Every finding on record at Westwood Center

Based on staff interviews, clinical record review and facility document review, the facility staff failed to provide supervision to prevent an accident for 1 of 2 resident records reviewed. (Resident #1) The findings were: For Resident #1, facility staff failed to provide supervision to prevent a tissue injury to the bottom of the resident's feet resulting in admission to an acute care hospital and eventually admission to a burn center. Resident #1's medical diagnoses included but were not limited to, dementia, Alzheimer's disease with late onset, second degree burn left foot, second degree burn of right foot, local infections of the skin and subcutaneous tissue, difficulty walking, and diabetes mellitus. Resident #1's minimum data set with an assessment reference date of 01/30/25 was signed as completed on 02/01/25. Within Section C (cognitive patterns) Resident #1 was assigned a brief interview for mental status summary score of 15 out of 15 which indicated the resident's cognition was intact. Section M (skin conditions) indicated Resident #1 had a second or third degree burn. Resident #1's care plan focus areas included but were not limited to the following: A. Created upon admission and initiated on 02/13/25: Resident at risk for skin breakdown related to advanced age (greater than 75 years) and intermittent incontinence, redness of groin, diabetic ulcers to 2nd and 4th toes of left foot, burns to bottoms of feet with wound vac in place. Observe skin for signs/symptoms of skin breakdown i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanche easily. Evaluate for any localized skin problems, i.e. dryness, redness, pustules, inflammation. Observe skin condition daily with activities of daily living care and report abnormalities. Weekly skin check by license nurse. Weekly wound assessment to include measurements and description of wound status (created on 10/17/24 and initiated on 02/13/25). Wound VAC to left foot change every Monday, Wednesday, and Friday (created and initiated on 2/18/25). B. Created on 01/29/25 and initiated on 02/13/25: Resident is resistive to care related to: Resident is continually refusing to allow staff to give him showers as scheduled. Educate resident on importance of leaving dressings intact to aid in the healing process and to refrain from picking at his feet to prevent infection and to enhance healing of the skin. Observe for non-verbal signs of resistance: e.g., rigid body position, clenched fists, etc (created and initiated on 01/29/25). A provider order dated 02/01/25 read, Wander Guard Placement due to Poor Safety Awareness, Left Wrist, EXP 5/2027 every day and night shift Check Placement of the Device and in supplemental Documentation - document the location. The care plan included a focus area, Resident is at risk for elopement related to: Cognitive Loss/Dementia Elopement risk Score= 3 which was created on 02/01/25 and initiated on 02/13/2025. Bracelet Placement to Left wrist, EXP Date 5/20/27. Resident #1's clinical record was reviewed. A licensed nurse progress note dated 01/22/25 at 4:30 a.m. read, This nurse called to room by cna (certified nursing assistant) and stated that resident stated he needed nurse to bandage right foot related to it leaking and causing bed linen to be soiled. This nurse then walked back to room to observe residents [sic} foot. Resident in chair oriented x 3. When this nurse walked in room resident was asked to remove his right shoe. when [sic] this nurse took off sock this nurse observed five blistered red and white toes in appearance with fifth toe missing skin and big toe with bubble filled appearance covering approximately 80% of toe. the [sic] bottom half of distal portion of foot red and missing approximately 1/3 of upper layer of skin. Area wet with beefy red appearance. Bloody drainage observed to site. This nurse then proceeded to obtain vitals and then call on call lumina (telehealth service). Resident stated he did not feel any pain and no symptoms of pain or distress was observed. This nurse received order to send out resident for evaluation related to skin presentation on right foot. This nurse propped foot up off of ground and encouraged resident to elevate until EMS (emergency medical services) arrived for ED (emergency department) visit. When this nurse asked resident what happened to foot, resident stated that his foot was like that because of treatment he was receiving and the medication being put on foot. This nurse then proceeded to interview staff to see if they had observed foot prior to this nurse finding place on right foot. Staff stated that this was the first time that they have observed area. When this nurse asked staff members if they could think of any reason why this area could be on foot staff stated that resident has been observed propping feet up on heaters in day room with shoes both on and off for the last couple of days to stay warm. This nurse then called report to (local acute care hospital initials omitted) and stated that this nurse found area on right foot and described details of residents [sic] condition and condition of foot. This nurse was asked about residents [sic] past medical history and if I knew what could have possibly happened to the residents[sic] foot. This nurse then stated that this was the first time I had observed the area but I was informed by cnas that he has recently been propping feet on heaters with shoes both on and off to stay warm. Paperwork was then faxed over to hospital before EMS left. The author of this progress note no longer worked at the facility therefore was not interviewed. An AFTER HOURS TELEHEALTH CONSULT nurse practitioner (NP) note dated 01/22/25 with an electronic signature on 01/23/25 at 3:35 a.m. read in part, Nursing reports patient presentwith [sic] a left foot injury. A large blister on the bottom of the left foot has popped, resulting in complete loss of skin on the top half of the plantar surface. The patient reports a dull pain in the affected area. The toes are noted to be swollen, and theexposed [sic] area is bright red and bleeding. There is concern for potential infection. The patient is observed to be shaking and trembling. The cause of the injury is unclear, but it is suspected to be due to a burn or a blister from a burn that has completely sheared away .Plan: Send patient to ER (emergency room) for urgent evaluation and treatment. On 02/25/25 at 9:25 a.m., the surveyor made observations of resident rooms, therapy room, day rooms, and activity/dining room. No space heaters noted. The surveyor interviewed Resident #1 in person on 02/25/25 at approximately 11:00 a.m. The resident was lying in bed with his legs and feet completely wrapped up with bed covers. The resident's feet were not visible but there was a wound vac present with tubing seen from the wound vac to the bottom of the bed, under the covers where his feet/legs were wrapped. When asked how he sustained the wounds on his feet, had he been resting his feet on a heat source the resident said, I never put my feet on any heater. I pulled my chair close to the wall heater in the day room. My shoes were on. The resident described having watery leakage in the floor when he was sitting in his wheelchair and notice the same leakage in the bed. The resident then reported a doctor down there said the problem with his feet came from frostbite which is how it dug down to the meat. The medical director's Info Note dated 01/22/25 read in part, Chief Complaint/Reason for this Visit. The patient is an [AGE] year-old male with cognitive impairment, seen today for evaluation of a left foot wound. HPI (history of present illness) Relating to this Visit. The patient reportedly sustained a partial-thickness burn to the distal plantar aspect of the left foot while sleeping with his foot on a radiator in the activities room. However, the patient has been wearing socks and shoes for the past 3 days, and the wound appears more consistent with sloughing of the epidermis versus desiccation of the epidermis via burn. The patient's shoe was intact without any evidence of disruption via heat, making it unlikely that the wound is consistent with a burn. The patient is unable to provide an accurate history due to his cognitive status, and reports of the patient sleeping with his foot on the radiator are hearsay, as it was not witnessed that the patient was actually placing his foot on the radiator Assessment and Plan 1. I96 Skin sloughing: An [AGE] year-old male presented with a wound on the plantar aspect of the left foot, initially suspected to be a burn. However, upon examination, the wound was more consistent with sloughing of the epidermis rather than a burn. The macerated appearance of the bilateral foot and the intact nature of the peri wound area are inconsistent with a thermal injury. The patient's shoe showed no evidence of heat disruption, further supporting this assessment. Plan: Recommended the continued application of Xeroform to the wound. The wound will be monitored for signs of infection or worsening condition. If necessary, a wound care specialist may be consulted for further management. 2. R41.89 Cognitive deficits: The patient's cognitive status was noted during the visit, as he was unable to provide an accurate history. This cognitive impairment may have contributed to the misunderstanding of the wound's etiology. Plan: A cognitive assessment will be scheduled to evaluate the extent of the patient's cognitive deficits. Depending on the results, a referral to a neurologist or geriatrician may be necessary for further evaluation and management. The patient's family will be educated about the importance of monitoring the patient's cognitive status and ensuring his safety. 3. F42.4 Skin-picking disorder: Nursing staff was able to find pieces of the epidermis that had been removed by the patient. It appears that the patient was picking at macerated epidermis and due to his peripheral neuropathy was unable to feel any pain related to the self-inflicted wound. Once again, wound is inconsistent with a burn. The medical director was interviewed on 02/26/25 at 10:40 a.m. The director reported having spent five (5) years as a wound care professional and a surgeon prior to those five years. The physician reported feeling strongly that Resident #1's wound was macerated tissue but stated he realized the tissue/area could also look like a burn, easily, close call. The medical director stated, We have never had any space heaters, tremendous liability. He reported Resident #1 sleeps with shoes and socks on for days at a time, had severe neuropathy so could not feel pain as the resident picked deeply at his skin. Staff found tissue in Resident #1's bed and shoes and socks were not damaged. He stated a severe burn would not have macerated tissue found. In relation to Resident #1's cognition, the physician stated the resident's cognition was relatively intact, he was tangential (erratic) but redirectable and able to answer questions appropriately initially but eventually goes on a tangent. Resident #1 returned to the nursing home facility on 01/24/25, two days after being transfered to the hospital. The hospital discharge summary read in part, Skin: Left foot: 8x9cm second degree burn with blistering and ulceration on the ball of the left foot, extends 5 cm down the medial aspect of the foot and 2 cm down the lateral aspect, across the entire plantar aspect of the foot, plantar aspect of toes 1-4 with blisters, toes 1 + 4 blisters intact. Right foot: single open 1x2cm blister at the base of the 4th toe. The resident had a follow up appointment with a burn center in an adjacent state on 02/03/25. The DON reported that Resident #1 was transported to the follow up appointment on 02/03/25 and did not return that evening. Facility staff called the burn center and found out they had admitted Resident #1. The resident returned to the nursing home on [DATE] with a wound vac to his left foot. The burn center's Surgery Discharge Summary dated 02/13/25 at 6:05 a.m. read in part, admission Diagnoses: Burn (any degree) involving less than 10% of body surface. Discharge Diagnoses: Principal Problem: Burn (any degree) involving less than 10% of body surface. Hospital Course: Patient was burned on bilateral soles of feet when he had his feet up next to a heater. Initially evaluated by and admitted to OSH (outside hospital) on 1/22/25 where he received IV (intravenous) antibiotics and local wound care for his burns. He was then seen in the (initials omitted) burn clinic on 2/3/2025 where he was evaluated and determined to have full thickness burns requiring operative debridement. Tangential excision of his left foot was done on 2/5/25 and the patient was plast [sic] in a wound vac. When post surgical dressings were removed, the left foot was found to have begun forming granulation tissue. Some areas of the left foot found to have nonviable tissue which was debrided bedside on 2/12/25. Burn team elected to not operate on his right foot but to continue local wound care and allow the burns to heal secondarily Thus, the patient is stable and suitable for discharge to the skilled nursing facility where he was a resident prior to admission. All burn wounds open at time of discharge (burn and grafts): TBSA (total body surface area <2% (less than 2%) The administration interviewed everyone employed when Resident #1's foot wounds were identified. Those written interviews were reviewed. One CNA working the night Resident #1's foot wound was identified reported in an interview with administration that Resident #1 wore shoes all the time and will not let staff take them off. The CNA's interview read that night, he saw the resident picking feet in bed and he consistently (surveyor unable to read the next word) scab and skin. The CNA's interview read saw feet propped up on heater, space between two Geri chairs. Advised resident to put down. Socks on both feet on heater. The resident had not complained of any pain in his feet until that morning. Stated feet was hurt while picking skin off. Less then an hour feet on heater. On 02/25/25 at approximately 11:40 p.m., the surveyor attempted to call and speak with this CNA, but he did not come to work that night. The CNA who encountered Resident #1 when he called for help with his foot bandage reported in the written interview the resident wore shoes all the time and the resident removed his shoes himself at the end of the day. She had never seen him picking at his skin or propping his feet on a heater. In a meeting with the administrator and DON on 02/26/25 at 4:00 p.m., the concern with Resident #1's tissue injury on both feet was discussed. Whether the origin of the injury was a heater versus macerated tissue was unclear, but both the administrator and DON acknowledged Resident #1 was treated at a burn center for second degree burns. No further information was provided prior to the exit conference. On 02/25/25 at 1:33 p.m., the administrator discussed the facility reported incident (FRI) and five-day investigation that followed. The administrator presented documentation of the facility's plan of correction which stemmed from Resident #1's injury. The information was reviewed to determine the allegation of compliance date which was documented as 01/24/25 with ongoing monitoring. On 02/26/25 at 1:07 p.m., the administrator presented the facility's plan of correction (POC) which had a completion date of 01/24/25 and read as follows: Plan of Correction: How will corrective action be accomplished for those residents found to have been affected by the deficient practice? On 01/22/25, a Licensed Nurse entered Resident #1 room to check on him due to the resident stating he needed the nurse to bandage right foot related to it leaking. On 01/22/25, the Licensed Nurse completed an assessment of his feet where it was identified that the resident has multiple blisters and open areas on the right foot. The Licensed Nurse contacted the on-call provider and received orders to send the resident out to the hospital for evaluation. The resident denied pain or discomfort at the time of assessment. Hospital records dated 01/22/25 indicated possible burn to the bottom of each foot. The baseboard supplemental heating unit located in the day room was turned off at the breaker to ensure the unit is not used for safety concerns on 01/22/25 by the Maintenance Director. How will the facility identify other residents having the potential to be affected by the same deficient practice? On 01/23/25, Nurse Managers and/or designee conducted an audit of residents identified with a high risk of foot complications/foot injuries to include a diagnosis of Diabetes Mellitus, diabetic Neuropathy, Peripheral Vascular Disease, Peripheral Arterial Disease, Paralysis, and Loss of Sensation and to validate the implementation of a person centered plan of care to maintain foot health and care. On 01/23/25, Nurse Managers and/or designee reviewed Nursing progress notes in the last 90 days to identify any resident with changes in skin condition to include blisters, abrasions, or new skin impairments to verify a treatment plan was implemented to heal and prevent any further skin impairments. Skin assessments on all residents were completed by Licensed Nurses on 01/23/25 to identify any skin impairments. No new skin impairments were identified. On 01/23/25, the Maintenance Director conducted an inspection of all baseboard supplemental heating units an PTACS (heating units in resident rooms) in the facility and recorded the temperature to validate the units were operating below the maximum surface temperature allowed by the Underwriters Laboratory Requirements. All units were operating below the maximum surface temperature. Additionally, the Maintenance Director conducted rounds to verify no unauthorized heating units were identified in resident rooms and common areas. No concerns were identified. Social Service Director and/or designee interviewed alert and oriented residents with a BIMS score of 13 to 15 to identify any concerns related to care and services. Any concerns were addressed through the grievance process. What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur: The Nurse Practice Educator and/or designee re-educated Licensed Nurses and Certified Nursing Assistants on Foot Health and Care with emphasis on diabetic foot care. Education was completed by 01/24/25. Nurse Practice Educator and/or designee will track and verify no Licensed Nurse(s) or Certified Nursing Assistant will be allowed to return to work with scheduled time off, on leave of absence (FMLA), vacation, or PRN until they have successfully completed the education/training. New hires will be educated by the Nurse Practice Educator during the orientation process. The Administrator re-educated the Maintenance Director on preventative maintenance tasks to ensure heating units are operating below the maximum surface temperature allowed by the Underwriters Laboratory Requirements by 01/23/25. The baseboard supplemental heating units located in the day rooms will remain disengaged and if supplemental heating is warranted, the Maintenance Director will install an infrared heating panel or install safety guards to eliminate potential risk to residents. A preventative maintenance task will be added to the TELS monitoring system. How will the facility monitor it's corrective actions to ensure the deficient practice will not recur? On 01/22/25, the center Administrator conducted an ADHOC Quality Assurance Improvement meeting to review and approve a plan of correction to include education, policies, and procedures and quality improvement monitoring beginning on 01/23/25. The Maintenance Director and or designee to conduct quality improvement monitoring through observation to ensure there are no supplemental heating units in use 5x per week for 4 weeks, 1x weekly for 4 weeks starting on 01/22/25. The Nursing Home Administrator and/or designee will review the results in the monthly QAPI meeting for one quarter to ensure compliance is achieved and sustained. Subsequent plans of correction will be implemented as necessary. Beginning 01/23/25, the Director of Nursing, Unit Manager or Designee will assess the feet of 5 residents twice weekly for eight weeks, and then 5 residents weekly for four weeks to ensure proper foot care/health and that appropriate interventions are in place. The Director of Nursing Services and/or designee will review the results of the audits in the monthly Quality Assurance Performance Improvement Committee meeting for one quarter to ensure compliance is achieved and sustained. Subsequent plans of corrections will be implemented as necessary. The Administrator will report the results of the monitoring to the QAPI committee for review and recommendations for the time frame of the monitoring period or as it is amended by the committee. Date of compliance: 1/24/25 On 02/26/25, the surveyor reviewed the credible evidence of the plan of correction's implementation. All staff had been educated if not in person, via phone calls by the DON. Those educated via phone calls signed the in-service sheet when they returned to the facility. Staff who had been educated via phone but had not yet returned to work were the only ones without signatures. On 02/26/25 at 12:40p.m., the surveyor interviewed in person all patient-care staff working. All interviewees voiced they received education on foot health and care by facility staff in January with one employee stating the education was provided upon being hired recently. This is a past non-compliance deficiency.

Based on observation, staff interview, clinical record review and facility document review the facility staff follow physician's orders for 2 of 22 residents, Resident #9 and Resident #63. The findings included: 1. For Resident #9 the facility staff failed to administer the medication carvedilol per the physician's order. Resident #9's face sheet listed diagnoses which included but not limited to hypotension, anemia, and anxiety. Resident #9's most recent minimum data set with an assessment reference date of 08/08/24 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #9's comprehensive care plan was reviewed and contained a plan for Resident exhibits or is at risk for cardiovascular symptoms or complications related to hypertension. Interventions for this care plan include Administer meds as ordered . Resident #9's clinical record was reviewed and contained a physician's order summary which read in part, Carvedilol Tablet 12.5 mg. Give 1 tablet by mouth two times a day for hypertension with meals. Resident #9's electronic medication administration record for the month of August 2024 was reviewed and contained an entry as above. This entry was blank on 08/06/24 at 5 pm and coded HD on 08/10/24 at 5 pm. Chart code HD is equivalent to hold/see nurses notes. Resident #9's nursing progress notes were reviewed and contained a note which read in part, 08/10/2024 17:18:00 Carvedilol Tablet 12.5 mg. Give 1 tablet by mouth two times a day for hypertension with meals. due to low BP (blood pressure), med held. MD and RP (responsible party) notified. This medication did not have parameters to hold for low blood pressure. Surveyor spoke with the director of nursing (DON) on 08/21/24 at 9:45 am regarding Resident #9's carvedilol. DON stated, If it's blank, they didn't give it. On 08/21/24 at 2:45, DON stated to surveyor, I can't say it was given, I talked with the nurse working that day and they can't remember if they gave it or not. Surveyor requested and was provided with a facility policy entitled Medication Administration General Guidelines which read in part, Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber .4. The resident's MAR/TAR (medication administration record/treatment administration record) is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration time. The concern of not administering Resident #9's medication per the physician's order was discussed with the administrator, DON, and regional nurse consultant on 08/21/24 at 3:30 pm. No further information was provided prior to exit. 49622 2. For Resident #63 the facility staff failed to follow a medical provider's orders to provide a functioning pressure redistribution mattress. Resident #63's diagnosis list indicated diagnoses that included, but were not limited to, Streptococcal Arthritis to Right Knee, Sepsis, UTI (urinary tract infection), Acute Kidney Failure, Hypertensive Chronic Kidney Disease-Stage 4, Peripheral Vascular Disease, Atrial Fibrillation, and Osteoarthritis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of, 8/19/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating Resident #63 was cognitively intact. On 8/18/24 at 3:45 PM, surveyor interviewed Resident #63 and she stated her air mattress was not working. Surveyor observed the mattress and the power button located on the footboard of the bed was in the on position, however the mattress was observed to not be functioning or receiving air. A review of the medical providers orders included an order for, Pressure-redistribution mattress to bed with a start date of 8/13/24. A facility assessment titled, Braden Scale for Predicting Pressure Sore Risk, dated 8/13/24, read in part, .1. Sensory Perception .3. Slightly Limited .Responds to verbal commands but cannot always communicate discomfort or the need to be turned or has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities .3. Activity .Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair .4. Mobility .3. Slightly Limited .Makes frequent though slight changes in body or extremity position independently .6. Friction & Shear .2. Potential Problem .Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets .7. Scoring .SCORING .AT RISK 15-18 . The progress note summary attached to the assessment revealed Resident #63 had a score of 16. On 8/18/24 at 3:55 PM, surveyor requested licensed practical nurse #4 (LPN#4) accompany her to resident's room. LPN#4 checked the power button and stated it was not working and she would check to confirm the bed was plugged into the power outlet. LPN#4 stated it was not plugged-in and she plugged it in and stated it should start building pressure now and she was not sure how it got unplugged. On 8/19/24 at 9:45 AM, surveyor and director of nursing (DON) entered Resident #63's room and the pressure redistribution mattress was on and functioning. The DON stated that she would check the provider orders to make sure staff is checking it (pressure-redistribution mattress). An additional review of the medical providers orders revealed a new order dated 8/18/24 with a start date of 8/19/24, that read in part, .Pressure-redistribution mattress to bed, check function Q (every) shift every day and night shift . This concern was discussed at the end of day meetings with the corporate nurse consultant, administrator, and director of nursing on 8/19/2024 at 4:30 PM, 8/20/24 at 4:19 PM, and again at the pre-exit meeting on 8/21/24 at 3:30 PM. Surveyor requested and received a facility policy titled, Skin Integrity and Wound Management, that read in part, .6.8 Implement pressure injury prevention for identified, modifiable risk factors. 6.9 Determine the appropriate support surface for the bed . No further information regarding this concern was presented to the survey team prior to the exit conference on 8/21/24.

Based on observations, staff interview, clinical record review and facility document review, the facility staff failed to provide supervision to prevent accidents for 2 of 6 closed record reviews, Resident #55 and Resident #209. This resulted in actual harm for resident #55 cited at past non-compliance. For resident #209, the facility failed to implement safety measures resulting in an elopement. The findings included: 1. For resident # 55 the facility staff failed to provide supervision as ordered by the physician and based on a recommendation by speech therapy, during meal times. Resident # 55's diagnoses included but were not limited to Alzheimer's Disease, history of a stroke, history of a traumatic brain injury and paranoid schizophrenia. The minimum data set (MDS) assessment with an assessment reference date of 7/17/24 assigned the resident a brief interview for mental status (BIMS) score of 8 out of 15 indicating moderate cognitive impairment. Under Section GG Functional Abilities and Goals, resident # 55 was coded as being independent for eating. Under section K Swallowing/Nutritional Status, there were no swallowing difficulties coded. During a review of resident # 55's clinical record a progress note dated 8/12/24 at 9:05 AM read, CNA set tray up in residents room for breakfast, when CNA returned to pick up tray after breakfast resident was found unresponsive. CNA notified Nurse, Nurse verified DNR orders. Medical Director notified. Notified RP, (name omitted). (name omitted) Funeral home called per son request. Another note dated 8/12/24 at 9:15 AM read, This nurse was called to residents room by LPN (Name omitted). Upon entering the room the resident was lying on back on bed. This nurse saw no rise or fall of chest, No pulse palpated, No heartbeat auscultated. Confirmed residents code status was a Do Not Resuscitate by nurse (name omitted) LPN. Resident was pronounced at 9:09 am. The orders for resident # 55 were reviewed. An order dated 5/27/24 for a diet change was noted. The order was for a regular/liberalized dysphagia advance diet texture and under order summary the order stated, Pt requires feeding assistance. The care plan was reviewed. An ADL focus with a created date of 5/3/24 read in part, Resident/Patient requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Recent illness, fall, hospitalization , etc.) resulting in fatigue, activity intolerance, confusion, etc), Chronic disease/condition: Dementia TBI, CVA, Schizophrenia Limited range of motion of Left Lower leg with Casting, Mood symptoms. An intervention read, Provide cueing for safety and sequencing to maximize current level of functioning. The nutritional care plan was reviewed. There was no diet order listed and it did not mention resident needing feeding assistance, there was no mention of resident not being allowed certain foods. On 8/20/24 at 1:24 PM this surveyor interviewed other employee # 3. They stated that they were working with resident # 55 in May when it happened the first time, but only for cognition.(Resident) didn't have a swallowing problem, it was a traumatic brain injury with behaviors. She would eat very fast and just shove everything in her mouth all at once. She needed cuing to slow down. Surveyor asked what Pt requires feeding assistance means, as that is how the order read, they stated, she needed supervision and cuing to not eat so fast. They stated that they did education with the CNA's in May but didn't have them sign anything and could not tell surveyor what CNA's had been present for the education. They stated, I know I should have been more specific in my recommendation. Surveyor asked what had happened in May and they stated, She got choked on a sandwich and had to have the Heimlich. That's why the order said no sandwiches. Surveyor asked if they could provide a copy of their recommendation as the order in the electronic medical record didn't include anything about resident not having sandwiches. They provided a form entitled, Food & Nutrition Services Diet Order & Communication Form. The form had resident # 55's name and room number on it and was signed by employee # 3. Under the heading Diet the box for Regular/Liberalized was checked. Under the heading Consistency Modification the box Dysphagia Advanced was checked. Under the heading Preferences a hand written note that read, Assistance with meals. *No sandwiches. was noted. On 8/20/24 at 1:40 PM this surveyor interviewed other staff member # 1. Surveyor asked what a regular liberalized dysphagia advanced diet was. They stated, The meat is ground and the vegetables and everything have to be fork tender, no raw vegetables, no hard bread. Surveyor asked what resident # 55 had been served the morning of 8/12/24 for breakfast, they stated, eggs and oatmeal and then we had a coffee cake too. Surveyor asked if the coffee cake was approved for the diet texture ordered for resident # 55 and they stated yes, I can show you the menu. They provided a document entitled, SNF SS 24 ALG Diet Guide Sheet for Monday (Day 2) breakfast. For the dysphagia advance texture the menu consisted of cinnamon oatmeal, western scrambled egg and peach streusel coffee cake. They stated, That coffee cake is real soft. Surveyor asked if they were aware that resident # 55 was not supposed to have sandwiches and they stated, Yes, we had that on her tray card, no sandwiches. On 8/21/24 at 11:05 AM this surveyor interviewed Certified Nursing Assistant (CNA) # 5. They stated they were the one who gave resident # 55 their tray on 8/12/24. I didn't know we were supposed to feed her. Nobody knew. When asked how the staff know what residents require assistance with feeding or supervision they stated, I always check the Kardex but it wasn't on there. It is now, they've went through and fixed everybody's and gave us lists, made sure we know who needs help and how much help. Surveyor asked to describe what happened, they stated, I took her tray in and sat her up on the side of the bed like we always do. I made sure she had everything and came out to pass more trays. I walked by little bit later and she was still sitting there, it looked like she had already finished with everything, I didn't see anything left on the tray. I didn't hear anything, and I was on the hall the whole time, like no coughing or anything, but when I went back in there, she was laying across the bed with her mouth and her eyes open and she wasn't breathing. I could see food in her mouth. I yelled for the nurse. Nothing was out of place. It was like she just laid down. On 8/21/24 at 11:28 AM this surveyor interviewed CNA # 4. They stated they weren't assigned to resident # 55 on the 12th but was working on the unit. They stated they came in the room after the nurse. Surveyor asked them to described what they saw, I seen her laying straight back with her mouth full, I think it was coffee cake, everything was in place like she didn't kick her legs out like you would expect or anything. Nothing was knocked off or over. She had ate and drank everything. When asked how they know what residents need help they stated, I usually check the Kardexes but all hers said was encourage fluids. I didn't know she was supposed to be fed or helped. They have went through and checked everybody's and made sure the Kardex and tray cards are right and they have in-serviced us. The ST (speech therapist) brought around a checklist and talked to us about precautions and things we are supposed to do. On 8/21/24 at 11:55 AM this surveyor met with the Director of Nursing (DON), the Administrator, and the Regional Nurse Consultant. Surveyor asked to speak with the Licensed Practical Nurse assigned to resident # 55 on 8/12/24. They stated that the nurse was on Family Medical Leave and could not be reached. The DON stated that they were the one who pronounced resident and had arrived in the room within just a couple minutes of the CNA finding the resident. They had already confirmed the code status as DNR (do not resuscitate), there were no signs of life so I pronounced and we notified the family and the funeral home. This surveyor asked why resident was not being assisted during meal times. The Regional Nurse Consultant stated, The diet change and recommendation was never transcribed to the care plan. If it had been put on the care plan, it would have crossed over to the Kardex. The Regional Nurse Consultant stated a Plan of Correction (POC) had been implemented for the incident and presented it at this time. The POC had a completion date of 8/20/24 and read as follows: Corrective Action: The code status for resident # 55 was verified by the Licensed Practical Nurse and no life sustaining measures were initiated due to resident was a DNR. Root Cause Analysis: Upon record review it was noted that the resident's diet was dysphagia advanced texture. Assistance with all meals. No sandwiches. The order was obtained 5/27/2024 by Speech Therapy and never transcribed to the residents Kardex. The staff were unaware of this recommendation by Speech Therapy. Resident # 55 was unable to feed herself without staff assistance. When LPN entered the room, resident # 55 was unresponsive and was noted to have food in her mouth. The LP attempted to removed the food. Resident # 55 was assessed and had no signs of life with no pulse present. The code status was verified and no life sustaining measures were initiated. Identification of Deficient Practice; How will corrective action be accomplished for those residents having potential to be affected by the same deficient practice: On 8/12/24 an audit of all residents with dysphagia diet orders was performed by the DON to ensure that orders are accurate, on the Kardex and the care plan is current. No issues were identified. On 8/12/24 an audit of all diet orders/tray tickets was performed by the DON/designee to ensure all orders were accurate. No issues were identified. On 8/14/24 all residents with dysphagia diet orders were re-evaluated by Speech Therapist to ensure the diets were appropriate. No issues were identified. On 8/12/24 an audit of all care plans/Kardex was performed by the MDS coordinator/designee to ensure that diets are care planned appropriately and are accurate. Any issues identified were corrected. Systemic Changes: On 8/12/24 the DON/designee began education with all nursing staff on verifying the resident's diet by the Kardex/care plan to ensure if any assistance with feeding is needed. If feeding assistance is needed the resident will not be left unsupervised. On 8/12/24 the DON began education with all nursing staff on verifying the tray tickets are accurate with the appropriate diet prior to serving the resident. If the tray ticket states feeding assistance is needed, the resident will not be left unsupervised. Effective 8/14/24, nursing staff will not be allowed to work until the education is completed. New hires will be provided this education by the Nurse Practice Educator during orientation. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Observation competency for any resident requiring feeding assistance will be completed for 12 weeks with (5) staff to ensure residents who require feeding assistance are not left unsupervised during meals. This will include all meals breakfast, lunch and dinner. All new orders will be reviewed 5x weekly in the Clinical Morning Meeting to ensure any new diet orders/changes are verified and updated on the plan of care/Kardex. New admissions will be reviewed 5x weekly in the Clinical Morning Meeting to ensure diet orders are reviewed for accuracy and the care plan/Kardex are updated. The Dietary Manager will perform audits on all tray tickets weekly for 12 weeks to ensure tickets are accurate. The DON will report the results of the plan of correction audits to the QAPI Committee. The QAPI Committee will review the audits and make recommendations to ensure compliance is sustained and ongoing and determine the need for any further auditing is needed. Completion Date: 8/20/24 Surveyor reviewed the credible evidence for the POC on 8/21/24 and found the audits and education to be complete other than two staff members who are on Family Medical Leave. The Administrator confirmed that the two employees are aware that they must complete education prior to working with patients. Interviews with nursing staff on 8/20/24 and 8/21/24 confirmed that staff are knowledgeable about ensuring diets are accurate and residents who require assistance are identified using the Kardex. No further information was provided prior to the exit conference. This is a past non-compliance deficiency. 49622 2. For Resident #209, the facility staff failed to provide care and services for a safe environment for prevention of elopement from the facility. This was a closed record review. Resident #209's diagnoses included, but were not limited to, Presence of Left Artificial Hip Joint, Anxiety Disorder, Type 2 Diabetes Mellitus, Congestive Heart Failure, Chronic Kidney Disease-Stage 3, Chronic Obstructive Pulmonary Disease, Depression, Dementia, and Adult Failure to Thrive. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/16/23, assigned the resident a brief interview for mental status (BIMS) summary score of 1 out of 15 for cognitive abilities, indicating Resident #209 was severely impaired in cognition. A review of the clinical record revealed a medical provider's order dated 5/4/23, that read in part, .Wander Guard/Wander Elopement Device due to wandering and elopement risk every night shift check function and document in supplemental documentation . A review of the June 2023 MAR (medication administration record) revealed Resident #209's wander guard was ineffective on 6/1/24 during day shift. A review of the progress notes revealed an elopement assessment note dated 6/1/23 that read in part, .continued wandering, patient eloped from the facility was found still in the parking lot . An encounter progress note dated 6/16/23, read in part, .placed on rounds by staff for exit seeking .Patient was placed on every 15 (fifteen) minute checks due to exit seeking. After review plan exit door has been identified. Wander guard is now working . A review of the Elopement Evaluation dated 6/1/23, revealed resident had a history of actual elopement or attempted elopement and had a history of wandering that placed resident at significant risk of getting to a potentially dangerous place, outside facility. The evaluation also indicated that Resident #209 hovered near exits, had impulsiveness, and restlessness. A review of the comprehensive care plan read in part, .is at risk for elopement related to: Cognitive Loss/Dementia and wandering within the facility, sometimes hovers at exits, history of elopement attempt, impulsiveness . with an initiated date of 12/13/2022 that included an intervention that read in part, .Redirect .away from exit doors . On 8/20/24 at 11:10 AM, surveyor interviewed discharge planner and she stated she was trying to find placement for Resident #209 at a dementia unit. She believes they found Resident #209 by the dumpsters, it was later afternoon/evening, and she was not at the facility when it happened. On 8/20/24 at 11:15 AM, surveyor interviewed admissions director and she remembered the incident being discussed, but she did not witness the incident. On 8/20/24 at 3 PM, surveyor interviewed administrator and director of nursing, neither worked at the facility at the time. Administrator called the former administrator, and she gave permission for surveyor to contact her via telephone. On 8/20/24 at 5:08 PM, surveyor spoke via phone with registered nurse #3 (RN#3) and she stated she remembered them talking about Resident #209 getting out, but she was not directly involved, and she believed the resident went out the mechanical room door by the dock and she did not believe that door had a wander guard. On 8/20/24 at 8:01 PM, surveyor interviewed former administrator-other staff #2 (OS#2) about the elopement and she stated they had challenges with Resident #209 leaving the facility with family when they visited. She stated resident went out of the mechanical room door and the door was located to the left of the administrator's office when you came through the double-doors in the lobby. She believed a therapist had found the resident on that day. On 8/21/24 at 8:45 AM, surveyor interviewed rehab director and she stated she found Resident #209 outside by the dumpsters when she was leaving work for the day. She stated as she was walking resident back towards the front doors of the building, staff came out the mechanical door and took resident back in. She could not recall which staff and did not know which door resident came out of. She stated she observed her walking around by the dumpsters and took surveyor outside and showed surveyor where she found resident by the dumpsters. On 8/21/24 at 10:50 AM, surveyor interviewed environmental services director and he showed surveyor the 2 (two) doors that lead into the laundry room. Both doors had a punch-key code lock (numbers are punched in for entry). Both doors lead to the mechanical room door. Immediately outside the mechanical room door was a sidewalk with a rail that led to the dumpster area approximately 50 (fifty) yards to the right of the door. On 8/21/24 at 1:45 PM, administrator informed surveyor he could not locate the investigation or staff statements from the incident that occurred on 6/1/23 in the files left by the former administrator. He also stated there was no wander guard system on the mechanical room doors. When asked the process for checking the wander guard system, administrator stated nursing sign-off on the MAR that it has been checked. Administrator performed tests on the 2 wander guard doors for surveyor and they were observed to be working correctly. No other staff who cared for Resident #209 were available for interview at the time of the survey. This allegation was discussed with the administrator, corporate nurse consultant, and director of nursing at the pre-exit meeting on 8/21/24 at 3:30 PM. Surveyor requested and received a facility policy titled, Elopement of Patient, that read in part, .Those determined to be at risk will receive appropriate interventions to reduce risk .Elopement is defined as any situation in which a patient leaves the premises or a safe area without the facility's knowledge and supervision . No further information regarding this concern was presented to the survey team prior to the exit conference on 8/21/24.

Based on observation, staff interview and facility document review, the facility staff failed to ensure proper disposal and/or containment of the facility's garbage/waste. The findings included: On 8/19/24 at approximately 2:30 PM, this surveyor and other employee # 4 made observations of the facility's garbage disposal area located outside the facility but on the campus. There were two dumpsters noted. All of the doors on the dumpsters were closed, however there was scattered debris noted around each one. Surveyor noted 7 gloves, 4 Styrofoam cups, a large black trash bag with unknown contents, the bag was tied. There were 4 large pieces of brown wood lying on the ground between the dumpsters. The surveyor asked the employee if they knew what the wood was and they stated, It looks like something maintenance would have put there. It looks like it was a cabinet or something. On 8/20/21 at 4:15 PM the survey team met with the Administrator, Director of Nursing and Regional Nurse Consultant. Surveyor requested and received the policy entitled, Waste Management with a review date of 5/1/24. The policy did not speak to the garbage disposal area outside the facility. On 8/21/24 at 3:30 PM the surveyor team met with the Administrator, Director of Nursing, and Regional Nurse Consultant. This concern was reviewed at that time No further information was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide residents and/or residents' representatives with the facility bed hold policy upon transfer for four (4) of 22 sampled residents, (Resident #30, Resident #17, Resident #5, and Resident #35). The findings include: 1. For Resident #30, the facility staff failed to provide the resident and/or the resident's representative with the facility bed-hold policy upon transfer on 7/6/24. Resident #30's diagnosis list indicated diagnoses that included, but were not limited to, Acute Kidney Failure, Encephalopathy, Chronic Respiratory Failure, Alzheimer's Disease, Weakness, Anemia, Bradycardia, Chronic Obstructive Pulmonary Disease and Anxiety Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/15/24, assigned the resident a brief interview for mental status (BIMS) summary score of 5 out of 15 for cognitive abilities, indicating Resident #30 was severely impaired in cognition. A review of the clinical record indicated Resident #30 was transferred to the hospital on 7/6/24. No evidence of the facility's bed-hold policy being provided to the resident and/or the resident's representative could be located. On 8/20/24 at 10:50 AM, surveyor interviewed the director of nursing and she stated there was no evidence of the resident and/or resident's representative being provided with the facility bed-hold policy. On 8/20/24 at 11:08 AM, surveyor interviewed the social worker, and she informed the surveyor that she had no evidence of Resident #30 or the resident's representative being given the facility bed-hold policy. This concern was discussed at the end of day meeting on 8/20/24 at 4:19 PM with the corporate nurse consultant, administrator, and director of nursing and again at the pre-exit meeting on 8/21/24 at 3:30 PM. Surveyor requested and received a facility document, titled, Discharge and Transfer, that read in part, .5.5 The Bed Hold Notice of Policy & Authorization form will be provided . A review of the facility document, titled, Bed Hold Notice of Policy & Authorization read in part, .Give the white copy of this notice to the resident/representative: add the signed yellow copy in the resident's medical record . No further information regarding this concern was presented to the survey team prior to the exit conference on 8/21/24. 2. For Resident #17, the facility staff failed to provide the resident and/or the resident's representative with the facility bed-hold policy upon transfer on 8/6/24. Resident #17's diagnosis list indicated diagnoses that included, but were not limited to, Acute Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Chronic Kidney Disease-Stage 3, Cerebral Aneurysm-Non-ruptured, Viral Hepatitis C, Encephalopathy, and Hypertensive Chronic Kidney Disease. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/5/24, assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating Resident #17 was cognitively intact. A review of the clinical record indicated Resident #17 was transferred to the hospital on 8/6/24. No evidence of the facility's bed-hold policy being provided to the resident and/or the resident's representative could be located. On 8/20/24 at 10:50 AM, surveyor interviewed the director of nursing and she stated there was no evidence of the resident and/or resident's representative being provided with the facility bed-hold policy. This concern was discussed at the end of day meeting on 8/20/24 at 4:19 PM with the corporate nurse consultant, administrator, and director of nursing and again at the pre-exit meeting on 8/21/24 at 3:30 PM. Surveyor requested and received a facility document, titled, Discharge and Transfer, that read in part, .5.5 The Bed Hold Notice of Policy & Authorization form will be provided . A review of the facility document, titled, Bed Hold Notice of Policy & Authorization read in part, .Give the white copy of this notice to the resident/representative: add the signed yellow copy in the resident's medical record . No further information regarding this concern was presented to the survey team prior to the exit conference on 8/21/24. 3. For Resident #5, the facility staff failed to provide the resident and/or the resident's representative with the facility bed-hold policy upon transfer on 4/29/24. Resident #5's diagnosis list indicated diagnoses that included, but were not limited to, Anxiety Disorder, Cirrhosis of Liver, Chronic Embolism and Thrombosis of Unspecified Deep Veins of Lower Extremity-Bilateral (both sides), Depression, Dependence on Renal Dialysis, End Stage Renal Disease, Heart Disease of Native Coronary Artery, Liver Transplant, Type 2 Diabetes Mellitus, Chronic Kidney Disease, and Generalized Edema. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/25/24, assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 for cognitive abilities, indicating Resident #5 was moderately impaired in cognition. A review of the clinical record indicated Resident #5 was transferred to the hospital on 4/29/24. No evidence of the facility's bed-hold policy being provided to the resident and/or the resident's representative could be located. On 8/21/24 at approximately 8:45 AM, the director of nursing informed surveyor there was no evidence of the resident and/or resident's representative being provided with the facility bed-hold policy. This concern was discussed at the pre-exit meeting on 8/21/24 at 3:30 PM with the corporate nurse consultant, administrator, and director of nursing. Surveyor requested and received a facility document, titled, Discharge and Transfer, that read in part, .5.5 The Bed Hold Notice of Policy & Authorization form will be provided . A review of the facility document, titled, Bed Hold Notice of Policy & Authorization read in part, .Give the white copy of this notice to the resident/representative: add the signed yellow copy in the resident's medical record . No further information regarding this concern was presented to the survey team prior to the exit conference on 8/21/24. 4. For resident # 35, the facility staff failed to provide a bed hold policy to the resident's representative for the 8/1/23 hospitalization. On 8/19/24 at 3:18 PM this surveyor interviewed the responsible party for resident # 44. When asked if they were satisfied with the care at the facility they stated, I got a little upset a couple weeks ago. I told them he had pneumonia and needed to go to the hospital. They said it was a COPD (chronic obstructive pulmonary disease) exacerbation and they were going to wait until the doctor came in the next day and ask for breathing treatments. I made them send out, we weren't waiting until the next day when I knew it was pneumonia. They stated they didn't get any paperwork about the hospitalization from the facility. They usually just call me on the phone for something like that. The clinical record was reviewed. Resident was sent to the hospital on 8/1/24 and admitted for pneumonia. There was no documentation to indicate the resident's representative was provided a bed hold policy. This surveyor requested and received a copy of the policy entitled, Bed Hold Notice of Policy & Authorization. On the bottom of the form the following statement was noted, Give the white copy of this notice to the resident/representative; add the signed yellow copy in the resident's medical record. There was no copy of a bed hold policy in the medical record. The policy entitled Discharge and Transfer with a review date of 11/15/22 was reviewed. Under the section with the heading For patients transferred to a hospital the policy read in part, The Bed Hold Notice of Policy & Authorization form (Smartworks #HHC-4731) will be provided per the Accounts Receivable Policies and Procedures, Bed Holds policy. On 8/20/24 at 11:08 AM the facility Social Worker was interviewed. They stated they have never informed the Ombudsman of any discharges to the hospital. They also stated they had no evidence of resident # 35 or his representative being sent written notification of transfer or bed hold policy They stated the nurses take care of discharges to the hospital. The survey team met with the Administrator, Director of Nursing, and Regional Nurse Consultant on 8/21/24 at 3:30 PM. This concern was discussed at that time. No further information was provided to the survey team prior to the exit conference.

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to provide written notification of reasons for transfer or discharge to the resident and the resident's representative(s) and failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care Ombudsman for four (4) or 22 sampled residents and/or residents' representatives, (Resident #30, Resident #17, Resident #5, and Resident #35). The findings include: 1. For Resident #30, the facility staff failed to provide the resident or the resident's representative written notice of the reason(s) of transfer/discharge to the hospital on 7/6/24 and failed to notify the Office of the State Long-Term Care Ombudsman of the transfer/discharge. Resident #30's diagnosis list indicated diagnoses that included, but were not limited to, Acute Kidney Failure, Encephalopathy, Chronic Respiratory Failure, Alzheimer's Disease, Weakness, Anemia, Bradycardia, Chronic Obstructive Pulmonary Disease and Anxiety Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/15/24, assigned the resident a brief interview for mental status (BIMS) summary score of 5 out of 15 for cognitive abilities, indicating Resident #30 was severely impaired in cognition. A review of the clinical record indicated Resident #30 was transferred to the hospital on 7/6/24. No evidence of written notice of the transfer being provided to the resident or the resident's representative could be located. On 8/20/24 at 10:50 AM, surveyor interviewed the director of nursing and she stated there was no evidence of the resident and resident's representative receiving written notice for reason of transfer/discharge to the hospital. On 8/20/24 at 11:08 AM, surveyor interviewed the social worker, and she informed the surveyor that she has never informed the ombudsman of any discharges and she had no evidence of Resident #30 or the resident's representative being sent written notification for the reason of transfer or discharge. This concern was discussed at the end of day meeting on 8/20/24 at 4:19 PM with the corporate nurse consultant, administrator, and director of nursing and again at the pre-exit meeting on 8/21/24 at 3:30 PM. Surveyor requested and received a facility document, titled, Discharge and Transfer, read in part, .5. For patients transferred to the hospital .the patient and patient representative will be notified .followed by written notification using the Notice of Hospital Transfer or state specific form .5.1.1 Copies of notices for emergency transfers must also be sent to the Ombudsman . No further information regarding this concern was presented to the survey team prior to the exit conference on 8/21/24. 2. For Resident #17, the facility staff failed to provide the resident or the resident's representative written notice of the reason(s) of transfer to the hospital on 8/6/24 and failed to notify the Office of the State Long-Term Care Ombudsman of the transfer/discharge. Resident #17's diagnosis list indicated diagnoses that included, but were not limited to, Acute Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Chronic Kidney Disease-Stage 3, Cerebral Aneurysm-Non-ruptured, Viral Hepatitis C, Encephalopathy, and Hypertensive Chronic Kidney Disease. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/5/24, assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating Resident #17 was cognitively intact. A review of the clinical record indicated Resident #17 was transferred to the hospital on 8/6/24. No evidence of written notice of the transfer being provided to the resident or the resident's representative could be located. On 8/20/24 at 10:50 AM, surveyor interviewed the director of nursing and she stated there was no evidence of the resident and resident's representative receiving written notice for reason of transfer/discharge to the hospital. On 8/20/24 at 11:08 AM, surveyor interviewed the social worker, and she informed the surveyor that she has never informed the ombudsman of any discharges. This concern was discussed at the end of day meeting on 8/20/24 at 4:19 PM with the corporate nurse consultant, administrator, and director of nursing and again at the pre-exit meeting on 8/21/24 at 3:30 PM. Surveyor requested and received a facility document, titled, Discharge and Transfer, read in part, .5. For patients transferred to the hospital .the patient and patient representative will be notified .followed by written notification using the Notice of Hospital Transfer or state specific form .5.1.1 Copies of notices for emergency transfers must also be sent to the Ombudsman . No further information regarding this concern was presented to the survey team prior to the exit conference on 8/21/24. 3. For Resident #5, the facility staff failed to provide the resident or the resident's representative written notice of the reason(s) of transfer/discharge to the hospital on 4/29/24 and failed to notify the Office of the State Long-Term Care Ombudsman of the transfer/discharge. Resident #5's diagnosis list indicated diagnoses that included, but were not limited to, Anxiety Disorder, Cirrhosis of Liver, Chronic Embolism and Thrombosis of Unspecified Deep Veins of Lower Extremity-Bilateral (both sides), Depression, Dependence on Renal Dialysis, End Stage Renal Disease, Heart Disease of Native Coronary Artery, Liver Transplant, Type 2 Diabetes Mellitus, Chronic Kidney Disease, and Generalized Edema. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/25/24, assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 for cognitive abilities, indicating Resident #5 was moderately impaired in cognition. A review of the clinical record indicated Resident #5 was transferred to the hospital on 4/29/24. No evidence of written notice of the transfer/discharge being provided to the resident or the resident's representative could be located. On 8/20/24 at 11:08 AM, surveyor interviewed the social worker, and she informed the surveyor that she has never informed the ombudsman of any discharges. On 8/21/24 at approximately 8:45 AM, the director of nursing informed surveyor there was no evidence of the resident and resident's representative receiving written notice for reason of transfer to the hospital. This concern was discussed at the pre-exit meeting on 8/21/24 at 3:30 PM with the corporate nurse consultant, administrator, and director of nursing. Surveyor requested and received a facility document, titled, Discharge and Transfer, read in part, .5. For patients transferred to the hospital .the patient and patient representative will be notified .followed by written notification using the Notice of Hospital Transfer or state specific form .5.1.1 Copies of notices for emergency transfers must also be sent to the Ombudsman . No further information regarding this concern was presented to the survey team prior to the exit conference on 8/21/24. 4. For resident # 35, the facility staff failed to provide the resident representative or the Ombudsman with a written transfer notice for the 8/1/24 transfer. On 8/19/24 at 3:18 PM this surveyor interviewed the responsible party for resident # 44. When asked if they were satisfied with the care at the facility they stated, I got a little upset a couple weeks ago. I told them he had pneumonia and needed to go to the hospital. They said it was a COPD (chronic obstructive pulmonary disease) exacerbation and they were going to wait until the doctor came in the next day and ask for breathing treatments. I made them send him out, we weren't waiting until the next day when I knew it was pneumonia. They stated they didn't get any paperwork about the hospitalization from the facility. They usually just call me on the phone for something like that. The clinical record was reviewed. Resident was sent to the hospital on 8/1/24 and admitted for pneumonia. There was no documentation to indicate the resident's representative was provided a written transfer notice. This surveyor requested and received a copy of the policy entitled, Discharge and Transfer with a review date of 11/5/22. The policy read in part, The patient and the patient representative must be notified in writing prior to the transfer or discharge and in a language or manner they understand. Under the heading, For patients transferred to a hospital the policy read in part, For unplanned, acute transfers, the patient must be permitted to return to the Center. Prior to the transfer, the patient and the patient representative will be notified verbally followed by written notification using the Notice of Hospital Transfer or specific state transfer form. Copies of notices for emergency transfers must also be sent to the Ombudsman, but they may be sent when practicable, such as in a list of patients on a monthly basis or per state requirements. On 8/20/24 at 11:08 AM the facility Social Worker was interviewed. They stated they have never informed the Ombudsman of any discharges to the hospital. They also stated they had no evidence of resident # 35 or his representative being sent written notification for transfer or bed hold policy They stated the nurses take care of discharges to the hospital. On 8/21/24 at 3:30 PM the survey team met with the Administrator, Director of Nursing and the Regional Nurse Consultant. This concern was reviewed at that time. No further information was provided to the survey team prior to the exit conference.

Based on resident and staff interviews, clinical record review, and facility document review, the facility staff failed to ensure that residents and/or resident representatives had the opportunity to develop an advanced directive for 3 of 22 residents in the survey sample, residents # 32, # 44 and # 39. The findings included: 1. For resident # 32, the facility staff failed to ensure the resident had the opportunity to develop an advanced directive. Resident # 32's diagnoses included but were not limited to metabolic encephalopathy, sepsis, chronic respiratory failure, chronic obstructive pulmonary disorder, type II diabetes, congestive heart failure, and chronic kidney disease stage 3. The minimum data set (MDS) with an assessment reference date (ARD) of 7/2/24, assigned the resident a brief interview for mental status (BIMS) score of 14 indicating they were cognitively intact. During a review of the clinical record, a physician's order with a revision date of 6/26/24 that read, Full Code was noted. Under the Assessment tab, a document entitled, Social Services Assessment and Documentation with an effective date of 7/1/24 was reviewed. On page 3, Item #5 read, Resident Rights/Healthcare Decision Making/Advanced Directives a. Information Provided with regard to resident rights, yes. b. Advanced Directives (e.g. Living Will, Healthcare Power of Attorney, or Healthcare Proxy) in place? yes. b.2. Healthcare agent/Proxy? no. c. Additional conversation regarding advanced care planning provided? no. f. Separate Healthcare order (POST- physician order for scope of treatment, POLST- physician order for life sustaining treatment, MOLST- medical order for life sustaining treatment, etc.) completed? yes. This surveyor was unable to locate any Advanced Directives, POST, POLST, or MOLST documents in the clinical record. The care plan was reviewed. There was a focus that read, Resident/patient established advanced directives: Full code. An intervention read, Advance Directive education and materials, including state forms provided. On 8/20/24 this surveyor asked the Director of Nursing for a copy of resident # 32's Advanced Directives. They were not able to provide a copy. Resident # 32 was interviewed on 8/21/24 at 11:03 AM. When asked if they had an Advanced Directive such as a Living Will or Power of Attorney they stated, No, I don't believe I do. When asked if they had been given any written information about Advanced Directives, they stated, I don't think so. 2. For resident # 44 the facility staff failed to ensure the resident had the opportunity to develop an advanced directive. Resident # 44's diagnoses included but were not limited to, unspecified dementia, malignant neoplasm of colon and essential hypertension. The minimum data set (MDS) assessment with an assessment reference date of 6/12/24 assigned the resident a brief interview for mental status (BIMS) score of 12 out of 15 indicating mild cognitive impairment. During a review of the clinical record an order for a code status of DNR or do not resuscitate was noted. Under the document section of the chart, Durable Do Not Resuscitate Order dated 6/11/24 and signed by a family member was noted. The top section of the order has two paragraphs, and each paragraph has a checkbox beside it. The first one reads, 1. The patient is capable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment. The second paragraph reads, 2. The patient is incapable of making an informed decision about providing, withholding or withdrawing a specific medical treatment or course of medical treatment because he/she is unable to understand the nature, extent or probable consequences of the proposed medical decisions, or to make a rational evaluation of the risks and benefits of alternatives to that decision. There is no mark in the box by either statement. The form had signatures but was not complete. Under the Assessment tab, a document entitled, Social Services Assessment and Documentation with an effective date of 7/2/24 was reviewed. On page 3, Item #5 read, Resident Rights/Healthcare Decision Making/Advanced Directives a. Information Provided with regard to resident rights, yes. b. Advanced Directives (e.g. Living Will, Healthcare Power of Attorney, or Healthcare Proxy) in place? no. c. Additional conversation regarding advanced planning provided? no. d. Opportunity to complete advance directives offered? no e. Advance directive educational materials, including state form provided? no f. Separate Healthcare order (POST- physician order for scope of treatment, POLST- physician order for life sustaining treatment, MOLST- medical order for life sustaining treatment, etc.) completed? no. This surveyor was unable to locate any Advanced Directives in the clinical record. The care plan for resident # 44 was reviewed. There was a focus that read, Resident/Patient has an established advanced directive DO NOT RESUSCITATE (DNR). There is no mention of a Living Will, Power of Attorney or other form of advance directives being discussed. This surveyor requested and received the policy entitled, Health Care Decision Making with a review date of 1/8/24. The policy read in part, It is the right of all patients/residents (herein after patient) to participate in their own health care decision-making, including the right to decide whether they wish to request, accept, refuse, or discontinue treatment, and to formulate or not formulate an advance directive. Centers: -Inform and provide written information to all patients concerning the right to accept or refuse medical or surgical treatment and, at the patient's option, formulate and advance directive; -Provide a written description of the Center's policies to implement advance directives and applicable state law;. Under the heading definitions, the document read in part, Advanced Care Planning: An ongoing process of communication between patients and their healthcare decision makers to understand, reflect on, discuss, and plan for future healthcare decisions for a time when patients are not able to make their own healthcare decisions. Advance care planning includes two key parts: 1. Face to face conversations with physician or other healthcare professionals and patients and their health care decision makers to discuss advance directive treatment decisions with or without completing relevant legal forms; and 2. Documenting treatment or wishes preferences. On 8/21/24 at 3:30 PM the survey team met with the Administrator, Director of Nursing and the Regional Nurse Consultant. These concerns were reviewed at that time. No further information was provided to the survey team prior to the exit conference. 34307 3. For Resident #39 the facility staff failed to ensure the resident had the opportunity to develop an advance directive. Resident #39's face sheet listed diagnoses which included but not limited to myeloid leukemia, polyosteoarthritis, and depression. Resident #39's face sheet indicated that the resident has a code status of do not resuscitate (DNR). Resident #39's most recent minimum data set with an assessment reference date of 06/13/24 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #39's comprehensive care plan was reviewed and contains a plan for Resident/Patient has an established advanced directive, DNR. Resident #39's clinical record was reviewed and contained a Social Services Assessment and Documentation dated 12/19/23 which read in part, 5. Residents Rights/Healthcare Decision Making/Advance Directives b. Advance Directive (e.g. Living Will, Healthcare Power of Attorney, Healthcare Proxy) in place? no. c. Additional conversation regarding advance care planning provided: no. d. Opportunity to complete advance directive offered: no. e. Advance directive educational materials, including state form, provided: no. Resident #39's clinical record contained a Virginia Department of Health Durable Do Not Resuscitate form signed by the resident. Surveyor could not locate any information related to an advance directive. Surveyor requested from the director of nursing (DON), information pertaining to Resident #39's advance directive. DON stated they did not have any information. Surveyor requested and was provided with a facility document entitled Health Care Decision Making which read in part, It is the right of all patients/residents (hereinafter patient) to participate in their own health care decision-making, including the right to decide whether they wish to request, accept, refuse, or discontinue treatment, and to formulate or not formulate an advance directive. Centers must: Inform and provide written information to all patients concerning the right to accept or refuse medical or surgical treatment and, at the patient's option, formulate an advance directive; Provide a written description of the Center's policies to implement advance directives and applicable state law; Approach a capable patient who does not have an advance directive upon admission; the patient will be approached by the Social Worker or another designated staff person on admission, quarterly, and with change in condition to discuss whether he/she wishes to consider developing an advance directive .Advance Directive: Written instruction, such as a living will or durable power of attorney for health care, recognized under state law relating to the provision of health care when the patient is incapacitated. Advance directives can be either Instructive or Proxy Directives and are activated in accordance with state requirements .Practice Standards 1.2 If the patient does not have an advance directive: 1.2.1 Inform the patient/patient representative of their rights under state law regarding health care decision making, including the right to prepare advance directive. 1.2.2 Ask whether the patient wishes to formulate an advance directive. 1.2.3 Provide advance directive information. 1.2.4 Document that information has been provided to the patient/patient representative. The concern of not ensuring Resident #39 had the opportunity to formulate an advance directive was discussed with the administrator, director of nursing, and regional nurse consultant on 08/21/24 at 3:30 pm. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review the facility staff failed to ensure 1 of 22 residents was free from significant medication errors. The findings included: For Resident #9 the facility staff failed to administer the medication, Meropenem per the physician's orders. Meropenem is an antibiotic used to treat bacterial infections. Resident #9's face sheet listed diagnoses which included but not limited to sepsis, severe sepsis with septic shock, necrotizing fasciitis, methicillin resistant staphylococcus aureus (MRSA), extended spectrum beta lactamase (ESBL) resistance, and pseudomonas. Resident #9's most recent minimum data set with an assessment reference date of 08/08/24 assigned the resident brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #9's comprehensive care plan was reviewed and contained a plan for Patient has a suspected/actual infection and is at risk for sepsis, has history of or risk factors for sepsis related to Septic Left Shoulder or has actual sepsis, ESBL, MRSA, Pseudomonas, Necrotizing Fasciitis. Interventions for this care plan include Administer medications as ordered. Resident #9's clinical record was reviewed and contained a physician's order summary which read in part, Meropenem Solution Reconstituted 1 GM. Use 1 gram intravenously every 8 hours for septic L(left) shoulder for 28 days. Resident #9's electronic medication administration record (eMAR) for the month of August 2024 was reviewed and contained an entry as above. This entry was not initialed as being administered on 08/12/24 at 6 am. Surveyor spoke with the director of nursing on 08/20/24 at 4:10 pm regarding Resident #9's meropenem. Looking at the blank on the eMAR, DON stated, It looks like it wasn't given. Maybe they didn't have it to give and should have written a hold order. On 08/21/24 at 8:55 am, DON stated the surveyor that the nurse working night shift on 08/11/24 had tested positive for COVID at 5 am on 08/12/24. DON stated another nurse came in to relieve night shift nurse, but didn't know if the Meropenem had been administered, so they didn't give it. Surveyor requested and was provided with a facility policy entitled Medication Administration General Guidelines which read in part, 7.1 General Guidelines. Policy. Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so .1. Medications are administered in accordance with written orders of the prescriber. The concern of not ensuring Resident #9 was free of significant medication error was discussed with the administrator, DON, and regional nurse consultant on 08/21/24 at 3:30 pm. No further information was provided prior to exit.

Based on staff interview, clinical record and facility document review the facility staff failed to ensure an accurate minimum data set for 1 of 6 closed record reviews, Resident #56. The findings included: For Resident #56 the facility staff coded the minimum data set (MDS) as discharged to critical access hospital, when the resident discharged to the community. Resident #56's face sheet listed diagnoses which included but not limited to urinary tract infection, sepsis, and dementia. Resident #56's discharge MDS with an assessment reference date of 06/21/24 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Section A, subsection A 2105, Discharge Status coded the resident as being discharged to a critical access hospital. Resident #56's clinical record was reviewed and contained a Discharge Plan Documentation dated 06/20/24 which read in part, O. Discharge 1. Estimated/Scheduled discharge date and Time: 06/21/2024 4:00. A. 3. Discharge Destination: Home with family. Surveyor spoke with registered nurse (RN) #4 on 08/21/22 at 2:05 pm regarding Resident #56. RN #4 stated that resident discharged home, and the MDS was coded wrong. RN #4 stated they would modify the assessment to correct it. The concern of not ensuring an accurate MDS for Resident #56 was discussed with the administrator, director of nursing, and regional nurse consultant on 08/21/24 at 3:30 pm. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review the facility staff failed to ensure a level I preadmission screening and resident review (PASARR) was completed for 2 of 22 residents, Resident #21 and Resident #32. The findings included: 1. For Resident #21 the facility staff failed to ensure a level 1 PASARR was completed. Resident #21's face sheet listed diagnoses which included but not limited to Alzheimer's disease, dementia, and bipolar disorder. Resident #21's most recent minimum data set with an assessment reference date of 06/18/24 assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #21's clinical record was reviewed, and surveyor could not locate a level 1 PASARR. Surveyor requested from the director of nursing information regarding Resident #21's PASARR. On 08/21/24 at 9:35 am, the regional nurse consultant (RNC) informed the surveyor that they did not have the PASARR. RNC stated, We don't have that, we are not doing them, and we recognize that it's an issue. Surveyor requested and was provided with a facility policy entitled, Pre-admission Screening for Mental Disorder and/or Intellectual Disability Patient which read in part, 1. Social Services will coordinate and/or inform the appropriate agency to conduct the evaluation and obtain results if: 1.1 It is learned after admission that the Pre-Admission Screening and Resident Review (PASRR) was not completed or is incorrect .3. The PASRR will be placed in the patient's medical record. The concern on not completing a level 1 PASARR for Resident #21 was discussed with the administrator, director of nursing, and RNC on 08/21/24 at 3:30 pm. No further information was provided prior to exit. 47299 2. For resident # 32 the facility staff failed to ensure a Level I PASARR (preadmission screening and resident review) was completed. Resident # 32's diagnoses included but were not limited to, bipolar disorder, anxiety disorder and depression. Resident # 32's minimum data set (MDS) assessment with an assessment reference date (ARD) of 7/2/24 assigns the resident a brief interview for mental status (BIMS) score of 14 out of 15, indicating they are cognitively intact. There were no mood indicators or behaviors captured during the look back period for this assessment. A clinical record review was done. This surveyor was unable to locate a Level I PASARR in the record. On 8/19/24 at 2:09 PM this surveyor asked the Director of Nursing (DON) for a copy of the PASARR for resident # 32. On 8/21/24 at 9:34 AM this surveyor asked the Regional Nurse Consultant about the PASARR for resident # 32. They stated, We don't have it. We recognize it's a problem and we will be working on it going forward, but we don't have it now. This surveyor requested and received the policy entitled, Pre-admission Screening for Mental Disorders and/or Intellectual Disability Patients with an effective date of 6/1/01 and a revision date of 2/16/24. The policy read in part, Center Social Worker or designated staff will assure that all patients with Mental Disorders (MD) and/or Intellectual Disability (ID) receive appropriate pre-admission screenings according to federal and/or state regulations. On 8/21/24 at 3:30 PM the survey team met with the Administrator, the DON and Regional Nurse Consultant. This concern was reviewed with them at that time. No further information was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review and facility document review, the facility staff failed to develop and/or implement a comprehensive person-centered care plan for 1 of 6 closed record reviews, Resident #55. The findings included: Resident # 55's diagnoses included but were not limited to Alzheimer's, history of stroke, history of traumatic brain injury and paranoid schizophrenia. The minimum data set (MDS) assessment with an assessment reference date of 7/17/24 assigned the resident a brief interview for mental status score of 5 out of 15 indicating a moderate cognitive impairment. The MDS did not indicate that resident had any swallowing difficulty. During a review of resident # 55's clinical record, an order dated 5/27/24 was noted that read, Regular/liberalized diet Dysphasia Advanced texture for Pt requires feeding assistance. The order was put in by the Speech Therapist. A progress note 5/20/24 at 8:00 PM read in part, Resident was walking down the hallway pushing bedside table CNA (Certified Nursing Assistant) redirected resident back to her room. Resident was helped into bed for ADL (activities of daily living) to be performed, then helped back into the wheelchair. Resident started gasping for air, lips was blue, CNA yelled for south side nurse, nurse came to resident performed the Heimlich maneuver then a finger sweep got small piece of bread out of resident mouth, resident started talking trying to put more of her sandwich in her mouth then turned blue then resident was placed to floor then four back blows was performed then resident went limp rolled to her side resident coughed a large piece of bread came up. Another progress note dated 8/12/24 at 9:15 AM read, This nurse was called to residents room by LPN (name omitted). Upon entering the room the resident was lying on back on bed. This nurse saw no rise or fall of chest, No pulse palpated, No heartbeat auscultated. Confirmed residents code status was a Do Not Resuscitate by nurse (name omitted) LPN. Resident was pronounced at 9:09 am. The care plan was reviewed. An ADL focus with a created date of 5/3/24 read in part, Resident/Patient requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Recent illness, fall, hospitalization , etc.) resulting in fatigue, activity intolerance, confusion, etc.), Chronic disease/condition: Dementia TBI, CVA, Schizophrenia Limited range of motion of Left Lower leg with Casting, Mood symptoms. An intervention read, Provide cueing for safety and sequencing to maximize current level of functioning. There was a nutritional care plan. The nutritional care plan did not specify a diet, or that resident required feeding assistance. There was no mention of any limitations to the types of food resident was allowed on meal trays. On 8/20/24 at 1:24 PM this surveyor interviewed other employee # 3. They stated that they were working with resident # 55 in May when it happened the first time, but only for cognition. (Resident) didn't have a swallowing problem, it was a traumatic brain injury with behaviors. She would eat very fast and just shove everything in her mouth all at once. She needed cuing to slow down. Surveyor asked what Pt requires feeding assistance means, as that is how the order read, they stated, she needed supervision and cuing to not eat so fast. They stated that they did education with the CNA's in May but didn't have them sign anything and could not tell surveyor what CNA's had been present for education. They stated, I know I should have been more specific in my recommendation. On 8/21/24 at 11:05 AM this surveyor interviewed CNA # 5. They stated they were the one who gave resident # 55 their tray on 8/12/24. I didn't know we were supposed to feed her. Nobody knew. When asked how the staff know what residents require assistance they stated, I always check the Kardex but it wasn't on there. On 8/21/24 surveyor met with the Administrator, Regional Nurse Consultant and Director of Nursing (DON). Surveyor asked what the process was for notifying the nursing staff that a resident needs assistance with meals. The Regional Nurse Consultant stated, the order was never transcribed to the Kardex. Usually, the speech therapist will do a diet sheet and put the order in, take the diet sheet to the dietary manager who updates the tray ticket, the orders are reviewed, and the care plan updated which would reflect on the Kardex. The policy entitled, Person-Centered Care Plan with a review date of 10/24/22 read in part, 4. A comprehensive person-centered care plan must be developed for each patient and must describe the following: 4.1 Services that are to be furnished . 6.1 The care plan must be customized to each individual patient's preferences and needs. 7.2 Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals. No further information was provided to the survey team prior to the exit conference.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team for one (1) of 22 sampled residents, (Resident #5). The findings included: For Resident #5, the facility staff failed to reassess the effectiveness of the interventions and review and revise the resident's activity care plan to meet the resident's needs. Resident #5's diagnosis list indicated diagnoses that included, but were not limited to, Anxiety Disorder, Cirrhosis of Liver, Chronic Embolism and Thrombosis of Unspecified Deep Veins of Lower Extremity-Bilateral (both sides), Depression, Dependence on Renal Dialysis, End Stage Renal Disease, Heart Disease of Native Coronary Artery, Liver Transplant, Type 2 Diabetes Mellitus, Chronic Kidney Disease, and Generalized Edema. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/25/24, assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 for cognitive abilities, indicating Resident #5 was moderately impaired in cognition. On 08/18/24 at 4:30 PM resident stated activities do not offer one-to-one activities in her room. A review of the current care plan revealed a Focus of, .While in the facility, [name omitted] states that it is important that she has the opportunity to engage in daily routines that are meaningful relative to their preferences . With a Goal of, .will have opportunities to make decisions/choices related to/for self-directed involvement in meaningful activities . The Interventions read in part, .Encourage and facilitate [name omitted] activity preferences .enjoys listening to music .would like pet visits .likes to use a phone listen to music, look out the window, lay down/rest, think by myself in my bedroom .It is important for [name omitted] to go outside when the weather is good and enjoy, sitting, talking/visiting, bird watching/wildlife observing .would benefit from accommodation for physical limitations by using adaptive materials/equipment such as gerichair . The care plan revealed an initiated date of 11/16/2023 with a revision date of 08/14/2024. No changes were identified for the Focus, Goal or Interventions during this revision. Surveyor could not locate any Activity Progress notes on the clinical record for Resident #5. An annual activity assessment could not be located in the clinical record for the annual MDS review with an ARD of 6/25/24. On 08/21/24 at 11:16 AM, surveyor interviewed activity director about activity assessments and activity progress notes, and she stated she does not do activity progress notes every ninety days or with care plan reviews. She stated she looks under UDA's (user-defined assessments) for activity assessments for quarterly assessments and nothing shows up. For annual reviews she stated she asks the questions for Section F (preferences for customary routine and activities) on the MDS but does not complete an activity assessment. She stated she did not know what the facility activity policy says about ninety-day activity progress notes. Surveyor inquired what activities she offers to Resident #5, and she stated there is a CD player in Resident #5's room. This concern was discussed at the pre-exit meeting on 8/21/24 at 3:30 PM with the corporate nurse consultant, administrator, and director of nursing. Surveyor requested and received the facility policy titled Recreation Assessment, which read in part, .Patients will have a recreation assessment completed .annually .To plan care that enables the individual to reach his/her highest practicable level of physical, mental, and psychosocial functioning .To obtain information regarding the patient's preferences for their daily routine and activities .1. Complete the appropriate Recreation Comprehensive Assessments .1.3 Annual Assessment: Community Life Assessment .2. Conduct interviews within the lookback period to obtain information about preferences directly from the patient . Surveyor also requested and received a facility policy titled, Quarterly Progress Note and Care Plan Evaluation, that read in part, .Recreation progress notes will be completed as part of the Assessments and Care Plan Process .Progress may be documented in the Recreation Quarterly Progress Note and Care Plan Evaluation .To document the effectiveness of recreation interventions and to review patient's progress .To review the individual's progress and response to care plan interventions . No further information regarding this concern was presented to the survey team prior to the exit conference on 8/21/24.

Based on observation, resident interview, staff interview, clinical record review and facility document review the facility staff failed to provide activities of daily living (ADL) care for 2 of 22 residents, Resident #39 and Resident #7. The findings included: 1. For Resident #7 the facility staff failed to provide nail care. Resident #7's face sheet listed diagnoses which included but not limited to type 2 diabetes mellitus, anxiety and depression. Resident #7's most recent minimum data set with an assessment reference date of 05/30/24 assigned the resident a brief interview for mental status score of 9 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired. Section GG, functional goals and abilities, coded the resident as dependent for personal hygiene. Resident #7's comprehensive care plan was reviewed and contained a care plan for Resident requires assistance/is dependent for ADL care related to HF (heart failure), DM (diabetes mellitus), resp. (respiratory) failure. Interventions for this care plan include Provide resident/patient extensive assist of 1 for personal hygiene (grooming). Surveyor spoke with Resident #7 on 08/18/24 at 4:20 pm. Surveyor observed resident's nails to be long and jagged. Resident stated that they have asked for nails to be cut, but no one has cut them. Resident also stated that they have a nail that it broken into the quick. Surveyor observed fingernail on resident's left hand to be broken along the side of the nail bed. Surveyor spoke with the director of nursing (DON) regarding Resident #7's fingernails on 08/20/24, and DON stated that the facility infection preventionist was checking/trimming fingernails, and that Resident #7's nails have been cut. Surveyor spoke with Resident #7 on 08/21/24 at 9:15 am. Resident stated their nails have been cut and showed surveyor. Surveyor requested and was provided with a facility policy entitled Activities of Daily Living which read in part, 4.2 A patient who is unable to carry out ADL's will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and oral hygiene. The concern of not providing nail care was discussed with the administrator, DON, and regional nurse consultant on 08/21/24 at 3:30 pm. No further information was provided prior to exit. 2. For Resident #39 the facility staff failed to provide showers/bed baths to maintain good personal hygiene. Resident #39's face sheet listed diagnoses which included but not limited to myeloid leukemia, polyosteoarthritis, and depression. Resident #39's most recent minimum data set with an assessment reference date of 06/13/24 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Section GG, functional abilities and goals coded the resident as needing substantial/maximal assistance for shower/bathing. Resident #39's comprehensive care plan was reviewed and contained a care plan for Resident/Patient is at risk for decreased ability to perform ADL(s) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Limited mobility, dx of generalized weakness, polyosteoarthritis, chronic pain, depression. Surveyor spoke with Resident #39 on 08/18/24 at 2:30 pm. Resident stated that they had once went 3 weeks without a shower or bed bath and felt as if this has contributed to them having urinary tract infections. Surveyor requested daily shower sheets and bathing records for Resident #39. Review of these forms indicated that resident went from 06/01/24-06/11/24 (total of 10 days), from 06/14/24-06/27/24 (total of 13 days), 06/29/24-07/09/24 (total of 9 days), and 07/19/24-07/29/24 (total of 10 days) without a shower/bed bath. During this time, there were two refusals documented. Surveyor requested and was provided with a facility policy entitled Activities of Daily Living which read in part, 4.2 A patient who is unable to carry out ADL's will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and oral hygiene. The concern of not providing Resident #39 with showers/bed baths was discussed with the administrator, director of nursing, and regional nurse consultant on 08/21/24 at 3:30 pm. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review facility staff failed to provide treatment and services to prevent and/or heal pressure ulcers for 1 of 22 residents in the survey sample, Resident #44. The findings included: Resident # 44's diagnoses included but were not limited to pressure ulcer of the sacral region, stage IV, muscle weakness, and difficulty walking. The minimum data set (MDS) assessment with an assessment reference date (ARD) of 6/12/24 assigned the resident a brief interview for mental status (BIMS) score of 12 out of 15 which indicates a mild cognitive impairment. The MDS was coded to reflect a stage IV pressure area that was present on admission. The care plan for resident # 44 was reviewed. A problem statement that read, Documented pressure ulcer was noted. Under interventions the care plan read in part, Wound care per treatment order. There was an order dated 6/13/24 that read, Cleanse stage IV to sacrum with wound wash, pat dry, apply honey to wound bed, apply dry dressing, change daily and prn (as needed). This order was discontinued on 8/8/24 and a new order was put in as follows, Cleanse stage IV to sacrum with wound wash, pat dry, apply idsorb, calcium alginate, cover with foam, change daily and PRN. The treatment administration record (TAR) was reviewed. There were blanks or holes on the TAR for 6/18/24, 7/20/24, 8/6/24 and 8/7/24. On 8/20/24 at 1:47 PM the surveyor asked the Director of Nursing (DON) what blanks on the TAR meant for those days. They stated they would have to check into it and let me know. On 8/21/24 at 8:52 the DON stated, The wound nurse was off those days and the floor staff would have been responsible to complete the treatments but apparently did not. They have been educated, they have to do it when she is off. Surveyor clarified that the wound care was not done as ordered for the days listed above and the DON stated, To my knowledge, they weren't, but the wound is improving. On 8/21/24 at 3:30 PM the survey team met with the DON, Administrator and Regional Nurse Consultant. This concern was discussed at that time. No further information was provided to the survey team prior to the exit conference.

Based on observation, resident interview, staff interview, clinical record review, and facility document review the facility staff failed to provide adequate respiratory care for 1 of 22 residents in the survey sample, (Resident #63). The findings include: For Resident #63 the facility staff failed to label and date each component of the oxygen extension tubing and failed to provide a new pre-filled humidifier bottle for resident upon utilization of the oxygen concentrator. Resident #63's diagnosis list indicated diagnoses that included, but were not limited to, Streptococcal Arthritis to Right Knee, Sepsis, UTI (urinary tract infection), Acute Kidney Failure, Hypertensive Chronic Kidney Disease-Stage 4, Peripheral Vascular Disease, Atrial Fibrillation, and Osteoarthritis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of, 8/19/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating Resident #63 was cognitively intact. On 8/18/24 at 3:45 PM, surveyor interviewed Resident #63 and observed resident to be on oxygen via nasal cannula. Resident stated she was on 2 (two) liters of oxygen. Surveyor observed the oxygen concentrator to be set at 2 liters and noted the humidification bottle was empty and dated 6/10/24. Surveyor observed the oxygen extension tubing to not be labeled or dated. A review of the medical providers orders included an order dated 8/13/24 which read in part, .Oxygen at 2 L/min (liters per minute) via Nasal Cannula, continuously. Every day and night shift . An additional order dated 8/13/24, read in part, Oxygen tubing .Label each component with date and initials . On 8/18/24 at 3:55 PM, surveyor requested licensed practical nurse #4 (LPN#4) accompany her to resident's room and asked her to look at the oxygen humidification bottle. LPN#4 stated the bottle was dated 6/10/24 and she agreed no water was observed to be in the humidification bottle. Surveyor asked LPN#4 what the date was on the extension tubing and she stated there was no date. On 8/19/24 at 9:45 AM, surveyor and director of nursing (DON) entered Resident #63's room and surveyor informed the DON of the observation of the humidification bottle being dated 6/10/24 yesterday and about the extension tubing having no label or date. The DON agreed and stated, absolutely the resident should have received a new humidification bottle upon admission and that resident was admitted late in the evening and staff must have grabbed a concentrator that was not in use. This concern was discussed at the end of day meetings with the corporate nurse consultant, administrator, and director of nursing on 8/19/2024 at 4:30 PM, 8/20/24 at 4:19 PM, and again at the pre-exit meeting on 8/21/24 at 3:30 PM. Surveyor requested and received a facility policy titled, Procedure: Oxygen: Concentrator, that read in part, .1. Verify Order .2. Gather supplies .2.4 Pre-filled humidifier bottle and adapter as needed .9. Label, date and attach pre-filled humidifier bottle .13. After a concentrator is discontinued, place the equipment in the soiled utility room. 13.1 Disinfect the concentrator .13.3 Place in the clean utility room for new set-up .14. Document .14.1 Date and time oxygen started . No further information regarding this concern was presented to the survey team prior to the exit conference on 8/21/24.

Based on observation, staff interview, facility document review and during a medication pass and pour observation the facility staff failed to ensure medications were available for administration for 1 of 22 residents, Resident #43. The findings included: For Resident #43 the facility staff failed to ensure the medication Diltiazem was available for administration. Resident #43's face sheet listed diagnoses which included but not limited to hypertension, congestive heart failure and atrial fibrillation. Resident #43's most recent minimum data set with an assessment reference date of 08/13/24 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #43's comprehensive care plan was reviewed and contained a care plan for Resident exhibits or is at risk for cardiovascular symptoms or complications related to hypertension, A FIb (atrial fibrillation), CHF (congestive heart failure). Interventions for this care plan included Administer medications as ordered . On 08/20/24 at 8:15 am, surveyor observed licensed practical nurse (LPN) #1 during a medication pass and pour. LPN #1 prepared Resident #43's medications but stated to surveyor that the Idolize was not in the medication cart, and they would have to pull it from the Cubex (emergency medication supply). After administering resident's medications, LPN #1 went to the medication room the pull the Diltiazem, but it was not available in the Cubex. LPN #1 then stated to surveyor that they would have to call the pharmacy to get a stat order. Surveyor told LPN #1 to let them know when the medication arrived from the pharmacy. On 08/20/24 at 9:30 am, LPN #1 informed surveyor that medication would not arrive from pharmacy in time to administer the medication, and they had obtained an order from the physician to hold the medication for one dose. Resident #43's medications were reconciled with the clinical record on 08/20/24. Resident #43's clinical record contained a physician's order summary which read in part, Diltiazem HCl Beads Oral Capsule Extended Release 24 Hour 240 mg orally one time a day for HTN (hypertension). Resident #43's clinical record contained a nurse's progress note which read in part, 08/20/2024 9:05:00 New order received and noted per . (name omitted) to hold Diltiazem 240 mg x 1 dose pharmacy to stat dose . Surveyor requested and was provided with a facility policy entitled Medication Shortages which read in part, The facility nurse must make every effort to ensure that a medication ordered for the resident is available to meet their needs. The concern of not having Resident #43's medication available for administration was discussed with the administrator, director of nursing, and regional nurse consultant on 08/21/24 at 3:30 pm. No further information provided prior to exit.

Based on observation, staff interview, and facility document review, the facility staff failed to appropriately store, prepare and/or serve resident food items. The findings included: On 8/18/24 at 2:12 PM during the initial tour of the dietary department, this surveyor and other employee # 4 entered the walk-in cooler. Employee # 4 had identified themselves as a cook/aide and stated, I'm second in command. They indicated they were in charge when the dietary manager is off. A plastic jug approximately 1/4 full, labeled peeled garlic was noted on the shelf. There were three dates written on the lid as follows, OP 3/20/24 underneath that 3/15/24 and underneath that was a date of 5/20, but the year was not legible, it had been smeared. Surveyor asked employee # 4 what each date means. They stated, This is the day it was opened pointing to the OP 3/20/24 date, and this would be the date that it came in because it's earlier pointing to the 3/15/24 date. When asked about the 5/20 date, they stated, I think that is 5/20/24. I think I need to throw it away. When surveyor asked what the third date is for, they stated, That's the date we should use it by or throw it away. I'm going to throw it away. The policy entitled, Refrigerated/Frozen Storage with an effective date of 5/1/23 was reviewed and read in part, all foods are labeled with the name of the product and the date received and use by date once opened. Manufacturer use by dates are used until opened. On 8/20/24 at 2:46 PM this surveyor checked the resident refrigerator on the North wing. There was a 6-ounce container of vanilla yogurt noted. On the foil lid was written, E.T. and a date of 7/31/24. There was a factory stamp with an expiration date of 8/14/24 noted on the container. The Dietary Manager was notified, and the yogurt was discarded. The policy entitled, Food brought in for Patients/Residents with an effective date of 11/28/17 was reviewed. Under the heading, Storing Food Brought in that Requires Refrigeration the policy read in, Food will be held in refrigerator for three (3) days following date on label and will be discarded by staff upon notification to patient/resident. The survey team met with the Administrator, Director of Nursing and Regional Nurse Consultant on 8/21/24 at 3:30 PM. This concern was discussed at that time. No further information was provided to the survey team before the exit conference

Based on staff interview, clinical record review and facility document review, the facility staff failed to ensure 1 of 22 residents was free from unnecessary psychotropic medications, Resident # 43. The findings included: The facility staff failed to monitor resident # 43 for behaviors or side effects related to psychotropic medications. Resident # 43's diagnoses included but were not limited to unspecified dementia without behavior disturbance, generalized anxiety disorder, major depressive disorder, insomnia and chronic pain syndrome. The minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/13/24 assigned the resident a brief interview for mental status (BIMS) score of 15 indicating they were cognitively intact. The MDS indicated the resident admitted to the presence of several mood indicators in the look back period. Resident # 43 reported little interest or pleasure in doing things, feeling down, depressed or hopeless, feeling tired or having little energy, and feeling bad about themselves. The medication administration record (MAR) was reviewed. Resident # 43 was noted to be prescribed Clonazepam 0.5 mg three times daily for anxiety, Doxepin 25 mg daily for depression, Duloxetine 60 mg daily for generalized anxiety disorder. Resident had been ordered the antipsychotic Seroquel up until it was discontinued on 8/5/24. There were no orders located for behavior monitoring or side effect monitoring related to any of these psychotropic medications in the clinical record for the month of August 2024. On 8/21/24 at approximately 3:30 PM the survey team met with the Administrator, Director of Nursing (DON) and the Regional Nurse Consultant. This concern was discussed. The DON provided the MARs for May, June and July which revealed resident was being monitored for side effects up until July 22, 2024 when the order was discontinued by the previous DON. I don't know why the order was discontinued. Review of the MAR for May, June and July did not reveal any behavior monitoring for those months. No further information was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review and facility document review the facility staff failed to ensure 2 of 22 residents were free from unnecessary medications, Resident #11 and Resident #29. The finding included: 1. For Resident #11 the facility staff administered insulin outside the physician ordered parameters. Resident #11's face sheet listed diagnoses which included but not limited to type 2 diabetes mellitus, anxiety and depression. Resident #11's most recent minimum data set with an assessment reference date of 06/28/24 as of signed the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #11's comprehensive care plan was reviewed and contained a plan for The resident has a diagnosis of diabetes with potential for hypo/hyperglycemia. Interventions for this care plan include Access and record blood glucose levels as ordered and SS (sliding scale) insulin per MD orders and Administer insulin per MD orders. Resident #11's clinical record was reviewed and contained a physician's order summary which read in part, Humalog KwikPen Subcutaneous Pen-Injector (insulin lispro). Inject 15 unit subcutaneously before meals for DM (diabetes mellitus). Hold for glucose under 150 and Levemir Solution (Insulin Detemir). Inject 37 unit subcutaneously one time a day for diabetes. HOLD IF BLOOD SUGAR IS < = (less than or equal to) 125. Resident #11's electronic medication administration record for the months of July and August were reviewed and contained entries as above. The entry for Humalog was initialed as administered on 07/08/24 at 11:30 am with a blood sugar of 132 and 08/18/24 at 6:30 am with a blood sugar of 115. The entry for Levemir was initialed as administered on 07/02/24 at 9 pm with a blood sugar of 114. Surveyor requested and was provided with a facility policy entitled Medication Administration General Guidelines which read in part, 7.1 General Guidelines. Policy. Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so .1. Medications are administered in accordance with written orders of the prescriber. The concern of not ensuring Resident #11 was free from unnecessary medications was discussed with the administrator, director of nursing, and regional nurse consultant on 08/21/24 at 3:30 pm. No further information was provided prior to exit. 49622 2. For Resident #29 the facility failed to ensure Resident #29 was free of an unnecessary medication, Novolin. (Novolin is a medication used to treat diabetes.) Resident #29's diagnosis list indicated diagnoses that included, but were not limited to, Lung Cancer, Type 2 Diabetes Mellitus, Atrial Fibrillation, Fibromyalgia, Anxiety Disorder, Depression, and Chronic Kidney Disease-Stage 2. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/14/24, assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating Resident #29 was cognitively intact. Resident #29's clinical record included a Nursing Report, that read in part, Includes the following Classifications: MRR (medication regimen review) For Recommendations Created Between 7/25/2024 And 7/25/2024 Includes Routings for: Nursing, IDT (interdisciplinary team) .Consultant Pharmacist .The resident has an order for NovoLIN R (regular) Injection Solution 100 UNIT/ML (milliliters) (Insulin Regular (Human)) Inject 22 (twenty-two) unit subcutaneously (under the skin) before meals for IDDM (insulin-dependent diabetes mellitus) with Hyperglycemia hold if less than 160 that was not administered according to the parameters .Please review the order with nursing and educate the importance of following charting/documentation as per ordered . An active medical provider order dated 5/14/24 read in part, .NovoLIN R Injection Solution 100 UNIT/ML .Inject 22 unit subcutaneously before meals for IDDM with Hyperglycemia (high blood sugar) hold if (blood sugar) less than 160 . A review of the July 2024 MAR (medication administration record) revealed Resident #29 received the medication, Novolin, on the following dates with BS (blood sugar) documented as follows: 7/9/24 with a documented BS of 122 7/18/24 with a documented BS of 131 7/23/24 with a documented BS of 135 7/25/24 with a documented BS of 154 7/31/24 with a documented BS of 154. A review of the August 2024 MAR revealed Resident #29 received the medication, Novolin, on the following date with BS documented as follows: 8/7/24 with a documented BS of 153. On 8/20/24 at 2:48 PM, this surveyor and the director of nursing reviewed the July 2024 MAR and the director of nursing stated she would check into the medication administration. She returned to the surveyor and stated it looks like they did give the medication outside of parameters. This concern was discussed at the pre-exit meeting on 8/21/24 at 3:30 PM with the corporate nurse consultant, administrator and director of nursing. Surveyor requested and received a facility policy titled, Medication Administration, that read in part, .Medications are administered as prescribed .Medication Preparation .3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR .if there is any other reason to question the dosage or directions, the prescriber's orders are checked for the correct dosage schedule .Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber . No further information regarding this concern was presented to the survey team prior to the exit conference on 8/21/24.

Based on staff interview, clinical record review and facility document review the facility staff failed to provide basic life support, including cardiopulmonary resuscitation to one of 57, residents, Resident #2. The findings included: For Resident #2, an agency-contracted staff failed to check code status and failed to initiate basic life support, including cardiopulmonary resuscitation for Resident #2. Resident #2 expired at the facility. Resident #2's face sheet listed diagnoses which included but not limited to acute respiratory failure, chronic obstructive pulmonary disease, chronic kidney disease with heart failure, and diabetes mellitus-type II. Resident #2's most recent minimum data set with an assessment reference date of [DATE] assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident was severely cognitively impaired. Resident #2's clinical record was reviewed and contained a physician's order summary which read in part, Full code. Resident #2's clinical record contained a Virginia Physician's Orders for Scope of Treatment form dated [DATE], which read in part A. Cardiopulmonary Resuscitation (CPR): Person has no pulse and is not breathing. [x] Attempt Resuscitation. [] Do Not Attempt Resuscitation (DDNR/DNR/No CPR). The box for attempt resuscitation was marked on this form. Resident #2's clinical record contained nurse's progress notes dated [DATE], which read in part [DATE] 06:30 Resident unresponsive, no respirations or lung sounds, . [name omitted] RN, DON [registered nurse, director of nursing] to be notified for further instructions-signed by licensed practical nurse (LPN) #3, [DATE] 07:02 Notified . [name omitted] RN, DON to report resident unresponsive, stated 'make a note of it and an RN will be there shortly to pronounce'-signed by LPN #3, [DATE]:40 Notified at approximately 0830 that resident has passed away. DON advised me that resident was a full code but that the nurse assigned to . [Resident #2] got confused about the resident's code status, therefore she did not initiate CPR. The resident was listed as a Full Code but there had been discussion earlier of the resident moving to an end of life comfort care status. The nurse was an agency nurse and her contract was terminated by the facility. MD was notified. Resident son was notified by me of the incident. He was understanding and advised that he felt like it would not have helped. OLC [Office of Licensure and Certification], APS [Adult Protective Services], Ombudsman and DHP [Department of Health Professions] have been notified as well-signed by administrator and [DATE] 14:28 Notified by . [name omitted] Agency nurse at approx. 0702 am via phone that resident had passed away. This nurse advised . [name omitted] to call on call provider and family. This nurse was advised by . [name omitted], resident had DNR on her chart. [name omitted], FNP [family nurse practitioner] advised this nurse via phone that resident had a full code on her chart but nurse . [name omitted] was confused about code status. This nurse called administrator to advise her that . [name omitted] the agency nurse did not start cpr. The resident was listed as a Full Code in pcc [point click care]. Previously, there had been discussion of end of life care. [name omitted], FNP was notified. Resident's son was notified by administrator of the incident. He was understanding and advised that he felt like it would not have helped. The agency nurse . [name omitted] contract terminated by the facility.-signed by DON. During an interview with the facility administrator on [DATE] at 11:40 am, the administrator stated that the resident's family had been to the facility earlier in the week to discuss the possibility of comfort care for Resident #2. Administrator stated, evidently there was some confusion, and a CNA [certified nurse's aide] told the nurse that the resident was DNR. Administrator stated that the nurse's excuse was that the computers were down, but there is a copy of each resident's code status in their paper chart located at the nurse's station. Administrator stated that nurse was an agency staff, and not a facility staff, and that her contract was terminated. Administrator stated that a 100% audit of code orders was completed, and a full plan of correction done immediately. This was provided to the surveyor for review. Surveyor spoke with the director of nursing (DON) on [DATE] at 2:20 pm and asked her to relate the events of [DATE]. DON stated, I was called at home around 7 am by . [LPN #3] and informed that Resident #2 had passed, and she needed someone to pronounce. I told her that an RN was on the way. I called the FNP to let her know that Resident #2 had passed, and she had her computer up, and informed me that Resident #2 was a full code. I then called the administrator. Once I arrived at the facility, I checked Resident #2's chart to confirm code status. She was a full code. Surveyor requested and was provided with a facility policy entitled Procedure: Cardiac and/or Respiratory Arrest. 1. Upon discovery of a patient in cardiopulmonary arrest (e.g., no apparent pulse, blood pressure or respiration, staff will immediately: 1.1 Call for assistance; 1.2 Alert the licensed nurse and CPR/automated external defibrillator (AED) certified staff. 1.3 Prepare the patient for CPR/AED while determining the presence of a Do Not Resuscitate order (DNR). 2.1 If there is no visual identification of DNR status or no DNR order on the patient's medical record: 2.1.1 CPR/AED certified staff will initiate CPR/AED application. 2.1.4 Continue CPR until one of the following occurs: 2.1.4.1 It is discovered that the patient had a DNR order; 2.1.4.2 Restoration of effective, spontaneous circulation; 2.1.4.3 Care is transferred to a team providing advanced life support . Facility administrator provided the surveyor with a copy of the facility's On-Site Orientation Checklist for agency nurses. This checklist included location of code status and orders, and center process for codes. The administrator also provided an LPN/LVN Skills Checklist for LPN #3 that the nursing agency provided to the facility. This form indicated that LPN #3 was able to perform CPR independently. This surveyor reviewed the plan of correction provided by the facility administrator. Plan of correction reads as follows: Advanced Directives Post Non Compliance Plan of Correction [DATE] Corrective Action: 1. The agency nurse was asked to leave the facility. 2. The MD and RP (responsible party) were notified of the incident. 3. All code status orders will be reviewed and updated to reflect the current wishes. 4. All resident care plans will have their advanced directive care plan updated to reflect the most current status. Completed on [DATE]. Identification of Deficient Practice: All residents in the facility are at risk. A 100% audit will be completed for all residents to ensure that all residents have been offered the ability to complete an advanced directive. All negative findings will be corrected immediately, and their orders will be updated as well as their care plan. Completed on [DATE]. Systemic Changes: The facility policy and procedure on Advanced Directives has been updated and no changes are warranted at this time. All licensed staff will be in-serviced on facilities P&P for Advanced Directives, immediately, but no later than prior to the start of their next shift. Completed on [DATE]. Monitoring: Social Services is responsible for maintaining compliance, all code status orders will be reviewed upon admission and quarterly for updates. Completed on [DATE] and on-going. Date of Completion: [DATE] In-services will continue until all staff are complete. Completed on ,d+[DATE] 23. Surveyor reviewed credible evidence and confirmed that each item has been completed and on-going monitoring done. Surveyor visualized each resident's code status in the paper charts located at each nurse's station. Interviews with nursing staff conducted on [DATE] confirmed that staff are knowledgeable on what to do in the event of resident being found unresponsive, and where to locate code status for each resident. The concern of an agency staff not providing basic life support to a resident was discussed with the administrator and DON on [DATE] at 10:30 am. No further information was provided prior to exit. This is a past non-compliance deficiency.

Based on observation, staff interview, resident interview, family interview, clinical record review, facility document review, the facility staff failed to provide wound management as evidenced by the absence of assessments, monitoring, and/or treatment for of 5 out 33 residents. This resulted in wound infections and/or wound deterioration for Resident #10, Resident #4, Resident #42, Resident #36, and Resident #149. The facility also failed to implement provider orders at the time they were ordered for 1 of 33 residents reviewed, Resident #199. On 3/15/23 at 3:50 PM, the surveyors notified the facility of the Immediate Jeopardy determination, Level IV Pattern. The facility staff implemented an abatement plan that was verified by the survey team through additional observations, interviews, and document reviews. The facility staff was notified that the Immediate Jeopardy was removed on 3/17/23 at 4:09 PM. The findings included: 1. For Resident #10 the facility staff failed to provide wound management resulting in a wound infection. Resident #10's face sheet listed diagnoses which included but not limited to anemia, chronic obstructive pulmonary disease, dementia, basal cell carcinoma of skin, and hypertension. Resident #10's most recent minimum data set with an assessment reference date of 02/07/23 coded the resident as 6 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Section M, skin conditions, subsection M1040, Other Ulcers, Wounds, and Skin Problems coded the resident as having open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion). Resident #10's comprehensive care plan was reviewed and contained a care plan for Resident at risk for skin breakdown r/t (related to) decreased mobility, incontinence, fragility of skin, oxygen use . Interventions for this care plan include Observe skin condition daily with ADL's (activities of daily living) and report abnormalities, provide wound treatment as ordered, and weekly skin checks by license nurse. Resident #10's clinical record was reviewed and contained a physician's order summary for the month of March 2023, which read in part Cleanse growth the center of back with Dakin's solution, pat dry, apply Dakin's wet to dry dressing to wound bed and secure with dry dressing, change BID (twice a day) and PRN (as needed) every day shift for wound care and Cleanse scalp wound (exposed skull) with soap and water, cleanse periwound with Dakin's solution, pat dry, apply TAO to irritated periwound and cover entire scalp wound with dry dressing BID and PRN every day and night shift for wound care. Resident #10's treatment administration record (TAR) for the month of March 2023 was reviewed and contained entries as above. The entry for Cleanse growth to center of back . only had one section for initials on the TAR. These entries were initialed as being completed as ordered. This surveyor observed Resident #10 on 03/12/23 at 3:30 pm. Resident was resting in bed; no dressing was observed in place to scalp wound. Exposed skull was observed by surveyor. Resident #10's clinical record contained a Physician's Telephone Order form dated 02/06/23, which read in part Keflex 500 mg TID (three times a day)-wound infection top of head x 10 days. This surveyor, along with licensed practical nurse (LPN) #1 and certified nurse's aide (CNA) #1 observed Resident #10 on 03/13/23 at 1:00 pm. Surveyor observed dressing in place to resident's scalp at this time. CNA #1 and LPN #1 rolled resident onto side, and surveyor observed dressing in place to lesion on resident's upper back. Surveyor asked LPN #1 if dressing had a date on it, and LPN #1 first stated that it did not, then stated Oh, yeah, it does. Surveyor asked LPN #1 what the date on the dressing was, and LPN #1 stated March 9th. Surveyor requested to see the dressing once it was removed and observed the date on the dressing to read 03/09/23 7a-7p along with initials. When LPN #1 removed the dressing from Resident #10's wound, surveyor observed moderate amount of drainage both on the dressing and wound bed. Dressing had a dark brown ring, with drainage in the center of the ringed area. Surveyor asked LPN #1 to describe the wound, and LPN #1 stated greenish-brown, foul-smelling discharge. LPN #1 stated to the surveyor that, according to the date on the dressing, that it appeared that 7 dressing changes have been missed to resident's back lesion. Surveyor asked LPN #1 if lesion had worsened since they last observed it, and LPN #1 stated, It definitely has more drainage. LPN #1 removed the dressing from resident's scalp and stated to surveyor that scalp wound was not supposed to have a dressing on it. This Surveyor observed scant amount of greenish discharge on scalp dressing. LPN #1 later informed surveyor that Resident #10 should have a dressing on scalp lesion. Review of Resident #10's clinical record revealed that resident was placed on oral antibiotic for wound infection starting 03/14/23. This surveyor spoke with the assistant director of nursing (ADON) on 03/14/23 at 10:50 am regarding Resident #10's wound care. Surveyor asked ADON what their expectations were for wound care, and ADON stated they would expect the nurses to follow the physician's orders for each resident receiving wound care. This surveyor reviewed Resident #10's clinical record and could not locate any wound assessments, including measurements, description of wounds, or skin assessments. The survey team spoke with the director of nursing (DON) on 03/15/23 at 10:00 am regarding wound management. DON stated they measure wounds weekly, and that information is located in their office. DON stated that weekly skin assessments were to be performed on all residents and recorded in clinical record. This Surveyor reviewed Resident #10's clinical record and could not locate any skin assessments. The survey team spoke with family nurse practitioner (FNP) on 03/20/23 at 1:25 pm regarding wound management. Surveyor asked FNP if missed assessments and dressing changes not being done as ordered could contribute to wound infections and FNP stated that it could. The concern of not providing wound management was discussed with the administrator, DON, and Market Clinical Lead on 03/20/23 at 3:00 pm. No further information was provided prior to exit. 2. For Resident #4 the facility staff failed to provide wound management which resulted in the resident being treated for a wound infection. Resident #4 was admitted the facility on 02/13/21 and readmitted on [DATE]. Resident #4's face sheet listed diagnoses which included but not limited to multiple sclerosis, depression, anxiety, and contractures of muscles. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 02/06/23 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Section M, skin conditions, coded the resident as having one stage 1 pressure ulcer that was present upon admission. Section M, subsection M1040, other ulcers, wounds and skin problems coded the resident as none of the above present. This subsection includes surgical wounds. Section M of Resident #4's admission MDS with an ARD of 02/20/21 coded the resident as having one stage III pressure ulcer present upon admission, one stage IV pressure ulcer present upon admission and one unstageable pressure ulcer present upon admission. Resident #4's comprehensive care plan was reviewed and contained a care plan for Resident at nutrition risk r/t (related to) . Wounds: Surgical PI Open wound to Rt. (right) hip skin fold, healing. PI Rt. Heel . and . is at risk for continuing impaired skin integrity related to diagnosis of MS (multiple sclerosis), impaired mobility . Type: Pressure ulcers. Interventions for both care plans included Provide wound treatment as ordered and Labs per orders. This Surveyor spoke with Resident #4 on 03/12/23 at 3:10 pm. Resident stated they have wounds to right hip and heel and that wound care is supposed to be done twice a day, but there are some nurses that don't do it. Resident #4 stated, I'm lucky if they do it once a day. Resident #4 was concerned that wound care was not being done as ordered. Surveyor spoke with Resident #4 on 03/13/23 at 11:30 am, and asked resident if their wound care had been completed, and resident stated, the dressing was changed yesterday (03/12/23) around lunch time and hasn't been changed since. This Surveyor, along with licensed practical nurse (LPN) #1 and certified nurse's aide (CNA) #1 observed Resident #4's dressing on R hip wound on 03/13/23 at 11:45 am. When CNA #1 rolled resident over, and dressing became visible, CNA #1 stated to LPN #1, it (dressing) don't have a date on it. Surveyor asked LPN #1 if dressing should be dated, and LPN #1 stated that it should be. Surveyor observed that dressing was not dated. LPN #1 removed the dressing, and stated, well, that tells me it's not been changed. Surveyor asked LPN #1 how they could tell dressing had not been changed, and LPN #1 stated by the color of the gauze and the amount of drainage on the dressing. Resident #4's clinical record was reviewed and contained a physician's order summary for the month of March 2023, which read in part Cleanse post-surgical wound to right hip with Dakin's solution, pat dry, apply collagen powder to wound bed, cover with calcium alginate and secure with dry dressing BID (twice a day) every day and night shift for Wound Right Hip Order Date 02/28/2023 Start Date 02/28/2023 and Wound(s): Monitor site(s) daily for status of surrounding tissue and wound pain. Monitor for status of dressing(s), If applicable, Additional Documentation in NN (nurse's notes) as needed every day shift. Order Date 03/12/2023. Start Date 03/13/2023. Resident #4's TAR for the month of March 2023 was reviewed and contained entries which read in part, Cleanse post-surgical wound to right hip with Dakin's solution, pat dry, apply collagen powder to wound bed, cover with calcium alginate and secure with dry dressing BID (twice a day) every day and night shift for Wound Right Hip. Order Date 02/28/2023. Start Date 02/28/2023, Cleanse are to right heel with IHWC. Apply betadine, let dry and apply skin prep every night shift for wound care and Wound(s): Monitor site(s) daily for status of surrounding tissue and wound pain. Monitor for status of dressing(s), If applicable, Additional Documentation in NN (nurse's notes) as needed every day shift. Order Date 03/12/2023. Start Date 03/13/2023. These entries were initialed as having been completed for all ordered times. This Surveyor reviewed Resident #4's clinical record from January to present for documentation of wound treatment provided to the right hip, right heel, and healing progress of the wounds. Resident #4's clinical record contained an Acute Care summary form dated 01/25/23, which read in part Chief complaint/Nature of Presenting Problem: Follow-up wounds. Location: Right hip fold. Duration: Chronic. Modifying Factors: Culture done and results pending. Quality: Stable. Review of Systems Skin: Open wound to right hip skin fold. Physical Exam Skin: Wound to right hip skin fold is tender to touch. There is yellow/white drainage to wound, and a foul odor is noted. Optifoam patch in place. Labs/Radiology/Tests. Labs: Wound culture has been collected and results pending per nursing. No results received today. Diagnosis, Assessment and Plan: .Open wound of right hip. Continue current wound treatment. This was signed by the family nurse practitioner (FNP). Resident #4's clinical record contained a physician's telephone order form dated 01/30/23, which read in part (1) Culture R (right) hip wound-redness, drainage, foul odor (2) After culture, start Bactrim DS-1 tab PO (by mouth BID (twice daily) x 10 days wound infection. This order was signed by the FNP. Resident #4's clinical record contained a laboratory report dated 02/10/23 for wound culture which indicated the presence of Proteus mirabilis, a gram-negative bacterium. Resident #4's treatment administration record (TAR) for the month of January 2023 was reviewed and contained and entry which read in part, Cleanse right hip with IHWC (wound cleanser), pat dry, apply Maxsorb, and place Optifoam on wound every night shift for wound healing. This entry had a start date of 01/30/23 listed and was initialed as being completed. There were no previous wound care orders related to right hip noted on this TAR. The TAR for January also contained entries which read in part Cleanse area to right heels with IHWC. Apply 4 x 4 boarder (sic) gauze or optifoam) gauze or optifoam for cushion. every day shift Mon, Wed, Fri, Sun for wound care-start date-01/04/2023, -D/C (discontinue) date-02/02/2023, Cleanse area to right heel with IHWC. Apply 4 x 4 boarder (sic) gauze or optifoam for cushion. every night shift for wound care-start date-01/30/2023, -D/C date-02/09/2023 and Wound(s): Monitor site(s) daily for status of surrounding tissue and wound pain. Monitor for status of dressing(s), if applicable, every day shift. The treatment to the heel wound was not initialed as completed on 01/02, 01/03, 01/06, 01/15, 01/18, and 01/23. Resident #4's TAR for the month of February was reviewed and contained entries which read in part, Cleanse right hip surgical wound with Dakin's solution, pat dry. Apply skin prep to peri-wound. Wet-to-dry dressing using Dakin's to wound bed. Secure with dry dressing. two times a day for wound healing-Start Date-02/09/2023 2000 -D/C Date-02/27/2023 2000, not initialed as completed on 02/18/23 at 8 pm. The TAR for February did not contain any entry for wound monitoring. The TAR for February also contained entries which read in part, Cleanse area to right heel with IHWC. Apply 4 x 4 boarder (sic) gauze or optifoam for cushion. every night shift for wound care-start date-01/30/2023, -D/C date-02/09/2023 and Cleanse area to right heel with IHWC. Apply betadine, let dry and apply skin prep every night shift for wound care. This treatment was not initialed as completed on 02/18/23. Resident #4's clinical record contained a physician's telephone order form dated 02/16/23, which read in part (1) Rocephin 1 gm I.V. q (every) day (2) Repeat wound culture x 7 (3) [NAME] consult wound vac R hip. This order was signed by the physician. Resident #4's clinical record also contained a physician's order summary for the month of February 2023, which read in part Culture wound to Right hip one time only for Wound Infection for 1 day This order had a start date of 02/25/23. Surveyor could not locate results of this wound culture. This Surveyor spoke with the assistant director of nursing (ADON) on 03/17/23 at 12:50 pm regarding Resident #4's wound cultures. ADON stated the culture order on 01/30/23 was collected 3 times, and when the lab was contacted for results, they were told the lab did not have a specimen. ADON stated they could not locate results for culture ordered to be done on 02/25/23. This Surveyor spoke with medical technician (MT) at the contracted lab on 03/20/23 at 10:15 am regarding Resident #4's wound cultures. MT stated that the only wound culture orders and specimens they had received were on 01/17/23 and 02/10/23. MT stated they had received no other orders or specimens for wound cultures for Resident #4. This Surveyor spoke with FNP on 03/20/23 at 1:25 pm. Surveyor asked FNP when they expected the wound culture ordered on 01/30/23 to be done, and FNP stated they expected it to be done on the order date. FNP said when they asked about the results, couple of nurses stated they had done it and lab lost it. Surveyor asked FNP if they expected the repeat wound culture to have been done, and FNP stated they did. Surveyor asked FNP if missed assessments and dressing changes not being done as ordered could contribute to wound infections and FNP stated that it could. This Surveyor spoke with the ADON on 03/14/23 at 10:50 am regarding Resident #4's wound care. Surveyor asked ADON what their expectations were for wound care, and ADON stated they would expect the nurses to follow the physician's orders for each resident regarding wound care. Surveyor asked ADON if wound dressings should be dated, and ADON stated that they should be dated and initialed by the nurse completing the wound care. ADON later stated per director of nursing (DON), facility policy did not state that dressings needed to be dated. This Surveyor requested and was provided with a facility policy entitled Wound Dressings: Aseptic which read in part, 2. Gather supplies: 2.7 Prepared label or secondary dressing with date and initials. 27. Apply prepared label. This Survey team spoke with the director of nursing (DON) on 03/15/23 at 10:00 am regarding wound management. DON stated they measure wounds weekly, and that information is located in their office. Surveyor asked DON if dressings should be dated and initialed when changed, and DON stated that is not a part of the facility policy, but they were hoping to have that changed, as that is the expectation. Surveyor referred DON to aforementioned policy, and asked DON what apply prepared label meant, and DON stated they did not know. Surveyor asked DON if Resident #4's hip wound was pressure related and DON stated that Resident #4's hip wound was surgical rather than pressure. Surveyor asked DON what type of surgery the resident had had to the hip and DON stated, Looks to me like he/she has had a hip replacement at some point. He/She has about an 18 scar on that hip. This Surveyor reviewed Resident #4's clinical record and could not locate any wound assessments, including measurements or description of wounds. This Surveyor requested and was provided with Skin Integrity Report forms, which were contained in a notebook housed in the DON's office. The Skin Integrity Report forms for Resident #4 indicated that wound to right hip was both pressure and surgical. The form did not indicate an initial wound date and contained measurements beginning on 01/30/23 and continuing weekly until 03/08/23 that indicate the wound is decreasing in size. A second form with an initial wound date of 02/09/23, indicated a pressure area to right heel, staged as a deep tissue injury. Wound was marked as in-house acquired, with measurements beginning on 02/09/23 and continuing weekly through 03/09/23. These measurements indicate no change to wound. This Surveyor requested evidence that Resident #4's hip wound was surgical rather than pressure and was provided with a surgical consult form which read in part Appt. Date/Time 02/26/2021. Chief Complaint: Skin lesion. HPI (history of present illness): Patient has bilateral hip decubitus ulcers that are necrotic. He/She needs debridement of both. He/She also has been noted to be anemic with hemoglobin in the eight. We will admit him/her to outpatient surgery for transfer transfusion before morning debridement. Plan transfer back to nursing home after surgery. Probable wound VAC application. Patient has severe lower extremity contracture secondary to advanced MS. The concern of not providing wound management for Resident #4 was discussed with the administrator, DON, and Market Clinical Lead on 03/20/23 at 3:00 pm. No further information was provided prior to exit. 3. For Resident #42 the facility staff failed provide wound management, resulting in a wound infection. Resident #42's face sheet listed diagnoses which included but not limited to hypertensive heart disease, heart failure, chronic kidney disease, type 2 diabetes mellitus, peripheral vascular disease, and anxiety. Resident #42's most recent minimum data set with an assessment reference date of 02/04/23 assigned the resident a brief interview for mental status score of 11 out of 15 in section C, cognitive patterns. Section M, skin conditions coded the resident as having five stage II pressure ulcers that were present upon admission, and no other skin conditions. Resident #42's comprehensive care plan was reviewed and contained a care plan for Resident has actual skin breakdown related to top of right foot, right heel, left upper buttocks, left lower buttock, right buttock, coccyx, and sacrum related to decreased activity, incontinence. Interventions for this care plan included Observe skin for signs/symptoms of skin breakdown, provide wound treatment as ordered, weekly skin checks by licensed nurse, and weekly wound assessment to include measurements and description of wound. Resident's clinical record was reviewed and contained a physician's order summary for the month of March 2023, which read in part . consult for necrotic wound to R ankle. Needs to be done as soon as possible, Cleanse area to top of right foot with Dakin's solution, 25%, pat dry. Apply Santyl on nonstick pad to wound bed. Cover with dry dressing daily and prn (as needed) every day shift for wound care, Cleanse stage 3 PU (pressure ulcer) to L (left) lower buttock with Dakin's solution, pat dry, apply skin prep to periwound, apply Dakin's wet to dry to wound bed and secure with dry dressing BID (twice a day) and PRN every day and night shift for wound care, Cleanse stage 3 PU to L upper buttock with Dakin's solution, pat dry, apply skin prep to periwound, apply Dakin's wet to dry to wound bed and secure with dry dressing BID and PRN every day and night shift for wound care for 2 weeks, Cleanse stage 3 PU to R buttocks with Dakin's solution, pat dry, apply skin prep to periwound, apply Dakin's wet to dry to wound bed and secure with dry dressing BID and PRN every day and night shift for wound care for 2 weeks, Cleanse unstageable PU on coccyx with Dakin's solution, pat dry, apply skin prep to periwound, apply Dakin's wet to dry to wound bed and secure with dry dressing BID and PRN every day and night shift for wound care for 2 weeks, Cleanse unstageable PU to center sacrum with Dakin's solution, pat dry, apply skin prep to periwound, apply Dakin's wet to dry dressing to wound bed and secure with dry dressing BID and PRN every day and night shift for wound care for 10 days, Cleanse unstageable PU to R heel with Dakin's solution, pat dry, apply skin prep to periwound, apply Santyl on nonstick pad and secure with dry dressing BID and PRN every day and night shift for wound care for 14 days, and Bactrim DS oral tablet 800-160 mg (Sulfamethoxazole-Trimethoprim). Give 1 tablet by mouth one time a day for wound infection for 14 days. Resident #42's clinical record contained a Physician's Telephone Orders form dated 02/27/23, which read in part (1) DC (discontinue) Macrobid. (2) Bactrim DS 1 tab PO (by mouth) BID (twice a day) x 10 days-wound infections R ankle, foot. This order was signed by the family nurse practitioner (FNP). Resident #42's treatment administration record (TAR) for the month of March 2023 was reviewed and contained entries as above. Each of these entries had not been initialed as completed on two separate occasions. Resident #42's February 2023 TAR contained entries, which read in part Cleanse area to right heel with IHWC (wound cleanser), pat dry and apply bordered foam dressing every day shift for open area, Cleanse area to right posterior thigh with IHWC, pat dry, and apply 4 x 4 bordered foam dressing every day shift for open area, Cleanse top of right foot with IHWC, pat dry, and apply bordered foam dressing every day shift for abrasion, and Cleanse area to coccyx with IHWC, pat dry, and apply bordered foam dressing every day shift for open area. Each of these entries had not been initialed as completed on three separate occasions. This Surveyor, along with licensed practical nurse (LPN) #1 observed Resident #42's dressings to sacrum, coccyx, and buttocks on 03/13/23 at 2:30 pm. Dressing to sacrum did not have a date on it. Dressings to resident's foot, heels, and ankles all had dates and initials. LPN #1 stated they had completed wound care to these area's earlier in the day. Surveyor asked LPN #1 how they knew when the dressings to the sacral area had last been changed, and LPN #1 stated that without a date, there was no way to know when wound care was last completed. This Surveyor spoke with the assistant director of nursing (ADON) on 03/14/23 at 10:50 am regarding Resident #42's wound care. Surveyor asked ADON what their expectations were for wound care, and ADON stated they would expect the nurses to follow the physician's orders for each resident regarding wound care. Surveyor asked ADON if wound dressings should be dated, and ADON stated that they should be dated and initialed by the nurse completing the wound care. ADON later stated per DON, facility policy did not state that dressings needed to be dated. This Surveyor requested and was provided with a facility policy entitled Wound Dressings: Aseptic which read in part, 2. Gather supplies: 2.7 Prepared label or secondary dressing with date and initials. 27. Apply prepared label. The Survey team spoke with the director of nursing (DON) on 03/15/23 at 10:00 am regarding wound management. DON stated they measure wounds weekly, and that information is located in their office. Surveyor asked DON if dressings should be dated and initialed when changed, and DON stated that is not a part of the facility policy, but they were hoping to have that changed, as that is the expectation. Surveyor referred DON to aforementioned policy, and asked DON what prepared label meant, and DON stated they did not know. This Surveyor requested and was provided with Skin Integrity Report forms, which were contained in a notebook housed in the DON's office. This notebook contained six forms for Resident #42, which addressed unstageable pressure areas to right heel, right achilles, sacrum/coccyx, right buttock, left outer thigh/lower buttock and a stage II pressure areas to upper left buttock. Each of these areas were marked as present upon admission, with weekly measurements beginning on 02/01/23 and continuing through 03/14/23. These measurements indicated the right heel wound was unchanged, right achilles wound had decreased from 2.5 cm x 1.7 cm to 2.1 cm x 1.3 cm, sacram/coccyx wound had decreased in length from 2 cm to 1 cm, but increased in width from 1 cm to 2.6 cm and went from a depth of 0 to .25 cm. Right buttocks wound decreased in length from 1 cm to 0.8 cm, and increased in width from 0.5 cm to 0.6 cm, and went from a depth of 0 to 0.25 cm. Right outer thigh wound decreased in length from 2 cm to 1.4 cm, and increased in width from 1 cm to 1.5 cm, anad went from a depth of 0 to .25 cm. Left buttock wound decreased in length from 2 cm to 1.8 cm, increased in width from 1.5 cm to 1.7 cm, and went from a depth of 0 to 0.25 cm. Two surveyors, along with LPN #1 observed Resident #42's wounds on 03/14/23 at 4:45 pm. LPN #1 stated that areas to the top of resident's right foot and right ankle/lower leg were arterial rather than pressure. Resident's right heel had dark brown eschar and LPN #1 stated that area was unstageable pressure ulcer. Areas to resident's sacral area (sacrum, coccyx, buttocks) were red with slough present in wound bed. This Survey team spoke with family nurse practitioner (FNP) on 03/20/23 at 1:25 pm regarding wound management. Surveyor asked FNP if missed assessments and dressing changes not being done as ordered could contribute to wound infections and FNP stated that it could. The concern of not providing wound management was discussed with the administrator, DON, and Market Clinical Lead on 03/20/23 at 3:00 pm. No further information was provided prior to exit. 22218 4. For Resident #36, facility staff failed to provide ordered wound care to promote healing. Resident #36 was admitted to the facility with diagnoses including (by listed date of diagnosis) type 2 diabetes mellitus with diabetic polyneuropathy, peripheral vascular disease, morbid obesity, obstructive sleep apnea, muscle weakness, hypertensive heart and chronic kidney disease with heart failure, local infection of the skin and subcutaneous tissue, methicillin resistant staphylococcus aureus infection, chronic obstructive pulmonary disease with acute exacerbation, atrial fibrillation, sepsis due to escherichia coli, bacteremia. On the minimum data set assessment with assessment reference date 2/1/23, the resident scored 14/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. This surveyor interviewed the resident on 3/12/23 concerning life in the facility. Clinical record review revealed two recent hospitalization s with wound infections: 12/27/22 through 1/3/23 and 1/14 through 1/20/23. Prior to the hospitalization on [DATE], clinical record review revealed A physician order dated 11/7/22 through 1/3/23 for Cleanse area to right stump with WC/VASHE (wound cleanser). Apply xeroform, then cover with border foam each day shift Tue, Thu for wound care. The treatment was not documented as completed 12/1, 12/6, 12/8, 12/13, 12/15, and 12/22. The resident was hospitalized for sepsis and right below the knee amputation infection on 12/27. A nursing progress note dated 12/26/22 stated Note: Resident noted to have scab on LLE front lower area. Redness, swelling and pain surrounding scabbing with bleeding present. This nurse contacted Dr. with new orders: 1) Culture wound in AM 2) CBC (complete blood count) and BMP (basic metabolic panel) 3) Keflex PO BID x 7 days. The most recent prior mention of the wound was a nursing progress note dated 12/21/22: The following skin injury/wound(s) were previously identified and were evaluated as follows: Other(s): Description: diabetic ulcer to right posterior calf. Another note dated 12/21/22 - Late Entry: Note: An improving diabetic wound in-house acquired Location: Right Calf was assessed today. Prognosis: Monitor/Manage: Wound healing not achievable due to untreatable underlying condition. Resident/Responsible Party Notified: 1 The practitioner has been notified: 1. A third note dated 12/21/22 Note: A skin check was performed. The following skin injury/wound(s) were previously identified and were evaluated as follows: Pressure Area(s): Location(s): Diabetic wound to right stump. TX in place. The resident was hospitalized [DATE] through 1/3/23. Per the hospital discharge, the resident was admitted with sepsis, right BKA (below knee amputation) infection, fever, and more. The surgeon assessed the right BKA wound and determined there was no need for surgical intervention. Dressings continued per surgeon orders. On 1/3/23, the resident returned to the facility. No orders for wound care were entered in the system. Nursing documentation included no skin assessments from 1/3/23 through 1/20/23. A facility nursing progress note dated 1/14/23 documented resident flushed, vomiting, low BP and went to hospital. The resident was hospitalized again from 1/14/23 through 1/20/23. Per the hospitalist discharge summary, discharge diagnoses included ESBL proteus and Vancomycin resistant enterococcus bacteremia. The summary indicated the facility staff had been notified the resident would need Intravenous antibiotics for 13 additional days. A facility nursing note dated 1/20/23 read: Resident returned via non-emergent BLS ambulance service. Resident is awake, alert, oriented, and able to make his needs known per his usual. A double lumen PICC line is in place in right upper arm. Resident will be receiving IV Invanz and Zyvox by mouth for VRE and Proteus bacteremia. Resident's buttocks are reddened, but blanchable, and dressing over RLE (right lower extremity)/foot amputation site is CDI (clean/dry/intact). Enhanced barrier precautions are in place, and staff is aware of the need to glove and gown before providing care, and resident is aware that he needs to sanitize his hands before leaving his room, and to notify the nurse if his dressing becomes soiled or loose while he is out of his roo [TRUNCATED]

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide the necessary treatment and services to promote wound healing and prevent infection for four of 33 residents in the survey sample, Resident #37, 42, 299, 199. Resident #37 experienced harm due to the development of osteomyelitis and the subsequent invasive treatment procedures that were required. The findings include: 1. For resident #37, the facility failed to provide treatment as ordered to the resident's left heel pressure ulcer leading to osteomyelitis (inflammation of bone caused by infection). In the course of treating the infection, resident #37 received a surgical wound debridement, insertion of a peripherally inserted central catheter (PICC line) for intravenous (IV) antibiotics and two wound cultures. Each of these procedures were invasive and placed the resident at risk for further discomfort and stress. Resident #37's diagnoses included but were not limited to the following: Diabetes type 2, congestive heart failure, chronic kidney disease and difficulty walking. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 12/6/22 assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15, indicating minor cognitive impairment. Under the functional ability section of the MDS, resident was coded as being independent with ambulation, with ambulation only occurring once or twice in the lookback period. Under the pain assessment interview section of the MDS, resident reported a pain level of 7 out of 10 on a numeric scale and reported that pain interfered with sleeping and limited their day-to-day activities. On 3/13/23 at 11:30 am surveyor observed resident #37 lying in bed with left foot exposed. Surveyor noted that resident had a wound on their heel that was open with slight drainage. Resident stated that the wound had been there, a good while and that the nurse was coming to see about it. Surveyor asked if the area was painful and resident stated, oh yeah, it hurts most of the time. During the clinical record review, surveyor noted that resident #37 was admitted to the facility on [DATE]. The Nursing Documentation Assessment for 8/31/22 was reviewed. The nurse documented that the skin was assessed and there were no wounds identified. There is another section that speaks specifically to the feet and the nurse marked no to the presence of redness, maceration or breakdown on the heels. The first mention of the left heel wound was by the nurse practitioner (NP) on 9/2/22 in a progress note that stated resident had a wound to the left heel. A provider order was received on the same date, 9/02/22, to treat the left heel wound by cleansing with wound cleanser and applying a wet to dry dressing daily. According to the September 2022 treatment administration record (TAR) this treatment was not done on 9/3/22 and 9/10/22 as there were blanks for those days. The NP saw resident #37 again on 9/13/22, the progress note documented in part, wound has healed except one area of peeling skin, which should require minimal treatment. A provider order was received on 9/13/22 to change the frequency of the treatment to every Tuesday, Thursday and Saturday. The October 2022 TAR indicated that the treatment to the left heel wound was not provided 10/6/22, 10/11/22, 10/22/22, and 10/29/22. The November 2022 TAR indicated treatment was also not provided on 11/10/22, 11/15/22, 11/17/22, 11/22/22, and 11/29/22. On November 11, 2022, the NP documented in a progress note that the left heel wound was draining brown drainage and gave an order for the antibiotic Bactrim DS 800-160 mg to be given orally twice daily for 10 days. The December 2022 TAR indicated that treatments to the left heel wound were not provided on 12/1/22, 12/6/22, 12/8/22, 12/13/22, 12/15/22, 12/22/22, 12/27/22, and 12/29/22. The January 2022 TAR indicated that treatment to the wound was not provided on 1/3/23, 1/12/23, 1/17/23, and 1/19/23. On 1/6/23 a provider order was received to x-ray the left foot. The conclusion in the radiology report stated, Subtle osteolysis/erosive changes at the posterior inferior calcaneus concerning for infection/osteomyelitis. An MRI was recommended. A wound culture of the left heel wound was ordered 1/11/23 which revealed the wound was infected with methicillin resistant staphylococcus aureus (MRSA). Bactrim DS 800-160 mg twice daily for ten days was again ordered for the infection. The wound culture was repeated per provider order on 1/23/23 which was positive for the presence of infection. Surveyor was unable to locate the sensitivity report in the clinical record. On 1/30/23 the NP documented in a progress note, ulcer has worsened with foul odor and black areas on edges as well as redness. On 2/1/23 another round of the antibiotic Bactrim DS was ordered twice daily for ten days. The MRI was done 2/3/23 and the report impression was large heel wound with osteomyelitis of the posterior calcaneus. Resident #37 underwent a surgical procedure to debride the wound on 2/6/23. On 2/9/23 resident #37 had a PICC line placed, and a wound vac was applied to the left heel. On 2/13/23 the NP documented in a progress note left foot wound was originally a diabetic ulcer that healed and then developed into a pressure ulcer due to the patient's habit of laying in the bed and friction on the foot. On 2-23-23 a new provider order was received to administer the antibiotic Vancomycin HCL intravenous solution, 1.5 grams every two days for six weeks for a diagnosis of osteomyelitis of the left heel. On 3/16/23 at 12:53 PM surveyor interviewed Licensed Practical Nurse (LPN) #3 regarding resident #37 and asked what the blanks on the TAR ' s indicated. They stated, if there's a blank for those days, it means the treatment wasn't done. Surveyor reviewed with LPN #3 the missing treatments and the progression of the wound and asked them what their professional opinion was. LPN #3 stated, I think the lack of treatment caused the wound to get worse. On 3/16/23 at 2:16 PM, surveyor asked the Director of Nursing (DON) for any wound measurements for resident #37's left heel from their admission 8/31/23 to current. On 3/20/23 at 11:44 am surveyor interviewed DON regarding the lack of documentation on admission of the left foot wound. DON stated they were not employed at the facility at that time. DON stated the wound should have been captured on the admission assessment/nursing documentation per policy, and if it was not there, she cannot speak as to why. DON agreed that a wound on the heel should be considered as pressure rather than diabetic. DON also stated that resident #37 was constantly up walking on it and digging their heels in the bed and foot board, before the foot board was removed. Surveyor was provided with a policy entitled, Skin Integrity and Wound Management, with a revision date of 2/1/23, that reads in part, A comprehensive initial and ongoing nursing assessment of intrinsic an extrinsic factor that influence skin health, skin/wound impairment, and the ability of a wound to heal will be performed. The DON also provided surveyor with copies of wound assessments for resident #37's left heel from September 2022 to November of 2022, but these were labeled as being a wound to the Right heel, not the left. DON reported that they began measuring the wound in January 2023 and provided surveyor with a worksheet entitled, Skin Integrity Report. This report had measurements documented each week beginning 1/25/23. On 3/20/23 at 1:40 PM surveyor interviewed the NP, other staff member #11. Surveyor asked if they were aware of the missed treatments in the months leading up to the osteomyelitis diagnosis, NP stated, no I was not. Surveyor asked if the missed treatments might have caused the wound to deteriorate, NP stated, yes it definitely could have. The above concerns were discussed with the Administrator, Director of Nursing and Assistant Director of Nursing on 3/17/23 at 4:00 PM and again with the Administrator and administrative staff #4 on 3/20/23. No further information was provided to the survey team prior to the exit conference. 34307 2. For Resident #42 the facility staff failed to provide treatment to promote healing and prevent infection of pressure ulcers. Resident #42's face sheet listed diagnoses which included but not limited to hypertensive heart disease, heart failure, chronic kidney disease, type 2 diabetes mellitus, peripheral vascular disease, and anxiety. Resident #42's most recent minimum data set with an assessment reference date of 02/04/23 assigned the resident a brief interview for mental status score of 11 out of 15 in section C, cognitive patterns. Section M, skin conditions coded the resident as having five stage II pressure ulcers that were present upon admission, and no other skin conditions. Resident #42's comprehensive care plan was reviewed and contained a care plan for Resident has actual skin breakdown related to top of right foot, right heel, left upper buttocks, left lower buttock, right buttock, coccyx, and sacrum related to decreased activity, incontinence. Interventions for this care plan included Observe skin for signs/symptoms of skin breakdown, provide wound treatment as ordered, weekly skin checks by licensed nurse, and weekly wound assessment to include measurements and description of wound. Resident's clinical record was reviewed and contained a physician's order summary for the month of March 2023, which read in part . consult for necrotic wound to R ankle. Needs to be done as soon as possible, Cleanse area to top of right foot with Dakin's solution, 25%, pat dry. Apply Santyl on nonstick pad to wound bed. Cover with dry dressing daily and prn (as needed) every day shift for wound care, Cleanse stage 3 PU (pressure ulcer) to L (left) lower buttock with Dakin's solution, pat dry, apply skin prep to periwound, apply Dakin's wet to dry to wound bed and secure with dry dressing BID (twice a day) and PRN every day and night shift for wound care, Cleanse stage 3 PU to L upper buttock with Dakin's solution, pat dry, apply skin prep to periwound, apply Dakin's wet to dry to wound bed and secure with dry dressing BID and PRN every day and night shift for wound care for 2 weeks, Cleanse stage 3 PU to R buttocks with Dakin's solution, pat dry, apply skin prep to periwound, apply Dakin's wet to dry to wound bed and secure with dry dressing BID and PRN every day and night shift for wound care for 2 weeks, Cleanse unstageable PU on coccyx with Dakin's solution, pat dry, apply skin prep to periwound, apply Dakin's wet to dry to wound bed and secure with dry dressing BID and PRN every day and night shift for wound care for 2 weeks, Cleanse unstageable PU to center sacrum with Dakin's solution, pat dry, apply skin prep to periwound, apply Dakin's wet to dry dressing to wound bed and secure with dry dressing BID and PRN every day and night shift for wound care for 10 days, Cleanse unstageable PU to R heel with Dakin's solution, pat dry, apply skin prep to periwound, apply Santyl on nonstick pad and secure with dry dressing BID and PRN every day and night shift for wound care for 14 days, and Bactrim DS oral tablet 800-160 mg (Sulfamethoxazole-Trimethoprim). Give 1 tablet by mouth one time a day for wound infection for 14 days. Resident #42's clinical record contained a Physician's Telephone Orders form dated 02/27/23, which read in part (1) DC (discontinue) Macrobid. (2) Bactrim DS 1 tab PO (by mouth) BID (twice a day) x 10 days-wound infections R ankle, foot. This order was signed by the family nurse practitioner (FNP). Resident #42's treatment administration record (TAR) for the month of March 2023 was reviewed and contained entries as above. Each of these entries had not been initialed as completed on two separate occasions. Resident #42's February 2023 TAR contained entries, which read in part Cleanse area to right heel with IHWC (wound cleanser), pat dry and apply bordered foam dressing every day shift for open area, Cleanse area to right posterior thigh with IHWC, pat dry, and apply 4 x 4 bordered foam dressing every day shift for open area, Cleanse top of right foot with IHWC, pat dry, and apply bordered foam dressing every day shift for abrasion, and Cleanse area to coccyx with IHWC, pat dry, and apply bordered foam dressing every day shift for open area. Each of these entries had not been initialed as completed on three separate occasions. Surveyor, along with licensed practical nurse (LPN) #1 observed Resident #42's dressings to sacrum, coccyx, and buttocks on 03/13/23 at 2:30 pm. Dressing to sacrum did not have a date on it. Dressings to resident's foot, heels, and ankles all had dates and initials. LPN #1 stated they had completed wound care to these area's earlier in the day. Surveyor asked LPN #1 how they knew when the dressings to the sacral area had last been changed, and LPN #1 stated that without a date, there was no way to know when wound care was last completed. Surveyor spoke with the assistant director of nursing (ADON) on 03/14/23 at 10:50 am regarding Resident #42's wound care. Surveyor asked ADON what their expectations were for wound care, and ADON stated they would expect the nurses to follow the physician's orders for each resident regarding wound care. Surveyor asked ADON if wound dressings should be dated, and ADON stated that they should be dated and initialed by the nurse completing the wound care. ADON later stated per DON, facility policy did not state that dressings needed to be dated. Surveyor requested and was provided with a facility policy entitled Wound Dressings: Aseptic which read in part, 2. Gather supplies: 2.7 Prepared label or secondary dressing with date and initials. 27. Apply prepared label. Survey team spoke with the director of nursing (DON) on 03/15/23 at 10:00 am regarding wound management. DON stated they measure wounds weekly, and that information is located in their office. Surveyor asked DON if dressings should be dated and initialed when changed, and DON stated that is not a part of the facility policy, but they were hoping to have that changed, as that is the expectation. Surveyor referred DON to aforementioned policy, and asked DON what prepared label meant, and DON stated they did not know. Surveyor requested and was provided with Skin Integrity Report forms, which were contained in a notebook housed in the DON's office. This notebook contained six forms for Resident #42, which addressed unstageable pressure areas to right heel, right achilles, sacrum/coccyx, right buttock, left outer thigh/lower buttock and a stage II pressure areas to upper left buttock. Each of these areas were marked as present upon admission, with weekly measurements beginning on 02/01/23 and continuing through 03/14/23. Two surveyors, along with LPN #1 observed Resident #42's wounds on 03/14/23 at 4:45 pm. LPN #1 stated that areas to the top of resident's right foot and right ankle/lower leg were arterial rather than pressure. Resident's right heel had dark brown eschar and LPN #1 stated that area was unstageable pressure ulcer. Areas to resident's sacral area (sacrum, coccyx, buttocks) were red with slough present in wound bed. Survey team spoke with family nurse practitioner (FNP) on 03/20/23 at 1:25 pm regarding wound management. Surveyor asked FNP if missed assessments and dressing changes not being done as ordered could contribute to wound infections and FNP stated that it could. The concern of not providing treatment to promote healing and prevent infection of pressure ulcers management was discussed with the administrator, DON, and Market Clinical Lead on 03/20/23 at 3:00 pm. No further information was provided prior to exit. 42353 3. For Resident #299, the facility staff failed to provide treatment as ordered to an area of excoriation that later developed into a pressure injury and failed to document an assessment of the pressure area at the time of discovery. This was a closed record review: Resident #299's diagnosis list indicated diagnoses, which included, but not limited to Metabolic Encephalopathy, Aftercare following Joint Replacement Surgery, Dislocation of Internal Right Hip Prosthesis, Chronic Obstructive Pulmonary Disease, Unspecified Dementia, and Type 2 Diabetes Mellitus. The admission minimum data set (MDS) with an assessment reference date (ARD) of 10/25/22 assigned the resident a brief interview for mental status (BIMS) summary score of 9 out of 15 indicating the resident was moderately cognitively impaired. Resident #299 was coded as requiring extensive assistance with bed mobility, dressing and being totally dependent on staff with toilet use and bathing. The resident was coded as being at risk of developing pressure ulcers/injuries with no current unhealed pressure ulcers/injuries. Resident #299 was coded for the presence of a surgical wound and moisture associated skin damage (MASD). Resident #299 was admitted to the facility on [DATE], the nursing admission assessment entitled Nursing Documentation - V 11 dated 10/18/22 at 11:07 pm documented the presence of moisture associated skin damage (MASD) to the coccyx. A physician's order to wash coccyx with soap and water, pat dry, and apply Calazime paste every day and night shift for excoriation began 10/19/22. According to the resident's October 2022 Treatment Administration Record (TAR) the treatment to the coccyx was not administered on 10/19/22 nightshift, 10/21/22 dayshift, and 10/22/22 dayshift. A nursing progress note dated 10/23/22 at 11:00 am stated in part . Stage 3 noted to coccyx. Pt [patient] states 'yeah, it's sore'. Orders placed . A new physician's order to cleanse coccyx with wound cleanser, pat dry, apply zguard, place non-adhesive optifoam on every 3 days or as needed. Surveyor was unable to locate documentation describing the area to the coccyx. Resident #299 was seen by the family nurse practitioner (FNP) on 10/24/22, the progress note stated in part .Wound care to buttocks per stage 2 protocol. Dr. [name omitted] consult for stage 2 wound with slough to buttocks . Surveyor was unable to locate any subsequent documentation of the area to the coccyx until 11/01/22 at which time the wound was photographed, measured, and assessed. At that time the area was documented as an unstageable pressure area to the sacrum measuring 9.15 cm in length and 4.91 cm in width with 100% of the wound bed with slough. The assessment documented the resident's pain level as a 6 out of 10 stating the resident complains of pain during dressing change and when wet. The assessment also noted to schedule a consult with Dr. [name omitted] immediately. A nursing progress note dated 11/07/22 at 4:59 pm stated in part Consultation complete with Dr. [name omitted]. Resident is to have wound debridement next Tuesday 11/15/22 at 9 am . A nursing progress note dated 11/15/22 at 8:49 am documented in part Resident #299 departed facility for wound debridement. On 3/14/23 at 10:20 am, surveyor spoke with the Clinical Reimbursement Coordinator (CRC) who documented the 11/01/22 wound assessment and they stated they must have been working the floor that day and does not recall the resident's wound. Resident #299's unstageable area to the coccyx was again assessed and photographed on 11/08/22. The area was described as measuring 7.26 cm in length and 4 cm in width reflecting a decrease in size. The wound bed was described as having 100% slough with an intact serum filled blister. Surveyor attempted to interview the wound nurse at the time of Resident #299's admission, however, they were no longer employed by the facility. Surveyor requested and received the facility policy entitled Skin Integrity and Wound Management with an effective date of 7/01/01 and a revision date of 2/01/23 which read in part: 6. The licensed nurse will: 6.5 Complete wound evaluation upon admission/readmission, new in-house acquired, weekly, and with unanticipated decline in wounds. On 3/17/23 at 4:00 pm, the survey team met with the administrator, director of nursing, and assistant director of nursing and discussed the concern of the staff failing to provide treatment to Resident #299's area of excoriation to the coccyx on three separate occasions prior to area deteriorating into a pressure injury and failing to document an assessment of the area when the pressure area was discovered. 28169 4. The facility staff failed to ensure pressure ulcer assessments and treatments were complete for Resident #199. Resident #199's admission record listed his diagnoses included but were not limited to, Covid-19, Type 2 Diabetes Mellitus, and Encephalitis (inflammation of the brain) and Encephalomyelitis (inflammation of the brain and spinal cord). The minimum data set (MDS) with an assessment reference date of 12/16/21 coded the resident's brief interview for mental status (BIMS) a 01 out of 15 in Section C (cognitive patterns). Section G (functional status) coded him needing extensive assistance with bed mobility, eating, and toilet use. The clinical record contained a Transfer Summary Sheet from an acute care hospital dated 12/01/21 which described Resident #199's skin integrity as multiple skin tears and a stage 2 decubitus on his left buttock. An admission nursing documentation progress note described the resident's skin injury/wounds as multiple skin tears to bilateral arms and pressure: Stage 2 Left Buttocks. Weekly skin check documents, dated 12/17/21 through 03/04/22, were reviewed. The injury/wound regarding the buttocks was described as moisture associated skin damage until 1/21/22 and 1/28/22 when it was described as a pressure injury with treatment in place. The remaining weekly skin check documents described the left buttocks as moisture associated skin damage, and a pressure injury with one week (2/18/22) not noting the left buttock wound. There was no further description noted on the document or within the progress notes; no wound measurements were found. Provider orders for cleansing the stage 2 injury to the left buttock with wound cleanser, pat dry, and apply Optifoam every day shift was not documented for 12/20/21, 01/25/22, and 3/02/22. The administrator was informed of these findings on 3/14/23 during an interview in person on 3/14/23 and again on 3/19/23. On 3/14/23 at approximately 4:45 p.m., the director of nursing (DON) acknowledged she did not find any wound measurements or further wound/injury descriptions for Resident #199. No further information was provided prior to the exit conference.

Based on staff interview, family interview, clinical record review, and facility document review the facility staff failed to ensure supervision, to prevent a fall with injury for one of 18 residents (Resident #7). For Resident #7, the facility staff failed to provide supervision, leaving the resident sitting on the side of his bed from which he fell to the floor causing head trauma that required stitches. The facility staff also failed to provide a hazard free environment for its residents related to storage of 3 house cleaning chemicals. The findings include: 1. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #7's [DIAGNOSES REDACTED]. Resident #7's minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/26/12 assessed him to sometimes understand and to usually be understood. His cognitive pattern score was 03. His functional status assessment revealed he needed assistance with transfers and in activities of daily living. He required the extensive assistance of two for bed mobility. He required the assistance of one in transferring from the bed to chair, wheelchair or in standing. The facility staff care planned Resident #7 to have vision impairment on 11/1/2012. His goal was as follows: "Resident will remain free from falls or injury or decreased socialization through next review. " He was care planed to be at risk for falls: due to impaired mobility, cognitive loss, and lack of safety awareness. Fall Interventions: Assess for change mental status, in mental status, pain status, medical status and report to MD. Assist resident with ADL ' s as needed due to high fall risk. His care plan showed him to have impaired cognitive function and communication as evidenced by difficulty understanding others and difficulty making self understood. For assistance in daily living (ADL), his care plan read as follows: resident requires assistance/ is dependent for ADL care in bathing, grooming, dressing, eating, bed mobility, transfer, locomotion, and toileting due to cognitive loss/dementia. Review of Resident #7's clinical record revealed the following nurse's note that read in part: 12/13/12, 17:54. Change in condition. "Resident #7 had an accident/incident/fall in past 72 hours, witnessed. sitting on side of bed. Onset And Duration: resident fell out of bed, received a laceration and swelling to left eye and forehead." A second nurse's note read as follows: "12/13/12, 12:51, transfer note. Resident #7 transferred to hospital-unplanned for evaluation and treatment via ambulance to (name of hospital) ER. Physician notified of transfer (name of Physician) responsible party notified of transfer (name of responsible party) copy of advance directive sent. Resident found in floor with laceration to fore head see transfer form for additional clinical findings." On 12/18/12 at 8:30 am, Resident #7 was observed sitting in his room in a wheel chair. He had bruising under both eyes, and stitches on the left side of his fore head. His left hand/wrist was bandaged. The surveyor asked Resident #7 what happened to cause the injuries. Resident #7's speech was not understandable. On 12/18/12, Resident #7's wife was contacted by the surveyor. During the phone call she was asked if she was aware of his fall. She said, " They let him fall. They said that girl was new and didn't know not to sit him on the side of the bed, but she should have known. She came and apologized." At the end of the day meeting on 12/18/12 at 5:20 pm, the administrator and the director of nurses were asked about Resident #7's fall. The director of nurses said, "It was an unwitnessed fall on 12/13/12. The CNA was across the hall when he fell . She sat him on the side of the bed with the overbed table in front of him and went to help another CNA get a resident up. She is a new CNA and did not know he could not be left on the side of the bed alone. I counseled the CNA." During the morning of 12/19/12 during an interview with the occupational therapist, he was asked about leaving the resident on the side of the bed alone. He said, "His sitting balance was fair/good. What made him unsafe was his cognition." On 12/18/12 at 8:30 a.m., the physical therapist was also asked if the resident should have been left on the side of the bed and she said, "He required assistance for sit-to-stand and with walking. I would not have left him sitting on the side of the bed alone." At 12/19/12, CNA #3, the restorative aide was asked about Resident #7's ability to sit alone. She said, "I would not sit him on the side of the bed; his balance is not that fantastic. Sometimes he would feel like he could get up, but he can't. We have to watch him." The CNA who left Resident #7 sitting on the side of the bed without supervision was not available for interview. However, the director of nurses provided the surveyor with the statement the CNA wrote during the facility investigation. Her statement read as follows: "On 12/13/12 (name of another CNA) and I had just finished getting name of another resident up with a Hoyer lift. After getting him up in the chair we looked across over into (Resident #7's) room number and noticed Resident #7 was in the floor face down bleeding from his head. LPN #3 came to the scene to see what had happened. The last place I observed Resident #7 was sitting on his bed which is where I sat him up. I had no idea he wasn't supposed to sit on the side of the bed." On 12/19/12 at 10am, during a meeting with the director of nurses and the administrator, the director of nurses was asked to read the nurse's note regarding Resident #7's fall. She said "Nobody witnessed the fall. The CNA sat him on the side of the bed with the overbed table and tray in front of him. She sat him up alone (no assistance). He should not have been left. He could not maintain a sitting balance with his memory. Any of the staff who work with him know you can't leave him alone." Resident #7's care plan was updated on 12/14/12 to include the following: "Head of bed elevated with overbed table across bed for meals if not going to dining room. Do not leave on side of bed unattended." A review of the facility policy titled 7.0 Falls Management revealed under Practice Standards the following: "1. Identify patient's fall risk by reviewing the nursing assessment. 2. Communicate patients fall risk status to care givers." Prior to exit on 12/19/12, no further information was given to the survey team regarding Resident #7's fall. 2. The facility staff failed to keep the chemical Virex *II 256, Bleach, and Lysol spray in safe storage away from a vulnerable resident's access. On 12/17/12, during the initial tour of the facility on the south unit, the surveyor and LPN#1 toured the shower room. In the shower room, was a cabinet without a lock on it. The surveyor opened the door to find 1 bottle of the Bleach in a spray bottle. Hanging on a rail beside the cabinet was a bottle of Virex II 256. In the shower room was a commode that had a can of Lysol spray sitting on the back of it. The surveyor asked the nurses during initial tour why the bleach was stored in the shower room in an unlocked cabinet. She stated, "There was a lock on the cabinet. I don't know why it is not now." She was asked why the bleach and the Lysol spray were stored in the shower room. She said, "I don't know why they are there." The surveyor informed the administrative team of the above issue on 12/18/12 p.m. and requested the material safety data sheet (MSDS) information for the Chemicals. The director of nurses and the administrator were asked if the chemicals should have been locked up. They both said, "Yes. " The material safety data sheet was provided to the surveyor for the Virex. The sheet read in part under section 3: " Hazard identification; Eyes: Corrosive. May cause permanent damage including blindness. Skin: Corrosive. May cause permanent damage. Inhalation: May cause irritation and corrosive effects to nose, throat and respiratory tract. Ingestion: Corrosive. May cause burns to the mouth, throat, and stomach. The MSDS information for the bleach was provided by the facility staff. The sheet read in part under Health Hazard Data: Causes severe but temporary eye injury. May irritate the skin. May cause nausea and vomiting if ingested, Exposure to vapor or mist may irritate nose, throat and lungs. No information related to the Lysol was provided by the facility staff. During a team meeting on 12/19/12 with the administrator and the director of nurses, the above information was discussed.