and pointed out areas throughout the facility where flies entered and explained the plans to reduce flies. The IDON stated, "We determined the maggots found on (Resident #7's name) were due to a fly problem in the building. We did a 100% larva check on all the residents with a PEG tube." On 9/9/11 at 11:00 am an interview was conducted with LPN#3. She stated she worked on 9/1/11 7/3 shift and signed off for cleaning the site, changing the drain sponge and placing a strip of tape across the sponge. She stated the dressing was not an occlusive type. She also said she did not observe drainage, any odor, swelling or problem with patency. She stated she did not see any flies around the resident and found it hard to think flies would find its way to the PEG site because the resident kept his covers pulled up high. She said she had called out on 9/2/11 and another nurse (LPN #4) was assigned to the resident. LPN #3 stated she was not asked by the UM to come in on 9/7/11 to sign off on care she provided the GT for 9/1/11. On 9/9/11 at 11:28 am an interview was conducted with LPN #4. She stated she was the assigned nurse on 9/2/11 for the 7/3 shift and did not perform site care to the GT and circled her initials on the TAR to indicate she did not provide the care. She stated, "I had so much to do and could not get around to cleaning and changing the sponge. I should have passed that information on to the next shift, but I didn't. I did not write a note to that effect either, but the tube worked and I was able to give medications through it." At the time of this interview, she stated the administrative staff had not talked to her about this issue and no one asked her to come in to sign off for anything on the TAR. On 9/9/11 at 1:00 pm, the Administrator presented a letter from the pest control company which indicated the following: "During my inspection on September 7th there were no visible evidence of flies in the areas that we were inspecting on the interior or the exterior of the building ...I am currently putting together a proposal that I will be forwarding to you shortly for the added program for fly control to you facility based on our discussions and recommendations ..." The Administrator also presented the professional information from the pest control company that refuted the 1-2 hour concept, and indicated the adult house fly could lay 20-50-75-100-150 eggs singly in clusters, laying 350-900 eggs in her lifetime. The eggs hatch in 8-20 hours and the larvae stages 3-7 days at 70-90 degrees Fahrenheit (F) before full grown and start to move out in another 3-4 days to a cool dry place in 3-4 days. The information indicated house flies were feeders on liquids and are attracted to many substances; live and feed on (usually dead and decaying) organic material from excrement, open sores, sputum, garbage to human food. In the larval stage, they survive in a protected warm location. On 9/13/11 at 9:55 am, an interview was conducted with the North IV RN UM. She went to the clean utility room and showed this writer a PEG tube and stated, "As much as 3-4 inches can be inside the stomach depending on the girth of the individual. Usually there is no drain sponge unless it is ordered by the physician. You must be diligent to clean the site and tubing with soap and water and apply any ordered treatment to site." She stated flies can be drawn to feed on excessive drainage around the PEG tube site, any regurgitation of stomach contents around the site, the warm tube feeding (food) that sometimes oozes around the site, as well as excoriated areas and odor. She said it was the job of the nurse assigned to licensed nurse assigned to the resident to provide meticulous care daily, inspection and monitoring for any signs and symptoms of infection and inflammation. She further stated, "Along with the functioning of the tube, if the assigned nurse was not able to provide the care or if she was not sure what she was looking at; she should tell the Unit Manager or RN supervisor." On 9/13/11 at 2:30 pm and interview was conducted with the Responsible Party (RP). She stated, "I asked the doctor in the emergency room ; 'How did this happen? How did the tube get to this state?' The doctor responded; 'From the appearance of the site, the infection of the area and the maggot infestation, the nurse's had not been consistently cleaning around the site appropriately.'" The RP further stated, "This just sealed the deal, (resident's name) would not be going back to (facility name). He was transferred from the hospital to another facility on 9/8/11." On 9/14/11 at 10:55 am, an interview was conducted with the RN MDS Coordinator. She stated she was in charge of coordinating resident care conferences and on 9/6/11, although the resident was still in the hospital, the RP was present during the conference for Resident #7 because the facility anticipated his return. She stated the RP expressed she did not want the resident to come back to the facility because of the lack of care for his GT and the maggots that were found because of it. On 9/14/11 at 11:14 am, an interview was conducted with the Social Worker. She stated she was also present during the aforementioned care conference and the RP voiced her concerns about condition of the feeding tube and the maggots. On 9/14/11 at 11:25 am, an interview was conducted with the Activities Director. She stated, "The focus and main concern of the care conference on 9/6/11 was the 'sore' on his stomach where he had the maggots." On 9/14/11 at 11:30 am, the IDON presented in-service information with LPN signatures from the North III RN UM dated 9/8/11 (un-timed) that indicated the licensed nurses on North III Unit were in-serviced by the UM regarding the policy and procedure for gastrostomy tube care. The IDON was not able to explain why this information was not presented when the UM was interviewed on 9/8/11 at 3:30 pm. He said he thought the education may have taken place during the morning huddle around 8:30 am on 9/8/11. On 9/14/11 at approximately 3:20 pm, the IDON stated he was only able to validate one licensed nurse (LPN #4) that did not provide R#7's GT care per physician's orders [REDACTED]. The IDON stated, "I came behind you (referring to this writer) to find out who did not perform the GT care!" The facility's policy and procedure entitled Gastrostomy: Stoma (incised opening that is kept open; in this case in the stomach for feeding) Care dated 1/12/10 indicated, stoma care would be provided as ordered. The site would be cleaned daily with soap and water, or as ordered. Use a spiral pattern beginning close to the stoma. Cleanse upper disk with cotton-tipped applicator. Chart date, time and condition of site. In the administration of enteral feeding via a Gastrostomy of Jejunostomy Tube, assess the skin around the tube exit site (stoma). The skin around the tube should be cleaned with warm water and mild soap. Assess the site frequently and report any drainage, redness, swelling, or displacement of the tube to the physician. Enteral feedings are to restore of maintain nutritional status and the maintain adequate water from the tube feeding itself, during medication administration and ordered flushes (Potter/Perry Fundamentals of Nursing, fifth edition 2001). COMPLAINT DEFICIENCY