Every finding on record at WI Veterans Home Moses Hall

Based on interview and record review, the facility did not ensure the member environment was as free of accident hazards as possible when staff did not follow an intervention to prevent/reduce the impact of a fall for 1 member (M) (M121) of 6 sampled members. M121 had a history of falls. On 5/15/26, staff did not follow an intervention in M121's care plan to prevent recurrence when they did not lock M121's bed height adjustment with the bed in the lowest position. M121 fell out of bed, landed on their face, and required sutures in the left eyebrow. (This is being cited at past non-compliance.) Findings include: The facility's Prohibition and Prevention of Member Abuse, Neglect, and Exploitation policy, dated 7/2024, indicates: .The facility shall implement policies and procedures to identify, correct, and intervene in situations where abuse, neglect, exploitation, and/or misappropriation of member property is more likely to occur. M121 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, and history of falls. M121's Minimum Data Set (MDS) assessment, dated 5/6/26, stated M121 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating severely impaired cognition. M121's Falls care plan (initiated 3/2/22 and revised 5/8/26) indicated they were at risk for falls related to a history of falls with debility, medication use, inpaired mobility and balance, cognitive deficits with occasional impulsive behavior, and decreased coordination with mobility. The care plan contained interventions for bed height adjustment to be locked when M121 is in bed, with bed in the lowest position (initiated 8/23/24 and revised 5/15/26) and encourage bed to be in lowest position when M121 is in bed (initiated 10/17/23 and revised 5/15/26). M121's medical record indicated M121 was found face down on the floor next to the bed and bleeding from the head on 5/15/26 at 3:20 AM. The bed was raised approximately three feet in the air and was not in a locked low position. M121 was tranferred to the hospital and received sutures in the left eyebrow. Surveyor reviewed a facility-reported incident (FRI) that indicated Certified Nursing Assistant (CNA)-C heard a thud from M121's room on 5/15/26 at 3:20 AM and observed M121 face down on the floor. CNA-C last checked on M121 at 3:00 AM. M121's bed was at the correct height at that time. M121 used the bed control to raise the height of the bed approximately three feet. It appeared M121 then sat up, attempted to exit the bed, and landed face-down on the floor. The nurse was notified and staff called 911. Emergency first-aid was provided until Emergency Medical Services (EMS) arrived. Upon review of M121's plan of care, it was noted the bed height adjustment should have been locked when M121 was in bed. CNA-C did not complete the task as instructed in M121's Kardex (an abbreviated care plan used by nursing staff). M121 sustained a laceration to the left eyebrow that required sutures. M121 was interviewed upon return from the hospital and stated they thought their bed was lower than it was. When asked if M121 raised the bed, M121 stated, I put it up, I think. M121 was educated to use the call light if they want to get out of bed. The investigation indicated M121 had many safety interventions in place to prevent harm and ensure safety due to a history of falls. After learning M121's care plan was not followed, CNA-C was removed from member care and the police were notified. M121's care plan and Kardex were updated. M121's CNA Tasks for Documentation were updated for staff to document M121's bed is in the lowest position and locked. Members' plans of care were reviewed to ensure all fall safety measures were in their care plan, Kardex, and CNA Tasks for Documentation. All staff were educated. On 6/16/26 at 2:40 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified CNA-C did not follow M121's care plan and indicated staff should follow members' care plans. NHA-A stated CNA-C was removed from member care pending the results of the investigation and educated prior to returning to work.

Based on interview and record review, the facility did not ensure bowel management protocol was followed for 1 member (M) (M82) of 6 members reviewed for hospitalization in a total sample of 36 members.M82 did not receive as needed (PRN) bowel medication per facility protocol. On 5/18/26, M82 was transferred to the hospital for a small bowel obstruction. In addition, M82's care plan was not updated after the hospitalization.Findings include:The facility's Bowel Management Protocol policy, dated 11/25/24, indicates: The absence of an adequate bowel elimination for seven consecutive nursing shifts shall result in the nurse offering the member a prescribed laxative on the eighth nursing shift; continued elimination absence for eleven consecutive nursing shifts shall result in the nurse offering a prescribed suppository or enema on the twelfth nursing shift.M82 was admitted to the facility on [DATE] and had diagnoses including drug-induced constipation and unspecified intestinal obstruction. M82's Comprehensive Minimum Data Set (MDS) assessment, dated 6/18/26, stated M82 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating M82 had intact cognition. The MDS assessment indicated M82 was occasionally incontinent of bowel and required substantial/maximal assistance with toileting, transferring to the toilet, and hygiene. An MDS assessment, dated 5/5/26 (which was prior to M82's hospitalization for a small bowel obstruction on 5/18/26), indicated M82 was fully continent of bowel and independent with transferring to the toilet and toileting hygiene. M82's medical record contained orders for daily Miralax and Dulcolax related to constipation.Between 6/15/26 and 6/17/26, Surveyor reviewed M82's bowel documentation which indicated M82 had a bowel movement on 5/14/26 at 6:34 AM. M82's next documented bowel movement was a medium bowel movememt on 5/17/26 at 8:29 PM which indicated M82 went nine shifts without a bowel movement. M82's medical record did not indicate M82 was offered PRN bowel medication per protocol on the eighth shift. M82 experienced a sudden change in condition and was transferred to the hospital on 5/18/26 at 2:00 AM. M82 returned to the facility on 6/1/26.Surveyor reviewed M82's care plan which did not indicate M82 experienced constipation or was recently hospitalized for a small bowel obstruction. On 6/17/26 at 11:21 AM, Surveyor interviewed Director of Nursing (DON-B) who confirmed M82 should have received bowel medication on the eighth shift but did not receive any. DON-B provided an order that was transcribed in M82's medical record on 5/17/26 at 7:02 PM for PRN Miralax but confirmed the medication was not documented as administered.

Based on staff interview and record review, the facility did not provide the necessary care and services during a choking incident for 1 member (M) (M1) of 1 sampled member. M1 had diagnoses including anoxic brain damage and dysphagia (difficulty swallowing) and was noted to be impulsive with lack of judgement. M1 and M1's family requested that M1 receive a regular texture diet for pleasure and were aware of the risks and benefits. On 2/4/26, M1 put half of a peanut butter sandwich in M1's mouth when Certified Nursing Assistant (CNA)-I stepped away to retrieve a towel. Staff noted M1 was choking but did not call 911 due to M1's Do Not Resuscitate (DNR) code status. M1 became pulseless and non-breathing and passed away due to the incident.The facility's failure to follow their policy and procedure for a member who showed signs of complete choking and was still breathing created a finding of immediate jeopardy that began on 2/4/26. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 4/8/26 at 2:30 PM. The immediate jeopardy was removed and corrected on 2/5/26. This is being cited at past non-compliance. Findings include: The facility's Choking Incident WVH (Wisconsin Veterans Home) 123-00-10 document, dated February 2025, indicates: Applies to: Members, visitors, volunteers, contracted parties, facility staff .Medical conditions that impact chewing or swallowing increase a person's chance of experiencing choking episodes. Partial choking is when the airway is not fully blocked, still allowing some air to pass. Complete choking is when the airway is fully blocked, and the person cannot breathe .All staff shall be aware of the signs and symptoms of choking .If the person is showing signs of complete choking, call 911 and prepare for cardiopulmonary resuscitation (CPR). Try to dislodge the object by alternating abdominal thrusts and chest thrusts. Continue until the person begins to breathe or becomes unresponsive.The facility's Choking Incident WVH (Wisconsin Veterans Home) 123-00-10, dated 2/10/26, indicates: Applies to:Employees, members, visitors .Partial choking is when the airway is not fully blocked, still allowing some air to pass. Complete choking is when the airway is fully blocked, and the person cannot breathe. Resuscitation does not include the Heimlich Maneuver or similar procedure used to expel an obstruction from the throat S 154.17 .All staff shall be aware of the signs and symptoms of choking .3. If the person is showing signs of complete choking, call 911 and prepare for CPR. Try to dislodge the object by alternating back blows and abdominal thrusts. Continue until the person begins to breathe or becomes unresponsive .On 4/9/26, Surveyor reviewed M1's medical record. M1 was admitted to the facility in 2012 and had diagnoses including anoxic brain damage, dysphagia, dementia with mood disturbance and anxiety, impulse disorder, unspecified psychosis, personality change due to known physiological condition, and aphasia (impaired ability to understand or produce speech). M1's Quarterly Minimum Data Set (MDS) assessment, dated 1/25/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated M1 had intact cognition. M1 had an activated Power of Attorney for Healthcare (POAHC) who was a family member and actively involved in M1's care. M1 had a diet order, dated 1/28/25, for a general diet (no skins/hulls, nuts/seeds, rice) Texture: Regular, Consistency: HoneyM1's care plan, dated 11/18/25, indicated M1 received dysphagia therapy. The care plan contained goals to advance PO (by mouth) diet plan to include sandwiches and hamburgers and hot dogs buns.The care plan also indicated M1 required assistance with eating meals and had an altered texture diet. M1 could eat snacks from store orders independently. M1's POAHC was aware of the risks of eating items not within M1's diet order and accepted the risks for M1's pleasure and quality of life (date initiated: 12/14/16).A Patient Referral for Speech Therapy and History doument, dated 11/18/25, indicated M1 had a consistent cough during the meal which was baseline for M1 and recently lodged a piece of peach that potentially penetrated M1's airway. The document indicated M1 had an up/down versus rotary chewing pattern, but had controlled regular textures for years. M1 and M1's family desired regular texture foods. M1 was fed by staff. Moderately thick liquids were recommended and a regular diet with no modifications. Speech Pathologist (SP)-N verified the assessment.On 4/9/26, Surveyor reviewed a facility-reported incident (FRI) that indicated Certified Nursing Assistant (CNA)-I assisted M1 with eating supper in the dining room on 2/4/26. M1's meal consisted of beverages, diced pears cut in bite-size pieces, and a peanut butter sandwich cut in half. CNA-I offered M1 a drink which M1 refused. M1 grabbed half of the sandwich, shoved it in M1's mouth, and asked CNA-I for a towel for M1's lap. CNA-I retrieved a towel from the linen cart which was steps from where M1 was seated. When CNA-I returned, CNA-I noted M1 was having trouble breathing. CNA-I aked CNA-J to get the nurse while CNA-I pushed the emergency button in the dining room and the code blue button in M1's room. Registered Nurse Supervisor (RNS)-K and Registered Nurse (RN)-L responded. RNS-K initiated the Heimlich Maneuver. M1 became unresponsive but still had a pulse. Staff moved M1 from a wheelchair to the floor. Staff continued the Heimlich Maneuver until M1 was pulseless and non-breathing. Staff did not call 911 or initiate CPR because M1's code status was DNR. M1 was pronounced dead at 5:33 PM by the on-call physician.On 2/5/26, Medical Examiner (ME)-M called the facility and asked whether 911 was called at the time of the choking incident. RNS-K stated 911 was not called because M1's code status was DNR. (Of note: The facility's policy indicates to call 911 if a member shows signs of complete choking.)On 4/9/26 at 8:52 AM, Surveyor interviewed ME-M who confired M1's cause of death was choking. On 4/8/26 at 9:31 AM, Surveyor interviewed SP-N who had a history of caring for M1. SP-N stated SP-N tried a pureed diet for M1 multiple times; however, M1 and M1's family did not want that type of diet. SP-N stated staff regularly fed and supervised M1 who had disorganized eating and swallowing. SP-N stated the facility, M1, and M1's family worked together over the years. M1 and M1's family chose quality of life and food preferences over a prescribed diet. SP-N stated M1 had a brain injury, was impulsive, had a lack of judgement, and lacked insight into how much food M1 put in M1's mouth. SP-N verified M1 grabbed half of the peanut butter sandwich and put it in M1's mouth. SP-N stated M1 got mad if sandwiches were cut in pieces and staff had to hold the sandwich to feed M1. SP-N stated M1 required the assistance of one staff for supervision and verified M1's care plan did not contain an intervention to keep meal trays out of M1's reach. SP-N also stated M1 became agitated and kicked staff if M1 did not like the food that was served. SP-N stated M1's last speech therapy evaluation was completed on 11/18/25 and was done because M1 did not want to trial pureed fruit or a modified diet. SP-N stated SP-N requested modifications previously, however, M1 and M1's family did not want diet modifications and requested a general diet to assist with M1's quality of life. On 4/8/26 at 12:00 PM, Surveyor interviewed NHA-A who verified staff did not follow the facility's choking incident policy and procedure and did not call 911 when M1 showed signs of complete choking. NHA-A confirmed staff should have called 911. The facility's failure to follow their policy and procedure for a member who was showing signs of complete choking and was still breathing created a reasonable likelihood for serious harm thus leading a finding of immediate jeopardy. The facility removed and corrected the jeopardy on 2/5/26 when it completed the following:1. Educated staff in-person and through Relias (the facility's online training program) training on unsafe eating behaviors, notifying the nurse if a member refuses to the follow their plan of care, and the facility's choking policy and procedure.2. Completed diet and meal settings audits for all members.3. Reviewed/revised members' diet care plans.4. Completed mock CPR/Automatic Defibrillatorr (AED) drills.

Based on observation, staff and member interview, and record review, the facility did not ensure adaptive eating/drinking equipment was used during meal time to prevent burns for 2 Members (M2 and M6) of 3 sampled members. M2 did not receive coffee in a covered mug during supper on 3/1/26. M2 attempted to transfer the coffee from the uncovered mug to an insulated mug with a cover. The coffee spilled in M2's lap and resulted in burns to M2's bilateral thighs. (This example is being cited at a level G.)M6 did not receive coffee in a covered mug during lunch on 4/8/26.Findings include:The facility's Adaptive Equipment policy, dated May 2023, indicates: Adaptive equipment shall be available to assist members in maintaining or achieving their highest level of independent functioning possible. 5. The equipment is provided at the needed meal times on the meal cart. The facility's Member Meals and Snacks policy, dated 3/13/26, indicates: Meal Distribution - Retherm Carts - Review care plans for adaptive equipment needs and eating/swallowing programs, provide as ordered. Between 4/7/26 and 4/8/26, Surveyor reviewed M2's medical record. M2 was admitted to the facility on [DATE] and had diagnoses including Multiple Sclerosis (MS), generalized muscle weakness, early onset Alzheimer's disease, and dysphagia (difficulty swallowing), oropharyngeal phase. M2's Minimum Data Set (MDS) assessment, dated 2/4/26, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated M2 had moderate cognitive impairment.M2's Activities of Daily Living (ADL) self-care deficit care plan, revised 2/7/24, indicated M2 was at risk for ADL self-care deficit related to limited mobility, MS with progressive declines, and early onset Alzheimer's disease. M2's nutrition care plan, revised 2/5/26, indicated M2 was at increased risk for altered nutritional status and had swallowing difficulty related to dysphagia, oropharyngeal phase as evidenced by a Speech Therapy review and recommendations for a modified texture/consistency diet. The care plan contained an intervention for an insulated coffee mug with lid and indicated M2 had a general ground with nectar thick consistency liquids diet order (dated 3/2/26). Surveyor reviewed a facility-reported incident (FRI) that indicated M2 spilled hot coffee on 3/1/26 which resulted in burns that blistered on M2's bilateral thighs. The investigation included a statement from Certified Nursing Assistant (CNA)-O who provided M2's supper tray on 3/1/26 at approximately 5:00 PM. CNA-O put the tray in front of M2, removed a coffee cup from the tray, and put the coffee cup on the table. CNA-O removed the cover of the coffee cup to allow it to cool. CNA-O left to retrieve M2's adaptive equipment which included a covered mug. While CNA-O was obtaining the equipment, M2 attempted to pour the coffee into M2's personal thermal mug. When M2 missed the mug, the thickened coffee spilled into M2's lap. M2 called for help. CNA-O and a nurse cleaned up and assessed M2. M2 had a reddened area on the right upper thigh. A statement from Registered Nurse (RN)-P indicated a CNA informed RN-P at approximately 9:00 PM that the reddened area was starting to become fluid-filled. A wound assessment, dated 3/2/26, indicated M2's left thigh had an intact blister that measured 2.6 centimeters (cm) x 1.5 cm. M2's right thigh had a 60% intact blister with 40% granulation tissue and scant exudate that measured 4 cm x 2.8 cm.On 4/7/26 at 12:26 PM, Surveyor interviewed CNA-C regarding education related to the incident. CNA-C indicated CNA-C was educated and a new process was implemented for serving meals. CNA-C indicated staff now prepare meal trays behind the counter and ensure adaptive equipment is on the tray before delivering trays to members.On 4/7/26, Surveyor reviewed M6's medical record. M6 was admitted to the facility on [DATE] and had diagnoses including gastroesophageal reflux disease (GERD,) legal blindness, vascular dementia, dysphagia oral phase, and esophageal obstruction. M6's MDS assessment, dated 1/7/26, had a BIMS score of 12 out of 15 which indicated M6 had moderate cognitive impairment. M6's ADL self-care deficit care plan, dated 12/9/19, indicated M6 was at risk for ADL self-care deficits related to poor vision and dementia. A revised approach (dated 1/12/26) indicated: Vision: Legally blind. M6's nutrition care plan, revised 1/9/26, indicated M6 was at increased risk for altered nutritional status and had difficulty swallowing related to dysphagia oral phase with esophageal stricture, history of need for dilation per Speech Therapy review, and recommendations for a modified texture diet. The care plan contained an intervention that indicated: Adaptive Equipment: Coffee cup with lid and white deep dish divided plate (dated 1/25/22).On 4/7/26 at 11:33 AM, Surveyor observed lunch on M2 and M6's unit. Staff prepared meal trays behind a counter and delivered the trays to residents. M2 received coffee in a covered mug. Surveyor started observing M6 shortly after M6's meal was delivered and observed M6 feel around for silverware. After M6 had searched for approximately one minute, staff approached and explained what food was on M6's plate and its location. Staff helped M6 find the utensils so M6 could eat. Surveyor observed an open cup of coffee to the left of M6's tray with a blue plate. Surveyor did not observe M6 drink coffee during the meal. On 4/7/26 at 12:26 PM, Surveyor interviewed CNA-D who helped serve and assist members during the meal. When Surveyor asked about adaptive equipment and M6's uncovered coffee mug and blue plate, CNA-D indicated M6 had a blue covered mug. When CNA-D and Surveyor approached M6, CNA-D verified M6 had a blue covered mug but also had a red uncovered coffee mug within reach. When Surveyor indicated M6's plate was blue but M6's care plan indicated M6 should have a white plate, CNA-D stated CNA-D was not sure. CNA-D stated meal carts contain bins with adaptive equipment which staff spread on the counter. If a member has adaptive equipment, it is indicated on a green meal tray ticket and staff check the pile on the counter for the member's equipment. CNA-C then approached Surveyor and CNA-D. CNA-C stated each member has a dysphagia card which tells staff if they need help eating. Surveyor reviewed M6's dysphagia card which did not indicate what adaptive equipment M6 needed. When Surveyor informed CNA-C that M6's meal tray contained an uncovered coffee mug and did not contain a white divided plate, CNA-C stated new staff do not always know what members need. When Surveyor asked if there is a list of what adaptive equipment members should have, CNA-C and CNA-D indicated adaptive equipment is listed on a member's Kardex (an abbreviated care plan used by nursing staff) in the binder at the nurses' station. CNA-C took Surveyor to the nurses' station. After paging through the binder for approximately one minute, CNA-C found M6's Kardex. On 4/7/26 at 1:35 PM, Surveyor interviewed CNA-D who stated the unit has two bins of adaptive equipment. CNA-D stated the bin with M6's adaptive equipment arrived late to the unit. M6 was already served when the bin arrived. Surveyor looked in the bin and observed a small coffee mug with a cover labeled with M6's name. On 4/8/26 at 11:39 AM, Surveyor observed lunch on M6's unit and noted M6's white divided plate and covered coffee mug were available to use during the meal. Surveyor tested the temperature of a cup of coffee from the same cart that held M6's meal tray. The temperature was 146.6 degrees Fahrenheit (F.) Per time and temperature tables for third degree burns, a third degree burn can occur at a liquid temperature of 140 degrees F in 5 seconds; and 148 degrees F in 2 seconds. On 4/7/26 at 2:02 PM, Surveyor informed Assistant Director of Nursing (ADON)-E of Surveyor's observations. ADON-E verified the only place to find what adaptive equipment a member should have is the member's care plan/Kardex. ADON-E confirmed if a member's adaptive equipment is not on the unit, staff should not serve the member until the adaptive equipment is available.

Based on staff interview and record review, the facility did not thoroughly investigate allegations of abuse for 1 member (M) (M3) of 1 sampled member.M3 made physical abuse allegations against staff on 12/15/25 and 1/3/26. The facility did not thoroughly investigate the allegations of abuse.Findings include:The facility's Prohibition and Prevention of Member Abuse, Neglect, and Exploitation policy, revised July 2024, indicates: .4. The Nursing Supervisor or Administrator immediately initiates initial reporting and conducts a thorough investigation. 1. All allegations are thoroughly investigated .8. During an investigation, staff are expected to disclose all information to investigating parties .Alleged Mistreatment.8. A list of possible witnesses is given to the Nursing Supervisor as soon as possible .Copies of daily schedules and staff statement forms .are placed on the 24-hour board; names of staff needing to provide statements are highlighted .Cross off the highlighted names after statements are obtained .Registered Nurses (RNs) follow-up with all staff who were on duty and may have provided care for the affected member at the time of the discovery and during the two previous shifts .14. A file containing .staff statements, any supporting documentation .is routed to administration for keeping .From 4/7/26 to 4/8/26, Surveyor reviewed M3's medical record. M3 was admitted to the facility on [DATE] and had diagnoses including dementia with Lewy body disorder, dementia with moderate agitation, visual hallucinations, and mood disturbance. M3's Minimum Data Set (MDS) assessment, dated 2/18/26, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated M3 had moderately impaired cognition. M3 had an activated Power of Attorney for Healthcare (POAHC). Surveyor reviewed the facility's investigations for two incidents, dated 12/15/25 and 1/3/26, in which M3 reported allegations of staff abuse. Surveyor reviewed staff schedules, dated 12/14/25 night (NOC) shift and 1/3/26, and compared staff interviews with the schedules. Surveyor noted staff who were working during the time the allegations were made were not interviewed. RN-G and Certified Nursing Assistant (CNA)-F were the only staff interviewed for the incident on 12/15/25. RN-H was the only staff interviewed for the incident on 1/3/26.On 4/7/25 at 11:43 AM, Surveyor asked Director of Nursing (DON)-B if the facility completed additional staff interviews for the incident on 12/15/25. DON-B indicated DON-B would check to see if there were other interviews.On 4/7/26 at 11:50 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-E who indicated other staff were not interviewed during the 12/15/25 NOC shift because nobody else was around. When asked if other staff were assigned to the unit besides RN-G and CNA-F, ADON-E indicated the other staff was assisting on another unit when the incident occurred. ADON-E verified the staff should have been interviewed. On 4/7/26 at 1:44 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated all staff working on the unit during the shift should have been interviewed regarding the abuse allegations.On 4/7/26 at 2:11 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and asked if the investigation for the incident on 1/3/26 contained any other staff interviews. NHA-A reviewed the file and found an Email with RN-H's statement, dated 1/6/26. The investigation did not contain any other staff statements. NHA-A indicated NHA-A would check if M3's 1:1 CNA was interviewed.On 4/8/26 at 9:22 AM, Surveyor interviewed NHA-A who verified RN-H was the only staff interviewed for the incident on 1/3/26. NHA-A verified other staff who were working should have been interviewed.On 4/8/26 at 12:09 PM, Surveyor interviewed DON-B who indicated no other staff were interviewed about the incident on 1/3/26. DON-B verified staff who were working at the time should have been interviewed.

Based on staff interview and record review, the facility was not free of significant medication errors for 2 residents (R) (R54 and R170) of 11 sampled residents. R54 received five extra doses of baclofen (a medication used to treat muscle spasms) on 1/15/25 and 1/16/25 due to a transcription error. R54 experienced overdose symptoms that required emergency transport and admission to the hospital on 1/17/25. R170 was administered double the ordered dose of long-acting insulin on 3/1/25 and 3/2/25. Findings include: The facility's Medication Administration policy, revised 2/6/25, indicates: .All medications shall be administered following the seven rights of administration. Right: Medication, Dose, Member, Route, Time, Documentation, Indication .Orders and administration instructions shall be followed at all times .Medication errors shall be reported immediately to the Registered Nurse (RN) . The facility's Orders Management policy, revised 5/1/24, indicates: .The RN is responsible to review the member's plan of care to address revisions needed based on prescribed orders. Orders transcribed in the electronic health record by anyone other than a nurse shall require RN review for accuracy and confirmation prior to administration. Orders from other than the Primary Care Physician (PCP)/designee shall be reviewed and verified with the PCP/designee .Order clarifications shall be documented in the clinical record. Holding orders shall require an end date or duration. Hold orders without an end date or duration shall be clarified with the provider and discontinued, requiring a new provider's order to restart. All orders shall be addressed and processed promptly unless clarification is needed; those needing clarification shall be addressed timely for processing. All transcription errors shall be promptly reported to the RN .When transcribing orders, the prescriber shall always be identified as the ordering provider . 1. On 3/17/25, Surveyor reviewed R54's medical record. R54 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease and chronic kidney disease. R54's Minimum Data Set (MDS) assessment, dated 1/8/25, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R54 had moderate cognitive impairment. R54 had a Power of Attorney for Healthcare (POAHC) who was responsible for R54's healthcare decisions. R54's medical record indicated R54 was transferred to the hospital on 1/17/25 and readmitted to the facility on [DATE]. An Order note, dated 1/14/25 at 4:59 PM, indicated baclofen 10 milligrams (mg) four times daily (QID) exceeded the usual frequency of one to three times per day. An Administration note by Licensed Practical Nurse (LPN)-F, dated 1/14/25 at 5:05 PM, indicated there was a duplicate order. A Respiratory Therapy note, dated 1/16/25 at 2:00 PM, indicated R54 was extremely drowsy during nebulizer treatments. The Respiratory Therapist reported the information to an RN. An Administration note by LPN-F, dated 1/16/25 at 8:43 PM, indicated R54 was unable to safely take a medication due to lethargy. A Notification note, dated 1/16/25 at 10:11 PM, indicated the on-call physician was notified of a medication error at 9:40 PM. The physician instructed staff to hold baclofen until R54 was alert and monitor R54 overnight. The note indicated R54's POAHC was notified of the medication error and monitoring order. An Incident note, dated 1/16/25 at 10:15 PM, indicated a new order was received on 1/14/25 to increase baclofen 10 mg from three times daily (TID) to QID; however, the TID order was not discontinued and an order to administer baclofen 10 mg QID was added. The error was found in the evening on 1/16/25. R54's vital signs were within normal limits, however, R54 exhibited increased fatigue and weakness. A note, dated 1/17/25 at 12:30 AM, indicated R54 was assessed by an RN. Adverse effects from the medication error were unknown at that time because R54 was sleeping soundly and slept through the assessment. R54's respiratory rate was even, shallow, and unlabored with no concerns. A Health Status note, dated 1/17/25 at 6:51 AM, indicated an RN was called to R54's room at approximately 5:25 AM because R54's legs were shaking. The RN observed R54 in bed and noted both lower legs were shaking with the left leg shaking more than the right. R54's arms could not extend and R54's fists were clenched. R54 was confused, answered only yes or no, and had a delayed response to questions. The on-call physician (who was already aware of the medication error) was notified and requested staff administer carbidopa/levodopa (a medication used to treat Parkinson's disease symptoms of stiff joints and movement), however, R54 was too sleepy to use a straw or swallow. The on-call physician instructed staff to send R54 to the emergency room (ER). R54 left the facility with Emergency Medical Services (EMS) at approximately 6:10 AM. The RN was unable to obtain vital signs due to R54's condition. ER physician notes, dated 1/17/25, indicated R54 was alert and had tremors of both lower legs with stiffness. R54 was sedate but responded to painful and loud verbal stimuli. R54 was conversant upon EMS' arrival at the facility but was sedate and tremulous upon arrival at the ER. The ER physician discussed the case with Poison Control and obtained additional blood levels based on Poison Control's recommendations. The levels were reassuring and R54's condition appeared to be an accidental baclofen overdose. A hospital history and physical note, dated 1/17/25, indicated there was difficulty assessing R54's neurological status at the time of admission to the hospital from the ER. R54 appeared uncomfortable. R54's eyes were open, however, R54 did not follow commands, moaned incomprehensible words, and did not answer questions. R54's arms were stiff with mild tremors. On 3/19/25 at 10:15 AM, Surveyor interviewed Medical Director (MD)-G via phone. MD-G indicated MD-G was aware of the baclofen medication error within 24 hours if not the same day. MD-G indicated the on-call physician was immediately notified when the error was discovered. MD-G indicated MD-G would have issued the same orders as the on-call physician. MD-G indicated when R54's baclofen order was increased by a specialty physician, the nurse should have entered the order in R54's medical record correctly by discontinuing the previous baclofen TID order or should have questioned the physician with any concerns. MD-G indicated the medication error led to R54's hospitalization and indicated the most severe outcomes of a baclofen overdose are mild respiratory distress, sedation, and cognitive changes. MD-G indicated the quantity of baclofen R54 received for the short period of time was not life-threatening but could cause cognitive changes. MD-G participated in the facility's improvement process to determine the cause of the error and reeducate staff in collaboration with the pharmacy. MD-G indicated R54's medical record should have triggered an alert when the order was entered because both the TID and QID orders together exceeded the standard dosing. MD-G indicated standard dosing for baclofen should not exceed 80 mg total per day. MD-G indicated the medication error put (R54) close to that. On 3/19/25 at 10:34 AM, Surveyor again interviewed MD-G via phone. MD-G indicated R54's medical record did generate an alert (see note above) and MD-G believed the pharmacy discontinued the TID order from their end. Surveyor reviewed R54's January 2025 medication administration record (MAR) which contained the following orders: ~ Baclofen 10 mg TID: ordered 9/4/24 and discontinued 1/16/25 at 8:36 PM - received all scheduled doses in January as ordered (at 6:30 AM, 10:30 AM and 6:30 PM) with the following exceptions: no signature on 1/14/25 for the 10:30 AM dose, the 1/14/25 6:30 PM dose was held, no signature on 1/16/25 for the 6:30 PM dose. ~ Baclofen 10 mg QID: ordered 1/14/25 at 3:00 PM and discontinued 1/21/25 at 11:58 AM - received all scheduled doses as ordered (6:30 AM, 10:30 AM, 2:30 PM and 6:30 PM) with the following exceptions: the 6:30 PM dose was documented as refused on 1/16/25. All doses thereafter were not administered because R54 was hospitalized . Based on the above information, R54's MAR indicated R54 received double doses of baclofen (a total of 20 mg each time) on 1/15/25 at 6:30 AM, 10:30 AM, and 6:30 PM and on 1/16/25 at 6:30 AM and 10:30 AM for a total of five double doses. On 3/19/25 at 10:49 AM, Surveyor interviewed Director of Nursing (DON)-B. Immediately after discovering the error, DON-B indicated the facility re-educated all nurses regarding the transcription process and provided one-on-one education to the RN who transcribed R54's baclofen order incorrectly. DON-B indicated LPN-F reported the duplicate order to the RN on 1/14/25 and the RN indicated the RN would take care of it but got distracted. DON-B indicated the facility conducted informal audits of orders following R54's medication error but had no documentation of the audits. DON-B indicated no medication errors had occurred since then. On 3/19/25, Surveyor reviewed the facility's investigation for the medication error which contained a Record of Conversation/Notice, dated 1/25/25, that indicated RN-H was counseled regarding failure to discontinue a duplicate order for a medication which resulted in a medication overdose and hospitalization . The investigation did not indicate a process change was implemented to prevent additional errors and did not contain audits to determine if any other residents were affected. On 3/19/25 at 1:51 PM, Surveyor interviewed DON-B who indicated the process change implemented in response to the medication error is to have staff enter the ordering physician's name with the order unless the PCP is the ordering provider. DON-B verified the process change did not really fix the root cause of the medication error. DON-B indicated the education provided to staff was on the process change plus the overall transcription process. 50479 2. From 3/17/25 to 3/19/25, Surveyor reviewed R170's medical record. R170 was admitted to the facility on [DATE] and had diagnosis of type 2 diabetes mellitus. R170's most recent MDS assessment, dated 2/3/25, indicated R170 had moderate cognitive impairment. On 3/17/25 at 10:21 AM, Surveyor interviewed R170 who indicated R170 had unpredictable fluctuations in R170's blood glucose levels since admission to the facility. On 3/19/25, Surveyor reviewed R170's MAR which included the following long-acting insulin orders: ~ Lantus SoloStar Subcutaneous Solution Pen-injector 100 units/milliliter (ml) (insulin glargine) Inject 14 units subcutaneously at bedtime for diabetes type 2. When pen is completed, please refer to Semglee order. Have RN initiate Semglee order and discontinue Lantus (ordered and started 1/27/25; discontinued 2/7/25). ~ Semglee Subcutaneous Solution Pen-injector 100 units/ml (insulin glargine-yfgn) Inject 14 units subcutaneously at bedtime for diabetes type 2 (ordered 1/27/25; started 1/29/25; discontinued 3/3/25). ~ Lantus SoloStar Subcutaneous Solution Pen-injector 100 units/ml (insulin glargine) Inject 12 units subcutaneously at bedtime for diabetes type 2. When pen is completed, please refer to Semglee order. Have RN initiate Semglee order and discontinue Lantus (ordered and started 2/7/25 for indefinite). R170's medical record indicated R170 was to transition from Lantus SoloStar to Semglee when R170's home supply of Lantus SoloStar was exhausted. The order for Semglee was entered and held from 1/27/25 to 1/29/25. On 3/1/25, Semglee was started but Lantus SoloStar was not discontinued. On 3/1/25 at 6:30 PM, R170 received 14 units of Semglee (insulin glargine-yfgn) and 12 units of Lantus (insulin glargine). On 3/2/25 at 2:30 AM, R170 had an episode of asymptomatic hypoglycemia (low blood sugar). R170's continuous glucose monitoring device alarmed for a blood glucose of 78. On 3/2/25 at 6:30 PM, R170 received 14 units of Semglee (insulin glargine-yfgn) and 12 units of Lantus (insulin glargine). On 3/3/25 at 4:36 AM, R170 had an episode of asymptomatic hypoglycemia. R170's continuous glucose monitoring device alarmed for a blood glucose of 78. On 3/19/25 at 1:54 PM, Surveyor interviewed DON-B who indicated there was not an investigation for the insulin error and staff were not interviewed following the error. DON-B indicated staff education was not completed and a process change(s) was not implemented to prevent similar medication errors.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect more than 4 of the 176 residents residing in the facility. Food items for resident consumption were not appropriately labeled and/or were beyond the discard date. Equipment in the main kitchen was not in clean condition and/or covered. Findings include: On 3/17/25 at 9:20 AM, Surveyor interviewed Dietary Manager (DM)-K who stated the facility follows the Federal Food Code. Food Labeling/Storage: The 2022 FDA Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking: .(B) Except as specified in (E)-(G) of this section, refrigerated, ready-to-eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. During an initial kitchen tour that began at 9:20 AM on 3/17/25, Surveyor noted an item in the cooler labeled tater tot casserole with a prepped date of 12/12/23, a pulled date of 12/13/23, and no use-by date. Surveyor noted an item in the freezer labeled gluten free (GF) hot dog bun (single) dated 2/12 with no year or use-by date. Surveyor also noted an open box of turkey breasts dated 9/25/22 with no use-by date. On 3/17/25 at 9:20 AM, Surveyor interviewed DM-K who confirmed the tater tot casserole, hot dog bun, and turkey breasts were past their expiration dates and should have been discarded. Cleanliness: The 2022 FDA Food Code documents at 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. The 2022 FDA Food Code documents at 4-602.13 Nonfood-Contact Surfaces: Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residue. The 2022 FDA Food Code documents at 4-903.11 Equipment, utensils, linens, and single-service and single-use articles: (a) Except as specified in (d) of this section, cleaned equipment and utensils, laundered linens, and single-service and single-use articles shall be stored: (1) in a clean, dry location; (2) where they are not exposed to splash, dust, or other contamination; and (3) at least 15 centimeters (cm) (6 inches) above the floor. (b) Clean equipment and utensils shall be stored as specified under (a) of this section and shall be stored: (1) in a self-draining position that allows air drying; and (2) covered or inverted. During an initial tour of the kitchen that began at 9:20 AM on 3/17/25, Surveyor observed a coffee dispensing machine and noted dried coffee ground-like debris on the interior compartment. Surveyor also noted a cleaning sign off log posted on the exterior of the dispenser. The cleaning log indicated the coffee dispenser should be cleaned weekly on Fridays and was last cleaned on 1/10/25. On 3/17/25 at 9:20 AM, Surveyor interviewed DM-K who confirmed the coffee dispenser should be cleaned weekly on Fridays. DM-K acknowledged the dried debris on the interior of the dispenser and verified the last time staff indicated it was cleaned was on 1/10/25. During a follow-up tour of the kitchen that began at 12:01 PM on 3/18/25, Surveyor noted the coffee dispenser appeared to have been cleaned and the cleaning log contained a date of 3/17/25. On 3/17/25 at 9:20 AM, Surveyor observed three standing mixers in the main kitchen. The mixers were not in use and were not covered. Surveyor also observed a vertical cutter mixer (VCM) and 5+ VCM disc blades that were hung on the wall. The VCM and disc blades were not covered. On 3/17/25 at 9:20 AM, Surveyor interviewed DM-K who stated the three stand mixers, the VCM, and the blades are not covered when not in use.

Based on staff and resident interview and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R147) of 2 residents reviewed for oxygen therapy. R147 did not have a physician order for oxygen therapy. Findings include: The facility's Oxygen Therapy policy, revised 10/2/24, indicates: A provider's order is required for extended oxygen use .Orders must indicate the liter flow rate and if delivery is to be continuous or on demand .Humidification bottle shall be replaced as needed; bottles shall be labeled with date opened and shall be discarded no later than 30 days from labeled date .Nasal cannula (NC) shall be replaced at least weekly and when visibly soiled or contaminated .Filters on concentrator units shall be cleaned weekly in warm, soapy water and allowed to air dry prior to replacing .1) When oxygen is ordered, each oxygen delivery device should be labeled with an identification band/label that includes the member's name, facility, room number, and oxygen order .4) When oxygen is discontinued or no longer used, discard all supplies .5) Replace NC/masks weekly Sundays on night shift and when visibly soiled or .6) Once per month, Certified Nursing Assistants (CNAs) replace in-use extension tubing on Sunday night shift when replacing NC/masks .Concentrator unit: .10) Record oxygen administration and member's response in the electronic health record .13) If in use, replace humidification bottle as needed and no later than 30 days since last replaced. When placing a new bottle, indicate date of opening on bottle with a permanent marker .14) When oxygen is no longer needed or discontinued power unit off, remove oxygen supplies from member .Remove unit from member's room . From 3/17/25 to 3/19/25, Surveyor reviewed R147's medical record. R147 was admitted to the facility on [DATE] and had diagnoses including chronic diastolic (congestive) heart failure, obstructive sleep apnea, and type 2 diabetes mellitus with diabetic chronic kidney disease. R147's Minimum Data Set (MDS) assessment, dated 2/12/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R147 had intact cognition. R147's medical record did not include physician orders or a care plan for oxygen therapy. On 3/17/25 at 10:23 AM, Surveyor observed R147 with oxygen running at 6 liters per minute (LPM) via nasal cannula connected to an oxygen concentrator. Surveyor noted R147's tubing and humidifier canister were not dated. Surveyor interviewed R147 who indicated R147 needed oxygen and had used oxygen for a while. On 3/18/25 at 1:11 PM, Surveyor interviewed Respiratory Therapist (RT)-J who reviewed R147's medical record and confirmed R147 did not have an order for oxygen even though R147 was known to use oxygen. RT-J indicated a resident on oxygen therapy should have orders for the dose, route, and pulse oximetry parameters. RT-J indicated CNAs were responsible for changing oxygen tubing once per week. On 3/18/25 at 1:20 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R147 did not have an order or care plan for oxygen therapy. DON-B indicated R147 should have an oxygen order and care plan. On 3/18/25 at 2:15 PM, DON-B provided Surveyor with a written physician order for R147 (dated 9/17/24) for oxygen 1-2 liters to keep saturation above 88%. DON-B indicated the order dropped off R147's physician orders but should not have.

Based on observation, staff interview, and record review, the facility did not ensure a call light was within reach for 1 resident (R) (R118) of 35 sampled residents. On 3/17/25, R118 did not have a call light within reach. Findings include: The facility's Member Rounds policy, dated 1/7/25, indicates call lights should be within reach. From 3/17/25 to 3/19/25, Surveyor reviewed R118's medical record. R118 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's dementia, chronic obstructive pulmonary disease, and adult failure to thrive. R118's Minimum Data Set (MDS) assessment, dated 2/25/25, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R118 had moderately impaired cognition. R118's risk for falls care plan indicated R118 was at risk for falls due to a screening evaluation and several predisposing factors. The care plan contained an intervention (dated 12/16/22) to remind R118 to be safe and call for assistance. On 3/17/25 at 10:25 AM, Surveyor observed R118 in a recliner with a pressure sensitive pad alarm. R118 did not have a call light within reach and was unable to call for assistance. Surveyor noted R118's call light was wrapped around a trapezius bar positioned above R118's bed. On 3/17/25 at 10:34 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who observed R118's call light. LPN-E verified R118's call light was not within reach and R118 was unable to call for assistance. On 3/18/25 at 2:51 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated residents should have call lights within reach.

Based on staff interview and record review, the facility did not ensure an allegation of misappropriation was thoroughly investigated for 1 resident (R) (R73) of 3 sampled residents. On 12/19/24, R73 reported that $150 was missing from R73's room. The facility did not thoroughly investigate the allegation of misappropriation. Findings include: The facility's Prohibition and Prevention of Member Abuse, Neglect, and Exploitation policy, dated 7/2/24, indicates: .To protect the member's right to be free from abuse, neglect, exploitation, and misappropriation of member's property .4. The nursing supervisor or facility administrator immediately initiates initial reporting and conducts a thorough investigation .8. A list of possible witnesses is given to the nursing supervisor as soon as possible .8.2. The Registered Nurses (RNs) follow-up with all staff who were on duty and may have provided care for the affected member at the time of discovery and during the two previous shifts .9. The nursing supervisor continues the investigation by potentially implementing additional interventions to maintain member safety; further investigation may include: .9.3. Interviewing the alleged victim, witnesses, accused individuals, and other members and staff . On 3/17/25, Surveyor reviewed R73's medical record. R73 was admitted to the facility on [DATE] and had diagnoses including multiple sclerosis and unspecified dementia without behavioral disturbance. R73's Minimum Data Set (MDS) assessment, dated 1/22/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R73 was not cognitively impaired. R73 had a Power of Attorney for Healthcare (POAHC) who was responsible for R73's healthcare decisions. On 3/17/25, Surveyor reviewed an investigation regarding R73's allegation of missing money. The investigation indicated R73 withdrew money from a bank account on the morning of 12/18/24 for a shopping trip on 12/19/24. R73 refused to have the money securely stored on the night of 12/18/24. When R73 left for the shopping trip on 12/19/24, the money was no longer in the bank envelope. The investigation included an Initial Statement Related to Incident form that contained nine staff names and signatures under the statement, I have no knowledge regarding this incident. Four of the signatures were dated 12/19/24, one signature was dated 12/20/24, two signatures were dated 12/24/24, one signature was dated 12/25/24, and one signature was undated. The investigation also included a Statement Related to Incident, dated 12/19/24, that indicated a staff member had reported R73's missing money to an RN on 12/19/24. On 3/17/25 at 12:09 PM, Surveyor interviewed Commandant (CMD)-C who (following a review of the investigation with Surveyor) verified all staff who had access to R73's room should have been interviewed during the timeframe in question. On 3/17/25 at 1:13 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B sent an email to CMD-C to be printed for Surveyor. DON-B verified all staff named in the email should have been interviewed regarding R73's missing money. DON-B verified not all staff were interviewed according to the investigation. On 3/17/25, Surveyor reviewed staffing documents from 12/18/24 and 12/19/24 along with an email from DON-B that explained which staff were assigned to R73's unit and on which shift on 12/18/24 and 12/19/24. Of the staff who had access to R73's room during the AM shift on 12/18/24 and 12/19/24, the PM shift on 12/18/24, and the night(NOC) shift from 12/18/24 to 12/19/24, four staff were not interviewed during the investigation.

Based on observation, staff and resident interview, and record review, the facility did not ensure the provision of care and treatment to prevent urinary tract infections (UTIs) for 1 resident (R) (R54) of 3 sampled residents. Staff did not provide suprapubic catheter (a tube that drains urine from the bladder through a small incision in the abdomen) site care for R54. Findings include: The facility did not provide a policy related to suprapubic catheter site care. From 3/17/25 to 3/19/25, Surveyor reviewed R54's medical record. R54 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease and chronic kidney disease. R54's Minimum Data Set (MDS) assessment, dated 1/8/25, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R54 had moderate cognitive impairment. R54 had a Power of Attorney for Healthcare (POAHC) who was responsible for R54's healthcare decisions. R54's medical record indicated R54 had a suprapubic urinary catheter due to urinary retention as a result of an atonic bladder (a condition where the bladder muscles don't contract which makes it hard to urinate). R54's medical record did not contain an order or indicate routine suprapubic catheter site care was provided to prevent UTIs. R54's medical record indicated R54's suprapubic catheter was changed monthly as ordered by the physician. On 3/17/25 at 11:12 AM, Surveyor interviewed R54 who indicated R54 experienced frequent UTIs at the end of summer in 2024. R54 indicated those have gotten better more recently. On 3/19/25 at 8:56 AM, Surveyor observed Certified Nursing Assistant (CNA)-I empty R54's catheter drainage bag. CNA-I indicated R54's catheter site care was provided by night (NOC) shift staff. On 3/19/25 at 10:56 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated nurses completed suprapubic catheter care. DON-B verified R54's medical record did not contain documentation that suprapubic catheter site care was completed. DON-B was unsure if the facility had a policy specific to suprapubic catheter care. On 3/19/25 at 12:53 PM, Surveyor interviewed DON-B who indicated DON-B searched suprapubic catheter care and the results indicated suprapubic catheter site care should be completed twice daily. DON-B indicated the handwriting on the below mentioned document was DON-B's handwriting from the search. On 3/19/25, Surveyor reviewed an email to DON-B, dated 3/19/25, that indicated the facility had a policy that indicated staff should cleanse suprapubic catheter sites with insertion and removal (when catheter tubing is changed). The email indicated the policy for catheter changes referenced another policy that only addressed routine perineal care with a Foley catheter (a tube inserted in the bladder through the urethra (natural tube through which urine normally exits body)). Handwriting on the email indicated to wash the site with warm soapy water, secure the catheter, and wipe down primal to distal with morning and evening care, and report any redness. On 3/19/25 at 1:55 PM, Surveyor interviewed DON-B who indicated DON-B could not provide documentation that R54 received suprapubic catheter site care. DON-B verified suprapubic catheter site care should have been completed.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R79 and R72) of 3 sampled residents. R79 was on enhanced barrier precautions (EBP). On 3/18/25, Licensed Practical Nurse (LPN)-D did not wear a gown during catheter care for R79. R72 was on EBP. On 3/8/25, LPN-D did not wear a gown while administering medications via gastrostomy tube (G-tube) to R72. Finding includes: The facility's Transmission-Based Precautions policy, dated 4/11/24, indicates: Enhanced Barrier Precautions (EBP): For members with novel or targeted multidrug-resistant organism (MDRO) infections, indwelling medical devices and wounds, including as part of a public health containment response. This type of precaution falls between standard and contact precautions and requires gown and glove use for certain members during specific high-contact member care activities that have been found to be at increased risk for MDRO transmission .Residents with device care or use: central line, urinary catheters, feeding tubes, tracheostomy/ventilator . 1. From 3/17/25 to 3/19/25, Surveyor reviewed R79's medical record. R79 was admitted to the facility on [DATE] and had diagnoses including diabetes and disorder of the bladder. R79 had an indwelling urinary catheter. R79's Minimum Data Set (MDS) assessment, dated 2/10/25, had a Brief Interview for Mental Status (BIMS) score of 15 of 15 which indicated R79 was not cognitively impaired. On 3/18/25 at 11:50 AM, Surveyor observed LPN-D empty R79's Foley catheter bag without wearing a gown. Surveyor interviewed LPN-D who verified LPN-D should have worn a gown when emptying R79's catheter bag per the facility's EBP policy. LPN-D verified R79 was on EBP. 2. From 3/17/25 to 3/19/25, Surveyor reviewed R72's medical record. R72 was admitted to the facility on [DATE] and had diagnoses including dysphagia, chronic obstructive pulmonary disease, and heart failure. R72 had a G-tube. R72's MDS assessment, dated 12/26/24, had a BIMS score of 15 out of 15 which indicated R72 was not cognitively impaired. On 3/18/25 at 11:56 AM, Surveyor observed LPN-D administer medication to R72 via G-tube without wearing a gown. Surveyor interviewed LPN-D who verified LPN-D should have won a gown when administering medication to R72 per the facility's EBP policy. LPN-D verified R72 was on EBP. On 3/18/25 at 2:53 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R79 and R72 were on EBP and LPN-D should have worn a gown during high-contact resident cares. DON-B indicated emptying a catheter bag and administering medication via G-tube were considered high-contact resident cares.

Based on observation, staff interview and record review, the facility did not ensure kitchen equipment was monitored appropriately to ensure food safety. This practice had the potential to affect all 164 residents residing in the facility. Mechanical warewashing wash, sanitization, and internal surface temperature logs were not consistently completed. Cooking and cooling temperature logs for food cooked in the oven were not consistently completed. Logs that documented parts per million (PPM) of the sanitizing solution in sanitizer buckets and sanitization levels in the 3 compartment sink were not consistently completed. Findings include: On 1/29/24 at 8:40 AM, Surveyor began an initial kitchen tour with Dietary Administrator (DA)-F and Food Service Manager (FSM)-I. DA-F indicated the facility followed the US Food and Drug Administration (FDA) Food Code. The FDA Food Code 2022 at 3-402.12 Records, Creation and Retention indicates: Records must be maintained to verify that the critical limits required for food safety are being met. Records provide a check for both the operator and the regulator in determining that monitoring and corrective actions have taken place. 1. The FDA Food Code 2022 at 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature indicates: (A) The temperature of the wash solution in spray type warewashers that use hot water to sanitize may not be less than: (4) For a multi-tank, conveyor, multi-temperature machine, 150 degrees Fahrenheit (F). The FDA Food Code 2022 at 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures indicates: (A) .in a mechanical operation, the temperature of the fresh hot water sanitizing rinse .(2) For all other machines, 180 degrees F. During the initial kitchen tour on 1/29/24, Surveyor requested to review the January 2024 dishwasher temperature log. FSM-I provided the log and Surveyor noted there were missing dates. On 1/30/24 at 11:08 AM, DA-F provided additional requested logs. DA-F stated the log should be filled out by the kitchen supervisor prior to the morning dish cycle and again during the afternoon dish cycle. Surveyor noted: ~The November 2023 dishwasher temperature log indicated temperatures were documented at least once daily for 10 out of 30 days and 20 days contained no documentation. ~The December 2023 dishwasher temperature log indicated temperatures were documented at least once daily for 11 out of 31 days and 20 days contained no documentation. ~The January 2024 dishwasher temperature log indicated temperatures were documented at least once daily for 14 out of 28 days and 14 days contained no documentation. Surveyor noted on the dates the temperatures were recorded, the warewashing machine external and internal sani-disk temperatures were within the appropriate wash and sanitization ranges. On 1/30/24 at 11:08 AM, DA-F indicated the logs should be completed twice daily by the kitchen supervisors. 2. The FDA Food Code 2022 at 3-501.14 Cooling indicates: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135 Fahrenheit (F) to 70 F; and (2) Within a total of 6 hours from 135 F to 41 F or less. (B) Time/Temperature Control for Safety Food (TCS) shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna. During the initial kitchen tour on 1/29/24, Surveyor requested to review cook temperature logs to ensure food was cooked to the appropriate temperature and cooled within the regulatory timeframe. On 1/30/24 at 11:08 AM, DA-F provided 4 logs for January 2024. The logs indicated at the top: Record product name along (include all versions) and final cooking temperature. Record cooling temperatures every hour during the cooling cycle. Record corrective action, if applicable. The food service manager will verify that the production staff is cooking and cooling food properly by visually monitoring production employees during the shift and reviewing, initialing, and dating this log daily. DA-F stated the facility uses a cook chill system in which some items are cooked in bulk in large kettles. The kettles are digitally monitored for time and temperature through the cooking and cooling process by a computerized line graph on a paper wheel. The facility uses a paper log for food items cooked in the oven and then cooled for the cook chill system. The paper log contains cook temperatures and cooling temperatures. For the month of January, DA-F provided a log for 1/8/24, 1/10/24, 1/15/24, and 1/29/24. On 1/30/24 at 11:22 AM, Surveyor interviewed Cook (CK)-G who confirmed paper logs are filled out for food cooked and cooled in the oven. CK-G and DA-F indicated the oven is not used every day, but was used more than the 4 days that were documented. DA-F indicated when food is cooked in the oven, staff should be document the cooking and cooling temperatures. Surveyor also noted the log was not completely filled out per the instructions at the top that indicated the food service manager would review, initial, and date the log daily. 3. The FDA Food Code 2022 at 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization-Temperature, pH, Concentration, and Hardness indicates: A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under 7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions. The FDA Food Code 2022 at 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration indicates: Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. The facility's PPM Monitoring for 3 Compartment Sanitation Sink and Sanitation Buckets policy, dated 11/6/15, indicates: The PPM of the sanitizing sink or bucket must be checked every 2 hours to ensure appropriate sanitizing levels. Procedure: At the indicated times on the recording sheet . The facility's Sanitizing Solution Concentration/Wiping Cloth Use policy, with a review date of April 2011, indicates: A PPM monitoring record shall be maintained with the daily mixing of sanitizing solution for spray bottles and sanitizing buckets. Completed monitoring records shall be filed along with the Bureau of Dietary Services for a period of at least 6 months. During the initial kitchen tour on 1/29/24, Surveyor requested to review the 3 compartment sink and sanitization bucket test logs. FSM-I provided logs for January 2024 that were incomplete. On 1/30/24, DA-F provided the November and December 2023 logs which contained the following information: Sanitization Bucket: ~The December 2023 log was completed for 3 out of 31 days. ~The January 2024 log was completed for 7 out of 28 days. 3 Compartment Sink: ~The November 2023 log was completed for 16 out of 30 days. ~The December 2023 log was completed for 17 out of 31 days. ~The January 2024 log was completed for 17 out of 29 days. On 1/30/23 at 11:08 AM, DA-F indicated sanitization bucket and 3 compartment sink testing should be completed per policy.

Based on resident and staff interview and record review, the facility did not ensure a comprehensive resident-centered care plan was developed for 1 Resident (R) (R118) of 32 sampled residents. R118 expressed delusional statements. The facility did not assess for the validity of the statements or develop a comprehensive care plan with individualized interventions to address the delusional statements. Findings include: On 1/29/24, Surveyor reviewed R118's medical record. R118 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and anxiety disorder. R118's Minimum Data Set (MDS) assessment, dated 11/1/23, contained a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R118 had moderate cognitive impairment. R118's Power of Attorney for Healthcare (POAHC) document, activated on 1/22/20, indicated R118's POAHC was responsible for R118's healthcare decisions. On 1/29/24 at 9:37 AM, Surveyor interviewed R118 who stated, . Men tried to trap me down in the office by the church. When I got down to the bottom, three of them worked me over . R118 indicated there were coyotes or something there and stated, I'm sure my mom wouldn't like it. They notified the police. On 1/29/24 at 10:28 AM, Surveyor interviewed POAHC-C via phone. When informed of the above statements from R118, POACH-C stated, (R118) doesn't know what's going on, not right in the head. On 1/29/24, Surveyor reviewed R118's care plan which contained no mention of a history of delusional thoughts or statements. R118's medical record contained documentation of other monitored behaviors, but the listed behaviors did not include delusional statements. R118's nursing progress notes did not contain mention of R118's delusional statements. R118's medical record contained a physician note, dated 11/9/23, that indicated: (R118) is a poor historian(secondary) to dementia, but continues false fixed belief about recent assault. This was the same conversation during my September interview with (R118). 'They threw a rock at me' 'Tore all my clothes off' 'Beat me down' .confusion noted .moderate late onset Alzheimer's dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety . On 1/30/24 at 1:33 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-D who indicated R118 can be pretty delusional at times. CNA-D stated, Sometimes (R118) will say two men put me in the basement and hit me with a brick. That's the kind of a story (R118) will go back to. Hard to redirect (R118). When asked what interventions staff use to help R118 during those times, CNA-D indicated staff try to change the subject or use food as a distraction. CNA-D stated, (R118) hangs onto things, even if we try to reassure (R118). (R118) has knee pain and sometimes (R118) will say (the above story) is the cause of (R118's) pain. On 1/30/24 at 1:41 PM, Surveyor interviewed Social Worker (SW)-E and asked if the facility's interdisciplinary team was aware of the above statements that R118 expressed to Surveyor. SW-E stated, (R118) has said that to (R118's) family too. We are aware of it. There was never any injury. SW-E indicated staff assess for injury when R118 expresses the delusional statements. When Surveyor indicated R118's care plan does not contain mention of delusional statements, SW-E stated, I haven't heard (R118) has said that in a long time. I was not aware (R118) has said that since admitted to [NAME] (Hall). (R118) said it when in (previous facility on same campus). When asked why R118's delusional statements were not contained in R118's care plan, SW-E stated, I don't have a good answer to give you. Following a discussion regarding CNA-D's interview and the 11/9/23 physician note, Surveyor asked if the delusional statements should be addressed in R118's care plan. SW-E stated, Yes and it will be.

Based on staff interview and record review, the facility did not ensure monitoring of high-risk medications for 1 Resident (R) (R41) of 5 residents reviewed for unnecessary medications. R41's medical record did not contain monitoring documentation for adverse reactions to anticoagulant and opioid medications. Findings include: According to the Davis's Drug Guide for Nurses 18th edition copyright 2023 adverse reactions/side effects of oxycodone include, but are not limited to: orthostatic hypertension, dry mouth, dizziness, loss of appetite, altered mental status, anxiety, constipation, depression, nausea, vomiting, pruritus, respiratory distress, sedation, urinary retention .Monitor for respiratory depression, rate, depth, after administration of pain medications. According to the Davis's Drug Guide for Nurses 18th edition copyright 2023 adverse reactions/side effects of Eliquis include bruise and bleed more easily or longer than usual .notify health care professional immediately if signs of bleeding (unusual bruising, pink or brown urine, red or black, tarry stools, coughing up blood, vomiting blood, pain or swelling in a joint, headache, dizziness, weakness, recurring nose bleeds, unusual bleeding from gums, heavier than normal menstrual bleeding, dyspepsia, abdominal pain, epigastric pain) occurs or if injury occurs, especially head injury. On 1/31/24, Surveyor reviewed R41's medical record. R41 had diagnoses including atrial fibrillation, muscle weakness, type 2 diabetes with diabetic polyneuropathy, chronic pain syndrome, and primary generalized osteoarthritis. R41's Minimum Data Set (MDS) assessment, dated 12/6/23, contained a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R41 had intact cognition. R41 did not have an activated decision maker. R41's medical record contained orders for Eliquis (an anticoagulant medication) 2.5 mg (milligrams) one tablet twice daily, oxycodone hydrochloride (an opioid medication used to treat pain) 5 mg every six hours as needed, and tramadol (an opioid medication used to treat pain) 50 mg every twelve hours as needed, but did not indicate staff monitored R41 for adverse reactions to the medications. On 1/31/24 at 9:02 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility's expectation is that staff monitor residents for adverse reactions to high-risk medications, such as anticoagulant and opioid medications, and that high-risk medications are included in residents' care plans. DON-B verified R41 had orders for Eliquis, oxycodone and tramadol. DON-B indicated staff know the residents well and recognize changes in condition. When Surveyor asked about agency staff and new hires who are not familiar with the residents and their medications, DON-B confirmed the information, including monitoring for adverse reactions, should be included in residents' care plans. DON-B stated DON-B would review R41's care medical record and care plan for monitoring of the high-risk medications. On 1/31/24 at 10:10 AM, DON-B approached Surveyor and confirmed R41's medical record and care plan did not include monitoring for adverse reactions of anticoagulant and opioid medications per the facility's expectation.

Based on staff interview and record review, the facility did not ensure pathology results were processed in a timely manner for 1 Resident (R) (R3) of 1 resident reviewed. R3 had a skin biopsy on 5/16/23. The biopsy results were received by the facility on 6/5/23. The facility did not act on or ensure R3 was updated on the biopsy results until 8/1/23. Findings include: The facility's Notification of Member Status Change policy, last reviewed 3/29/23, indicated the facility will immediately inform the member, consult with the physician, and notify the member's representative (consistent with his or her authority) when there is a need to alter treatment significantly. On 1/16/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE]. A diagnosis of malignant neoplasm of skin was added to R3's diagnoses list on 1/2/24. R3's most recent Minimum Data Set (MDS) assessment, dated 12/27/23, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R3 had intact cognition. The MDS also indicated R3 required assistance with some activities of daily living (ADLs). On 1/16/24 at 10:07 AM, Surveyor interviewed Unit Clerk (UC)-D who indicated R3 had a skin biopsy on 5/16/23 and returned to the facility with orders on how to care for the biopsy site. UC-D indicated Dermatology Office (DO)-C stated they would get back to the facility with the biopsy results and next steps. UC-D indicated the facility received the biopsy results on 6/5/23 and uploaded the results into R3's medical record. On 1/16/24 at 10:25 AM, Surveyor interviewed Registered Nurse (RN)-E who indicated R3 asked about the biopsy results after the procedure. RN-E looked up the results in EPIC (an electronic medical records system) and noted a document, dated 5/16/23, from DO-C that stated, Follow up in 1 year. Other Instructions: Pending pathology. RN-E could not recall if RN-E saw the statement Pathology pending when RN-E reviewed the document in EPIC. On 1/16/24 at 11:02 AM, Surveyor interviewed R3 who stated, They scheduled it for removal pretty quick .I can't remember if I asked the nurse about the biopsy. On 1/16/24 at 11:25 AM, Surveyor interviewed Social Worker (SW)-F who indicated R3 was R3's own decision maker, but preferred R3's daughter be updated with health issues and other concerns. On 1/16/24 at 12:29 PM, Surveyor interviewed Director of Nursing (DON)-B who recalled a conversation with R3's daughter regarding a lack of communication between DO-C and the facility regarding the biopsy results. Surveyor showed DON-B a document from DO-C, dated 5/16/23, that stated on page 2, Follow up in 1 year. Other instructions: Pending pathology. DON-B indicated staff could have done better in handling the communication related to R3's biopsy results. On 1/16/24 at 12:59 PM, Surveyor called DO-C and spoke to Dermatology Staff (DS)-G who indicated DO-C's records indicated DO-C called the facility on 6/5/23, spoke with a nurse (name unknown), and faxed the pathology report that indicated R3 had basal cell carcinoma. DS-G stated DO-C called the facility again on 7/5/23 and left a message requesting a call back. DO-C called the facility again on 8/1/23 and spoke with a nurse (name unknown). DS-G indicated an appointment was made on 8/1/23 for surgical removal of R3's cancerous skin lesion on 8/30/23.

Based on staff interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 Member (M) (M2) of 6 sampled members. On 6/21/23, M2 reported to the facility that all of M2's money was missing from M2's wallet. The facility did not report the suspected crime of misappropriation of member property to law enforcement. Findings include: The facility's Prohibition and Prevention of Member Abuse, Neglect, and Exploitation policy, with a revision date of April 25, 2023, stated the purpose of the policy was to protect the member's right to be free from abuse, neglect, exploitation, and misappropriation of member's property. All incidents shall be investigated and reported to the appropriate agency as required. Incidents not resulting in serious bodily injury must be reported to law enforcement no later than 24 hours after forming a suspicion. On 8/1/23, Surveyor reviewed M2's medical record. M2 was admitted to the facility with diagnoses to include diabetes mellitus and end stage renal disease. M2's annual Minimum Data Set (MDS) assessment, dated 7/19/23, indicated M2's cognition was 15 out of 15 (the higher the score, the more cognizant). On 8/1/23, Surveyor reviewed M3's medical record. M3 was admitted to the facility with diagnoses to include a history of alcohol abuse and dementia. M3's quarterly MDS assessment, dated 6/28/23, indicated M3's cognition was 15 out of 15. On 8/1/23, Surveyor reviewed a facility-reported incident (FRI) with a date occurred of 6/21/23. The FRI indicated M2 reported to Registered Nurse Supervisor (RNS)-C that M2 was at the vending machines and placed M2's wallet on the counter. While getting purchases, M2 dropped change. M3 wheeled over and offered to help M2 look for the change. When M2 put the change found back in M2's wallet, the rest of M2's money was missing from M2's wallet. M2 indicated M2 had 25 dollars (all [NAME]) in the wallet. When RNS-C asked if M2 wanted law enforcement called, M2 declined and did not want to press charges. M2 just wanted M2's money back. Permission was obtained to view security tape from the vending area. Upon review of the security tape, it was discovered M3 assisted M2 at the vending machine, left the area, took the elevator somewhere, came back to the lobby, and left the facility via taxi. M3 was interviewed and stated M3 assisted another member with looking for change in the vending machine area. M3 gave permission for the facility to search M3's room. Two bottles of vodka were found in M3's room. M3 verified M3 took a taxi to the gas station and bought the alcohol which cost almost 15 dollars and the cost of the taxi was 10 dollars with tip included. M3 then stated M3 had not been accused of stealing before. M3 had 24 dollars in M3's room. M3 gave the money to the facility to give back to M2 and the facility provided one dollar to total 25 dollars which was returned to M2 on 6/22/23. The investigation indicated law enforcement was not notified by the facility on the 24 hour and five day reports submitted to the State Agency (SA). On 8/1/23 at 11:54 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-D regarding the facility's policy on notifying law enforcement after an allegation of misappropriation of member property. ADON-D verified law enforcement was not notified after M3 stole money from M2's wallet and stated, I was not aware police needed to be called if a member doesn't want police called even though M3 committed theft, which is a crime. On 8/1/23 at 1:58 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding the facility's policy on notifying law enforcement after an allegation of misappropriation of member property. NHA-A verified M3 took M2's money. NHA-A indicated taking money is theft and theft is a crime.

Based on record review and resident and staff interview, the facility did not ensure all allegations of abuse and misappropriation were thoroughly investigated for 3 Residents (R) (R34, R28 and R21) of 35 sampled residents. R34 alleged R28 sexually abused R34. R34 also alleged Registered Nurse (RN)-L was rough with R34. In addition, R34 alleged R34's Power of Attorney (POA) took money from R34 and tried to kill R34. The allegations of abuse and misappropriation were not thoroughly investigated. R21 alleged R21 was missing money as well as other possessions. The allegation of misappropriation was not thoroughly investigated. (Of note, the word resident and member are used interchangeably in the citation). Findings include: The facility's Prohibition and Prevention of Member Abuse, Neglect and Exploitation, with a review date of December 2022, contained the following information: Purpose: To protect the member's right to be free from abuse, neglect, exploitation, and misappropriation of member's property. Policy: All incidents shall be investigated .Immediate interventions shall be initiated to maintain member safety with all observed or suspected allegations. Reporting: 4. The Nursing Supervisor or Executive Director immediately initiates initial reporting and conducts a thorough investigation. Alleged Mistreatment:. 3. Any accused staff should be removed from directly working with members . 3.1. During the investigation, the person, if known, who allegedly committed the act will be interviewed for their statement. 4. The Nursing Supervisor or Executive Director/designee conducts an initial evaluation of the incident. 5. The RN notifies the member/legal representative of the alleged incident. 9. The Nursing Supervisor continues the investigation process by potentially implementing additional interventions to maintain member safety. 10. The Social Worker will be involved in taking statements from the members involved in the situation and those who also could have been affected by this or a similar incident. 14. A file containing the Supervisor's summary, initial incident report, staff statements, any supporting documentation, and items submitted to DQA (Division of Quality Assurance) is routed to Administration .a copy goes to the building Executive Director. On 1/4/23 at 1:40 PM, Surveyor reviewed R34's electronic health record (EHR). R34 was admitted to the facility on [DATE] and had an activated POA (Power of Attorney). A nursing progress note, dated 9/26/22 at 4:30 AM and written by RN-J, read as follows: I'm afraid of (R28). (R28) stuck a 39 inch penis up my (expletive) and (R28) is laughing at me because (R28) has all (R28's) electronics on. Member offered PRN (as needed) lorazepam (a medication commonly used as a sedative and/or for anxiety) several times, but refused. On 1/4/23 at 2:31 PM, Surveyor interviewed Director of Nursing (DON)-B who was unaware of the allegation of sexual abuse. In the presence of Surveyor, DON-B interviewed RN-L who was aware of the allegation and stated, (R34) hallucinates. The other day (R34) told me that (RN-L) was rough on (R34). (R34) sees me all the time, but didn't realize it was me (that R34 was talking to). DON-B confirmed the allegations should have been thoroughly investigated. On 1/4/23 at 2:56 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who had no Facility-Reported Incidents (FRIs) or grievances related to R34 and was unaware of the allegations of abuse reported by R34. NHA-A verified the allegations should have been thoroughly investigated. On 1/4/23 at 7:30 PM, Surveyor interviewed RN-J. RN-J recalled R34's allegation of sexual abuse involving R28. RN-J stated RN-J contacted either RN-E or RN-F who were the night Nurse Supervisors when the allegation was reported. When asked if an investigation was conducted, RN-J stated one of the RN Supervisors told RN-J to chart the allegation since R28 could not physically get to R34 (both residents required staff assistance for transfers) and the allegation was not believed to have occurred. RN-J stated R34 made the allegation at approximately 3:30 AM and RN-J also reported the allegation to day shift staff during morning report. RN-J stated (R34) makes flippant comments and indicated R34 also made allegations against R34's POA. RN-J indicated the allegations against R34's POA were made on a PM shift and were charted by RN-K. RN-J further stated R34 made comments about RN-L and did not want RN-L in R34's room. Surveyor conducted further review of R34's EHR. A progress note, dated 11/3/2022 at 8:37 PM by RN-K, contained the following information: While changing dressing this PM, member asked if writer could sit and talk. Member began telling writer that this guy stole all my money over the years. Member also noted the person member was speaking about had at some time tried to have member murdered .Member eventually said, I don't know what to do or who to talk to. I don't have any family or friends . Writer .noted POA and member stated, That's the guy who took my money and tried to have me murdered! Writer offered to have Social Worker speak to member tomorrow . A progress note, dated 11/4/2022 at 9:33 AM by SW-G, contained the following information: .Writer notified of member concern shared with RN .Writer went to talk with member this AM. Member was asleep. Writer spoke with RN-L and RN-L stated member often speaks like this. Member has made comments like this regarding others as well .Writer will attempt to talk with member again today and will update Social Worker (SW)-H for follow up .If POA visits, will ask member if would like to see POA and if so, will ask if member would like to visit in an area that can be observed by staff. Writer will call POA to discuss . A progress note, dated 11/4/22 at 9:49 AM by SW-G, contained the following information: .Writer spoke with POA regarding member's concern. POA stated hasn't been up to see member for about 4 weeks. POA stated that when POA was there, member was able to recognize POA, but that member thought member was in China .Writer suggested when POA comes to visit, they visit in an area they can be observed .Additionally, POA will check in with nursing staff prior to visit to see how member is . On 1/5/23 at 12:19 PM, Surveyor interviewed SW-H who was aware R34 had a life-long friend (POA) who R34 accused of trying to kill R34. SW-H stated there was no evidence the allegation occurred. SW-H was not aware of the allegation that POA took money from R34. SW-H stated R34's care plan briefly contained an intervention to have POA visit in a common area. SW-H was unsure if an investigation was completed. When asked about the allegation regarding RN-L, SW-H was not aware of the allegation and, therefore, was unsure if an investigation was completed. On 1/5/23 at 1:10 PM, Surveyor interviewed NHA-A who was not aware of the allegations involving R34's POA or RN-L and confirmed investigations were not completed. 2. R21 was admitted to the facility on [DATE]. R21 was R21's own decision maker. On 1/3/23 at 10:35 AM, Surveyor interviewed R21 who was upset due to missing personal items, including a dictionary. R21 stated R21 told several staff members; however, nothing was done. On 1/4/23 at 2:17 PM, R21 requested to speak with Surveyor. R21 stated R21 reported missing money to SW-H a couple weeks ago and was told staff would look for it. R21 reported a missing 10 dollar bill. In another instance, R21 reported a missing 5 dollar bill. On 1/5/23 at 10:13 AM, Surveyor interviewed SW-H. SW-H stated R21 moved rooms multiple times. SW-H was not aware of a missing dictionary and stated it was not on R21's inventory list. On 1/5/23 at 12:14 PM , Surveyor interviewed SW-H about R21's allegation of missing money. SW-H did not recall an allegation of missing money and was unsure if the allegations of misappropriation were investigated. On 1/5/23 at 1:10 PM, Surveyor interviewed NHA-A who was not aware of the missing items and confirmed the allegations of misappropriation were not investigated.

Based on record review and resident and staff interview, the facility did not ensure all allegations of abuse and misappropriation of property were reported to Nursing Home Administrator (NHA)-A and the State Agency (SA) for 3 Residents (R) (R34, R28 and R21) of 35 sampled residents. R34 accused R28 of sexual abuse. R34 also alleged Registered Nurse (RN)-L was rough with R34. In addition, R34 alleged R34's Power of Attorney (POA) took money from R34 and tried to have R34 killed. The allegations were not reported to NHA-A, the SA or law enforcement. R21 alleged R21 was missing money as well as other possessions. The allegation was not reported to NHA-A or the SA. (Of note, the words resident and member and Executive Director (ED) and Nursing Home Administrator (NHA) are used interchangeably in this citation). Findings include: The facility's Prohibition and Prevention of Member Abuse, Neglect and Exploitation policy, with a review date of December 2022, contained the following information: Purpose: To protect the member's right to be free from abuse, neglect, exploitation and misappropriation of member's property. Policy: All staff shall be expected to immediately report any, and all, observed or alleged abuse and other reportable incidents. All incidents shall be investigated and reported to the appropriate agency as required by the agency. Reporting: 1. On observation of actual or suspected abuse, or other reportable incident, staff immediately reports event to the RN, Nursing Supervisors or Executive Director, e.g., injury of unknown source, member to member, missing property, suspicious bruising, etc. In circumstances where it is suspected that a crime has been perpetrated against a member, an Elder Justice Report is required. 3. RN immediately reports the event to the nursing supervisor, who notifies the Executive Director. 4. The Nursing Supervisor or Executive Director immediately initiates initial reporting . 5. The Nursing Supervisor or Executive Director submits all incidents meeting regulatory criteria .to the appropriate agency as soon as possible, and no later than 2 hours after forming the suspicion that the event involved abuse or resulted in serious bodily injury, and not to exceed 24 hours from discovery. 1. On 1/4/23 at 1:40 PM, Surveyor reviewed R34's electronic health record (EHR). R34 was admitted to the facility on [DATE] and had an activated POA. A nursing note, dated 9/26/22 at 4:30 AM by RN-J, contained the following information: I'm afraid of (R28) (R34's roommate). (R28) stuck a 39 inch penis up my (expletive) and (R28) is laughing at me because (R28) has all (R28's) electronics on. Member offered PRN (as needed) lorazepam (a medication commonly used as a sedative and/or for anxiety) several times, but refused. On 1/4/23 at 2:31 PM, Surveyor interviewed Director of Nursing (DON)-B who was unaware of the allegation of abuse. In the presence of Surveyor, DON-B interviewed RN-L who verified RN-L was aware of the allegation of abuse. DON-B reminded RN-L to report allegations of abuse to which RN-L stated, We did. RN-L stated, (R34) hallucinates. The other day (R34) told me that (RN-L) was rough on (R34). (R34) sees me all the time, but didn't realize it was me (that R34 was talking to). DON-B confirmed the allegations of abuse should have been reported to the SA. On 1/4/23 at 2:56 PM, Surveyor interviewed NHA-A who did not have any Facility-Reported Incidents (FRIs) or grievances related to R34 and was unaware of the allegations of abuse. NHA-A stated the allegations should have been reported to the night shift RN Supervisor, in morning report and to the SA. On 1/4/23 at 3:44 PM, Surveyor interviewed Social Worker (SW)-I who was not aware of the the allegations of abuse. On 1/4/23 at 7:30 PM, Surveyor interviewed RN-J who recalled the allegation of abuse reported by R34 and stated it was reported at approximately 3:30 AM. RN-J said RN-J contacted the night shift RN Supervisor which was either RN-E or RN-F. RN-J stated the RN Supervisor instructed RN-J to chart the allegation because R28 could not physically get to R34 (both residents required staff assistance for transfers) and the allegation was not believed to have occurred. RN-J also relayed the allegation of abuse to AM shift staff during morning report. RN-J stated R34 makes flippant comments and also made allegations against R34's POA. RN-J stated the allegations regarding R34's POA were made on the PM shift and charted by RN-K. RN-J also confirmed R34 did not want RN-L in R34's room. RN-J believed it was because RN-L completed R34's wound care which was painful. On 1/5/23 at 9:26 AM, Surveyor interviewed RN-E who was not aware of the allegation of abuse involving R34 and R28. On 1/5/23 at 9:42 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who confirmed RN-E and RN-F were the night shift RN Supervisors when R34 reported an allegation of abuse involving R28. ADON-C stated the facility's process was for the unit nurse to document which RN Supervisor they contacted. On 1/5/23 at 9:52 AM, Surveyor interviewed RN-F who did not recall the allegation of abuse involving R34 and R28. Surveyor conducted further review of R34's EHR. A nursing note, dated 11/3/2022 at 8:37 PM by RN-K, contained the following information: While changing dressing this PM, member asked if writer could sit and talk. Member began telling writer that this (person) stole all my money over the years. Member also noted the person member was speaking about had at some time tried to have the member murdered .member eventually said, I don't know what to do or who to talk to. I don't have any family or friends. Writer noted member did have friends listed in medical record, noted POA .and member stated, That's the (person) who took my money and tried to have me murdered!' Writer offered to have SW come speak to R34 tomorrow .R34 requested same, but stated, I've talked to Social Workers before and when I mention murder they just shut down and stop listening. A progress note, dated 11/4/2022 at 9:33 AM by SW-G, contained the following information: Writer notified of member concern shared with RN .Writer went to talk with member this AM. Member was asleep. Writer spoke with RN-L and RN-L stated member often speaks like this. Member has made comments like this regarding others as well. SLUMS (Saint Louis University of Mental Status Examination) score of 3 (indicates dementia) .Writer will attempt to talk with member again today and will update SW-H for follow up .If POA visits, will ask member if would like to see POA and if so, will ask if member would like to visit in an area that can be observed by staff. Writer will call POA to discuss . A progress note, dated 11/4/22 at 9:49 AM by SW-G, contained the following information: .Writer spoke with POA regarding member's concern. POA stated hasn't been to see member for about 4 weeks. POA stated when POA was there, member was able to recognize POA, but member thought member was in China .Writer suggested when POA comes to visit, they visit in an area they can be observed .POA will check in with nursing staff prior to visit to see how member is . On 1/05/23 at 12:19 PM, Surveyor interviewed SW-H who was aware R34 had a friend who R34 accused of trying to kill R34. SW-H stated there was no evidence that occurred. SW-H stated R34's care plan briefly contained an intervention to have the friend (POA) visit in a common area. SW-H was unsure if R34 had missing money. When asked if R34 alleged RN-L was rough and requested RN-L not enter R34's room, SW-H was unaware of the allegation. On 1/05/23 at 1:10 PM, Surveyor interviewed NHA-A who was not aware of the allegations regarding R34's POA and RN-L. NHA-A stated NHA-A expected staff to notify NHA-A when allegations were made. 2. R21 was admitted to the facility on [DATE] and was R21's own decision maker. On 1/3/23 at 10:35 AM, Surveyor interviewed R21 who was upset due to personal items that were missing, including a dictionary. R21 stated R21 told several staff members, but nothing was done. R21 stated, I don't even bother telling them anymore. On 1/4/23 at 2:17 PM, R21 requested to speak with Surveyor and stated R21 told SW-H about missing money a couple weeks ago. R21 stated SW-H said staff would look for the money; however, R21 did not see SW-H again. R21 also told other staff about the missing money which included a 10 dollar bill in one instance and a 5 dollar bill in another instance. On 1/4/23 at 9:48 AM, Surveyor interviewed ADON-D who stated if a resident told staff something was missing, staff were to tell the RN who would then tell the RN Supervisor. On 1/4/23 at 10:13 AM, Surveyor interviewed SW-H who stated R21 changed rooms multiple times. SW-H unpacked R21's belongings following the last move, did not recall seeing a dictionary and stated a dictionary was not on R21's inventory list On 1/5/23 at 12:14 PM, Surveyor interviewed SW-H regarding the allegation of missing money. SW-H stated R21 reported a missing red pocket knife and staff searched for it; however, R21 did not report missing money. On 1/5/23 at 1:10 PM, Surveyor interviewed NHA-A who was unaware of R21's missing items and confirmed the missing items were not reported to the SA. NHA-A stated NHA-A expected staff to notify NHA-A of all allegations of misappropriation.

Based on observation and resident and staff interview, the facility did not ensure 2 Residents (R) (R21 and R72) of 2 residents had access to the use of a telephone in a private area in which calls could be made without being overheard. R21's room did not contain a phone jack. R21's family purchased a modem to connect a land line phone per the facility's suggestion; however, the system did not work. R21 was offered use of the facility's dining room phone; however, the phone was not in a private area which made it difficult for R21 to use with hearing aides. R72's room did not contain a working phone. R72 stated R72 had to use the phone in the dining room which was not in a private area. Findings include: 1. R21 was admitted to the facility on [DATE]. R21 moved to the newly constructed [NAME] Hall in October of 2022. On 1/03/23 at 10:51 AM, Surveyor interviewed R21. R21 stated R21's biggest concern was that R21's telephone did not work and pointed to a land line phone in R21's room. Surveyor noted the telephone was lit and displayed the date and time. The telephone was plugged into an electrical outlet and also contained a cord which was connected to a modem that contained two antennae. R21 stated R21's family brought in three different phones, but none of them worked. Surveyor observed a list of names and phone numbers next to the phone which R21 stated were family and friends. R21 asked Surveyor to try dialing out. Surveyor lifted the receiver; however, no dial tone was heard and after dialing a number, nothing happened. R21 stated, I don't have anyone to talk to so it would be nice to able to call my family or friends. R21 stated there was a phone in the dining room; however, it was difficult for R21 to use because R21 had hearing aides. R21 stated R21 had a speaker feature on the room phone that worked better with the hearing aides and prevented the plastic on the hearing aides from hitting the plastic on the phone. R21 also stated the location of the dining room phone was hard for someone in a wheelchair to reach on their own. Surveyor recalled that prior to interviewing R21, Surveyor observed another resident using the dining room phone at approximately 10:00 AM while other residents were in the room within listening distance. Surveyor observed the countertop where the phone was located and noted the counter was centrally located in the dining room. Surveyor also noted the counter was deep in width and if the phone was set on the back of the counter, the phone could be hard to reach for someone attempting to access it from a wheelchair. On 1/3/23 at 2:00 PM, Surveyor attempted to utilize a cellular phone within the facility to contact resident representatives and noted there were issues with cellular reception. On 1/04/23 at 10:13 AM, Surveyor interviewed Social Worker (SW)-H. SW-H stated, Phones have been a challenge. SW-H indicated the newly constructed building did not have phone [NAME] in resident rooms. SW-H verified R21's family brought R21 a phone and stated, I struggle to get that thing (room phone) to work. SW-H stated R21's family did exactly what they were supposed to do. SW-H also stated another resident obtained a modem and it seemed to work; however, the same system did not work for R21's phone. SW-H indicated R21 also had a cell phone, but it did not work either as cell phones frequently did not work in the building. SW-H stated residents had to get a modem or use the phone located in the dining room counter or a phones in a staff's office. SW-H stated that from what SW-H heard, the desk phones (which had a cordless handset) dropped off fairly quickly (in terms of reception) when taken down hallways where resident rooms were located. SW-H confirmed offices were only open when staff were working (weekday/day shift mostly). Surveyor noted the doors to offices and non-public areas had automatic closing devices and most required a badge to enter. SW-H sent a letter to families regarding the phone issues and verified SW-H saw residents use the telephone in the dining room. On 1/4/23 at 11:13 AM, Surveyor interviewed Activities Staff (AS)-N who assisted residents with phone usage. AS-N verified the facility did not have phone [NAME] installed in resident rooms; therefore, residents did not have land lines. AS-N stated there were modems residents could purchase (outside the facility) which enabled Wi-Fi calls. AS-N stated, I am struggling to get them to work to be honest. I don't know if it is due to the concrete jungle we are in. Surveyor asked the distance a desk phone with a cordless handset reached if a resident tried to utilize one in their room. AS-N responded, I don't know how far from the base they go, my guess would not be far. On 1/4/23 at 11:30 AM, Surveyor reviewed R21's electronic health record (EHR) which included the following progress notes documented by SW-H: 10/24/2022 at 2:56 PM, Social Service Progress Note: .Returned call to POAHC (Power of Attorney for Health Care) today, as POAHC was concerned that (R21) had not answered (R21's) cell phone lately. I checked phone and it was charged next to (R21's) bed. Will check volume on phone to be sure (R21) can hear it ring . 10/25/2022 at 1:54 PM, Social Service Progress Note: .I checked on (R21's) phone again today. Tried to call POA (Power of Attorney), but phone says there is no service. Told (R21) that (R21) can call (R21's) family from the nurse's station until we can get this phone situation figured out . 10/27/2022 at 2:22 PM, Care Conference Assessment Note: Care Conference Date: 11/02/2022 Summary: (R21) attended meeting and POAHC attended via phone. We reviewed care and adjustment since move .POAHC is aware of phone difficulties we are having. (R21's spouse) will eventually get (R21) a new phone, hopefully with the capability of Wi-Fi calling .(R21) was escorted back to (R21's) room. On 1/05/23 at 11:54 AM, Surveyor interviewed SW-H again who confirmed SW-H received family complaints related to phones not working. SW-H stated, It was hard during the holidays. Family has had to take on the burden of finding this modem as well. SW-H also stated, Some residents may not even have noticed the lack of phone calls coming in yet, but families are certainly aware. On 1/05/23 at 1:10 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A. NHA-A stated, Phone reception in this facility is not good. NHA-A verified residents can use phones located in the lobby or the conference rooms; however, the conference rooms were locked and required a badge to enter. NHA-A also stated the facility's Social Workers knew different systems residents could use to have better reception. NHA-A confirmed there were no phone [NAME] for land lines in resident rooms and stated there were no documented grievances related to the phone system. NHA-A also verified the facility did not have a designated room in which residents could make a private phone calls. 43361 2. R72 was admitted to the facility on [DATE] and had a diagnosis of legal blindness. R72 recently moved to a private room in the newly constructed building. R72 had a Brief Interview for Mental Status (BIMS) score (a brief verbal test that indicates an individuals level of cognition) of 15/15 which indicated R72 was cognitively intact. On 1/3/23 at 10:45 AM, Surveyor interviewed R72 who stated the only thing R72 wanted was a working phone in R72's room. R72 stated R72 had a cordless phone that worked fine in R72's previous building; however there was no place to plug in R72's cordless phone in the new room and nothing seemed to work. On 1/3/23 at 11:38 AM, Surveyor observed R72 in the dining/lobby area of R72's household. R72 yelled for help and stated, I need a button pusher. Staff assisted R72 who made two phone calls while in the lobby. Surveyor could hear R72's conversations. Surveyor also observed other residents sitting in the dining/lobby area during R72's phone conversations. On 1/4/23 at 9:12 AM, Surveyor completed a follow-up interview with R72 who stated the facility's phones did not reach R72's room. R72 called R72's spouse daily and stated the only phone to use was in the lobby. R72 stated a private area for conversing would be nice. On 1/4/23 at 9:45 AM, Surveyor interviewed Unit Clerk (UC)-Q who didn't think there were land line phones in residents rooms. UC-Q also stated cell phones didn't work in the building. When asked about cordless phones to take into resident rooms, UC-Q stated, They will go a little bit down the hall, but once you enter the resident's room, they stop working. UC-Q verified residents used the phone in the dining/lobby area. UC-Q was not aware of a private space residents could use a phone and stated no one asked UC-Q. On 1/4/23 at 3:17 PM, Surveyor interviewed Ombudsman (OMB)-R regarding another topic. OMB-R asked Surveyor if there were phone issues in the new building. OMB-R stated OMB-R spoke with SW-H in November of 2022 (when there were approximately 20 residents in the building) regarding phones not working in resident rooms and concerns that the only phones residents could use were in the lobby. At that time, OMB-R stated SW-H said, No one wants to come out in their jammies to make a phone call. OMB-R stated SW-H said there was a plan in place to rectify the situation; however, the plan was nixed. OMB-R was curious if it was still an issue because OMB-R had not heard anything since then.

Based on record review and staff interview, the facility did not provide the necessary care and services to maintain the highest practicable well being for 1 Resident (R) (R1) of 1 resident when a diabetic medication was started and when a change in a surgical wound occurred. R1 was admitted to the facility for aftercare following surgery and had previously well controlled diabetes. While in the hospital, R1 received sliding scale insulin for higher than usual blood glucose levels. R1's discharge orders contained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The insulin order was not transcribed on R1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's note, dated 7/14/21, stated MD (Medical Doctor)-D prescribed a daily dose of [MEDICATION(S)] (an oral medication used for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not continue to monitor R1's blood sugar level as ordered: beginning with the PM shift on 7/15/21 to 7/21/21, there were no recorded blood sugar levels. On 7/22/21 at approximately 7:00 AM R1 was found unresponsive with a blood sugar level of 28. R1 was transported to a local hospital and diagnosed with an acute [CONDITION(S)] due to severe [CONDITION(S)] (low blood sugar) with an emerging persistive vegetative state (a chronic state of brain dysfunction in which a person shows no signs of awareness). R1 passed away on 8/02/21. The facility's failure to monitor R1's blood sugar following the start of a diabetic medication created a finding of immediate jeopardy that began on 7/15/21. RFOD (Regional Field Operations Director)-L notified NHA (Nursing Home Administrator)-A of the immediate jeopardy on 2/04/22 at 10:31 AM. The immediate jeopardy was removed on 2/04/22; however, the deficient practice continued at a scope/severity level G (actual harm/isolated) as evidenced by the following: R1 was admitted to the facility for aftercare following a laminectomy and fusion. R1 had a surgical incision on the lower back and treatment orders for wound care. Staff did not update R1's physician when R1's wound incurred a change in condition approximately three weeks post-op, including increased drainage which necessitated more frequent dressing changes. R1 was admitted to a local hospital on 7/22/21 and diagnosed with MSSA ([CONDITION(S)]-susceptible Staphylococcus aureus) (a strain of staph bacteria that responds well to medicine used to treat staph infections) bacteremia (the presence of viable bacteria in the circulating blood) likely due to a surgical site infection. Findings include: 1. On 2/03/22, the Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] for aftercare following a laminectomy (surgery in which all or part of the vertebral bone is removed to ease pressure on the spinal cord or nerve roots) and fusion (a neurosurgical technique that joins two or more vertebrae) and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Admission MDS (Minimum Data Set), dated 7/14/21, indicated R1 was not cognitively impaired but required extensive assistance of staff for bed mobility and most ADLs (activities of daily living). Hospital paperwork prior to R1's admission to the facility indicated R1 received a total of 3 units of sliding scale insulin ([MEDICATION(S)]) (a fast-acting insulin that controls blood sugar around meal times for both type 1 and type 2 diabetes) on 6/28/21, 6 units on 6/29/21, 5 units on 7/01/21, 9 units on 7/02/21, 9 units on 7/03/21, 6 units on 7/04/21, 10 units on 7/05/21, 13 units on 7/06/21 and 11 units on 7/07/21. R1's hospital discharge instructions, dated 7/08/21, contained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's facility admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 7/08/21, stated to check R1's blood glucose level twice daily for one week and update R1's PCP (primary care provider). The Surveyor noted the sliding scale insulin order was not included in R1's facility admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Surveyor reviewed R1's July 2021 MAR (medication administration record). The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Surveyor noted the following blood sugars: 1. 7/08/21 at 4:00 PM - 242 2. 7/09/21 at 6:30 AM - 152; 4:00 PM - 366 3. 7/10/21 at 6:30 AM - 153; at 4:00 PM - 306 4. 7/11/21 at 6:30 AM - 175; at 4:00 PM - 358 5. 7/12/21 at 6:30 AM - 209; at 4:00 PM - 313 6. 7/13/21 at 6:30 AM - 199; at 4:00 PM - 383 7. 7/14/21 at 6:30 AM - 189; at 4:00 PM - 367 8. 7/15/21 at 6:30 AM - 180 An admission note, written by MD-D on 7/14/21, indicated R1's past history included type 2 diabetes without complications or use of long-term insulin. The note stated R1's diabetes was previously treated with [MEDICATION(S)] and [MEDICATION(S)]; however, R1's [MEDICATION(S)] was discontinued in the hospital for unknown reasons. R1's blood sugars since admission were noted to be in the mid-100s to upper 100s in the morning and in the 200s to 300s before supper. The assessment/plan section stated R1's blood sugars were above goal and instructed staff to continue R1's current dose of [MEDICATION(S)], start [MEDICATION(S)] 1000 mg once daily and continue to monitor blood sugars. A lab report, dated 7/14/21, stated R1's HbA1C (a blood test used in the management of diabetes that measures one's average blood sugar levels over the past three months) was high at 6.9%. (The reference range was 4.0-5.6%). R1's glucose was also high at 211. (The reference range was 70-99 mg/dL (deciliter)). The Surveyor noted R1's [MEDICATION(S)] was started on 7/15/21 at 6:30 AM. The Surveyor noted R1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Following the start of [MEDICATION(S)], the Surveyor noted R1's blood sugar was not checked between 6:30 AM on 7/15/21 and approximately 7:00 AM on 7/22/21. A nursing note, dated 7/22/21 at 7:06 AM, stated R1 was found unresponsive. A health status note, dated 7/22/21 at 10:05 AM, stated at 7:05 AM, R1 was diaphoretic (sweating heavily) and unresponsive to multiple sternal rub attempts. R1 had a blood glucose level of 28. IM (intramuscular) [MEDICATION(S)] (a hormone used to treat severely low blood sugar) was administered. At 7:10 AM, R1's blood sugar was 33. At 7:15 AM, R1's blood sugar was 44. At approximately 7:16 AM, EMS (emergency medical services) administered 25 (grams) of D50 (50% dextrose solution) (used in emergency care to treat [CONDITION(S)] and to manage coma of unknown origin) and R1's blood sugar rose to 367. R1 again remained unresponsive after a sternal rub and was transported to a local hospital. A nursing note, dated 7/22/21 at 6:10 PM, stated R1 was unresponsive on a ventilator with a low blood sugar and tremors. A hospital History and Physical, dated 7/22/21, stated R1 was last seen at 9:00 PM on 7/21/21 and found unresponsive on 7/22/21 at approximately 7:00 AM with a blood sugar of 22. (Documentation in R1's medical record indicated R1's blood sugar was 28). R1 was given IM [MEDICATION(S)] and IV (intravenous) dextrose. R1 was comatose upon arrival at the hospital and was intubated. A hospital Discharge Summary, dated 8/02/21, stated R1 remained unresponsive on no sedation since admission (7/22/21) consistent with severe [CONDITION(S)] (a disease of the brain that alters brain function or structure) and emerging vegetative state. The note stated R1 had an acute [CONDITION(S)] from severe [CONDITION(S)] with no metabolic derangements to explain mental status except severe, sustained hypoglycemic injury. The note further stated R1's prognosis was extremely poor this far out and in (R1's) age group (no literature-documented recovery from ABI (acute [CONDITION(S)]) from severe [CONDITION(S)] beyond ten days) . A hospital History and Physical, dated 8/02/21, stated R1 was (eleven) days out from a prolonged period of [CONDITION(S)] of uncertain duration and remained unresponsive without sedation. The History and Physical stated no reversible causes were identified to explain R1's persistent vegetative state. R1 was diagnosed with an acute [CONDITION(S)] from severe prolonged [CONDITION(S)] causing severe neuroencephalopathy (any diffuse disease of the brain that alters brain function or structure) consistent with an emerging persistent vegetative state . A death summary, dated 8/03/21, stated R1's cause of death was acute [CONDITION(S)] due to [CONDITION(S)]. On 2/03/22 at 12:30 PM, the Surveyor interviewed ADON (Assistant Director of Nursing)-C regarding R1. ADON-C verified R1's sliding scale insulin order was not transcribed or addressed during R1's admission process. ADON-C also verified R1 did not receive sliding scale insulin while in the facility. On 2/03/22 at 1:45 PM, the Surveyor interviewed FM (Family Member)-P regarding R1. FM-P stated R1 was admitted to the hospital from the facility on 7/22/21 with unmonitored blood sugar levels. FM-P stated, (R1) was fine when (R1) went (to the facility). (R1) just needed rehab. FM-P stated R1 may never have walked again, but (R1) would have had quality of life. FM-P stated R1's [MEDICATION(S)] was discontinued in November of 2020, not during R1's hospitalization for surgery. FM-P stated R1 was legally blind and had a talking meter for blood sugar checks. FM-P stated R1 monitored R1's blood sugar approximately three to four times per week prior to surgery. FM-P stated R1's blood sugar was never an issue prior to surgery. On 2/03/22 at 2:25 PM, the Surveyor interviewed ADON-G regarding R1. ADON-G stated ADON-G was unsure why blood sugar monitoring was not initiated following the start of [MEDICATION(S)]. On 2/03/22 at 4:00 PM, the Surveyor interviewed MD-D regarding R1. MD-D declined to answer questions regarding R1. When asked MD-D's expectation for how often staff should have monitored R1's blood sugar following the initiation of [MEDICATION(S)] on 7/15/21 and the realization that R1's blood sugars were above goal between 7/08/21 and 7/15/21, MD-D stated MD-D could not recall the situation and did not have access to R1's record at that time. MD-D suggested the Surveyor check with the facility for protocols regarding accuchecks and monitoring. On 2/03/22 at 5:06 PM, the Surveyor interviewed RN (Registered Nurse)-F regarding R1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-F verified R1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/04/22 at 8:18 AM, the Surveyor interviewed LPN (Licensed Practical Nurse)-K regarding R1. LPN-K stated on the morning of 7/22/21, a CNA (Certified Nursing Assistant) exited R1's room and stated R1 wasn't acting right and needed to be checked. LPN-K stated, I know (staff) had to give [MEDICATION(S)]. LPN-K stated nursing staff indicated R1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . I know (LPN-O) said it wasn't on the (MAR) for (LPN-O) to check (R1's blood sugar). On 2/04/22 at 2:27 PM, the Surveyor interviewed LPN-O regarding R1. LPN-O stated, I remember (R1) was a daily blood sugar (check) and then (R1) wasn't. The morning (R1) was sent out (7/22/21), (R1) came up as a blood sugar (check), but I hadn't gotten (R1's blood sugar) yet. I don't know where the weekly blood sugar monitoring order (dated 7/21/21) originated from. The failure to monitor a resident with abnormal blood sugar levels after the initiation of a new medication led to serious harm (i.e. death) for R1 which created a finding of Immediate Jeopardy. The facility removed the jeopardy on 2/04/22 when it completed the following: 1. Educated RNs to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Educated physicians on the importance of ordering appropriate parameters for blood glucose monitoring when starting or changing diabetic medications. 3. Educated licensed staff on the Portable Blood Glucose Monitoring and Goals for Diabetic Treatment policies. The deficient practice continues at a scope/severity level G based on the following example: 2. R1's hospital discharge paperwork, dated 7/08/21, stated: Incision Care There are many different ways to close and cover an incision .Follow your health care provider's instructions about: 1. Incision care 2. Bandage (dressing) changes and removal 4. Check your incision area every day for signs of infection. If you cannot see your incision, have someone check it for you. Watch for: a. Redness, swelling or pain b. Fluid, blood or pus Seek Medical Care If: 4. You have pain, numbness or weakness that lasts longer than three weeks after surgery. Seek Immediate Medical Care If: a. You have fluid, blood or pus coming from your incision A hospital physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . (R1) and (R1's spouse) were provided with a new [MEDICATION(S)] dressing. An admission skin check, dated 7/08/21, stated R1 had a dressing over a surgical wound that was present upon admission and not to be removed yet. A Medicare note, dated 7/09/21, stated, .Incision wound on lumbar spine has [MEDICATION(S)] bandage covering. Removed and is well approximated, no (signs or symptoms) of infection . A physician order, dated 7/09/21, stated, Place a new [MEDICATION(S)] dressing on (R1's) surgical wound (7/12/21) and leave in place for (five) days. Remove and perform daily dressings as needed . A nursing note, dated 7/12/21 at 1:16 PM, stated, Dressing to mid/low back changed .minimal dark brown drainage. No redness or odor noted. A Medicare note, dated 7/12/21 at 8:15 PM, stated R1's dressing was intact with a dime-sized amount of shadowing noted. The note stated the dressing was scheduled to be changed in five days on 7/18/21. The Surveyor noted 7/18/21 was six days from 7/12/21. A Medicare note, written by RN-H on 7/17/21 at 6:50 PM, stated, Dressing to low/mid back .rolled up in back from sling, rolled back down by writer. Dressing to be changed and measured on 7/18/21 . Nursing notes, written on 7/18/21 and 7/19/21 by LPN-O stated, Small amount of drainage noted on bandage, 4 x 4 [MEDICATION(S)] (an adhesive, waterproof foam dressing that has a high fluid-handling capacity) placed in location of drainage. (Four) steri-strips remain. No (signs or symptoms) of infection. A nursing note, dated 7/20/21 at 9:08 AM, stated R1's wound had a small amount of bloody drainage to the lower part of the incision, but no signs or symptoms of infection. A nursing note, written by RN-E on 7/20/21 at 11:30 AM, stated, (R1's) surgical site is covered with (two) Optifoams. The top [MEDICATION(S)] has bloody drainage. Under the [MEDICATION(S)] are steri-strips and (cannot) measure the open area through the steri-strips. A Medicare note, dated 7/20/21 at 7:40 PM, stated R1's [MEDICATION(S)] dressing was half off. Sanguineous (the leakage of fresh blood produced by an open wound) drainage was noted. The area was cleansed, measured and redressed by the writer. A nursing order, dated 7/20/21, stated, (Discontinue) daily AM dressing changes to surgical site to back. Cleanse surgical wound site to low/mid back with (normal saline), apply skin prep (to) peri-wound, cover (with) non-adherent dressing (and) secure (with) tape BID and PRN. According to R1's nursing notes, R1's dressing was changed three times on 7/20/21; however, R1's TAR (treatment administration record) indicated R1's dressing was changed once. A weekly wound assessment, dated 7/20/21, stated R1's low/mid back surgical wound measured 14 cm (length) by 0.5 cm (width) by 0.01 cm (depth). The assessment stated the wound edges were well approximated, but irregular. Epithelial tissue (provides a protective shield for underlying tissues) was present. The assessment stated (sanguineous) drainage and a moderate amount of exudate (fluid and leukocytes that move to the site of injury from the circulatory system in response to local inflammation) were present. No signs or symptoms of infection were noted. R1 reported R1 had minimal sensation and could feel pressure to the area, but not pain. A Medicare note, dated 7/21/21 at 5:40 PM, stated, .Dressing treatment to back updated due to heavy drainage today. The note stated R1's dressing was changed twice on the PM shift due to (serosangineous) (composed of red blood cells and serous fluid) drainage. A nursing order, dated 7/21/21 at 8:56 PM, stated the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A note at the bottom of the order stated, Treatment applied in afternoon was saturated, area cleansed and covered again, two layers of ABD pad applied per (RN-I) to attempt to contain drainage. A handwritten order contained in R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Surveyor noted R1's dressing was changed three times on 7/21/21. A health status note, written by NE (Nurse Educator)-J on 7/22/21 at 7:05 AM, stated, (R1's) incision to back was assessed this (AM). Steri-strips remained intact scant (sanguineous) drainage noted to mid incision, incision remained well approximated. No increased warmth, no increased swelling, A health status note, written by NE-J on 7/22/21 at 10:05 AM, stated R1 was unresponsive at 7:05 AM and had a blood glucose level of 28. After initiating [CONDITION(S)] protocol, EMS (emergency medical services) transported R1 to a local hospital. A Consultation note, dated 7/23/21, stated R1 was referred to infectious disease for urgent consult of Staph aureus bacteremia (a leading cause of community-acquired and hospital-acquired bacteremia. Patients with S. aureus bacteremia can develop a broad array of complications that may be difficult to recognize initially and can increase morbidity). The admission exam noted evidence of redness along the lumbar incision with dehiscence (a surgical complication where the edges of a wound no longer meet) and purulence (a thick, milky discharge that indicates an infection or an unhealthy wound). The note stated R1 had a surgical site infection of the lumbar spinal incision; however, it was difficult to determine if the infection was superficial or deep. Blood and wound cultures were obtained. R1 also had MSSA bacteremia likely due to the surgical site infection. IV (intravenous) antibiotics were administered. The note stated infections disease would continue to follow R1 given the high risk of mortality associated with Staph aureus [CONDITION(S)] and bacteremia. A hospital Discharge Summary, dated 8/02/21, stated R1 was admitted on [DATE] for altered mental status. Further workup indicated R1 had MSSA bacteremia due to an infected surgical site. The wound was dehisced and MRI (magnetic resonance imaging) revealed fluid collection spanning the surgical site. R1 was transferred to the operating room for washout and a wound vac was placed. On 7/24/21, the postsurgical changes to R1's surgical incision were stable. The note stated the medical team was confident [CONDITION(S)] was not responsible for R1's persistive vegetative state because R1's [CONDITION(S)] was resolved. On 2/03/22 at 2:20 PM, the Surveyor interviewed ADON-C regarding R1's wound. ADON-C verified R1's medical record indicated there was a change in condition in R1's surgical wound. ADON-C also verified RN-H should have cleansed R1's wound and changed the dressing to prevent infection on 7/17/21 when R1's dressing rolled up. ADON-C stated ADON-C was unsure why R1's physician was not notified when blood, increased drainage and more frequent dressing changes were required beginning on 7/20/21. When asked if staff were expected to cleanse R1's surgical wound when initial orders instructed staff to change the dressing on 7/12/21 and five days later, but didn't instruct staff to cleanse the wound, ADON-C said ADON-C was unsure if staff cleansed the wound and stated, Some (staff) think it's standard procedure (to cleanse the wound), but some need (the order) spelled out. On 2/03/22 at 2:38 PM, the Surveyor interviewed NE-J regarding R1. NE-J, who is wound care certified, verified NE-J assessed R1's wound on 7/22/21. NE-J sated NE-J did not think R1's wound looked infected and stated it was the first time NE-J assessed R1. On 2/03/22 at 2:53 PM, the Surveyor interviewed RN-I regarding R1. RN-I stated RN-I recalled having a conversation with day shift about (R1's) wound draining more. RN-I stated RN-E contacted someone to get a better dressing for R1. RN-I could not recall if RN-I updated R1's physician on the 7/21/21 PM shift when R1's wound had increased drainage. On 2/03/22 at 3:08 PM, the Surveyor interviewed RN-H regarding R1. RN-H verified R1's surgical dressing rolled up on 7/17/21; however, RN-H could not recall the extent to which R1's dressing rolled up. RN-H stated, If I felt it was okay to pull (the dressing) down, I would. RN-H stated certain residents' dressings had to remain in place for various periods of time; however, if necessary or indicated, RN-H could change a dressing outside the parameters of the order if the change didn't cause further irritation to the wound. RN-H was unsure if RN-H updated R1's physician regarding the change in R1's wound. During a follow up interview with RN-H at 3:36 PM, the Surveyor asked if RN-H cleansed R1's wound on 7/12/21 even though the order did not state to do so. RN-H stated, Usually we follow the orders as written. I can't say whether I cleansed the wound or not. RN-H stated usually RN-H cleansed wounds with normal saline; however, if the order did not say to do so, RN-H could not be sure RN-H did so. On 2/03/22 at 3:25 PM, the Surveyor interviewed RN-E regarding R1. RN-E stated R1's surgical incision looked good; however, RN-E sought different bandages from the campus' medical supply. RN-E stated, I think I had (NE-J) look at (R1's wound). RN-E stated R1's incision initially had a larger bandage that the facility didn't have so RN-E sought an equivalent bandage in an equivalent size. When asked if RN-E updated R1's physician regarding the increased drainage from R1's wound, RN-E stated, I imagine I would have .It would be in my charting. On 2/03/22 at 4:43 PM, the Surveyor interviewed ADON-G regarding wound treatments. ADON-G stated wound sites should be cleansed during dressing changes in accordance with the facility's wound care protocol; however, how and when to cleanse depended on the dressing and the treatment order. On 2/04/22 at 8:18 AM, the Surveyor interviewed LPN-K regarding R1. LPN-K verified LPN-K changed R1's dressing on 7/12/21. LPN-K stated the wound contained two small spots of serosanguineous drainage near R1's coccyx; however, the wound did not look infected and was not dehisced. LPN-K stated staff were expected to measure and chart the characteristics of wounds; however, staff did the best they could if staffing was an issue. LPN-K stated LPN-K believed R1's wound started to dehisce at the end. On 2/04/22 at 2:27 PM, the Surveyor interviewed LPN-O regarding R1. LPN-O verified LPN-O changed R1's dressing on 7/18/21. LPN-O stated R1's wound did not drain much initially; however, the wound drained more as time went on. LPN-O stated LPN-O notified an unnamed RN who asked LPN-O to put an ABD pad over the wound for more absorption. LPN-O stated LPN-O did not notify R1's physician regarding the change in R1's wound because RNs notified the providers. LPN-O stated, (R1's) wound didn't drain for a long time. I was concerned (the wound) was dehiscing because there was more drainage. LPN-O stated LPN-O asked an unnamed RN to assess the wound and was unsure what happened after that.

Based on record review and staff interview, the facility did not ensure 1 Resident (R) (R1) of 1 resident received the necessary care and services to promote healing and/or prevent pressure injuries from developing. R1 was admitted to the facility following a laminectomy (surgery in which all or part of the vertebral bone is removed to ease pressure on the spinal cord or nerve roots) and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was assessed to be at mild risk for the development of pressure injuries and at high risk for foot complications. Interventions to elevate and protect R1's feet were not initiated until R1 developed unstageable pressure injuries on both heels. Findings include: The facility's Wound Prevention and Treatment Program policy, dated 7/02/20, states: Purpose: * To provide prompt assessment of risk, implementation of preventative measures and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] * To optimize the member's ability to maintain skin integrity. Policy: * An RN (Registered Nurse) certified in Wound Care (WCC) shall be designated to serve as the Wound Care Coordinator . * The facility designated WCC(s) shall have responsibilities that include: 1. Being a resource in skin care, injury prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Providing feedback and education to nursing staff regarding skin care, wound prevention and treatment. On 2/03/22, the Surveyor reviewed R1's medical record. R1 was admitted to the facility for rehabilitation following a laminectomy and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Admission MDS (Minimum Data Set), dated 7/14/21, indicated R1 was not cognitively impaired, but required extensive assistance of staff for bed mobility and most ADLs (activities of daily living). The MDS indicated R1 was at risk for pressure injuries and had pressure relieving devices for bed and chair. In addition, R1 wore a support brace on the right foot to prevent foot drop. The brace was put on in the morning and removed at bed time. A neurology progress note prior to admission, dated 7/07/21, stated, R1 reported a decreased sensation from below the knee down in both legs. R1's Skin Integrity care plan, initiated on 7/10/21 and revised on 7/19/21, stated R1 was at risk for skin integrity related to hospitalization , surgery, diabetes and [CONDITION(S)] (swelling). One of two goals was for R1 to remain free of foot complications. The care plan contained an intervention, dated 7/10/21, that stated R1 was at high risk for foot complications due to diabetes and instructed staff to assess R1's risk factors at least quarterly. The care plan also contained an intervention, dated 7/10/21, that stated R1 was at low risk for skin breakdown according to a Braden Scale assessment (a standardized evidence-based assessment tool used to assess and document patients at risk for forming pressure injuries). A Braden Scale assessment, dated 7/08/21, indicated R1's ability to walk was severely limited or non-existent. The assessment indicated R1 did not have sensory deficits that limited R1's ability to feel pain or discomfort. R1 was able to make occasional slight changes in body or extremity position, but was unable to make frequent or significant changes independently. The assessment indicated R1 was at mild risk for pressure injuries. A skin check, dated 7/08/21, stated non-pitting [CONDITION(S)] (excess fluid build up in the body that causes swelling that does not indent when pressure is applied) was present on the right foot and leg below mid-calf. Skin checks, dated 7/09/21 and 7/16/21, noted no new skin issues. Medicare notes, dated 7/09/21 and 7/11/21, stated R1 had non-pitting [CONDITION(S)] to the LLE (left lower extremity) and 2+ pitting [CONDITION(S)] (the least severe type of pitting [CONDITION(S)] in which pressure leaves an indentation of 3-4 mm (millimeters) that rebounds in fewer than 15 seconds) to the RLE (right lower extremity) with support brace in place. Medicare notes, dated 7/12/21 and 7/15/21, stated R1 could lift R1's LLE, but had limited ROM (range of motion) to the RLE. The note indicated R1 had 2+ pitting [CONDITION(S)] to both lower extremities from the knees to the ankles and stated, (R1) reports numbness from knee down to BLE (bilateral lower extremities). An Admission History and Physical, written by MD (Medical Doctor)-D and dated 7/14/21, stated R1 was admitted for a probable short-term rehab following elective spine surgery due to severe lumbar stenosis (a narrowing of the open spaces in the lower lumbar spine) and weakness in the lower extremities. R1's postoperative course was complicated by continued weakness in the lower extremities. The note stated R1 reported intermittent right leg pain. A Medicare note, dated 7/16/21, stated R1 reported bilateral ankle numbness and tingling. A Braden Scale assessment, dated 7/16/21, stated R1's sensory perception was slightly limited which indicated R1's ability to feel pain or discomfort in one or two extremities was impaired. The assessment also stated R1 was chairfast with very limited mobility with friction and shear a potential problem. The assessment indicated R1 was at mild risk for pressure injuries. A Medicare note, dated 7/17/21, stated, .Numbness and tingling from knee down to BLE continues . A Medicare note, dated 7/18/21, stated, .Some [CONDITION(S)] noted in (R1's) lower extremities . A Medicare note, dated 7/21/21 at 5:40 PM, stated R1 had BLE non-pitting [CONDITION(S)] as well as blisters to the back of both heels. Treatments and interventions were initiated, including a heel lift pillow while in bed. A nursing note, dated 7/21/21 at 9:40 PM, stated, (MD-Q) updated on blisters found to bilateral heels .wound care team to be updated. (MD-Q) in agreement with interventions. A weekly wound assessment, dated 7/21/21, stated, Left heel: Closed blister, opaque, unable to see fluid under. The assessment stated the wound was an unstageable pressure injury with purple skin around the blister that measured 2.5 cm (centimeters) (length) by 4.0 centimeters (width). The treatment plan contained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A weekly wound assessment, dated 7/21/21, stated, Right heel: Closed blister, opaque, unable to see fluid under. The assessment stated the wound was an unstageable pressure injury with slightly pink skin around the blister that measured 1.8 cm by 1.7 cm. The treatment plan contained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/03/22 at 12:30 PM, the Surveyor interviewed ADON (Assistant Director of Nursing)-C regarding R1. ADON-C verified R1 developed unstageable pressure injuries on both heels. ADON-C stated R1's foam mattress was replaced with an air mattress on 7/16/21; however, a heel lift pillow was not provided until after the pressure injuries were discovered on 7/21/21. ADON-C verified R1's care plan contained contradictory interventions that stated R1 was at high risk for foot complications, but low risk for skin breakdown. ADON-C stated ADON-C expected staff to put interventions in place to protect R1's feet and heels prior to the development of the pressure injuries due to R1's risk factors of diabetes, lower extremity weakness and a pin-prick, tingling sensation in the lower legs and feet. On 2/03/22 at 2:20 PM, the Surveyor interviewed ADON-G regarding R1. ADON-G verified the facility followed the NPIAP (National Pressure Injury Advisory Panel) guidelines and stated, We could do better with putting interventions in place for those at risk for foot complications.

Based on record review and staff interview, the facility did not ensure a medical provider was notified when 1 Resident (R) (R1) of 1 resident experienced a change in condition of a surgical wound. R1 was admitted to the facility for aftercare following a laminectomy (surgery in which all or part of the vertebral bone is removed to ease pressure on the spinal cord or nerve roots) and fusion (a neurosurgical technique that joins two or more vertebrae). R1 had a surgical incision on the lower back and treatment orders for wound care. Staff did not update R1's physician when R1's wound incurred a change in condition approximately three weeks post-op. R1 was admitted to a local hospital on 7/22/21 and diagnosed with MSSA ([CONDITION(S)]-susceptible Staphylococcus aureus) (a strain of staph bacteria that responds well to medicine used to treat staph infections) bacteremia (the presence of viable bacteria in the circulating blood) likely due to a surgical site infection. Findings include: The facility's Notification of Member Status Change policy, dated 11/03/17, states: Purpose: * To ensure that the members will receive timely medical and nursing care during a change in physical, mental or emotional status, an emergency and/or a sudden illness. * To inform the provider and member representative of any situation that causes a change in status. Policy: * Any changes in the status of any member shall be reported to the RN (Registered Nurse) who shall take appropriate action. * The RN or designee shall immediately inform the member, consult with the member's provider and notify the member representative and nursing supervisor when there is: c. A need to alter treatment significantly (i.e. a need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment); * Members having a change in status shall be placed on the 24 Hour Report for as long as necessary to resolve the situation. * Members on 24 Hour Report shall have monitoring assessments and documentation. Procedure: 1. Detailed documentation of each attempt at notification of a member's status change to the provider and member representative (to include what the nurse told the provider/member representative, the provider's/member representative's response and the exact time and date) is made in the electronic health record. 2. Documentation of the nurse's assessment of findings, which she/he relays to the provider via telephone, is recorded in the member's electronic health record. 7. All further documentation in the electronic health record indicates the success or lack of success of the defined approaches; any further assessment necessary; and that this information is being communicated with other members of the interdisciplinary team. Findings include: On 2/03/22, the Surveyor reviewed R1's medical record. R1 was admitted to the facility for aftercare following a laminectomy and fusion and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Admission MDS (Minimum Data Set), dated 7/14/21, indicated R1 was not cognitively impaired, but required extensive assistance of staff for transfers, bed mobility and most ADLs (activities of daily living). R1's hospital discharge paperwork, dated 7/08/21, contained the following instructions: Incision Care There are many different ways to close and cover an incision .Follow your health care provider's instructions about: 1. Incision care 2. Bandage (dressing) changes and removal 4. Check your incision area every day for signs of infection. If you cannot see your incision, have someone check it for you, Watch for: a. Redness, swelling or pain b. Fluid, blood or pus Seek Medical Care If: 4. You have pain, numbness or weakness that lasts longer than three weeks after surgery. Seek Immediate Medical Care If: a. You have fluid, blood or pus coming from your incision A hospital physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission skin check, dated 7/08/21, stated R1 had a dressing over a surgical wound that was present upon admission and not to be removed yet. A Medicare note, dated 7/09/21, stated, .Incision wound on lumbar spine has [MEDICATION(S)] bandage covering. Removed and is well approximated, no (signs or symptoms) of infection . A physician order, dated 7/09/21, stated, Place a new [MEDICATION(S)] dressing on R1's surgical wound (7/12/21) and leave in place for (five) days. Remove and perform daily dressings as needed . A nursing note, dated 7/12/21 at 1:16 PM, stated, Dressing to mid/low back changed .minimal dark brown drainage. No redness or odor noted. A Medicare note, dated 7/12/21 at 8:15 PM, stated R1's dressing was scheduled to be changed in five days on 7/18/21. The Surveyor noted 7/18/21 was six days from 7/12/21. On 2/04/22 at 8:18 AM, the Surveyor interviewed LPN-K regarding R1. LPN-K verified LPN-K changed R1's dressing on 7/12/21. LPN-K stated the wound contained two small spots of serosanguineous drainage near R1's coccyx; however, the wound did not look infected and was not dehisced. LPN-K stated LPN-K believed R1's wound started to dehisce at the end. Nursing notes, written on 7/18/21 and 7/19/21 by LPN (Licensed Practical Nurse)-O stated, Small amount of drainage noted on bandage, 4 x 4 [MEDICATION(S)] (an adhesive, waterproof foam dressing that has a high fluid-handling capacity) placed in location of drainage .No (signs or symptoms) of infection. A nursing note, dated 7/20/21 at 9:08 AM, stated R1's wound had a small amount of bloody drainage to the lower part of the incision, but no signs or symptoms of infection. A nursing note, written by RN-E on 7/20/21 at 11:30 AM, stated, (R1's) surgical site is covered with (two) Optifoams. The top [MEDICATION(S)] has bloody drainage On 2/03/22 at 3:25 PM, the Surveyor interviewed RN-E regarding R1. When asked if RN-E updated R1's physician regarding the increased drainage from R1's wound, RN-E stated, I imagine I would have .It would be in my charting. (There is no charting to indicate RN-E consulted with R1's physician this date.) A Medicare note, dated 7/20/21 at 7:40 PM, stated R1's [MEDICATION(S)] dressing was half off and sanguineous (the leakage of fresh blood produced by an open wound) drainage was noted. On 7/20/21, R1's wound treatment was changed via a nursing order from daily dressing changes to twice daily and as needed dressing changes. The Surveyor noted R1's dressing was changed three times on 7/20/21. A weekly wound assessment, dated 7/20/21, stated R1's surgical wound measured 14 cm (centimeters) (length) by 0.5 cm (width) by 0.01 cm (depth). The assessment stated the wound edges were well approximated, but irregular. Sanguineous drainage and a moderate amount of exudate (fluid and leukocytes that move to the site of injury from the circulatory system in response to local inflammation) were present. No signs or symptoms of infection were noted. R1 stated R1 had minimal sensation to the area and could feel pressure, but not pain. A Medicare note, dated 7/21/21 at 5:40 PM, stated, .Dressing treatment to back updated due to heavy drainage today. The note also stated R1's dressing was changed twice on the PM shift due to serosangineous (a thin, watery fluid that is pink in color due to the presence of a small amount of red blood cells) drainage. A nursing order, dated 7/21/21 at 8:56 PM, instructed staff to cleanse R1's wound and apply an ABD (abdominal) pad (used to absorb discharge from heavily draining wounds) secured with tape. A note at the bottom of the order stated, Treatment applied in afternoon was saturated, area cleansed and covered again, two layers of ABD pad applied (per RN-I) to attempt to contain drainage. The Surveyor noted R1's dressing was changed three times on 7/21/21. On 2/03/22 at 2:53 PM, the Surveyor interviewed RN-I regarding R1. RN-I recalled having a conversation with the day shift about (R1's) wound draining more. RN-I could not recall if RN-I updated R1's physician on the 7/21/21 PM shift when the wound was noted to have increased drainage. A health status note, written by NE (Nurse Educator)-J on 7/22/21 at 7:05 AM, stated R1's surgical incision was assessed. Sanguineous drainage was noted to the mid-incision. On 2/03/22 at 2:38 PM, the Surveyor interviewed NE-J regarding R1. NE-J, who is wound care certified, verified NE-J assessed R1's wound on 7/22/21 and saw no signs or symptoms of infection. A health status note, dated 7/22/21 at 10:05 AM, stated R1 was found unresponsive at 7:05 AM with a blood sugar level of 28. The facility's hypoglycemic protocol was initiated and R1 was transported to a local hospital. A consultation note, dated 7/23/21, stated R1 was referred to infectious disease for urgent consult of Staph aureus bacteremia (a leading cause of community-acquired and hospital-acquired bacteremia. Patients with S. aureus bacteremia can develop a broad array of complications that may be difficult to recognize initially and can increase morbidity). The admission exam noted evidence of redness along the lumbar incision with dehiscence (a surgical complication where the edges of a wound no longer meet) and purulence (a thick, milky discharge that indicates an infection or an unhealthy wound). The note stated R1 had a surgical site infection of the lumbar spinal incision; however, it was difficult to determine if the infection was superficial or deep. Blood and wound cultures were obtained. R1 also had MSSA bacteremia likely due to the surgical site infection. IV (intravenous) antibiotics were administered. The note stated infections disease would continue to follow R1 given the high risk of mortality associated with Staph aureus [CONDITION(S)] and bacteremia. A hospital discharge summary, dated 8/02/21, stated R1 was admitted on [DATE] for altered mental status. Further workup indicated R1 had MSSA bacteremia due to an infected surgical site and the wound was dehisced. R1 underwent a wound washout and a wound vac was placed. On 7/24/21, the postsurgical changes to R1's incision site were stable and R1's [CONDITION(S)] was resolved. On 2/03/22 at 2:20 PM, the Surveyor interviewed ADON (Assistant Director of Nursing)-C regarding R1. ADON-C verified R1's medical record indicated there was a change in condition in R1's surgical wound. ADON-C was unsure why R1's physician was not notified when blood, increased drainage and more frequent dressing changes were required beginning 7/20/21. On 2/03/22 at 3:08 PM, the Surveyor interviewed RN-H regarding R1. RN-H was unsure if RN-H updated R1's physician regarding the change in R1's wound. On 2/04/22 at 2:27 PM, the Surveyor interviewed LPN-O regarding R1. LPN-O verified LPN-O changed R1's dressing on 7/18/21. LPN-O stated R1's wound did not drain much initially; however, the wound drained more as time went on. LPN-O stated LPN-O notified an unnamed RN who asked LPN-O to put an ABD pad over the wound for more absorption. LPN-O stated LPN-O did not notify R1's physician regarding the change in R1's wound because RNs notified the providers. LPN-O stated, (R1's) wound didn't drain for a long time. I was concerned (the wound) was dehiscing because there was more drainage. LPN-O stated LPN-O asked an unnamed RN to assess the wound and was unsure what happened after that.

Based on record review and staff interviews, the facility did not provide the necessary care and services to maintain the highest practicable physical well-being for 1 (member #1) of 18 sampled members. Member #1 requested CPR and activation of the EMS (emergency medical system) transport system upon admission to the facility. Member #1 was discovered pulseless and non-breathing. Staff reported they had been with member #1 ten to fifteen minutes prior to discovering the member pulseless and non-breathing. The charge RN (Registered Nurse) did not initiate CPR or activate the EMS for transport to the hospital to allow member #1 to receive advanced cardiac life support. Member #1 expired at the facility. This had the potential to affect 12 members that resided on the unit who were a full code status and had requested CPR (cardiopulmonary resuscitation). Facility failure to initiate CPR when member #1 was found pulseless and non-breathing created a finding of immediate jeopardy that began on [DATE]. The facility was notified of the immediate jeopardy on [DATE]. The immediate jeopardy was removed on [DATE], however, the deficient practice continues at a scope/severity of E (potential for harm that is not immediate jeopardy/patterned) as the facility continues to implement its action plan. Findings include: CMS memo S&C (Survey and Certification Group letter) ,[DATE] and DQA (Division of Quality Assurance) memo ,[DATE] note that nursing homes must have staff certified in CPR on duty every shift. These individuals must provide CPR for any resident who becomes pulseless and non-breathing unless: (1) the resident has a do not resuscitate (DNR) order; (2) the resident has obvious signs of clinical death (e.g., rigor mortis, dependent lividity (pooling of the blood that occurs after death and may look blue, purple or black and is similar to bruising), decapitation, transection, or decomposition) or (3) the initiation of CPR could cause injury or peril to the rescuer. The facility's policy and procedure for Cardiopulmonary Resuscitation with a revision date of [DATE], indicated the trained staff will activate the EMS system and initiate CPR for a member who suffers a cardiopulmonary arrest, unless the member has a no CPR/DNR (do not resuscitate) order properly recorded in the chart or if the member is wearing an approved DNR bracelet. On [DATE], surveyor # reviewed member #1's medical record. According to the CPR Form signed by member #1 on [DATE], documented action desired by the member/legal representative in an arrest situation included: ~ Provide resuscitation and call the local emergency medical provider to provide advanced cardiac life support. Health care life support (provided by staff) includes: ~ Perform chest compressions ~ Establishing an airway ~ Use of AED (automated external defibrillator) Advanced cardiac life support (provided by EMS and hospital) includes: ~ Perform chest compressions ~ Insert advanced airways ~ Administer cardiac resuscitation drugs ~ Establish an intravenous line ~ Provide ventilatory assistance (put on a breathing machine) ~ Defibrillate Member #1's most current physician's orders [REDACTED].#1's code status was: Yes CPR. These physician's orders [REDACTED]. The Advanced Directives Documentation dated [DATE], indicated member #1 chose Yes to CPR. Member #1's nurse's notes dated [DATE] at 3:43 a.m. and signed by RN-B, indicated member #1 passed away peacefully in (member's) sleep. The initial assessment indicated member #1's pupils were fixed and dilated. No carotid pulse for 1 full minute, no respirations for 1 full minute and no cardiac activity for 1 full minute via chest auscultation. The notes indicated a physician was notified at 3:30 a.m., and time of death pronouncement was at 3:30 a.m. The notes indicated the family and funeral home were notified, and the body was released at 4:40 a.m., to the funeral home. RN-B's written statement documented he had been checking on member #1 when he discovered the member was not breathing. RN-B indicated he went and retrieved the vitals cart and confirmed the resident was pulseless. RN-B's statement included he was aware that member #1 was a full code. RN-B's statement indicated member #1 was cool to touch and was gray in color and that RN-B was adamant that member #1 was to the point that the member would not be able to be brought back. The statement indicated CNA-F was in to check member #1 prior to taking her break. On [DATE] at 9:10 a.m. and 9:40 a.m., surveyor # conducted a telephone interview with RN-B regarding member #1. RN-B verified he was the RN in charge of member #1's care on the night shift of [DATE]. RN-B stated he recalled the CNAs telling him member #1 was restless and was removing the oxygen cannula. RN-B indicated he told the CNAs to check on the member frequently and reapply the cannula if needed. RN-B stated he entered member #1's room and discovered the member wasn't breathing, the member's hand was cool to the touch and lips were blue. RN-B indicated the member's skin color was ashen and pupils were fixed and dilated. RN-B indicated member #1 was lying on back in bed, with the linens pulled up to the umbilical area, with feet partially exposed. RN-B indicated the member was wearing a hospital gown and thought an incontinent product also. RN-B stated he had to remove member #1's left arm from the chest area to observe for respirations and the member's arm was already stiff. RN-B stated he did not move the body nor did he observe the posterior aspect of the member's body (which would have indicated if pooling of the blood - lividity - was present). RN-B indicated the member did not have a pulse or respirations. RN-B stated he was aware member #1 had requested CPR, but he did not perform CPR because the member was already cool to the touch, light gray in color and the member's hand and arm were stiff. RN-B stated he went out into the hall and updated the CNA staff that member #1 had passed away. RN-B indicated at that time a CNA told him that she was in the room with the member about 20 -30 minutes prior and the member was alive. RN-B stated the night supervisor reviewed the CPR P&P with him, but was not aware if he had not provided appropriate care regarding the death of member #1. RN-B stated he was CPR and AED certified. The facility provided a written statement by CNA (Certified Nursing Assistant)-F. The statement indicated that CNA-F checked on member #1 before taking her break and at the time, found member #1 with oxygen off, holding the tubing in both hands. CNA-F indicated she had told the member she needed to put the oxygen back on and the member did not respond verbally, but the CNA felt resistance as the member was pulling back on the oxygen tubing when the CNA removed from the member's hand. The statement documented CNA-F ended her break early because she heard a member hollering and RN-B was coming out of member #1's room. CNA-F indicated RN-B asked her if member #1 was still alive when she was in the room. The statement indicated CNA-F informed RN-B that member #1 was alive when she replaced the oxygen back on the member. CNA-F's statement indicated there was only about 10 minutes that passed when she saw member #1 and when RN-B indicated member #1 had passed away. On [DATE] at 12:50 p.m., surveyor # conducted a telephone interview with CNA-D regarding member #1. CNA-D stated she was not in the member's room just prior to the member's death, but indicated another CNA was just in there, as the CNAs do rounds at 3:30 a.m. CNA-D indicated RN-B came to the CNAs and stated resident member #1 passed away and she thought another CNA had commented that it was strange, as there was just a CNA in the room with member #1. On [DATE] at 4:00 p.m., surveyor # conducted a telephone interview with CNA-E regarding member #1. CNA-E stated staff were checking on member #1 about every 15 minutes. CNA-E indicated she recalled the estimated amount of time between the last time a CNA checked member #1 and when RN-B stated member #1 had passed away. CNA-E stated CNA-F takes her breaks in the solarium at the end of the hall that member #1 lives and was going on a 15 minute break. CNA-E indicated CNA-F was going to check on member #1 before she went on break. CNA-E commented it was about 10 - 15 minutes later when RN-B came out of member #1's room and asked for me to get the vitals cart, but she (CNA-E) couldn't respond as she was with another member. CNA-E indicated RN-B thought member #1 had passed away. CNA-E stated she was the one that cleaned member #1's body after passing and the member's body was not stiff. CNA-E stated member #1's body was not bluish in color and the member's joints were easily moveable. CNA-E stated member #1's skin temperature was cool and the skin color was white. On [DATE] at 10:50 a.m., surveyor # interviewed RN-C regarding CPR training and when CPR should be initiated for members that are a full code. RN-C stated CPR training/certification is completed annually and the last training she received was [DATE]. RN-C indicated all RN's are certified in CPR and on a different schedule for recertification. RN-C indicated if a member had a witnessed cardiac event and was a full code, CPR would be started immediately. RN-C indicated if a member was discovered pulseless, non-breathing, no signs of bluish coloring or rigor mortis and the member was a full code, CPR would be started immediately. RN-C indicated if a member was a full code and was found pulseless, non-breathing, was bluish in color and rigor mortis was present, CPR would not be started. On [DATE] at 12:30 p.m., surveyor # interviewed RN-G regarding when to initiate CPR. RN-G indicated CPR would not be started if the member was pulseless, non-breathing, cold, stiff and the skin was purplish in color. RN-G stated if a member was discovered that did not fit the above criteria and was a full code, she would start CPR as staff would not know if the member passed away 2 minutes ago or 10 minutes ago. On [DATE] at 12:37 p.m., surveyor # interviewed LPN (Licensed Practical Nurse)-H regarding when to initiate CPR. LPN-H stated if a member was a full could she would start CPR even if there was not a witness to the event. LPN-H indicated if a member was observed breathing 10 minutes prior to being discovered pulseless and non-breathing, she would always start CPR. On [DATE] at 8:25 a.m., surveyor # interviewed NHA (Nursing Home Administrator)-A regarding member #1. NHA-A stated the facility did complete an investigation after member #1 passed away at the facility. NHA-A indicated the facility's investigation determined staff responded appropriately when member #1 was discovered pulseless and non-breathing. NHA-A stated even though the facility did respond appropriately for member #1, the facility reviewed their CPR P&P (policy and procedure). NHA-A stated she thought a CPR memo was sent out to the staff at(NAME)Hall, but could have been for the entire campus. Surveyor # did not receive documentation regarding the CPR policy sent to staff. Failure to provide CPR and to activate the EMS transport system for Member #1 created a finding of immediate jeopardy. Although it is not known if Member #1 would have been revived, the failure to provide CPR and to activate the EMS call system deprived the resident of the only possibility for surviving. The jeopardy was removed when the facility implemented the following: 1. The facility reviewed the CPR policy and updated it to include the following language: Rescuers to initiate CPR unless: 1) a valid DNR order is in place, 2) obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present, or 3) initiating CPR could cause injury or peril to the rescuer. 2. Facility staff were educated on the CPR policy update prior to working their next scheduled shift. 3. Code status of members have been reviewed to ensure facility's system to notate their status on their chart was up to date and accurate. 4. Facility will continue to perform annual training on CPR and DNR procedures to staff. 5. Staff who are CPR-certified will continue to receive training to maintain their certification as needed.