Every finding on record at Wexford Senior Care Center

Based on interview and record review, the facility failed to ensure adequate supervision by failing to effectively identify and assess elopement risk to assure resident safety needs for one resident (Resident #4) of three residents reviewed for supervision.Findings Include:Resident #4 (R4) was admitted to the facility on [DATE] with diagnoses that included alcohol dependence with alcohol-induced persisting dementia, Wernicke's Encephalopathy (a potentially life-threatening neurological disorder caused by a severe deficiency of thiamine [vitamin B1]), and adjustment disorder with mixed anxiety and depressed mood. The Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderately impaired cognition.On 6/8/26 at approximately 6:55 AM, R4 exited the facility unsupervised and without staff knowledge following activation of a fire alarm on the 100 North Hall. Facility investigation revealed R4 exited through the 100 North Hall exit door and ambulated with a walker down the sidewalk toward the employee parking lot. Staff did not hear the door alarm over the fire alarm until they reached the exit door.On 6/22/26 at 11:30 AM, Licensed Practical Nurse (LPN) D stated R4 exhibited exit-seeking behaviors since admission but was typically easily redirected. LPN D stated that just before 7:00 AM on 6/8/26, while the fire alarm was sounding, a Certified Nursing Assistant (CNA) asked whether R4 was permitted outside unattended. LPN D stated R4 was not allowed outside unsupervised.Record review showed multiple documented behaviors indicating elopement risk, including cognitive impairment, wandering, exit-seeking, and impaired safety awareness, as evidenced by: 3/10/26: Staff documented R4 pacing between the dining room and his room, and he attempted to exit near the dining room before being redirected. 3/12/26: An Elopement and/or Exit Seeking Behavior Analysis documented no changes in risk level. Narrative descriptions were provided for questions 3, 6, 11, 14, and 18, but question 20 indicated Resident is NOT at risk, despite documentation of exit seeking statements, dementia, and recent medication changes. 4/11/26: Staff documented pacing, repeated requests to use the phone, and restlessness. 5/19/26: Behavior documentation indicated exit seeking, agitation, and argumentativeness. Staff contacted R4's daughter, and the behavior somewhat improved. 6/4/26: Another Elopement and/or Exit Seeking Behavior Analysis indicated no changes, and question 20 again stated Resident is NOT at risk.During an interview on 6/22/26 at 2:25 PM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) stated they would not include elopement interventions in a care plan unless a resident made repeated attempts to leave, rather than verbalizing intent. The DON stated elopement assessments were completed upon admission, quarterly, and as needed. When asked how many affirmative responses on the assessment indicated risk, or how risk was determined when narrative comments replaced yes/no answers, the NHA and DON were unable to specify criteria and stated the determination was based on clinical judgment.On 6/22/26 at 2:35 PM, a phone interview was conducted with R4's Guardian who stated she feels that R4 just wants to go home. She stated she cannot take R4 out for a leave of absence because he continuously asks to go home and doesn't understand why he cannot go.Review of the facility's Elopement and/or Exit Seeking Management policy, revised 10/11/19, indicated: 1. Identify resident risk for elopement and implement interventions as needed.The facility failed to complete a comprehensive elopement risk assessment in response to changes in condition and failed to revise the resident's care plan to include individualized interventions to mitigate elopement risk.

Based on observation, interview, and record review, the facility failed to monitor and assess nutritional interventions and modify or implement revised interventions for one resident (#6) of two residents reviewed for nutrition with significant weight loss. Findings include:Resident #6 (R6)R6 was admitted to the facility 2/21/24 with primary diagnoses of psychotic disturbance, mood disturbance, and anxiety. On 8/6/25 at 1:08 PM, R6 was observed at a table in the dining room during the lunch meal. R6 had a plate of Salisbury steak, mashed potatoes, and peas in front of her. R6 was not eating and did not appear interested in the meal. R6 was not encouraged to eat or assisted by staff. Licensed Practical Nurse (LPN) J offered R6 an alternate meal but R6 declined. LPN J provided R6 a MightyShakes(R) (a liquid nutritional supplement) but R6 refused to drink any of the supplement. LPN J said, Sometimes [R6] doesn't drink her shake.A Minimum Data Set (MDS) assessment for R6 dated 7/1/25 documented a weight loss of 5% or more in the past month or loss of 10% or more in the past six months without being on a physician-prescribed weight loss regimen. The MDS did not code swallowing disorders or issues with dentition. The MDS indicated a Brief Interview for Mental Status (BIMS) score of six, reflecting R6 had severe cognitive impairment. Further review of the MDS revealed R6 required supervision or touching assistance for eating.Review of the Electronic Medical Record (EMR) of R6 disclosed a weight of 172 pounds on 2/1/25 and a weight of 150 pounds on 8/1/25, a weight loss of 12.79% in six months. The EMR reflected R6 was weighed monthly with no indication of increased monitoring of weight following a weight loss trend. Physician's orders in the EMR of R6 included an order dated 12/2/24 for a regular diet with MightyShakes(R) TID (three times daily) with meals. There were no other physician orders pertaining to dietary or nutritional interventions. R6's Medication Administration Record (MAR), Treatment Administration Record (TAR) and Task documentation in the EMR were reviewed but there was no documentation of the amount of MightyShakes(R) consumed by R6 nor was there documentation of the frequency R6 was offered MightyShakes(R).The nutritional care plan for R6 included an intervention dated 12/8/24 that read offer hs (hour of sleep - bedtime) snacks. The MightyShakes(R) were not documented as an intervention on the care plan.Task documentation in the EMR did not contain the option for Certified Nursing Aides (CNA) to document the offering or acceptance of any snacks to R6 at bedtime as directed in the care plan. Review of the EMR did not disclose documentation of hs snacks being offered to R6 or if R6 consumed hs snacks as directed in the care plan intervention.An assessment by the Registered Dietician (RD) in the EMR dated 4/1/25 and documented on a form Dietary Profile read, in part: .She receives a Healthshake [sic] @ [at] dinner. Sig. [significant] weight loss x 90 [days] and 180 days; stable x 30 d [days].CP reviewed and updated. Recommend weekly weights x 4 [weeks] due to weight loss. No nutritional interventions or amendments to dietary interventions were noted in the Dietary Profile despite R6 being identified with significant weight loss over the previous 90 days and 180 days, and no new interventions were reflected in the nutritional care plan.There were no subsequent Dietary Profiles in the EMR by the RD until 7/8/25. The Dietary Profile of 7/8/25 noted R6 had a stable weight for 30 days but continued with significant weight loss for 180 days related to increased meal refusals.The RD was interviewed on 8/6/25 at 2:04 PM. The RD was asked what interventions were attempted aside from MightyShakes(R) to address R6's weight loss. The RD initially answered that Med Pass(R) 2.0 (a high calorie and protein drink designed for people at high risk for malnutrition) was initiated but refused by R6. The EMR was reviewed by the RD who then said Med Pass(R) 2.0 was not ordered or implemented for R6. The RD said, Oatmeal was added and as far as I know she's eating it. When asked the root cause of the weight loss, The RD said it was meal refusals. The RD admitted R6 had continued to lose weight and required reassessment. When asked where MightyShakes(R) consumption was documented, the RD said it is included in the meal percentage intake. When asked where hs snacks were documented, the RD responded hs snacks were provided by nursing and documented on the MAR. The RD was asked the standard process when a resident was identified with weight loss greater than 10% in six months. The RD said interventions would be revised and reviewed, the family and physician would be notified, and the resident would be placed on weekly weights.The Director of Nursing (DON) was interviewed on 8/6/25 at 3:22 PM. The DON said she was aware of the concern with the weight loss, and said R6 would be re-evaluated by the RD for appropriate interventions and recommendations, evaluated by the physician, placed on weekly weights and meal observations, and referred to Occupational Therapy. The DON was asked where nutritional supplements and hs snacks were documented. The DON confirmed the MightyShakes(R) and hs snacks should be documented in the EMR. The DON reviewed the EMR of R6 and confirmed there was no documentation for offering MightyShakes(R) and hs snacks nor was there documentation for MightyShakes(R) and hs snacks consumed by R6. The EMR of R6 documented a weight entry of 145 pounds on 8/6/25 at 3:46 PM, a 5-pound weight loss in six days. The policy Nutrition Assessment dated 11/21/24 read, in part: . The facility will: . Recognize, evaluate and address the needs of every individual, including but not limited to the individual at risk or already experiencing impaired nutrition. Care plan approaches should be revised based on the individual's outcomes, needs and choices. progress notes are written a minimum of every 90 days; and with each significant change in status. Individuals with high-risk conditions will need to be reviewed more frequently. The policy Nutrition at Risk dated 7/1/08 read, in part: .Residents with altered nutrition status or with potential for nutritional risk will receive appropriate interventions to make sure nutritional needs are met to maintain/improve their quality of life.

Based on interview and record review, the facility failed to honor the advanced directive for code status for one Resident (#71) of one resident reviewed for advanced directives (a legal document that allows a person to identify decisions about end-of-life care ahead of time). This deficient practice resulted in the potential for decisions regarding end-of-life care to not be honored by the facility. Findings include:Resident #71 (R71)The Electronic Medical Record (EMR) of R71 included an active physician's order dated 7/18/25 that read DNR [do not resuscitate].A Power of Attorney (POA) document in the EMR was signed by R71 on 1/5/24. The document indicated R71 designated her daughter to make health care decisions if R71 became incapable of making independent healthcare decisions.The POA document read, in part: 4. Specific instructions for life-support treatment. ‘Life-support treatment' includes, for example, a breathing machine, getting food or water through tubes, and CPR. The document directed R71 to select and initial a Choice for end-of-life care. R71 initialed Choice 3, which read I always want life-support treatment to the greatest extent possible consistent with sound medical practice - regardless of my condition, my chance for recovery, or the cost. Under the portion of the document to indicate specific instructions to the agent (person designated at POA), a hand-written entry made by R71 read as follows: Regarding #4. Specific instructions for life-support treatment: I always want life-support treatment to the greatest extent possible for at least 30 days. After this 30 day period my choice on #4 changes from Choice 3 [I always want life support treatment to the greatest extent possible .] to Choice 1 [I do not want life-support treatment if any of these conditions exist .] I understand that changing my choice after 30 days of life support could lead to my death. The hand-written entry was signed by R71 and expressly conveyed the designated POA(s) were to follow these specific instructions regardless of R71's competence to make medical decisions.A code status form dated 3/26/24 was in the EMR of R71. The code status form read In the event of Cardiopulmonary Arrest, I wish to be given CPR. The form was signed by R71 and dated 3/26/24.On 9/25/24, two physicians signed documents stating R71 was now unable to make healthcare decisions. As a result, the POA was activated. On 7/18/25, the daughter and POA for R71 signed a DNR code status for R71 that read, in part: .I authorize that in the event the declarants/ward's heart and breathing should stop, no person shall attempt to resuscitate the declarant.An advanced directive care plan dated 7/18/25 was in the EMR of R71. The first goal documented on the care plan read: I want to be active in my advance care planning decisions/or honor my decisions.The Director of Nursing (DON) was interviewed on 8/6/25 at 3:27 PM. The DON agreed residents have the right to determine their own code status and make decisions regarding end-of-life care. The conflicting information pertaining to R71's advanced directive/POA designation versus the code status of DNR was shared with the DON. The DON reviewed the documents and said she would follow up with the daughter/POA of R71. On 8/6/25 at 4:40 PM. The DON said the daughter/POA of R71 was currently out of the country, but she spoke with R71's grandson. The DON said the grandson indicated R71 had changed her advanced directive and would provide the document. On 8/7/25 at 9:46 AM, the DON said she spoke with the POA of R71 and R71 did not revise or amend the advanced directive dated 1/5/24. The DON said she spoke with R7 about code status directives. The DON said R71 was confused but said, CPR can keep you alive. The DON stated they did not recall any conversation with the POA about R71's express wishes regarding code status and stated there was no documentation of any discussion with the POA prior to the code status change which expressly went against R71's wishes expressed while they were still of sound mind. The DON acknowledged the facility should have advocated for the express wishes of R71.R71 was interviewed on 8/7/25 at 10:00 AM. R71 appeared confused when queried regarding end-of-life care decisions, but when asked if she wanted CPR if her heart stopped beating, R71 responded, Yes.The policy Advance Directives [sic] dated as revised 3/25/15 read, in part: .We are obligated to follow the resident's wishes as expressed in valid Advance Directives.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 62 residents. Findings include: On 8/13/24 at approximately 11:45 AM, the steam table located in the kitchen was observed to have food ready for the noon meal. [NAME] B was asked if the food in the steam table was at proper temperature and ready to be served. [NAME] B stated it was. A stainless steel hotel pan containing what was identified by [NAME] B to be ground meat for the noon meal and was prepared for the specified ground texture diet. The temperature of the ground meat was measured with a Super Fast metal stem digital thermometer. Multiple locations within the ground meat product were measured to have temperatures of 112 F, 114 F, and 116 F. No internal areas of the food product were measured to be above 135 F. At approximately 11:55 AM [NAME] B was observed measuring the temperatures of the hot food located in the hotel pans in the steam table. Once [NAME] B had completed the measuring and recording the temperatures, [NAME] B was asked what temperature she had measured in the ground meat product. [NAME] B replied 147 degrees. [NAME] B was then requested to measure the temperature of the ground meat again with her thermometer. While observing the measuring task, [NAME] B was asked what her thermometer was reporting. [NAME] B stated between 114 F and 116 F. On 8/13/24 at 12:15 PM, an interview was conducted with Registered Dietitian (RD) A, with the above condition being discussed. RD A stated the food had been at the proper temperature when the product was placed in the steam table, approximately 10 minutes prior to the above observations of temperature measuring. When asked how it was possible that the temperature of a product, with the density of ground meat, could lose over 20 degrees while in a steam table, RD A stated I don't know. The FDA Food Code 2017 states: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54 C (130 F) or above; On 8/13/24 at approximately 7:30 AM, observations were made of the walk in cooler. A stainless steel pan with a label of goulash and a pan of scallop potatoes from the previous day (8/12/24) were observed on a cart. RD A was requested to show that the products had been properly cooled and documented. A book labeled cooling logs was found on a shelf in the food preparation area. A page was located with the date of 8/12/24 with entries of goulash and scallop potatoes. A initial time of 1:20 PM and temperature of 135 F were found documented. No additional tracking of the products was located. RD A stated the two pans of product would be disposed of. The FDA Food Code 2017 states: 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); P and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less.

Based on observation, record review, and interview the facility failed to implement enhanced barrier precautions (EBP) for six residents (Resident #4, #20, #27, #39, #63, #64) of 24 sampled residents reviewed for EBP. This deficient practice has the potential for development and transmission of multi-drug resistant organism (MDRO) infections. Findings include: On 8/13/24 at 7:47 AM, during observations on the 200 and 400 unit, it was noted that no EBP signs were on resident doors for sampled residents who were identified as meeting criteria for EBP. These signs are used to alert staff to utilize personal protective equipment (PPE). There were also no carts located in these areas for the availability to store gloves, gown, and shields. (Staff are required to wear a gown and gloves during direct high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition such as residents with wounds or indwelling medical devices). High contact resident care activities include dressing, bathing/showering, transferring, toileting, providing hygiene, changing linen or briefs, device care or use: central line, urinary catheters, feeding tube, tracheostomy/ventilator or wound care. The following rooms were identified: a.) room [ROOM NUMBER]- Resident #20 (R20) b.) room [ROOM NUMBER]- Resident #64 c.) room [ROOM NUMBER]- Resident #4 d.) room [ROOM NUMBER]- Resident #63 e.) room [ROOM NUMBER]- Resident #27 (R27) f.) room [ROOM NUMBER]- Resident #39 On 8/13/24 at 2:10 PM, during an observation of a pressure ulcer wound care for R20 performed and assisted by Registered Nurse (RN) C and D failed to don PPE to abide by the EBP guidelines for wound care. On 8/14/24 at 8:00 AM, during an observation of a medication pass via peg tube for R27 it was noted that Licensed Practical Nurse (LPN) F did not don the proper PPE and failed to wear a gown during the entire process. On 8/14/24 at 10:05 AM, during an observation of a indwelling urinary catheter care performed by certified nursing assistant (CNA) E did not don proper PPE and failed to wear a gown during the entire process. During interview with Infection Preventionist (IP) RN G, on 8/14/24 at 10:10 AM, she stated, RN G had read, and it was her understanding that EBP was discretionary in how the facility utilized it. This Surveyor asked for clarification of what she meant by discretionary. RN G stated, They utilize it for those suspected of infections or known infections, but have not utilized it for everyone with catheters, wounds, or feeding tube. RN G asked if we could speak with the Director of Nursing (DON) to gain her understanding. The DON voiced that they were utilizing EBP on residents with known or suspected infections, but not those residents without known infections. A review of policy titled, Enhanced Barrier Precautions, dated 2/23, read in part, . 1. c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. 2. Initiation of Enhanced Barrier Precautions: a. Nursing staff may place residents with certain conditions or devices on enhanced barrier precautions empirically while awaiting physician orders. b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. ii. Infection or colonization with any resistant organisms targeted by the CDC and epidemiologically important MDRO when contact precautions do not apply. 3. Implementation of Enhanced Barrier Precautions - a. Make gowns and gloves available immediately outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray. b. Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room). c. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. d. The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. e. Provide education to residents and visitors .

Based on observation, interview, and record review, the facility failed to ensure catheter securement devices were in place to prevent indwelling urinary catheter dislodgement for two residents (Resident #20 and Resident #64) of three residents reviewed for catheter care. Findings include: Resident #20 (R20) According to the Minimum Data Set (MDS) assessment dated [DATE], R20 scored 8/15 (moderately impaired cognition) on her BIMS (Brief Interview for Mental Status) assessment, and required extensive assistance with two person transfers. R20 was incontinent of bowel and had an indwelling catheter. Diagnoses for R20 included diabetes mellitus, anxiety, muscle weakness, and need for assistance with personal care. During an observation and interview on 8/13/24 at 12:10 PM, Registered Nurse (RN) C was performing a sacral wound dressing change for R20, who had a urinary catheter. R20 was observed with no indwelling catheter securement device in place. RN C stated, (R20) is dependent on staff for her cares. RN C acknowledged that R20 did not have a catheter secure device in place. RN C acknowledged there was no catheter securement device and stated, (R20) should have a catheter secure device on her leg to prevent the tubing from being pulled during cares or while she is being moved. Resident #64 (R64) According to the MDS, dated [DATE], R64 scored 13/15 (intact cognition) on the BIMS assessment, and required extensive assistance with two person transfers. R64 was incontinent of bowel and had an indwelling catheter. Diagnoses for R64 included urinary tract infection, benign prostatic hyperplasia. On 8/12/24 at 2:48 PM, R64 was observed lying in his bed. R64 was uncovered and wearing an incontinence brief. R64 had an indwelling urinary catheter that was visible and draped over his left leg connected to a urinary collection bag. R64's catheter tubing appeared taught. R64 was asked if they felt a pulling sensation where the tubing enters the body and replied, Yes, it is pulling. I can feel it pulling some. R64 was asked if there was ever a catheter securement device in place on the tubing and replied, I used to have one on my right leg, but it is not there anymore. On 8/13/24 at 7:45 AM, an interview was conducted with RN C and was asked if R64 should be wearing a catheter securement device and replied, Yes, let me check his orders. R64 lacked an order or intervention in the care plan for a catheter securement device. On 8/13/24 at 12:10 PM, an observation was made of R64 lying in bed. R64 was uncovered and wearing a brief and did not have a urinary catheter securement device on either leg. On 8/13/24 at 12:30 PM, an interview was conducted with the Director of Nursing (DON) and was asked if residents with indwelling urinary catheters were required to wear a catheter securement device and replied, Yes, all urinary catheters need a catheter secure, and the devices need to be used at all times. The DON was made aware that two residents were observed without catheter securement devices. On 8/14/24 at 10:05 AM, CNA E was observed performing catheter care on R64 in his room. R64 now had a catheter securement device in place. R64 was asked if the catheter secure device helped them not feel the pulling sensation described yesterday and replied, Yes, it feels much better now without the pulling. Review of policy titled, Catheters Care, dated 10/20, read in part, .It is the policy of this facility to provide catheter care to all residents that have an indwelling catheter .Policy explanation and compliance guidelines .24.) Ensure that the catheter is secure to the leg every shift .

Based on observation, interview and record review, the facility failed to ensure tube feeding was administered and dated per standards of practice to meet the nutritional needs of one Resident (R27) of one resident reviewed for tube feeding. Findings include: Review of R27's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses including dysphagia, perforation of esophagus, and moderate protein-calorie malnutrition. On 8/12/24 at 11:15 a.m., R27 was observed in bed watching television with Jevity 1.5 [tube feeding formula supplying 1.5 calories per milliliter (mL)] infusing at 55 ml per hour (ml/hr). The Jevity 1.5 tube feeding formula bottle and the flush bag hanging above the tube feeding pump was undated and did not have nursing initials. On 8/13/24 at 8:47 a.m., R27 was observed in his bed sleeping with his tube feeding bottle dated 8/12/24 and his flush bag undated with no nursing initials. On 8/14/24 at 11:22 a.m., R27 was observed in his bed with his tube feeding bottle dated 8/13/24 and his flush bag undated with no nursing initials. Review of R27's Quarterly Nutrition assessment dated [DATE] read, in part, .(R27) is NPO (nothing by mouth) with enteral feeds via PEG (feeding tube that delivers nutrition to your stomach through your abdomen). Jevity 1.5 @ 55 ml/hr continuous with 50 ml water flushes q (every) 3 hours. This provides 1980 kcals (kilocalories) 84 g (grams) protein, 1000 ml free water from formula plus 400 ml water flush . Review of R27's Medication Administration Record (MAR) for August 2024 read, in part, Enteral Feed Order every 4 hours for NPO Jevity 1.5 55/hr continues with 50 ml water flush q 3 hours; start date 5/15/24. Review of this physician order showed no documentation of how much tube feed R27 received during a 24-hour period to ensure he was receiving the correct amount per his nutrition assessment. An interview was conducted with Registered Dietitian (RD) A and Charge Nurse/Registered Nurse (RN) D on 8/14/24 at 11:32 a.m. RD A stated that she made the recommendations for R27 to have his tube feed run every hour continuously and would expect that nursing staff was documenting how much tube feed R27 was receiving to ensure he had adequate nutritional intake. RN D stated that the physician order was placed in R27's MAR that way otherwise nurses would have had to check off they reviewed the tube feed every hour. RN D confirmed that R27's physician order was not documented correctly, and that staff should also be labeling and initialing R27's tube feed bottle and flush bag.

Based on observation, interview and record review, the facility failed to ensure grievances were documented, investigated, tracked and resolved for the members of the Resident Council, resulting in feeling of anger, frustration and unresolved grievances. Findings include. During a Resident Council meeting on 08/29/23 at 02:32 PM, 20 residents attended this meeting and shared frustration of unresolved grievance matters. Ten of 20 residents complained they were still getting cold food served to them. Four of 20 residents complained of small portions and when asked for more, the kitchen staff had left for the day. Six of 20 residents stated they do not have a choice on what they eat, they were served what was made. Adding the menu is hard to see where it is posted for those in a wheelchair. Eight of 20 residents stated the facility does not honor dislikes from meal ticket. Ten of 20 residents stated they were served meat, mainly fish that was not fully cooked, still cold from being froze in the middle. Twelve of 20 residents stated carrots are under cooked and cannot chew them. They are served over cooked or under cooked vegetables on a regular basis. Peas were served and butter would not melt because vegetable was room temperature. Six of 20 residents stated they are served plain macaroni noodles no sauce, rice, no sauces. Twelve of 20 residents stated they were served potatoes with no gravy or butter, and they were cold. Sixteen of 20 residents stated they do not get fresh water every shift. Adding they may wait for a whole day or day and a half to get any fresh water. Fourteen of 20 residents stated they do not feel they were treated with respect and dignity. Adding they did not trust administration and did not want to risk retaliation for filling out grievance forms, especially when they needed assistance with filling out the form from staff. Ten of 20 residents stated call light wait time had been up to an hour and a half to get their needs met. Residents also stated that some staff would come into the room to ask what they wanted, turn the call light off and never return to provide the care. Twelve of 20 residents stated they hear staff talking about other residents in front of residents. Also stated it was not about care they needed; it was about negative, derogatory comments. During an interview on 08/29/23 at 3:30 PM, Certified Nursing Assistant (CNA) S stated when a resident has a complaint/grievance they tell the Social Worker (SW) who keeps the grievance forms, then the Social Worker will talk to the resident about the issue. During an interview on 08/29/23 at 4:30 PM, Nurse Manger P stated the Grievances forms were at the entrance on 300 hall (this hall was not being used) and at the entrance of the main lobby. Also stated the Ombudsman came to the last resident council meeting, introduced himself to everyone, gave them his business card. During an interview on 08/30/23 at 11:35 AM, Nurse Manager (NM) P came to the conference and stated she misunderstood, the grievance forms are with the Social Worker, and she follows up with the resident. The forms at the entrances of the facility are for family, residents or anyone with a concern. NM P then stated these were two different forms. During an observation on 08/30/23 at 12:00 PM, writer could not locate any grievance forms for residents to access within three resident hallways or both entrances to the facility. During record review of past six months of resident council meeting minutes, food was listed as a concern for five months out of the six months of meeting notes. Staffing related to call light response time was listed two months out of six months of meeting notes. Record review of missing items and concern resolution form listed residents name, missing items, found or replaced. No dates were listed, no tracking was completed, no resident signatures of received and happy with resolution form. There was not an investigation into shifts these took place or time of day items were missing. Record review did not include food investigations, tracking or resolution.

Based on observation and interview, the facility failed to ensure the environment was safe, sanitary and functional as evidenced by carpeting on the 200 and 400 halls being stained, torn, emanating foul odors, rippled and uncleanable. This deficient practice has the potential to contribute to falls, and a general feeling of discomfort to 64 residents living on the halls, of a total 75 residents in the facility, staff and visitors. Findings include: On 8/28/23 between 10:30 and 11:15 AM, observations were made in the 200 and 400 hall corridors. These observations revealed urine-like odors emanating from the carpeting in the 200 halls, along with observations of torn and stained areas, and lumps and ripples throughout the 200 and 400 corridors. On 8/28/23 at 11:15 AM an interview was conducted with Certified Nurse Aide (CNA) A regarding the carpeting. CNA A stated she could smell the urine/mildew odors and attributed it to the carpeting and the inability to maintain it in a clean condition. On 8/29/23 at 9:50 AM, an interview was conducted with maintenance staff C who stated that regardless of how many times the carpeting was cleaned with a hot water extractor, it was impossible to eliminate the odors and deeps stains. On 8/29/23 at 11:30 AM, an interview with the Nursing Home Administrator (NHA) was conducted who acknowledged the carpeting was beyond cleaning and recognized it needed to be replaced. The NHA stated the facility had not yet ordered the flooring for these two halls at the time of the survey.

Based on observation, interview, and record review the facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident (#426) of 18 residents reviewed for accurate assessments resulting in the potential for inaccurate plans of care and unmet resident care needs. Findings Included: Resident #426 (R426) Review of the medical record revealed R426 was admitted to the facility 08/18/2023 with diagnoses that included osteomyelitis (inflammation of bone caused by infection) of vertebra, congestive heart failure (CHF), urinary tract infection, peripheral vascular disease (PVD), hydronephrosis (excessive back of urine in the kidney) , bacteremia (viable bacteria in the blood), Legionnaire's disease (type of pneumonia caused by legionella bacteria), hypertension, anxiety, fibromyalgia (wide spread muscle pain or tenderness), hyperlipidemia (high fat content in blood), morbid obesity, atrial fibrillation, chronic respiratory failure, and intervertebral disc degeneration. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/24/2023, revealed R426 had a Brief Interview of Mental Status (BIMS) of 12 (moderately impaired cognition) out of 15. During observation and interview on 08/28/2023 at 10:23 a.m. R426 was observed sitting up in a chair at the side of her bed. R426 was observed to be wearing a nasal cannula, which delivered oxygen. R426 explained that she used oxygen prior to her coming to the facility and continued to use oxygen during her stay at the facility. During medical record R426 MDS with an ARD of 08/24/2023, demonstrated that Section O (Special Treatments, Procedures, and Programs), sub section O0100C (oxygen) was documented yes while not a resident and was documented as no while a resident. Review of the medical record demonstrated a physician order, date of initiation 08/21/2023, Oxygen via (by way of) NC (nasal cannula) at 3 L (liters). In an interview on 08/30/2023 at 10:03 a.m. MDS Coordinator I explained that R426 was on oxygen since her admitted [DATE]. After review of R426's MDS with an ARD of 08/24/2023 section O0100C, MDS Coordinator I explained that the documentation no while a resident was not correct. She explained that it should have been documented as yes while a resident. MDS Coordinator I explained that a corrected MDS would have to be completed for R426. MDS Coordinator I explained that it was an error on her part.

Based on observation, interview, and record review, the facility failed to create a COPD (Chronic Obstructive Pulmonary Disease) care plan for one resident (R40) of eighteen residents reviewed for care plans, resulting in a potential to initate goals and interventions for the resident's diagnosis. Findings include: On 8/28/23 at 11:19 AM, R40 was observed lying in bed hunched over. R40 had a continuous cough which produced yellow phlegm. R40 was observed to have difficulty breathing, and wheezing sounds were audile upon inhalation and exhalation. R40 was asked if he was okay to which he stated, I get stuff (yellow phlegm) like this up all the time. On 8/29/23 at 8:09 AM, during an interview with Licensed Practical nurse (LPN) N, she said R40 was sent out for respiratory failure and hypercapnia (increased carbon dioxide in the blood). LPN N said R40 was receiving Mucinex and the Nurse Practitioner was going to see him. A review of R40's EMR (Electronic Medical Record) revealed, R40 was admitted to the facility on [DATE]. R40 had medical diagnoses including: COPD and Dementia. A review of R40's MDS (Minimum Data Set) dated 5/23/23 revealed, R40 had a BIMS (Brief Interview for Mental Status) score of 10/15 (moderately impaired). R40 required extensive one person assistance with personal hygiene. A review of R40's orders revealed the following: - Oxygen via NC up to 2L to maintain O2 sats above 90%, with an order date of 5/31/23. - Incruse Ellipta Inhalation Aerosol Powder Breath Activated 62.5 MCG/ACT one puff inhale orally one time a day, with an order date of 5/22/23. A review of R40's care plan revealed, no focus, goal, and interventions related to COPD were created to the comprehensive care plan created on 5/23/23. On 8/29/23 at 10:37 AM, during an interview with NS (Nurse Supervisor) O regarding the creation of a care plan for R40's COPD diagnosis, she stated, You are correct. He does not have a care plan related to COPD. On 8/30/23 at 10:12 AM, during an interview with the DON (Director of Nursing) B, she stated, The expectation is for the nurses to put in a care plan for a resident who comes in with COPD.

Based on interview, and record review the facility failed to develop a discharge summary which included a recapitulation of stay for one (Resident #74) of one reviewed for discharged , resulting in the potential for the receiving caregivers to not be fully informed of the resident's history and status. According to the clinical record, Resident 74 (R74) was admitted on [DATE] with diagnoses that included pneumonia and chronic obstructive pulmonary disease. Review of the clinical record further reflected nursing progress notes dated 06/03/23 10:41 , R74 oxygen saturation level was 75% while on 2 liters of oxygen and R74 was noted to have been using accessory muscles to breath. R74 refused to be hospitalized , the family, Nurse Practitioner and Director of Nursing (DON) B were all notified, hospice services were requested by R74's son. Nursing progress notes dated progress notes 06/03/23 at 14:18 reflected R74 had been signed on to hospice services. Nursing progress notes dated 06/04/23 at 13:01 reflected transport company had arrived to transport R74 home. Further review of the clinical record reflected there was not a discharge care pan, a discharge summary, recapitulation of stay, there were no progress notes or documentation that reflected who would be caring for R74, what R74's medical and care needs were and if the caregiver in the home setting was educated and informed of medication regimen, oxygen etc There was no mention on durable medical equipment needs, or what was in place or to be ordered. 08/30/23 08:47 AM, during an interview with Social Worker (SW) M she reported that R74 was admitted and discharged over a weekend and she had no involvement with her discharge as she does not work weekends. SW M reviewed R74's medical record and agreed there was not a discharge plan of care, discharge summary or recapitulation of stay. SW M also agreed that information from the medical record did not contain pertinent documentation related to the discharge as to what the care needs were and who was going to full fill those needs along with what assistance/education the facility provided for a smooth transition.

Based on observation, interview, and record review, the facility failed to provided treatment (Mucinex) for one resident (R40) of three resident reviewed for respiratory care, resulting in the delaying of treatment cough and respiratory concerns (increased phlegm production and audible wheezing). Finding include: On 8/28/23 at 11:19 AM, R40 was observed lying in bed hunched over. R40 had a continuous cough which produced yellow phlegm. R40 was observed to have difficulty breathing, and wheezing sounds were audile upon inhalation and exhalation. R40 was asked if he was okay to which he stated, I get stuff (yellow phlegm) like this up all the time. On 8/29/23 at 8:09 AM, during an interview with Licensed Practical nurse (LPN) N, she said R40 was sent out for respiratory failure and hypercapnia (increased carbon dioxide in the blood). LPN N said R40 was receiving Mucinex and the Nurse Practitioner was going to see him. A review of R40's EMR (Electronic Medical Record) revealed, R40 was admitted to the facility on [DATE]. R40 had medical diagnoses including: COPD and Dementia. A review of R40's MDS (Minimum Data Set) dated 5/23/23 revealed, R40 had a BIMS (Brief Interview for Mental Status) score of 10/15 (moderately impaired). R40 required extensive one person assistance with personal hygiene. A review of R40's orders revealed the following: - Oxygen via NC up to 2L to maintain O2 sats above 90%, with an order date of 5/31/23. - Incruse Ellipta Inhalation Aerosol Powder Breath Activated 62.5 MCG/ACT one puff inhale orally one time a day, with an order date of 5/22/23. A review of R40's care plan revealed, no focus, goal, and interventions related to COPD were created to the comprehensive care plan created on 5/23/23. A review of a Physician progress note dated 8/22/23 revealed, The patient today complains of a continues cough that does not clear. The patient has an aerosol ordered. Also today I started the patient on Mucinex twice daily for 14 days. Nurses have been consulted and prior encounters reviewed. Respiratory Positive: CTA Negative: Respiratory distress Notes: He sent his bilateral wheezing which does not clear on cough. He also expectorates the mucus. Today is been started on Mucinex VAD for 14 days. On 8/29/23 at 10:37 AM during an interview with NS O regarding the Mucinex order for R40, she stated, I do not see where he put the order in. When our physician sees them (the resident) they will put the orders in directly. On 8/30/23 at 10:12 AM during an interview with DON B, she stated, As a nurse, I would want the nurses to follow up on the orders. If it was unclear whether the physician put in the order, or if the physician did not state it verbally the nurses should be following up on the progress notes. Especially if the nurse made the concern known to the physician.

Based on interview and record review, the facility failed to change a urinary catheter per Physician order for one resident (R9) of two residents reviewed for urinary catheter, resulting in the potential for the development of a UTI (Urinary Tract Infection). Findings include: A review of R9's EMR (Electronic Medical Record) revealed R9 was admitted to the facility on [DATE]. R9 had medical diagnoses including: Urinary Tract Infection, Neuromuscular Dysfunction of the Bladder, and Quadriplegia. A review of R9's MDS (Minimum Data Set) dated 6/7/23 revealed, R9 had a BIMS (Brief Interview for Mental Status) score of 1/15. R9 had an indwelling urinary catheter. A review of R9's care plan revealed, (R9) has Indwelling Foley Catheter: Neurogenic bladder . (R9) will show no s/sx of Urinary infection through review date .CATHETER: last changed: 05/28/23. Change catheter every 4 weeks. 18 French10cc balloon Foley catheter. A review of R9's orders revealed, Foley catheter change monthly 18 French 10 cc. Foley catheter one time a day starting on the 28th and ending on the 28th every month. A review of R9's TAR (Treatment Administration Record) revealed on 6/28/23 and 8/28/23 the foley catheter change was not documented. On 8/30/23 at 10:09 AM during an interview with Licensed Practical Nurse (LPN) N regarding the urinary catheter change order, LPN N stated, I did not change the catheter this month and it does not appear as of yet that anyone has. On 8/30/23 at 10:12 AM during an interview with the DON (Director of Nursing), she stated, I don't see the documentation in the administration record and I did not see it in the progress note that the catheter change has been documented . Unfortunately there is no documentation in the EMR. 08/30/23 10:12 AM [NAME], DON- I didn't see it in the administration and I did not see it in the progress note that the catheter change has been documented. Unfortunately there is no documentation in the EMR. The expectation is for the nursing staff to follow the order and document it. If there was a reason the catheter was not changed the nursing staff should document it and let the provider know.

Based on interview and record review, the facility failed to documented refusals for missed dialysis treatments for one (R16) of one resident reviewed for dialysis, resulting in the potential for miscommunication for dialysis treatments missed. Findings include: A record review of R16's Electronic Medical Record (EMR) revealed R16 was admitted to the facility 8/16/21. R16 had a medical diagnosis of Chronic Kidney Disease, Stage 4. A review of R16's MDS (Minimum Data Set) dated 7/2/23 revealed R16 had a Brief Interview for Mental Status (BIMS) score of 12 out 15 (cognitively intact). R16 has urinary catheter and receiving dialysis. A review of R16's orders revealed the following: - Hemodialysis Treatments, three times per week, M W F runs beginning approximately at 0700 and running through approximately 1100. Please contact Fresenius Dialysis at [PHONE NUMBER] with any dialysis related concerns. - Check fistula (left forearm) for bruit and thrill one time a day for Fistula Check Check fistula (left forearm) for bruit and thrill. A review of R16's care plan dated 10/6/2019 revealed, Focus: R16 needs Hemodialysis r/t renal failure stage 4 .Goal: R16 will have no s/sx of complications from dialysis through the review date .Interventions: R16 typically will only attend scheduled dialysis times two out of the three times weekly; R16's dialysis times have recently changed to Monday, Wednesday and Fridays. R16 has been provided education on the importance of going to all dialysis txs by the facility (Nurse, RD, and Providers), as well as by the dialysis team. A review of R16's dialysis communication forms for June, July, and August revealed missing communication forms for 6/9/23, 6/16/23, 8/11/23, and 8/16/23. A review of the progress notes for those dates did not document the resident refusing to go to dialysis. On 8/29/23 at 1:49 PM during an interview with CM (Clinical Manager) P regarding the missing communication forms, she stated, I'll be honest and say that the nurses probably did not put in a note. If I was a floor nurse I would put in a note saying the resident was not going to dialysis. On 8/30/23 at 7:57 AM during an interview with DON (Director of Nursing) B regarding the missing communication forms, she stated, My exectation is that the nurses put in a progress note stating that the resident refused to go to dialysis.

Based on observation, interview, and record review the facility failed to implement infection control practices to change oxygen tubing/nasal cannulas for two residents (51, #426) of three residents reviewed for oxygen usage resulting in the potential of residents to develop respiratory infections. Findings Included: Resident #426 (R426) Review of the medical record revealed R426 was admitted to the facility 08/18/2023 with diagnoses that included osteomyelitis (inflammation of bone caused by infection) of vertebra, congestive heart failure (CHF), urinary tract infection, peripheral vascular disease (PVD), hydronephrosis (excessive back of urine in the kidney) , bacteremia (viable bacteria in the blood), Legionnaire's disease (type of pneumonia caused by legionella bacteria), hypertension, anxiety, fibromyalgia (wide spread muscle pain or tenderness), hyperlipidemia (high fat content in blood), morbid obesity, atrial fibrillation, chronic respiratory failure, and intervertebral disc degeneration. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/24/2023, revealed R426 had a Brief Interview of Mental Status (BIMS) of 12 (moderately impaired cognition) out of 15. During observation and interview on 08/28/2023 at 10:23 a.m. R426 was observed sitting up in a chair at the side of her bed. R426 was observed to be wearing a nasal cannula, which delivers oxygen. It was also observed that R2426 oxygen tubing was not dated. R246 explained that she used oxygen prior to her coming to the facility and continued to use oxygen during her stay at the facility. R426 explained that she could not remember when the last time that the oxygen tubing had been changed. Review of the medical record demonstrated a physician order, date of initiation 08/21/2023, Oxygen via (by way of) NC (nasal cannula) at 3 L (liters). During observation and interview on 08/29/2023 at 08:57 a.m. R426 was observed sitting up on the side of her bed, eating breakfast. She was observed to be wearing a nasal cannula, which delivers oxygen. The oxygen tubing still was not dated. R426 explained that the oxygen tubing had not been changed since the last time that this surveyor was in the room, on 08/28/2023 at 10:23 a.m. In an interview on 08/29/2023 at 09:00 a.m. Licensed Practical Nurse (LPN) L explained that when a resident is admitted and oxygen is required, it is the expiation that the nurse staff provide the oxygen tubing to the resident. She explained that it was the expectation and the policy that the oxygen tubing was to be dated at that time. LPN L explained that it was the expectation and the policy that resident oxygen tubing was change once per week by a contracted oxygen provider. In an interview on 08/29/2023 at 09:17 a.m. Director of Nursing (DON) B explained that it was the expectation and facility policy that resident oxygen tubing was to be marked with a date for which the oxygen tubing was to be applied or changed. She explained that the nursing staff would apply and date the oxygen tubing for newly admitted residents. DON B explained that a contracted oxygen company would change and date residents' oxygen tubing weekly. During observation on 08/29/2023 at 09:20 a.m., with DON B present, R426 was observed that R426 was lying down in bed and was wearing oxygen tubing with a nasal cannula. DON B confirmed that R426 oxygen tubing did not have date applied to the oxygen tubing. DON B' explained that the oxygen tubing would be replaced and dated. During record review of policy entitled Oxygen Administration Policy (effective date 01/2028, and a last revision date of 11/2021) revealed 5b., which stated, Change oxygen and mask/cannula weekly and as needed if it becomes soiled or contaminated. 45135 Resident 51 (R51) Review of the medical record reflected R51 was an initial admission to the facility on [DATE] and then readmitted from hospital to facility on 08/03/23. Diagnosis includes congestive heart failure, stage 3 kidney disease, diabetes and primary pulmonary hypertension (lung disease that causes high blood pressure in the lungs). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/03/2022, revealed R51 had a Brief Interview of Mental Status (BIMS) of 15 out of 15 (cognitively intact) and requires 2-person assistance with mechanical lift for transferring from bed to wheelchair. Incontinent of bowel and bladder and requires oxygen at 3 liters per minute per nasal canula. During an observation on 08/28/23 at 11:30 AM, R51 was wearing oxygen at 3 liters per minute per nasal canula. The oxygen tubing was dated for 07/30/23. During an observation on 08/29/23 at 09:20 AM, R51 was wearing oxygen at 3 liters per minute per nasal canula. The tubing label that was dated 07/30/23 yesterday had been removed from the tubing and there was not a new label placed. During an observation on 08/29/23 at 09:27 AM of a staff member walking in and out of every room of residents that use oxygen and checking the dates on the tubing. During an observation on 08/30/23 at 10:07 AM, R51 had new oxygen tubing with a label dated 08/29/23 on it.

Based on observation, interview, and record review the facility failed to administer pneumococcal immunizations in accordance with the Center for Disease Control and Prevention (CDC) recommendations for one residents (#17) of five residents reviewed resulting in the potential for server illness and complications from pneumococcal disease. Findings Included: Resident #17 (R17) Review of the medical record revealed R17 was admitted originally admitted to the facility 10/16/2013. She was discharged from the facility 07/25/2023 and readmitted [DATE] with diagnoses that included sepsis, disorder of teeth, metabolic encephalopathy (brain disease or damage causing impaired brain function), constipation, anemia (low red blood cells), chronic obstructive pulmonary disease (COPD), hypertension, post-traumatic stress syndrome, adjustment disorder, depression, heart failure, and type 2 diabetes. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/03/2023, revealed R17 had a Brief Interview of Mental Status (BIMS) of 5 (severely impaired cognition) out of 15. During observation and interview on 08/30/2023 at 10:26 a.m. R17 was observed lying in bed. She explained that she recently had returned to the facility after a short hospital stay. She could not explain the reason for her hospitalization . Review of R17's the medical record demonstrated immunization documentation which stated Pnuemovac Dose 2- no eligible. No other documentation was present demonstrating reason for ineligibility. In an interview on 08/30/2023 at 07:45 a.m. Infection Control Preventionist (ICP) J provided MCIR (Michigan Care Improvement Record) information that R17 had received the pneumococcal immunization vacation PCV13 on 05/19/2015. ICP J' explained that R17 had recently been discharged to the hospital for an infection related to a tooth abscess. ICP J explained that when R17 was readmitted to the facility she signed a consent to receive a pneumococcal immunization on 07/28/2023. ICP J explained that it was necessary for R17 to receive one does of PPSV23 (pneumococcal immunization) at least one year after PCV13. She explained that R17's need for another pneumococcal immunization was based on Center for Disease and Control (CDC) guidelines. ICP J could not explain why the facility had not identified this prior to her readmission. ICP J explained that she had just ordered the immunization on 08/29/2023 and demonstrated a physician order which stated Pneumovax 23 injection injectable 25 mcg (micrograms)/0.5 ml (milliliters). She could not explain why the pneumococcal vaccination had not been provided yet, since re-admission on 07/28/2023.

This citation pertains to intake: MI00137002 and MI00137533 Based on interview and record review, the facility failed to prevent staff to resident abuse (verbal) for one Resident (R1) of seven residents reviewed for abuse. This deficient practice resulted in R1 being spoken to inappropriately by staff and for other residents to be spoken to inappropriately. Findings include: A review of R1's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses including seizures, intracerebral hemorrhage, impulse disorder, vascular dementia with behavioral disturbance, and obsessive-compulsive disorder. The 3/1/23 Minimum Data Set (MDS) assessment revealed he scored a 6/15 on the Brief Interview for Mental Status (BIMS) score indicating severely impaired cognition. Further review of the 3/1/23 MDS assessment revealed he required extensive two person assist for bed mobility, transfers, dressing, and toileting and was always incontinent of urine and frequently incontinent of bowel. A review of the facility's incident report stated the following, The following is in summation to the event that occurred on 5/13/23 with the following resident: (R1) .on 5/13/23 at approximately 10;15 p.m., CNA (Certified Nurse Aide A) was working in resident (R1's) room with Agency (CNA B) assisting in getting (R1) ready for bed. (R1) was using foul language toward the two CNA's, she noted this to be typical behavior from (R1), ( CNA A) stated that Agency ( CNA B) proceeded to take a washcloth, put it over (R1's) mouth and say, 'you get soap in your mouth when you say naughty words' . An attempted phone interview was conducted on 7/26/23 at 1:03 p.m. for (CNA A). No return call was made. CNA A's witness statement revealed the following: Date of Incident: 5/13/23 . (Agency CNA B) wanted me to help put (R1) to bed so I did. But while I was helping her, she was being very forceful towards (R1) .Once we got him on the edge of the bed (Agency CNA B) threw (R1) legs on the bed. Then (R1) said something dirty, so (Agency CNA B) took the washcloth that she was going to use on his bottom and put it over his mouth. Then she said, 'You get soap in your mouth when you say naughty words.' This statement was signed by CNA A. A written statement signed by Registered Nurse (RN) C dated 5/13/23 read, in part, Report received at appro. (approximately) 2215-2220 (10:15 p.m. - 10:20 p.m.) from (CNA A) that the Agency CNA was mean to this resident (R1) .later learned it was (Agency CNA B). (CNA A) reports that Agency CNA (B) was rough with (R1), swinging his legs forcefully when he was sitting on bed to sitting position, then (R1) cursed at CNA (B), CNA (B) cursed at (R1) and took a washcloth and put it over (R1's) mouth and stated she needed to wash his mouth out with soap like in the old days . Further review of the facility's incident reported stated the following, .Director of Nursing (DON) spoke with (Agency CNA B) via phone regarding the incident. Agency CNA (B) stated the following: '(R1) was cursing at us like always, saying nasty things, I put his legs in his bed, he started cussing worse. I told him not to talk like that because it wasn't nice.' (Agency CNA B) denied 'being rough' with (R1) as well denied cussing at (R1) after he cussed at her. (Agency CNA B) was asked about putting a washcloth over (R1's) mouth and noted the following: 'I did not put a washcloth over his mouth. I did say, if this was the old days someone would wash your mouth out with soap. DON asked (Agency CNA B) if she felt that was an appropriate interaction to have with a resident, (Agency CNA B) stated 'yes, he shouldn't talk like that.' .DON notified (Agency CNA B) that she would need to leave facility immediately . An interview was conducted with Regulation Agent L on 7/26/23 at 12:24 p.m. Regulation Agent L stated he had conducted his investigation prior to the abbreviated survey and substantiated abuse between Agency CNA B and R1. Regulation Agent L stated a recommendation to impose negative enforcement action against the license of Agency CNA B was sent to the governing agency. Review of R1's Care Plan read the following, in part, .(R1) has a history of resisting care and threatening to hit staff at bedtime r/t (related to) confusion about the care that is being provided .(R1) has recently been making sexually suggestive comments and gestures toward staff .(R1) has the potential for further adverse behaviors r/t impaired cognitive functioning and poor impulse control. Date initiated: 8/15/18 .Interventions/Tasks'. Explain all procedures prior to and while performing them. If (R1) becomes agitated, attempt to distract him by discussing another topic, such as the family photos that are displayed in his room. If agitation persists, calmly walk away, and return later. Date Initiated 12/3/18 .If (R1) begins making sexually suggestive remarks, intervene before the comments escalate to acting out. Politely remind (R1) that you are his caregiver, be stern in your speech as soon as he starts saying inappropriate things. If (R1) continues to make suggestive remarks, ensure his safety, needs are met, reapproach task later in the shift, walk calmly away. Date initiated 7/25/19 .Remind (R1) of socially acceptable behaviors as needed (e.g., No inappropriate touching, no inappropriate language, no name calling, etc.) Maintain FIRM boundaries and be consistent. Do not give mixed messages by joking or allowing the comments to occur one time and then redirecting the comments another time. Date initiated: 7/18/19 . Review of the facility's Abuse, Neglect and Exploitation Policy revised on 4/2021 read, in part, Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .the facility must: not use verbal, mental, sexual or physical abuse, corporal punishment, or involuntary seclusion . An interview was conducted with the Nursing Home Administrator (NHA) and DON on 7/26/23 at approximately 3:00 p.m. The NHA and DON confirmed the allegation was substantiated by the facility.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: A. Failing to ensure four of four ice machines and dispensers were cleaned in a manner which prevented the potential contamination of ice used by residents. B. Failing to ensure expired food was discarded. C. Failing to maintain a freezer in a sanitary condition. This deficient practice has the potential to result in food borne illness among any or all 76 residents in the facility. Findings include: A. On [DATE] at approximately 10:15 AM, during the initial tour of the kitchen, the Hoshizaki bin type ice machine was observed to have a black mold like biofilm substance on the ice deflector shield. At approximately 11:45 AM, an interview with Certified Dietary Manager (CDM) B while showing her the interior of the ice machine. CDM B acknowledged the biofilm material should not be present in the bin. When asked when the last cleaning had been conducted, CDM B stated she was not sure but the maintenance department should have records. On [DATE] at approximately 1:15 PM an interview with maintenance Staff M was conducted related to the cleaning of the ice machines. When asked when the last time the ice machine in the kitchen had been cleaned and disinfected, staff M stated the same time the filter was changed . When told the filter had a date written on it of [DATE], Staff M stated that it would have been cleaned at that time. An interview with CDM B at 1:30 PM revealed she felt there should not be any black mold like substance on the interior of the machine if it had been cleaned on [DATE]. CDM B affirmed remembering the machine had been cleaned in February of this year, due to having a mock survey conducted and black mold being found in the machine at that time also. On [DATE] at 2:30 PM an interview with the Nursing Home Administrator (NHA) was conducted and the condition of the ice machine in the kitchen discussed. The NHA acknowledged the condition and agreed to discontinue the use of the machine until it had been properly cleaned. On [DATE] at approximately 8:30 AM, Maintenance Supervisor A produced a document in the form of an email dated [DATE] which last documented the cleaning of the machine. On [DATE] at approximately 10:00 AM an interview with Maintenance Staff C related to the previous day's cleaning of the ice machine in the kitchen. Staff C described his process of using a chemical cleaner, which he was unsure of the name or compound, and rinsing and flushing thoroughly. When asked about the disinfection step for cleaning the bin and sanitizing the interior, Staff C stated he was unaware of that process. When asked if he had read or seen the manual which described the cleaning and disinfecting procedures, he stated he was not aware of any. Staff C was requested to show the chemical used for the cleaning of the machine. A gallon bottle of Liquid Ice Machine Cleaner manufactured by Nu-Calgon. When asked about how it was used, Staff C stated he put 8 oz in the machine then added water and let it run though. When asked how the deflector shield inside the machine had been disinfected, Staff C stated he had put bleach on a sponge and wiped the surface off. No additional rinsing was conducted and the concentration of hypochlorite (active disinfecting chemical of bleach) on the surface was not known. A search for the Safety Data Sheet (SDS) for the Nu-Calgon Liquid Ice Machine cleaner was conducted and found. The SDS identified the key component as a de-scaling [MEDICATION(S)]. A review was conducted of the Manufacturer's manual (dated [DATE]) for the Hoshizaki ice machine, provided by Staff M . The manual described a cleaning process using a methanesulphonic acid product in difference to the [MEDICATION(S)] compound used by the facility. When asked if there were specific directions for the use of the chemical being used, Staff C stated he did not know. Further review of the manual identified a sanitizing cycle using a diluted bleach solution containing 1.25 oz of 5.25% bleach to 2.5 gallons of water and flushing the solution through. Three additional flushes with clear water were then required to accomplish the disinfection process. On [DATE] at approximately 10:30 AM, an interview with the NHA was conducted. The process followed by the maintenance staff for cleaning the ice machine the previous day was discussed and agreed was inappropriate and needed to be done over. The machine's use was again discontinued, and shut down. On [DATE] between 8:15 AM and 8:45 AM, observations were made of the ice machine/dispensing units in the 100 unit dining area, 200 unit's utility room and 300 hall's utility room. Using a flashlight and looking up into the discharge spout, large accumulations of brown to black biofilm was observed. Ice being discharged from these chutes would have to pass over these surfaces to exit the machine into containers used by the facility to distribute ice water. At approximately 9:00 AM, an interview was conducted with the NHA and shown pictures of the ice machines' chutes with the biofilm. She stated the machines would be shut down until they were properly cleaned. The FDA Food Code 2013 states: ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood_Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch B. On [DATE] at approximately 2:15 PM a carton of potato salad with an expiration date of [DATE] was observed in the walk in cooler. This was shown to CDM B who acknowledged it should have been discarded on the 7th. The FDA Food Code 2013 states: ,d+[DATE].11 Safe, Unadulterated, and Honestly Presented. FOOD shall be safe, unADULTERATED, and, as specified under § ,d+[DATE].12, honestly presented. C. On [DATE] at approximately 7:50 AM, the small 1.5 Cubic Foot Haier freezer, located in the 100 hall's dining area was observed to have a plastic cup with a straw extending out from the top. The freezer was also observed to contain food snacks for the residents. The interior of the freezer had thick accumulation of ice and frost impeding the function and air flow of the unit. On [DATE] at approximately 9:25 AM, a picture of the interior of the small Haier freezer was shown to CDM 'B who stated it was unacceptable to have a cup that had been drank from stored in the freezer with other food. She also acknowledged that the unit needed to be defrosted.

This citation has two dificiency practice statements (DPS) and will be labled as DPS A and DPS B. DPS A Based on interview and record review, the facility failed to develop a comprehensive Water Management Plan (WMP) to address the control and spread of Legionella bacteria in the facility water system, in accordance with QSO 17-30 Hopsitals/CAHs/NH, Revised 7-6-2018. The facility failed to develop and implement a water management program that considers the ASHRAE 188 (American Society of Heating, Refrigerating and Air-Conditioning Engineers) and the CDC (Centers for Disease Control) tool kit. The failure to develop a comprehensive Water Management Plan has the potential for the proliferation and transmission of Legionella in the circulating water of the building and the spread of Legionella infections in all 76 residents. Findings include: On 7/21/22 at 8:30 AM, an interview with the Nursing Home administrator and Maintenance Director/Staff A was conducted to review the facility's WMP for the control of Legionella in the water supply system. Staff A produced a document: Policy NO: 5.1 Water Management Program, Effective Date 11/17 as the water management plan. The policy was signed on 10/29/17. This policy directed the facility to: to establish procedures to reduce the risk of Legionella and other opportunistic pathogens in the facility's water system. Under policy Explanation and Compliance Guidelines, the document states: 1. The Maintenance Director maintains documentation that describes the facility's water system. A copy is kept in the water management program binder. 2. A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. 3. The risk assessment will be completed by facility leadership and the infection Preventionist with collaboration from other facility team members such as maintenance employees, safety officers, risk and quality management staff, and Director of Nursing. 4. Examples of water system components include: Items a thru r. 5. Data to be used for completing the risk assessment may include, but are not limited to: a. Lab Reports b. Environmental culture results. c. Rounding observation data d. Water temperature logs e. Water quality reports 6. Based on the risk assessment control will be applied to address potential hazards 7. Testing protocols and control limits will be established for each control measure The facility did not produce evidence of any of the above seven components of the policy being developed or implemented into a Water Management Program. The water management program binder was not located and provided for review. On 7/20/22 at approximately 9:00 AM, an interview with the NHA confirmed the lack of a Water Management Plan and the control of Legionella in the water supply had not been evaluated or discussed by the facility Quality Assurance and Performance Improvement (QAPI) team. The following components were absent from the facility WMP: A. Designation of a Water Management Team (WMT). B. An assessment of the facility's water system to identify risk locations. C. Identification of control points where effective mitigation or control measures can used. D. Identification of set critical limits related to the risk areas and control measures identified, which can be controlled. E. Identification of defined control measures and locations related to risk and the critical limits which are set. F. Implementation of regular scheduled mitigation program including what data is to be collected and how it will be analyzed. G. An evaluation process to determine how the WMP is functioning. H. An annual review of the water management plan. During this same interview, the NHA acknowledged a comprehensive WMP had not been developed and implemented. DPS B: Based on observation, interview and record review the facility failed to disinfect / sanitize a shared glucometer properly for one (Resident #17) out of 24 residents reviewed for infection control practices. This deficient practice resulted in the potential for blood borne pathogens to be transmitted to other residents residing on Station North 200 Hallway. Findings include: On 7/21/22 at approximately 8:00 AM, Licensed Practical Nurse (LPN) D was observed during medication preparation and pass. LPN D was observed preparing to obtain a blood glucose finger stick on Resident #17. LPN D was observed in Resident #17's room and placed the glucometer on his bedside table without a barrier. LPN D checked Resident #17's blood sugar with the glucometer and then gathered the glucometer, single-use lancet (small needle to poke the skin for blood collection) and proceeded back to her medication cart. LPN D then placed all the dirty items on top of her medication cart and discarded the blood glucose test strip in the sharp's container along with the single-use lancet. LPN D then took a small alcohol pad to clean the area where the blood glucose test strip is inserted into the glucometer and discarded the alcohol pad in the trash then placed the glucometer back into the medication cart. LPN D did not disinfect / sanitize the top of her medication cart and proceeded with her next medication pass. On 7/25/22 at approximately 10:15 AM, an interview was conducted with Infection Control Preventionist / RN H. RN H was asked if it was appropriate to clean the glucometer test strip area only, not wipe down the whole glucometer, allow for wet time, and place the glucometer back into the medication cart and responded, No. The nurses are to use the wipes and wipe them down and then allow for a wet time of two minutes. RN H verified that LPN D should have also wiped down the top of her cart and should have used a barrier in the room with her. Review of facility Glucometer Cleaning Instructions, no date, read in part, Cleaning/Disinfecting Equipment: .Use name brand cleaning cloth wipes to wipe down glucometer, then allow 2 minute wet time. Do not allow cleaning solution to run into the meter through areas such as around the buttons or the meter's test strip or data ports. This will be performed after each use of a glucometer. Review of facility policy titled Infection Prevention and Control Program, dated 10/16/17, read in part, Objective: It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .8.) Equipment Protocol: a.) All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. Review of facility policy titled Glucometer Disinfection, dated 8/20, read in part, Objective: The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood sampling devices to prevent transmission of blood borne diseases to residents and employees .Policy Explanation and Compliance Guidelines: 1.) The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use .h.) Retrieve two disinfectant wipes from the container, per manufacture recommendations. i.) Using first wipe, clean first to remove heavy soil, blood and / or other contaminants left on the surface of the glucometer. j.) After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the cleaning product kill time.

This citation refers to intake(s): MI 263, MI 633 Based on interview and record review, the facility failed to provide adequate supervision for safety to prevent falls and failed to develop and implement appropriate interventions to prevent further falls for two Residents (#1, #2) of three Residents reviewed for falls. This deficient practice resulted in repeated falls with subsequent injuries requiring hospitalization for Resident #1. Findings include: Resident #1 A review of Resident #1's electronic medical record (EMR) revealed an admission to the facility on [DATE] with diagnoses including: left femur fracture, muscle weakness, difficulty in walking, and chronic pain. Resident #1 discharged from the facility to the community on 11/30/21. A review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed he scored a 15/15 on the Brief Interview for Mental Status indicating he was cognitively intact, and required extensive two person assist for bed mobility, transfers, walking, and personal hygiene. Review of Resident #1's Fall Risk Evaluation dated 11/5/21 revealed a score of seven and marked that he had no falls in the past three months. Review of Resident #1's Incident and Accident Reports from 11/5/21 through 11/30/21 revealed the following: 11/13/21 09:00 Staff notified this nurse of need to come to room .bathroom. Upon entrance into bathroom observed (Resident #1) lying on left side in front of toilet .c/o (complaints of) low back/butt pain at time of incident assessment . 11/16/21 16:30 (4:30 pm) Observed resident (#1) laying on his right side with right arm under him, resident rolled over onto his back .assessed for injuries bruise noted of right outer elbow, c/o right rib pain with palpation, and low back pain . On 11/29/21 1130 CNA (certified nurse aide) I was in the resident's room weighting the resident, after the resident was weighed, he stated he needed to use the restroom, when resident stood up, he lost his balance and stumbled backwards landing on the floor. (Resident #1) hit his head on the O2 (oxygen) tank and his elbow on the foot board as he went down .(Resident #65) had a superficial bump on the back of his head with a small amount of blood and a small abrasion to his right elbow with no bleeding .transported to ER (emergency room ) per family insisted he be transferred .CENA I was not using a gait belt at the time of the transfer . Review of Resident #1's November 2021 Medication Administration Record (MAR) and Treatment Medication Record (TAR) revealed the following order: Evaluate for pain and Document two times a day, start date 11/5/21. It was noted that during 11/13/21 and 11/17/21 Resident #1 experienced a pain rating of the following: 11/15/21 7:00 a.m. pain level 9, 11/16/21 7:00 a.m. pain level 5, 11/16/21 7:00 p.m. pain level 4, 11/17/21 7:00 a.m. pain level 4, 11/17/21 7:00 p.m. pain level 11. Review of Resident #1's Radiology Order dated 11/16/21 revealed an order date for 11/13/21 which was rescheduled until 11/16/21. Resident #1's Radiology Report on 11/17/21 revealed the following: .questionable right lateral 8th rib fracture .There are compression fractures present at T12 .the compression fracture at T12 is a roughly 50% compression. There is a slight degree of increased density in the adjacent paraspinal soft tissues at T12 acute compression fracture is not excluded . Review of Resident #1's Care Plan for falls initiated 11/18/21 read, in part, .high risk for falls r/t (related to) impaired mobility & altered gait post left hip fracture and post-polio syndrome, potential for diminished safety awareness 2* (secondary) dementia, hx (history) falls with injuries, and hx getting up without assistance despite safety education . (Resident #1) has an ADL (activity daily living) self-Care Performance Deficit r/t left hip fracture .ambulation: 1 assist with gait belt and walker .transfer: requires (2) staff extensive participation with transfers . An interview was conducted with CNA I on 12/7/21 at 4:00 p.m. During the interview, CENA I explained that she did not use a gait belt with Resident #1 on 11/29/21 when Resident #1 needed to use the restroom. CENA I stated Resident #1 fell backwards onto the floor hitting his head on his oxygen tank and his elbow on the foot board. Resident #2 A review of Resident #2's EMR record revealed admission to the facility on [DATE] with diagnoses including: muscle weakness, dementia, and abnormalities of gait and mobility. A review of Resident #2's 10/25/21 MDS assessment revealed a BIMS score of 9/15 indicating moderate cognitive impairment. Resident #2 required extensive two person assist for bed mobility, transfers, toileting, and personal hygiene. Review of Resident #2's 10/21/21 Fall Risk Assessment revealed a score of 15, marking him at high risk for falls. Review of Resident #2's Incident and Accident Report dated 11/19/21 read, in part, (Resident #2) observed on the floor by CNA (later identified as CNA K) .observed sitting on buttocks upright leaning back onto recliner .CNA stated she assisted him to the bathroom and instructed him to wait while she gets washcloths to clean him up. When she returned within a few minutes, he was observed on the floor .Resident has a history of multiple falls r/t impaired safety awareness, unsteady gait, and generalized weakness. Nursing staff educated on the importance of staying with residents in bathroom who are considered a high risk for falls . An interview was conducted with CNA K on 12/7/21 at 3:41 p.m. CNA K stated she did not realize Resident #2 could walk on his own because he required so much assistance, and that once she had transferred him to the toilet, she went to retrieve wash cloths to assist him, he then self-transferred himself out of the bathroom and was found on the floor near his recliner. Review of Resident #2's Care Plans read, in part, (Resident #2) is high risk for falls r/t deconditioning, gait/balance problems . date initiated 10/21/21 . (Resident #2) needs prompt response to all requests for assistance . Resident #2's Care Plan showed an intervention adding motion sensor alarms to floor on 11/19/21 (date of his fall),which was observed on 12/7/21 at 12:52 p.m. Review of the facility's Fall management Policy dated 12/20 read, in part, .Policy: To formulate care plans to reduce risk of falls and effectively monitor fall interventions. To educate staff on fall reduction techniques .upon admission, all residents/patients are assessed for transfer status, safety and equipment needs by Licensed Nurse .If there is a fall or a risk is identified by nursing, the Licensed Nurse will: provide education to staff about the intervention to prevent falls .

Based on interview and record review, the facility failed to prevent Resident to Resident physical abuse, resulting in harm for one Resident (#18) of four residents reviewed for abuse. This deficient practice resulted in a fall with injury (fractured left hip) requiring surgical repair. Findings include: Intake Number: MI 613 Review of Resident #18's Minimum Data Set (MDS) assessment, reference date 4/16/20, and Face Sheet, print date 4/8/21, revealed Resident #18 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #18 scored a 99 on the Brief Interview for Mental Status (BIMS), which indicated she was unable to complete the interview. She was noted to have moderately impaired cognition and resided in the secure (locked) memory care unit within the facility. At the time of reference, Resident #18 walked without the use of a mobility device. Review of Resident #44's MDS assessment, reference date 3/6/20, and Face Sheet, reference date 4/8/21, revealed Resident #44 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #44 was noted as having verbal behavioral symptoms directed towards others one to three days in the look back period of the MDS assessment. Resident #44 required supervision while walking in room and in corridor. Resident #44 scored 11/15 on the BIMS, reflective of moderate cognitive impairment, walked without the use of a mobility device, and resided in the facility secure (locked) memory care unit. Resident #44 had a Designated Power of Attorney (DPOA) for medical care decisions. Review of a Fall report, dated 4/16/20, revealed Resident #18 was found .lying on the floor in the hallway .grabbing her left hip. The left lower limb was externally rotated and shortened . (Resident #18) stated she was in pain she was gripping her left hip. When asked what happened she stated that she was pushed. She then stated that she lost her balance and then fell on to the floor. The report was completed by Registered Nurse (RN) S. Review of the Incident and Accident dated 4/16/20, revealed the following. (Resident #44) was in her own room with a Velcro Stop sign across doorway- and resident (#18) was in the hallway near resident (#44's) doorway. Staff reported hearing resident (#44) yell out at resident (#18) .Nursing Home Administrator (NHA), Director of Nursing (DON), Clinical Manager/RN T reenacted the incident with staff and was unable to substantiate physical contact between (Resident #44) and (Resident #18). It was determined (Resident #44) did yell out at (Resident #18) and threatened her not to come in her room. Investigation revealed that the stop sign being used was intact and resident (#44) was in her room behind the stop sign at the time of the incident. When (Resident #18) was asked what happened she was not able to give consistent response . (Resident #44) left the community for an outside appointment shortly after the incident. Upon (Resident #44's) return at 4:00 p.m. the same afternoon, NHA was able to interview (Resident #44) . (Resident #44) stated she yelled at (Resident #18) when she passed her doorway. When asked if she hit her or pushed her (Resident #44) could not respond and just kept saying 'I'm sorry, she was going to come in my room, I don't want to go to jail.' .On 4/17/20 staff members Certified Nurse Aide (CNA) U and activity aide/staff V spoke with supervisor RN T and Activity director/staff W about possible abuse between (Resident #44) and (Resident #18) .(Resident #44) was crying when staff talk with her and kept apologizing that she didn't mean to hurt that women .NHA who for the 2nd time interviewed (Resident #44) and (Resident #44) stated she did push at her, when asked if she touched (Resident #18) she just kept saying she was going to come in my room, I didn't mean it . Review of the facility's Witness Report written by Physical Therapist (PT) X revealed, Date of incident: 4/16/20 Time: Around 12:40 p.m.This PT was in room [ROOM NUMBER]-1 and observed (Resident #18) falling on her left side in the hallway by door of 412-1 with resident (#44) standing at door way and upset with (Resident #18) trying to get closer or get in her room .This PT was unable to see if (Resident #18) hit her head or not due to wall in way. This PT was unable to see if there was any physical contact between two residents. Review of Resident #18's hospital Discharge Instructions dated 4/20/20, revealed the following: .Medical Problems - hip fracture, left S/P ORIF (open reduction internal fixation) fracture .Additional Information Additional Instructions: wbat (weight bearing as tolerated), daily dry dressing changes as needed, follow up with ortho (orthopedics) in six weeks, staples out in ten days . Review of Resident #18's MDS, assessment reference date 4/27/20, revealed Resident #18 required extensive two person assist with bed mobility, transfers, toilet use, and dressing following the resident-to-resident altercation on 4/16/20 which resulted in a fall with major injury. Review of Resident #18's April 2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Evaluate for pain and document two times a day. Start date 8/25/19. D/C (discontinued date) 4/17/20. There were three documented times of pain for Resident #18 from April 1st through April 17th. 2. Evaluate for pain and document two times a day. Start date 4/20/20. There were 15 documented times of pain for Resident #18 from April 20th through April 30th, with the highest report of pain noted to be 6 on a scale of 10. 3. [MEDICATION(S)] Tablet 50 MG (milligrams), Give 1 tablet by mouth every 4 hours as needed for pain for 3 days. Start date 4/20/20. Documented as administered on 4/20, 4/21, 4/22 and 4/23. 4. [MEDICATION(S)] Tablet 50 MG, give 1 tablet by mouth every 4 hours as needed for Severe Pain. Start date 4/24/20. Documented as administered 14 times between April 24th and April 30th. 5. Tylenol Tablet (Acetaminophen) Give 650 MG by mouth every 4 hours as needed for Mild Pain. Start date: 4/24/20. Documented as administered on 4/27 and 4/28. Review of Resident #44's Care Plans with revisions revealed the following: . (Resident #44) has impaired cognitive functioning r/t (related to) Unspecified Dementia .has poor insight into the nature of her medical issues and difficulty understanding other points of view .has been known to become verbally and physically aggressive toward other residents who get into her personal space and/or do not behave as she would like them to behave. Her recent behavioral symptoms include yelling, slapping, and physically escorting other residents out of her room. Date Initiated: 12/20/19. Interventions: Keep (Resident #44) apart from resident (#18) as much as possible. Resolved Date: 6/8/20. Interventions: .moved to room [ROOM NUMBER] on 4/21/20 for her comfort and to reduce the likelihood of other residents wandering into her room . On 4/5/21 at approximately 3:15 p.m. an interview was conducted with CNA U regarding the incident on 4/16/20. CNA U confirmed that she was not present on the day of the incident, but the next day Resident #44 asked where Resident #18 was and became visibly upset when she found out she had been injured. CNA U stated it was when Resident #44 found out Resident #18 had been injured that she told them she had pushed Resident #18. CNA U stated Resident #44 did not like Resident #18, and they had previous altercations with each other. On 4/7/21 at 3:45 p.m. an interview was conducted with Activity Aide/Staff Y. Staff Y stated Resident #44 told her the following day that she had pushed Resident #18 down. Staff Y confirmed Resident #44 and Resident #18 did not like each other. I don't understand why (Resident #44) was here in the locked unit, but yes, (Resident #44) did not like her (Resident #18). She would yell at her all the time. On 4/7/21 at 4:00 p.m., an interview was conducted with the NHA. When asked why Resident #44 resided in the secure (locked) memory care unit despite her BIMS score and aggressive behavior towards Resident #18, the NHA stated, We offered her a room change multiple times, but she refused. I believe she (Resident #44) was first put down in the unit because of the information we received from the hospital. We added a stop sign to try and keep other residents from wandering in her room. When asked if Resident #44 and Resident #18 had previous altercations with each other prior to the incident on 4/16/20, the NHA stated, Yes, and those were reported to the State. A request for the previous altercations between Resident #44 and Resident #18 were made by this Surveyor. Review of Resident #44's and Resident #18's previous incidents revealed there had been two prior altercations on 2/22/20 and 3/22/20, respectively. The incident on 3/22/20 resulted in a skin tear to Resident #44. Both incidents were reported to the state agency (SA). On 4/8/21 at 1:30 p.m., an interview was conducted with Resident #44. Resident #44 was in her room near Station 3 lying in bed watching television. When asked if Resident #44 liked her room compared to her old room in the secure (locked) memory care unit, she stated, Yes. It is much better. I didn't like those walkers. Resident #44 returned to her television program and asked this Surveyor to leave the room. On 4/8/21 at 1:45 p.m., an interview was conducted with housekeeper/Staff Z, who stated she was working in the secure (locked) memory care unit on 4/16/20 and heard Resident #44 state she had pushed Resident #18 because she would not stay out of her room. Staff Z confirmed she did not see the altercation but saw Resident #44 in her room with the Velcro Stop Sign still in place and Resident #18 was on the floor. When asked if Resident #44 still had any aggressive behaviors towards staff or residents had, Staff Z stated, Yes. She continues to be aggressive when we try to clean her room. She even hit me once. Review of Resident #44's Quality of Life Reviews dated: 2/20/20, 2/28/20, 3/23/20, and 4/16/20, respectively showed no communication between Resident #44 and her DPOA regarding a room change. Review of the facility's Abuse, Neglect and Exploitation policy dated 6/02 revealed, .Prevention of Abuse, Neglect, and Exploitation .Observe resident behavior and their reaction to other residents, roommates, tablemates. Place residents in accommodations and environments that keep them calm .temporary or permanent room or roommate change, where incompatibility creates the potential for abuse .

Based on interview and record review, the facility failed to provide safe and effective care related to swallowing concerns for one Resident (# 35) of twenty-two residents reviewed for quality of care. This deficient practice resulted in a hospitalization secondary to aspiration pneumonia (caused by ingesting food/fluids orally and entering the lungs). Findings include: On 07/23/19 at 09:38 AM, an interview with Resident # 35 revealed the following: Resident # 35 stated About three or four weeks ago, my [DEVICE] was fixed after I had been asking for my [DEVICE] to be fixed for two weeks, because it was leaking and broken. I was scheduled upper and lower GI, and I had this chemical that I needed to drink for it. A nurse (Registered Nurse (RN) X) gave me this chemical I needed to drink, and at 7 PM she came in and told me I needed to drink this. It was in a large glass. I told her I needed a spoon, and she said no, just drink it. I called my brother to come in because I was going to aspirate the way this nurse was trying to give me this chemical. I asked this nurse four times to let me use a spoon, and she said no it will be ok. So I drank the first cup, and about that time my brother came in and he said 'Send him to the hospital now, because he is aspirating.' She said no, I've got a plan. My brother left because he had to deal with work, and I told him it was ok, I will be ok. By this time I had already had 4 cups the nurse had me drink. (Then later) She knew I wasn't doing well, and told me I had to go to the hospital . Then another nurse came in a said the whole midnight shift will get fired if you don't go . so I went to the hospital. I ended up with Aspiration Pneumonia again, and I had just gotten over it. A review of the Progress Notes section of the Electronic Medical Record (EMR) for Resident #35 revealed the following: 7/23/2019 (1:36 PM) . (Resident #35) was seen today for follow up and concerns of low urine output x 3-4 days. Upon review of his output chart, his urine output has been staying between 1300 cc (cubic centimeters) and 2000 cc per day mostly. He is getting about 300 cc TID (Three Times Daily) free water via peg tube, and oral intake is about 300 - 400 cc per day. He states that he gets Charlie horses if he is not getting enough water . . / HOSPITAL COURSE BY PROBLEM: 1. Acute hypoxic (oxygen deprived) [MEDICAL CONDITION] in the setting of aspiration pneumonia. [AGE] years old male presented here from (Facility) with a history of progressive shortness of breath, noted patient has a history of Pontine ([DIAGNOSES REDACTED]) stroke with their locked i[DIAGNOSES REDACTED] (aware but unable to move or speak due to complete paralysis of nearly all voluntary muscles in the body) in the past with left-sided hemiparalysis (one sided paralysis). Patient has high risk of recurrent aspiration. Patient found to have aspiration pneumonia with large infiltrate (substance or number of infiltrating cells) in the right lower lobe. Patient initially kept nothing by mouth, therapy evaluated the patient and recommended dysphagia (difficulty swallowing) diet (mechanically altered) . Also noted that patient has a PEG (Percutaneous Endoscopic Gastrostomy) tube; therefore consulted (Physician DD) and PEG tube has been replaced. Patient is feeling better currently. Tolerating oral diet. Calorie count has been done which is adequate. Therefore plan to discharge patient to (the facility). Patient will benefit from outpatient physical therapy and occupational therapy however considered patient's insurance reasons that can not be arranged per case manager report. 2. Aspiration pneumonia with large infiltrate in the right lower lobe. 3. History of Pontine stroke and history of [DIAGNOSES REDACTED] in the past with left-sided [MEDICAL CONDITION] with high aspiration risk. 4. History of [MEDICAL CONDITION] disorder in the setting of previous stroke. 5. Hypertension. 6. [MEDICAL CONDITION] reflux disease. 7. Obstructive sleep apnea. Patient uses [MEDICAL CONDITION] (Continuous Positive Airway Pressure (device)) at night. 8. Severe anxiety and depression. He was then sent out to the hospital for respiratory distress secondary to aspiration while drinking bowel preparation liquid. PAST MEDICAL HISTORY: - Brainstem stroke . - Hypertension . - [MEDICAL CONDITION] (Slow Heart Rate) -Acute [MEDICAL CONDITION] with [MEDICAL CONDITION] . - [MEDICAL CONDITION] disorder . - Locked i[DIAGNOSES REDACTED] . - Acute incomplete flaccid (Lack of muscle tone) [MEDICAL CONDITION] (paralysis in all four extremities) secondary to stroke - Ventilator dependence . - Dysphagia following cerebral infarction . - NSTEMI (non-ST elevated [MEDICAL CONDITION] infarction([MEDICAL CONDITION])) . - Stroke . -CNS (Central Nervous System): speech slow with dysarthria (motor speech disorder) . - Left [MEDICAL CONDITION] . Slight right facial droop . ASSESSMENT: Oliguria (low urine output); seems resolved/ stable. output is adequate. Fatigue (extreme tiredness) and lethargy (lack of energy), better. Aspiration pneumonia, resolved. Acute [MEDICAL CONDITION] with [MEDICAL CONDITION], stable. resolved. [MEDICAL CONDITION] and [MEDICAL CONDITION] following cerebral infarction affecting left non-dominant side Dysphagia; ST (Speech Therapy) eval (evaluation) . Excessive salivation and secretions, good response to [MEDICATION NAME] (secretion management medication) patch. NSTEMI (Non-ST(segment of an electrocardiogram) elevated [MEDICAL CONDITION] infarction([MEDICAL CONDITION]), managed medically. Aspiration pneumonia, s/p (status [REDACTED]. hx (history) of prior stroke with left [MEDICAL CONDITION]. Acute on chronic urine retention; indwelling Foley. Hx of Brainstem stroke and [DIAGNOSES REDACTED], with improvement. Hx of cerebral infarction (stroke) with left [MEDICAL CONDITION] . Hx of incomplete flaccid [MEDICAL CONDITION] secondary to stroke PLAN: Increase peg tube free water to 400 cc TID (Three Times Daily). Follow up with GI . 6/18/2019 03:12 (AM) Nurse's Note Note Text: Resident complaining of difficulty breathing and increased secretions. O2 (oxygen)saturation 84%. Resident was placed on O2 at 4L (liters) via N/C (nasal cannula), rattling noted in upper lobes, lower lobes clear. [MEDICATION NAME] (skin adhering patch) scope patch not on resident, new one was place behind his right ear. Duo neb (medicated nebulizer medication) given. O2 saturation increased to 92%. Resident requested to be seen in the ED. (Family EE) notified and will meet resident at the ER (emergency room ). (Physician Z) notified. Resident sent to (Hospital) via ambulance. 6/13/2019 (3:32 PM) Medical Staff Narrative(Progress)Note Note Text: CONCERN VISIT: He was seen today for concerns of being sleepy and tired all the time since he came back from hospital. His [MEDICATION NAME] (anti-anxiety medication) was increased at readmission to 1 mg (milligram) BID (Twice Daily), but due to increased sleepiness and lethargy, it was decreased back to 0.5 mg BID. He still feels tired and fatigued all the time . 6/10/2019 12:10 (PM) Medical Staff Narrative(Progress)Note Note Text: READMISSION HISTORY AND PHYSICAL: He was seen today for readmission history and physical. He was sent out to the hospital for respiratory distress secondary to aspiration while drinking bowel preparation liquid. SUBJECTIVE: He denies any complaints today. Reports his breathing as OK. He says he is getting ground meat, but doesn't like it and wants chopped meat instead. Per hospital discharge summary, his diet is to be Dysphagia 2 (mechanically altered ground foods), soft and moist, nectar liquid. Assistance during feeding, aspiration precautions . 6/3/2019 (6:59 PM) Nursing Admission Note Note Text: Resident admitted on [DATE] from (Hospital). Arrived via Wheelchair, with the Dx of . PNEUMONITIS (Pneumonia) DUE TO INHALATION OF FOOD AND VOMIT . Nutrition: Regular, Dysphagia 2, nectar thick liquids., L[NAME](Level of Conciousness): Alert, Person, Place, Time, Situation, Appropriate . Communication: Understood, Understands . 5/29/2019 02:30 (AM) Nurse's Note Note Text: Resident noted to have increased SOB (Shortness Of Breath), increased respirations, decreased Sp 02 (oxygen saturation), increased B/P (Blood Pressure), and increased temp(erature). New order to send resident to hospital for evaluation. Explained to resident that he needed to be sent to hospital to be evaluated for possible pneumonia. Resident stated that he did not want to go to ER (emergency room ). Educated resident on why he needed to go to the ER. Resident continued to refuse to go to ER. Call Nurse from another unit and had her explain why it was necessary for him to go to the hospital. Resident continued to refuse saying he would be fine. Nurse continued with education and resident agreed to go to Hospital. (Family II) notified of plan to transfer resident, dispatch called and resident was transported to (hospital) for evaluation . 5/28/2019 (8:30 PM) Nurse's Note Late Entry: Note Text: Received call back from (Physician JJ), explained to (Physician JJ) that resident (# 35) was not tolerating the [MEDICATION NAME] and that he was coughing and I was concerned that he was going to [MEDICATION NAME] (aspirate-sic) on the [MEDICATION NAME]. (Physician JJ) said that he needed to complete the bowel prep with the [MEDICATION NAME], he recommended slowing down the [MEDICATION NAME]. Resident continued with bowel prep at a reduced pace. 5/28/2019 (7:30 PM) Nurse's Note Late Entry: Note Text: Resident was observed coughing while trying to drink bowel prep for Colonoscopy (Gastrointestinal Diagnostic Test) scheduled for 5/29/19. Lung sounds noted with crackles in bilateral upper lobes, encouraged resident to attempt to cough. Scheduled [MEDICATION NAME] given and effective. Told resident to hold off on continuing with bowel prep until I talk surgeon . 5/28/2019 (5:55 PM) Nurse's Note Late Entry: Note Text: Assessed patient's lung sounds and they are CTA (Clear To Auscultation (Listening via stethoscope) with mildly diminished bases. No c/o (complaint of) of pain or SOB. (Resident # 35) does express a dislike of the taste of bowel prep in white grape juice . Peg tube is not patent and unable to use for bowel prep. Will notify next shift to monitor LS (Lung Sounds) r/t (related to) oral intake and patient's dislike/intolerance. Advised patient to do his best and take it slow if he needed and if he continues to have difficulty we would just re-schedule. Patient wants to continue trying to take bowel prep thickened liquid. 5/28/2019 04:18 (AM) Skilled Progress Note Reason for skilled services(Not OT (Occupational Therapy) & PT (Physical Therapy)) Acute condition:[MEDICAL CONDITION](Hypertension), pneumonia due to aspiration, cerebral infarct Cognition (short&long term memory, decision making) : alert, orient x 4 (Person, Place, Time, Situation) . ADL's (transfers, bed mobility, toilet use and how they eat): requires setup for upper body care, is totally dependent for lower body care, 1-2 person transfer, diet changing, needs supervision with eating r/t to hx aspiration. taking foods/meds (medications) orally now as PEG tube is clogged and will be replaced . Nutrition/Oral Status(Diet, special needs, Dentures, etc.): PEG tube clogged at this time, taking meds and food orally without incident, will be clear liquids at 0600 (AM) and NPO (Nothing by Mouth) at midnight for upcoming procedure . 5/20/2019 (2:29 PM) Nurse's Note Note Text: Peg tube continues to be clogged, (Physician Z) aware, to arrange for him to have tube replaced . 5/20/2019 08:37 (AM) Nurse's Note Note Text: While administrating HS (bedtime) medication Peg tube became clogged. Attempted to clear peg tube unsuccessfully. Unit manager notified and AM medications held. 5/14/2019 06:46 Skilled Progress Note Reason for skilled services(Not OT&PT) Acute condition: cerebral infarct, HTN, Pneumonia due to aspiration of food Cognition (short&long term memory, decision making) : alert, orient x 4 . ADL's (transfers, bed mobility, toilet use and how they eat): needs setup for upper body care, with total dependence with lower body care, 1-2 person transfer, diet changing, needs close supervision with eating r/t dysphagia . Nutrition/Oral Status(Diet, special needs, Dentures, etc.): peg tube, reg (regular) diet ,mech (mechanical) soft, nectar thick liquids . 5/7/2019 15:25 Note for physician's orders [REDACTED]. Diet upgrade to nectar thick liquids and small chopped mechanical soft solids Small single sips and bites by spoon Chin tuck with PO (Oral) intake. Repeat effortful swallow Liquid wash for thick/sticky foods. Re-train use of compensatory strategies to include the above recommended strategies in place of multiple throat clears post swallow. (Physician Z) approved this upgrade and recommendation. RD (Registered Dietitian) notified and given copy of report. DC (Discontinue) Pleasure feeding and allow meals as ordered per resident. On 07/25/19 at 08:24 AM an interview with RN X revealed the following: When asked who discovered the PEG tube was not working, RN X stated, I did, at that point he was getting medications through the tube, and then it became clogged during a medication pass for me. It was his HS (bedtime) med (medication) pass. I sent my unit manager a conversation (form of electronic instant messaging that will go to unit manager phone and is encrypted and protected) about it, and at the same time I let the physician know about it. When asked what the physician directed, RN X stated, I honestly can't remember. He was being given [MEDICATION NAME] for a GI test. About half the container mixed with about 32 oz of liquid. When asked how was it being administered when it was started, RN X stated (Resident # 35) was drinking it. When asked if there were any family concerns brought up, RN X stated, If he aspirated, he wouldn't be able to have the test, he was crackling when I got here, I gave him a nebulizer and he cleared it. I called the (Physician JJ) to let him know what was happening, and he instructed us to slow down the administration, and that he needed to continue or they couldn't do the test. I explained (what Physician JJ instructed) to (Resident # 35), and he told me he wanted to continue. I just gave him a cup at a time. When asked if anyone followed up with (Physician Z, the facility Medical Director about (Resident # 35's) difficulty in taking the [MEDICATION NAME] prior to him having to be hospitalized , RN X stated, No, I only called the GI doctor, because he was the one who ordered the test. On 07/25/19 at 09:38 AM, an interview with RN KK Unit Manager revealed the following: When asked what the expectation of the staff would be in a situation similar to the issue Resident # 35 experienced, given his history and risk of aspiration, RN KK stated My expectation would have been . you should assess your resident, be aware of the risks, and be an advocate for your resident . if something is not safe then it should be a hard stop to make sure the safety of your resident will be maintained . I don't think the nurses felt they could question the GI doctor, and by all means they can. The safety of the resident comes first. A review of the orders revealed the following: [MEDICATION NAME] Powder (Polyethylene [MEDICATION NAME] 3350) Order- 5/22/19 1524 Give 238 gram by mouth one time only for 5/29/19 procedure bowel preparation until 05/28/2019 20:00 AT 5 PM: Mix in 64 oz (half gallon) water; review instructions in (hospital) folder On 07/25/19 at 10:00 AM, an interview with Family II revealed the following: I was fully aware of the upper GI, he had to take in a bunch of that fluid for the test, and the tube had been plugged for about a week and a half, so they were giving his meds orally to work around it. I got a phone call immediately after (Family EE) had gone up to see what was going on, and (Resident # 35) had said the fluid was too thin. According to (Family EE) and (Resident # 35), they had both asked to have (Resident # 35) sent up to the hospital and (Family EE and Resident # 35) were told (the facility) wanted to take care of it (health issue). The staff there initially told (Family EE and Resident # 35) 'No, (Resident # 35) will be fine', and kept (Resident # 35) (at the facility) at that time. Later on around 2:30 (AM) in the morning (the facility) called me and said they finally sent (Resident # 35) to the hospital. The doctor there at the emergency room told (Resident # 35), the prep should never have been given to (Resident # 35) by mouth because it was too unsafe for (Resident # 35), and that it should have been given through (Resident # 35's PEG) tube. When (Resident # 35) told (the ER Doctor) the tube was plugged, the doctor told (Resident # 35) the facility should have sent him to get it replaced when that happened. (Physician Z) saw (Resident # 35) when (Resident # 35) came back said to (Resident # 35), that (Resident # 35) should not have been taking all that fluid by mouth because it was unsafe for (Resident # 35). (Physician Z) also told (Resident # 35) that he should have told the staff that he wanted to go to the hospital at that time (when the crisis started). (Resident # 35) told (Physician Z) that both he and (Family EE) did ask to go out to the hospital because (Resident # 35) was concerned with aspirating. (Physician Z) told (Resident # 35) that he had the right to go to the hospital, and (Resident # 35) told (Physician Z) that he didn't know that. Apparently, one of the nurses decided to thicken the liquid to the point that it was sticking in (Resident # 35's) mouth and throat, and he couldn't swallow it. We talked about this issue in (Resident # 35's) care conference. (Resident # 35) wanted to know what credentials the person had who was giving him the [MEDICATION NAME]. The administrator told him 'We don't need to cry over spilled milk. He's had maybe 3 issues with aspiration that had put him in the hospital. The first one, was when he first got there, and had drank a protein shake, and he aspirated on that which caused him to have pneumonia. A review of the Census history in the EMR for Resident #35 revealed a discharge from the facility on 05/29/19 , and subsequent readmission to the facility on [DATE] following a hospitalization for Aspiration Pneumonia. Further Review indicated Resident # 35 was indeed discharged on [DATE], one day after the original admission date of [DATE]. This corresponds to the issue described shortly after admission by Family II. Resident # 35 did not return to the facility until 02/19/19. The census history also revealed another discharge on 02/27/19, and readmission on 03/02/19. One additional discharge was noted on 03/03/19, and a subsequent readmission on 03/08/19. A review of the care plan requested from the facility for Resident # 35 prior to hospitalization on [DATE] revealed the following problems/goals/interventions: (Resident # 35) requires tube feeding r/t Dysphagia ( however has been declining) , Swallowing problem, Pontine stroke w (with)/locked i[DIAGNOSES REDACTED] with swallowing difficulties, aspiration pneumonia. Date Initiated: 03/08/2019 (Resident # 35) will be free of aspiration through the review date. Regular diet; Mechanical soft (ground) texture Nectar Thick liquids A review of chest x-ray for Resident # 35 dated 5/29/19 at 03:49 AM revealed the following: Air space opacity at the lung bases, greater on the right suspicious for pneumonia/aspiration pnuemonitis. A review of the history and physical from the hospital dated 5/29/19 at 08:57 AM revealed the following: . has a history of Pontine stroke with significant left-sided [MEDICAL CONDITION] and history of recurrent aspiration and swallowing difficulties. Patient is status [REDACTED]. a long term resident of (the facility) who initially been scheduled to have an upper endoscopy and colonoscopy as an outpatient by (Physician DD). However, apparently patient stated his PEG tube get blocked and patient was not receiving tube feeding for the last two weeks at (the facility). Patient has been tried to have the bowel prep to get by oral route and patient had an episode of aspiration and patient became significantly short of breath and patient has been transferred to the emergency department . In the emergency department found to have patient has a subjective wheeze and patient found to be significantly hypoxic with 84% at room air . Chest x-ray has been done which shows patient has infiltrate in the right lower lobe consistent with aspiration pneumonia and general medicine team has been consulted for further management and plan . Anticipated length of stay is likely more than two midnights considering patient has extensive pneumonia with [MEDICAL CONDITION] and needs extensive medical management . A review of a consultation note performed by Physician DD on 5/29/19 at 02:34 PM revealed the following: . history of Pontine stroke and significant left-sided [MEDICAL CONDITION] and a history of recurrent aspiration and swallowing difficulties. He has a PEG and a Foley and is a long-term resident of (the facility) and has seen me in the office and was set up to actually have an upper and lower endoscopy today by myself, however, because his feeding tube was not working they tried to give him the prep by mouth and he aspirated. Subsequently he has been admitted here with aspiration pneumonia and I have been asked to see the patient about his feeding tube. A review of an Admission/Readmission Assessment for Resident # 35 dated 2/19/19 at 19:17 revealed a noted swallowing difficulty per the assessment. A review of an Admission/Readmission Assessment for Resident # 35 dated 3/2/19 at 13:31 revealed a noted chewing and swallowing difficulty per the assessment. A review of an Admission/Readmission Assessment for Resident # 35 dated 3/8/19 revealed under reason for admission Unresolved pneumonia cause for admission to hospital, continued need for care and pain management related to this admission at (the facility). This assessment also noted a history of swallowing difficulty. A review of an Admission/Readmission Assessment for Resident # 35 dated 6/3/19 revealed an admission to the facility from the hospital after PNEUMONITIS DUE TO INHALATION OF FOOD AND VOMIT. On 07/24/19 at 03:35 PM, an interview with Physician Zrevealed the following: When asked if it was felt taking bowel prep orally for this resident would have been safe, Physician Z stated, Bowel prep (orally) would not have been the plan at that time, but (Resident # 35) was taking his medications orally ok at that time. It was a pretty big quantity of liquid, about a liter or so. Do you feel like taking that amount of fluid orally for him would have been safe given his history? I don't think so. It's not easy for anybody to drink that amount of fluid, let alone him.

Based on observation, interview, and record review, the facility failed to accommodate the needs of two Residents (#40 and #47) when they failed to ensure adequate wheelchair lower extremity supports for Resident #47, and adequate seating and positioning for Resident #40. This deficient practice resulted in actual harm for Resident #40, including pain and discomfort, and contributed to the development/progression of an ankle contracture and right heel pressure injury, and the potential for harm for Resident #47, due to lack of support for his bilateral lower extremities, and the potential for worsened medical condition. Findings include: Resident #40: According to the Minimum Data Set (MDS) assessment, reference date 6/08/19, Resident #40 had [DIAGNOSES REDACTED]. Resident #40 required extensive, one-person assistance with bed mobility, transfers, dressing, and toileting. The Brief Interview of Mental Status (BIMS) showed a score of 5, which indicated severe cognitive impairment. During an observation on 7/23/19 at 10:35 a.m., Resident #40 was observed seated in her reclining high-back wheelchair in her room during wound care by this Surveyor and Surveyor 2. Her right foot was noted to be pointed down in a non-weight bearing posture, which appeared to be a possible contracture at the right ankle. Registered Nurse Q was asked to attempt to move Resident #40's ankle to a flat foot, weight bearing posture. RN Q reported she was unable to reposition the right foot, which appeared pointed down and internally rotated. During an observation on 7/23/19 at 5:30 p.m., Resident #40 was observed sitting in the day/dining room in her manual, high-back, reclining wheelchair, with her right lower extremity adducted (towards the body midline). Her right leg was adjacent to her left lower extremity, positioned off the right elevating footrest entirely. A soft padded boot was in place over her right foot and ankle. There was no foot cradle or wheelchair leg support pad to keep the right lower extremity (leg) from sliding off the right calf pad and footrest. Resident #40's right foot was pointed down in the soft boot. During an observation on 7/24/19 at 11:28 a.m., Resident #40 was observed in the day room, seated in her wheelchair, with her right leg and foot positioned off the elevating footrest and calf rest, dangling unsupported with the right leg adducted (positioned toward) the left leg and foot. The right foot was pointed down with the right soft foam boot positioned sideways, not fully protecting the foot and ankle from pressure against the foot pedal of the wheelchair. Review of Resident #40's most recent Physical Therapy Evaluation, provided by the Rehabilitation Director, Staff F, dated 9/11/18, revealed, R LE ROM (right lower extremity range of motion) = Impaired (right knee flexion AAROM (active assistive range of motion) 70 degrees, PF (prior function) contracture in place .WFL (within functional limits) otherwise . There was no mention of an ankle plantar flexion (foot pointed down) contracture. Review of Resident #40's Physical Therapy Discharge Summary, provided by the Rehabilitation Director, Staff F, dated 10/03/18 revealed, Long Term Goal #2-Met on 10/03/18. Resident will improve B LE ROM (bilateral lower extremity range of motion) in progressive manner to tolerate proper positioning on foot pedals to prevent decline in function and to prevent worsening of contractures. Discharge: pt (patient) is able to place feet on foot pedals . The discharge summary also included a referral to restorative therapy services; Discharge Recommendations: FMP/RNP (Functional Maintenance Program/Restorative Nursing Program) .To facilitate patient maintaining current level of performance and in order to prevent decline . Review of recent therapy screenings for Resident #40 revealed the following: 6/07/19: 8. Change in Positioning. Yes. CNA (Certified Nurse Aide) reports that patient has recently been complaining of back pain in all positions, increasing when getting out of bed. She also reports patient's left hip is increasingly internally rotated .Results of Screen. Skilled Therapy Evaluation for PT. Note was signed by Physical Therapy Assistant RR. 6/14/19: 9. Change in Positioning. Yes. LE ROM L (left) R (right) . Yes. Change in contracture. Yes. 13. Comments: Resident has increased difficulty maintaining R LE (right lower extremity) on w/c (wheelchair) leg rest. Staff report that when attempting to reposition R LE resident c/o's (complains of) increased hip pain. F. Results of Screen. Form showed 4 boxes designated 1. PT, 2. OT, 3. SLP, 4. None of the above. All boxes were unmarked, and the document was unsigned. Review of Resident #40's progress notes during June, 2019, revealed the following: 6/04/19: Resident has been c/o (complaining of) pain to her lower back . 6/07/19: (Resident) c/o pain in her lower back .she stated that it hurt when I touched her. 6/08/19: Resident continues to c/o increased pain in her lower back and at times her left hip area . Review of the form, Nursing to Therapy Communication Form, dated 7/18/19, revealed, Nursing Request: 1. Physical Therapy, Poor sitting balance. 2. Occupational Therapy. Difficulty feeding self. The bottom half of the form was incomplete, with no therapy recommendations. During an interview on 07/24/19 at 8:59 a.m., the Rehabilitation Director/Staff F, was asked when Resident #40 was last in therapy. Staff F responded, .2018. That was the last time we picked her up (for therapy services) . This Surveyor asked why Resident #40 is not currently receiving any physical or occupational therapy. Staff F acknowledged that (Staff R) did not complete the therapy screen, and added, .Since it (the screen) wasn't finished, there was no follow through . During an interview on 07/24/19 at 12:37 p.m. Certified Occupational Therapist Assistant/Staff R was asked about an incomplete screening form she completed (per the Rehabiliation Director) dated 6/14/19. Staff R responded, I was up in the (Locked dementia unit name) for other business, (Resident #40) was complaining her foot hurt her, her right foot, I talked to the nurse and looked at it as an OT (occupational therapist). I haven't worked closely with her in several years, I was going to check with the PT; they were not available at that point .It (the contracture) was observed at the knee and at the ankle. (Resident #40) wasn't placing her foot on the foot pedal at that time .It was my mistake that I didn't follow through with PT (physical therapy) .No, I didn't talk to the PT . When asked if the supervising occupational therapist sees the screens or addresses them, Staff F responded, They (the supervising occupational therapists) don't sign off on them (therapy screening forms) . Review of nursing progress note dated 7/10/2019 at 20:51 (8:51 p.m.) revealed, CNA (Certified Nurse Aide) 'BB' noted issue with feet while giving resident shower and called nurse (Registered Nurse (RN) E) in to assess. (The) nurse noted (an) unstageable decub ('decubitus' pressure ulcer) to inner rt heal 2.5 x 2 cm . Review of Resident #40's facility weekly skin/wound notes revealed the following: 7/11/19: Stage one pressure wound on inner lateral aspect of her right foot. Wound is blue/black at center and fades to red at outer rim. Circular wound measures 2 cm. Skin intact. Current treatment: Skin prep. Continue to float heels on bed. Remove (name brand compression) hose until further notice . 7/22/19: Unstageable. R inner ankle, 2.2 cm x 1.8 cm. Circular ulcer with black eschar in wound bed. Skin is intact. Current treatment: Skin prep . Review of the policy Therapy Screenings, unsigned, dated 2/2013, revealed, After a screen is completed, if therapy is recommended, orders will be requested from the facility Review of the policy, Pressure Ulcer Prevention and Management, revised 4/07/17, revealed, Unstageable pressure ulcer is characterized by full-thickness tissue loss in which the base of the ulcer in the wound is covered by slough, eschar, or both . During an interview on 7/23/19 at 10:17 a.m., RN Q was asked about the cause of the new pressure ulcer on Resident #40's right foot/heel. RN Q responded, I think it's (due to) the foot pegs on the wheelchair During an interview on 7/25/19 at 9:10 a.m., with Registered Nurse (RN) T and the Director of Nursing (DON) present, RN T was asked about Resident #40's positioning in her wheelchair. RN T responded, (Resident #40's) foot appears contractured, and confirmed it was a change in the right foot for this resident. RN T added that she put a pillow underneath the right leg, and asked therapy to evaluate/screen Resident #40 today. This Surveyor reviewed with the DON that Resident #40 had at least two referrals (screens) to therapy which were not completed. The DON acknowledged this, and added a third referral on 7/18/19 for feeding/positioning this month had also not been completed. The DON confirmed Resident #40 was not receiving any facility therapy services at that time, despite the three referrals for therapy. During an observation with the DON on 7/25/19 at 9:16 a.m., the DON accompanied this Surveyor to the locked unit to observe Resident #40's position in her wheelchair. Resident #40 was found sacral sitting (sliding forward) on her wheelchair seat (cushion); her right foot was observed in a soft boot and was pointed down, positioned off the footrest. The left elevating footrest anchor was unlocked, which caused the left leg to be abducted (away from the midline of the body) to the left side. The DON acknowledged Resident #40 was not positioned appropriately in her wheelchair. The DON was asked if it appeared Resident #40 had a contracture of the right foot. The DON checked the range of motion of Resident #40's foot with her permission and responded, Yes, this is a contracture. Resident #40 then pointed to her right leg and foot, and reported, That hurts all the time, my leg and foot. Resident #47 Review of the medical facesheet revealed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Sets (MDS) assessment dated [DATE], revealed Resident #47 was cognitively intact (BIM 15/15) and required extensive assist from 1 to 2 facility staff members with activities of daily living (ADL's). Review of the Occupational Therapy (OT) evaluation/treatment plan dated 4/8/2019 through 5/6/2019, revealed a plan that included wheelchair positioning for trial of varying positions/pressure relief aides to decrease the risk of skin breakdown/injury and to facilitate comfort and support. The Resident was identified to utilize a tilt in space wheelchair with standard footrests though it was acknowledged that due to lower extremity deformities, he did not use the footrests often. The evaluation documented the Resident's leg rests were standard but the Resident's . knees flexed significantly and behind footrests, unable to tolerate straightening of his knees to place in standard footrests for any length of time as the patient begins arching his back and pushing up . The report documented his body alignment as impaired due to maximally flexed knees and ankle deformities and is unable to tolerate on leg rests or in a 90 degree position. The evaluation continued with a determination for staff to utilize to determine the Resident's pain level based on behaviors exhibited by the patient; arching/pushing away with movement of the lower extremities to the footrests. On 7/22/2019 at 12:10 pm, Resident #47 was observed seated in his tilt in space wheelchair, in the main dining room, with his bilateral lower extremities dangling unsupported between the footrests. He was observed to arch his body, then straighten it out so as to reposition himself. On 7/24/2019 at 9:04 am, Resident #47 was observed seated in his tilt in space wheelchair, in the hallway, with his bilateral lower extremities dangling unsupported between the footrests. He was observed to arch his body, then straighten it out so as to reposition himself. On 7/25/2019 at 9:37 AM, Resident #47 was observed to arch his back and hyperextend his legs in effort to reposition self in his wheelchair. His legs were then observed to drop forward, behind his footrests, and he again attempted to reposition them, unsuccessfully, to the footrests. His lower extremities then remained positioned out over the thick seat of his wheelchair in a dangling, cross-legged, dependent position. He then was observed to pull his cross-legged lower extremities up tight against the underside of his wheelchair seat. During an interview, he told the Surveyor he does not like new things, . but a new wheelchair might be good for me. He said it might relieve some of his pain. He stated he experienced pain of his hips and shoulders. During a phone interview on 7/24/2019 at 10:55 am, Registered Occupational Therapist (OTR) G said, I spoke with the family at care conference. We've tried to position him; he repositions himself. If you move him he arches his body due to discomfort. We padded his leg rests. He doesn't like his feet positioned outward to the area of his footrests; it sets him off and he arches. He needs a calf support board; something that keeps his legs out in front of the footrests. We really need to get a specialized wheelchair company in to evaluate him; I'll talk with the administrator. During an interview on 7/25/2019 at 7:50 am, the Nursing Home Administrator said, Our goal is to get him (Resident #47) a special wheelchair to meet his needs. I have no issue with that. During an interview on 7/25/2019 at 8:20 am, the Director of Nursing said, I think he (Resident #47) probably needs a specialty wheelchair at this point. We want to give him comfort, but also maintain his abilities. It's time to go forward.

This citation has two deficient practices, A. and B.: A. Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to prevent a pressure injury from developing for one Resident (#40) of four residents reviewed for skin integrity. This deficient practice resulted in actual harm, with the development/progression of a right heel deep tissue pressure injury. Findings include: According to the Minimum Data Set (MDS) assessment, reference date 6/08/19, Resident #40 had [DIAGNOSES REDACTED]. Resident #40 required extensive, one-person assistance with bed mobility, transfers, dressing, and toileting. The Brief Interview of Mental Status (BIMS) showed a score of 5, which indicated severe cognitive impairment. Review of Resident #40's facility skin incident report, dated 7/10/19, revealed, CNA (Certified Nurse Aide) 'BB' called this nurse (Registered Nurse (RN) E) into shower room for skin issue noted on resident's inner right heal .nurse noted an unstageable decubitus (pressure injury) to inner right heal of foot 2.5 cm x 2cm black base with red and white boarders (sic) . The facility weekly skin/wound notes for Resident #40 revealed the following: 7/11/19: Stage one pressure wound on inner lateral aspect of her right foot. Wound is blue/black at center and fades to red at outer rim. Circular wound measures 2 cm. Skin intact. Current treatment: Skin prep. Continue to float heels on bed. Remove (name brand compression) hose until further notice. 7/22/19: Unstageable. R inner ankle, 2.2 cm x 1.8 cm. Circular ulcer with black eschar in wound bed. Skin is intact. Current treatment: Skin prep. The medical staff/physician note dated 7/12/19 for Resident #40 revealed: 7/12/2019: She (Resident #40) was seen today for follow up visit. She (Resident #40) has developed a new deep tissue injury on her right heel last 2 days. Skin is still intact . Review of a Quarterly Braden Risk Assessment for Resident # 40 dated 6/10/19, revealed the following: 6/10/19 Quarterly: Score 11. High Risk (of pressure sore development). The skin care plan for Resident # 40, with a review date of 6/11/19, revealed: (Resident #40) is at risk for skin breakdown due to impaired mobility, bowel and bladder incontinence, hx (history) of breakdown to her heels, occasional poor PO (by mouth) intake, and presence of multiple bony prominences 7/10/19 DTI (deep tissue injury) right heel .Date initiated: 7/06/18 During an interview on 7/23/19 at 10:17 a.m. Registered Nurse (RN) Q was asked about the cause of the new pressure wound on Resident #40's right foot. RN Q responded, I think it's (due to) the foot pegs on the wheelchair . During an observation on 7/23/19 at 10:24 a.m., Resident #40 was observed seated in her reclining high-back wheelchair in her room prior to wound care observation by this Surveyor and Surveyor 2. Surveyors noted Resident #40 was wearing a soft foam padded boot, however, her foot/leg was not fully supported by the footrest, and the back and bottom of the boot was observed against the edge of the footrest. Her right foot was noted to be pointed down in a non-weight bearing posture, which appeared to be a possible contracture at the right ankle. Registered Nurse Q was asked to attempt to move Resident #40's ankle to a flat foot, weight bearing posture. RN Q reported she was unable to reposition the right foot, which was also internally rotated. During wound observation at 10:37 a.m., Surveyors observed Resident #40's right foot wound with her permission. The nickel-sized wound was located on the inner (medial) right heel. The wound was dark black and purple with central eschar, with a linear central eschar area of 1.5 cm. Nurse (RN) Q sprayed skin prep to the wound, and then reapplied the soft positioning boot. This Surveyor observed the right foot was not adequately supported by the wheelchair footrest, which may have contributed to pressure to the foot/leg. During an observation on 7/23/19 at 5:30 p.m., Resident #40 was observed sitting in the day/dining room in her manual, high-back, reclining wheelchair, with her right lower extremity adducted (positioned towards) the left lower extremity, off the right elevating footrest entirely. A soft padded boot was in place over her right foot and ankle. There was no foot cradle or wheelchair leg support pad to keep the right lower extremity (leg) from sliding off the right calf pad and footrest. Resident #40's right foot was pointed down in the soft boot; the right foot appeared unable to achieve a flat foot position, required for weight-bearing. During an observation on 7/24/19 at 11:28 a.m., Resident #40 was observed in the day room, seated her wheelchair, with her right leg and foot positioned off the elevating footrest and calf rest, dangling unsupported with the right leg adducted (moving towards body midline), adjacent to the left leg and foot. The right foot was pointed down, with the right soft foam boot positioned sideways, not protecting the foot and ankle from pressure against the foot pedal of the wheelchair. During an interview on 7/24/19 at 9:03 a.m., Resident #40's facility physician, Dr. Z, was asked during a phone interview about the recent pressure wound. Dr Z reportedly referred to his notes, and responded, .We are talking about the right heel .It's hard to say how (Resident #40) developed it, she may have bumped it. It is a deep tissue injury, the skin was intact .Sometimes, if someone is in a wheelchair a number of hours every day, that could .cause that. (We will) let it heal over time, it's going to take a few weeks . Review of Resident #40's most recent Physical Therapy Evaluation, provided by the rehabilitation director, Staff F, dated 9/11/18, revealed, R LE ROM (right lower extremity range of motion) = Impaired (right knee flexion AAROM (active assistive range of motion) 70 degrees, PF (prior function) contracture in place .WFL (within functional limits) otherwise . There was no mention of an ankle plantar flexion (toe pointed down) contracture. Review of Resident #40's most recent Physical Therapy Discharge Summary, provided by the rehabilitation director, Staff F, dated 10/03/18, revealed, Long Term Goal #2-Met on 10/03/18. Resident will improve B LE ROM (bilateral lower extremity range of motion) in progressive manner to tolerate proper positioning on foot pedals to prevent decline in function and to prevent worsening of contractures. Discharge: pt (patient) is able to place feet on foot pedals . The discharge summary also included a referral to restorative therapy services, Discharge Recommendations: FMP/RNP (Functional maintenance program/Restorative nursing program) .To facilitate patient maintaining current level of performance and in order to prevent decline . Review of recent therapy screenings for Resident #40 revealed the following: 6/07/19: 8. Change in Positioning. Yes. CNA (Certified Nurse Aide) reports that patient has recently been complaining of back pain in all positions, increasing when getting out of bed. She also reports patient's left hip is increasingly internally rotated .Results of Screen. Skilled Therapy Evaluation for PT. signed by physical therapy assistant, Staff RR, dated 6/07/19. 6/14/19: 9. Change in Positioning. Yes. LE ROM L (left) R (right) . Yes. Change in contracture. Yes. 13. Comments: Resident has increased difficulty maintaining R LE (right lower extremity) on w/c (wheelchair) leg rest. Staff report that when attempting to reposition R LE resident c/o's (complaints of) increased hip pain. F. Results of Screen. Form showed 4 boxes designated 1. PT, 2. OT, 3. SLP, 4. None of the above. All boxes were unmarked, and the document was unsigned. Review of Resident #40's progress notes during June, 2019, revealed the following: 6/04/19: Resident has been c/o (complaining of) pain to her lower back . 6/07/19: (Resident) c/o pain in her lower back .she stated that it hurt when I touched her. 6/08/19: Resident continues to c/o increased pain in her lower back and at times her left hip area . Review of the form, Nursing to Therapy Communication Form, dated 7/18/19, revealed, Nursing Request: 1. Physical Therapy, Poor sitting balance. 2. Occupational Therapy . The bottom half of the form was incomplete, with no therapy recommendations. During an interview on 07/24/19 at 8:59 a.m., the Rehabilitation Director/Staff F, was asked when Resident #40 was last in therapy. Staff F responded, (YEAR). That was the last time we picked her up (for therapy services) . When asked why Resident #40 was not currently receiving any physical or occupational therapy, Staff F acknowledged Staff R did not complete the therapy screen, and added, .Since it (the screen) wasn't finished, there was no follow through . During an interview on 07/24/19 at 12:37 p.m. Certified Occupational Therapist Assistant/Staff R was asked about an incomplete screening form she completed (per the rehab director), dated 6/14/19. Staff R responded, I was up in the (Locked dementia unit name) for other business, (Resident #40) was complaining her foot hurt her, her right foot. I talked to the nurse and looked at it as an OT (occupational therapist). I haven't worked closely with her in several years, I was going to check with the PT; they were not available at that point .It (the contracture) was observed at the knee and at the ankle. (Resident #40) wasn't placing her foot on the foot pedal at that time .It was my mistake that I didn't follow through with PT (physical therapy) .No, I didn't talk to the PT . This surveyor asked if the supervising occupational therapist sees the screens or addresses them. Staff F responded, They (the supervising occupational therapists) don't sign off on them (the screenings) . Review of facility document labeled, Restorative Program, unsigned and undated, provided by the Director of Nursing (DON), revealed Resident #40 was not receiving restorative services for range of motion or ambulation. The DON directed this Surveyor to speak with Clinical Manager, RN (Registered Nurse) S, to ascertain if Resident #40 had received any restorative services since her discharge from therapy in (YEAR). During an interview on 7/24/19 at 12:54 p.m. the Clinical Manager/RN S, was asked if Resident #40 had been restorative services since her therapy discharge in (MONTH) (YEAR), per therapy referral at that time. RN S responded, I am not in charge of it (the restorative program); the previous unit manager on rehab was in charge I do not believe so I have been doing this position since the end of (MONTH) this year. (There is) no record of anything with restorative services (for Resident #40) . During an interview on 7/24/19 at 1:46 p.m., the Director of Nursing (DON) was asked to clarify who oversees restorative services. The DON responded I guess I'm charge of it now, (new hire name) is being trained as the new restorative nurse .Yes, that is our current list (of residents on restorative services). I went through active care plans. I don't see anything in the current care plans. Correct, there were no restorative services (for Resident #40) in the last year. During an interview on 7/25/19 at 9:10 a.m., with Registered Nurse (RN) T and the DON present, RN T was asked about Resident #40's positioning in her wheelchair. RN T responded, (Resident #40's) foot appears contractured. and confirmed it was a change in the right foot for this resident. RN T added she put a pillow underneath the right leg, and asked therapy to evaluate/screen Resident #40 today. This Surveyor reviewed with the DON that Resident #40 had at least two referrals (screens) to therapy which were not completed. The DON acknowledged this, and added a third referral on 7/18/19 for feeding/positioning this month had also not been completed. The DON confirmed Resident #40 was not receiving any facility therapy services at this time, despite the three nursing referrals for therapy. During an observation with the DON on 7/25/19 at 9:16 a.m., the DON accompanied this Surveyor to the locked dementia unit to observe Resident #40's position in her wheelchair. Resident #40 was found sacral sitting (sliding forward) on her wheelchair seat (cushion); her right foot was observed in a soft boot and pointed down, positioned off the footrest. The left elevating footrest anchor was unlocked, which caused the left leg to be abducted (away from the midline of the body) to the left side. The DON acknowledged Resident #40 was not positioned appropriately in her wheelchair. The DON was asked if it appeared Resident #40 had a contracture of the right foot. The DON checked the range of motion of Resident #40's foot with her permission and responded, Yes, this is a contracture. Resident #40 then pointed to her right leg and foot, and reported, That hurts all the time, my leg and foot. The DON acknowledged potential causes for the pressure injury may be from the footrest positioning, newly wearing slippers, or the [NAME] hose, which were discontinued after the pressure wound was discovered. Review of the facility policy, Pressure Ulcer Prevention and Management, revised 4/07/17, revealed, To establish a system to prevent and manage resident(s) pressure ulcers .Staging. 1. Suspected Deep Tissue Injury/Unstageable is characterized by a purple or maroon localized area of intact skin or blood-filled blister that results from damage to underlying soft tissue from pressure or shear. The depth of the suspected deep tissue injury is unknown .6. Unstageable pressure ulcer is characterized by full-thickness tissue loss in which the base of the ulcer in the wound bed is covered by slough, eschar, or both. Until enough slough or eschar is removed to expose the base of the wound, the true depth and therefore, stage, can't be determined . B. Based on interview and record review, the facility failed to follow the physician order for [REDACTED]. Findings include: The medical facesheet revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Sets (MDS) assessment dated [DATE], revealed Resident #24 was severely cognitively impaired (BIM 6/15), and required extensive assist from 1 to 2 facility staff members with activities of daily living (ADL's). Review of the care plans, initiated 11/19/2012, revealed Resident #24 was identified with presence of chronic pressure ulcers of her gluteal fold and right upper buttocks due to history of skin breakdown, incontinence, noncompliance with preventive measures, immobility, and co-morbidities. Listed as goals of treatment were, Will remain free of further alteration in skin integrity and will heal without complications. An intervention to the plan of care included, Treatment to right gluteal fold, right upper buttock open area as ordered and directed. The Braden skin assessment dated [DATE], revealed Resident #24 continued to be at risk for pressure ulcers. The facility policy and procedure entitled Pressure Ulcer Prevention dated 4/7/2017, and provided to Surveyors by the Director of Nursing on 7/24/2019 at 3:18 pm as the current policy and procedure utilized by facility staff, states, Treatments shall be completed using established guidelines within the community and orders received from the physician. The physician order dated 5/20/2019 (untimed), specified Resident #24's pressure ulcers should be cleaned with saf clens, pat dry, wet to dry dressing to tunneling, apply skin prep around wound, cover with Allevyn, change daily and as needed. According to the nurses note dated 7/22/2019 at 23:25 am, Registered Nurse (RN) [NAME] documented, Resident tried to communicate that she needed brief change at 23:00. While this process was being done CNA (certified nurse aide) noted No dressing to wounds to buttock and no packing in wound. During an interview on 7/24/2019 at 7:25 am, RN [NAME] said, Wound care was done earlier on my shift on 7/23/2019. I received report from LPN N at 10:45 pm that the Resident (#24) was ok; nothing specific to the wound. A CNA (M) told me that during bed check there were no dressings on her (R#24) bottom, when the brief was changed. I went to look and there was no dressing in place and none on the bed. She is dependent on all ADL's and no use of her right side. Her dressing was not reachable for her. It's on her right gluteal fold, and her diaper was intact. I looked all around her bedside and did not see any of her dressing or packing in the area of her bed. I looked specifically for the dressing. Later my aides told me my Resident's (#24) dressing was found, dated 7/22/2019, in the shower room on the floor, not in the trash. I only have 2 residents with dressings, (identified as Residents # 43 and R# 24); the other resident was found with his dressing intact. Her (#24) pressure ulcer is a stage 4 , with tunneling. The CNA (M) left the diaper as it was , so that I could see what she was seeing; the diaper was not soiled, but it was damp with urine. That puts that resident at risk for wound contamination. The wound care was not done as it was ordered. I have worked this Resident for the past 90 days, as of yesterday. I have not seen this Resident pull out her dressing, and I haven't received any report from other nurses or CNA's that she has removed her dressing. During an interview on 7/25/2019 at 7:30 am, CNA M said, I've worked with this Resident (#24) for along time. (CNA O) was filling in on our hall, and reported to me she just put the Resident on the bedpan, taken her off, and cleaned her up. I noticed a wet spot on the resident's chux, removed her brief, and didn't see any of her dressings (cover and packing). I showed the nurse (RN E). During an interview on 7/24/2019 at 5:07 pm, LPN N said, It was not reported to me that night by my CNA (O) that there was a problem with the Resident's (#24) dressing or packing. If it had become soiled or would have come off, and reported to me or any nurse, it should have been changed. I was told prior to giving report to the night nurse (RN E) that night that the dressing was dry and intact, prior to report. I did see the dressing, earlier on my shift about 8:30 pm; the dressing was intact. I was working with (CNA O), an aide; she doesn't typically work our 300's hall, she works on 200's hall. If the dressing had been soiled, or had come loose or had needed to be changed for any reason, CNA O was expected to notify me; she didn't. During an interview on 7/24/2019 at 5:23 pm, CNA O said, I know her, not well 'cause I don't typically work that hall. I was working with (LPN N). I didn't give the Resident a shower that night. I did change her brief. She also used the bedpan; I did help her get on it. I was not aware she had a dressing on her backside. I seen a pink pad on her lower bottom and gauze. The gauze was obvious on her butt cheek area. The pink pad was over her tail bone area or higher. I could see the gauze under the pink pad or just a bit lower; the dressing and the gauze were coming loose from the wound. I didn't report it to the nurse. It wasn't soiled. It was not wet at that time. Didn't seem to see any urine flow back to that area. She did move her bowels. Stool didn't get the dressing soiled. I would've let the nurse know. She used the bedpan more than one occasion that night. She rolled side to side. I was only on that floor 'til 11 pm. I didn't take any break until 11 pm, when I got to the next assignment on rehab. I gave her a bed bath that night before bed, around 9 or 10 pm. I didn't see the dressing, I don't know that it slid; it just was covering another location. It looked like there were 2 dressings back there. During an interview on 7/25/2019 at 7:50 am, the Nursing Home Administrator said, Staff are to do wound care as ordered. My understanding is that the wound dressing fell off and may not have been replaced. That should have been picked up by staff and the dressing replaced as soon as it was discovered off the resident. During an interview on 7/25/2019 at 8:20 am, the DON said, (Resident #24) was found without a dressing and packing. Loss of the dressing would lead to an infected wound and she is incontinent. I expect dressings done as ordered and they should be monitored to be sure they're in place.

This citation has two deficient practices, A. and B.: A. Based on interview and record review, the facility failed to conduct a root cause analysis of multiple falls and implement and implement appropriate interventions to prevent falls with injury for one Resident (#226) out of four reviewed for falls. This deficient practice resulted in repeated falls with lack of appropriate intervention to prevent injury. Findings include: A review of Resident #226's record revealed he had admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #226 expired in the facility on [DATE]. A review of Resident #226's fall reports revealed the following falls and interventions: [DATE] - . resident (found) crawling on hands and knees in hallway . Unwitnessed fall. [DATE] followup note revealed, .Medication changes noted [DATE]: Increase in [MEDICATION NAME] and addition of [MEDICATION NAME] . Ensure environment is clear of obstacles. Care plan reviewed and updated . [DATE] - (Resident #226) had a witness(ed) fall this morning at 0715 (a.m.) in his bedroom. He was walking backwards and lost his balance . has some redness under his right upper arm . [DATE] follow up note revealed, . Care plan reviewed: Included on care plan is to ensure (Resident #226) has non-skid footwear on when up and about. This has been reinforced for safety . [DATE] - CENA (Certified Nursing Assistant) heard a loud noise from resident's room . observed resident on the floor lying on the left side with head against the big wheel of wheelchair . observed resident lying on left side with blood noted on the floor . Nurse cleanse resident on cheeks and back of left ears and noted that left rear top of head was bleeding. Cleanse and applied pressure that developed to huge hematoma about 10 cm (centimeters) x 5 cm. Send to ED (Emergency Department) . Follow up progress note on [DATE] revealed, .Following this fall occurrence, IDT (interdisciplinary team) met [DATE]. Family agreeable for Memory Care transition. (Resident #226's) room is close to the nurses station and common area for heightened supervision. [DATE] - Resident fell next to his closet, the cena notified me that 'When I got to the resident's room to check on him, I seen him walking to his closet, lose his balance and fell on to his bottom. [DATE] followup note revealed no new interventions. [DATE] - At approx. 0335 (3:35 a.m.) I was alerted to residents room by CNA. Upon arrival I found resident asleep in bed with blood dripping down the right side of his face and on his right knee. Upon assessment after I cleaned the wound he was found to have several small skin tears around his right orbit with some redness. Upon investigation of the scene it was found that the wheelchair was parked closely to the bed with minimal (sic?) to get to the bathroom. Resident stated that he went to the bathroom and got dizzy on his way back. Resident reminded to ask for assistance and his walker was made available as he will likely forget. Increased frequency of checks . [DATE] - CENA called to room, resident was sitting on floor, CENA was holding compress of paper towel to bleeding nose. After ,[DATE] min (minutes) resident stopped bleeding and was able to transfer self from floor to bed to sit . small hairline laceration noted to left nostril . saw (Resident #226) standing up without his wheelchair in his room . quickly got up to assist him back into bed, as he was repositioning himself from foot of bed to closer to head of bed . he lost his balance and fell to floor hitting nose on bedside waste basket . [DATE] follow up note included the intervention of, . requested Pharmacy Medication review. Care plan reviewed and updated . [DATE] - This nurse heard a loud noise from Resident's room. Went to this room and observed him sitting on the floor at the end of his bed. Call light was within reach . [DATE] follow up note revealed, .Updated with intervention: During periods of anxiety, attempt to calm, redirect with calm voice. Offer foods/fluids. Spend some time with (Resident #226) in a quiet area . [DATE] - Notified by Cena that Resident was sitting on the floor in his room. Writer observed resident in sitting position with his back up against the bathroom door . Review of [DATE] follow up note, . care plan reviewed and remains appropriate . No new interventions were added. [DATE] - While at the desk charting I heard a loud noise. I went to walk down the hall and saw that (Resident #226) was sitting on the floor at the foot of his bed [DATE] follow up note revealed, .plan: PT (physical therapy) to screen post fall occurrence . [DATE] - I was sitting at the desk and I heard a crash. I went to investigate and observed (Resident #226) laying on the floor next to his sink. He was attempting to get off the floor and was was able to make it to a sitting position . unable to say if he was in pain but when I asked him if he hurt anywhere he put his hand on his side over his ribs on the right side . A review of the [DATE] follow up note revealed, . at risk for falls r/t (related to) altered gait (and) balance 2 (secondary to) potential [MEDICAL CONDITION] disease and diminished safety awareness 2 (secondary to) dementia. Does not remember to use his call light or that he needs staff assist for steadiness/safety. New [DIAGNOSES REDACTED]. Interventions reviewed: Along with 15 minute checks, staff ensure (Resident #226) is wearing appropriate footwear, environment clear of obstacles . [DATE] - This nurse was sitting at nursing station heard noise from residents room, went to room and observed resident on floor beside bed. CNA and nurse have been doing 15 minute visual checks due to resident frequently attempting to go to the bathroom unaided . Resident was sent to hospital for evaluation of need for stitches . A review of a [DATE] follow up note revealed, .additionally, a sensor alarm has been added to his bed given increase frequency of falls . A review of the progress notes for Resident #226 revealed the following: [DATE] .MRI (Magnetic Resonance Imaging) shows progression and resident probably has a [DIAGNOSES REDACTED] ([DIAGNOSES REDACTED]). MD (doctor) estimated on his notes that it could be stage 3 or 4 (advanced stage) . [DATE] . late entry for 0940 (a.m.) : resident remains confused/disoriented, does not remember or know what happened last night (ie-ER visit). he has 3 staples to right parietal area . re-educated resident to call for assistance, call-light in place. [DATE] Right eye ecchymotic (brusing) with minimal swelling. Denies pain, and no new skin issues since recent fall . [DATE] 0300 nurse and cna heard loud noise come from residents room. observed resident on floor bleeding from temple . applied pressure to laceration to rt (right) temple . called supervisor who agreed that resident might need stitches to laceration approx. ,[DATE] inch long. bruise also noted to rt cheek of face [DATE] Wound on right side of forehead secured with steri-strips . [DATE] progress note by Registered Nurse (RN) E, Received call from (Administrator) at 1915 (7:15 p.m.) instructing (Resident #226's) bed to be put in the low position with matts(sic) on either side on floor as well as motion sensor. A review of Resident #226's Falls care plan initiated [DATE] revealed the following interventions: 15 minute checks (initiated [DATE]) . anti-tip bars to w/c (wheelchair) (initiated [DATE]) .anticipate and meet residents needs ([DATE]) . assist (Resident #226) to the bathroom upon rising, before, after meals, HS (at hour of sleep) and PRN (as needed) ([DATE]) . Be sure the residents call light is within reach and encourage/remind him to use it for assistance. He needs prompt response to all requests for assistance ([DATE]) .low bed with bedside matts ([DATE]) . Sensory alarm added to bed ([DATE]). On [DATE] at 10:00 a.m., an interview was conducted with the Director of Nursing (DON). When asked if interventions were documented on the care plan on the dates they are initiated, the DON stated, Yes. That is the policy. When asked to confirm esident #226's care plan intervention of 15 minute checks was not initiated until [DATE], the DON stated, I dont know. I can't answer that question. The Administrator stated, They (15 minute checks) may have been more sporadic. It may have been when they saw he was restless so they (nursing staff) started them. When asked why the sensor alarm to the bed was not initiated until after Resident #226 had had multiple falls in his room, he Administrator stated, I thought he had one (alarm) on the other unit. (Registered Nurse (RN) S) would know more. On [DATE] at 10:10 a.m., RN S was asked whether the 15 minutes checks were started prior to [DATE] and stated, I can't really remember. When asked why the sensor alarm wasn't added as an intervention until [DATE], RN S stated, He wasn't falling from bed. RN S reported that Resident #226 was falling after he was already up unassisted in his room. When asked if Resident #226 was supposed to be up ambulating and transferring independently, RN S stated, He was independent originally. But he wasn't safe to be up unsupervised toward the end. On [DATE] at 10:55 a.m., a phone interview was conducted with RN E. When asked if she had taken care of Resident #226 while he resided on the Memory Care unit, RN [NAME] stated, Correct. When asked what kinds of interventions were in place to prevent Resident #226's falls, RN [NAME] stated, We did 1:1 visuals when in the common area, we had a movement sensor, and a low bed and floor pads. When asked when the movement sensors were added, RN [NAME] stated, Toward the end of his time here. When asked why the sensors were not started sooner, RN [NAME] stated, I don't know, because I requested and requested and requested them. I don't know if you can track all time times I requested it, but we (nursing staff) did and they (IDT team) never responded to it. When asked if the IDT team ever consulted with the staff involved in the falls to get their input, RN [NAME] stated, No, not from me anyway. On [DATE] at 11:13 a.m., a phone interview was conducted with CNA U. When asked about Resident #226's falls, CNA U stated, He fell really often. Mostly at night. When asked if Resident #226 had a sensor alarm that would help to notify staff when he was getting up unassisted, CNA U stated, He did, but not until after he went to the hospital (the second time, [DATE]). When asked if she felt that if the intervention of the sensor alarm had been initiated earlier in his stay rather than after the repeated falls, it would have help the staff to minimize his falls, CNA U stated, Yes. And to be honest, I talked with more than one nurse about getting a sensor for him and they didn't do anything. It was really hard trying to keep track of him and take care of everyone else. A review of the facility policy titled, Falls Prevention, Analysis and Follow-up revised ,[DATE] revealed, .The Community shall ensure that a system is in place for managing falls and identifying interventions related to residents at risk for falls . 4. Safety devices including, but not limited to, an alarm, motion detector (sensor), mat on the floor or low bed will be provided on admission and as needed when a resident is at risk for a fall .all interventions will be included on the care plan . B. Based on observation, interview and record review the facility failed to ensure the resident environment was free from accident hazards as evidenced by: 1. Water temperatures at sinks and other fixtures used by residents exceeding 130°F potentially affecting 64 of the 84 residents in the facility by causing scalding burn injuries. 2. Free standing wardrobe cabinets unsecured and able to be rotated forward potentially falling on residents and trapping them under and/or inside, potentially affecting 21 of 84 residents in the facility. Findings include: 1. On [DATE] at 12:20 PM observations were made of hot water temperatures at sink faucets in the following Resident rooms with the aid of a super fast Thermapen digital thermometer: room [ROOM NUMBER] =128°F room [ROOM NUMBER] =124°F room [ROOM NUMBER] =125°F room [ROOM NUMBER] =126°F room [ROOM NUMBER] =126°F On [DATE] at 12:25 PM the following temperatures were measured in Rehab dining room hand sink while running hot water: 130°F On [DATE] at 12:27 PM the following temperatures were measured in resident rooms at the sink faucet while running hot water: (locked unit) room [ROOM NUMBER] = 127°F room [ROOM NUMBER] =127°F room [ROOM NUMBER] shower room sink =127°F On [DATE] at 12:35 PM the following temperatures were measured in resident rooms at the sink faucet while running hot water: room [ROOM NUMBER] =128°F room [ROOM NUMBER] =128°F room [ROOM NUMBER] =130°F room [ROOM NUMBER] =130°F room [ROOM NUMBER] =130°F On [DATE] at 12:44 PM the following temperatures were measured in resident rooms at the sink faucet while running hot water: room [ROOM NUMBER] =124°F room [ROOM NUMBER] =120°F room [ROOM NUMBER] =124°F room [ROOM NUMBER] =114°F On [DATE] at 2:50 PM the following temperatures were measured in resident rooms at the sink faucet while running hot water: room [ROOM NUMBER] =132°F room [ROOM NUMBER] =133°F On [DATE] at 3:00 PM observations were made with the supervisor of environmental services A. Staff A accompanied this surveyor to resident rooms [ROOM NUMBERS]. Staff A measured the stream of water in these rooms while running hot water and the following was observed by both Staff A and this surveyor using separate thermometers. room [ROOM NUMBER] = 130°F room [ROOM NUMBER] = 129°F Staff A stated Oh that's too much when the temperature readout on the thermometer was observed. On [DATE] at 3:10 PM an interview with Staff A was conducted and Staff A confirmed that the 200, 300 and 400 resident hallways and the hot water plumbing were all on the same loop (same water heaters and mixing valves.) At this same time the mixing valve and attached thermometer, located in boiler room were observed. The thermometer was reading 130°F. Staff A stated it reading 115°F. When it was pointed out that the thermometer was actually reading 130°F, Staff A responded by stating Oh, it just jumped up. The thermometer did not, in fact, move during the 5 seconds it was being observed. Staff A went on to stated This is a brand new unit and it struggles. it's (mixing valve) a couple of years old. The facility was requested to provide documentation that hot water temperatures were being monitored. Tthe documents titled Domestic Hot Water Random Temperature check in Resident Rooms for years (YEAR) and 2019 were provided and reviewed. The following was documented on the monitoring forms: On (MONTH) 21, 2019: Resident room [ROOM NUMBER] was documented at 122°F; Resident room [ROOM NUMBER] was documented at 124°F; and Resident room [ROOM NUMBER] was documented at 122°F. There was no evidence the facility conducted subsequent monitoring to ensure the temperatures at resident room sinks were decreased to a safe level. Further review of the hot water monitoring forms was made and the following was documented: On (MONTH) 17, 2019 resident room [ROOM NUMBER] water temperature was documented at 131.3 °F; Resident room [ROOM NUMBER] documented at 131.5°F and resident room [ROOM NUMBER] was documented at 131.2°F. Again, there was no evidence the facility conducted subsequent monitoring to ensure the temperatures at resident room sinks were decreased to a safe level. On [DATE] at 04:54 PM an interview was conducted with the administrator and Staff A. Staff A was asked to show evidence the facility had monitored and ensured that the water temperature at resident room sinks had been decreased to a safe level, but no evidence that any follow up was conducted after the (MONTH) 17, 2019 readings when temps exceeded 130°F. Staff A stated there was no documentation. When asked if the water temperature had been decreased, Staff A stated Yes. When asked how he knew it had been decreased and to what level, Staff A stated I don't remember. When asked how it was accomplished and who was responsible for it, Staff A stated It was verbal. Staff A went on to say They did something with the mixing valve a few years ago. I don't know what. Staff A continued and stated When there is low usage of hot water the temperature can increase. When asked how that can happen when there is no additional energy added to heat the water and the fact there is a circulation pump on the hot water system. Staff A did not answer. On [DATE] at 08:21 AM an interview was conducted with Maintenance staff D. Staff D stated he was not asked to do any monitoring after the (MONTH) 17 high temperature finding. Staff D stated Staff B was responsible for that. He is a contingent and does the tweaking of the valve. On [DATE] at 08:40 AM a phone interview was conducted with Staff B who stated when asked about the high water temperature readings from (MONTH) 17, 2019: If I am asked to do it at 3:00 PM I don't; have enough time to go back and do it. When asked if Staff A had told him to continue to monitor, Staff B stated I can't say for sure if he did or not. Staff A was aware of the elevated temperature. I only work part time. There should be follow up on that but I can't always get to it. I will say he probably asked me, but I don't think I did it. On [DATE] at 09:13 AM an interview with Staff C was conducted and asked about monitoring following the documented elevated hot water temperatures in resident areas. Staff C stated he was never asked to do any monitoring of water temperatures after the (MONTH) 17 finding of 131°F. 2. On [DATE] at 02:17 PM it was observed to have individual free standing wardrobe cabinets were unsecured and able to be rotated forward potentially falling on residents and trapping them under and/or inside, in all rooms on the 100 hall (rooms ,[DATE]) as well as in resident room [ROOM NUMBER] (A total of 21 residents occupying these rooms at the time of survey). None of the units were secured to the wall and were found to be unstable when pressure was applied with a light forward pulling action. This could result in the wardrobes being pulled onto a resident who is attempting to remove clothing from the units On [DATE] at 08:09 AM an interview with the administrator was conducted in the presence of the wardrobe cabinet in room [ROOM NUMBER]. It was demonstrated, to the administrator, the ease at which the cabinet could be tipped forward when pulling on the clothes hangars inside. The administrator stated I see what you mean. The Environmental Baseline report, dated [DATE], was reviewed with the administrator. The report had identified the problem with the wardrobe cabinets and recommended they be secured to the wall at that time. The administrator stated I am new to this position. I was not aware of this report.

Based on interview and record review, the facility failed to provide services according to professional standards of quality for 1 Resident (#301) of 4 residents reviewed for provision of professional services, from a total of 4 sampled residents, when facility staff failed to provide adequate post operative care and monitoring . This deficient practice resulted in a worsened medical condition and hospitalization for this resident. Findings include: Record review of the Minimum Data Set ((MDS) dated [DATE] documented Resident #301 as a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) revealed a score of 11/15 indicating Resident #301 was moderately impaired cognitively. The MDS assessment revealed Resident #301 did not ambulate and he required a two person assist for dressing and hygiene and was set up and supervision for meals. An interview was conducted on 07/27/17 at 3:55 pm with Family Member (FM) J of Resident #301. He stated when his father was admitted to the facility on [DATE], they did not do adequate care for him post-operatively. I asked if they (staff) were doing anything: vital signs, tests, lab work. But I wasn't getting answers . I saw him every day and my sister was there often too. We both asked staff about if they were monitoring his fluid intake and were told no. At 5:30 pm on 07/27/17, a phone interview was conducted with FM K about Resident 301's care at the facility. She stated, I was there everyday at 7 am. He never got cleaned up, they never did anything; not take his hearing aides out or in, his dentures out or in. They would dress him and that's it. They'd bring his food and leave it- he couldn't reach it. They don't help get his teeth in. I never left him alone in the morning again. I never saw any vitals done. He never got bathed. FM K said she never saw any catheter care done. On 06/29/17 I helped him (Resident #301), but he seemed awfully tired. He went to Therapy, so I left and came back later. He looked terrible .said something is terribly wrong with my dad. The nurse said it might be a blood clot, and besides he's 95. I said so what! I want an ambulance! The younger nurse called right away. The first thing the EMT said was his urine is really cloudy. The ER (emergency room ) said this is a very very sick man and we don't know if we can save him. On 08/01/17 at 4:55 pm an interview was conducted with the Director of Nursing (DON) regarding the Total Hip Replacement Protocol. She stated all clinical stuff comes from Lippincott (Nursing Manual), and the online edition the facility used was from 2014. The facility followed the Lippincott Hip and Knee Arthroplasty Post Procedure Care guide dated 2014 and the Total [MEDICAL CONDITION] Clinical Protocol. The DON provided a copy of the guide which states: Arthroplasty post- procedure care includes providing routine postoperative care, maintaining alignment of the affected joint,and assisting with exercises. Nursing responsibility includes teaching, safe mobility, home care, and exercises that may continue for several years. Nursing steps listed to do include: 1. Monitor for: Blood Clotting- which includes anti-embolism stockings, baseline coagulation studies, and [MEDICAL CONDITION] medications as ordered. Phlebitis- Observe for bleeding and inflammation of a vein, usually in the legs. Infection- increased pain, temperature greater than 101, redness/swelling/drainage at incision, numbness/tingling/change in color of affected leg. The DON also provided a copy of the Major Joint Replacement education guide on 08/02/17 Which included what should be followed: 1. vital Signs, 2. Pain, 3. nausea/vomiting, 4. Constipation, 5. Perform neurovascular assessment of affected leg, 6. Assess safety needs, 7. Prevent Pneumonia post-op (teach/encourage coughing and deep breathing or incentive spirometry), 8. Prevent Venous [MEDICAL CONDITION], 9. Dressing changes, 10. Monitor fluid intake and output and electrolyte levels . Review of the Vital Signs Monitoring Policy, dated/reviewed 06/28/05 documents New admissions will be monitored every shift X (times) 72 hours. Review of Resident #301's medical records revealed: Physician orders- Oxygen was ordered on [DATE] at 2 liters while sleeping and as needed for dyspnea. There was no order for checking oxygen saturation levels with vital signs. Ted hose were ordered on [DATE] to be started on 06/22/17, to be applied in the a.m. and off in the p.m. (a 4 day delay) Total Hip Replacement Protocol was ordered on [DATE]. Per the facility policies and protocols Resident #301 did not have vital signs recorded as ordered. Temperature, pulse, respiratory rate and blood pressure were not recorded every shift for 72 hours upon admission nor were they recorded daily through day eight per the Total [MEDICAL CONDITION] Clinical Protocol. There were no baseline labs ordered for monitoring [MEDICAL CONDITION], coagulation studies or electrolytes per the policies. The DON could not produce an intake and output record for Resident #301. There were no records on educating/observing Resident #301 for coughing and deep breathing or use of an incentive spirometer. On 06/29/17 (day 11 after admission to facility) Resident #301 was sent to the ER, where Resident #301 was found to have pneumonia, urinary tract infection [MEDICAL CONDITION] with a white blood count of 43,000.

Based on interview and record review, the facility failed to provide the necessary care and/or services for one Resident (#301) of one resident reviewed for post operative care from the total sample of four residents, by failing to consistently assess Resident #301 post-operatively and failed to follow the [MEDICAL CONDITION] clinical protocol which described how the resident's care was to be managed. This deficient practice resulted in increased complications including pneumonia, Urinary tract infection [MEDICAL CONDITIONS] and increased mortality risk. Findings include: Record review of the Minimum Data Set ((MDS) dated [DATE] documented Resident #301 as a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) revealed a score of 11/15 indicating Resident #301 was moderately cognitively impaired. The MDS assessment revealed Resident #301 did not ambulate and he required a two person assist for dressing and hygiene and was set up and supervision for meals. On 08/01/17 at 4:55 pm an interview was conducted with the Director of Nursing (DON) regarding the Total Hip Replacement Protocol. She stated all clinical stuff comes from Lippincott. The edition they use online is from 2014. The facility follows the Lippincott Hip and Knee Arthroplasty Post Procedure Care guide dated 2014 and the Total [MEDICAL CONDITION] Clinical Protocol. The DON provided a copy of the guide which states: Arthroplasty post- procedure care includes providing routine postoperative care, maintaining alignment of the affected joint,and assisting with exercises. Nursing responsiblity includes teaching, safe mobility, home care, and exercises that may continue for several years. Things listed to do include: 1. Monitor for: Blood Clotting- which includes anti-embolism stockings, baseline coagulation studies, and [MEDICAL CONDITION] medications as ordered. Phlebitis- Observe for bleeding and inflammation of a vein, usually in the legs. Infection- increased pain, temperature greater than 101, redness/swelling/drainage at incision, numbness/tingling/change in color of affected leg. The DON also provided a copy of the Major Joint Replacement education guide on 08/02/17 Which states things ths should be followed: 1. vital Signs, 2. Pain, 3. nausea/vomiting, 4. Constipation, 5. Perform neurovascular assessment of affected leg, 6. Assess safety needs, 7. Prevent Pneumonia post-op (teach/encourage coughing and deep breathing or incentive spirometry), 8. Prevent Venous [MEDICAL CONDITION], 9. Dressing changes, 10. Monitor fluid intake and output and electrolyte levels, 11. Indwelling catheter (remove 1-3 days post-op or as soon as it is no longer needed to prevent UTI) . Review of the Vital Signs Monitoring Policy, dated/reviewed 06/28/05 read, New admissions will be monitored every shift X (times) 72 hours. Review of Resident #301's medical records revealed: Physician orders- Oxygen was ordered on [DATE] at 2 liters while sleeping and as needed for dyspnea. There was no order for checking oxygen saturation levels with vital signs. Ted hose were ordered on [DATE] to be started on 06/22/17, to be applied in the a.m. and off in the p.m. ( a 4 day delay) Total Hip Replacement Protocol was ordered on [DATE]. Per the facility policies and protocols Resident #301 did not have vital signs recorded as ordered. Temperature, pulse, respiratory rate and blood pressure were not recorded every shift for 72 hours upon admission nor were they recorded daily through day eight per the Total [MEDICAL CONDITION] Clinical Protocol. There were no baseline labs ordered for monitoring [MEDICAL CONDITION], coagulation studies or electrolytes per the policies. The DON could not produce an intake and output record for Resident #301. There were no records on educating/observing Resident #301 for coughing and deep breathing or use of an incentive spirometer. On 06/29/17 (day 11 after admission to facility) Resident #301 was sent to the ER, where Resident #301 was found to have pneumonia, urinary tract infection, [MEDICAL CONDITION] with a white blood cell count of 43,000 (indicative of active infection).

Based on observation, interview, and record review, the facility failed to to provide necessary treatment and services to prevent the development of an avoidable pressure ulcer for one Resident (#2), and failed to provide adequate nutrition to promote healing of an existing pressure ulcer for one Resident (#3) of 5 residents reviewed for pressure ulcers from a total sample of 18 residents. This deficient practice resulted in pain and debility for these residents with increased risk for mortality. Findings include: According to the initial Minimum Data Set (MDS) assessment dated [DATE], Resident #2 is a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's MDS identified him as having a Brief Interview for Mental Status (BIMS) score of 15/15 indicating he was cognitively intact. The MDS dated [DATE] also showed Resident #2 required extensive assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #2's initial MDS further identified him as not having a pressure ulcer upon admission, but at high risk for developing pressure ulcers. Resident #2's Care Area Assessment (CAA) dated 12/31/15 read, in part: At risk for developing pressure wounds due to impaired mobility, incontinence, obesity. He does not have any pressure wounds at this time. A weekly skin/wound note for Resident #2 dated 1/19/16, was reviewed and described a right heel pressure ulcer: Right heel with intact blood blister that is draining old dried blood, firm to touch. Measures 4.2 X 6 centimeters (cm). Covered with heel Allevyn. A Nurse Practitioner note dated 1/27/16 read, Resident (#2) seen for evaluation of wound to right heel. Undetermined length of time. Resident reports area is painful. Written under plan: unstageable pressure ulcer right heel. (suspect deep tissue injury). On 2/23/16 at 10:05 a.m., Resident #2's heel was observed during a treatment being performed while he was lying in bed. Resident #2's right posterior heel was observed with a soft black eschar area measuring approximately 3.2 cm by 4.0 cm with a 1.2 cm by 1.2 cm pink area slightly medial. Resident #2 expressed pain from the pressure ulcer during the treatment. After the treatment was completed and the nurse left the room, Resident #2 and his wife Family Member (FM) WW were interviewed regarding positioning (floating) of his heels off the bed to prevent pressure ulcer development. Resident #2 and FM WW, who said she is at the facility all day long, both indicated his heels had not been floated off the bed until he had developed the blister on the right heel. Both further indicated Resident #2 could not lift his legs off the bed, and normally would lie on his back with his head elevated to breath easier, resulting in prolonged pressure to the backs of his heels. Resident #2 and FM WW expressed concern to this Surveyor that this wound may delay his discharge home because of the dressing changes required for the right heel. An interview was conducted with the Physician Assistant (PA) B on 2/23/16 at 11:15 a.m. regarding Resident #2's right heel pressure ulcer. PA B stated she thought it (pressure ulcer ) could have been avoided with proper positioning. An interview took place with the Director of Nursing (DON) on 2/24/16 at 8:30 a.m. regarding any care plans to prevent Resident #2's right heel pressure ulcer, specifically care plan interventions to float or relieve pressure from his heels. The DON confirmed no specific care plan interventions had been put in place to avoid the heel pressure ulcer for Resident #2. An interview was conducted with with Registered Nurse (RN) E on 2/25/16 at 1:30 p.m. regarding Resident #2's right heel pressure ulcer. RN E was asked by this Surveyor if there had been any specific care plan interventions in place to prevent the right heel pressure ulcer for this resident. RN E replied No, not until the blood blister had been discovered. According to the MDS dated [DATE], Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nutritional note written by the Registered Dietitian (RD) F on 2/12/16 read recommend multi-vitamin with minerals daily along with additional Resource 2.0 120 cubic centimeters (CC) every day to promote wound healing. A review of the Medication Administration Record [REDACTED]. During an interview with RD F on 2/22/16 at 12:15 p.m., she stated The multi-vitamin with minerals and the Resource (dietary supplement) should have been implemented within 24 hours to promote wound healing. RD F confirmed nutritional needs including protein, are increased for individuals with open wounds. On 2/23/16 at 9:45 a.m. Resident #3's treatment to the coccyx was observed. Resident #3 was observed to have a 1.0 cm by 0.5 cm red partial thickness loss of the dermis surrounded by pink tissue. ( )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE LIFE RESUSCITATING INTERVENTIONS IN ACCORDANCE WITH THE RESIDENT'S ADVANCE DIRECTIVES FOR 1 OF 20 RESIDENTS (#19) FROM A SAMPLE OF 20 RESIDENTS REVIEWED FOR ADVANCED DIRECTIVES, IN A TOTAL FACILITY POPULATION OF 96 RESIDENTS. THIS FAILURE RESULTED IN CARDIOPULMONARY RESUSCITATION AND EMERGENCY MEDICAL SERVICES NOT BEING PROVIDED, WHICH PLACED RESIDENT #19 IN IMMEDIATE JEOPARDY TO HER HEALTH AND SAFETY. RESIDENT #19 EXPIRED AT THE FACILITY. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON [DATE] AT 11:30 AM. THE IMMEDIATE JEOPARDY BEGAN ON [DATE] AT 7:25 PM WHEN REGISTERED NURSE (RN) STAFF "F" ENTERED RESIDENT #19'S ROOM TO ADMINISTER PAIN MEDICATION, THAT RESIDENT #19 HAD REQUESTED AT 7:15 PM, AND FOUND RESIDENT #19 UNRESPONSIVE, WITHOUT HEARTBEAT OR RESPIRATIONS, PUPILS FIXED AND DILATED AND SKIN CYANOTIC, COOL AND DRY. DESPITE RESIDENT #19'S NEED FOR EMERGENCY MEDICAL SERVICES AND RESIDENT #19'S DOCUMENTED MEDICAL DETERMINATION DATED [DATE], DIRECTING FACILITY STAFF TO PROVIDE FULL RESUSCITATION EFFORTS, STAFF RN "F" DID NOT ALLOW RESIDENT #19 TO EXERCISE HER RIGHTS AND FAILED TO INITIATE CARDIOPULMONARY RESUSCITATION (CPR) AND ACTIVATE EMERGENCY MEDICAL SERVICES (EMS). CARDIOPULMONARY RESUSCITATION (CPR) IS AN EMERGENCY PROCEDURE WHICH IS PERFORMED AS AN EFFORT TO MANUALLY PRESERVE INTACT BRAIN FUNCTION, UNTIL FURTHER MEASURES ARE TAKEN TO RESTORE SPONTANEOUS BLOOD CIRCULATION AND BREATHING, DURING A [MEDICAL CONDITION]. IT IS INDICATED FOR THOSE WHO ARE UNRESPONSIVE, WITH NO BREATHING OR WITH ABNORMAL BREATHING. CPR ALONE IS UNLIKELY TO RESTART THE HEART; IT'S MAIN PURPOSE IS TO RESTORE PARTIAL FLOW OF [MEDICATION NAME] BLOOD TO THE BRAIN AND HEART. THE OBJECTIVE IS TO DELAY TISSUE DEATH AND EXTEND THE WINDOW OF OPPORTUNITY FOR A SUCCESSFUL RESUSCITATION. CPR MAY SUCCEED IN INDUCING A HEART RHYTHM WHICH MAY BE SHOCKABLE. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON [DATE] AT 3:42 P.M. AND A WRITTEN PLAN FOR REMOVAL WAS REQUESTED. ON [DATE], THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THE SURVEYOR VERIFIED THE FOLLOWING: -ALL RESIDENTS MEDICAL RECORDS HAD BEEN REVIEWED BY THE FACILITY TO ENSURE THAT A FULL CODE STATUS WAS DOCUMENTED FOR 32 OF 96 RESIDENTS IN THE FACILITY AS OF [DATE]. -IDENTIFICATION OF 24 LICENSED NURSES WHO DID NOT HAVE CURRENT CPR CERTIFICATION ON FILE WERE REQUIRED TO PROVIDE DOCUMENTATION OF VALID CPR CERTIFICATION. IF CPR CERTIFICATION WAS NOT VALIDATED, THE LICENSED NURSING STAFF WOULD BE REQUIRED TO COMPLETE BASIC LIFE SUPPORT (PRO TRAINING) BY [DATE], WITH COMPLETE CERTIFICATION (SKILLS CHECK LIST) BY [DATE]. -ON [DATE], THE FACILITY BEGAN EDUCATION FOR ALL LICENSED NURSING STAFF, PRIOR TO THE BEGINNING OF THEIR SCHEDULED ASSIGNMENTS, REGARDING THE FACILITY'S REVISED CPR POLICY. -THE DIRECTOR OF NURSING HAD ENSURED THAT ALL SHIFTS, THROUGH THE CURRENT SCHEDULE ENDING [DATE], HAD AT LEAST 1 LICENSED NURSE WITH CURRENT CPR CERTIFICATION ASSIGNED TO EACH SHIFT. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY DEFICIENT PRACTICE WAS NOT CORRECTED AND REMAINED AT A SCOPE AND SEVERITY OF A PATTERN WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM, PENDING COMPLETION OF THE FOLLOWING: -ALL LICENSED NURSING STAFF HAVE BEEN EDUCATED REGARDING THE REVISED CPR POLICY, DETAILING WHEN AND HOW TO INITIATE LIFE RESUSCITATION MEASURES; -ALL LICENSED NURSING STAFF HAVE PROVIDED DOCUMENTATION OF SUCCESSFULLY COMPLETED CPR CERTIFICATION; -VALIDATION BY THE STATE AGENCY OF THE FACILITY'S ABILITY TO MAINTAIN SUBSTANTIAL COMPLIANCE RELATED TO ACKNOWLEDGING AND IMPLEMENTING LIFE RESUSCITATING MEASURES IN ACCORDANCE WITH EACH RESIDENT'S ADVANCE DIRECTIVE. FINDINGS INCLUDE: A REVIEW OF RESIDENT #19'S MEDICAL FILE REFLECTED ON HER "ADMISSION RECORD" DATED [DATE] THAT SHE WAS A [AGE] year OLD FEMALE admitted TO THE FACILITY WITH [DIAGNOSES REDACTED]. A REVIEW OF THE HOSPITAL "HISTORY AND PHYSICAL", DATED [DATE], REFLECTED THAT RESIDENT #19 HAD BEEN LIVING INDEPENDENTLY AT HOME PRIOR TO HER hospitalization . AN UNTITLED FACILITY FORM DATED [DATE], SIGNED BY THE ATTENDING PHYSICIAN ON [DATE], REFLECTED THAT RESIDENT #19 WAS MENTALLY COMPETENT. A DOCUMENT TITLED "REQUEST TO LIMIT TREATMENT" SIGNED AND DATED BY RESIDENT #19 ON [DATE] REFLECTED: "IT IS MY WISH THAT IN THE EVENT I SHOULD HAVE AN INCURABLE OR IRREVERSIBLE CONDITION WHICH WILL CAUSE MY DEATH IN A RELATIVELY SHORT TIME, I DO OR DO NOT WANT THE FOLLOWING" (AND) MARKED WITH AN X UNDER THE "I DO" COLUMN: "1. IN THE EVENT OF CARDIOPULMONARY ARREST, WISH TO BE GIVEN CPR TO INCLUDE AMBU BAG. 2. WISH TO BE TRANSFERRED TO THE HOSPITAL..." A REVIEW OF RESIDENT #19'S MEDICAL RECORD PROGRESS NOTES DATED [DATE] AND SIGNED BY RN "F" AT 21:43 (9:43 PM) REFLECTED: "NOTIFIED BY CNA (CERTIFIED NURSES AIDE) THAT PT (PATIENT) IS REQUESTING SOMETHING FOR PAIN BEHIND HER RIGHT SHOULDER THIS WAS AT 1915 (7:15 P.M.) TYLENOL TAKEN TO HER ROOM AT 1925 (7:25 P.M.) AND PT WAS FOUND UNRESPONSIVE, NO HEART BEAT, OR RESP (RESPIRATIONS), COLOR IS CYANOTIC SKIN IS COOL AND DRY, PUPILS ARE FIXED AND DILATED..." THE NURSES PROGRESS NOTES DID NOT INDICATE THAT CPR WAS STARTED. A COPY OF RESIDENT #19'S CERTIFICATE OF DEATH, SIGNED BY THE PHYSICIAN ON [DATE], REFLECTED THE RESIDENT'S CAUSE OF DEATH AS "[MEDICAL CONDITION], HYPERTENSION, AND DIABETES MELLITUS." THE RECORDED ACTUAL OR PRESUMED TIME OF DEATH AND THE PRONOUNCED DEAD TIME WERE BOTH 7:25 P.M. ON [DATE], THE TIME WHEN RN "F" WENT INTO RESIDENT #19'S ROOM AND FOUND HER UNRESPONSIVE. A DECLARATION OF DEATH POLICY DATED 2003 DEVELOPED BY THE AMERICAN MEDICAL DIRECTOR'S ASSOCIATION (AMDA) FOUND AT WEB SITE WWW.AMDA.COM <http://WWW.AMDA.COM>, READS, IN PERTINENT PART: "...WE EMPHASIZE THE IMPORTANCE OF IDENTIFYING PATIENTS' ADVANCE DIRECTIVES AND TREATMENT PREFERENCES AND THE MORAL OBLIGATIONS OF PHYSICIANS, NURSES, AND OTHER HEALTH CARE PROVIDERS TO HONOR THOSE DIRECTIVES ..." PER THE DOCUMENT TITLED "2005 AMERICAN HEART ASSOCIATION GUIDELINES FOR CARDIOPULMONARY RESUSCITATION AND EMERGENCY CARDIOVASCULAR CARE" FROM CIRC.AHAJOURNALS.ORG (DOWNLOADED FROM INTERNET [DATE]), UNDER THE SECTION "PRINCIPLE OF FUTILITY" IT STATES: "...THE PATIENTS DESIRES...ABOUT INITIATION OF RESUSCITATION SHOULD BE SUPPORTED." UNDER THE SECTION TITLED "WITHHOLDING AND WITHDRAWING CPR" IT STATES : "...ALL PATIENTS IN [MEDICAL CONDITION] SHOULD RECEIVE RESUSCITATION UNLESS: THE PATIENT HAS A VALID 'DO NOT ATTEMPT RESUSCITATION' ORDER, THE PATIENT HAS SIGNS OF IRREVERSIBLE DEATH (E.G., RIGOR MORTIS, DECAPITATION, DECOMPOSITION, OR DEPENDENT LIVIDITY (POOLING OF BLOOD IN TISSUES) (OR) NO PHYSIOLOGICAL BENEFIT CAN BE EXPECTED BECAUSE VITAL FUNCTIONS HAVE DETERIORATED DESPITE MAXIMAL THERAPY (E.G., PROGRESSIVE SEPTIC OR CARDIOGENIC SHOCK). DURING AN INTERVIEW ON [DATE] AT 10:35 A.M. IN THE CONFERENCE ROOM, THE DON (DIRECTOR OF NURSING) STATED THAT IF A RESIDENT IS FOUND UNRESPONSIVE, A FULL CODE / "CODE BLUE" WOULD BE CALLED, CPR WOULD BE STARTED AND 911 CALLED. THE DON SAID THAT THE "CODE BLUE" WOULD BE DOCUMENTED IN THE FACILITY PROGRESS NOTES. HOWEVER, THE DON STATED THAT THE FACILITY DID NOT CONDUCT ANY INVESTIGATION RELATED TO RESIDENT #19'S DEATH BECAUSE RN "F" HAD CALLED HER (THE DON) AT HOME AT THE TIME OF THE DEATH, AND DUE TO THE FACT THAT THE RESIDENT WAS "ALREADY GONE" WHEN RN "F" ENTERED THE ROOM, CPR WAS NOT NECESSARY, EVEN THOUGH SHE (RESIDENT #19) WAS A FULL CODE. THE DON CLARIFIED THE FACILITY'S EXPECTATIONS AS FOLLOWS: IF ANY FACILITY RESIDENT WAS FOUND UNRESPONSIVE AND NOT BREATHING ON MIDNIGHT SHIFT, BY A CNA OR LICENSED NURSE DURING THEIR EVERY 2 HOUR ROUNDS, AND THE RESIDENT WAS FULL CODE (WISHING TO HAVE CPR IF THEIR HEART STOPPED) AND THE RESIDENT HAD NOT BEEN SEEN SINCE THE LAST ROUNDS, CPR WOULD NOT BE STARTED IF THE RESIDENT'S PUPILS WERE DILATED, THEIR SKIN WAS COOL, OR THEY WERE CYANOTIC. THE DON STATED, "THAT IS WHAT WE DO ALL THE TIME, IF SOMEONE IS FOUND IN THAT CONDITION." THE DON ALSO INDICATED THAT THE FACILITY WAS NOT REQUIRING THAT LICENSED STAFF BE CERTIFIED IN CPR TRAINING, AND SAID THAT ONLY 10 OF THEIR 34 LICENSED STAFF HAD CURRENT CERTIFICATION IN CPR. THE DON STATED, "MOST OF THE LICENSED NURSES' CERTIFICATION HAD EXPIRED IN FEBRUARY 2013." DURING CONTINUED INTERVIEW WITH THE DIRECTOR OF NURSING (DON) [DATE] AT 10:35 A.M. IN THE CONFERENCE ROOM, SHE STATED THAT RESIDENT #19 HAD BEEN admitted TO THE FACILITY'S SHORT TERM REHABILITATION UNIT AND WAS TO BEGIN PHYSICAL AND OCCUPATIONAL THERAPY. THE GOAL OF SHORT TERM REHABILITATION IS FOR RESIDENTS TO RECEIVE SKILLED SERVICES IN ORDER TO BE ABLE TO RETURN HOME, OR TO ANOTHER LESS RESTRICTIVE CARE SETTING. AN INTERVIEW CONDUCTED WITH RN "F" [DATE] BY TELEPHONE AT 11:10 A.M. REVEALED THAT, UPON ENTERING RESIDENT #19'S ROOM ON THE EVENING OF [DATE], RN "F" FOUND RESIDENT #19 UNRESPONSIVE, PUPILS DILATED AND RESIDENT #19 COOL TO THE TOUCH. RN "F" STATED, "NO, CPR WAS NOT STARTED, IT WAS A NURSING JUDGEMENT. RESIDENT WAS ALREADY GONE." THE FACILITY PROGRESS NOTES DATED [DATE] AT 9:05 A.M. HAD DESCRIBED RESIDENT #19'S LARGE PUPILS AS NORMAL FOR HER. THE NOTES DOCUMENTED: "... PUPILS UNEQUAL. LARGE. REPORTS (THIS) IS HER NORM D/T (DUE TO) DIABETIC RETINOPATHY..." ON [DATE] AT 10:45 A.M. THE DON WAS ASKED FOR THE FACILITY'S POLICY THAT ADDRESSED WHEN STAFF WERE TO INITIATE CPR OR "CODE BLUE". ON [DATE] AT 11:00 A.M. THE DON PROVIDED AN UNDATED POLICY TITLED "CODE BLUE POLICY". UNDER THE SECTION TITLED "PROCEDURE", THE FOLLOWING WAS DOCUMENTED: " (WHEN) RESIDENT HAS REQUESTED TO BE A FULL CODE, AND/OR CPR IS INDICATED, STAFF SUMMONS HELP IMMEDIATELY. BEGIN CPR, CALL A CODE BLUE...AND REPEAT THIS 3 TIMES OVER THE INTERCOM. CALL 911. RESPONDING STAFF INITIATE AND CONTINUE CPR AS NECESSARY, UTILIZING THE AED (AUTOMATED EXTERNAL DEFIBRILLATOR), UNTIL EMS (EMERGENCY MEDICAL SERVICES) RELIEVES STAFF OF DOING CPR AND ASSUMES CARE...DOCUMENTATION IS COMPLETED BY LICENSED NURSING STAFF AS APPROPRIATE." DURING INTERVIEW ON [DATE] AT 10:45 A.M., THE DON STATED THAT REGISTERED NURSES (RN'S) WERE ABLE TO PRONOUNCE A RESIDENT'S DEATH BY DOING A NURSING ASSESSMENT, AND BASED ON THAT ASSESSMENT, IT WAS THE RN'S JUDGEMENT IF CPR SHOULD BE INITIATED. ( ) ON [DATE] AT APPROXIMATELY 1:30 P.M., LICENSED PRACTICAL NURSE (LPN) STAFF "O" WAS INTERVIEWED IN THE RESTORATIVE THERAPY OFFICE. STAFF "O" IDENTIFIED HERSELF AS THE FACILITY'S IN-SERVICE COORDINATOR. STAFF "O" STATED, BEGINNING EARLY THIS YEAR (2013), THE FACILITY HAD ADOPTED AN ON-LINE BASIC LIFE SUPPORT EDUCATION PROGRAM TO CERTIFY THE NURSING STAFF IN BASIC LIFE SUPPORT. THE TRAINING PROGRAM INCLUDED NUMEROUS VIDEO PRESENTATIONS AND A WRITTEN EVALUATION TEST. HANDS ON TRAINING WAS TO BE ENCOURAGED. STAFF "O" WAS ASKED IF THE CARDIOPULMONARY RESUSCITATION (CPR) TRAINING ADDRESSED WHETHER THERE WOULD BE ANY CIRCUMSTANCES WHEN A STAFF MEMBER WOULD NOT INITIATE CPR FOR A RESIDENT DESIGNATED AS "FULL CODE." STAFF "O" REPLIED BY STATING, "NO. IT DOES TALK ABOUT CIRCUMSTANCES SUCH AS (BEING) UNRESPONSIVE, OR UNCONSCIOUS, BUT I CAN HONESTLY TELL YOU THAT IT DOESN'T GO INTO THAT MUCH DEPTH." DURING THE INTERVIEW, STAFF "O" WAS UNABLE TO SHOW THAT ANY SPECIFIC CRITERIA HAD BEEN PROVIDED TO THE FACILITY NURSING STAFF REGARDING WHEN TO INITIATE AND WHEN TO WITHHOLD CPR FOR RESIDENTS WHO HAD ELECTED "FULL CODE" STATUS. ( )

This citation pertains to MI# 349 Based on interview and record review the facility failed to provide the necessary care and services (assessing leg pain) for 1 (Resident #101) of 4 sampled residents, from a total sample of 4 residents, resulting in Resident #101 reporting leg pain to the nursing staff, being given pain medication and discharged on [DATE] and emergency hospitalization on [DATE] resulting in [MEDICAL CONDITION]. Findings include: Record review of Resident #101's surgical progress note fax dated 9/6/12 located in the residents closed medical record revealed the resident was examined and that there was bilateral lower extremity [MEDICAL CONDITION] noted. The physician noted a history of venous [MEDICAL CONDITION] and embolism. Record review of Resident #101's Hospital discharge summary dated 9/7/12 listed discharge [DIAGNOSES REDACTED]. Record review of Resident #101's minimum data set ((MDS) dated [DATE] revealed an [AGE] year old female with brief interview of mental status score of 15 out of 15, independent with decisions consistent and reasonable. Record review of Resident #101's facility face sheet information dated 9/18/12 revealed the resident was post-surgical for incisional hernia repair (of the abdomen) with [DIAGNOSES REDACTED]. Record review of Resident #101's facility admission orders [REDACTED]. Record review of facility "[MEDICATION NAME]/INR Monitoring and Administration of [MEDICATION NAME] Policy Statement" dated 7/2006, revealed "Residents on [MEDICATION NAME] ([MEDICATION NAME]) will be monitored by in house finger-stick coagu-check every 4 weeks unless otherwise indicated, at nursing discretion and or per order of attending physician. An INR of 2.0-3.2 will be maintenance expectation....." Record review of "Nursing 2013 Drug Handbook" located on the nurse medication carts, page 1407, [MEDICATION NAME] (anticoagulant) noted indications for [MEDICAL CONDITION] embolism, [MEDICAL CONDITION] Record review of Resident #101's [MEDICATION NAME]/INR information sheet dated 9/10/12 revealed that a PT/INR was done using a Coagucheck machine and the results were: [MEDICATION NAME]: 14.5, Previous [MEDICATION NAME]: 12.6, INR: 1.2, previous INR: 1.2. The current medication dose was noted at the bottom of the form. The form had a fax date of 9/10/12. Review of physician orders [REDACTED]. Record review of Resident #101's nurse note dated 9/10/12 at 10:30 (AM) revealed that an order was received from physician to increase the [MEDICATION NAME] dose. Record review of Resident #101's physician admission progress note dated 9/12/12 revealed the resident was post-surgical with plans to rehab and return home. The physician noted the resident had a history of [REDACTED]. Record review of facility "Pain Policy" dated 6/12/02, revealed page 1. Assessment/recognition -"a resident will be assessed ......with change in condition and anytime pain is suspected by licensed staff. Assessment should include utilization of pain form, history, signs and symptoms, known medical conditions, personal patterns and habits. You will utilize this information to determine if the resident has a specific need, condition, problem or risk. You should describe and define the nature of the pain, onset, duration and frequency". Record review of Resident #101's "Weekly Progress Note" for physical therapy dated 9/2/12 to 9/13/12 revealed pain level of "0 (zero)-very little abdominal area" Record review of Resident #101's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. No pain medication was given 9/15, 9/16/12. Then on 9/17/12, 9/18/12 and 9/19/12 the nurse noted pain medication for "Prior to therapy", but did not document the location of the pain or intensity of pain (with movement or no movement). On 9/20/12 pain medication was given for leg pain rated at 9/10 at 8:15 AM and at 3:10 PM by the day shift nurse. On 9/21/12 and 9/22/1 Resident #101 received pain medication for leg pain. Record review of Resident #101's [MEDICATION NAME]/INR information sheet dated 9/17/12 revealed that a PT/INR was done using a Coagu-check machine and the results were: [MEDICATION NAME]: 17.9, Previous [MEDICATION NAME]: 14.5, INR: 1.5, previous INR: 1.2. The current medication dose was noted at the bottom of the form. The form had a fax date of 9/17/12. Record review of physician orders [REDACTED]. Record review of Resident #101's nurse notes dated 9/17/12 revealed that there was no documented communication with the physician or follow up if the physician received the faxed coagu-check results. Record review of Resident #101's "Weekly Progress Note" for physical therapy dated 9/14/12 to 9/20/12 revealed pain level of "5-7 of 10 to abdominal area, 5/10 bilateral lower extremities thigh area". Record review of physical therapy narrative note dated 9/20/12 revealed complaints of increased pain to abdomen and bilateral lower extremities with nursing notified. In an interview on 4/1/13 at 8:40 AM with physical therapy assistant (PTA) #4 revealed that when a resident complains of pain she (the PTA) reports the complaints to the charge nurse on the residents unit on the day the resident reports the pain. PTA #4 stated that she did document the complaint of pain and that she documented reporting to the nursing staff. Record review of facility staff schedules for 9/6/12 through 9/23/12 revealed that licensed practical nurse (LPN) #3 was Resident #101's day shift nurse 11 of the 16 days the resident resided at the facility. LPN #3 was the residents nurse 9/17/12 through 9/19/12 when the residents pain location changed from abdominal to leg pain. Record review of LPN #3's nurse notes for Resident #101 was on 9/19/12 at 1:40 PM included staples removed from abdomen incision, with no sign/symptoms of infection, no drainage. Incision well approximated. Order noted to DC (discharge) home on 9/22/12. There was no documentation of assessing lower extremities or thighs for swelling, redness or pain. In an interview on 4/1/13 at 10:50 AM with LPN #3 while reviewing the closed medical record of resident #101, revealed that the LPN stated that she did not assess the resident's leg pain because the resident did therapy and that she would contribute the pain to being on the bike/exercise. The LPN when asked about new complaints of pain stated that someone would look at site and document it and that she did not chart anything (no assessment). LPN #3 stated that if she was told of pain that was new area, she would tell the clinical coordinator/ registered nurse about it. LPN #3 was asked if she assessed or looked at Resident #101's legs or thighs, or asked the resident about the cause of the pain (nature of the pain, onset, duration and frequency) and LPN #3 stated she did not and that she thought it was from doing therapy. Record review of Physical Therapy "Discharge Summary" dated 9/21/12 revealed pain level of 5/10 to abdominal surgical incision area, and 5/10 right inner thigh. Record review of Occupational Therapy "Discharge Summary" dated 9/21/12 revealed resident complained of pain level to medial thigh and reported it to nursing and physical therapy. Record review of Resident #101's "Summary and Instructions at Discharge" dated 9/22/12 revealed nursing summary of stay pertinent lab results: Check PT/INR weekly. Last checked 9/17/12. [MEDICATION NAME] 17.9 and INR 1.5. Due to be checked next on 9/24/12. Discharge medications included [MEDICATION NAME]. Record review of Resident #101's emergency room physician record dated 9/23/12 at 12:28 PM revealed the resident came by ambulance for right leg pain rated at 9 out of 10. Physical exam noted moderate pain when moving right lower leg. Right lower leg calf tenderness was noted. Record review of Resident #101's hospital admitted [DATE] history and physical revealed the resident had a history of [REDACTED]. The [MEDICATION NAME] therapy was interrupted for surgical procedure which was performed three week prior to emergency room visit. Resident #101 was noted to have been restarted on [MEDICATION NAME] therapy and had spent two weeks in nursing home for rehabilitation. It was noted that while in the nursing home Resident #101 complained of worsening and recurrent right leg pain. It was noted that the pain was especially severe in the right thigh and interfered with her physical therapy. The Resident #101 was noted to not have any evaluation for this leg pain......While in the emergency room Resident #101 had a venous ultrasound, which demonstrated an acute [MEDICAL CONDITION] that involved the right femoral vein and right popliteal vein. Record review of Resident #101's radiology report dated 9/23/12 at 2:01 PM revealed history of right leg pain and swelling. Ultrasound impression [MEDICAL CONDITION] throughout the right femoral and popliteal veins. Record review of facility form "Know when to notify physicans about abnormal labs" revealed: 'Faxing a pile of normal and abnormal lab reports to the physician office may not constitute proper notification. In some situations, the facility continues to have responsibility for identifying potential problems is the laboratory reports and notifying the physician by phone. This is especially true in coagulation test and laboratory values suggesting dehydration, which are both commonly overlooked by nursing personnel. A nurse must review the lab repots soon after they are returned to the facility and determine whether the values warrant phone notification or further nursing action.........Additionally, nurses are responsible for recognizing conditions and risk factors for which we have nursing diagnoses.' #

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE AN ASSISTIVE DEVICE (AN EFFECTIVE WHEELCHAIR FOOTREST) FOR ONE RESIDENT (#2) OF FOUR RESIDENTS REVIEWED FOR FALLS OUT OF TOTAL SAMPLE OF FIVE RESIDENTS IN A FACILITY RESIDENT POPULATION OF 115, RESULTING IN RESIDENT #2 FALLING FROM HER WHEELCHAIR AND SUSTAINING A LEG FRACTURE. FINDINGS INCLUDE: A REVIEW OF THE FACILITY'S 7/5/12 INVESTIGATION REPORT SHOWED ON 7/4/12 AT 1:00 P.M., RESIDENT #2 WAS BEING PROPELLED IN HER WHEELCHAIR BY CERTIFIED NURSE AIDE (CNA) "A". THE REPORT DOCUMENTED RESIDENT #2'S LEFT FOOT SLID OFF THE WHEELCHAIR FOOTREST, CAUGHT ON THE FLOOR, WITH RESIDENT #2 "FLIPPING" FORWARD AND FALLING TO THE FLOOR. THE OUTCOME OF RESIDENT #2'S FALL FROM THE WHEELCHAIR, PER THE REPORT, SHOWED RESIDENT #2 WAS SENT TO THE HOSPITAL AND diagnosed with [REDACTED]. RESIDENT #2'S CLINICAL CHART FACE SHEET DOCUMENTED SHE IS NINETY-SIX YEARS OLD AND admitted to the facility on [DATE]. THE 4/11/12 MINIMUM DATA SET (MDS) ASSESSMENT SHOWED RESIDENT #2'S [DIAGNOSES REDACTED]. THE MDS ASSESSMENT SHOWED RESIDENT #2'S COGNITION AS MODERATELY IMPAIRED AND THAT SHE USUALLY UNDERSTOOD WHAT WAS SAID TO HER. THE MDS AND 4/12 CARE PLAN DOCUMENTED HER NEED FOR EXTENSIVE ASSISTANCE WITH PROPELLING HER WHEELCHAIR THROUGH THE FACILITY. THE CARE PLAN SHOWED RESIDENT #2 WAS NOT ABLE TO REPOSITION HER LEFT LEG WITHOUT STAFF ASSISTANCE. AN INTERVIEW WAS ATTEMPTED WITH RESIDENT #2 IN HER ROOM ON 7/11/12 AT 9:05 A.M. RESIDENT #2 WAS ASKED ABOUT THE INCIDENT AND IF SHE RECALLED HAVING A PROBLEM WITH KEEPING HER LEFT FOOT ON THE WHEELCHAIR FOOTREST WHEN STAFF WERE PROPELLING HER WHEELCHAIR. RESIDENT #2'S ANSWER TO THE QUESTIONS WAS ALWAYS "I DON'T REMEMBER ANY DETAILS." DURING THE 7/11/12 INTERVIEW WITH RESIDENT #2, HER WHEELCHAIR WAS OBSERVED. RESIDENT #2 STATED THE WHEELCHAIR WAS HER "SPECIAL" WHEELCHAIR. THE WHEELCHAIR WAS OBSERVED TO HAVE A LEFT ARM PAD THAT WAS USED TO CRADLE HER ARM. THE LEFT FOOTREST WAS OBSERVED TO BE A FLAT SURFACE CONTAINING NO SIDES TO THE OUTSIDE OF THE FOOTREST. CERTIFIED NURSE AIDE (CNA) "A" WAS INTERVIEWED ON 7/11/12 AT 10:20 A.M. SHE STATED SHE WAS THE CNA WHO WAS PROPELLING RESIDENT #2'S WHEELCHAIR AT THE TIME OF THE 7/4/12 INCIDENT. CNA "A" SAID THE FACILITY'S REPORT WAS CORRECT. SHE EXPLAINED, "...YOU DON'T GET A WARNING WHEN (RESIDENT #2'S) FOOT IS GOING TO SLIP OFF (THE WHEELCHAIR FOOTREST)... (RESIDENT #2) DOESN'T KNOW WHEN IT'S GOING TO HAPPEN AND WE DON'T GET A WARNING LIKE A TWINGE OR JERK OF HER LEG OR FOOT... (RESIDENT #2) CAN'T HOLD THAT LEFT LEG UP WHEN THE FOOT SLIPS... WE TRY TO WATCH FOR IT (FOOT SLIPPING OFF THE FOOTREST)... IT DROPS LIKE A WEIGHT AND WHEN IT HITS THE FLOOR THAT WHEELCHAIR STOPS ON A DIME... THAT'S WHAT THREW (RESIDENT #2) FORWARD OFF THE CHAIR (WHEELCHAIR)..." CNA "A" WAS ASKED IF SHE HAD EVER VOICED HER CONCERN TO A NURSE ABOUT RESIDENT #2'S FOOT SLIPPING OFF THE WHEELCHAIR FOOTREST. SHE STATED SHE WAS "PRETTY SURE" SHE HAD BUT COULD NOT REMEMBER WHAT NURSE OR WHEN SHE MAY HAVE TOLD THEM. ON 7/11/12, INTERVIEWS WERE CONDUCTED WITH CNAS "G", "C", "E" AND "H" AT 8:45 A.M., 9:10 A.M., 10:10 A.M. AND 11:05 A.M. RESPECTIVELY. THE FOUR CNAS SAID THEY HAD ALL ASSISTED RESIDENT #2 AND PROPELLED HER IN HER WHEELCHAIR. THEY ALL STATED RESIDENT #2'S FOOT SOMETIMES WOULD FALL OFF THE FOOTREST WHILE THEY WERE PROPELLING HER WHEELCHAIR. CNA "G" EXPLAINED, "...WHEN (RESIDENT #2'S) FOOT DROPS OFF (THE FOOTREST), IT'S LIKE QUICKLY PUTTING ON THE (WHEELCHAIR) BRAKE... THAT (WHEEL) CHAIR STOPS ON A DIME... I COULD SEE HOW (RESIDENT #2) COULD BE THROWN FROM THE CHAIR..." CNA "H" SAID "...AT LEAST SIX MONTHS AGO..." SHE THOUGHT SHE HAD TOLD A NURSE ABOUT RESIDENT #2'S WHEELCHAIR FOOTREST ISSUE. CNA "H" STATED SHE SUGGESTED THEY USE A VELCRO STRAP "OR SOMETHING" TO HOLD RESIDENT #2'S LEG AND KEEP THE FOOT FROM FALLING OFF THE FOOTREST. SHE SAID SHE COULD NOT REMEMBER WHO SHE TOLD. THE DIRECTOR OF NURSING (DON), REGISTERED NURSE (RN) "B" (THE CLINICAL SUPERVISOR FOR THE UNIT RESIDENT #2 RESIDES ON), AND ASSISTANT DIRECTOR OF NURSING (ADON) "D" WERE INTERVIEWED ON 7/11/12 AT 8:15 A.M., 9:45 A.M. AND 10 A.M. RESPECTIVELY. THE THREE NURSES STATED THEY WERE NOT AWARE OF RESIDENT #2 HAVING A PROBLEM KEEPING HER LEFT FOOT ON THE FOOTREST. RN "B" SAID, "I SHOULD'VE BEEN MADE AWARE OF THE FOOT PROBLEM... THE AIDES (CNAS) ARE USUALLY REALLY GOOD AT SHARING RESIDENT INFORMATION WITH ME... IF I WOULD'VE KNOWN, WE COULD'VE PROBABLY SECURED (RESIDENT #2'S) LEG OR USED ONE (FOOTREST) THAT HAD SIDES..." ( )