Every finding on record at Williamsburg Post Acute & Rehabilitation

Based on interview clinical record review and facility documentation the facility staff failed to ensure that residents were free from significant medication errors for 3 residents (Resident #'s 1, 2 and 3) of 3 Residents in the survey sample. 1. For Resident #1 the facility staff failed to ensure the resident received Levoquin (an antibiotic), Umeclidinium-Vilanterol (an inhaler for COPD) and dexamethasone (a steroid) per physician orders. Resident #1 was admitted to the facility on [DATE] with diagnoses that included but not limited to hemiplegia and hemiparesis following cerebral infarction (stroke), heart failure, atrial fibrillation, dysphagia, hypertension, pneumonia, history of repeated falls, major depressive disorder, and insomnia. Resident #1's most recent BIMS (Brief Interview of Mental Status) scored the Resident 15 out of a possible 15, indicating no cognitive impairment. Resident #1 is wheelchair dependent and has left sided paralysis due to the history of 2 CVA's (strokes), the most recent being in October of 2025. On 11/12/25 a review of the clinical record revealed the following medications were documented as unavailable for administration to Resident #1: 8/22/25 10:53 pm Levaquin [an antibiotic] tablet 750 mg give 1 tablet by mouth one time per day for PNA [pneumonia] for 7 days until finished. On the hands of the pharmacy 10/8/25 12:37 pm Umeclidinium-Vilanterol [Anoro Elipta] inhalation aerosol powder breath activated 62.5-25mcg/act inhale 1 puff orally one time a day for COPD. med missing 10/19/25 9:14 am Umeclidinium-Vilanterol inhalation aerosol powder breath activated 62.5-25mcg/act inhale 1 puff orally one time a day for COPD. med not on cart 8/23/25 dexamethasone – med on way from pharmacy. Further, chart review revealed dexamethasone was documented as unavailable on 9/4, 9/5, 9/6, 9/12, 9/13, and 9/16. On 11/13/25 a review of the list of medications available in the Omnicell (stat medication dispensing device), revealed that although Dexamethasone was not available Prednisone was available in 5 mg, 10 mg and 20 mg strengths and Levoquin was available in 500 mg strength. There is no documentation that the physician was contacted notified of the unavailability of Dexamethasone and availability of Prednisone. On 11/12/25 at approximately 1:45 pm an interview was conducted with LPN 2 who stated that if a medication is unavailable the nurse should first check the Omnicell then, notify the pharmacy, to see if it will be on the next run, notify the physician and notify the family if the med will be late or if they need to substitute the medication for something else until the medication arrives. On 11/13/25 a review of the pharmacy policy regarding unavailable medications read as follows: Page 105 of 223; Paragraph 3 The nursing staff shall: 1. Notify the attending physician (or on-call physician when applicable) of the situation and explain the circumstances, expected availability, and alternative therapy (ies) if available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or directions. 2. Obtain new order and cancel / discontinue the order for the non-available medication. 3. Notify the pharmacy of the replacement order. On 11/13/25 during the end of day meeting the Administrator was made aware of the concerns and no further information was made available. 2. For Resident #3 the facility staff failed to administer Eliquis (an anticoagulant) Carbidopa Levodopa (a dopaminergic anti-Parkinson drug) and sertraline (an antidepressant) as directed by physician. Resident #3 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Parkinson's disease, type 2 diabetes, CVA, hypertension and personal history of TIA (Transient Ischemic Attack). On 11/12/25 a review of the clinical record revealed that Resident #3 had orders that included: Eliquis 5 mg twice a day for CVA. Sertraline 12.5 mg 1 time a day for depression Carbidopa / Levodopa oral tablet 23-100 mg give one tablet by mouth three times a day for Parkinsons A review of the progress notes revealed the following: 11/2/25 8:34 am - Eliquis Oral Tablet 5 mg give one tablet by mouth 2 times per for CVA. Reordered. 11/2/25 10:23 pm Eliquis Oral Tablet 5 mg give one tablet by mouth 2 times per for CVA Awaiting pharmacy 11/7/25 4:24 pm Eliquis Oral Tablet 5 mg give one tablet by mouth 2 times per for CVA Awaiting pharmacy 9/17/25 8:17 am Sertraline [an antidepressant] HCL tablet give 12.5 mg by mouth 1 time per day for depression med is on order. 10/18/25 2:13 pm Carbidopa-Levodopa oral tablet 23-100 mg give one tablet by mouth three times a day for Parkinsons -Reordered 11/2/25 2:05 pm Carbidopa-Levodopa oral tablet 23-100 mg give one tablet by mouth three times a day for Parkinsons -Reordered On 11/13/25 a review of the list of medications available in the Omnicell (stat medication dispensing device), revealed that Eliquis was available for use in 2.5 mg and 5 mg doses and sertraline was available in the 25 mg dose. There is no documentation that the physician was contacted notified of the unavailability of Eliquis, carbidopa/ levodopa, and Sertraline. On 11/12/25 at approximately 1:45 pm an interview was conducted with LPN 2 who stated that if a medication is unavailable the nurse should first check the Omnicell then, notify the pharmacy, to see if it will be on the next run, notify the physician and notify the family if the med will be late or if they need to substitute the medication for something else until the medication arrives. On 11/13/25 a review of the pharmacy policy regarding unavailable medications read as follows: Page 105 of 223; Paragraph 3 The nursing staff shall: 1. Notify the attending physician (or on-call physician when applicable) of the situation and explain the circumstances, expected availability, and alternative therapy (ies) if available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or directions. 2. Obtain new order and cancel / discontinue the order for the non-available medication. 3. Notify the pharmacy of the replacement order. On 11/13/25 during the end of day meeting the Administrator was made aware of the concerns and no further information was made available. 3. For Resident #2, the facility staff failed to ensure her medications (Dapagliflozin, Incruse Ellipta, Buspar and Ipratropium) were administered according to the physician's orders. Resident #2 was admitted to the facility on [DATE] with diagnoses including but not limited to chronic obstructive pulmonary disease with exacerbation, type 2 diabetes mellitus, history of pulmonary embolism, obstructive sleep apnea, iron deficiency anemia secondary to blood loss, chronic kidney disease, stage 3, hypertension, vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, hypokalemia, post-traumatic stress disorder, major depressive disorder, interstitial pulmonary disease, morbid obesity, acute and chronic respiratory failure, with hypoxia, pneumonia and acute on chronic diastolic (congestive) heart failure and fibromyalgia. Resident #2's most recent MDS (Minimum Data Set) Quarterly Assessment with an ARD (Assessment Reference Date) of 10/4/25 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 14 out of a possible 15 indicating her cognition is intact. On 11/12/25 a review of Resident #2's Physician Order Summary was completed which revealed that the resident had orders for Dapagliflozin (a prescription medication used to treat adults with type 2 diabetes, heart failure and chronic kidney disease) , Incruse Ellipta ( a prescription maintenance medication used to treat chronic obstructive pulmonary disease in adults), Buspar (an anti-anxiety medication used to treat symptoms of anxiety) and Ipratropium (a prescription medication used to relax the muscles around the airways which opens them up and makes breathing easier). Further record review of Resident #2's July, August, September and October Medication Administration Records and progress notes were coded as 9 which means see nurses notes and nurses notes revealed medication not available, on order, awaiting delivery or insurance company won't distribute until next Monday (a week away) According to the clinical record Medication Administration Record and progress notes: 7/30/25 at 9:00AM Dapagliflozin Propanediol Oral Tablet 10 MG, give 1 tablet by mouth one time a day for DM 2 and the Medication Administration Record was coded as 9 which means to see nurses notes and per nurse's notes nurse documented Not available on reorder. 7/30/25 at 9:00AM Incruse Ellipta 62.5 MCG/ACT Aerosol Powder, breath activated, give 1 puff by mouth one time a day related to chronic obstructive pulmonary disease with exacerbation was coded as 9 which means to see nurses notes and per the nurses notes the nurse documented on order. 8/13/25 at 9:00AM Incruse Ellipta 62.5 MCG/ACT Aerosol Powder, breath activated, give 1 puff by mouth one time a day related to chronic obstructive pulmonary disease with exacerbation was coded as a 9 which means to see nurses notes and per nurses notes the nurse documented on order. 9/27/25 and 9/29/25 at 9:00AM Incruse Ellipta 62.5 MCG/ACT Aerosol Powder, breath activated Give 1 puff by mouth one time a day related to chronic obstructive pulmonary disease with exacerbation was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented med on order. 10/1/25 at 9:00AM Incruse Ellipta 62.5 MCG/ACT Aerosol Powder, breath activated Give 1 puff by mouth one time a day related to chronic obstructive pulmonary disease with exacerbation was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented available this nurse called pharmacy, pharmacy stated that insurance won't distribute until next Monday 10/1/25 at 9:00AM Buspar Oral Tablet 10 MG give 1 tablet by mouth three times a day for depression was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented med on order 10/2/25 at 9:00AM Incruse Ellipta 62.5 MCG/ACT Aerosol Powder, breath activated Give 1 puff by mouth one time a day related to chronic obstructive pulmonary disease with exacerbation was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented med on order not available due to insurance till Monday 10/2/25 at 9:00AM Buspar Oral Tablet 10 MG give 1 tablet by mouth three times a day for depression was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented med on order 10/2/25 at 1:00PM Buspar Oral Tablet 10 MG, give 1 tablet by mouth three times a day for depression was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented on order 10/3/25 9:00AM Buspar Oral Tablet 10 MG give 1 tablet by mouth three times a day for depression at was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented med on order 10/3/25 at 9:00AM Incruse Ellipta 62.5 MCG/ACT Aerosol Powder, breath activated, give 1 puff by mouth one time a day related to chronic obstructive pulmonary disease with exacerbation was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented med on order 10/18/2025 at 14:32 Ipratropium Bromide Inhalation Solution 0.02 % 1 dose inhale orally three times a day for wheezing was coded as 9 which means see nurse's note and per the nurses note the nurse documented writer spoke to the pharmacy; this medication will be delivered next drop off, 10/19/25 at 9:00AM 00AM Incruse Ellipta 62.5 MCG/ACT Aerosol Powder, breath activated, give 1 puff by mouth one time a day related to chronic obstructive pulmonary disease with exacerbation was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented awaiting delivery 10/20/2025 08:55 According to a nurse's note: Ipratropium Bromide Inhalation Solution 0.02 % 1 dose inhale orally three times a day for wheezing was administered as Resident #2 had complained of shortness of breath (SOB). Resident states her nurses yesterday refused to give her breathing treatments and some said she was out. Brought box to residents to show, it is not a new box, it is half used. And it has her name on it. Resident also states she was not given her sleep medication or anxiety medication, resulting in her being up all night not able to sleep. Gave resident all her normal morning medicine and included as needed (PRN) medication for anxiety. Assessment: Before breathing treatment 90 %, during breathing treatment, 92 %, after breathing treatment. And after morning medication 94 %, shortness of breath (SOB) is better. No evidence that the medical provider was notified of medications not available or that the insurance provider was not approving a medication for dispensing until 10/8/25. On 11/13/25 at 10:01AM, an interview was conducted with LPN#1 on what she would do if a medication was not available in the medication cart for the resident and she replied, I would look in the STAT box and then I think I would call the doctor Oh I need to ask [NAME] about that I am not sure exactly. On 11/13/25 at 10:07AM, an interview was conducted with LPN #2 on what she would do if a medication was not available in the medication cart for the resident and she replied, I would check my cart in the overstock medication drawer and if not there I would check in the Omnicell (an on-site machine used in long term facilities to store and manage medication accessibility), if still not there I would call the pharmacy and ask them if the med was enroute and when it would arrive, if none of that can get the med here timely then I would call the nurse practitioner or doctor to see if they have other orders On 11/13/25 at 10:34AM, an interview was conducted with the Interim Director of Nursing (Employee #3) and according to her she was aware that medications had not been administered per physician's orders for some residents due to residents not being entered into the pharmacy's automatic refill program. They were working on this process and had educated nurses on what to do if medications were not available. On 11/13/25 a review of the pharmacy policy regarding unavailable medications read as follows: Page 105 of 223; Paragraph 3, The nursing staff shall: 1. Notify the attending physician (or on-call physician when applicable) of the situation and explain the circumstances, expected availability, and alternative therapy (ies) if available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or directions. 2. Obtain new order and cancel / discontinue the order for the non-available medication. 3. Notify the pharmacy of the replacement order. On 11/13/25 during the end of day meeting, the Administrator, Interim Director of Nursing, New Director of Nursing and Regional Director of Clinical Services were made aware of concerns, and no further information was provided

Based on interview clinical record review and facility documentation the facility staff failed to ensure routine medications were available to be administered to 3 residents (#'s 1, 2, and 3) in a survey sample of 3 residents.1, For Resident #1 the facility staff failed to ensure that routine medications were available for administration to the resident. Resident #1 was admitted to the facility on [DATE] with diagnoses that included but not limited to hemiplegia and hemiparesis following cerebral infarction (stroke), heart failure, atrial fibrillation, dysphagia, hypertension, pneumonia, history of repeated falls, major depressive disorder, and insomnia. Resident #1's most recent BIMS (Brief Interview of Mental Status) scored the Resident 15 out of a possible 15, indicating no cognitive impairment. Resident #1 is wheelchair dependent and has left sided paralysis due to the history of 2 CVA's (strokes), the most recent being in October of 2025. Resident #1 has left sided paralysis and uses a wheelchair for mobility. A review of the progress notes revealed the following documentation about routine medications that were unavailable to Resident #1: 9/4/25 10 am Saline nasal mist solution 0.65 spray in each nostril every 12 hours. Awaiting pharmacy delivery. The same documentation Awaiting Pharmacy delivery was present on 9/16, 9/19, 9/23, 10/6, 10/21, 10/23, 10/24, 10/29, 10/5/25 12:02 pm Umeclidinium-Vilanterol Inhalation Aerosol Powder Breath Activated 62.5-25 MCG/ACT1 puff inhale orally one time a day for COPD Insurance doesn't approve this med. 10/8/25 12:37 pm Umeclidinium-Vilanterol inhalation aerosol powder breath activated 62.5-25mcg/act inhale 1 puff orally one time a day for COPD. med missing 10/19/25 9:14 am Umeclidinium-Vilanterol inhalation aerosol powder breath activated 62.5-25mcg/act inhale 1 puff orally one time a day for COPD. med not on cart 8/25/25 10:43 am Cholecalciferol oral tablet 25 mcg I tablet by mouth one time per day supplement med unavailable. 10/24/25 9:10 am Lidocaine Pain Relief External Patch 4% apply to bilateral knees 1 time per day Meds Reordered. 9/1/25 and 10/6/25 Fiber Formula oral caps. Give 3 capsules by mouth one time per day Medication is not available. On 11/12/25 at approximately 1:45 pm an interview was conducted with LPN 2 who stated If a medication is unavailable the nurse should first check the Omnicell then, notify the pharmacy, to see if it will be on the next run, notify the physician and notify the family if the med will be late or if they need to substitute the medication for something else until the medication arrives. A review of the Policy entitled Unavailable Medications revealed the following: Page 105 of 223; Paragraph 3 The nursing staff shall: 1. Notify the attending physician (or on-call physician when applicable) of the situation and explain the circumstances, expected availability, and alternative therapy (ies) if available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or directions. 2. Obtain new order and cancel / discontinue the order for the non-available medication. 3. Notify the pharmacy of the replacement order. On 11/13/25 during the end of day meeting the Administrator and the DON were made aware and no further information was provided. 2. For Resident #3 the facility staff failed to ensure medications were available for administration to the resident. Resident #3 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Parkinson's disease, type 2 diabetes, CVA, hypertension and personal history of TIA (Transient Ischemic Attack). On 11/12/25 a review of the clinical record revealed that Resident #3 had orders that included Eliquis 5 mg twice a day for CVA. A review of the progress notes revealed the following documentation about medications that were unavailable to Resident #1: 11/2/25 8:34 am - Eliquis Oral Tablet 5 mg give one tablet by mouth 2 times per for CVA. Reordered. 11/2/25 10:23 pm Eliquis Oral Tablet 5 mg give one tablet by mouth 2 times per for CVA Awaiting pharmacy 11/7/25 4:24 pm Eliquis Oral Tablet 5 mg give one tablet by mouth 2 times per for CVA Awaiting pharmacy 9/17/25 8:17 am Sertraline [an antidepressant] HCL tablet give 12.5 mg by mouth 1 time per day for depression med is on order. 10/18/25 2:13 pm Carbidopa-Levodopa oral tablet 23-100 mg give one tablet by mouth three times a day for Parkinsons -Reordered 11/2/25 2:05 pm Carbidopa-Levodopa oral tablet 23-100 mg give one tablet by mouth three times a day for Parkinsons -Reordered On 11/13/25 a review of the list of medications available in the Omnicell (stat medication dispensing device), revealed that Eliquis was available for use in 2.5 mg and 5 mg doses and sertraline was available in the 25 mg dose. There is no documentation that the physician was contacted notified of the unavailability of Eliquis, carbadopa/ levadopa, and Sertraline. On 11/12/25 at approximately 1:45 pm an interview was conducted with LPN 2 who stated that if a medication is unavailable the nurse should first check the omnicell then, notify the pharmacy, to see if it will be on the next run, notify the physician and notify the family if the med will be late or if they need to substitute the medication for something else until the medication arrives. On 11/13/25 a review of the pharmacy policy regarding unavailable medications read as follows: Page 105 of 223; Paragraph 3 The nursing staff shall: 1. Notify the attending physician (or on-call physician when applicable) of the situation and explain the circumstances, expected availability, and alternative therapy (ies) if available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the the nursing supervisor and contact the Facility Medical Director for orders and/or directions. 2. Obtain new order and cancel / discontinue the order for the non-available medication. 3. Notify the pharmacy of the replacement order. On 11/13/25 during the end of day meeting the Administrator was made aware of the concerns and no further information was made available. 3. For Resident #2, the facility staff failed to ensure her medications (Dapagliflozin, Incruse Ellipta, Buspar and Ipratropium) were available to be administered according to the physician's orders. Resident #2 was admitted to the facility on [DATE] with diagnoses including but not limited to chronic obstructive pulmonary disease with exacerbation, type 2 diabetes mellitus, history of pulmonary embolism, obstructive sleep apnea, iron deficiency anemia secondary to blood loss, chronic kidney disease, stage 3, hypertension, vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, hypokalemia, post-traumatic stress disorder, major depressive disorder, interstitial pulmonary disease, morbid obesity, acute and chronic respiratory failure, with hypoxia, pneumonia and acute on chronic diastolic (congestive) heart failure and fibromyalgia. Resident #2's most recent MDS (Minimum Data Set) Quarterly Assessment with an ARD (Assessment Reference Date) of 10/4/25 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 14 out of a possible 15 indicating her cognition is intact. On 11/12/25 a review of Resident #2's Physician Order Summary was completed which revealed that the resident had orders for Dapagliflozin (a prescription medication used to treat adults with type 2 diabetes, heart failure and chronic kidney disease) , Incruse Ellipta ( a prescription maintenance medication used to treat chronic obstructive pulmonary disease in adults), Buspar (an anti-anxiety medication used to treat symptoms of anxiety) and Ipratropium (a prescription medication used to relax the muscles around the airways which opens them up and makes breathing easier). Further record review of Resident #2's July, August, September and October Medication Administration Records and progress notes were coded as 9 which means see nurses notes and nurses notes revealed medication not available, on order, awaiting delivery or insurance company won't distribute until next Monday (a week away) According to the clinical record Medication Administration Record and progress notes: 7/30/25 at 9:00AM Dapagliflozin Propanediol Oral Tablet 10 MG, give 1 tablet by mouth one time a day for DM 2 and the Medication Administration Record was coded as 9 which means to see nurses notes and per nurse's notes nurse documented Not available on reorder. 7/30/25 at 9:00AM Incruse Ellipta 62.5 MCG/ACT Aerosol Powder, breath activated, give 1 puff by mouth one time a day related to chronic obstructive pulmonary disease with exacerbation was coded as 9 which means to see nurses notes and per the nurses notes the nurse documented on order. 8/13/25 at 9:00AM Incruse Ellipta 62.5 MCG/ACT Aerosol Powder, breath activated, give 1 puff by mouth one time a day related to chronic obstructive pulmonary disease with exacerbation was coded as a 9 which means to see nurses notes and per nurses notes the nurse documented on order. 9/27/25 and 9/29/25 at 9:00AM Incruse Ellipta 62.5 MCG/ACT Aerosol Powder, breath activated Give 1 puff by mouth one time a day related to chronic obstructive pulmonary disease with exacerbation was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented med on order. 10/1/25 at 9:00AM Incruse Ellipta 62.5 MCG/ACT Aerosol Powder, breath activated Give 1 puff by mouth one time a day related to chronic obstructive pulmonary disease with exacerbation was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented available this nurse called pharmacy, pharmacy stated that insurance won't distribute until next Monday 10/1/25 at 9:00AM Buspar Oral Tablet 10 MG give 1 tablet by mouth three times a day for depression was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented med on order 10/2/25 at 9:00AM Incruse Ellipta 62.5 MCG/ACT Aerosol Powder, breath activated Give 1 puff by mouth one time a day related to chronic obstructive pulmonary disease with exacerbation was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented med on order not available due to insurance till Monday 10/2/25 at 9:00AM Buspar Oral Tablet 10 MG give 1 tablet by mouth three times a day for depression was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented med on order 10/2/25 at 1:00PM Buspar Oral Tablet 10 MG, give 1 tablet by mouth three times a day for depression was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented on order 10/3/25 9:00AM Buspar Oral Tablet 10 MG give 1 tablet by mouth three times a day for depression at was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented med on order 10/3/25 at 9:00AM Incruse Ellipta 62.5 MCG/ACT Aerosol Powder, breath activated, give 1 puff by mouth one time a day related to chronic obstructive pulmonary disease with exacerbation was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented med on order 10/18/2025 at 14:32 Ipratropium Bromide Inhalation Solution 0.02 % 1 dose inhale orally three times a day for wheezing was coded as 9 which means see nurse's note and per the nurses note the nurse documented writer spoke to the pharmacy; this medication will be delivered next drop off 10/19/25 at 9:00AM 00AM Incruse Ellipta 62.5 MCG/ACT Aerosol Powder, breath activated, give 1 puff by mouth one time a day related to chronic obstructive pulmonary disease with exacerbation was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented awaiting delivery 10/20/2025 08:55 According to a nurse's note: Ipratropium Bromide Inhalation Solution 0.02 % 1 dose inhale orally three times a day for wheezing was administered as Resident #2 had complained of shortness of breath (SOB). Resident states her nurses yesterday refused to give her breathing treatments and some said she was out. Brought box to residents to show, it is not a new box, it is half used. And it has her name on it. Resident also states she was not given her sleep medication or anxiety medication, resulting in her being up all night not able to sleep. Gave resident all her normal morning medicine and included as needed (PRN) medication for anxiety. Assessment: Before breathing treatment 90 %, during breathing treatment, 92 %, after breathing treatment. And after morning medication 94 %, shortness of breath (SOB) is better. No evidence that the medical provider was notified of medications not available or that the insurance provider was not approving a medication for dispensing until 10/8/25. On 11/13/25 at 10:01AM, an interview was conducted with LPN#1 on what she would do if a medication was not available in the medication cart for the resident and she replied, I would look in the STAT box and then I think I would call the doctor Oh I need to ask [NAME] about that I am not sure exactly. On 11/13/25 at 10:07AM, an interview was conducted with LPN #2 on what she would do if a medication was not available in the medication cart for the resident and she replied, I would check my cart in the overstock medication drawer and if not there I would check in the Omnicell (an on-site machine used in long term facilities to store and manage medication accessibility), if still not there I would call the pharmacy and ask them if the med was enroute and when it would arrive, if none of that can get the med here timely then I would call the nurse practitioner or doctor to see if they have other orders On 11/13/25 at 10:34AM, an interview was conducted with the Interim Director of Nursing (Employee #3) and according to her she was aware that medications had not been administered per physician's orders for some residents due to residents not being entered into the pharmacy's automatic refill program. They were working on this process and had educated nurses on what to do if medications were not available. On 11/13/25 a review of the pharmacy policy regarding unavailable medications read as follows: Page 105 of 223; Paragraph 3, The nursing staff shall: 1. Notify the attending physician (or on-call physician when applicable) of the situation and explain the circumstances, expected availability, and alternative therapy if available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or directions. 2. Obtain new order and cancel / discontinue the order for the non-available medication. 3. Notify the pharmacy of the replacement order. On 11/13/25 during the end of day meeting, the Administrator, Interim Director of Nursing, New Director of Nursing and Regional Director of Clinical Services were made aware of concerns, and no further information was provided.

Based on interviews and facility document review, the facility failed to designate an individual as the infection preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program (IPCP) for the facility.Findings include:The facility administration failed to designate an individual who had completed specialized training in infection prevention and control practices to oversee the facility's Infection Prevention and Control Program. On 11/12/25 a review was conducted on the facility's infection control binder which revealed the Infection Control Tracking Log (surveillance log) dated 7/1/25 through 7/31/25 was incomplete for 5 residents for onset date, site, infection related diagnosis, culture/labs/diagnostic test results, organism, antibiotics, isolation, whether infection was healthcare associated infection or not and date resolved. The Infection Control binder was further reviewed and revealed that from May to present numerous months were incomplete for infection control tracking logs, McGeer's criteria, mapping and monthly reports. On 11/12/25 an interview was conducted with the Interim Director of Nursing (Employee #3) and the Regional Director of Clinical Services (Employee #4) on incomplete infection control program reports and tracking and they replied that they had had several people overseeing the facility's infection control program since the former Assistant Director of Nursing had left in April and they had not filled that position. Copies of the Infection Control training certification for the staff overseeing the program since April were requested and the Regional Director of Clinical Services provided a copy of CDC's Nursing Home Infection Preventionist Training Course Certification for 8/20/25 through 10/20/25 for the former Interim Director of Nursing and another certificate for the current Interim Director of Nursing 10/20/25 to present but no evidence that an individual was designated as the Infection Preventionist who had completed specialized training/certification in infection prevention and control for the time period of 5/1/25 through 8/20/25 A review of the facility's Infection Control Policies provided by the Administrator was completed:The policy entitled: Infection Control Program revealed:Policy: Specific Procedures/Guidance 1. h. Monitoring and timely reporting of infection control data as required by federal and state regulations or guidance.2. The Infection Control program will be overseen by the Infection Preventionist in collaboration with Medical Director/Designee, Pharmacy Representative, Director of Nursing, Administrator and other staff were assigned.The policy entitled: Infection Preventionist Policy revealed:Policy: Specific Procedures/Guidance3. The Infection Preventionist will collect, analyze and provide infection and antibiotic usage data and trends to nursing staff and health care practitioners; consult on infection risk assessment and prevention control strategies; provide education and training; and the implementation of evidence-based infection prevention and control practices.The policy entitled: Infection Preventionist - Job Description revealed:Qualified Candidate: Educational and Certification Requirements Certification in Infection Control and Epidemiology (i.e.: CIC copyrighted preferred) or, attainment prior to employmentOn 11/13/25 during the end of day meeting, the Administrator, Interim Director of Nursing, New Director of Nursing, Regional Director of Clinical Services and Regional Director of Operations were made aware of concerns, and no further information was provided.

Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to notify the physician and resident representative of changes in the residents' condition for 2 of 3 (Residents #1 and # 2) residents in a survey sample of 3 Residents.The findings included: 1.For Resident #1 the facility staff failed to notify the physician of changes in condition, and availability of medications. Resident #1 was admitted to the facility on [DATE] with diagnoses that included but not limited to hemiplegia and hemiparesis following cerebral infarction (stroke), heart failure, atrial fibrillation, dysphagia, hypertension, pneumonia, history of repeated falls, major depressive disorder, and insomnia. Resident #1's most recent BIMS (Brief Interview of Mental Status) scored the Resident 15 out of a possible 15, indicating no cognitive impairment. Resident #1 is wheelchair dependent and has left sided paralysis due to the history of 2 CVA's (strokes), the most recent being in October of 2025. A review of the clinical record revealed that Resident #1 had orders for dexamethasone that read Dexamethasone 6 mg give one tablet every one tablet by mouth one time per day for pna [pneumonia]. A review of the progress notes revealed that on 8/23/25 dexamethasone was documented med on way from pharmacy. On 9/4/25, 9/5/25, 9/6/25, 9/12/25, and 9/13/25 the progress notes documented dexamethasone oral tablet 6 mg pending pharmacy delivery. On 11/12/25 at approximately 1:45 pm an interview was conducted with LPN 2 who stated If a medication is unavailable the nurse should first check the Omnicell then, notify the pharmacy, to see if it will be on the next run, notify the physician and notify the family if the med will be late or if they need to substitute the medication for something else until the medication arrives. A review of the Policy entitled Unavailable Medications revealed the following: Page 105 of 223; Paragraph 3 The nursing staff shall: 1. Notify the attending physician (or on-call physician when applicable) of the situation and explain the circumstances, expected availability, and alternative therapy (ies) if available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or directions. On 11/13/25 during the end of day meeting the Administrator and the DON were made aware and no further information was provided. 2. For Resident #2, the facility staff failed to notify the physician or nurse practitioner of low blood pressure readings and low pulse rates on 10/20/25. Resident #2 was admitted to the facility on [DATE] with diagnoses including but not limited to chronic obstructive pulmonary disease with exacerbation, type 2 diabetes mellitus, history of pulmonary embolism, obstructive sleep apnea, iron deficiency anemia secondary to blood loss, chronic kidney disease, stage 3, hypertension, vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, hypokalemia, post-traumatic stress disorder, major depressive disorder, interstitial pulmonary disease, morbid obesity, acute and chronic respiratory failure, with hypoxia, pneumonia and acute on chronic diastolic (congestive) heart failure and fibromyalgia. Resident #2's most recent MDS (Minimum Data Set) Quarterly Assessment with an ARD (Assessment Reference Date) of 10/4/25 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 14 out of a possible 15 indicating her cognition is intact. Per clinical record review on 11/13/25: A nurse's note dated 10/20/2025 08:55 addressed Ipratropium Bromide Inhalation Solution 0.02 % 1 dose inhale orally three times a day for wheezing was administered as Resident #2 had complained of shortness of breath (SOB). Resident states her nurses yesterday refused to give her breathing treatments and some said she was out. Brought box to residents to show, it is not a new box, it is half used. And it has her name on it. Resident also states she was not given her sleep medication or anxiety medication, resulting in her being up all night not able to sleep. Gave resident all her normal morning medicine and included as needed (PRN) medication for anxiety. Assessment: Before breathing treatment 90 %, during breathing treatment, 92 %, after breathing treatment. And after morning medication 94 %, shortness of breath (SOB) is better. And further review of the nurse's note for 10/20/25 at 10:48AM Resident #2 complained that her shortness of breath (SOB) had returned after the breathing treatment ended and the resident was assessed and vital signs obtained – Blood pressure taken by 2 different machines, and manually. Pulse ox and pulse taken by 2 different machines. Pulse taken manually. B/P 78/44, 84/40, 90/64; pulse 46, 52, 55. No evidence that the physician or nurse practitioner were notified of Resident #2's low blood pressure and pulse rates being low or that the resident had complained she was still short of breath after the breathing treatment. On 11/13/25 at 11:15AM, an interview was conducted with the Interim Director of Nursing (Employee #3) on the low blood pressure and low pulse rate for Resident #2 that were documented in the nurses notes on 10/20/25 and she replied, I was not aware of those low vital signs for her. According to the Interim Director of Nursing she said her expectations would be that the nurse would notify the doctor or the nurse practitioner when a resident's vital signs are abnormal and to notify them when medications are not available to be given at the prescribed time and to document the notification. On 11/12/25 a review of Resident #2's Physician Order Summary was completed which revealed that the resident had orders for Dapagliflozin (a prescription medication used to treat adults with type 2 diabetes, heart failure and chronic kidney disease), Incruse Ellipta ( a prescription maintenance medication used to treat chronic obstructive pulmonary disease in adults), Buspar (an anti-anxiety medication used to treat symptoms of anxiety) and Ipratropium (a prescription medication used to relax the muscles around the airways which opens them up and makes breathing easier). Further record review of Resident #2's July, August, September and October Medication Administration Records and progress notes were coded as 9 which means see nurses notes and nurses notes revealed medication not available, on order, awaiting delivery or insurance company won't distribute until next Monday (a week away) According to the clinical record Medication Administration Record and progress notes: 7/30/25 at 9:00AM Dapagliflozin Propanediol Oral Tablet 10 MG, give 1 tablet by mouth one time a day for DM 2 and the Medication Administration Record was coded as 9 which means to see nurses notes and per nurse's notes nurse documented Not available on reorder. 7/30/25 at 9:00AM Incruse Ellipta 62.5 MCG/ACT Aerosol Powder, breath activated, give 1 puff by mouth one time a day related to chronic obstructive pulmonary disease with exacerbation was coded as 9 which means to see nurses notes and per the nurses notes the nurse documented on order. 8/13/25 at 9:00AM Incruse Ellipta 62.5 MCG/ACT Aerosol Powder, breath activated, give 1 puff by mouth one time a day related to chronic obstructive pulmonary disease with exacerbation was coded as a 9 which means to see nurses notes and per nurses notes the nurse documented on order. 9/27/25 and 9/29/25 at 9:00AM Incruse Ellipta 62.5 MCG/ACT Aerosol Powder, breath activated Give 1 puff by mouth one time a day related to chronic obstructive pulmonary disease with exacerbation was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented med on order. 10/1/25 at 9:00AM Incruse Ellipta 62.5 MCG/ACT Aerosol Powder, breath activated Give 1 puff by mouth one time a day related to chronic obstructive pulmonary disease with exacerbation was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented available this nurse called pharmacy, pharmacy stated that insurance won't distribute until next Monday 10/1/25 at 9:00AM Buspar Oral Tablet 10 MG give 1 tablet by mouth three times a day for depression was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented med on order 10/2/25 at 9:00AM Incruse Ellipta 62.5 MCG/ACT Aerosol Powder, breath activated Give 1 puff by mouth one time a day related to chronic obstructive pulmonary disease with exacerbation was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented med on order not available due to insurance till Monday 10/2/25 at 9:00AM Buspar Oral Tablet 10 MG give 1 tablet by mouth three times a day for depression was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented med on order 10/2/25 at 1:00PM Buspar Oral Tablet 10 MG, give 1 tablet by mouth three times a day for depression was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented on order 10/3/25 9:00AM Buspar Oral Tablet 10 MG give 1 tablet by mouth three times a day for depression at was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented med on order 10/3/25 at 9:00AM Incruse Ellipta 62.5 MCG/ACT Aerosol Powder, breath activated, give 1 puff by mouth one time a day related to chronic obstructive pulmonary disease with exacerbation was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented med on order 10/18/2025 at 14:32 Ipratropium Bromide Inhalation Solution 0.02 % 1 dose inhale orally three times a day for wheezing was coded as 9 which means see nurse's note and per the nurses note the nurse documented writer spoke to the pharmacy; this medication will be delivered next drop off, 10/19/25 at 9:00AM 00AM Incruse Ellipta 62.5 MCG/ACT Aerosol Powder, breath activated, give 1 puff by mouth one time a day related to chronic obstructive pulmonary disease with exacerbation was coded as a 9 which means to see nurses notes and per the nurses notes the nurse documented awaiting delivery 10/20/2025 08:55 According to a nurse's note: Ipratropium Bromide Inhalation Solution 0.02 % 1 dose inhale orally three times a day for wheezing was administered as Resident #2 had complained of shortness of breath (SOB). Resident states her nurses yesterday refused to give her breathing treatments and some said she was out. Brought box to residents to show, it is not a new box, it is half used. And it has her name on it. Resident also states she was not given her sleep medication or anxiety medication, resulting in her being up all night not able to sleep. Gave resident all her normal morning medicine and included as needed (PRN) medication for anxiety. Assessment: Before breathing treatment 90 %, during breathing treatment, 92 %, after breathing treatment. And after morning medication 94 %, shortness of breath (SOB) is better. No evidence that the physician or nurse practitioner were notified of medications not available or that the insurance provider was not approving a medication for dispensing until 10/8/25. On 11/13/25 at 10:01AM, an interview was conducted with LPN#1 on what she would do if a medication was not available in the medication cart for the resident and she replied, I would look in the STAT box and then I think I would call the doctor Oh I need to ask [NAME] about that I am not sure exactly. On 11/13/25 at 10:07AM, an interview was conducted with LPN #2 on what she would do if a medication was not available in the medication cart for the resident and she replied, I would check my cart in the overstock medication drawer and if not there I would check in the Omnicell (an on-site machine used in long term facilities to store and manage medication accessibility), if still not there I would call the pharmacy and ask them if the med was enroute and when it would arrive, if none of that can get the med here timely then I would call the nurse practitioner or doctor to see if they have other orders On 11/13/25 at 10:34AM, an interview was conducted with the Interim Director of Nursing (Employee #3) and according to her she was aware that medications had not been administered per physician's orders for some residents due to residents not being entered into the pharmacy's automatic refill program. They were working on this process and had educated nurses on what to do if medications were not available. On 11/13/25 a review of the pharmacy policy regarding unavailable medications read as follows: Page 105 of 223; Paragraph 3, The nursing staff shall: 1. Notify the attending physician (or on-call physician when applicable) of the situation and explain the circumstances, expected availability, and alternative therapy (i.e.s) if available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or directions. 2. Obtain new order and cancel / discontinue the order for the non-available medication. 3. Notify the pharmacy of the replacement order. On 11/13/25 during the end of day meeting, the Administrator, Interim Director of Nursing, New Director of Nursing and Regional Director of Clinical Services were made aware of concerns, and no further information was provided

Based on observation and staff interview, the facility staff failed to ensure adherance to the expiration dates for over-the counter (OTC) medications in bulk containers. The findings included: On 10/23/24 at 3:30 PM, medication checks of one medication cart was conducted on the Colonial Unit. Based on observation and staff interviews, the facility staff failed to ensure adherence to the expiration dates for over-the-counter (OTC) medications in bulk containers. The findings included: On 10/23/24 at 3:30 PM, medication cart checks were conducted on the Colonial Unit. One bottle of Thiamine Vitamin B-1 had an expiration date of 7/2024 and a marked open date of 10/17/24. Registered Nurse (RN) #1 said the medication should have been removed from the medication cart, and could not explain why the expired drug was marked as open on 10/17/24, well after the expiration date. RN#1 stated it was a facility policy to dispose of expired medications at least within 30 days of the expiration date with another nurse. The Unit Manager was present, and the Director of Nursing (DON) was made aware of the abovementioned observation. The DON stated she checked the other facility unit's medication carts for expired drugs. No further information was provided before the survey exited.

Based on staff interview, resident interview, facility documentation review, and clinical record review, the facility staff failed to maintain the professional standards of medication and treatment administration in nursing practice for one Resident (Residents #63) in a survey sample of 27 Residents. For Resident #63, the facility staff failed to administer treatments and pain medications for a dependent Resident with wounds and pain. The findings included: Resident #63's diagnoses included; Osteomyelitis right ankle and foot with amputation, acute and chronic respiratory failure with continuous oxygen use, chronic pain syndrome, anxiety and PTSD, foot drop, and hypothyroidism. Resident #63's most recent MDS (minimum data set) was coded as a quarterly assessment. Resident #63 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or no cognitive impairment. Resident #63 was also coded as requiring extensive to total dependence on one to two staff members to perform activities of daily living, such as hygiene, transferring, and bed mobility. The resident was coded as incontinent of bowel and bladder. On 4-16-24 at 12:00 noon, Resident #63 was observed in bed, with the head of the bed slightly elevated, during the initial tour of the facility, th resident was interviewed during this time. The resident stated that her legs and arms itching all the time, and that she would like to have some medicated cream to help that. She was observed to be scratching her thighs while speaking to the surveyor. The resident continued to state that she was in pain most of the time, and needed more pain medication daily. The resident's physician orders were reviewed and reveal orders for wound treatments, and pain medication administration for chronic pain treatment. Those orders were for the following; Treatments; 1. Ordered 1-11-24 foam border gauze to sacrum wound every day at 9:00 a.m. 2. Ordered 1-11-24 xeroform dressing to right foot every day at 9:00 a.m. 3. Ordered 1-15-24 Collagen sheet to sacrum every day at 9:00 a.m. 4. Ordered 1-20-24 Betadine left posterior knee every day at 9:00 a.m. Medications; 1. Ordered 1-24-24 Fentanyl patch 72 hour 25 mcg (micrograms) per hour change every 3 days for pain. 2. Ordered 1-26-24, discontinued 2-7-24, Hydromorphone 4 mg (milligrams) give 1/2 tablet every 6 hours as needed for pain. 3. Ordered 2-8-24 Hydromorphone 2 mg (milligrams) give 1/2 tablet every 8 hours as needed for pain. 4. Ordered 3-22-24 Hydromorphone 2 mg give 1/2 tablet 2 times per day at 6:00 a.m., and 6:00 p.m. for chronic pain syndrome. 5. Ordered 3-22-24 Methocarbamol 500 mg two times per day at 10:00 a.m., and 10:00 p.m. for chronic pain syndrome. 6. Ordered 4-9-24 Percocet 10-325 mg 1 tablet per day at 1:00 p.m. for chronic pain, one hour prior to physical or occupational therapy. The Medication and Treatment Administration Records (MAR/TAR) were reviewed for February and April 2024, and revealed the absence of nursing signatures indicating that the treatments and medications were omitted on multiple occasions. Those follow; Treatments; (13 opportunities) Foam border - 2-8-24, 2-19-24. Xeroform - 2-6-24, 2-8-24, 2-10-24, 2-13-24, 2-15-24, 2-16-24. Collagen - 2-8-24, 2-19-24, 2-24-24. Betadine - 2-8-24, 2-19-24. Medications; (8 opportunities) 1. Fentanyl patch - 4-3-24, 4-9-24. 2. Hydromorphone 2 mg (milligrams) give 1/2 tablet at 6:00 a.m., and 6:00 p.m. - 4-7-24 both doses, 4-8-24 both doses. 3. Methacarbamol - 4-7-24 at 10:00 p.m. 4. Percocet - 4-11-24 Nursing medication administration notes do not indicate why the treatments and medications were not administered. Nurses on the nursing unit were asked if treatments and medications were administered on the dates in question and the responses were if it's not documented, it's not done. Guidance for the administration of medications is given by The National Institutes of Health (NIH), and is as follows; National Institutes of Health & Medline.gov Insulin must be given as per a doctor's order and on the schedule indicated. If a dose is missed the doctor must be notified. Do not miss doses as ordered to decide proper dosing needed. Do not discontinue medication without seeking a doctor's help. Stopping narcotic pain medications may increase the risk of precipitous withdrawal which can be life threatening. The nursing facility stated [NAME] as their nursing standard. [NAME] stated all medications must be administered per the physician's order. Resident #63's care plan was reviewed and revealed a care plan for chronic pain and wound treatments that instructed to administer medications and treatments as ordered by the physician. Nursing and physician progress notes were reviewed, and revealed no notes documenting that the treatments and medications had been omitted, nor that the doctor was made aware of the omissions. On 4-18-24 at 5:30 p.m., the DON and Administrator were interviewed and stated that they had been unaware that treatments and medications had not been given, nor that the doctor and family were not notified of them being omitted by staff. On 4-19-24 at approximately 10:00 a.m., at the end of day debrief, the Corporate Director of Operations and DON were again made aware of the failure of staff to administer treatments and medications as ordered. No further information was provided.

Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to store medication in a secure location for 1 resident, Resident #61, out of a survey sample of 27 residents. The findings included: For Resident #61, facility staff failed to store prescribed antifungal powder in a secure location to ensure only authorized persons had access to the medication. On 4/16/24 at approximately 2:45 PM, Surveyor B observed a 3 ounce bottle which read, Antifungal Powder with Miconazole Nitrate 2%, expiration date 01/2025, with a prescription label from an outside provider attached to the bottle with Resident #61's name, date of birth, and prescriber/pharmacy information. The bottle was located on top of Resident #61's bedside table next to the head of his bed. On 4/16/24 at 2:50 PM, an interview was conducted with Resident #61 who stated, My wife brought that [referencing the bottle of antifungal powder] in the other day, it has been there [referencing his bedside table] a couple of days, I don't know if it is being used or not, the nurses put some kind of powder on me each day but that's all I know. On 4/16/24 at 3:00 PM, an interview was conducted with RN B, who also identified himself as the Unit Manager. RN B observed the medication at Resident #61's bedside, picked it up to remove it, and stated, I am not sure how this [medication] got there [bedside table] but I am going to look into it. RN B stated, Staff have been in here several times today, someone should have seen it, removed it, and locked it up, that is both my expectation and facility policy. A facility policy was requested and received. Review of the facility policy, Medication Storage, read, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. On 4/17/24 at approximately 10:15 AM, the Facility Administrator was updated on the findings. No further information was provided.

Based on observation, staff interview, and facility policy review, the facility staff failed to properly store, label and date food items, and clean the floors in 2 out of 4 refrigerators/freezers located within the facility's main kitchen. The findings included: 1. Facility staff failed to label and date food items located within the vegetable and meat freezers. On 4/17/24 at approximately 2:00 PM, an interview and kitchen tour was conducted with the Dietary Manager (DM). A partial bag of crinkle-cut french fries, which had been previously opened, was observed in the vegetable freezer, however the bag was not labeled or dated. A partial bag of round meat patties, which had been previously opened, was observed in the meat freezer, however the bag was not labeled or dated. The DM stated, These bags should be labeled and dated, I will dispose of these things right now. The DM also stated, Labels are needed to identify food items so that potential food allergans can be identified before serving it to people and dating food lets us know when it may no longer be safe to serve. 2. Facility staff failed to ensure the floors in the beverage refrigerator and the walk-in refrigerator, located within the facility kitchen, was free from dirt and debris. On 4/16/24 at approximately 1:00 PM, an interview and kitchen tour was conducted with the DM. Observations of the beverage refrigerator and the walk-in refrigerator revealed dirt and debris, including food/beverage spillage, located on the bottom/floor of the refrigerators. The DM stated, It is dirty and not acceptable, I will be sure that it gets cleaned up. On 4/17/24 at approximately 2:15 PM, the Facility Administrator was informed of the findings. A facility policy was requested and received. The facility policy titled, Receiving and Storage of Food, dated 10/1/21, Policy: Foods shall be received and stored in a manner that complies with safe food handling practices, Item 1, read, Food Services, or other designated staff, will maintain clean food storage areas at all times and Item 8 read, All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). The facility policy titled, Refrigerators and Freezers, dated 10/1/21, Policy: The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines, Item 10, read, Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. No additional information was provided.

Based on staff interview and facility documentation review, the facility staff failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, having the potential to affect all 72 residents residing in the facility. The findings included: The facility staff failed to maintain an effective QAPI program that was sustained during transitions in leadership and staffing, regarding call bells, abuse protocol, and resident and staff immunizations. Throughout the survey conducted 10/17/2023 - 10/20/2023, the survey team inspected and investigated the facility's systems and processes regarding correcting previously cited deficiencies and resident care concerns. It was noted the facility had several systemic failures and remained out of compliance in several areas that had previously been cited as deficient during a standard survey conducted 04/11/2023 - 04/13/2023. 1. The facility staff failed to maintain an effective QAPI program regarding their resident call bell system and staff response to call bells. On 10/17/2023, the survey team noted that two residents (Residents #70 and #274), who had no other means to call facility staff for assistance, did not have a call bell in reach. Another resident (Resident #59) was noted to have a call bell that was not functioning. Review of the facility grievances revealed concerns expressed by Resident #54 of his call bell not being answered timely and being told if he put his call bell on staff would not answer it. Review of the facility's policy titled, Answering the call light, it was noted, .QAPI. 1. Resident/resident representatives concerns regarding timeliness of answering call bells will be referred to the Director of Nursing, Grievance officer and/or administrator for investigation and follow up. 2. Grievances regarding call bell response time will be monitored through the facility Quality Assurance Performance Improvement Committee. 2. The facility staff failed to maintain an effective QAPI program regarding their abuse protocol and policy. It was noted that during a standard survey conducted at the facility 04/11/2023 - 04/13/2023, the facility failed to report an allegation of neglect. As part of their plan of correction they stated the following, .3. The leadership of the facility have been provided education on the [corporate ownership name redacted] Abuse and neglect policy by the regional nurse consultant. The Director of Nursing will provide campus wide education on [corporate ownership name redacted] Abuse and Neglect policy. 4. The facility Interdisciplinary Team (IDT) will complete an audit of all FRI for 8 weeks. Results of the audits will be reported monthly by the NHA [nursing home administrator] to the QAPI Committee x 3 months. The facility QAPI Committee is responsible for the on-going monitoring of Compliance. On 10/17/2023, a review of the facility grievance log revealed on 07/20/2023, Resident #54 was threatened by a CNA who stated, If you ring that call bell, I am NOT going to answer it. This grievance was written in the grievance book by the Social Worker (Employee F). A review of the complaint/grievance report read as follows: Resident was wanting air conditioner turned up and felt like he was abruptly handled. Stated that aid told him if he puts his call light on, they will not answer it. Upset and smelled of urine. [dated 7/20/23]. Resident was saturated and upset about getting a shower to be cleaned up. He is ok now. [dated 7/20/23] Resident given shower and is ok at this time. No issues after shower. [signed by unit mgr. dated 7/20/23]. The facility staff had failed to identify the allegation of abuse and neglect as such and responded to it as a service concern. The facility staff failed to conduct an investigation, report the incident, and take measures to protect the resident from any alleged perpetrators while an investigation was conducted. There was also evidence that Resident #14 had been the victim of financial exploitation while a resident of the facility. The facility staff had conducted an investigation and involved outside agencies to include the Ombudsman and Adult Protective Services. Resident #14 was found to have been exploited by a family member, who was also a resident of the facility. Despite having knowledge of Resident #14 being a victim of financial exploitation, they continued to allow Resident #14's perpetrator to have unrestricted access to her, as evidenced by, the facility Administration indicated that Resident #14 was found to have vodka in her room during the survey and it was removed by the facility Administrator. The facility administration stated they felt the family member, who was previously found guilty of financial exploitation, had provided it to Resident #14. Review of the facility's policy titled, Abuse Prevention Program, was conducted. An excerpt from this policy read, .9. Establish and implement a QAPI review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse. 3. The facility staff failed to maintain oversight from the QAPI committee to ensure ongoing infection control systems and procedures were sustained during changes in staffing. It was noted during a standard survey conducted at the facility 04/11/2023 - 04/13/2023, the facility failed to maintain an effective infection control program based on nationally approved standards for immunization(s) for residents and facility staff. As part of their plan of correction they indicated, 2 .The facility completed a facility wide audit of resident immunizations. The DON or designee will complete an audit of all residents to ensure education was provided on the benefits and potential side effects of the influenza immunization and the pneumococcal vaccines. In addition to the education the facility will offer the immunization and vaccines to the residents. 3. The Interdisciplinary team of the facility will be educated by the Director of Nursing or designee on the company policy and CDC guidance for Immunizations and vaccines. 4. The Facility will audit the status of 3 residents weekly for 8 weeks, and all new admissions. New Admissions will also be provided the education on benefits and potential side effects of the immunization and vaccines. Results of the audit will be reported monthly to the facility QAPI Committee x 3 months. The QAPI Committee is responsible for the on-going monitoring of compliance. During this survey, a sample of 5 recently admitted residents was selected for immunization review. All 5 were noted to be deficient regarding being provided education and being offered immunization for flu or pneumonia. On 10/20/2023 at 1:58 p.m., an interview was conducted with the facility Administrator and Corporate Nurse Consultant, Employee C. During this interview, the QAPI program/plan was reviewed. The Administrator and Employee C stated the purpose of the QAPI program is to identify anything from the previous month and implement system changes to bring the facility into compliance. They indicated, The organization has a standardized system to identify issues. When asked if previously survey results are reviewed, Employee C stated, It does include survey results from past surveys and if we wrote a plan of correction, we designate that action to our QA, and they monitor ongoing compliance. If we feel we meet substantial compliance, we take it off [meaning the QAPI committee stops the monitoring of that item]. The facility Administrator was asked to reference their previously submitted and approved plan of correction for the survey ending 04/13/2023 regarding resident immunizations. The Administrator read the plan of correction and was asked if the QAPI committee provided oversight? Employee C said, The reality is the plan we developed incorporated the Infection Preventionist Nurse, when that position turned over, it appears we did not adjust our plan. When the position turned over, we didn't go back and identify that. Employee C was asked, Is it fair to say, you made some changes, and the results would have been talked about for 3 months? He said, I'm thinking we resolved both of them in July. We felt the process was hard wired and the process was effective. We would have fixed it if we had known it. It could have been something that was missed. When that role [Infection Preventionist] transitioned, it fell through the cracks. Review of the facility policy titled, Quality Assurance Performance Improvement (QAPI) Committee, was conducted. Excerpts from this policy read as follows, The facility will maintain systems and processes to ensure that the quality assurance/performance improvement program identifies and addresses issues and/or risks and that implements corrective action plans as necessary. All appropriate and reasonable efforts will be made, and resources provided to maintain compliance with applicable regulations for nursing facilities and needs of residents .2. The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to resident based on performance indicator data, and resident, resident representative, provider and staff input, and other information . 3. iii. Action plans, corrective and preventative, will be developed and monitored for quality improvement based on identified opportunity. After implementing those actions, the facility will monitor and measure the success, and track performance to ensure that improvements are realized and sustained . 13. The QAPI program is sustained during transitions in leadership and staffing. No further information was provided.

Based on observation and staff interview, the facility staff failed to heat sanitize dishware on rinse cycle at an adequate temperature in the industrial dish washing machine, potentially impacting 70 of 72 residents in the facility. The machine was restored to sanitize rinse temperature on the third day of survey in accordance with the professional standards for food service safety. The findings included: The industrial dish machine only reached a temperature of 150 to 160 degrees at the manifold where the temperature gauge is located, and it should be at 180 degrees for high temperature sanitizing of dishware to prevent food borne illness. For 2 days, during observations on 10/17/23 and 10/18/23, the staff had no temperature monitoring strips to ascertain if the machine would actually reach a temperature of 160 degrees at the rack or 180 degrees at the manifold. The Corporate Dining Director was present and interviewed by the surveyor on 10/19/23. The Corporate Dining Director stated that a new dish machine was being ordered, and the facility had placed a call to a repair service to get the dish machine fixed that day. He further stated they would be using paper and plastic products for meals until it was fixed, and also using the three compartment sink to chemically sanitize cooking pans and utensils. On the third day, the temperature sensor strips were obtained and the machine had been fixed. No further information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide education and offer COVID-19 vaccines for 4 residents (Residents #125, #274, #275, and #276) in a survey sample of 5 residents reviewed for immunizations and 5 staff (Staff #1, #2, #3, #4 and #5). The findings included: 1. For Residents #125, #274, #275 and #276, the facility staff failed to provide COVID-19 immunization, to include education of risks/benefits about COVID-19 immunization. On 10/18/2023, a clinical record review was conducted of each of the residents' clinical charts. There was no information noted that indicated the residents' current COVID-19 immunization status, no evidence they had been educated on the risk/benefits of immunization, and no evidence they had been offered the COVID-19 immunization. On 10/19/2023 at 4:28 p.m., an interview was conducted with the Director of Nursing (DON) who accessed the clinical records for Residents #125, #274, #275, and #276 and verified the findings. The DON confirmed there was no information regarding the residents' COVID-19 immunization status, nor any evidence of any education or offer to receive the COVID-19 immunization following admission to the facility. During a survey entrance conference, the facility's policy regarding COVID-19 immunizations was requested and received. A review of the facility policy entitled, COVID-19 Vaccinations for Residents, was conducted. It stated under the subtitle, Specific Procedures/Guidance, item 1, Prior to admission, the facility will validate COVID-19 vaccination status. 2. Resident/resident representatives will be educated on: a. risks/benefits of COVID-19 vaccination .b. current CDC guidelines for vaccination of residents for COVID-19 and; c. Symptoms, risks and benefits associated with the COVID-19 virus. 3. Residents will be encouraged to accept COVID-19 vaccinations in accordance with CDC guidance. The Centers for Disease Control and Prevention (CDC) document titled, CDC COVID-19 Vaccination Program Provider Requirements and Support, dated 10/06/2023, gives guidance to providers. The document read, On Monday, Sept. 11, 2023, the FDA took action authorizing and approving the updated 2023-2024 monovalent XBB.1.5 variant mRNA COVID-19 vaccines by Moderna and Pfizer-BioNTech. On September 12, 2023, CDC recommended use of these updated 2023-2024 COVID-19 vaccines in all individuals ages 6 months and older. And, on October 3, 2023, FDA authorized the updated 2023-2024 monovalent XBB.1.5 variant Novavax COVID-19 Vaccine, Adjuvanted, which is recommended by CDC for use in individuals [AGE] years and older. Accessed online at: https://www.cdc.gov/vaccines/covid-19/vaccination-provider-support.html#print The U.S. Food and Drug Administration (FDA) document titled, Novavax COVID-19 Vaccine, Adjuvanted Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) Authorized for Individuals [AGE] years of Age and Older, was accessed. It read, On October 3, 2023, the Food and Drug Administration amended the emergency use authorization (EUA) of Novavax COVID-19 Vaccine, Adjuvanted to include the 2023-2024 formula. The Novavax COVID-19 Vaccine, Adjuvanted, a monovalent vaccine, has been updated to include the spike protein from the SARS-CoV-2 Omicron variant lineage XBB.1.5 (2023-2024 formula). The Novavax COVID-19 Vaccine, Adjuvanted (Original monovalent) is no longer authorized for use in the United States. Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) is authorized for use in individuals [AGE] years of age and older as follows: Individuals previously vaccinated with any COVID-19 vaccine: one dose of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) is administered at least 2 months after receipt of the last previous dose of an original monovalent (Original) or bivalent (Original and Omicron BA.4/BA.5) COVID-19 vaccine. Individuals not previously vaccinated with any COVID-19 vaccine: two doses of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) are administered three weeks apart. Immunocompromised individuals: an additional dose of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) may be administered at least 2 months following the last dose of a COVID-19 vaccine (2023-2024 Formula). Additional doses of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) may be administered at the discretion of the healthcare provider, taking into consideration the individual's clinical circumstances. The timing of the additional doses may be based on the individual's clinical circumstances. Accessed online at: https://www.fda.gov/vaccines-blood-biologics/coronavirus-covid-19-cber-regulated-biologics/novavax-covid-19-vaccine-adjuvanted On 10/19/2023 during the end of day meeting, the facility Administrator, Director of Nursing and corporate staff were made aware of the findings. No further information was provided. 2. For facility Staff #1, #2, #3, #4, and #5, the facility staff failed to maintain documentation that staff were provided education on the risks/benefits of the COVID-19 vaccine and were offered the vaccine, or information on obtaining the vaccine. On 10/19/2023 at 4:28 p.m., an interview was conducted with the Director of Nursing (DON). The DON was given the names of the staff sample being reviewed for immunizations and asked to provide any evidence she had regarding their immunization status and education of immunization benefits and risks. On the morning of 10/20/2023, the DON provided Surveyor C with the staff immunization information she had on file. It included the following: a. For Staff #1, a copy of the staff's COVID-19 vaccination record card was provided that was emailed to the human resources director that morning. It indicated that Staff #1 had received 2 doses of a COVID-19 vaccine in 2021. There was no evidence of any education, offer, or information to obtaining COVID-19 booster vaccines. b. For Staff #2, a copy of the staff member's COVID-19 vaccine record card was submitted that indicated she had received 2 doses of the COVID-19 vaccine in 2021. There was no evidence submitted regarding education, offer, or information on how to obtain COVID-19 booster vaccines. c. For Staff #3, a copy of the staff member's COVID-19 vaccine record card was submitted that indicated she had received 2 doses of the COVID-19 vaccine in 2021. There was no evidence submitted regarding education, offer, or information on how to obtain COVID-19 booster vaccines. d. For Staff #4, a copy of the staff member's COVID-19 vaccine record card was submitted that indicated she had received 3 doses of the COVID-19 vaccine, with the last dose being administered 03/18/2022. There was no evidence submitted regarding education, offer, or information on how to obtain COVID-19 booster vaccines. e. For staff #5, no information was submitted. In the early afternoon of 10/20/2023, the DON was asked to clarify if she had any additional information to show the employees had been educated on, offered, or given information on how to obtain the 2023-2024 Formula COVID-19 vaccine. The DON stated she had nothing further to submit. No facility policy regarding COVID-19 immunizations for facility staff was provided to the survey team. The Centers for Disease Control and Prevention (CDC) document titled, CDC COVID-19 Vaccination Program Provider Requirements and Support, dated 10/6/23, gives guidance to providers. The document read, On Monday, Sept. 11, 2023, the FDA took action authorizing and approving the updated 2023-2024 monovalent XBB.1.5 variant mRNA COVID-19 vaccines by Moderna and Pfizer-BioNTech. On September 12, 2023, CDC recommended use of these updated 2023-2024 COVID-19 vaccines in all individuals ages 6 months and older. And, on October 3, 2023, FDA authorized the updated 2023-2024 monovalent XBB.1.5 variant Novavax COVID-19 Vaccine, Adjuvanted, which is recommended by CDC for use in individuals [AGE] years and older. Accessed online at: https://www.cdc.gov/vaccines/covid-19/vaccination-provider-support.html#print The U.S. Food and Drug Administration (FDA) document titled, Novavax COVID-19 Vaccine, Adjuvanted Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) Authorized for Individuals [AGE] years of Age and Older was accessed. It read, On October 3, 2023, the Food and Drug Administration amended the emergency use authorization (EUA) of Novavax COVID-19 Vaccine, Adjuvanted to include the 2023-2024 formula. The Novavax COVID-19 Vaccine, Adjuvanted, a monovalent vaccine, has been updated to include the spike protein from the SARS-CoV-2 Omicron variant lineage XBB.1.5 (2023-2024 formula). The Novavax COVID-19 Vaccine, Adjuvanted (Original monovalent) is no longer authorized for use in the United States. Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) is authorized for use in individuals [AGE] years of age and older as follows: Individuals previously vaccinated with any COVID-19 vaccine: one dose of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) is administered at least 2 months after receipt of the last previous dose of an original monovalent (Original) or bivalent (Original and Omicron BA.4/BA.5) COVID-19 vaccine. Individuals not previously vaccinated with any COVID-19 vaccine: two doses of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) are administered three weeks apart. Immunocompromised individuals: an additional dose of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) may be administered at least 2 months following the last dose of a COVID-19 vaccine (2023-2024 Formula). Additional doses of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) may be administered at the discretion of the healthcare provider, taking into consideration the individual's clinical circumstances. The timing of the additional doses may be based on the individual's clinical circumstances. Accessed online at: https://www.fda.gov/vaccines-blood-biologics/coronavirus-covid-19-cber-regulated-biologics/novavax-covid-19-vaccine-adjuvanted On 10/20/2023 during the end of day meeting, the facility Administrator, Director of Nursing and corporate staff were made aware of the findings. No further information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide influenza and pneumococcal vaccines for 5 residents (Residents #124, #125, #274, #275, and #276), in a survey sample of 5 residents reviewed for immunizations. The findings included: 1. The facility staff failed to provide education of the risks/benefits about influenza immunization, and offer flu vaccines for Residents #125, #274, #275, and #276. On 10/18/2023, clinical record reviews were performed and revealed the following: Residents #125, #274, #275, and #276, had no immunization information under the immunization tab of their clinical record. The miscellaneous tab and progress notes were reviewed, and revealed no evidence of the residents' immunization status regarding the flu and had no evidence that education had been provided or the vaccine offered. On 10/19/2023 at 4:28 p.m., Surveyor C met with the Director of Nursing (DON), who was also the facility's Infection Preventionist. During the above interview, the DON was asked to access each of the residents' clinical records and identify their vaccine status regarding the flu. The findings were as follows: a. Resident #125 was admitted to the facility on [DATE]. The DON confirmed he had not been educated or offered the flu vaccine and his current immunization status was unknown. b. For Resident #274, who was admitted to the facility on [DATE], there was no information regarding the flu vaccine noted. c. For Resident #275, the DON confirmed the resident was admitted to the facility on [DATE]. The DON also confirmed the resident's immunization status for flu was unknown, and they had not been educated nor offered the vaccine. d. For Resident #276, who was admitted to the facility on [DATE], the facility had no information regarding the flu vaccine status, being educated, or offered the vaccine. 2. The facility staff failed to provide education of the risks/benefits about pneuococcal immunization, and offer pneumococcal vaccines for Residents #124, #125, #274, #275, and #276. On 10/18/2023, clinical record reviews were performed and revealed the following: Residents #124, #125, #274, #275, and #276, had no immunization information under the immunization tab of their clinical record. The miscellaneous tab and progress notes were reviewed and revealed no evidence of the residents' immunization status regarding pneumonia vaccines, and had no evidence that education had been provided or the vaccine offered. On 10/19/2023 at 4:28 p.m., Surveyor C met with the Director of Nursing (DON), who was also the facility's Infection Preventionist. The DON accessed each of the residents' clinical records (Residents #124, #125, #274, #275, and #276), and confirmed they did not know the residents' pneumonia immunization status and had no evidence of the residents being educated and/or offered the vaccine. On 10/19/2023 at 4:28 p.m., the DON was asked, Why is it important to know someone's immunization status? The DON stated, You want to know if they are protected from whatever, you don't want to administer a vaccine if they are allergic to it or have already had it, and because we live in a community lifestyle, we want to keep people as protected as possible. The DON stated on admission the facility should identify the resident's immunization status, educate them on vaccines, and offer any vaccines the resident is eligible for. The DON was asked to explain the process about immunizations. The DON stated, I am the only one with access to the VIIS [Virginia Immunization Information System] system, so I do it in the first couple of days. I look to see their immunization status for COVID, pneumonia and flu. We are doing the flu vaccines right now. The DON also stated she has the flu vaccine in-house and on hand and can administer it when a resident requests and/or consents to it. The facility policy titled, Influenza Vaccination, was received and reviewed. Excerpts from this policy read as follows: All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The facility will provide pertinent information about the significant risks and benefits of vaccine to staff and residents (or residents' legal representatives); for example, risk factors that have been identified for specific age groups or individuals with risk factors such as allergies or pregnancy .1. Residents and employees of the long-term care facility will be offered the influenza vaccination upon initial admission to the nursing home in accordance with the guidelines set forth by the Center for Disease Control and/or ACIP [Advisory Committee on Immunization Practices]. The Advisory Committee on Immunization Practices gives guidance in their document titled, Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP)-United States, 2023-24. The recommendations read, .Summary of Recommendations .Groups recommended for vaccination: Routine annual influenza vaccination is recommended for all persons aged = 6 months who do not have contraindications . Adults Aged = [AGE] years: ACIP recommends that adults aged = [AGE] years preferentially receive any one of the following higher dose or adjuvanted influenza vaccines: quadrivalent high-dose inactivated influenza vaccine (HD-IIV4), quadrivalent recombinant influenza vaccine (RIV4), or quadrivalent adjuvanted inactivated influenza vaccine (aIIV4). If none of these three vaccines is available at an opportunity for vaccine administration, then any other age-appropriate influenza vaccine should be used. Accessed online at: https://www.cdc.gov/flu/pdf/professionals/acip/acip-2023-24-Summary-Flu-Vaccine-Recommendations.pdf The facility policy titled, Pneumococcal Vaccine, was reviewed. The policy read, 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Residents of the long-term care facility will be offered the pneumococcal vaccination upon initial admission to the nursing home in accordance with the guidelines set forth by the Center for Disease Control and/or ACIP. 3. Before offering pneumococcal immunization, each resident or the resident's legal representative will receive education regarding the benefits and potential side effects of the immunization. On 10/19/2023 during an end of day meeting, the facility Administrator, Director of Nursing, and Corporate staff were made aware of the above findings. No further information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to transmit resident assessments/Minimum Data Set (MDS) in a timely manner to Centers for Medicare & Medicaid Services (CMS) for 8 residents (Residents #1, #2, #33, #36, #39, #61, #63, and #68) in a survey sample of 39 residents. The findings included: 1. For Residents #1, #2, #33, #36, #39, #61, #63, and #68, the facility staff failed to transmit the MDS to the CMS system within the required timeframe of 14 days. On 10/19/2023 at 8:50 a.m. during the completion of the survey process, clinical record reviews were conducted of Residents #1, #2, #33, #36, #39, #61, #63, and #68's MDS assessments with particular attention to the date(s) they were transmitted to CMS. The following was noted: a. Resident #1 had a quarterly MDS with an Assessment Reference Date (ARD) of 08/27/2023, completed on 09/11/2023. This assessment was not transmitted to CMS until 10/16/2023. Review of the transmission batch report revealed this assessment had been rejected by the CMS system; therefore, it was still not accepted as being transmitted. b. Resident #2 had a quarterly MDS with an ARD of 09/13/2023, completed on 09/22/2023. This assessment was not transmitted to CMS until 10/16/2023, which exceeded the required 14 days from completion. c. Resident #33 had a quarterly MDS with an ARD date of 08/23/2023 completed on 09/06/2023. This assessment was not transmitted to CMS until 10/13/2023. The following assessments were transmitted to CMS late: quarterly assessment with an ARD of 09/08/2023 was completed on 09/30/2023. This assessment was not transmitted to CMS until 10/16/2023. Another quarterly MDS with an ARD date of 09/22/2023 was completed on 9/30/23. This assessment was not transmitted to CMS until 10/16/2023. d. Resident #36 had a quarterly MDS with an ARD of 09/01/2023. This assessment was completed on 09/17/2023, and was not transmitted to CMS until 10/16/2023. e. Resident #39 had a Quarterly MDS with an ARD of 08/22/2023 and was completed on 09/06/2023. This assessment was not transmitted to CMS until 10/13/2023. The resident also had an annual MDS with an ARD of 09/08/2023. The assessment and care plan were completed on 09/17/2023. This assessment was not transmitted to CMS until 10/16/2023. f. Resident #61 had a Discharge, Return Not Anticipated assessment with an ARD of 09/08/2023. The assessment was completed on 09/08/2023 and was not transmitted to CMS until 10/13/2023. g. Resident #63 had a quarterly MDS with an ARD of 08/24/2023 completed on 09/06/2023. This assessment was not transmitted to CMS until 10/13/2023. h. Resident #68 had a quarterly MDS with an ARD of 09/01/2023. The assessment was completed on 09/30/2023 and was not transmitted to CMS until 10/16/2023. On 10/19/2023 at 10:34 a.m., an interview was conducted with the facility's MDS nurse/LPN H. LPN H was asked to explain the frequency and timing of MDS. LPN H said, They all have dates and times they need to be done. When asked to explain the time frames and how she knows when they have to be completed and transmitted, LPN H stated, The computer tells me. LPN H then showed Surveyor C in the electronic health record where dates are noted when assessments must be completed and transmitted. It was noted that some of the dates were in black text, some in red text, and some in green text. When asked what the different colors meant, LPN H was unsure. LPN H was asked about the transmission of MDS to CMS. LPN H said, Transmitting to the state is actually done by my regional, I am an LPN so my RN has to sign for me, and normally the RN that signs for me is my regional. She signs and then will transmit. She will give me the ok to transmit. LPN H also stated, We started the new things in Oct. [referring to the MDS changes that went into effect October 1, 2023] she is looking and paying attention to see what I am doing is correct. There are some things that haven't been transmitted because of that. I usually transmit on Fridays unless she tells me not to and she wants to check something. Prior to October, I transmit every Friday. During the above interview the MDS Coordinator, LPN H, was asked if she has a policy or document she follows that gives her direction and timeframes. LPN H said, The RAI manual, it is like the bible of MDS. LPN H was then asked to pull up several of the above residents, which included Resident #1, #33, and #36. LPN H was shown that the text in red meant that the MDS was completed or transmitted late. LPN H confirmed the findings. Also during the above conversation/interview with LPN H, the Corporate Nurse Consultant, Employee C, joined Surveyor C and LPN H. Employee C confirmed that MDS are to be transmitted within 14 days of completion. Employee C later in the morning approached Surveyor C and said he had spoken to the corporate MDS person, and found out they had some difficulty with the third-party vendor/system they use to transmit MDS around the beginning of October. Employee C was asked to provide any evidence and/or documentation of where they had communicated with the third-party vendor or CMS about the issues they were having. Nothing further was submitted. The facility policy titled, Electronic Transmission of the MDS, was reviewed. This policy read, Specific Procedures/Guidance: 1. Staff members responsible for completion of the MDS receive training on the assessment, data entry, and transmission processes, in accordance with the MDS RAI Instruction Manual, before being permitted to use the MDS information system. An electronic copy of the MDS RAI Instruction Manual is maintained by the MDS coordinator . The facility policy titled, MDS Completion and Submission Timeframes, was reviewed. This policy read, The facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Specific Procedures/Guidance: 1. The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual . The CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.18.11, October 2023 was reviewed. On page 5-3 of the RAI Manual, it read, .Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements. Care plans are not required to be transmitted. Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days) . The prior version of the RAI manual was reviewed and it noted the same requirements/dates for transmission of MDS. Therefore, there were no changes to the timing of MDS transmission to CMS with the revisions made in October 2023. On 10/19/2023 during the end of day meeting, the facility Administrator, Director of Nursing, and corporate staff were made aware of the concerns regarding the facility not transmitting MDS timely to CMS. No further information was provided.

Based on resident interview, facility staff interview, clinical record review, and facility documentation, the facility staff failed to implement the abuse, neglect, and exploitation policy for 2 residents (Residents #54 and #14) in a survey sample of 39 residents. The findings included: 1. For Resident #54, the facility staff failed to implement the abuse/neglect policy when Resident #54 reported to the Social Worker an allegation of abuse/neglect. Resident #54 is a [AGE] year-old resident with diagnoses of, but not limited to, bradycardia, chronic kidney disease Stage 3, chronic obstructive pulmonary disease, history of falls, hypertension, muscle weakness, unsteady on feet, muscle wasting and atrophy. On 10/17/2023, a review of the facility grievance log revealed that on 07/20/2023 Resident #54 was threatened by CNA who stated, If you ring that call bell, I am NOT going to answer it. This grievance was written in the grievance book by the Social Worker (Employee F). A review of the complaint/grievance report read as follows: Resident was wanting air conditioner turned up and felt like he was abruptly handled. Stated that aid told him if he puts his call light on, they will not answer it. Upset and smelled of urine. [dated 7/20/23]. Resident was saturated and upset about getting a shower to be cleaned up. He is ok now. [dated 7/20/23] Resident given shower and is ok at this time. No issues after shower. [signed by unit manager & Social Worker dated 7/20/23] A review of the clinical record revealed there were no progress notes for 07/20/2023 addressing this situation. On 10/19/2023 at approximately 2:00 p.m., an interview was conducted with Resident #54 who stated that on the day of the incident he was wanting the air conditioner turned up and the CNA told him if he rings the call bell, they will not answer it. When asked how that makes him feel he stated, I hear stuff like that all the time around here. Resident #54 stated he was also in need of incontinence care, but the staff had failed to answer the call bell. He stated he ended up having to get a shower to get cleaned up because they waited so long to change him. He stated he complained to the Social Worker about it. Resident #54 was not able to recall who the staff member was that threatened to not answer the call bell. On 10/19/2023, an interview with the Social Worker was conducted, and he was not able to identify this issue as abuse or neglect; therefore, did not escalate it up to an abuse allegation. On 10/19/2023 at 6:28 p.m., an interview was conducted with the Administrator and Employee C (the Corporate Clinical Nurse Consultant). They were asked if the Social Worker/Grievance Officer should be able to identify and report abuse and neglect. The Administrator stated all the staff should be able to identify and report abuse and neglect. The Administrator and Employee C were shown the grievance report from 07/20/2023 involving Resident #54, and agreed it was a threat to neglect the resident. When asked if this incident was investigated, the Administrator stated it had not been. When asked if this was reported to the appropriate offices, the Administrator stated it had not been. On 10/19/2023, a review of the facility's abuse policy revealed the following excerpts: Page 1 Paragraph 1: Definitions: ABUSE is also the deprivation by an individual, including a caretaker, of good or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing. Page 3 Paragraph 4: Identification: B. Staff are encouraged to identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. Immediately following ensuring the resident's safety, staff are to report any allegation or observation of abuse to their supervisor, director of nursing, administrator or facility leadership member. On 10/19/2023 during the end of day meeting, the Administrator was made aware of the concerns. No further information was provided. 41449 2. For Resident #14, the facility staff failed to implement their abuse policy as evidenced by failure to protect the resident from a known perpetrator by allowing unrestricted/unsupervised visits between the resident and her known perpetrator. On 10/17/2023 in the afternoon, Resident #14 was visited in her room. During the interview/conversation, cognitive impairment and difficulty with memory recall was noted. The resident did acknowledge she had been to visit her daughter earlier in the day. Resident #14's daughter is also a resident of this facility. Resident #14 reported they can go and visit each other anytime they want. During the interview, observations were made of the resident's room, and revealed that Resident #14 had 2 blister packs of medication sitting on her bed and in a 3-drawer clear storage container there was a bottle of Tylenol and 2 cans of jock itch spray. Review of the facility's investigation documents revealed that on 2/3/23, there was an incident between Resident #14 and her daughter, Resident #55. The incident was witnessed by 2 staff members and involved Resident #55 being verbally abusive to Resident #14. The facility's investigation findings concluded, The investigation showed that [Resident #55's name redacted] did verbally abuse her mother and upset her .APS [adult protective services], the physician and local police were notified. In conclusion, the facility stated, The facility substantiated this verbal abuse due to the relationship of these two individuals it is tough to hold tight on interventions because of resident rights and the mother daughter relationship. In Resident #14's chart, there was a nursing progress note dated 06/23/2023, that read, I was called to the residents' room. Upon entering the residents' room, the resident expressed concerns about her daughter, she said she had not seen her for a couple days and was worried about her and asked if I could go check on her daughter for her. I received permission from the ADON [Assistant Director of Nursing] that the mother and daughter could have a supervised dinner in the dining area. The mother and daughter were supervised throughout the whole dinner. The daughter asked if she could help the mother find her Medicare card, permission was given, only the Medicare card was taken out of the wallet and given to the mother. The mother placed all her cards in her wallet and placed them in her purse. There was no personal contact noted during the dinner. The daughter left the dining room first then the mother was taken back to her room after the dinner. This progress note established that at some point the facility staff identified the necessity to supervise and restrict visits between Residents #14 and #55. On the afternoon of 10/19/2023, the Corporate Nursing Consultant advised Surveyor C that the Administrator had found 2 bottles of vodka in Resident #14's room and had to remove them. They felt Resident #14's daughter was providing/putting the items in Resident #14's room, to sabotage the survey. Throughout the survey, an abundance of over-the-counter medications were noted in Resident #14's room, which the facility staff also reported she was getting from her daughter, Resident #55. On 10/19/2023 during the end of day meeting, an interview was conducted with the facility Administrator, Director of Nursing, and Corporate Nursing Consultant. During the interview, the survey team shared concerns with regards to Resident #55 providing Resident #14 with items that could be potentially harmful, to include the over-the-counter medication and vodka. The administration was asked what steps they were taking to protect Resident #14's safety. On the morning of 10/20/2023, the facility Administrator and Corporate Nursing Consultant reported to the survey team that Resident #14's room assignment had been moved directly across from the nursing station for closer monitoring and a staff member had been assigned to Resident as 1-on-1 to supervise any visits with Resident #55 and ensure that no items were given to Resident #14. On 10/20/2023, interviews were conducted with CNA B, LPN D, and LPN C, the unit manager. All three stated that prior to 10/20/2023, Residents #14 and #55 have been permitted to have unrestricted and unsupervised visits with each other ad lib [as they choose]. The facility policy titled, Abuse, was reviewed. Excerpts from the policy read, .6. Protection: a. In the event of an allegation or observation of abuse, the facility will immediately assess the resident, notify the physician and resident representative, and protect the resident and other residents from further harm or incident. b. The resident's plan of care will be revised to reflect interventions to minimize recurrence and to treat any injury or harm identified through assessment of the resident . No further information was provided.

Based on interview, clinical record review, and facility documentation, the facility staff failed to ensure freedom from abuse and neglect for 1 resident (Resident #54) in a sample of 39 residents. The findings included: For Resident #54, the facility staff failed to ensure the resident was not verbally abused by a CNA who threatened to, and did in fact, neglect the resident's needs. Resident #54 is a [AGE] year-old resident with diagnoses of, but not limited to, bradycardia, chronic kidney disease Stage 3, chronic obstructive pulmonary disease, history of falls, hypertension, muscle weakness, unsteady on feet, muscle wasting and atrophy. On 10/17/2023, a review of the facility grievance log revealed that on 07/20/2023, Resident #54 was threatened by CNA who stated, If you ring that call bell, I am NOT going to answer it. This grievance was written in the grievance book by the Social Worker (Employee F). A review of the complaint/grievance report read as follows: Resident was wanting air conditioner turned up and felt like he was abruptly handled. Stated that aid told him if he puts his call light on, they will not answer it. Upset and smelled of urine. [dated 7/20/23]. Resident was saturated and upset about getting a shower to be cleaned up. He is ok now. [dated 7/20/23] Resident given shower and is ok at this time. No issues after shower. [signed by unit mgr. dated 7/20/23]. A review of the clinical record revealed there were no progress notes for 07/20/2023 addressing this situation. On 10/19/2023 at approximately 2:00 p.m., an interview was conducted with Resident #54 who stated that on the day of the incident he was wanting the air conditioner turned up and the CNA told him if he rings the call bell, they will not answer it. When asked how that makes him feel, he stated, I hear stuff like that all the time around here. Resident #54 stated he was also in need of incontinence care, but the staff failed to answer the call bell. He stated he ended up having to get a shower to get cleaned up because they waited so long to change him. The resident stated he complained to the Social Worker about it. Resident #54 was not able to recall who the staff member was that threatened to not answer the call bell. Resident #54 went on to state he had the Social Worker purchase prune juice to keep in his room because the staff would not give it to him when he asked for it. He stated they would sit at the nurses station and ignore the call bell to the point he would have to wheel himself to the nurses' station, which has a high wall, and Resident #54 could not see over it while in his wheelchair, so he would have to go around the side to see if anyone was at the nurses' station. He stated many times they would be quiet and not answer until he went around the side and could see they were there. On 10/19/2023, an interview with the Social Worker was conducted, and he stated he did not identify this incident as abuse or neglect; therefore, did not escalate it up to an abuse allegation. On 10/19/2023 at 6:28 p.m., an interview was conducted with the Administrator and Employee C (Corporate Clinical Nurse Consultant). They were asked if the Social Worker/Grievance Officer should be able to identify and report abuse and neglect. The Administrator stated that all the staff should be able to identify and report abuse and neglect. The Administrator and Employee C were shown the grievance report from 07/20/2023 involving Resident #54 and agreed it was a threat to neglect the resident. When asked if this incident was investigated, the Administrator stated it had not been. When asked if this was reported to the appropriate offices, the Administrator stated it had not been. On 10/19/2023, a review of the facility's abuse policy read as follows: Page 1 Paragraph 1 Definitions: ABUSE is also the deprivation by an individual, including a caretaker, of good or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing. On 10/19/2023 during the end of day meeting, the Administrator was made aware of the concerns. No further information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide a proper Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to 2 residents (Residents #43 and #70) in a survey sample of 3 residents reviewed for such notices. The findings included: For Residents #43 and #70, the facility staff failed to utilize a CMS approved SNF ABN form, which provided the option for the resident to select/choose to continue services and pay for the care without Medicare being billed. On 10/17/2023, the facility Administrator was asked to provide a listing of residents who were discharged from Medicare Part A services, prior to exhausting their benefit days. From this listing, a sample of 3 residents was selected, which included Residents #43 and #70. The notices issued to these residents was requested and received. Review of the SNF ABN forms revealed the following: 1. For Resident #43, the facility staff provided a SNF ABN notice on 09/11/2023, which indicated therapy services were ending. The form provided Resident #43 with 2 options to select from. The Centers for Medicare & Medicaid Services (CMS) approved form provides 3 options. 2. For Resident #70, the facility staff provided a SNF ABN notice on 09/11/2023, which indicated therapy services were ending. The form provided Resident #70 with 2 options to select from. The Centers for Medicare & Medicaid Services (CMS) approved form provides 3 options. The form provided to Residents #43 and #70, as indicated above, only offered them 2 options to choose from. The options given read as follows: Option 1. YES. I want to receive these items or services. I understand that Medicare will not decide whether to pay unless I receive these items or services. I understand you will notify me when my claim is submitted and that you will not bill me for these items or services until Medicare makes its decision. If Medicare denies payment, I agree to be personally and fully responsible for payment. That is, I will pay personally, either out of pocket or through any other insurance that I have. I understand that I can appeal Medicare's decision. Option 2. NO. I will not receive these items or services. I understand that you will not be able to submit a claim to Medicare and that I will not be able to appeal your option that Medicare won't pay. I understand that, in the case of any physician-ordered items or services, should notify my doctor who ordered them that I did not receive them. On 10/18/2023 at 4:13 p.m., an interview was conducted with Employee F, the Social Services Director, and Employee J, the social worker. Both employees stated they are responsible for issuing Advance Beneficiary Notices (ABN). When asked to explain the purpose of the form, Employee F said, With a part A you also do a SNF ABN to go with the NOMNC (Notice of Medicare Non-Coverage). Employee F went on to say, The NOMNC is 2 pages and the ABN, which is 1 page, says after this date you will incur a fee between $150-$300 for therapy if you decided to stay and do therapy, after this day you either go home or decide I'm going to be here long-term care. Both Employees F and J indicated the notices are issued 48 hours before the last covered day. Both employees further confirmed the SNF ABN form has 3 options for the resident to choose from. During the above meeting, Employees F and J were shown the notices provided to Residents #43 and #70, which only indicated 2 options. Both employees stated they were not aware of and had not noticed the change and confirmed it was not the CMS approved form issued. The facility policy titled, Medicare Liability Notice was reviewed. It read, .4) The Social Worker, Business Office representative, or designee will; fully complete the required liability notice and provide it to the beneficiary/beneficiary representative prior to stopping the Medicare coverage. 5. The facility will utilize and follow the Medicare approved notices and instructions . The approved CMS form CMS-10055 titled, Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) was reviewed. The facility's Social Services Director, Employee F, provided Surveyor C with a blank form. The CMS approved form had 3 options for the beneficiary to choose from. The options read as follows: OPTIONS (Check only one box. We can't choose a box for you).: Option 1: I want the care listed above. I want Medicare to be billed for an official decision on payment, which will be sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I'm responsible for paying, but I can appeal to Medicare by following the directions on the MSN. Option 2: I want the care listed above, but don't bill Medicare. I understand that I may be billed now because I am responsible for payment of the care. I cannot appeal because Medicare won't be billed. Option 3: I don't want the care listed above. I understand that I'm not responsible for paying, and I can't appeal to see if Medicare would pay. The Centers for Medicare & Medicaid Services (CMS) provides facilities with the following guidance document titled, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055. An excerpt from this document read, .Completing the SNF ABN: The SNFABN is available for download by selecting the FFS SNFABN link from the menu on the webpage http://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html. The SNFABN is a CMS-approved model notice and should be replicated as closely as possible when used as a mandatory notice. Failure to use this notice or significant alterations of the SNFABN could result in the notice being invalidated and/or the SNF being held liable for the care in question . Accessed online at: https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-snf-abn On 10/18/2023, the facility Administrator was made aware of the above findings. No further information was provided.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to notify the physician and family of a resident's change in medications and change in condition for one resident (Resident #14) in a survey sample of 39 residents. The findings included: For Resident #14, who had a medication change which was not communicated to the family, there was a noted increase in sleeping and she was difficult to arouse following the start of an antipsychotic medication. The facility staff failed to notify the doctor and family member of the change until prompted by survey team. On 10/17/2023, Resident #14 was visited in her room by Surveyor C. Resident #14 was awake, able to engage in conversation with no difficulty, and appeared to have some memory loss. There was no obvious significant hearing deficit noted. On 10/18/2023, Surveyor C visited Resident #14's room on 3 occasions, once mid-morning, once early afternoon, and lastly around 3:30 p.m. Each time, Surveyor C knocked on the resident's room door, entered the room, and called the resident's name. The resident was observed laying on her bed asleep. Surveyor C got closer to the resident and called her name again, Resident #14 did not arouse. On 10/18/2023 at approximately 3:30 p.m., Surveyor C interviewed CNA D. CNA D was in the hallway outside of Resident #14's room, and was filling a water pitcher with ice. CNA D was asked about Resident #14 and asked if she normally sleeps a lot. Surveyor C explained that she had attempted to visit the resident on several occasions, but Resident #14 would not arouse. CNA D said he was in the hall filling the water pitcher to not awaken the resident. He said that normally she is awake. On 10/19/2023 at approximately 8:30 a.m., Surveyor C went to visit Resident #14 in her room again. Surveyor C knocked on the door, entered the room, and called the resident's name. Resident #14 did not respond. Surveyor C approached the bedside and observed Resident #14 asleep on top of the covers, with her dentures protruding from her mouth. Surveyor C again called Resident #14's name, with no response. On 10/19/2023 at approximately 9:00 a.m., Surveyor C interviewed CNA B and CNA E. They were asked if Resident #14 usually sleeps a lot and is hard to arouse. They said she does sleep at times but is easily aroused. They were informed that Surveyor C had made multiple attempts to visit the resident yesterday and again this morning, but Resident #14 was asleep and not responding to her name being called. They stated this was not the resident's normal behavior, but she had awakened for breakfast. On 10/19/2023, an interview was conducted with CNA F. CNA F was asked about Resident #14. CNA F said he was not too familiar with the resident's pattern, but knew she stayed in her room a lot and would doze on and off at times. On 10/18/2023 - 10/19/2023, a clinical record review was conducted. A progress note dated 10/16/2023, read, Resident was seen by her outside PCP today. New order for Sulfamethoxazole 400 mg- Trimethoprim 80 mg, 1 tab every 8 hours x 7 days. Also an increase in Quetiapine/Seroquel to 50 mg once a day at bedtime. There was no indication Resident #14's family member had been notified of the start of an antipsychotic medication. Review of the Medication Administration Record (MAR) for October 2023 revealed that Resident #14 was not receiving Seroquel prior to 10/16/2023. Resident #14 did receive a dose on 10/17/2023 and 10/18/2023. Physician's orders and the MAR revealed that that Resident #14 was started on Sertraline HCl oral tablet, (also known as Zoloft, which is an antidepressant) 50 mg, once daily for depression symptoms starting 08/12/2023. At the time of survey, this medication continued. Review of the progress notes revealed no evidence of any behaviors in the past 30 days that would have precipitated the medication change. On the afternoon of 10/19/2023 during an end of day meeting, the facility Administrator, Director of Nursing, and corporate staff were made aware of the above concern that Resident #14 was displaying significant somnolence and had a recent medication change that may be a contributing factor as well as the over-the-counter medications that were noted in the room, since they are unaware of what and how much the resident may be self-administering. A copy of the physician's progress notes from 10/16/2023 was requested. On 10/20/2023 during the morning, Resident #14 was visited in her room and was sitting at the bedside and awaiting her breakfast. She was talkative and able to engage in conversation. On the morning of 10/20/2023, Surveyor C requested the physician's progress note from 10/16/2023. A clinical record review was conducted again and revealed that following the end of day meeting held on 10/19/2023, the facility staff had completed an SBAR Communication Form, which indicated Resident #14 had a change in Altered level of consciousness, which was reported to the physician. In response to this, an order was received to change the dosage of the Seroquel to decrease it to 25 mg daily at bedtime. On 10/20/2023 in the afternoon, the facility staff provided Surveyor C with the physician's progress note from 10/16/2023. It was reviewed and there was no indication for the medication, Quetiapine, other than diagnosis listed on a Report of Consultation that included, compulsive behavior, and generalized anxiety. There were no other details given as to why the Quetiapine/Seroquel was being ordered. No further information was provided.

Based on observation, resident interview, facility staff interview, clinical record review, and facility documentation review, the facility staff failed to accommodate the needs of 2 residents (Residents #274 and #70) in a survey sample of 39 residents. The findings included: 1. For Resident #274, who was unable to get out of bed without assistance, the call bell was not in reach; therefore, leaving the resident with no way to call facility staff for assistance. On 10/17/2023 at 1:45 p.m., Resident #274 was visited in his room. The resident was noted to be alert, oriented x4 and a good historian upon interview. The resident was observed lying in bed, was noted to be a bilateral amputee of lower extremities. Resident #274 said, his call bell is the only way he can call for assistance and frequently it is out of reach or has fallen behind the bed. He said he frequently has to get his roommate to use his call bell to get assistance to the room. Resident #274 reports he does not get out of bed. On 10/17/2023 at 1:49 p.m., an interview was conducted with CNA B. CNA B was asked about the call bells, to explain their purpose, and where they are located. CNA B said, The call bell is how the residents let us know if they need something. If they can't get out of bed, that is the only way they can call for assistance other than staff checking on them regularly. CNA B accompanied Surveyor C to the room of Resident #274 and confirmed the call bell was laying on the bed frame at the foot of the bed and out of reach of the resident. CNA B further confirmed the resident had no way of calling staff for assistance if he had needed it. A clinical record review of Resident #274's chart was conducted on 10/17/2023. This review revealed that he was dependent on facility staff for activities of daily living (ADL). There was a care plan initiated on 10/08/2023, that indicated Resident #274 Is at risk for falls r/t [related to] bilateral BKA's [below knee amputations]. One intervention listed read, Be sure The [sic] resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Review of the facility policy titled, Answering the Call Light was conducted. An excerpt from the policy read, .5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the Resident . On 10/17/2023 during an end of day meeting, the facility Administrator, Director of Nursing and Corporate staff were made aware of the above findings. No further information was provided. 41450 2. For Resident #70, the call bell was located beyond his reach, making it unavailable for him to call for assistance. On 10/17/2023 at approximately 1:35 p.m. during initial tour, Resident #70 was observed lying awake in his bed with his call bell located on the floor at the foot of his bed. When asked if he knew where his call bell was, he felt around his bed and shook his head, No. Resident #70 was unable to speak due to previous history of a stroke. LPN B, assigned to Resident #70's unit, was asked to come into Resident #70's room. LPN B was asked if she thought Resident #70 could reach his call bell to call for assistance, and she stated, No, he cannot get to that [the call bell], it should be kept within his reach at all times so he can use it. He cannot speak but he does know how to use his call bell. LPN B picked the call bell up off the floor and secured it to Resident #70's bedspread within his reach. On 10/17/2023, a facility policy regarding call bells was requested and received. The facility policy entitled, Answering the Call Light, item 5 read, When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. On 10/17/2023, the Facility Administrator and Director of Nursing were updated on the findings. No further information was provided.

Based on observation, resident interview, staff interviews, facility documentation review, and clinical record review, the facility staff failed to assess and determine if a resident was safe to self-administer medications, for one resident (Resident #14) in a survey sample of 39 residents. The findings included: For Resident #14, who had medications stored in their room, the facility staff failed to assess if Resident #14 was safe to self-administer medications. On 10/17/2023 at approximately 12:40 p.m., observations were conducted of Resident #14's room. Resident #14 was not present in the room. It was noted that Resident #14 had a basket on the bed that contained two blister packets of medications. There was also a 3-drawer plastic storage unit against the wall that had clear drawers and it was observed there was a bottle of Tylenol and 2 cans of jock itch spray present. On 10/17/2023 at 1:33 p.m., Resident #14 was visited in her room. When asked about medications, Resident #14 said, the facility staff give her medications. On 10/18/2023, during mid-morning, observations were made in Resident #14's room. Resident #14 was present but asleep and unable to be aroused with verbal stimuli, which included knocking and calling out her name. Surveyor C noticed on the bed, in a basket were 2 blister packs of medications which were labeled as Mucinex and Nauzene. The clear 3-drawer storage unit contained Tylenol, Pepto Bismol, and jock itch spray. On 10/19/2023, during the early afternoon, Resident #14 was visited in her room again. All of the above noted medications were still present and in addition, Preparation H cream was noted sitting on top of the 3-drawer storage bin. Resident #14 was asked about the items, and she said she puts the Preparation H on herself. When asked where she obtained the items from, the resident was unsure. A review of Resident #14's entire clinical record, to include but not limited to, physician's orders, care plan, nursing notes, assessments, and interdisciplinary team meeting notes, there was no indication that Resident #14 had been assessed for his ability to self-administer medications. Resident #14 was initially admitted to the facility on [DATE] and readmitted on [DATE] following a hospitalization . On 10/19/2023 at 11:21 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated they do not have any residents who self-administer medications. When asked about the protocol for this, the DON said, If a Resident wanted to self-administer, I would speak to the doctor and do an assessment. When asked if there was a specific assessment that is used, the DON said, Yes, there is an assessment and we would have them do a successful return demonstration, we would give them a supply [of medication being self-administered], we would check to make sure they have supply, and that they have given it properly. When asked where the medication that is being self-administered would be stored, the DON said, In a lock box. When asked why a lock box is used to store the medications, the DON said, Because I wouldn't want anyone else to have access to it, and confirmed they do have residents that wander and go into other residents' rooms. During the above interview with the DON, she was asked to provide a copy of the facility policy regarding self-administration of medications and the assessment tool used to assess residents for this ability. On the afternoon of 10/19/2023, the facility policy and self-administration of medication assessment was received. On the afternoon of 10/19/2023, the facility Administrator, Director of Nursing, and Corporate staff were made aware that Resident #14 was not assessed for the ability to self-administer medications and medications were noted at the bedside. The Corporate Nursing Consultant advised Surveyor C that the Administrator had found 2 bottles of vodka in Resident #14's room and had to remove them. They felt Resident #14's daughter was providing/putting the items in Resident #14's room to sabotage the survey. Of note, Resident #14's daughter is also a resident of the facility. A review was conducted of the facility policy titled, Self-Administration of Medications and Treatments. Excerpts from the policy read, Policy: Residents have the right to self-administer medications/treatments if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Specific Procedures/Guidance: 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities and choice to determine whether self-administering medications and/or treats is clinically appropriate for the resident .3. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment .8. Self-administered medications and/or treatments will be stored in a safe and secure place, which is not accessible by other residents . On 10/20/2023, prior to conclusion of the survey, the facility staff provided the survey team with a listing of items removed from Resident #14's room, which included the following: Mucinex, Pepto Bismol, acne treatment, Preparation H gel, Tylenol, Diclofenac Gel, Preparation H cream, jock itch spray, Nauzene, Salonpas patches, which are all over the counter medications. No further information was provided.

Based on resident interview, facility staff interview, clinical record review, and facility documentation review, the facility staff failed to protect one resident (Resident #14) from misappropriation of property in a survey sample of 39 residents. The findings included: For Resident #14, the facility staff failed to protect the resident from a known perpetrator, who had been identified by the facility as a verbal abuser and who had previously financially exploited the resident. The facility staff continued to permit unsupervised and unrestricted access to Resident #14 and her personal possessions by the known perpetrator, which allowed the perpetrator to gain access to Resident #14's bank cards when she had no legal right to possess the items. On [DATE] in the afternoon, Resident #14 was visited in her room. During the interview/conversation, cognitive impairment and difficulty with memory recall was noted. The resident did acknowledge she had been to visit her daughter earlier in the day. Resident #14's daughter is also a resident of this facility. Resident #14 reported they are able visit each other anytime they want. Review of the facility's investigation documents revealed that on [DATE], there was an incident between Resident #14 and her daughter, Resident #55. The incident was witnessed by 2 staff members and involved Resident #55 being verbally abusive to Resident #14. The facility's investigation findings concluded, The investigation showed that [Resident #55's name redacted] did verbally abuse her mother and upset her .APS [Adult Protective Services], the physician and local police were notified. In conclusion, the facility stated, The facility substantiated this verbal abuse due to the relationship of these two individuals it is tough to hold tight on interventions because of resident rights and the mother daughter relationship. On [DATE], the Social Worker wrote a progress note that read, [Resident #14's name redacted] met with the city of [City name redacted] Adult Protective Services social worker, [APS worker's name redacted], the Director of Nursing, Social Services, and the Business Office Manager to review bank statements. [APS worker's name redacted] reviewed transactions on the bank statements that displayed funds that were being utilized for means not pertaining to [Resident #14's name redacted]'s stay in the facility. [Resident #14's name redacted] expressed that she did not want to get her daughter into any trouble or arrested. The Director of Nursing comforted [Resident #14's name redacted] by stating that the purpose of the meeting was for to ensure that the facility was being a good steward of the Medicare and Medicaid process in an effort to protect the best interest of [Resident #14's name redacted]. [Resident #14's name redacted] verbalized that she does not want her daughter to control her money anymore. She also stated that she wants to revoke her power of attorney on file. [APS worker's name redacted] stated that she would attempt to collaborate with an outside organization to revoke the power of attorney and enter into a fiduciary agreement with [Resident #14's name redacted] to make sure her funds are used for her stay in the facility. [Resident #14's name redacted] was in complete agreement as she stated, I have never dealt with money in my life. She also authorized for her Social Security checks to be direct deposited into her Resident Fund Management Services account. [APS worker's name redacted] praised the staff for providing excellent care. Social Services will continue to monitor. Another entry by the Social Worker was made into Resident #14's chart on [DATE]. This entry read, Social services was given the paperwork with the new POA [power of attorney] information that was orchestrated with the assistance of APS [Adult Protective Services]. The son of the resident is now the current POA which was awarded to him by his mom [Resident #14's name redacted], and the paperwork has been uploaded into [name of electronic health record system redacted]. Social services will continue to monitor the resident at this time. According to facility investigation documents, on [DATE], Resident #55 Alerted staff that she called the police because a bag with clothes and purse were taken from her mother's room and given to her and she believed that items may have been stolen out of the purse, but she holds her mother's debit, medical and identification cards . Also in the investigation documents was a typed timeline dated [DATE]. This document read, At 9:30 this writer [writer did not sign document, so unaware of who the writer was] was called to the front lobby to meet [Resident #55's name redacted] .[Resident #55's name redacted] called police to say [Resident #14's name redacted] purse was taken out of her room and taken to laundry and then brought to her [Resident #55] room. The purse was in a clear bag with [Resident #14's name redacted] soiled clothes from the hospital Writer spoke with [Resident #55's name redacted] and asked her to identify the housekeeper that brought her the purse. [Resident #55's name redacted] identified the housekeeper. This writer asked the housekeeper how she got the clear bag and the items in it, and she stated that the evening CNA brought it down to be laundered [sic] . Also in the document titled, timeline, was the following statement, The police officers and APS worker and this writer interview [sic] [Resident #14's name redacted] if she gave [Resident #55's name redacted] her debt [sic] cards before she went to her doctor's appointment on [DATE] or she had them taken from her by [Resident #55's name redacted]. [Resident #14's name redacted] stated she gave them to [Resident #55's name redacted] to hold. [APS worker's name redacted] reeducated [Resident #14's name redacted] that [Resident #55's name redacted] is not the power of attorney, and she is not authorized to hold her debit cards. The investigation summary stated, After investigation was completed by Local Police Department and Local Adult Protective Services were on site to obtain the debit cards from [Resident #55's name redacted] as this resident is not the Power of Attorney for [Resident #14's name redacted] because of prior financial exploitation .In work with the Local Police Department and Local Adult Protective Services they will be reopening the case on [Resident #55's name redacted] of financial exploitation of [Resident #14's name redacted] and will subpoena financial records for both [Resident #14 and #55's names redacted] . In Resident #14's clinical record there was a progress note dated [DATE], written by the Director of Nursing. It read, Medical Director notified by this RN that Residents purse was misplaced for a short period of time. Resident stated that nothing was missing from purse. It was later identified that Residents daughter had obtained cards from Residents purse. APS [adult protective services] notified [City name redacted] Police and both entities as well as Residents RP [responsible party/son] came to the Facility. APS and [police department name redacted] initiated an investigation. Medical Director verbalized understanding of all information provided, no questions or concerns voiced. Therefore, it is unclear how Resident #55's obtained Resident #14's bank cards, but the facility staff allowed unrestricted and unsupervised access between the two residents which permitted Resident #55 to have access to Resident's #14's personal possessions. Review of Resident #14's care plan revealed no mention of the prior abuse between Residents #14 and #55, the relationship of the two, or any other problems. Within Resident #14's clinical record was a document titled, Psychological Assessment, with an evaluation date of [DATE]. This document read, .Reason for Referral: [Resident #14's name redacted] was referred for assessment by [City name redacted] Department of Social Services to help determine her need for guardianship assistance. Specific concern was expressed that a seeming inability to monitor her finances was leaving her open to financial exploitation . The document went on to read, .Conclusions and Recommendations: [Resident #14's name redacted] is demonstrating a range of cognitive declines/deficits consistent with early-stage and progressing dementia. She currently appears incapacitated to the point that she will need another person to make decisions for her regarding her personal affairs to include residential planning, medical care, and all aspects of her finances. [Resident #14's name redacted] is capable of offering limited input regarding her preference of where she might live but cannot make sound living arrangement/residential placement decisions (and is easily misguided in that area). Her cognitive deficits are ones for which she will be unable to make improvements. That is, there is no known treatment by which they can be remedied to any meaningful extent, and instead, her deficits can be expected only to worsen over time. [Resident #14's name redacted] appears in need of legal guardian to manage her personal and financial affairs. She appears to possess the capacity to grasp that nature of a guardianship and conservatorship but lacks the ability to intelligently consent to the appointment of a guardian or conservator. The above is true and correct to the best of my information and belief . [signed by a Licensed Clinical Psychologist, whose name is redacted]. Throughout the course of the survey, it was noted that Resident #14 had multiple over-the-counter medications in her room. On the afternoon of [DATE], the facility Administrator, Director of Nursing, and Corporate staff were made aware that Resident #14 had multiple over-the-counter medications at the bedside. The Corporate Nursing Consultant advised Surveyor C that the Administrator had removed 2 bottles of vodka from Resident #14's room earlier that day. The administrative staff reported to the survey team that Resident #14's daughter, Resident #55, was the one giving Resident #14 items. On [DATE] during the end of day meeting, an interview was conducted with the facility Administrator, Director of Nursing and Corporate Nursing Consultant. During the interview, the survey team shared concerns regarding Resident #55 and Resident #14. The administration was asked what steps they were taking to protect Resident #14's safety. In response to the survey team's shared concerns, on the morning of [DATE], the facility Administrator and Corporate Nursing Consultant reported to the survey team that on the evening of [DATE], following the end of day meeting with the survey team, Resident #14's room assignment had been moved directly across from the nursing station for closer monitoring. Additionally, a staff member had been assigned to Resident #14 as one-to-one, to supervise any visits between Resident #14 and Resident #55 to ensure there was no exchange of items or items being brought into Resident #14's room that were not permitted. On [DATE], interviews were conducted with CNA B, LPN D and LPN C, the unit manager. All three stated that prior to [DATE], Residents #14 and #55 have been permitted to have unrestricted and unsupervised visits with each other ad lib [as they choose]. The facility policy titled, Abuse, was reviewed. Excerpts from the policy read, .6. Protection: a. In the event of an allegation or observation of abuse, the facility will immediately assess the resident, notify the physician and resident representative, and protect the resident and other residents from further harm or incident. b. The resident's plan of care will be revised to reflect interventions to minimize recurrence and to treat any injury or harm identified through assessment of the resident . No further information was provided.

Based on staff interviews, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff neglected to provide goods and services to one Resident (Resident #316) in a sample size of 32 Residents. For Resident #316, the facility staff failed to provide adequate hydration for over 24 hours after a registered nurse assessed that Resident #316 was dehydrated. Resident #316 was hospitalized and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: On 03/27/2022 and 03/28/2022, Resident #316's clinical record was reviewed. Resident #316's most recent Minimum Data Set with an Assessment Reference Date of 12/16/2021 was coded as a quarterly assessment. Cognitive Skills for Daily Decision-Making were coded as severely impaired. Resident #316's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the progress noted from October 2021 through January 2022 included but were not limited to the following: Excerpts of a nurse's skilled note dated 01/12/2022 at 00:00 A.M. documented the following: Current vital signs are: Temperature: T 98.0 - Route: Forehead (non-contact) Pulse: P 82 Pulse Type: Regular Respirations: R 18 Blood pressure: BP 128/72 Position: Lying r/arm [right arm] Pain level: 0 Pain scale: Numerical. Level of consciousness noted as oriented to person Hx [history] [CONDITION(S)]. Skin is warm dry. Swallowing problems are not noted [no punctuation] refusing all offers of fluids. Mood status is flat affect. There was not a skilled note written on 01/13/2022 through 01/17/2022. A Medication Administration note dated 01/14/2022 at 9:18 P.M. documented, Resident not eating or taking medications. A Medication Administration note dated 01/14/2022 at 9:19 P.M. documented, Insulin not given as resident is not eating and BS [blood sugar] 150 [milligrams per deciliter]. A Medication Administration note dated 01/15/2022 at 10:31 A.M. documented, Resident would not open her mouth to take her medicine and turns head whenever offered to her, resident educated. A nurse's note written by Licensed Practical Nurse F (LPN F), agency nurse, dated 01/16/2022 at 6:14 A.M. documented, Note Text: Resident laying bed not responding to verbal stimuli. Resident has some response to physical stimuli VS [vital signs] [blood pressure] 89/64 [respirations] 18 [pulse] 68 [temperature] 97.5 BS [blood sugar] 147. Call placed to on call. Awaiting response. RN [registered nurse] on duty called to unit to assess resident. Pushing fluids. Report to oncoming shift when MD returns call to request IV to be started. Will continue to attempt oral fluid intake until further instructed. A nurse's note dated 01/16/2022 at 6:47 A.M. documented, Note Text: Continue to push fluid with minimal success. Resident able to swallow only a few times. Will continue to monitor. A Medication Administration note dated 01/16/2022 at 10:23 A.M. documented, res [resident] not swallowing md [medical doctor] made aware rp [responsible party] made aware. A nurse's note written by Licensed Practical Nurse G (LPN G) dated 01/16/2022 at 12:49 P.M. documented, Note Text: res [resident] not swallowing holding food and meds crushed in pudding in mouth when offered fluid via spoon res [resident] holding fluid in mouth not swallowing res awake with eyes open waving hand at times vital signs at this time 96/52 [blood pressure] 114 [pulse] 96.8 [temperature] 16 [respirations] 97% [oxygen saturation] MD [medical doctor] made aware gave orders to hold meds and insulin until 1/17/22 res [resident] is to be seen by MD [medical doctor] in the AM [morning]. A nurse's note written by Registered Nurse B (RN B) dated 01/16/2022 at 5:00 P.M. documented, Note Text: This nurse spoke with resident's [responsible party] and informed that resident was not eating, she was pocketing food and not drinking much. Her [responsible party] suggested we try ice chips to get fluid in her. A nurse's note dated 01/17/2022 at 10:09 A.M. documented, Note Text: Writer called RP [responsible party] and made aware that resident was being sent out to ED for eval [emergency department for evaluation] and treatment. Voiced understanding. Resident #316's Emergency Department (ED) medical records dated 01/17/2022 at 12:52 P.M. under the header ED Course documented, Patient presents with [CONDITION(S)] initial [CONDITION(S)] [CONDITION(S)] [sic] is improved now on 4 liters of oxygen blood pressure is normalized after 2 liters of fluid is COVID positive severe dehydration case discussed with the hospitalist soft plan will be medical admission. Under the header Clinical Impression it was documented, 1. COVID 2. Dehydration. An excerpt under the header Physical Exam documented, Unresponsive, occasional grimace due to pain. On 03/29/2022 at 9:40 A.M., Certified Nursing Assistant F (CNA F) was interviewed. CNA F confirmed she had taken care of Resident #316. When asked about Resident #316's eating and drinking, CNA F stated that Resident #316 was eating and drinking at first. CNA F then stated that at one point Resident #316 wouldn't eat but would hold a cup and drink fluids. CNA F stated that then [at some point] Resident #316 wouldn't take anything [food or fluids]. On 03/29/2022 at 10:20 A.M., Registered Nurse B (RN B) was interviewed. When asked about Resident #316's eating and drinking, RN B stated that Resident #316 refused to eat and often refused her drinks, too. When asked about the process if a Resident refuses to eat and drink fluids, RN B stated We inform the doctor. RN B also stated that [Resident #316] would drink some but not enough and that's why she went to the hospital. When asked how fluid intake is monitored, RN B stated We don't track I and O [meaning intake and output] unless there is a doctor's order. When asked about the process if a Resident is not drinking adequate amount of fluids, RN B indicated she would notify the physician because of the need to send them out [to the hospital]. RN B also stated that she would obtain vital signs. RN B did not mention assessment for dehydration. On 03/29/2022 at 11:50 A.M., the Director of Nursing (DON) was interviewed. This surveyor and the DON reviewed the nurse's note written by LPN F dated 01/16/2022 at 6:14 A.M. When asked about the expectation of the nurse at that time, the DON stated they have a policy that if the nurse cannot get in touch with the physician, they are to call the administrator or the nurse on call. When asked who the RN was referencing in the note, the DON stated she would find out. When asked about the expectation of the RN, the DON stated she would expect the RN to assess and document findings. The DON also stated that based on the RN's assessment findings, she could've sent [Resident #316] out [to the hospital]. This surveyor and the DON reviewed the note written by Licensed Practical Nurse G (LPN G) dated 01/16/2022 at 12:49 P.M. When asked about the expectation of the nurse at that time, the DON stated the nurse should ask the physician if [Resident #316] can be sent out [to the hospital]. When asked about monitoring for adequate hydration, the DON stated the nurse should check skin turgor [elasticity] and mucous membranes. The DON also stated that the nurse should ask the aides how many cc's [cubic centimeters meaning milliliters] intake the Resident has had. The DON also stated that output should also be measured. On 03/29/2022 at 2:25 P.M., LPN G was interviewed. The surveyor and LPN G reviewed the note written by Licensed Practical Nurse G (LPN G) dated 01/16/2022 at 12:49 P.M. When asked why she called the physician about [Resident #316], LPN G stated that [Resident #316 was not swallowing and was concerned because her blood pressure was low and her pulse was up. LPN G stated that [Resident #316] I know she was dehydrated because she wasn't drinking anything or swallowing. LPN G also stated that she thought the physician would send her out but he didn't [send her out]. When asked if she felt she had other options, LPN G stated, I did not. LPN G verified the on-call physician was [Employee L]. On 03/29/2022 at approximately 3:00 P.M., the DON provided the name of the RN referenced in the note dated 01/16/2022 at 6:14 A.M. as (RN C). On 03/29/2022 at 4:00 P.M., Employee L, the on-call physician, was interviewed. When asked about the process of being the on-call physician, the on-call physician indicated he does not take notes on the calls he receives and he does not have access to the clinical record. The on-call physician stated he relies on the nurse's report. When asked about [Resident #316]'s status on 01/16/2022, the on-call physician stated he did not remember [Resident #316]. This surveyor and the on-call physician reviewed the nurse's note written by LPN G dated 01/16/2022 at 12:49 P.M. When asked if he would want to send [Resident #316] to the emergency department for evaluation based on the note, the on-call physician stated No because it sounded like a chronic problem. The on-call physician indicated that unless the Resident was lethargic or choking on food or aspirating, he would not send the Resident out but have the primary provider address it in the morning. When asked about the hydration status, the on-call physician stated that It could've been dehydration; I might have thought about that. The on-call physician stated that he sent a message to the nurse practitioner to evaluate [Resident #316] the following day [Monday morning]. This surveyor and the on-call physician reviewed the note written on 01/16/2022 at 6:14 A.M. The on-call physician stated he wasn't aware [Resident #316] not responding to verbal stimuli. The on-call physician indicated that [LPN G] did not convey that information. On 03/29/2022 at 4:55 P.M., an interview with RN C was conducted. RN C verified she was the RN referenced in the note written by LPN F dated 01/16/2022 at 6:14 A.M. When asked about the events indicated in the note, RN C stated that [LPN F] asked her to look at [Resident #316] at approximately 6:30 A.M. [on 01/16/2022]. RN C stated that [Resident #316] had dry lips, dry mucous membranes, and poor skin turgor. RN C stated that Resident #316 looked dehydrated to me. RN C stated she told [LPN F] she was unsure he would even be able to get an IV [intravenous catheter] in her because she was dehydrated. RN C stated she told LPN F that if he couldn't get an IV into her, they would have to send her out [to the hospital]. RN C stated that LPN F called the physician and left a message. When asked if she had documented her assessment findings, RN C stated no. RN C indicated that she had her own assignment and was not working as a supervisor. On 03/30/2022 at 9:30 A.M., a follow-up interview with RN C was conducted. When asked about Resident #316's level of consciousness at the time of her assessment on the early morning of 01/16/2022, RN C stated that Resident #316 was at her [level of consciousness] baseline but she definitely needed an intervention because she was dehydrated. RN C also stated that she wished she had gone back to check on [Resident #316] and followed up. A review of the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility staff provided a copy of their policy entitled, Abuse, Neglect, Exploitation & Misappropriation. An excerpt under the header Definitions documented the following: Neglect is the failure of the center and its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Examples include but are not limited to: Failure to provide adequate nutrition and fluids. On 03/30/2022 at approximately 3:30 P.M., the administrator and DON were notified of findings. The administrator stated they had no further information or documentation to submit.

Based on staff interviews, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide care according to professional standards of practice for one Resident (Resident #316) in a sample size of 32 Residents. For Resident #316, the facility staff failed to: 1) convey Resident #316's dehydration status to the on-call physician 2) document assessment findings 3) address the dehydration status in a timely fashion after a registered nurse assessed that Resident #316 was dehydrated which resulted in hospitalization and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: On 03/27/2022 and 03/28/2022, Resident #316's clinical record was reviewed. Resident #316's most recent Minimum Data Set with an Assessment Reference Date of 12/16/2021 was coded as a quarterly assessment. Cognitive Skills for Daily Decision-Making were coded as severely impaired. Resident #316's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the progress noted from October 2021 through January 2022 included but were not limited to the following: Excerpts of a nurse's skilled note dated 01/12/2022 at 00:00 A.M. documented the following: Current vital signs are: Temperature: T 98.0 - Route: Forehead (non-contact) Pulse: P 82 Pulse Type: Regular Respirations: R 18 Blood pressure: BP 128/72 Position: Lying r/arm [right arm] Pain level: 0 Pain scale: Numerical. Level of consciousness noted as oriented to person Hx [history] [CONDITION(S)]. Skin is warm dry. Swallowing problems are not noted [no punctuation] refusing all offers of fluids. Mood status is flat affect. There was not a skilled note written on 01/13/2022 through 01/17/2022. A Medication Administration note dated 01/14/2022 at 9:18 P.M. documented, Resident not eating or taking medications. A Medication Administration note dated 01/14/2022 at 9:19 P.M. documented, Insulin not given as resident is not eating and BS [blood sugar] 150 [milligrams per deciliter]. A Medication Administration note dated 01/15/2022 at 10:31 A.M. documented, Resident would not open her mouth to take her medicine and turns head whenever offered to her, resident educated. A nurse's note written by Licensed Practical Nurse F (LPN F), agency nurse, dated 01/16/2022 at 6:14 A.M. documented, Note Text: Resident laying bed not responding to verbal stimuli. Resident has some response to physical stimuli VS [vital signs] [blood pressure] 89/64 [respirations] 18 [pulse] 68 [temperature] 97.5 BS [blood sugar] 147. Call placed to on call. Awaiting response. RN [registered nurse] on duty called to unit to assess resident. Pushing fluids. Report to oncoming shift when MD returns call to request IV to be started. Will continue to attempt oral fluid intake until further instructed. A nurse's note dated 01/16/2022 at 6:47 A.M. documented, Note Text: Continue to push fluid with minimal success. Resident able to swallow only a few times. Will continue to monitor. A Medication Administration note dated 01/16/2022 at 10:23 A.M. documented, res [resident] not swallowing md [medical doctor] made aware rp [responsible party] made aware. A nurse's note written by Licensed Practical Nurse G (LPN G) dated 01/16/2022 at 12:49 P.M. documented, Note Text: res [resident] not swallowing holding food and meds crushed in pudding in mouth when offered fluid via spoon res [resident] holding fluid in mouth not swallowing res awake with eyes open waving hand at times vital signs at this time 96/52 [blood pressure] 114 [pulse] 96.8 [temperature] 16 [respirations] 97% [oxygen saturation] MD [medical doctor] made aware gave orders to hold meds and insulin until 1/17/22 res [resident] is to be seen by MD [medical doctor] in the AM [morning]. A nurse's note written by Registered Nurse B (RN B) dated 01/16/2022 at 5:00 P.M. documented, Note Text: This nurse spoke with resident's [responsible party] and informed that resident was not eating, she was pocketing food and not drinking much. Her [responsible party] suggested we try ice chips to get fluid in her. A nurse's note dated 01/17/2022 at 10:09 A.M. documented, Note Text: Writer called RP [responsible party] and made aware that resident was being sent out to ED for eval [emergency department for evaluation] and treatment. Voiced understanding. Resident #316's Emergency Department (ED) medical records dated 01/17/2022 at 12:52 P.M. under the header ED Course documented, Patient presents with [CONDITION(S)] initial [CONDITION(S)] [CONDITION(S)] [sic] is improved now on 4 liters of oxygen blood pressure is normalized after 2 liters of fluid is COVID positive severe dehydration case discussed with the hospitalist soft plan will be medical admission. Under the header Clinical Impression it was documented, 1. COVID 2. Dehydration. An excerpt under the header Physical Exam documented, Unresponsive, occasional grimace due to pain. On 03/29/2022 at 9:40 A.M., Certified Nursing Assistant F (CNA F) was interviewed. CNA F confirmed she had taken care of Resident #316. When asked about Resident #316's eating and drinking, CNA F stated that Resident #316 was eating and drinking at first. CNA F then stated that at one point Resident #316 wouldn't eat but would hold a cup and drink fluids. CNA F stated that then [at some point] Resident #316 wouldn't take anything [food or fluids]. On 03/29/2022 at 10:20 A.M., Registered Nurse B (RN B) was interviewed. When asked about Resident #316's eating and drinking, RN B stated that Resident #316 refused to eat and often refused her drinks, too. When asked about the process if a Resident refuses to eat and drink fluids, RN B stated We inform the doctor. RN B also stated that [Resident #316] would drink some but not enough and that's why she went to the hospital. When asked how fluid intake is monitored, RN B stated We don't track I and O [meaning intake and output] unless there is a doctor's order. When asked about the process if a Resident is not drinking adequate amount of fluids, RN B indicated she would notify the physician because of the need to send them out [to the hospital]. RN B also stated that she would obtain vital signs. RN B did not mention assessment for dehydration. On 03/29/2022 at 11:50 A.M., the Director of Nursing (DON) was interviewed. This surveyor and the DON reviewed the nurse's note written by LPN F dated 01/16/2022 at 6:14 A.M. When asked about the expectation of the nurse at that time, the DON stated they have a policy that if the nurse cannot get in touch with the physician, they are to call the administrator or the nurse on call. When asked who the RN was referencing in the note, the DON stated she would find out. When asked about the expectation of the RN, the DON stated she would expect the RN to assess and document findings. The DON also stated that based on the RN's assessment findings, she could've sent [Resident #316] out [to the hospital]. This surveyor and the DON reviewed the note written by Licensed Practical Nurse G (LPN G) dated 01/16/2022 at 12:49 P.M. When asked about the expectation of the nurse at that time, the DON stated the nurse should ask the physician if [Resident #316] can be sent out [to the hospital]. When asked about monitoring for adequate hydration, the DON stated the nurse should check skin turgor [elasticity] and mucous membranes. The DON also stated that the nurse should ask the aides how many cc's [cubic centimeters meaning milliliters] intake the Resident has had. The DON also stated that output should also be measured. On 03/29/2022 at 2:25 P.M., LPN G was interviewed. The surveyor and LPN G reviewed the note written by Licensed Practical Nurse G (LPN G) dated 01/16/2022 at 12:49 P.M. When asked why she called the physician about [Resident #316], LPN G stated that she was told in report that [Resident #316 was not swallowing and she observed herself that [Resident #316 was not swallowing and was concerned because her blood pressure was low and her pulse was up. LPN G stated that [Resident #316] I know she was dehydrated because she wasn't drinking anything or swallowing. LPN G also stated that she thought the physician would send her out but he didn't [send her out]. When asked if she felt she had other options, LPN G stated, I did not. LPN G verified the on-call physician was [Employee L]. On 03/29/2022 at approximately 3:00 P.M., the DON provided the name of the RN referenced in the note dated 01/16/2022 at 6:14 A.M. as (RN C). On 03/29/2022 at 4:00 P.M., Employee L, the on-call physician, was interviewed. When asked about the process of being the on-call physician, the on-call physician indicated he does not take notes on the calls he receives and he does not have access to the clinical record. The on-call physician stated he relies on the nurse's report. When asked about [Resident #316]'s status on 01/16/2022, the on-call physician stated he did not remember [Resident #316]. This surveyor and the on-call physician reviewed the nurse's note written by LPN G dated 01/16/2022 at 12:49 P.M. When asked if he would want to send [Resident #316] to the emergency department for evaluation based on the note, the on-call physician stated No because it sounded like a chronic problem. The on-call physician indicated that unless the Resident was lethargic or choking on food or aspirating, he would not send the Resident out but have the primary provider address it in the morning. When asked about the hydration status, the on-call physician stated that It could've been dehydration; I might have thought about that. The on-call physician stated that he sent a message to the nurse practitioner to evaluate [Resident #316] the following day [Monday morning]. This surveyor and the on-call physician reviewed the note written on 01/16/2022 at 6:14 A.M. The on-call physician stated he wasn't aware [Resident #316] not responding to verbal stimuli. The on-call physician indicated that the nurse did not convey that information. On 03/29/2022 at 4:55 P.M., an interview with RN C was conducted. RN C verified she was the RN referenced in the note written by LPN F dated 01/16/2022 at 6:14 A.M. When asked about the events indicated in the note, RN C stated that [LPN F] asked her to look at [Resident #316] at approximately 6:30 A.M. [on 01/16/2022]. RN C stated that [Resident #316] had dry lips, dry mucous membranes, and poor skin turgor. RN C stated that Resident #316 looked dehydrated to me. RN C stated she told [LPN F] she was unsure he would even be able to get an IV [intravenous catheter] in her because she was dehydrated. RN C stated she told LPN F that if he couldn't get an IV into her, they would have to send her out [to the hospital]. RN C stated that LPN F called the physician and left a message. When asked if she had documented her assessment findings, RN C stated no. RN C indicated that she had her own assignment and was not working as a supervisor. On 03/30/2022 at 9:30 A.M., a follow-up interview with RN C was conducted. When asked about Resident #316's level of consciousness at the time of her assessment on the early morning of 01/16/2022, RN C stated that Resident #316 was at her [level of consciousness] baseline but she definitely needed an intervention because she was dehydrated. RN C also stated that she wished she had gone back to check on [Resident #316] and followed up. A review of the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Fundamentals of Nursing by Perry & Potter, Eighth Edition, 2013, page 217 under the header, Documentation Data, it was documented, Data documentation is the last part of a complete assessment. The timely, thorough, and accurate documentation of facts is required in recording patient data. If you do not record an assessment finding or problem interpretation, it is lost and unavailable to anyone else caring for the patient. If information is not specific, the reader is left with only general impressions. Observing and recording patient status are legal and professional responsibilities. The Nurse Practice Acts in all states and the American Nurses Association Nursing's Social Policy Statement (2010) require accurate data collection and recording as independent functions essential to the role of the professional nurse. In Chapter 34 entitled, Communication on page 316, an excerpt documented, Research indicates that effective communication between health care providers and other members of the health care team ensures patient safety and promotes optimal patient outcomes. On 03/30/2022 at approximately 3:30 P.M., the administrator and DON were notified of findings. The administrator stated they had no further information or documentation to submit.

Based on observation, Resident interview, staff interview, facility documentation review, and clinical record review the facility staff neglected to provide care and services for two Residents (Resident #139 and #134) in a survey sample of 46 Residents. This resulted in harm for Resident #139. Immediate Jeopardy was identified for Resident #134 on 08/14/2019 at 5:16 pm at which time the facility was notified. After verification, Immediate Jeopardy was abated on 08/20/2019 at 7:40 pm and the scope and severity was lowered to a Level three isolated due to Resident #139. The findings included: 1. For Resident #139, the facility staff neglected to assess and treat an ongoing urinary tract infection as it developed [MEDICAL CONDITION] and caused hospitalization resulting in harm. Resident #139, a [AGE] year old male, was admitted to the facility on [DATE] and discharged to a local hospital on [DATE]. His [DIAGNOSES REDACTED]. Resident #139's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/19/2019 was coded as a quarterly assessment. Resident #139 was coded a BIMS (Brief Interview of Mental Status) score of 15/15 which indicated no cognitive impairment. He was totally dependent on the assistance of 1-2 persons for his activities of daily living. He was always incontinent of bowel and used a suprapubic catheter (a catheter that goes through the abdominal wall into the bladder) for urinary elimination. On 7/17/2019 a physician assessment indicated that Resident #139 was positive for a urinary tract infection. He was prescribed the antibiotic [MEDICATION NAME] to continue for 7 days. The (MONTH) 2019 MAR (Medication Administration Record) indicated that this medication was administered. There was no urinalysis culture and sensitivity report which would confirm the [DIAGNOSES REDACTED]. Thus it was not certain that [MEDICATION NAME] was the proper antibiotic for this infection. There were no further notes indicating any distress for Resident #139 until 8/6/2019 at 2:01 AM. A note at that time indicated that he had experienced a large watery bowel movement, and he was unresponsive to painful stimuli. The physician was notified and he issued an order to transfer Resident #139 to the local hospital emergency department. Hospital records were obtained and reviewed. The records indicated that when Resident #139 arrived at the hospital he was still unresponsive and he was immediately intubated due to low respirations, altered mental status, and declining oxygen saturation. An initial urinalysis at the hospital showed a severe urinary tract infection, and bloodwork showed a [NAME] Blood Cell count of 24.9 (normal=4-11) indicating that an infection was present. There was dark tea colored urine in the urine bag. Resident #139 [DIAGNOSES REDACTED]. The Care Plan was reviewed and the presence of Resident #139's suprapubic catheter was noted, and instructed staff Suprapubic catheter care and change as noted. It also stated that nursing staff should initiate urology consults as ordered. There was no mention in the clinical record that catheter care took place and that staff were sufficiently alarmed at the dark colored urine in the catheter bag to alert the physician for a urology consult. This is a harm level deficiency 2. For Resident #134 the facility staff neglected to provide an operating air mattress. This Resident had known stage IV pressure ulcers. Resident #134 was admitted to the facility on [DATE], with a recent readmission date of [DATE]. Resident #134's [DIAGNOSES REDACTED]. Resident #134's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 6/29/19 was coded as a quarterly assessment, Resident #134 was coded as having a BIMS (brief interview for mental status) score of 15, which indicated he was cognitively intact. Resident #134 was coded as being totally dependent upon two staff persons for transfers. On 8/14/19 at approximately 9:30am surveyor G entered the room of Resident #134. Upon opening the room door an audible whooshing noise could be heard. Upon further investigation it was noted that the air hoses coming from the pump connecting to the mattress were taped and the air heard, was air escaping from the hoses. Further observations revealed that Resident #134 was sitting in the middle of his bed and appeared to be sitting in a sunken in area with the mattress around him at a significantly higher elevation than where he was sitting. On 8/14/19 at approximately 9:30am during a Resident interview, Resident #134 stated if he put his hand underneath his buttocks he could feel the bed frame. On 8/14/19 at approximately 9:45am Surveyor C accompanied Surveyor G to the Room of Resident #134. Surveyor C observed air leaking from the air hoses as well. Surveyor C advised nursing staff at the nursing station that the air mattress for Resident #134 was not working properly. Review of Resident #134's physician orders [REDACTED]. Review of Resident #134's careplan revealed an entry dated 8/7/19 that read, Focus: (Resident #134's name redacted) has potential/actual impairment to skin integrity of the r/t (related to) (sic) [MEDICAL CONDITION], use of condom catheter, history of pressure ulcer, side effect of medications. Goal: (Resident #134's name redacted) will maintain or develop clean and intact skin and will be free from further skin breakdown by the review date. Interventions: pressure relieving/reducing mattress to protect the skin while IN BED. Review of hospital records for Resident #134's hospitalized from [DATE]-8/5/19 revealed a wound consult that occurred on 8/2/19 and read, Pt (patient) has two Stage 4 pressure injury wounds. One to each ischial tuberosity . Review of the Admission/Readmission Data Collection form dated 8/5/19, section M on page 8-9 revealed an entry that stated right buttock, left buttock which contained no description, the description box was blank. Review of a Nurse Practitioner progress note dated 8/15/19 revealed the following Pt has a history of of (sic) noncompliance with his mediation (sic) and treatments. He has a stage 4 pressure ulcer to his left and right gluteus, the left gluteus measures 11 cm x 8 cm x 4cm and the right gluteus measures 9.5 cm x 5 cm x 0.2 cm. There was scant sanguineous drainage noted . On 8/14/19 at 11:29am Surveyor [NAME] accompanied Surveyor G to the room of Resident #134. RN A, the unit manager and LPN C, the treatment nurse were also present. Upon entering the room of Resident #134, Surveyor G remained on the opposite side of the privacy curtain while Surveyor E, RN A and LPN C approached the Resident. On 8/14/2019 at 11:29 a.m., observation of wounds was conducted by Surveyor [NAME] for Resident # 134 with the Wound Care Nurse, LPN (Licensed Practical Nurse) C. RN A, the Unit manager stated the wounds were a stage III and LPN C stated they were a stage IV because bone could be observed. Observations revealed the following: Right Ischial Tuberosity-Stage IV, measurements 7.5 cm x 11.2 cm x 1.5 cm depth, Full thickness tissue loss with bone exposed, white maceration around the rolled edges, wound bed noted as beefy red with yellow, adherent slough present, and redness noted around perimeter of the wound. A small amount of serosanguineous drainage was noted on the bandage when removed. Left Ischial Tuberosity- Stage IV-measurements 8.2 cm x 11.0 cm x 3.5 cm depth, full thickness tissue loss with tunneling, bone exposed. Wound bed appeared beefy red with slough present with rolled edges. LPN C stated there is more bone exposed on this one and you can see facia. During the wound care observation on 8/14/19 at 11:29am LPN C and RN A were asked about the air mattress, neither acknowledged they had previously been aware of the mattress not working properly. On 8/14/19 at 2:43pm maintenance was observed changing out the air mattress for Resident #134. When the Maintenance Director was asked what he was doing, he stated nursing told me it had a hole. When asked what the tape on the hoses was for, the maintenance director stated I figured nursing taped it up. He stated he had no prior knowledge of the air mattress not operating. On 8/14/19 at 3:07pm the Maintenance Director was observed in the room of Resident #134 and Resident #134 was reporting that the replacement air mattress was not working properly. On 8/14/19 at 3:27pm an interview was conducted with RN A, the Unit Manager. RN A was asked if the air mattress for Resident #134 was operating properly now and RN A said I know he had to get a new pump and is there adjusting it now. On 8/14/19 at approximately 3:40pm an interview was conducted with the Maintenance Director and he stated the first pump I put on one of the buttons didn't work so I put a new pump on and it's working fine. On 8/15/19 at 4:15pm an interview was conducted with the Maintenance Director in the presence of Surveyors C and Surveyor [NAME] When asked about the preventative maintenance sticker on the air mattress, that was removed from Resident #134's bed which had the broken air hoses, the maintenance director stated he had called the rental company and it was marked as lost in their system. The sticker revealed preventive maintenance had been performed 5/16 (May (YEAR)) and was due 5/17 (May (YEAR)). When asked if anyone checks the beds or does preventative maintenance, the maintenance director stated, not really, unless they tell me they are broken not really, housekeeping just cleans them. On 8/15/19 at 4:15pm with the Maintenance Director Surveyors C & G observed the following: the air supply filter was severely soiled to the point light was not permeable through it. When asked if he could see light through the filter, the maintenance director held the filter to the light he indicated not through that, no. He removed the tape that was wrapped around the tubing where air was escaping. When asked what it was, the maintenance director said nursing tape and some kind of plastic or something. Further evaluation revealed the plastic appeared to be a kitchen product, like saran wrap and contained a sticker that had writing ** (two letters, redacted as they are Resident's initials) . Previous observations of Resident #134's room revealed sandwiches on his bedside table which were wrapped in a plastic, similar to what was being observed on the plastic tubing, and Resident #134 stated they provide him with peanut butter sandwiches to increase his protein intake. On 8/15/19 at approximately 4:45pm Surveyor D accompanied Surveyor G to the beauty shop where the air mattress which had been removed off of Resident #134's bed was stored. Surveyor G then obtained the following details: the tubing/air hoses had a circumference of 3 inches. The air tubes were a corrugated accordion type clear plastic tube with white coated pvc rings with the clear plastic between the rings. One of the tubes revealed that 1 inch of the clear plastic tube remained intact, while 2 inches was severed, being the hole. The second hose was also a circumference of 3 inches. It was broken in two places, with only 1/2 inch intact, with the remaining 2 1/2 inches being severed and was severely damaged. On 8/15/19 at 4:52pm an interview was conducted in the conference room, with all surveyors present, with Employee D, the supply clerk. Employee D was asked to identify the material that maintenance had identified as nursing tape that was wrapped around the damaged air hoses. Employee D stated I know exactly what that is and returned with a roll of Medfix EZ dressing retention tape. The product appears to be porous and the package labeling read, uses: secures primary dressings and medical appliances. Features: low sensitivity adhesive, water resistant, perforations for easy tearing. Change frequency: up to 7 days. Review of the policy titled Bio-medical Equipment Management-Rental with an effective date of 11/30/2014 read as follows: All biomedical equipment that is rented shall be subject to the same requirements for testing and maintenance as facility owned equipment. Procedure: 1. Any company supplying the facility or its residents with bio-medical equipment, will provide the facility with a copy of its procedures for testing and maintaining their equipment. 2. All equipment will be required to have a tag or label showing the last date that it was tested . 3. During the quarterly check of all bio-medical equipment tags by the maintenance department, all rental equipment should be checked to make sure that the date of the last inspection is within the prior six month period. 4. All equipment without the proper tag should be placed out of service until the vendor can assure compliance with the preventative maintenance schedule. Review of the RecoverCare Manual for STAT 5000 C Low Air Loss Mattress Replacement System read on page 6. Air filter and filter cap. No tools are necessary to remove filter cap. MedaSTAT USA, LLC recommends that the filter should be inspected and cleaned or replaced with a [MEDICATION NAME] MedaSTAT USA, LLC replacement part once a month to ensure optimal performance of the power unit. Page 9 stated, 15.0 Routine Maintenance. The STAT family of products are designed to need very little maintenance. MedaSTAT USA, LLC recommends that the air filter should be checked once a month and cleaned of visible soil. Page 10 read, 16.0 Troubleshooting. Problem. 2. Patient is bottoming out inspection procedure: 2.2 check for mattress leaks. 2.3 check air filter for dirt/lint. Possible Solutions: 2.2 replace with appropriate spare parts. 2.3 clean or replace air filter. Page 11 read, 17.0 Returns for Service. This device is NOT user serviceable. SERVICE AND REPAIR MUST ONLY BE PERFORMED BY AN AUTHORIZED MEDASTATE USA, LLC TECHNICIAN OR REPRESENTATIVE. All service issues should be referred to your local MedaSTAT USA LLC dealer. No further information was provided. Immediate Jeopardy was identified on 08/14/2019 at 5:16 pm at which time the facility was notified. The facility presented the following abatement plan: Resident #134 Mattress was replaced on 8/14/19 and is working properly. 1. Residents with the potential to be affected by alleged deficient practice: The facility Maintenance Director will conduct an audit on 8/14/19 of all air mattresses to ensure that they are in proper working order. Any issues identified will be reported to the Executive Director and immediately corrected. 8/19/19- All residents have the potential to be affected by this alleged deficient practice. The facility RN Unit Managers will conducted a facility wide skin sweep and document the findings in the medical record. Any identified previously undocumented skin impairment concerns will be reported to the attending physician and the responsible party in accordance with the facility wound policy. Any treatment orders will be obtained and implemented immediately. 2. Systemic Changes: The facility staff; Nursing, Housekeeping/Laundry, Dietary, Administration, Therapy, Maintenance, Social Services, and Activities will be educated on abuse and neglect, types of abuse, training, prevention, identification, investigating, protection, reporting/response, resident's rights, reporting reasonable suspicion of a crime, Elder Justice Act, resident privacy, and the release of resident protected information. Abuse and Neglect education will be provided to all staff of the facility. This education will specifically address prevention and protection for residents. Education was initiated on 8/16/19 and will be on-going, no staff will return to work until they have completed the mandatory education on abuse and neglect. This education will be provided to all new employees as part of new hire orientation, contract staff and agency staff, this education will be provided prior to starting work. All staff currently working will be educated on abuse and neglect immediately. The center Divisional Executive Director to conduct an ADH[NAME] Quality Assurance Performance Improvement meeting 8/16/19, including the Director of Nursing, Director of Rehab, MDS Nurse, Housekeeping Manager, the Business Office Manager, the Human Resources Coordinator, Central Supply Clerk, Dietary Manager, Activity Director and the Environmental Services Director regarding the plan of removal of immediacy. The survey team verified the following: - Resident #134 had a new mattress. - Residents/family/staff (for BIMS 8 or below with no family) interviewed to ensure free from abuse, neglect. - All air mattresses in working order. - All staff education on abuse/neglect. - Skin assessments were done on all residents and if issues, MD/RP notified and treatments ordered/ in place. After verification, Immediate Jeopardy was abated on 08/20/2019 at 7:40 pm and the scope and severity was lowered to a Level three isolated.

Based on observation, Resident interview, staff interview, facility documentation review, and clinical record review the facility staff failed to provide care and treatment to prevent and treat pressure ulcers for three Residents (Resident #133, #134, and #145) in a survey sample of 46 Residents. This resulted in harm for Resident #133. Immediate Jeopardy was identified on 08/14/2019 at 5:16pm at which time the facility was notified. After verification, Immediate Jeopardy was abated on 08/20/2019 at 3:54pm and the scope and severity was lowered to a Level three isolated. The findings included: 1. For Resident # 133, the facility staff failed to identify a pressure wound until it was identified as a stage 3 pressure wound ulcer on the Achilles heel on 8/8/2019 and described as a stage 3. This is harm. Resident #133, a [AGE] year old female, was originally admitted to the facility on [DATE], discharged on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. The most recent Minimum Data Set assessment was a 14 day Medicate Assessment with an assessment reference date (ARD) of 8/11/2019. Resident # 133 was coded as having severe cognitive impairment. Resident #133 was coded as requiring extensive to total assistance of one to two staff persons for Activities of Daily Living to include she required extensive assistance of two staff persons for bed mobility and transfer Review of the clinical record was conducted on 8/14/2019 and 8/19/2019. Resident #133 had a history of [REDACTED]. Resident developed a stage 3 pressure ulcer on her right heel that was identified on 8/8/19 (4 days after the A[NAME] date). This was the same foot on which Resident # 133 was ordered to receive daily treatments to the toes on the right foot since returning to the facility on [DATE] after amputation of her right lesser toe. The staff failed to administer treatments to the right heel as ordered by the physician on 8/11/19 and 8/14/19. Review of the Hospital Discharge Summary dated 7/30/2019 revealed no documentation of a heel wound on discharge from the hospital on [DATE]. Review of the nurses notes revealed the following documentation: 8/7/2019 at 1400 (2 p.m.) Nursing Progress Note: Focus: The resident has surgical wound of amputated 2nd toe on right foot. Non pressure wound to 3rd toe on right foot. 8/8/2019 17:45 (5:45 p.m.) Nursing Progress Note: Late Entry: Clarification order for clean tongue with sponge every shift . (there was no mention of any wound assessment or wound care ) 8/11/2019 at 06:09 (6:09 a.m.) Nursing Progress Note: Writer change dressing. No pain or distress at the time of dressing change. Writer apply therahoney sheet to lower right Achilles heel topically every day shift for wound healing cleanse area with normal saline apply honey sheet and cover with dry dressing (sic) There were two Physicians Orders written on 8/3/2019 for treatments to the toes on the right foot. One was written for the 3rd toe on the right foot and the other was for the 2nd toe on the right foot. Review of Physicians Orders revealed there was no documentation of a heel wound until 8/8/2019 when an order was written for: TheraHoney Sheet apply to lower right Achilles Heel topically every day shift for wound healing. cleanse area with normal saline apply honey sheet and cover with dry dressing. Review of the Weekly Skin Integrity Review Forms revealed a form dated 8/7/2019 under weekly skin evaluation that read site: right toe(s), description: 3rd toe.; Skin intact: yes; Notes: toe was bandaged and wrap by wound nurse today (sic). There was no mention of a heel wound. There were four Non-Pressure Skin Condition Forms, two on 8/9/19 and two on 8/15/19. There were no mention of a heel wound. Pressure Ulcer Wound Rounds dated 8/9/19 at 9:04 a.m. Initial Identification: the box was not checked for present on admission Site: Right Heel , Type: Pressure , Length: 1.7 cm, Width: 0.5 cm, Stage III Wound Bed: Slough, Color: Pink, Wound Edges: Redness, Drainage: Small, Type: Purulent, Odor: None, Color: Pink/Red, Peri Wound Area: intact Signed by Wound Care Nurse, LPN (Licensed Practical Nurse) C. 8/15/19 at 14:05 (2:05 p.m.) Site: Right Heel , Type: Pressure , Length: 1.4 cm, Width: 0.5 cm, Stage III Wound Bed: Slough, Color: Yellow, Wound Edges: Firm/ No Redness, Drainage: Moderate, Type: Purulent, Odor: None, Color: Pink/Red, Peri Wound Area: intact Signed by Wound Care Nurse, LPN (Licensed Practical Nurse) C. Review of the (MONTH) 2019 Treatment Administration Record revealed no documentation that treatments were administered to Resident # 133's Achilles heel on 8/14/2019. There were blanks for 8/14/19. There was a number 9 written for the treatments scheduled on 8/11/2019 ( number 9 was the code for Other/ See Nurse Notes). Review of the nurses notes for 8/11/2019 revealed documentation Medication Administration Note: done previous shift. There was no documentation on the Treatment Administration Record of who or if anyone administered the treatment on 8/11/2019. Observation of the right heel wound was conducted on 8/19/19 with Licensed Practical Nurse C. The wound on the right heel was a Stage 3 with Full thickness tissue loss and yellow slough, measurement 1.4 cm x .5 cm. Review of the 8/6/2019 5 Day Medicare MDS Assessment revealed documentation in the MDS section M0100 (Skin conditions), Resident # 133 was coded as at risk for pressure ulcer formation. The Resident currently had no pressure ulcers during the assessment at section (M0900). In review of section M1200, skin and ulcer treatments (preventive measures), only pressure reducing device for bed was coded. The section was also coded for surgical wound care. That mattress was classified by the manufacturer as a pressure reducing mattress according to the Corporate Registered nurse. Review of the 8/11/2019 14 Day Medicare MDS Assessment revealed documentation in the MDS section M0100 (Skin conditions), Resident # 133 was coded as at risk for pressure ulcer formation. The Resident currently was coded for an unhealed pressure ulcer noted during the assessment at section (M0900). The pressure ulcer was coded as a Stage 3. In review of section M1200, skin and ulcer treatments (preventive measures), only pressure reducing device for chair, and pressure reducing device for bed were coded. Review of the (MONTH) 2019 physician's orders [REDACTED].#133's right heel on 8/8/2019. On 8/19/19, LPN C, the wound care nurse, was asked about the purpose of the TAR. The reply was that tells us what the doctor ordered, so the nurses can complete the treatments, and shows they are completed when we sign them off. LPN C stated the nurses should administer treatments as written by the physician. On 8/20/19 at approximately 2:45 p.m., Corporate Nurse (Employee I) was asked to provide information about Resident # 133's wounds. Employee I stated the wounds to Resident # 133's toes were caused by [DIAGNOSES REDACTED] and presented information from the Hospital Discharge Summary. No information was provided about the heel wound. No further information was provided by the facility. 2a. For Resident #134 the facility staff failed to provide a functioning air mattress, this Resident had known Stage IV pressure ulcers. Resident #134 was admitted to the facility on [DATE], with a recent readmission date of [DATE]. Resident #134's [DIAGNOSES REDACTED]. Resident #134's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 6/29/19 was coded as a quarterly assessment, Resident #134 was coded as having a BIMS (brief interview for mental status) score of 15, which indicated he was cognitively intact. Resident #134 was coded as being totally dependent upon two staff persons for transfers. On 8/14/19 at approximately 9:30am, Surveyor G entered the room of Resident #134. Upon opening the room door an audible whooshing noise could be heard. Upon further investigation it was noted that the air hoses coming from the pump connecting to the mattress were taped and the air heard, was air escaping from the hoses. Further observations revealed that Resident #134 was sitting in the middle of his bed and appeared to be sitting in a sunken in area with the mattress around him at a significantly higher elevation than where he was sitting. On 8/14/19 during a Resident interview, Resident #134 stated if he put his hand underneath his buttocks he could feel the bed frame. On 8/14/19 at approximately 9:45am Surveyor C accompanied Surveyor G to the Room of Resident #134. Surveyor C observed the mattress to be broken and air leaking from the air hoses as well. Surveyor C advised nursing staff at the nursing station that the air mattress for Resident #134 was not working properly. Review of Resident #134's physician orders [REDACTED]. Review of Resident #134's careplan revealed an entry dated 8/7/19 that read, Focus: (Resident #134's name redacted) has potential/actual impairment to skin integrity of the r/t (related to) (sic) [MEDICAL CONDITION], use of condom catheter, history of pressure ulcer, side effect of medications. Goal: (Resident #134's name redacted) will maintain or develop clean and intact skin and will be free from further skin breakdown by the review date. Interventions: pressure relieving/reducing mattress to protect the skin while IN BED. During a wound care observation on 8/14/19 at 11:29am LPN C and RN A were asked about the air mattress, neither acknowledged they had previously been aware of the mattress not working properly. On 8/14/19 at 2:43pm maintenance was observed changing out the air mattress for Resident #134. When the Maintenance Director was asked what he was doing, he stated nursing told me it had a hole. When asked what the tape on the hoses was for, the maintenance director stated I figured nursing taped it up. He stated he had no prior knowledge of the mattress not operating. On 8/14/19 at 3:07pm the Maintenance Director was observed in the room of Resident #134 and Resident #134 was reporting that the replacement air mattress was not working properly. On 8/14/19 at 3:27pm an interview was conducted with RN A, the Unit Manager. RN A was asked if the air mattress for Resident #134 was operating properly now and RN A said I know he had to get a new pump and is there adjusting it now. On 8/14/19 at approximately 3:40pm an interview was conducted with the Maintenance Director and he stated the first pump I put on one of the buttons didn't work so I put a new pump on and it's working fine. On 8/15/19 at 4:15pm an interview was conducted with the Maintenance Director in the presence of Surveyors C and Surveyor [NAME] When asked about the preventative maintenance sticker on the air mattress, that was removed from Resident #134's bed which had the broken air hoses, the maintenance director stated he had called the rental company and it was marked as lost in their system. The sticker revealed preventive maintenance had been performed 5/16 (May (YEAR)) and was due 5/17 (May (YEAR)). When asked if anyone checks the beds or does preventative maintenance, the maintenance director stated, not really, unless they tell me they are broken not really, housekeeping just cleans them. On 8/15/19 at 4:15pm with the Maintenance Director Surveyors C & G observed the following: the air supply filter was severely soiled to the point light was not permeable through it. When asked if he could see light through the filter, the maintenance director held the filter to the light he indicated not through that, no. He removed the tape that was wrapped around the tubing where air was escaping. When asked what it was, the maintenance director said nursing tape and some kind of plastic or something. Further evaluation revealed the plastic appeared to be a kitchen product, like saran wrap and contained a sticker that had writing ** (two letters, redacted as they are Resident's initials). On 8/15/19 at approximately 4:45pm Surveyor D accompanied Surveyor G to the beauty shop where the air mattress which had been removed off of Resident #134's bed was stored. Surveyor G then obtained the following details: the tubing/air hoses had a circumference of 3 inches. The air tubes were a corrugated accordion type clear plastic tube with white coated pvc rings with the clear plastic between the rings. One of the tubes revealed that 1 inch of the clear plastic tube remained intact, while 2 inches was severed, being the hole. The second hose was also a circumference of 3 inches. It was broken in two places, with only 1/2 inch intact, with the remaining 2 1/2 inches being severed and was severely damaged. On 8/15/19 at 4:52pm an interview was conducted in the conference room, with all surveyors present, with Employee D, the supply clerk. Employee D was asked to identify the material that maintenance had identified as nursing tape that was wrapped around the damaged air hoses. Employee D stated I know exactly what that is and returned with a roll of Medfix EZ dressing retention tape. The product appears to be porous and the package labeling read, uses: secures primary dressings and medical appliances. Features: low sensitivity adhesive, water resistant, perforations for easy tearing. Change frequency: up to 7 days. Review of the policy titled Bio-medical Equipment Management-Rental with an effective date of 11/30/2014 read as follows: All biomedical equipment that is rented shall be subject to the same requirements for testing and maintenance as facility owned equipment. Procedure: 1. Any company supplying the facility or its residents with bio-medical equipment, will provide the facility with a copy of its procedures for testing and maintaining their equipment. 2. All equipment will be required to have a tag or label showing the last date that it was tested . 3. During the quarterly check of all bio-medical equipment tags by the maintenance department, all rental equipment should be checked to make sure that the date of the last inspection is within the prior six month period. 4. All equipment without the proper tag should be placed out of service until the vendor can assure compliance with the preventative maintenance schedule. Review of the RecoverCare Manual for STAT 5000 C Low Air Loss Mattress Replacement System read on page 6. Air filter and filter cap. No tools are necessary to remove filter cap. MedaSTAT USA, LLC recommends that the filter should be inspected and cleaned or replaced with a [MEDICATION NAME] MedaSTAT USA, LLC replacement part once a month to ensure optimal performance of the power unit. Page 9 stated, 15.0 Routine Maintenance. The STAT family of products are designed to need very little maintenance. MedaSTAT USA, LLC recommends that the air filter should be checked once a month and cleaned of visible soil. Page 10 read, 16.0 Troubleshooting. Problem. 2. Patient is bottoming out inspection procedure: 2.2 check for mattress leaks. 2.3 check air filter for dirt/lint. Possible Solutions: 2.2 replace with appropriate spare parts. 2.3 clean or replace air filter. Page 11 read, 17.0 Returns for Service. This device is NOT user serviceable. SERVICE AND REPAIR MUST ONLY BE PERFORMED BY AN AUTHORIZED MEDASTATE USA, LLC TECHNICIAN OR REPRESENTATIVE. All service issues should be referred to your local MedaSTAT USA LLC dealer. 2b. For Resident #134 the facility staff failed to provide treatment to wounds as ordered. Review of current physician orders [REDACTED]. There was another order dated 8/6/19 that read, Calcium Alginate Miscellaneous Apply to right buttock topically every day shift for wound healing cleanse wound with normal saline, pat dry, and apply calcium alginate, cover with abdominal pad, and secure with tape. Review of the TAR (treatment administration record) revealed that Resident #134 received no treatment to his left or right buttock wound from his return from the hospital on [DATE] until 8/9/19, when the calcium alginate was applied. Review of the entire clinical record, to include but not limited to nursing notes, assessments, physician progress notes [REDACTED]. 2c. For Resident #134 the facility staff failed to clarify an order and notify the physician of orders from the hospital. Prior to Resident #134's hospitalization (from 7/31/19 to 8/5/19) his wounds were assessed at the facility on 7/25/19 and identified on the Pressure Ulcer Wound Rounds form as left buttock, 9.7 cm x 9 cm, x 1 cm stage III; right buttock, pressure wound 10 cm x 5.5 cm, stage III. Review of hospital records for Resident #134's hospitalized from [DATE]-8/5/19 revealed a wound consult that occurred on 8/2/19 and read, Pt (patient) has two Stage 4 pressure injury wounds. One to each ischial tuberosity. R (right) wound is 4.5 x 11 x 1cm with ruddy red base. Tissue smooth without signs of granulation. Undermining at the base at 3oclock with 20% yellow slough. L (left) wound is 7.5 x 10.5 x 1.5cm with undermining from 8 to 4oclock. Depths of undermining at 4oclock is 2cm; 9oclock is 2.5cm and 11oclock is 4cm. Drainage is a tan yellow coloration. Wound base is ruddy red with palpable bone and yellow [MEDICATION NAME] slough. Pt is reported to do limited turning which q (every) 2 hour turning would actually be beneficial for wound healing or at least assisting with keeping the wound stable. Recommend to clean wound with Vashe then place [MEDICATION NAME] and fill void with [MEDICATION NAME], cover with dry dressing held with [MEDICATION NAME] tape. This dressing can be changed daily. Review of the hospital discharge summary dated 8/5/19 read, START taking these medications: [REDACTED]. STOP taking these medications: [REDACTED] Review of a Nurse Practitioner progress note dated 8/15/19 revealed the following Pt has a history of of (sic) noncompliance with his mediation (sic) and treatments. He has a stage 4 pressure ulcer to his left and right gluteus, the left gluteus measures 11 cm x 8 cm x 4cm and the right gluteus measures 9.5 cm x 5 cm x 0.2 cm. There was scant sanguineous drainage noted. His discharge paperwork showed to his wound treatment to be vashe cleanser apply topically. The order however is an incomplete order and didn't indicate the location to apply, what treatment to use for the actual wound and what dressing to apply. Due to the order not being complete it was not used. 3. For Resident #145, the facility staff failed to provide pressure relieving boots on both feet as ordered while she was in bed on 08/19/2019. Resident #145, a [AGE] year old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #145's most recent Minimum Data Set with an Assessment Reference Date of 07/03/19 was coded as a quarterly review. The Brief Interview for Mental Status was coded as 3 out of possible 15 indicative of severe cognitive impairment. Functional status for bed mobility was coded as requiring extensive assistance from staff. Risk for developing pressure ulcers was coded as yes. On 08/19/19, the clinical record was reviewed. A physician's orders [REDACTED]. The care plan was reviewed. A focus initiated on 06/06/2019 and revised on 06/20/2019 documented, The resident has pressure injury r/t (related to) immobility, incont & fragile skin (incontinence and fragile skin). Has lower extremity contractures. Has wd (wound) to sacrum. One intervention associated with this Focus dated 08/16/2019 documented, Pressure-relieving boots while in bed. On 8/19/2019 at 6:20 p.m., Resident #145 was observed lying in her bed with the head of the bed elevated 60 degrees. Certified Nurse Aide K (CNA K) was observed assisting Resident #145 to eat for dinner. Resident #145 was covered with a sheet from the waist down. CNA K was asked if Resident #145 was wearing her soft boots and he lifted the sheet to expose both of her feet and she did not have her soft boots on. When asked if Resident #145 was supposed to have soft boots on while in bed, CNA K stated he didn't know and added that he was only assisting her with feeding and someone else does all the other care. On 08/20/2019, the Treatment Administration Record for 08/01/2019 through 08/19/2019 was reviewed. For the treatment (initiated on 08/08/19 at 1500) entitled, Pressure relieving boots on both feet while in bed. Every shift, there were 6 shifts out of 35 shifts left blank and not signed off as administered. On the evening it was observed that Resident #145 did not have her boots on and the facility staff was unable to locate them in her room, they were signed off as administered for all three shifts (08/19/2019). On 08/20/2019 at approximately 10 a.m., the DON was asked about her expectations and the use of pressure reducing devices. When shared concerns regarding Resident #145, the DON stated I would expect that she would have her boots on as ordered. The facility provided a copy of their policy entitled Clinical Guidelines Skin & Wound. The policy did not specifically address ensuring pressure-relieving devices were implemented as ordered by the physician. On 06/20/2019 at approximately 7:45 PM, the administrator and the DON had no further information or documentation to offer. Immediate Jeopardy was identified on 08/14/2019 at 5:16pm at which time the facility was notified. The facility presented the following abatement plan: Resident #134 Mattress was replaced on 8/14/19 and is working properly. Resident #134 to be assessed by the attending physician and hospital discharge summary orders for wound care will be addressed on 8/15/19. 1. Residents with the potential to be affected by alleged deficient practice: All residents with pressure ulcers who have the potential to be affected by this alleged deficient practice. Residents with pressure ulcers will be assessed to ensure that they have all ordered interventions in place and they are in working order. Residents who were readmitted from the hospital in the past 30 days with wounds will be audited for discharge orders to ensure orders were addressed. The facility Maintenance Director conducted an audit on 8/14/19 of all air mattresses to ensure that they are in proper working order. Any issues identified will be reported to the Executive Director and immediately corrected. 2. Systemic Changes: I. The facility staff- Nursing, Housekeeping/Laundry, Dietary, Administration, Therapy, Maintenance, Social Services, and Activities will be educated on pressure ulcers and include interventions such as air mattresses being in proper working order, and process of reporting any malfunctioning equipment to maintenance staff and facility leadership. Education initiated on 8/14/19 and be on-going, no staff will return to work until they have completed the mandatory education on pressure ulcers. This education will be provided to all new employees as part of new hire orientation, contract staff and agency staff, this education will be provided prior to starting work. All staff currently working will be provided the mandatory education. II. The center Divisional Executive Director to conduct an ADH[NAME] Quality Assurance Performance Improvement meeting 08/15/19, including the Director of Nursing, Director of Rehab, MDS Nurse, Housekeeping Manager, the Business Office Manager, the Human Resources Coordinator, Central Supply Clerk, Dietary Manager, Activity Director and the Environmental Services Director regarding the plan of removal of immediacy. The Regional Director of Clinical Services will make the Medical Director aware of the immediate jeopardy abatement plan via telephone on 8/15/19. The survey team verified the following: - New mattress for Resident #134 - All residents with pressure ulcers will be assessed and ensure all ordered interventions are in place and in working order - All residents readmitted in last 30 days with wounds audit DC orders were addressed - All air mattresses in working order - All staff educated on pressure ulcers and the process for reporting malfunctioning equipment by staff interviews After verification, Immediate Jeopardy was abated on 08/20/2019 at 3:54pm and the scope and severity was lowered to a Level three isolated.

Based on observation, staff interview, facility documentation review and clinical record review the facility administration failed to mitigate accident hazards for one Resident (Resident #134) in a survey sample of 46 Residents. Immediate Jeopardy was identified on 08/14/2019 at 5:16pm at which time the facility was notified. After verification, Immediate Jeopardy was abated on 08/19/2019 at 3:30 pm and the scope and severity was lowered to a Level two isolated. The findings included: For Resident #134, during a mechanical lift, the base of the lift was not fully extended. In addition, Resident #134 was left alone in a lift. Resident #134 was admitted to the facility on [DATE], with a recent readmission date of [DATE]. Resident #134's [DIAGNOSES REDACTED]. Resident #134's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 6/29/19 was coded as a quarterly assessment, Resident #134 was coded as having a BIMS (brief interview for mental status) score of 15, which indicated he was cognitively intact. Resident #134 was coded as being totally dependent upon two staff persons for transfers. On 8/14/19 at 2:46pm, CNA F was observed in the room with Resident #134 without PPE (personal protective equipment) on, the Resident was on contact precautions. On 8/14/19 at approximately 2:50pm when CNA F exited the room, she was interviewed. CNA F stated, I had to hurry up and get him off the lift and didn't see any gowns. He was left just hanging. When asked who had gotten Resident #134 into the mechanical lift CNA F indicated she didn't know she had just come on her shift. On 8/14/19 at approximately 2:47pm, this surveyor went to the nursing station and it was revealed that CNA G and CNA H had assisted Resident #134 into the lift. Upon interview CNA G stated, I gowned up, took the lift into the room and wasn't comfortable with how he wanted me to put the sling under him so I came out and got him (referring to CNA H). CNA G then stated, we (referring to CNA H and herself) returned to the room, we hooked it up and asked if he wanted to sit in the chair or other bed and he said he would prefer to sit in the sling. I let maintenance know the bed was ready and while we were waiting we unbuckled the mattress, we saw a lot of bio-hazard so we got that together, took the gown off and came out of the room. CNA H stated, he was just hanging over the A bed. CNA G and CNA H confirmed they had left Resident #134 suspended in the air in the mechanical lift sling and left the room. They stated that maintenance was in the room. On 8/14/19 in the afternoon, an interview was conducted with Employee E, the Maintenance Director and he indicated he was working on changing out the mattress and was not supervising Resident #134 and was not aware nursing staff had even exited the room. On 8/14/19 at 3:50pm, CNA I and CNA J went into Resident #134's room with a mechanical lift. They used the mechanical lift and at no point moved the legs of the lift out to extend the base of support and raised Resident #134 into the air. They were not able to obtain a weight because they had not zeroed out the scale prior to lifting. Surveyor G asked CNA I and CNA J if they had used this lift previously and CNA J stated I have not. They again lifted Resident #134 into the air, again without extending the legs of the scale to extend the base of support. On 8/19/19, during review of the facility plan of correction, conducted by Surveyor A and Surveyor F there was evidence of a skills fair held. This skills fair included a competency on use of the mechanical lift. The Mechanical Lift Competency Skills Checklist stated under number 2. Two staff members are used during transfer. under number 7. adjust the base of the mechanical lift so that the legs of the lift will be as wide as possible. CNA H and CNA I attended this training on 7/31/19 and CNA J attended this training on 7/16/19. There was no evidence CNA G attended this training. No further information was provided. Immediate Jeopardy was identified on 08/14/2019 at 5:16pm at which time the facility was notified. The facility presented the following abatement plan: 1. The corrective action for the alleged deficient practice will be accomplished by: Residents #134 was attempted to be assessed by the License Nurse on 8/14/19, resident refused to allow assessment and stated that he had no injuries. Staff who failed properly supervise and use the mechanical lift while transferring Resident #134 at the time of the alleged deficient practice received one on one education regarding the Policy and procedure for use of the mechanical lift in accordance with manufacture instructions and expectations to utilize 2 staff members at all times when using the mechanical lift and that residents are to never be left unattended when in the sling. This education was provided by the Director of Nursing on 8/15/19. 2. Residents with the potential to be affected by alleged deficient practice: All residents who require the use of a mechanical lift had the potential to be affected by the alleged deficient practice. On 8/14/19 the Nursing Administration team identified residents that require use of a mechanical lift for transfer. Each resident identified to require a mechanical lift for transfer will be assessed to ensure no signs of injury present. Any identified adverse findings will be immediately reported and addressed in accordance with facility policy. 3. Systemic Changes: I. Direct care staff, which includes License Nurses, Certified Nursing Assistants & Therapy Staff, will receive education on Mechanical Lift Policy and Procedure in accordance with manufacture instructions by the Staff Development Coordinator/Designee. Education was initiated on 8/14/19 to all staff currently working on site at the facility. Education will remain on-going and no direct care staff member will be allowed to begin work until the mandatory education has been completed regarding the Mechanical Lift Policy, manufacture instructions, and a mechanical lift competency is completed. This Education will be provided to all new direct care employees as part of their new hire orientation, also to include contract and agency staff prior to them starting work. II. The center Divisional Executive Director to conduct an ADH[NAME] Quality Assurance Performance Improvement meeting on 8/15/19, including the Medical Director, Director of Nursing, MDS Nurse, Housekeeping Manager, the Business Office Manager, the Human Resources Coordinator, Dietary Manager, Activity Director and the Environmental Services Director regarding the plan of removal of immediacy. The Regional Director of Clinical Services made the Medical Director aware of the immediate jeopardy abatement plan via telephone on 8/15/19. The survey team verified the following: - Staff education on mechanical lift competency/supervision by interviewing staff After verification, Immediate Jeopardy was abated on 08/19/2019 at 3:30 pm and the scope and severity was lowered to a Level two isolated.

Based on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to ensure treatment was received for four residents (Residents #139, 125, 103, 109 ) in a survey sample of 46 residents. Resulting in harm for resident #139 The findings include: 1. For Resident #139, the facility staff failed to provide needed care and services for a urinary tract infection causing progression [MEDICAL CONDITION] and hospitalization . This is harm. Resident #139, a [AGE] year old male, was admitted to the facility on [DATE] and discharged to a local hospital on [DATE]. His [DIAGNOSES REDACTED]. Resident #139's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/19/2019 was coded as a quarterly assessment. Resident #139 was coded a BIMS (Brief Interview of Mental Status) score of 15/15 which indicated no cognitive impairment. He was totally dependent on the assistance of 1-2 persons for his activities of daily living. He was always incontinent of bowel and used a suprapubic catheter (a catheter that goes through the abdominal wall into the bladder) for urinary elimination. On 7/17/2019 a physician assessment indicated that Resident #139 was positive for a urinary tract infection. He was prescribed the antibiotic [MEDICATION NAME] to continue for 7 days. The (MONTH) 2019 MAR (Medication Administration Record) indicated that this medication was administered. However, there was no urinalysis culture and sensitivity report which would confirm the [DIAGNOSES REDACTED]. Thus, it was not certain that [MEDICATION NAME] was the proper antibiotic for this infection. There were no further notes indicating any distress for Resident #139 until 8/6/2019 at 2:01 AM. A note at that time indicated that he had experienced a large watery bowel movement, and he was unresponsive to painful stimuli. The physician was notified and he issued an order to transfer Resident #139 to the local hospital emergency department. Hospital records were obtained and reviewed. The records indicated that when Resident #139 arrived at the hospital he was still unresponsive and he was immediately intubated due to low respirations, altered mental status, and declining oxygen saturation. An initial urinalysis at the hospital showed a severe urinary tract infection, and bloodwork showed a [NAME] Blood Cell count of 24.9 (normal=4-11) indicating that an infection was present. There was dark tea colored urine in the urine bag. Resident #139 [DIAGNOSES REDACTED]. 2. For Resident #125, the facility staff failed to initiate a physician's orders [REDACTED]. Resident #125, a [AGE] year old male, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #125's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/21/2019 was coded as a quarterly assessment. Resident #125 was coded a BIMS (Brief Interview of Mental Status) score of 13/15, indicating no cognitive impairment. Resident #125 required extensive assistance of 1-2 persons for his activities of daily living and was coded as being always incontinent of bowel and bladder. On 7/18/2019 a wound care physician visited Resident #125 to provide care for lymphademic wounds on both feet. He prescribed gauze sponges to be applied to both feet and wrapped in gauze dressing. On 8/20/2019 at 3:00 PM, Resident #125 was seen on the outside patio in a wheelchair. His legs and feet were covered with Unna Boots, gauze bandages impregnated with zinc oxide and wrapped tightly around the lower legs and feet. This was not the treatment that the wound care physician had ordered. 3. For Resident #103, the facility staff failed to administer her [MEDICATION NAME] on 08/13/2019 as ordered by the physician. Resident #103, a [AGE] year old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #103's most recent Minimum Data Set with an Assessment Reference Date of 08/01/2019 was coded as an annual assessment. Total Severity Score for Mood was coded as 00 indicative of no depressive symptoms. Antidepressant Medications Received was coded as 7 meaning Resident #103 received an antidepressant each day during the 7-day look-back period. On 08/14/2019 at approximately 8:45 AM, Resident #103 was asked if she had any concerns. Resident #103 stated she did not receive her medications last evening. On 08/14/2019, the physician's orders [REDACTED]. On 08/14/2019 at approximately 10:45 AM, Registered Nurse B (RN B), the unit manager, was asked about the medications Resident #103 received on the evening of 08/13/2019. This surveyor and RN B observed the electronic Medication Administration Record [REDACTED]. All of Resident #103's evening medications were signed off as administered with the exception of [MEDICATION NAME]. For the administration of [MEDICATION NAME] (scheduled 08/13/2019 at 5pm), it was coded as 9 meaning Other/see Nurse Notes and signed by Licensed Practical Nurse D (LPN D). An eMAR note dated 08/13/2019 at 6:58 PM by LPN D documented, [MEDICATION NAME] tablet 10 mg Give 1 tablet by mouth in the evening for depression not available. On 08/14/2019 at approximately 11:00 AM, this surveyor and RN B approached the med cart to observe the medications available for Resident #103. There were 2 tablet cards of [MEDICATION NAME] ([MEDICATION NAME] 10 mg) for Resident #103. Each tablet card had a capacity for 30 tablets. There were 6 tablets remaining in one card and 17 tablets remaining in the other card. RN B and this surveyor also observed [MEDICATION NAME] tablet in the back-up box. On 08/14/2019 at 4:30 PM, an interview with LPN D was conducted. When told about the observation of [MEDICATION NAME] tablet cards in the med cart, LPN D stated that she didn't see them in the cart on 08/13/2019. The care plan was reviewed. A focus initiated on 12/15/2015 and revised on 10/17/2016 documented, (Resident #103) use anti-depressant medication for dx (diagnosis) of major [MEDICAL CONDITION]. The goal associated with this focus (revised on 08/08/2019) had a target date of 11/14/2019 and documented, (Resident #103) will have no issues related to anti depressant use thru (sic) next review date. An intervention associated with this focus/goal initiated on 03/01/2016 documented, Medication as ordered (see MAR). According to Lippincott Manual of Nursing Practice, 10th edition, 2014, under the header, Standards of Practice, it was documented that common departures from the standards of nursing care included failure to administer medications properly and in a timely fashion or to report and administer omitted doses appropriately. The facility staff provided a copy of their policy entitled, General Dose Preparation and Medication Administration. Procedures associated with medication unavailability were not addressed in the policy. On 06/20/2019 at approximately 7:45 PM, the administrator and the DON had no further information or documentation to offer. 4. For Resident #109 the facility staff failed provide timely comprehensive wound care. Resident #109 was re-admitted to the facility on [DATE] for rehab after a fall and fracture of her right knee with surgery to repair it. The Resident wore a knee immobilizer when she returned to the facility. The resident had a history of [REDACTED]. Resident #109's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 7-17-19. Resident #109 was coded with a Brief Interview of Mental Status score of 13 out of a possible 15 indicating no cognitive impairment. Resident #109 required limited assistance of one staff member for all activities of daily living except locomotion off of the unit which required extensive assistance with a wheel chair. The Resident was coded as having a surgical wound which required wound care. On 8-14-19 at approximately 3:00 p.m , the Resident was interviewed in her room and she refused to allow the knee dressing to be removed to view the wound. Physician orders [REDACTED]. 1. Ordered 6-15-19 to begin 6-16-19 - Remove immobilizer to right knee every day to access area for skin breakdown. The Treatment Administration Record (TAR) documented this as having been completed by staff. 2. Ordered 7-9-19 - Consult wound care as needed. 3. Ordered 7-9-19 - Weekly skin checks every Wednesday to begin 7-10-19, and every Saturday to begin 7-13-19. This appeared on the TAR, however, only for Wednesdays, and not for Saturdays, as the physicians orders required. Skin checks were not completed on Wednesday 8-7-19, and were never completed on Saturdays. 4. Ordered 7-26-19 - TheraHoney sheet (wound dressing) apply to right knee topically every day shift for wound healing cleanse with normal saline and apply dry dressing. Discontinued 8-8-19. 5. Ordered 8-8-19 [MEDICATION NAME] capsule (antibiotic) 500 mg every six hours (to be given at 12mn, 6 a.m., 12 noon, and 6 p.m.) by mouth for surgical site infection for 7 days. To start on 8-9-19. The MAR (Medication Administration Record) revealed that on all four administration times for 8-9-19, 8-10-19, 8-11-19, and on 8-12-19 at midnight only, nurses documented the code U (which means unknown in the MAR indicated [REDACTED]. The medication was not administered for 3 days after ordered, and was omitted for a total of 13 doses. The facility stat box contents were reviewed and [MEDICATION NAME] (Keflex) was available in the facility stat medication box for immediate need of administration. 6. Ordered 8-9-19 - Santyl Ointment (enzymatic removal agent for dead necrotic tissue) 250 unit/GM (grams) apply to right knee topically every day shift for wound healing cleanse with normal saline apply Santyl and cover with dry dressing. To start 8-9-19, and was not completed on 8-12-19. Review of the nursing notes documented by LPN C (wound nurse) indicated that on 8-3-19 the interdisciplinary team met and discussed the findings by Licensed practical Nurse (LPN) C. He had assessed the knee and had documented the following: On 8-3-19 at 4:46 p.m., the nurse wrote slight slough and drainage from the incision (surgical site) noted to right knee, also redness around wound bed noted. Continue with current treatment orders, will continue to monitor daily. No other nursing notes describe the wound until 3 days later 8-6-19 at 2:29 p.m., when LPN C documents again Wound to right knee 30% slough and drainage from incision (surgical wound still closed) noted to right knee, also redness around wound bed noted, no odor noted, will continue to monitor. The Resident continues to complain of knee pain in the notes daily. On 8-8-19 a social work note describes that the social worker has set up transportation to an orthopedic appointment scheduled for 8-16-19, at 10:30 a.m. On 8-9-19 the Resident continues to complain of knee pain. A nursing note describes the Resident as continue oral antibiotic related to right knee wound. Which is documented as not given on the MAR, and small amount purulent (infected pus) blood tinged drainage, and resident tolerates well (wound care). On 8-12-19 the nursing note documents at 1:56 a.m., patient continues on antibiotic from right knee infection. However, this was documented as not given on the MAR. From 8-13-19 through the time of survey the Resident continued to complain of pain and was administered pain medication with effective results. physician progress notes [REDACTED]. The note revealed a [DIAGNOSES REDACTED]. All (MONTH) 2019 Weekly skin integrity review(WSIR) 2 page assessment documents , and Non-pressure Skin Condition (NPSC) 3 page assessment documents, were reviewed and revealed that LPN C assessed the wound and documented the following; WSIR On 8-1-19, No description, only: Right knee open area treatment in place. NPSC On 8-1-19, left leg, drainage small to medium amount, yellow, purulent, with no odor, wound edges intact. NPSC On 8-6-19, left knee (front), drainage small to medium amount, pink/red, purulent, with no odor, peri wound area intact. WSIR On 8-8-19, Right knee (front) surgical incision-recent knee surgery/broken patella (knee cap), skin intact. The surgical incision was in the right knee, and all 4 of these assessments were conducted by LPN C. LPN C was interviewed by surveyors and stated he may have made some errors, and it was the right knee. The care plan was reviewed and revealed the following: F[NAME]US - initiation Dated 7-31-19 - The Resident is at risk for metabolic complications related to [DIAGNOSES REDACTED]. INTERVENTIONS - If infection present consult doctor regarding any changes in diabetic medications. Monitor/document/report as needed any signs symptoms of infection to any open areas: Redness, pain, heat, swelling, or pus formation. F[NAME]US - initiation all Dated 8-9-19, unless another date is listed - (name) the Resident has right knee unhealed surgical wound. INTERVENTION - Administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing. Monitor dressing to ensure it is intact and adhering. Report loose dressing to nurse. Monitor/document/report as needed any changes in skin status. Observe for pain during wound care. Remove immobilizer to right knee daily and as needed to assess for skin integrity (7-31-19). Administer antibiotic per doctor's order (7-9-19). The facility Administrator and her team were advised of the failure of staff to provide timely comprehensive wound care for Resident #109 on 8-20-19 at the end of day meeting. They presented no further information.

Based on observation, resident interview, staff interview, facility documentation review, clinical record review and in the course of a complaint investigation, the facility staff failed to ensure Residents are free from abuse, neglect, misappropriation of resident property and exploitation for 10 Residents (Resident #184, Resident #176 Resident #94, Resident #125, Resident #327, Resident #76, Resident #29, Resident #102, Resident #97, Resident #2) in a survey sample of 76 Residents. This resulted in harm for Residents #187, #176, #125, #76, and #2. Immediate Jeopardy was identified on 06/18/2019 at 2:25 pm at which time the facility was notified. After verification, Immediate Jeopardy was abated on 06/20/2019 at 3:40 pm and the scope and severity was lowered to a Level three pattern. The findings included: 1. The facility failed to protect Resident #184 from being sexually abused by another Resident. This is harm. Resident #184, a [AGE] year old female, was admitted to the facility on [DATE]. Her medical history includes [MEDICAL CONDITION]([MEDICAL CONDITION]-Stroke) causing right side weakness and [MEDICAL CONDITION]. Her BIMS (Brief Interview of Mental Status) could not be determined and she was assessed as having severe cognitive deficiencies via a staff assessment. Resident #184 was fully ambulatory. On 4/22/2019 at approximately 4:00 PM Resident #184 was in the day room where she was assaulted by Resident #21. Resident #119 saw Resident #21 place his hand inside the front of Resident #184's pants. She summoned a nurse who intervened and stopped the assault. Resident #184 would not allow the staff to examine her for injury, and the decision was made to send her to the hospital for evaluation. Adult Protective Services and local police were notified. Hospital records were obtained and revealed that there was evidence of laceration in the vaginal area. The record stated SANE (Sexual Assault Nurse Examiner) reports posterior fourchette laceration and other evidence of sexual activity. Patient unable to provide subjective information due to underlying medical conditions. Resident #184 was held in the hospital overnight for observation and released to another local facility on 4/23/2019. On 6/5/2019 at noon an interview was conducted with Employee A, Administrator. She stated that Resident #21 was placed on 1:1 observation immediately after the incident. He remained on 1:1 observation until 6/3/2019. She stated that he did not exhibit any further behaviors to justify 1:1 observation. She stated that the local police investigated the incident and did not press charges against Resident #21 since he had dementia. She stated that Resident #21 denied any wrongdoing towards Resident # 184. On 6/5/2019 at 8:25 AM, an interview was conducted with Resident # 119. She stated that she saw Resident #21 force his hand into Resident #184's pants while in the dayroom. She summoned a nurse who stopped the assault. She further stated that, on 6/3/2019, while she was sitting in the day room, Resident #21 looked at her and grabbed and rubbed his crotch. She ignored him and he went away. This was the same day that 1:1 observation was discontinued. Resident #119 had a BIMS of 13 indicating no cognitive impairment. On 6/5/2019 at 11:45 AM Resident #21 was seen in his room eating lunch. He was alert and oriented and he was pleasant. Resident #21, an [AGE] year old male, was readmitted to the facility on [DATE]. He had [DIAGNOSES REDACTED]. He had a BIMS score of 15/15 indicating no cognitive impairment. Resident #21 had a documented history of sexual misconduct during his residence in the facility. There were 9 separate entries since (YEAR) in progress notes stating resident has a history of inappropriate sexual behavior. In (YEAR) there were two separate FRI's (Facility Reported Incidents) where Resident #21 was receiving oral sex from another resident. These incidents were in Resident #21's Care Plan advising of his sexual behavior. His current Care Plan states Resident has a behavior problem related to inappropriate sexual incidents. Resident #21's behavior was well known and documented. The facility did not protect Resident #184 from being injured by Resident #21. 2. For Resident #176 the facility staff neglected to properly assess Resident #176 and seek out further medical attention. This is harm. Resident #176 a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident's most recent (Minimum Data Set) MDS with an Assessment Reference Date of 6/28/18 coded as a Quarterly Assessment coded Resident as having a (Brief Interview of Mental Status) BIMS score of 15 indicating no cognitive impairment. Resident #176 was also listed as her own (Responsible Party) RP. An entry into the progress notes on 7/4/19 states that the resident requested that to be sent out to the emergency room due to complaints of Nausea Vomiting and Diarrhea, and having just completed antibiotics for [MEDICAL CONDITION] (an inflammation of the colon caused by bacteria). An excerpt from the progress notes dated 7/4/2018 at 3:22 AM reads, she wanted to get anxiety med but wasn't due for it. she (sic) received pain and n/v (nausea/vomiting) med an hour before. she (sic) had large bm (bowel movement) loose and sm (small) amt (amount) of vomitus, she asked if she could go to the hospital since nurse could not give anxiety (sic) med, and was informed that was not an emergency. Resident then called the rescue squad from her cell phone and according to EMS Report dated 7/4/19 the EMS squad was dispatched to the facility and was met at the door by a nurse who stated that she didn't call EMS and it must be a false alarm. The report goes on to further state the resident stated she called 911 because the facility staff refuse to take care of her or send her to the hospital, she stated they won't even take my blood pressure. The EMS report stated that as she was being prepared for transport they noticed a large amount of dark loose stools soaking the bed and the resident. They further state that Resident #176 stated she had been that way for a while that the staff refused to clean her up. An excerpt from the EMS report stated While leaving (facility name redacted) some remarks are exchanged between the patient and a nurse . for calling 911. An excerpt from the medical record dated Resident presented to the ER with Nausea Vomiting and Diarrhea. Patient states she has been ill for the last week with profuse diarrhea. Patient was admitted here from 6/17/18-6/20/18 [MEDICAL CONDITION] due to C- Diff [MEDICAL CONDITION] and was discharged on [MEDICATION NAME] PO (by mouth). The patient finished her Antibiotics on 7/2/18. Pt has end stage [MEDICAL CONDITION] and has not missed any of her [MEDICAL TREATMENT] sessions. Patient has appearance of dried blood on side of mouth pt. admits to having hematemesis (vomiting blood). An excerpt from the hospital report states Pt brief changed by this RN and (name redacted) RN and (name redacted) RN, pt. completely soiled from head to toe in black dried tarry stool. When asked if she had contacted the staff to come and change her she stated she did multiple times but no one came. Pt states that she was also on the bedpan for 2 1/2 hours at one point tonight and finally someone came to take her off. She is frustrated that she hasn't received any care in the last 2 days at (facility name redacted). Hemoglobin on arrival to ER - 4.5 Normal Range -12.0 -16.0 (grams per deciliter) gm/dl Hematocrit on arrival to ER - 15.1 % Normal Range - 37 - 47% (Hemoglobin measures protein in red blood cells responsible for delivering oxygen. Hematocrit measure the volume of red blood cells compared to the total blood volume) The Resident was admitted to the Intensive Care Unit for critically low Hemoglobin and Hematocrit due to GI Bleed. On 6/11/19 at 10:00 AM in an interview with the DON she stated If a resident is her own RP and requests to seek emergency medical attention we should get a set of vitals and notify MD of Resident desire to be transferred to ER and then call 911. A resident should never have to call the EMS by themselves. When asked how often should incontinent care be provided to residents she stated It is the expectation of the facility that CNA's make rounds a minimum of every two hours to check for incontinent needs and change the resident every two hours and PRN. She also stated that No resident should be left on a bedpan for 2 1/2 hours that can cause breakdown. When asked what black tarry loose stools indicates she stated it is the sign of a Gastro-Intestinal bleed. On 6/20/19 during end of day meeting the facility Administrator was made aware of findings and no further information was provided. 3. For Resident #94 the facility staff failed to ensure resident was free from abuse and neglect related to injury of unknown origin. Resident #94, an [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#94 as having a (Brief Interview of Mental Status) score of 99 indicating she was unable to answer questions. Her MDS also coded the Resident as a total care patient with 1 person physical assistance for bed mobility, feeding, dressing, bathing, and a 2 person physical assist for all transfers. According to a (Facility Related Incident) FRI on 5/6/19, Resident #94 was found (by family) to have a hematoma to her left forehead and a discolored area to left side of her face near her left eye. The facility did an investigation and informed the authorities. On 6/13/19 at 2:15 PM an interview was conducted with family member who stated that the bruise and swelling was found by the family. They reported it to the charge nurse and they also stated they were at the facility on the previous evening and she did not have the swelling or bruise. The facility doctor ordered x-ray but the family preferred to have her examined at the hospital. An excerpt from the CT Scan Reports reads Mild scalp soft tissue swelling at the left vertex without underlying skull fracture. According to the Witness Statements provided by facility CNA G (who has been named in another abuse allegation during this survey) was assigned to the Resident and stated I washed her up and had to roll her side to side to pull up her pants. According to the Findings of the facility investigation, It appears that her head hit the left side of assistance rail of the bed to cause the swelling. On 6/13/19 during the interview the family member stated She does not move, if you put her in a position she will stay that way. I know this because I see her every day. I come here every day to make sure she is fed and taken care of She couldn't have rolled over into that rail, she is not able to move her body. During the end of day meeting on 6/20/19 the Administrator was made aware and no new information was provided. 4. For Resident #125 the facility staff neglected to assist the resident to the restroom and the resident urinate on himself (resulting in humiliation) and failed to address back pain Resident was experiencing. This is harm. Resident # 125, a [AGE] year old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Resident 125's most recent MDS dated [DATE], coded as a PPS 5 Day, the Resident has a (Brief Interview of Mental Status) score of 15 indicating no cognitive impairment. The MDS also codes him as Extensive Assist with 1 person physical assist needed for Bathing, Dressing, Toileting, Bed Mobility, and Transfers. On 6/7/19 at 9:15 AM this surveyor was told by Resident #125 that he called 911 to go to the ER because he was in so much pain in his back. He stated I rang that call bell and no one answered, I needed help getting to the bathroom. I had been on a metal table getting a scan today and I was hurting so bad I couldn't even sit up by myself. I kept trying to get help and get my [MEDICATION NAME] for muscle spasms but no one would come. I couldn't hold it any longer and I ended up peeing on myself that was so humiliating. He further stated that he waited so long for someone to answer that he called 911 himself around 130 AM. He said A nurse finally came in and I told her I called 911 and she said we better get you cleaned up so they don't think we neglected you. According to the EMS Report the Rescue Squad arrived at the facility at 1:36 AM. In an interview with the DON on 6/7/19 at 10:30 AM she stated that she had a call out and asked the 3-11 nurse to stay and that nurse got angry left her keys and left the building. She left at 11:41 PM according to her time clock report. The DON stated she spoke with her and told her she couldn't leave her patients. The nurse did not return until 1:30 AM. In an interview with the nurse who left (an RN) she stated she did not abandon her patients that she left and came back a couple of hours later. She stated she had something to do that couldn't wait. She further stated that her coworkers were aware of her leaving and the need to cover her patients. An excerpt from a written statement provided by the Administrator He used his cell phone to call EMS himself. Nurse assisted EMS staff and (name redacted) was transferred to the ER per his request. Nursing Progress Notes dated 6/7/19 at 7:07 AM read Resident called 911 because of back pain refused to take medicine. Sent via Ambulance Resident is own RP. MD made aware. Nursing Progress Notes dated 6/7/19 at 2:30 PM Resident stated that he called 911 due to increased pain. Resident stated the pain was unbearable and he felt he needed to go to the ER. An excerpt from the Hospital ER Report reads Hx of [MEDICAL CONDITION] and chronic back pain States had a DaT Scan today at (hospital name redacted) 1:00 PM -and his chronic back pain began to hurt-- has asked the Staff at (facility name redacted) for his [MEDICATION NAME] and they wouldn't give him any-- thus he called 911. During the end of day meeting on 6/20/19 the Administrator was made aware of the issues and no further information was provided. 5. For Resident # 327 the facility staff failed to ensure Resident was transported safely in wheel chair by staff. Resident #327, a [AGE] year old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #327 does not have an MDS due to being a new admission. On 6/20/19 this surveyor was informed by Administrator that she sent in a FRI involving Resident #327. Administrator submitted the FRI investigation folder to survey team and it was noted that witness statement, signed by CNA G states: Around 4 PM or after (room number) asked me to take him to therapy to get walker. Therapy grab walker & me therapist & resident went back to (room number). When I got to the room the resident asked the therapist about help to get back to bed I stopped the chair at the door and walked back to the nurse's station. Therapist came out of the room & stated that I pushed the resident into him. I said I did not push him into you the must (sic) continued to roll there after I said MY Bad it was not my intention to have him roll into you. Therapist continued to argue with me stating that I pushed him into him. I then said OK Conversation over and walked away. According to the Witness Statement from the Therapist: Finished w/treatment coming back to rehab w/aid & resident went back to room with him (therapist name redacted) and CNA pushed him in the room PT asked why did you not lock the breaks to CNA and CNA said Why should I. PT assumed the wheelchair was pushed by CNA based on him flying by and unable to push chair. According to the Witness statement by the Resident: She really didn't push me I was talking to the Therapist and when she pushed me in the room my wheel chair hit his leg (Therapist) but she wasn't intentionally being mean or tying to be abusive. When I turned around she was gone (resident name) OH Lord! Interview was conducted with the Therapist. When asked what happened he stated that they were walking back to the room and he went in first and then the next thing he knew the Resident wheelchair hit him in the leg not hard to hurt but it the CNA was gone so it was clear the CNA pushed him in the room and didn't wait to put on the breaks or see if he was safe she just pushed him in to the room and kept on walking. I asked her why she did that and she said you were in there. In an interview with the Administrator she stated that CNA G had just had her abuse and neglect training on 6/18/19. She also stated this is the second allegation involving CNA [NAME] CNA G was suspended during the investigation, attempts to contact CNA G were unsuccessful. On 6/20/19 during the end of day meeting the Administrator was made aware of the findings and provided no further information. 6. For resident # 76 the facility staff neglected to properly assess and treat wounds resulting in hospitalization . This is harm. Resident # 76, a [AGE] year old man who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #76's Responsible Party is his sister. The most recent (Minimum Data Set) MDS coded as a quarterly with an Assessment Reference Date of 4/22/19 coded as a Quarterly coded Resident as extensive assistance for bed mobility with physical assist of 1, total dependence with a mechanical lift and physical assist of 2 + persons, bathing and dressing requires physical assist of 2 people, mobility is coded as wheelchair with physical assist of 1. On 6/7/19 Resident #76 sat in his wheelchair in the day room area legs and feet wrapped in ace bandage and very swollen. When attempting to interview Resident #76 he stated I am with the FBI and CIA and I'm undercover here. On 6/7/19 during a clinical record review it was found that Resident # 76 had been admitted to the hospital on [DATE]. According to the Progress Notes: 4/9/19 11:42 AM- Nursing Progress Note-Resident observed slumped over in wheelchair, pillow under left arm for stablization.(sic) No change in L[NAME] (level of consciousness) but apparent weakness and distress, able to slowly converse with undersigned. Physically unable to sit upright in wheelchair or complete ROM (range of motion), complaint of stomach hurting. Increased [MEDICAL CONDITION]- Bilateral Extremities. Vitals 134/73 -122 - 16- 100%. Supervisor (sic) /MD notified. 911 called. EMT arrived. unable to transfer patient with sit to stand lift due to weakness, resident sent out to ED for eval. According to the Hospital Discharge Report: Pt brought in via EMS from (facility name redacted) for fevers and AMS (altered mental status). (Facility name redacted) reports fevers as high as 104.5 and has not been acting himself for the last three days. Pt has lower leg swelling and [MEDICAL CONDITION] that are oozing. Pt arrives with lower extremities wrapped in ace bandage, two stage III open wounds wrapped in lower thighs, and pt. incontinent of stool. Pt states I don't feel good and I got bit by a snake. Pt [MEDICAL CONDITION] (rapid heart rate) on the monitor, hot to touch, temperature 103. Pt unreliable historian states I been throwing up snakes maybe one of them bit me. Presenting from (facility name redacted) unkempt and covered in feces and urine. Stage III decubitus ulcers on posterior thigh with chronic sever [MEDICAL CONDITION] Sepsis due to Streptococcus pyogenes POA (present on arrival) YES Pressure injury Stage III- POA - YES -[MEDICAL CONDITION] of Left Thigh POA - YES - Pt was admitted with findings consistent [MEDICAL CONDITION] with acute metabolic [MEDICAL CONDITION], diarrhea, [DIAGNOSES REDACTED], lactic acidosis. Chest X-Ray Impression - Streaky bibasilar parenchymal opacity which suggests Aspiration Pneumonia. Pt presenting from (facility name redacted) unkempt and covered in feces and urine. He developed decubitus (pressure ulcers) in the posterior portion of his thighs also has chronic weeping wounds was diagnosed with [REDACTED]. Later found to have out of 2/2 bottles (blood cultures) positive for Streptococcus pyogenes. Started on [MEDICATION NAME] and [MEDICATION NAME] with significant improvement. Will need at least 14 days of Antibiotic therapy, was recent blood cultures drawn on 4/11/19. Will need PICC (Peripherally Inserted Central Catheter) line placed once bacteria clearance has been documented. Hospital discharge instructions stated: Follow up with (facility name redacted) Wound Clinic is recommended Recommended Studies on Follow up - BMP (Basic Metabolic Panel) on 4/20/19 with dose adjustments of potassium supplement depending on serum potassium levels. On 6/17/19 at 9:45AM this surveyor requested to see copies of labs done on or around 4/20/19 as per discharge instructions. On 6/19/19 at 3: 00 PM this surveyor again requested the labs recommended on discharge- DON stated They were not done until this morning. I will get you the results. When asked if the Resident was followed up with the recommended wound clinic wound nurse Employee stated we do his wound care in house. On 6/20/19 during end of day meeting Administrator was made aware of findings and no further information was provided. 7. For Resident #29 the facility staff neglected to provided supervision during a shower resulting in a fall with injury. Resident #29 a [AGE] year old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His latest MDS coded as a Quarterly with an (Assessment Reference Date) ARD of 3/14/19 codes the Resident as having a (Brief Interview of Mental Status) Score of 13 indicating mild cognitive impairment. His MDS also codes this Resident as needing Supervision for Bathing Toileting and Personal Hygiene and 1 person physical assist. On 6/17/19 approximately 1:00 PM this surveyor observed Resident #29 being loaded into ambulance. Upon inquiry this surveyor was told Resident #29 had fallen during his shower. Nursing progress notes from that day read: Resident's aide reported to the nurse that he resident told her he fell in the shower room. Resident was asked by the nurse how did he get himself up? He responded that he placed some towels on the floor and got up on his knees and he got in the wheelchair. No skin tear was noted, he was alert and oriented X4, he c/o (complained of) severe back and neck pain. He rated his pain as 8-9 on a 0-10 scale. He received 2 Tylenol for pain. Resident requested to go to ER for evaluation and treatment. H was sent to the ER with care plan, transfer SBAR and bed hold. NP and MD did not answer telephone calls. Unit manager made aware and resident is the responsible party. On 6/17/19 during clinical record review it was noted that according to the care plan, the Resident was on Fall Protocol since 12/3/18. Resident's Physicians Orders reveal that the Resident was on the following medications: [REDACTED] [MEDICATION NAME] ER ([MEDICATION NAME] Extended Release, an anti-anxiety medication) Trintellix (Anti-Depressant) [MEDICATION NAME] Patch 50 (Micrograms) mcg/hr. (Narcotic pain patch) [MEDICATION NAME] (muscle relaxer) [MEDICATION NAME] (narcotic pain medication) PRN [MEDICATION NAME] 0.5 mg PRN (as needed) [MEDICATION NAME] ([MEDICATION NAME]) ([MEDICAL CONDITION] medication also given for neuropathic pain) On 6/19/19 at 10:00 AM in an interview with Resident # 29 when asked how he got into the bathroom and if he knew the code to the bathroom door, he stated No the CNA (CNA G name redacted) let me in. They always let me in to do my shower alone. All the CNA's know I shower alone. Resident #29 went on to explain how he fell , he stated that the floor drain backed up and there was a lot of water on the floor and when he went to move from the shower chair to the wheelchair the wheelchair slid and he feel injuring his back and neck. He went on to say he managed to get himself up into the wheelchair and that he then reported to the CNA that he fell . In an interview with DON on 6/19/19 at 11:00 AM, the DON was asked if a resident is taking these medications what some of the possible side effects are. She indicated that dizziness and drowsiness are side effects for the narcotics as well as the anti-anxiety and possibly the muscle relaxer and [MEDICATION NAME] as well. The DON stated, No patient should be left alone to shower if they are not care planned for independent bathing and hygiene, especially on those combinations of medicines. A copy of the Fall Protocol mentioned in the Care Plan was requested. However, the DON stated, We don't have an official policy for that we just notify the doctor and try to find the root cause of why they fell . During the end of day conference on 6/20/19 the Administrator was made aware of the findings and no further information was provided. 8. For Resident #102, the facility staff failed to prevent neglect, assist her with her meals, and prevent a significant weight loss of 6.26% in 13 days. Resident #102, a [AGE] year old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #102's most recent Minimum Data Set with an Assessment Reference Date of 05/05/2019 was coded as a significant change in status assessment. The Brief Interview for Mental Status was coded as 9 out of possible 15 indicative of moderate cognitive impairment. Functional status for bed mobility and dressing were coded as requiring extensive assistance from staff. Functional status for eating was coded as requiring supervision/encouragement/cueing from staff and set-up help only for support. On 06/06/2019 at 2:41 PM, Resident #102 was observed in her bed sleeping wearing a pink sweatshirt and brief and lying on her left side. Resident #102 was partially covered with a sheet. Resident #102 appeared thin. The food tray from lunch was on her tray table which was partially over her bed. The lunch tray had a manwich, green beans, strawberry shortcake and a peanut butter and jelly sandwich, all uneaten. There was a small bowl of macaroni salad with a spoon in it and there appeared to be approximately a spoonful of macaroni salad removed. There were bits of macaroni salad observed on her sheets next to her. On 06/06/2019 at approximately 6:30 PM, Resident #102 was observed in her bed. The bed was flat and the dinner tray was on the tray table that was positioned perpendicular to the bed over Resident #102's bed. Resident #102 was propped up on one elbow and the tray table was still at a height above her head. Resident #102 had an eating utensil in her other hand and was observed struggling to reach up and over to access her food. Resident #102 was attempting to scoop food and food was falling onto her head and chest and sheets. Surveyor D alerted Certified Nurse Assistant C (CNA C) that (Resident #102) needed assistance. CNA C entered the room. Resident #102 reached out to CNA C and stated, Help. CNA C stated to Resident #102, You can't eat like this, let me sit you up. CNA C attempted to raise the head of the bed with the bed controller but it was not functioning. Another CNA (CNA E) entered the room. CNA C stated to CNA [NAME] This isn't good and went on to explain that (Resident #102) was lying flat trying to eat and food was all over her. A third CNA, CNA D, entered the room and fixed the bed controller function by adjusting a cable under the bed. When CNA C left the room after rendering care, she stated to Surveyor D it would be a good idea if (Resident #102) had supervision when eating. On 06/12/2019, the clinical record was reviewed. On 05/01/2019, Resident #102 weighed 97.6 pounds (mechanical lift). On 06/04/2019, the resident weighed 102.2 pounds (mechanical lift) which is a 4.71 % Gain in 34 days. On 12/03/2018, the resident weighed 100 lbs. (scale type not recorded). On 06/04/2019, Resident #102 weighed 102.2 pounds (mechanical lift) which is a 2.20 % Gain in 6 months. A dietary note dated 03/27/2019 at 4:53 PM documented, Resident discussed in weekly IDT (interdisciplinary team) meeting. Triggers for 7.5%, 8# (pound) weight loss x 1 month. CBW (current body weight) 99.2# (pounds) BMI 18.18 (underweight). Regular diet with fortified foods; intakes 26 to 100% of meals. Multiple supplements: Health shake with meals, Magic Cup BID (twice a day), Med Pass 120 ml TID (three times a day). Dx (diagnosis) [MEDICAL CONDITIONS], dementia; weight loss may be unavoidable r/t (related to) dx (diagnosis) and disease progression. Despite trigger for weight loss, weights have stabilized. Continue P[NAME] (plan of care). Under the header Subjective on the nurse practitioner provider note dated 04/02/2019 (6 days later) , it was documented, (Resident #102) requires total assistance with ADL (activities of daily living) care, transfers and set up with meals. In an excerpt under the header ROS (review of systems), it was documented, patient denies any recent changes in weight. A dietary note dated 04/11/2019 at 11:22 AM documented, Resident discussed in weekly IDT meeting. Triggers for a 5.4% weight gain in 2 weeks, desired gain. CBW 101.6# (pounds) BMI 18.6 (borderline). Regular diet with fortified foods; intakes 26 to 100% of meals. Multiple supplements: Health shake with meals, Magic Cup BID (twice a day), Med Pass 120 ml TID (three times a day). Dx (diagnosis) [MEDICAL CONDITIONS], dementia; weight loss may be unavoidable r/t (related to) dx (diagnosis) and disease progression. Resident noted often refusing to leave bed. On restorative feeds - discussed encouraging resident to sit up for meals. Despite trigger for weight loss, weights have stabilized. Continue P[NAME] (plan of care). On 06/13/2019 at approximately 10:15 AM, the unit manager Licensed Practical Nurse C (LPN C) was notified of observations on 06/06/2019 and stated that all residents should be set up to eat so they can get to their food. On 06/17/2019 at approximately 11:55 AM, this surveyor observed CNA K obtain a weight via mechanical lift for Resident #102. Her weight was 95.8 pounds. On 06/04/2019, Resident #102 weighed 102.2 pounds (mechanical lift). On 06/17/2019, Resident #102 weighed 95.8 pounds (mechanical lift) which is a 6.26% weight loss in 13 days. Resident #102's height was 52 inches so body mass index (BMI) value decreased to 17.5. The facility provided a copy of their policy entitled, Abuse, Neglect, Exploitation & Misappropriation. In an excerpt under the header Neglect, it was documented, Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid harm, pain, mental anguish or emotional distress. Examples include but are not limited to: Failure to provide adequate nutrition and fluids. On 06/20/2019 at the end of survey, the interim administrator had no further information or documentation to offer. 9. For Resident #97, the facility staff failed to protect her right to be free from abuse by a staff member on 05/11/2019. Resident #97, a [AGE] year old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #97's most recent Minimum Data Set with an Assessment Reference Date of 05/02/2019 was coded as a quarterly review. The Brief Interview for Mental Status was co

Based on Resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to prevent and or promote healing of pressure areas for 2 Residents (121 and 376) in a survey sample of 76 Residents. This resulted in harm for Resident 121 and 376. The findings include: 1. For Resident #121, the facility staff discovered 4 wounds that were Stage III pressure injuries with slough in the wound beds. This is harm. Resident #121, a [AGE] year old male, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #121's most recent Minimum Data Set with an Assessment Reference Date of 05/15/2019 was coded as a quarterly review. The Brief Interview for Mental Status was coded as 00 out of 15 indicative of severe cognitive impairment. Functional status for bed mobility and transfers were coded as requiring extensive assistance from staff. Walking in room and corridor were coded as not occurring. Functional status for eating was coded as requiring supervision from staff (one-person physical assist for support). Current number of unhealed pressure ulcers were coded as 0 (meaning none) for Stage I pressure injuries, 0 for Stage II pressure injuries, 1 (meaning 1) for Stage III pressure injuries, and 0 for Stage IV pressure injuries. On 06/12/2019, the clinical record was reviewed. The physician orders [REDACTED]. Right hip inferior wound - cleanse with wound cleanser, pat dry, apply hydrogel to wound bed and cover with foam dressing daily and as needed. Every day shift for wound care. Right hip Superior wound - cleanse with wound cleanser, pat dry, apply a hydrogel to wound bed and cover with foam dressing daily and as needed. Every day shift for wound care. Right hip wound - cleanse with wound cleanser, pat dry, apply hydrogel to wound bed and cover with foam dressing daily and as needed. Every day shift for wound care. Right trochanter superior wound - cleanse with wound cleanser, pat dry, apply hydrogel to wound bed and cover with foam dressing daily and as needed. Every day shift for wound care. Right upper buttock wound, cleanse with wound cleanser, pat dry, apply hydrogel to wound bed and cover with foam dressing daily and as needed. Every day shift. An active order dated 05/07/2019 documented, Weekly skin checks. Two active orders dated 05/07/2019 documented, Pressure reducing mattress and Pressure reducing cushion to wheelchair. An order dated 04/30/2019 documented, Regular diet, mechanical soft texture, honey thickened fluids consistency, for dysphagia. The diet was changed in an order dated 05/13/2019 that documented, Regular diet mechanical soft texture, thin liquids consistency, double portions related to dysphagia. An order dated 04/23/2019 documented, Vitamin D3 tablet 1000 unit Give 1 tablet by mouth on time a day for supplement. There were no other orders for supplements or vitamins. The weight flowsheet was reviewed. Resident #121's height was 77 inches on date of admission (04/22/2019) and a standing weight value dated 04/23/2019 was 161.2 pounds. On 05/01/2019, a standing weight of 158 pounds was documented. On 05/15/2019, a standing weight of 157.6 pounds was documented. On 05/22/2019, a wheelchair weight of 155.2 pounds was documented. A wheelchair weight dated 05/22/2019 was 158.8 pounds and a standing weight dated 06/04/2019 was 164.4 pounds. A nurse's note dated 05/09/2019 at 10:00 AM entered by RN C documented, Resident with Stage III to right superior hip 1x1.5x0.1 20% pink wound base 80% white slough, Stage III to middle right hip 0.5 x 0.5 x 0.1 20% pink wound base 80% white slough, Stage III to right inferior hip 0.2 x 0.2 x 0.1 50% pink wound bed 50% white slough, Stage II to right trochanter upper 1.5 x 2 x 0.1 pink wound base, Stage II right trochanter lower 0.2 x 0.2 x 0.1. Pink wound base. All wounds above in close proximity of one another. Stage III to right upper buttock 1.7 x 0.7 x 0.2 20% pink wound base 80% white slough. RP and NP aware. New treatments in place in performed by this nurse. The skin assessment documents were reviewed. Each Stage III wound discovered on 05/09/2019 was evaluated by RN C weekly as follows: Right hip superior: 05/09/2019: 1 x 1.5 x 0.1, Stage III, 20% pink wound bed, 80% white slough 05/15/2019: 1 x 1 x 0.1, wound bed granulation 05/28/2019: wound has closed Right hip middle: 05/09/2019: 0.5 x 0.5 x 0.1, Stage III, 20% pink wound bed, 80% white slough 05/15/2019: 0.1 x 0.1 x 0, wound bed [MEDICATION NAME] Right hip inferior: 05/09/2019: 0.2 x 0.2 x 0.1, Stage III, 50% pink wound bed, 50% white slough 05/15/2019: 0.1 x 0.1 x 0, wound bed [MEDICATION NAME] Right buttock: 05/09/2019: 1.7 x 0.7 x 0.2, Stage III, 20% pink wound bed, 80% white slough 05/15/2019: 1.5 x 0.5 x 0, wound bed [MEDICATION NAME] A provider progress note dated 05/11/2019 (by the nurse practitioner that ordered the wound treatments on 05/09/2019) documented under the header entitled, Skin: Normal, no rashes, no [MEDICAL CONDITION] noted. A nurse's note dated 5/15/2019 at 11:15 AM written by RN C documented, Stage III to right hip superior to other wounds 1 x 1 x 0.1, decreased in size, no slough present, pink wound bed, Stage III to right hip (middle) in between superior and inferior hip wound 0.1 x 0.1 x 0 pink area, no longer open. Stage III to right hip inferior to other wounds 0.1 x 0.1 x 0 pink area, no longer open, Stage III to right upper buttock 1.5 x 1.5 x 0 red area, no longer open, Stage II to right trochanter superior to other wound to same area 1 x 1 x 0 red area, no longer open, Stage II to right trochanter inferior to other wound of same area 0.1 x 0.1 x 0 red area, no longer open. Will continue to monitor closed areas for reoccurrence. Current treatment to open area with hydrogel. NP in RP aware. On 06/13/2019 at approximately 1:50 PM, Registered Nurse C (RN C, wound care nurse) and this surveyor performed a skin assessment on Resident #121. There were no open pressure areas visualized on right hip and buttocks. Resident #121 was in bed lying on his left side (on a pressure reducing mattress) and refused to turn over to complete skin check. On 06/13/2019 at approximately 2:00 PM, an interview with RN C was conducted. When asked how she discovered the above wounds, RN C stated a nurse told her Resident #121 had wounds that needed to be evaluated. RN C stated that the same day, she assessed the wounds, put new treatments in place, and documented her findings. She also stated she could not remember the nurse that told her about the wounds. The facility staff provided a copy of their policy entitled, Clinical Guideline Skin & Wound. Under the header, Overview, it was documented, To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. Under the header, Process, the first two items listed On admission/re-admission the resident's skin will be evaluated for baseline skin condition and documented in the medical record. Braden Risk Evaluation to be completed on admission/re-admission, weekly for 4 weeks from admission, quarterly and with a significant change in condition. On 06/13/2019 at approximately 3:10 PM, an interview with unit manager, Licensed Practical Nurse C (LPN C), was conducted. When asked about expectations regarding pressure injury prevention, LPN C stated she would expect to see preventative measures in place before it was discovered. She also stated she would expect the resident to have an air mattress and meal intake supplemented to help with healing process. She also stated she would expect to see it on the care plan. On 06/20/2019 by then end of survey, the administrator had no further documentation or information to offer. 2. For Resident #376, the facility staff discovered an unstageable scrotal wound with slough in the wound bed on 07/03/2018. This is harm. Resident #376, an [AGE] year old male, was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. Resident #376's most recent Minimum Data Set associated with the timeframe of the complaint had an Assessment Reference Date of 10/31/2018 and was coded as a discharge assessment. The Brief Interview for Mental Status was coded as an 8 out of possible 15 indicative of moderate cognitive impairment. Functional status for transfers and locomotion were coded as not occurring (or any part of the ADL was not performed at all over the entire 7-day look-back period). Bathing was coded as total dependence on staff. Bowel and bladder function were coded as always incontinent. Skin conditions were coded as 0 meaning no unhealed pressure ulcers present. The Minimum Data Set prior to the discovery of the unstageable scrotal wound had an Assessment Reference Date of 05/17/2018 and was coded as a quarterly review. Functional status for bed mobility and transfers were coded as requiring extensive assistance from staff. Mobility devices were walker and wheelchair. Risk for Pressure Ulcer was coded as yes. The physician's orders [REDACTED]. An order dated 05/09/2018 documented, Apply moisture barrier to reddened bony prominences as needed. An order dated 05/24/2018 documented, Consistent Carbohydrate diet mechanical soft texture, thin liquid consistency, double protein portions for diet. An order dated 06/10/2018 documented, [MEDICATION NAME] powder to scrotum topically every shift for itching, apply to scrotum and groin every shift until healed. In the course of a complaint investigation, the nurse's notes from (MONTH) (YEAR) through (MONTH) (YEAR) were reviewed. A nurse's note dated 07/03/2018 at 1:23 PM documented, I assessed (Resident #376)'s scrotum today after his nurse informed me he had an ulcer there. Measurements taken, unstageable pressure ulcer with slough, orders received from NP (nurse practitioner) and put in computer. He has been added to the weekly pressure wound rounds. The care plan was reviewed. A focus initiated on 11/20/2017 documented, The resident has the potential for impaired skin integrity r/t (related to) frequent bladder/bowel incontinence. Interventions associated with this focus documented, Administer treatments as ordered and monitor for effectiveness; apply barrier cream post incontinence care; Braden scale quarterly; float heels as tolerated when in bed; and weekly skin checks. There were no other interventions such as a pressure-reducing mattress or cushion for the wheelchair. A focus on the care plan initiated 7/26/18 (3 weeks after the unstageable pressure ulcer was discovered). It documented The resident has impaired skin integrity to scrotum. Interventions associated with this focus documented, Administer treatments as ordered in monitor for effectiveness; apply Barrier cream post incontinence care; assess/record/monitor wound healing weekly. Measure length, width, and depth where possible; Assist resident with turning in position frequently each shift; encourage adequate nutrition and hydration and order to promote healthier skin; follow physician order [REDACTED]. There were no pressure-reducing measures listed. The Treatment Administration Record was reviewed. Wound care as ordered was not administered on 07/13/2018, 07/16/2018, 07/17/2018, 07/29/2018, 07/30/2018, 08/09/2018, and 08/10/2018. An excerpt of a nurse's note dated 08/15/2018 at 9:26 AM documented, (Resident #376)'s pressure ulcer on his scrotum has healed. The facility staff provided a copy of their policy entitled, Clinical Guideline Skin & Wound. Under the header, Overview, it was documented, To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. Under the header, Process, the first two items listed On admission/re-admission the resident's skin will be evaluated for baseline skin condition and documented in the medical record. Braden Risk Evaluation to be completed on admission/re-admission, weekly for 4 weeks from admission, quarterly and with a significant change in condition. On 06/20/2019 at approximately 9:25 AM, an interview with the DON was conducted. When asked about expectations for pressure injury prevention, she stated she would expect to see a skin breakdown risk assessment, air mattress, cushion on the wheelchair, diet supplements and expect to see it all on the care plan. The DON verified there was no skin breakdown risk assessment documentation and the only preventative measures in place were barrier cream and [MEDICATION NAME]. In reference to the treatment record where wound care was not administered as ordered, the DON stated that it should've been done daily as ordered and documented. In summary, there were no pressure-reducing interventions implemented before or after the scrotal wound was discovered when unstageable with slough in the wound bed. Wound treatments were not administered daily as ordered (missed treatments). On 06/20/2018 at the end of survey, the interim administrator had no further information or documentation to offer.

Based on observation, resident interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to prevent actual/potential accident hazards facility-wide and for 2 residents (Resident #40, Resident #121) in a sample size of 76 residents. This resulted in Harm for Resident #40 The Findings Include: 1. For Resident #40, the facility staff failed to assess for fall risk or have preventative measures in place when she fell and hit her head resulting in face swelling and laceration. This is harm. Resident #40, a [AGE] year old female was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. The most recent Minimum Data Set associated with this complaint had an Assessment Reference Date of 10/15/2018 and was coded as a quarterly review. The Brief Interview for Mental Status was 12 out of possible 15 indicative of moderate cognitive impairment. Functional status for dressing and personal hygiene coded as requiring extensive assistance from staff. Transfers coded as requiring extensive assistance from staff and one-person physical assist for support. Bowel and bladder coded as always incontinent. Fall history in the last 2-6 months was not coded. On 06/18/2019 at 3:10 PM, in the course of a complaint investigation, fall investigations from (MONTH) - (MONTH) (YEAR) were requested. The facility staff provided a fall investigation dated 06/21/2018 that documented details not consistent with the allegations in the complaint. The event was dated 06/16/18 at 1:30 PM and the description documented, patient was trying to get in the bed without assistance and fell on her buttocks. No injuries noted denies pain. There was no evidence in the documentation that preventative measures were put in place after the fall. A nurse's note associated with this event dated 06/16/18 at 1:00 PM documented, patient was trying to get in the bed unassisted. She fell on floor, no injuries noted, denies pain or discomfort. Unit manager notified, (name) (nurse practitioner) notified. The facility staff verified there were no other fall investigations in addition to the fall event on 06/16/18. The nurse's notes from (MONTH) - (MONTH) (YEAR) were reviewed. A nurse's note dated 08/18/2018 at 5:16 AM documented, At approximately 0425 heard resident yelling for nurse. This nurse finished rounds at 0345. Upon entering room found resident on floor withshe (sic) blood coming from the left side of her head. Resident state (sic) she was looking for her wheelchair. Resident was assessed and 911 was called d/t (due to) head resident (sic) never lose consciousness injury (sic). Vital signs 130/82 (blood pressure), 76 (pulse), 18 (respirations), o2 sat 97% (oxygen saturation). No other injuries noted. Resident was clean new hospital gown and brief. EMT's (emergency medical technicians) arrived and resident taken to hospital. DON and nurse practitioner (name) notified. A nurse's note dated 08/19/2018 at 9:30 AM documented, Resident returned from ED (emergency department) with glue closure of left eye, some swelling noted to area. Ice applied for comfort. Per ED note, resident had a CT (computed tomography, CAT scan) which was normal. Neuro WNL. An excerpt of a nurse's note dated 08/19/18 at 12:40 PM documented, Resident has ice in place to eye and received Tylenol for her discomfort and reports comfortable at this time. A nurse's note by a wound care RN dated 08/20/18 at 10:17 AM documented, I assessed (Resident #40)'s face today s/p (status [REDACTED]. She has a hematoma above her left eye. The left eye is swollen almost shut. The area around her right eye is also swollen but not to the same degree. Left side of face is swollen and purple in color. Measurements taken. On 06/19/2019 at 10:38 AM, the DON verified that there was no fall risk assessment before or after the event and no fall risk or actual fall problems addressed in the care plan. The DON stated that all patients are a fall risk and should have a risk assessment done on admission and quarterly. The DON also stated fall risk and actual falls should be addressed on the care plan. On 06/20/2019 by the end of survey, the interim administrator had no further information or documentation to offer. 2. For Resident #121, the facility staff failed to provide adequate supervision to prevent a potential accident/fall. Resident #121 was observed ambulating in the hall unassisted with bare feet and had an unsteady gait on 06/06/2019. Resident #121, a [AGE] year old male, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #121's most recent Minimum Data Set with an Assessment Reference Date of 05/15/2019 was coded as a quarterly review. The Brief Interview for Mental Status was coded as 00 out of 15 indicative of severe cognitive impairment. Functional status for locomotion on unit was coded as not occurring. Balance During Transitions was coded as not steady when moving from seated to standing position. Functional status for eating was coded as requiring supervision from staff (one-person physical assist for support). Behaviors for [MEDICAL CONDITION] or wandering were coded as not exhibited. On 06/06/19 at 08:26 AM, this surveyor observed Resident #121 in another resident's room (a female resident identified in the sample as Resident #37). Resident #121 was seated on the side of her bed eating her breakfast that was on her tray table. Resident #37 was not in her room (room A) and her roommate was asleep in her bed by the window. This surveyor alerted Licensed Practical nurse D (LPN D) at the nurse's station, and LPN D went to room A and redirected Resident #121 back to his room (room B). Resident #121 was barefoot and wearing a hospital gown that was open in the back exposing his bare back, legs, and a loosely-fitted brief. When they reached the doorway of room B, LPN D instructed Resident #121 to go sit down and then LPN D walked back toward the nurse's station. At 08:30 AM, Resident #121 entered his room and sat down in a chair in front of his tray table. The breakfast plates/tray on top of the table were empty. There were bits of food on the floor under the table, the chair, and under and around the feet of Resident #121. Resident #121 then stood up, walked out into the hall, and asked this surveyor for pancakes. This surveyor alerted nearby staff and the wound nurse, Registered Nurse C (RN C), stated she would find out how to order more pancakes for Resident #121. On 06/06/19 at 09:07 AM, this surveyor observed Resident #121 standing outside room C. Resident #121 had a hospital gown on, open in the back, exposing his back, legs, and loosely-fitted brief. Employee K, a housekeeper, also saw Resident #121 and told him to go back to his room and pointed in the direction of which hall to walk down to get to his room. There were no nurses seen at the nurse's station by room C or down either hall. The housekeeper and this surveyor observed Resident #121 walking with an unsteady gait into and out of room C. The housekeeper stated that room D used to be Resident #121's room. Resident #121 continued to walk down the hall and entered room E, walked to the food tray and picked up an unwrapped straw. At that time, certified nursing assistant B (CNA B) entered room E, saw Resident #121, redirected him, and walked alongside Resident #121 headed toward his room. On 06/06/2019 at approximately 9:15 AM, LPN D was asked about Resident #121 and she stated Sometimes he gets confused where his room is, we redirect him. On 06/11/19 at 08:45 AM, Resident #121 was observed getting up out of bed, ambulating to hall and asking this surveyor for a Pepsi. Resident #121 was wearing a red shirt and blue pants. There was spilled food on his pants and on the room floor that resembled oatmeal where Resident #121 was walking. Resident #121's pants fell below the level of his mid-thighs before he pulled up his pants as he left his room and ambulated down the hall with an unsteady gait unassisted. This surveyor had to alert an aide to assist Resident #121 ambulate back to his room. On 06/12/2019, the care plan was reviewed. The focus initiated by the MDS Coordinator dated 05/09/2019 documented, The resident is at risk for falls r/t (related to) gait/balance problems. Interventions associated with this focus documented, Anti-tipper on W/C (wheelchair); be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; bed in low position; DUMP W/C (sloped wheelchair, higher in the front); wedge cushion in W/C. Resident #121 was not observed in a wheelchair throughout the survey process. On 06/13/2019 at approximately 10:15 AM, an interview with the unit manager, LPN C, was conducted. When notified of observations on 06/06/2019, LPN C stated all staff should make sure his dignity remains intact, covering him up, ensuring safety, making sure he had skid-proof socks on, making sure his room is tidy, and also check on him if he's still hungry, get him something to eat. When asked how long this behavior had been occurring, LPN C stated that staff said (Resident #121) does this from time to time and went on to say but there's no documentation about it. When asked about expectations for documenting behaviors, LPN C stated she expects to see documentation any and all behaviors each shift and follow-up so the IDT (interdisciplinary team) can make adjustments and meet their needs. She stated she would also expect to see it on the care plan as it happens. On 06/20/2019 at the conclusion of the survey, the administrator had no further documentation or information to offer. 3. The facility staff failed to provide repair to a broken sliding glass door, and prevent resident access to the broken glass. On 6/5/19 at approximately 2:15pm it was observed that in the Liberty Day Room one of the sliding glass doors had broken glass. At the bottom, about 1 1/2 feet from the floor, there was an area of impact with an object that broke the glass causing a spider web pattern of glass breakage that extended all the way to the top of the door and across each side. The height of the door was approximately 6 1/2 feet tall and the width was approximately 3 feet. A thin flexible material, the Maintenance Director stated the material was bubble wrap had been put over the broken glass but had become unadheared, leaving it accessible. The material that was over the door, had been secured with duct tape at some point, but it had come unsecured and the material was hanging down. When the window blind was opened the material fell allowing full access to the broken glass. On 6/5/19 at approximately 2:20pm an interview was conducted with Resident #114 who was sitting in the Liberty Day Room. Resident #114 stated the sliding glass door had been broken for about 2 months. On 6/5/19 at 2:52pm an interview was conducted with Employee F, Maintenance Director. The maintenance director said, I know it is dangerous that is why I put that bubble wrap up. On 6/5/19 at 3:15pm the facility Administrator was asked about the sliding glass door. The Administrator stated, I actually checked it the other day. The Administrator was asked to go look at the door. She returned to the conference room and stated, I didn't know it had fallen down, we will get it replaced, I have someone watching the door until we can get it put back up.

Based on observations, resident interviews, staff interviews, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to develop a comprehensive, resident-centered care plan for 6 residents (Resident #40, Resident #121, Resident #65, Resident #376, Resident #29, Resident #15) in a sample size of 76 residents. This resulted in harm for Resident #40. The findings included: 1a. For Resident #40, the facility staff failed to assess for fall risk or have preventative measures in place when she fell and hit her head resulting in face swelling and laceration. This is harm. Resident #40, a [AGE] year old female was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. The most recent Minimum Data Set associated with this complaint had an Assessment Reference Date of 10/15/2018 and was coded as a quarterly review. The Brief Interview for Mental Status was 12 out of possible 15 indicative of moderate cognitive impairment. Functional status for dressing and personal hygiene coded as requiring extensive assistance from staff. Transfers coded as requiring extensive assistance from staff and one-person physical assist for support. Bowel and bladder coded as always incontinent. Fall history in the last 2-6 months was not coded. On 06/18/2019 at 3:10 PM, in the course of a complaint investigation, fall investigations from (MONTH) - (MONTH) (YEAR) were requested. The event was dated 06/16/18 at 1:30 PM and the description documented, patient was trying to get in the bed without assistance and fell on her buttocks. No injuries noted denies pain. There was no evidence in the documentation that preventative measures were put in place after the fall. A nurse's note associated with this event dated 06/16/18 at 1:00 PM documented, patient was trying to get in the bed unassisted. She fell on floor, no injuries noted, denies pain or discomfort. Unit manager notified, (name) (nurse practitioner) notified. The facility staff verified there were no other fall investigations in addition to the fall event on 06/16/18. The nurse's notes from (MONTH) - (MONTH) (YEAR) were reviewed. A nurse's note dated 08/18/2018 at 5:16 AM documented, At approximately 0425 heard resident yelling for nurse. This nurse finished rounds at 0345. Upon entering room found resident on floor withshe (sic) blood coming from the left side of her head. Resident state (sic) she was looking for her wheelchair. Resident was assessed and 911 was called d/t (due to) head resident (sic) never lose consciousness injury (sic). Vital signs 130/82 (blood pressure), 76 (pulse), 18 (respirations), o2 sat 97% (oxygen saturation). No other injuries noted. Resident was clean new hospital gown and brief. EMT's (emergency medical technicians) arrived and resident taken to hospital. DON and nurse practitioner (name) notified. A nurse's note dated 08/19/2018 at 9:30 AM documented, Resident returned from ED (emergency department) with glue closure of left eye, some swelling noted to area. Ice applied for comfort. Per ED note, resident had a CT (computed tomography, CAT scan) which was normal. Neuro WNL. An excerpt of a nurse's note dated 08/19/18 at 12:40 PM documented, Resident has ice in place to eye and received Tylenol for her discomfort and reports comfortable at this time. A nurse's note by a wound care RN dated 08/20/18 at 10:17 AM documented, I assessed (Resident #40)'s face today s/p (status [REDACTED]. She has a hematoma above her left eye. The left eye is swollen almost shut. The area around her right eye is also swollen but not to the same degree. Left side of face is swollen and purple in color. Measurements taken. On 06/19/2019 at 10:38 AM, the DON verified that there was no fall risk assessment before or after the event and no fall risk or actual fall problems addressed in the care plan. The DON stated that all patients are a fall risk and should have a risk assessment done on admission and quarterly. The DON also stated fall risk and actual falls should be addressed on the care plan. On 06/20/2019 by the end of survey, the interim administrator had no further information or documentation to offer. 1b. For Resident #40, ADL (activities of daily living) care was not on the care plan. Resident #40, a [AGE] year old female was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. The most recent Minimum Data Set associated with this complaint had an Assessment Reference Date of 10/15/2018 and was coded as a quarterly review. The Brief Interview for Mental Status was 12 out of possible 15 indicative of moderate cognitive impairment. Functional status for dressing and personal hygiene coded as requiring extensive assistance from staff. Eating coded as requiring limited assistance from staff and a one-person physical assist for support. Bathing was coded as total dependence on staff. Transfers coded as requiring extensive assistance from staff and one-person physical assist for support. Bowel and bladder coded as always incontinent. Rejection of Care was coded as behavior not exhibited. In the course of a complaint investigation, the bathing logs from (MONTH) through (MONTH) (YEAR) were reviewed. Resident #40 was at the facility for 28 days in (MONTH) (YEAR). Of those 28 days, there were 9 days Resident #40 did not receive either a bed bath, partial bath, or shower. The longest gap in bathing care was 3 days. Resident #40 was at the facility for 25 days in (MONTH) (YEAR). Of those 25 days, there were 9 days Resident #40 did not receive either a bed bath, partial bath, or shower. The longest gap in bathing care was 3 days. Resident #40 was at the facility for 31 days in (MONTH) (YEAR). Of those 31 days, there were 18 days Resident #40 did not receive either a bed bath, partial bath, or shower. The longest gap in bathing care was 9 days. There was one instance where Resident $30 refused care and received a partial bath later in the day. For the 30 days in (MONTH) that Resident #40 was at the facility, there were 27 days Resident #40 did not receive either a bed bath, partial bath, or shower. Resident #40 received a bed bath on 09/01/18, 09/06/18, and a partial and bed bath on 09/14/18. For the 28 days in (MONTH) that Resident #40 was at the facility, there were 23 days Resident #40 did not receive either a bed bath, partial bath, or shower. Resident #40 received a partial bath on 10/03/2018 and a bed bath on 10/15/18, 10/26/18, and 10/31/18. There was one instance where Resident #40 refused care and received a partial bath later in the day. The care plan was reviewed. A focus addressing ADL care and bathing was initiated on 11/20/18, over 9 months after her admission to the facility and 3 weeks after this complaint was received. There was a focus addressing behaviors for refusing meds/care but that was initiated on 11/20/18. On 06/19/19 at 10:38 AM, the DON was notified of findings. When reviewing Resident #40's care plan, the DON stated the ADL care should've been on the care plan. On 06/20/19 at the end of the survey, the interim administrator had no further information or documentation to offer. 2. For Resident #121's care plan did not address actual skin breakdown due to pressure injuries. Resident #121, a [AGE] year old male, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #121's most recent Minimum Data Set with an Assessment Reference Date of 05/15/2019 was coded as a quarterly review. The Brief Interview for Mental Status was coded as 00 out of 15 indicative of severe cognitive impairment. Physical/verbal behaviors toward self/others was coded as not exhibited, Behaviors of [MEDICAL CONDITION] or wandering were coded as not exhibited. Resident #121 had actual skin breakdown due to pressure injuries as documented in the nurse's notes and skin assessments forms. The care plan was reviewed and there was no focus addressing potential or actual skin breakdown. On 06/13/2019 at approximately 3:10 PM, an interview with unit manager, LPN C, was conducted. When asked about expectations regarding pressure injury prevention, LPN C stated she would expect to see preventative measures in place before it was discovered. She also stated she would expect the resident to have an air mattress and meal intake supplemented to help with healing process. She also stated she would expect to see it on the care plan. On 06/20/2019 at the conclusion of the survey, the administrator had no further information or documentation to offer. 3. For Resident #65, the facility staff failed to include a comprehensive list of her activity preferences on the care plan. Resident #65, an [AGE] year old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #65's most recent Minimum Data Set with an Assessment Reference Date of 04/18/2019 was coded as a quarterly review. The Brief Interview for Mental Status was coded as 3 out of possible 15 indicative of severe cognitive impairment. On 06/14/2019 at approximately 11:15 AM, an interview with Employee N, the Activities Director, was conducted. When asked about activities for Resident #65, Employee N stated that (Resident #65) she likes to reminisce; she likes music, and she likes to sit outside. Employee N stated (Resident #65) does not do well in large group activities. Employee N stated we do one-on-one in smaller settings in the blue room. Employee N also stated that (Resident #65) should have one-on-one three times a week on Tuesday/Thursday/Saturday schedule. A copy of (Resident #65)'s activity schedule and a facility policy on activities were requested. On 06/14/2019 at approximately 12:00 PM, the activities schedule and activity notes were reviewed. An activity note dated 04/18/2019 at 9:57 AM documented, (Resident #65) receives 2-3 friendly visits per week, she enjoys people watching she (sic) is independent in her room with activities of her choice which including (sic) watching TV and walking to and from her bed to door. The activities flowsheet for (MONTH) 2019 was reviewed. There were no on-on-one activities documented from 05/10/2019 through 05/20/2019. During that time, there was one group activity documented (05/15/2019). On 06/14/2019, the care plan was reviewed. A focus dated 05/15/2019 and initiated by Employee N documented, The resident is independent for meeting emotional, intellectual, physical, and social needs r/t (related to) cognitive deficits, depression, and anxiety. An interventions associated with this focus documented, The resident's preferred activities are : socializing with peers, friendly visits. There was no evidence in the care plan Resident #65 likes to reminisce, listen to music, sit outside, or watch TV. On 06/14/2019, the facility provided an Activity policy entitled, Completion of Resident Participation Record. The policy addressed documentation of activities. It did not address the development, scheduling, or implementation of resident-centered activities. On 06/20/2019 by the end of survey, the interim administrator had no further information or documentation to offer. 4. For Resident #376, pressure-reducing measures were not on the care plan before and after an unstageable wound was discovered with slough in the wound bed on 07/03/2018. Resident #376, an [AGE] year old male, was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. Resident #376's most recent Minimum Data Set associated with the timeframe of the complaint had an Assessment Reference Date of 10/31/2018 and was coded as a discharge assessment. The Brief Interview for Mental Status was coded as an 8 out of possible 15 indicative of moderate cognitive impairment. Skin conditions were coded as 0 meaning no unhealed pressure ulcers present. Nurse's notes from (MONTH) (YEAR) through (MONTH) (YEAR) were reviewed. A nurse's note dated 07/03/2018 at 1:23 PM documented, I assessed (Resident #376)'s scrotum today after his nurse informed me he had an ulcer there. Measurements taken, unstageable pressure ulcer with slough, orders received from NP (nurse practitioner) and put in computer. He has been added to the weekly pressure wound rounds. The Minimum Data Set prior to the discovery of the unstageable scrotal wound had an Assessment Reference Date of 05/17/2018 and was coded as a quarterly review. Functional status for bed mobility and transfers were coded as requiring extensive assistance from staff. Mobility devices were walker and wheelchair. Risk for Pressure Ulcer was coded as yes. The physician's orders [REDACTED]. An order dated 05/09/2018 documented, Apply moisture barrier to reddened bony prominences as needed. An order dated 05/24/2018 documented, Consistent Carbohydrate diet mechanical soft texture, thin liquid consistency, double protein portions for diet. An order dated 06/10/2018 documented, [MEDICATION NAME] powder to scrotum topically every shift for itching, apply to scrotum and groin every shift until healed. The care plan was reviewed. A focus initiated on 11/20/2017 documented, The resident has the potential for impaired skin integrity r/t (related to) frequent bladder/bowel incontinence. Interventions associated with this focus documented, Administer treatments as ordered and monitor for effectiveness; apply barrier cream post incontinence care; Braden scale quarterly; float heels as tolerated when in bed; and weekly skin checks. There were no other interventions such as a pressure-reducing mattress or cushion for the wheelchair. A focus on the care plan initiated 7/26/18 (3 weeks after the unstageable pressure ulcer was discovered). It documented The resident has impaired skin integrity to scrotum. Interventions associated with this focus documented, Administer treatments as ordered in monitor for effectiveness; apply Barrier cream post incontinence care; assess/record/monitor wound healing weekly. Measure length, width, and depth where possible; Assist resident with turning in position frequently each shift; encourage adequate nutrition and hydration and order to promote healthier skin; follow physician order [REDACTED]. There were no pressure-reducing measures listed. On 06/20/2019 at approximately 9:25 AM, an interview with the DON was conducted. When asked about expectations for pressure injury prevention, she stated she would expect to see a skin breakdown risk assessment, air mattress, cushion on the wheelchair, diet supplements and expect to see it all on the care plan. The DON verified there was no skin breakdown risk assessment documentation and the only preventative measures in place were barrier cream and [MEDICATION NAME]. In summary, there were no pressure-reducing interventions implemented before or after the scrotal wound was discovered when unstageable with slough in the wound bed. Wound treatments were not administered daily as ordered (missed treatments). On 06/20/2018 at the end of survey, the interim administrator had no further information or documentation to offer. 5. For Resident #29 the care plan failed to address the behavioral health needs of Resident #29 as it relates to his [DIAGNOSES REDACTED]. Resident #29 a [AGE] year old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His latest MDS coded as a Quarterly with an (Assessment Reference Date) ARD of 3/14/19 codes the Resident as having a (Brief Interview of Mental Status) Score of 13 indicating mild cognitive impairment. On 6/16/19 during clinical record review it was noted that Resident #29's care plan does not adequately address his mental health / behavioral health needs. Review of Care Plan states: Focus- Resident has a behavior problem refuses nicotine patch and suicidal ideation--Initiated 6/3/19 GOAL-- Resident will have no evidence of behavioral problems to be reviewed by 6/20/19 INTERVENTIONS Administer medications as ordered and document for side effects and effectiveness.--Date initiated 6/3/19 Anticipate and meet resident needs-- Date initiated 6/3/19 Caregivers to provide opportunity of positive interaction, attention. Stop and talk with him or her when passing by -Date initiated 6/3/19 Educate the resident on successful coping interaction strategies --Date initiated 6/3/19 Psych Eval at times when needed.--Date initiated 6/3/19 The care plan failed to assess, identify and specify coping strategies specific to this Resident and the care plan failed to identify [MEDICAL CONDITION] on the care plan and have regular mental health visits. The Administrator was made aware on 6/20/19 during the end of day meeting no further information was provided. 6. For Resident #15, the facility staff failed to implement his Care Plan for catheter care. Resident #15 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #15's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 3/4/19 was reviewed. Resident #15 was coded as having a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. On 6/10/19 at 1:19 P.M. an interview was conducted with Resident #15. He complained of not receiving care, in a timely manner. Resident #15's care plan was reviewed. An excerpt from the care plan read, 5/22/19. The resident has Suprapubic catheter. The resident will remain free from catheter-related trauma. Catheter care as ordered. Resident #15's Treatment Administration Record for April, 2019 was reviewed. Foley Catheter care was scheduled for every shift and as needed 18 F/10 cc balloon size. Foley Catheter was not provided on the following days/shifts: 4/1/19 Day 4/5/19 Evening 4/9/19 Day 4/16/19 Day 4/19/19 Night 4/20/19 Day 4/21/19 Day 4/23/19 Evening 4/26/19 Night 4/28/19 Day

Based on observation, resident interview, staff interview, clinical record interview, facility documentation review, and in the course of investigating a complaint, the facility staff failed make reasonable accommodations of needs for 3 (resident #25, 37, and 30) of 76 sampled residents. This resulted in harm for Resident #25. The Findings included: 1. The facility staff failed to provide an appropriately sized bed for Resident #25 who was 7 feet tall and weighed 466 pounds, resulting in psychological harm. Resident #25 was a [AGE] year old who was admitted to the facility in 10/4/17. His [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 3/11/19 was reviewed. Resident #25 was coded as requiring the extensive physical assistance of 2 or more persons for transfers, personal hygiene, and toileting. On 6/05/19 at 2:34 P.M., during a facility tour, Resident #25's door was observed to be open. From the hallway, the resident was observed with his legs (from the knee down) and feet hanging over the foot of his bed. Upon entering the room, the resident was interviewed. Resident #25 complained of not being able to move in the bed. He stated that he cut his foot on the footboard because he couldn't stretch his leg out. He said because of the injury, the staff had removed the footboard and placed against the wall. He pointed to the footboard, which was on the floor, placed against the wall opposite the foot of his bed. An observation was made of the second toe of his right foot, which had a laceration on it. Resident #25 stated that his bed was too short, and that it had caused him to feel humiliated, anxious and frustrated. He stated that he transferred rooms in February, and that he had an appropriately long bed in his former room. He stated that the facility did not transfer the bed with him. He further stated that he was frustrated due to his inability to move around and shift his weight in the bed. He stated that the facility had refused to set up transportation and help him obtain outside psychiatric services, as was his preference. On 6/5/19 an observation was conducted of Resident #25's former room and bed. The extended length bariatric bed was in the room. On 6/6/19 at 9:15 [NAME]M., an interview was conducted with the Regional Clinical Director (Employee H) in the hallway outside of Resident #25's room. His door was open. When asked to describe what she noticed about Resident #25, she stated, He's hanging off, it could cause pressure sores. You can develop a pressure ulcer very quickly. You should change position every two hours. Upon entering the room, Resident #25 was asked by the surveyor to describe how the bed affected him. He stated, It restricts my movement. I have to stay in one position. I can't move from side to side. I feel cramped. My neck gets stiff on the right side. I feel anxiety and depression. I want to see an outside psychiatrist, and I want a longer bed. On 6/6/19 at 6:00 P.M. an interview was conducted with the facility Administrator. She stated, I found out how to extend the bed. We did it and added a mattress extender. We have fitted sheets. When asked why the bed hadn't been adjusted since February, the Administrator did not respond. A follow-up observation was conducted of Resident #25 in his bed. His legs and feet were on the mattress and he appeared to be comfortable. His bed had been adjusted, and he stated that he was more comfortable and satisfied with it. On 6/6/19 a review was conducted of facility documentation, revealing the manufacturers' instructions. The Bar 750 Bariatric bed width could be extended from 39 inches to 48 inches. The length could be extended from 88 inches to 96 inches. The weight limitation was 750 pounds. On 6/5/19 a review was conducted of Resident #25's clinical record. His most recent recorded weight was 466 pounds, as recorded on 6/5/19, and his height was 7 feet. According to the Social Service progress notes, Resident #25 complained of being depressed on 4/11/19, 4/12/19, and on 4/27/19 the resident requested psychiatric services due to depression. On 5/3/19 the facility Nurse Practitioner ordered [MEDICATION NAME] 50 MG every morning. On 6/17/19 an interview was conducted with the Interim Director of Nursing (Employee B). She stated, The proper bed should have been available at the time of the move. 2. For Resident #37, the facility failed to provide linen so she could receive [NAME]M. care on 06/11/2019. Resident #37, a [AGE] year old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #37's most recent Minimum Data Set with an Assessment Reference Date of 03/21/2019 was coded as a quarterly review. The Brief Interview for Mental Status was not completed but cognitive skills for daily decision-making were coded as moderately impaired. Rejection of Care was coded as occurring 1 to 3 days of the 7-day look-back period. Functional status for dressing and personal hygiene were coded as requiring extensive assistance from staff. On 06/11/2019 at approximately 8:40 AM, Resident #37 was observed in a hospital gown lying in her bed with the head of the bed elevated approximately 45 degrees. Resident #37 stated she wanted to get out of bed now. This surveyor returned to the nurse's station to alert staff Resident #37 would like to get out of bed. CNA F was standing at the nurse's station looking down at her cell phone. CNA F quickly put her cell phone in her pocket, shook her head and stated, We don't have any linen. CNA F went on to explain they need to bathe (Resident #37) before she gets up; otherwise, she won't cooperate later. The small linen cart by room A was empty. On 06/11/19 at approximately 9:00 AM, an interview with the Director of Linen Services, Employee P, was conducted. When asked about his expectation for linen par levels, Employee P stated he just started working here 4 weeks ago and has been working on adjusting to make better par levels. Employee P stated he needed to get with nursing to see what they need. Employee P expects there should be three sheet sets per bed. When asked how many beds are on the liberty unit (where Resident #37 resides), Employee P stated, I don't know, I need to find out. Employee P provided a copy of a form entitled, Linen Delivery Schedule and it contained a list of the following linen par levels for the unit where Resident #37 resides: Flat sheets (35), fitted sheets (35), pillow cases (10), towels (60), washcloths (60), gowns (10), pads (10), blankets (6), and spreads (6). When asked if the nursing staff currently had linen on the unit where Resident #37 resides, Employee P stated, No, because the cart is being filled now (in the laundry room) and will be transported to the unit after filling. On 06/11/19 at approximately 09:35 AM, an interview with the unit manager, Licensed Practical Nurse C (LPN C), was conducted. When asked about the census on the unit where Resident #37 resides, LPN C referred to the electronic records and stated there were 45 people on the unit and of those 45 people, 10 are continent. For incontinent residents, LPN C stated We change their linen daily. LPN C stated for approximately 6 or 7 residents, the sheets are changed at least every shift. When asked if the unit runs out of linen, she stated that the nurses do run out of linen. LPN C also stated that she has spoken with the linen department about it because They need to provide more linen. There were 45 residents residing on the unit and a par level of 35 fitted sheets, 35 flat sheets, and 10 pillow cases. On 06/20/2019 by the end of survey, the interim administrator had no further documentation or information to offer. 3. For Resident #30 the facility staff failed to ensure a reasonable accommodation of needs. Resident #30 could not take his service dog with him in the dining room during meal service or any activities involving food but he also could not leave his service dog alone in his room in order to attend meal service in the dining room or activities that involved food. Resident #30, a [AGE] year old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #30's most recent (Minimum Data Set) MDS coded as a Quarterly Assessment, with an (Assessment Reference Date) ARD of 3/14/19 codes Resident #30 as having a (Brief Interview of Mental Status) BIMS score of 15 indicating no cognitive impairment. The MDS also codes Resident as using wheelchair for transport and is a total assist for transfers. Resident is unable to stand or bear weight. On 6/5/19 at 2:00 PM during initial tour Resident #30 was observed sitting in his wheelchair in his room with a small dog in his lap. The Resident indicated that the dog was his service dog. Resident stated that the facility staff would not allow his service dog into the dining room. The Resident further elaborated that this also included any activities that included food. The Resident stated he would like to go to Bingo and the Ice Cream Socials, or other activities but was not allowed to bring his service dog and he stated he could not leave his dog alone in his room because of the Contract he signed with the Administrator. On 6/7/19 at 10:45 AM in an interview with Administrator she was asked if the Dog was allowed in the dining room she stated that she was not. When asked if the Dog was trained she stated that the dog was well behaved. When asked does the dog cause a disruption in the dining room by barking or begging for food or running around the dining room, she stated that the dog stays in Resident #30's lap. When asked if the dog was being appropriately cared for walked, fed, required shots and medical care and kept clean she stated that she had no problems with the care of the dog. When asked why the dog was not allowed in the dining room she stated Well we took a vote in Resident Council. Administrator produced a contract and copies of the Dog's Service dog certification as well as the dog's medical record. During the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on observation, resident interview, staff interview, clinical record review, facility documentation, and in the course of a complaint investigation, the facility staff failed to ensure the highest practicable well being for 3 residents (#120, #15, and #33), resulting in harm for Resident #120, in a survey sample of 76 residents. The findings included: 1. For Resident #120, the facility staff failed to provide care and treatment resulting in harm. Resident #120, a [AGE] year old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record for Resident #120 found Nursing Progress Notes on 4/29/19 at 3:49pm that noted blood in the Foley (urinary catheter) collection bag. The Nurse Practitioner was contacted and an order was given to make an appointment with Urology. A Nursing Progress Note on 4/30/19 at 06:40am noted bloody urine in the catheter bag and communication to Social Services regarding the previous order to make an appointment with a Urologist. At 10:15pm on 4/30/19, the Nurse Practitioner was notified again of bloody urine in the Foley bag with no new orders noted. A Nursing Progress Note dated 5/4/19 at 11:04am read, Resident sent out non emergent ambulance to (redacted) ER due to what appears to be a large amount of blood and pus in foley leg bag .resident baseline is usually oriented .staring off at the ceiling so sent to the ER to be evaluated. Resident #120 was admitted to the hospital and returned to the facility on [DATE]. Review of the hospital Discharge Summary dated 5/8/19 noted that Resident #120 arrived to the ER with a urinary tract infection associated with catheterization of the urinary tract that was present on admission and pustular drainage from dirty chronic indwelling Foley presented with obstructed indwelling catheter (that) had appeared grossly dirty and acute kidney failure-present on admission. The follow-up instructions on the hospital Discharge Summary included: follow up with provider (Urologist name redacted), targeted follow up time: 2-3 weeks, instructions for follow up: schedule an appointment with Urology for re-evaluation of your [MEDICAL CONDITION]. On 6/17/19, clinical record review revealed an active physician order [REDACTED].#120. Review of the Treatment Administration Record (TAR) shows no documentation of catheter care given on 6 shifts in April. On 6/17/19, a staff interview was conducted with the Regional Clinical Director (Employee H) who stated, the Social Services department never made an appointment with Urology because they said he (Resident #120) went to the hospital, I don't know what has happened here, it should have been done, I also don't know why the Nurse Practitioner didn't see him when bloody urine was reported, I have no answers. All physician notes were requested and five physician notes were provided, however there was no documentation regarding assessments or treatment plans related to nursing reports of Resident #120's change in condition prior to his hospitalization for a urinary tract infection with obstruction related to his indwelling urinary catheter and acute kidney failure. 2. For Resident #15, the facility staff failed to implement physician ordered diabetic management in a timely manner. Resident #15 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #15's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 3/4/19 was reviewed. Resident #15 was coded as having a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. On 6/10/19 a review was conducted of Resident #15's clinical record, revealing a A1C lab test result which is obtained for diabetic management. The test was dated 1/24/19. The Reference Range of normal levels was 4.0 - 6.0. Resident #15's level was 11.2, which was coded as being High. Resident #15's signed physician orders [REDACTED]. Inject 15 unit subcutaneously three times a day related to Type 2 Diabetes. His doses were scheduled for specific times of administration. On 6/10/19 a review was conducted of Resident #15's clinical record, revealing Resident #15's Medication Audit Report. Resident #15 received his insulin between approximately 2 to 5 hours late on the following days: Date Scheduled Administered 6/1/19 4:00 P.M. 7:27 P.M. 6/3/19 11:00 [NAME]M. 1:04 P.M. 6/3/19 4:00 P.M. 9:52 P.M. 6/7/19 4:00 P.M. 9:17 P.M. 6/9/19 4:00 P.M. 7:50 P.M. On 6/10/19 at approximately 3:00 P.M., an interview was conducted with the Director of Nursing (Employee B). When asked to describe the possible consequences of Residents not receiving insulin as ordered, she stated, They can either have a adverse reaction, including a diabetic coma or [MEDICAL CONDITION]. No further information was received. 3. For Resident #33, the facility failed to promptly assess/treat [DIAGNOSES REDACTED] and notify MD as ordered on [DATE]. Resident #33, a [AGE] year old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #33's most recent Minimum Data Set with an Assessment Reference Date of 03/22/2019 was coded as an admission assessment. The Brief Interview for Mental Status was 15 out of possible 15 indicative of intact cognition. On 06/10/19 at approximately 09:33 AM, an interview with Resident #33 was conducted. When asked how she was feeling, she stated her blood sugar was 51 this morning. When asked if she ate breakfast this morning, Resident #33 stated she didn't want the breakfast they sent; she wanted a salad, some fruit, and some broth instead. She also stated she didn't feel well. On 06/10/19 at approximately 09:36 AM, the unit manager, Licensed Practical Nurse C (LPN C), was notified of Resident #33's statements. LPN C looked at Resident #33's electronic health record and stated that her blood sugar was 54 at 8:14 AM. When asked what was done about that, LPN C stated there was no documentation about that. LPN C went on to say that the nurse was supposed to inform the MD. Looking through the electronic health record, LPN C also stated that the nurse gave Resident #33 her Magic Cup and ProStat (sugar-free protein supplements) this morning and stated she would find Resident #33's nurse and find out what was done about the low blood glucose level. On 06/10/19 at approximately 09:42 AM, this surveyor and LPN C went to talk with Resident #33. Resident #33 confirmed again that she didn't eat breakfast and wanted a salad, fruit, and broth. When LPN C asked Resident #33 if she was feeling woozy, Resident #33 stated, Yes. LPN C and this surveyor then approached LPN D near the nurse's station. When asked what was done to address the low blood glucose, LPN D stated she still needed to notify the MD and recheck her blood sugar. On 06/10/19 at 09:47 AM, LPN D was observed rechecking the blood sugar for Resident #33 and stated her blood sugar was now 73. When asked if she assessed whether or not Resident #33 ate her breakfast, LPN D stated she didn't ask if (Resident #33) and went on to say she set her up with her breakfast this morning and she ate eggs. When LPN D was told Resident #33 stated she did not eat breakfast, LPN D stated, She ate her oatmeal. LPN D then stated she would still call MD to see what he wants her to do and then walked away from the nurse's station. The unit manager, LPN C, was asked about expectations when a resident presents with a low blood sugar. The unit manager stated that the nurse should have called the MD and followed up a lot quicker than what she did. She should make sure there is something like [MEDICATION NAME] in place and also make sure (Resident #33) eats her food. On 06/10/2019 at approximately 10:30 AM, the clinical record was reviewed. An active physician's orders [REDACTED]. Notify MD if BG (blood glucose) less than 70 or greater than 400. An active physician's orders [REDACTED]. Give to alert res (resident) with BS (blood sugar) less than 70. The Medication Administration Record [REDACTED]. The Glucose Gel 40% was not administered. A nurse's noted dated 6/10/2019 at 10:24 AM by LPN D documented, Resident BS (blood sugar) was 54 at 0817, NP has been made aware. BS was 73 on recheck. On 06/10/19 at 11:00 AM, the DON was notified of findings. When asked about expectations for management of low blood glucose values, the DON stated she expects the nurse to assess what the resident ate, recheck the level, give something with protein to stabilize, give [MEDICATION NAME], recheck blood glucose level, and notify the MD. A copy of their policy/protocol on monitoring blood glucose levels was requested. On 06/20/2019 by the end of survey, the administrator had no further information or documentation to offer.

Based on observation, resident interview, staff interview, clinical record review, facility documentation, and in the course of a complaint investigation, the facility staff failed to ensure that services provided met professional standards for 19 residents (#111, #54, #104, #2, #180, #98, #47, #68, #15, #181, #42, #60, #57, #97, #33, #40, #376, #68, #183), resulting in harm for Resident #111, #2, in a survey sample of 76 residents. The findings included: 1. For Resident #111, the facility staff failed to follow physician orders [REDACTED].>a) labwork, resulting in harm; b) dressing changes; c) Insulin administration. Resident #111, a [AGE] year old female, was admitted to the facility on [DATE] for IV (intravenous) antibiotic treatment, wound care, and physical therapy following right foot surgery for [REDACTED]. 1a) On [DATE] during initial tour, Resident #111 expressed concerns regarding the nursing care she was receiving by stating, the nurses are not following my doctor's orders, I saw him (Infectious Disease physician) just a couple of weeks ago and he was looking for my lab work results that he had ordered for me, I told him that they have not done any, he was upset .the nurses here are also not giving me my insulin like I am supposed to get, it is never on time and my blood sugars are all over the place, I have had problems in the past and have been in ICU before because of my blood sugars and I am sitting here constantly worried that something is going to happen to me, I don't even go outside my room, I wish I wasn't here, I will never come back to this place. On [DATE], during clinical record review, admission orders [REDACTED]. Resident #111's BUN and creatinine levels were noted to be within normal limits on [DATE] per hospital records dated [DATE]. Resident #111 saw the ID Specialist for a follow-up appointment on [DATE] with no labwork being performed by the facility. The ID Specialist sent written orders back to the facility with Resident #111 that read in large, bolded writing, please draw labs today ([DATE]), pts (patient's) IV abx (intravenous antibiotics) stop date for now is (MONTH) 5th 2019, stop date will be based on lab results!!. The facility obtained labwork from Resident #111 on [DATE]. Resident #111's BUN and creatinine levels were elevated above normal limits. The lab results were faxed to the ID Specialist on [DATE]. The facility had stopped the IV antibiotic medication on [DATE]. 1b) On [DATE], during review of treatment records for Resident #111, an order for [REDACTED]. From [DATE] to [DATE], Resident #111 only received 3 dressing changes (,[DATE], ,[DATE], and ,[DATE]) to the surgical wound on her right heel with a total of 8 dressing changes not performed. A staff interview was conducted with Assistant Director of Nursing (ADON, RN G) who stated, if wound care is not done as ordered, the wound could get worse, a person can become septic, and infection can spread. 1c) On [DATE], a review the Medication Administration Record (MAR) and Medication Administration Audit Report regarding insulin administration to Resident #111 was conducted and revealed that from date of admission on [DATE] to [DATE] there were 78 scheduled doses of insulin to be given per physician order. Only 27 insulin doses (33%) were given that met professional and facility guidelines to administer medication at the correct time. A staff interview was conducted with the Regional Clinical Director (Employee H) who stated, An acceptable time range to give a scheduled medication dose is within an hour before or an hour after a scheduled time on the MAR, anything other than that is not acceptable as it does not meet our expectations or comply with professional practice and more importantly with insulin, the right time is essential to controlling blood sugar, if not given at the right time it can be detrimental to the resident, it can cause serious harm. 2. For Resident #54, the facility staff failed to notify the ordering physician of potential drug to drug interactions for a medication ordered on [DATE]. Resident #54, an [AGE] year old male, was admitted to the facility on [DATE]. On [DATE], during clinical record review, an Orders Progress Note dated [DATE] documented a new medication order that triggered a drug protocol alert/warning related to potential drug to drug interactions with 4 medications already on Resident #54's medication administration record (MAR). The potential interactions range from mild to severe which included an increased risk for GI (gastrointestinal) toxicity. There was no documentation that indicated that the ordering physician was notified of the drug alerts/warnings. On [DATE], an interview with the Director of Nursing (DON, Employee B) was conducted. She stated, the physician should have been notified of these warnings so he can decide whether or not it is okay for the resident to take them, it could hurt them otherwise; the nurse should document that she notified the doctor. 3a. For Resident #104, the facility staff failed to notify the ordering physician of potential drug to drug interactions for a medication ordered on [DATE]. Resident #104, a [AGE] year old female, was admitted to the facility on [DATE]. On [DATE], during clinical record review, an Orders Progress Note dated [DATE] documented 2 new medication orders that triggered a drug protocol alert/warning related to potential drug to drug interactions with 7 medications already on Resident #104's medication administration record (MAR). The potential interactions range from moderate to severe which included an increased risk for GI (gastrointestinal) toxicity, increased risk for kidney failure and lactic acidosis, GI bleeding, and development of serotoni[DIAGNOSES REDACTED]. There was no documentation that indicated that the ordering physician was notified of the drug alerts/warnings. On [DATE], an interview with the Director of Nursing (DON, Employee B) was conducted. She stated, the physician should have been notified of these warnings so he can decide whether or not it is okay for the resident to take them, it could hurt them otherwise; the nurse should document that she notified the doctor. 3b. For Resident #104, the facility staff failed to administer medication as ordered by the physician. Resident #104, a [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], an interview was conducted with Resident #104 who stated, a couple of weeks ago, they did not give me my pain patch for almost a week. A review of Resident #104's clinical record and medication administration record (MAR) revealed no documentation for the administration of a [MEDICATION NAME] 72 hour 75 mcg/hr, apply 1 patch [MEDICATION NAME] every 72 hours for 2 consecutive occurrences ([DATE] and [DATE]). A Nursing Progress Note dated [DATE] at 22:28 indicated [MEDICATION NAME]es on order from the pharmacy. Refill request was faxed and telephoned to pharmacy . The next documented administration for the [MEDICATION NAME] was [DATE] at 11:55pm. An interview was conducted with the Regional Clinical Director (Employee H) on [DATE]. She stated, I have no idea what happened here, it's unacceptable. COMPLAINT DEFICIENCY 4. Resident #2 did not receive a physician ordered IV (intravenous fluid infusion) on [DATE] due to staff inability to access a vein to infuse the fluids, and, the Resident failed to receive Hypodermoclysis fluid injections in the subcutaneous tissue as ordered due to unavailability of the IV fluids in the facility on [DATE], resulting in harm. Resident #2 was admitted to the facility on [DATE], after treatment for [REDACTED]. Resident #2's [DIAGNOSES REDACTED]. Resident #2's most recent Minimum Data Set (MDS) was an admission assessment dated [DATE]. Cognitive skills for daily decision-making were coded as 13 of 15, and no cognitive impairment. Functional status for bed mobility, transfers, eating, dressing, and personal hygiene were all coded as extensive dependence on staff. Review of the closed record physician progress notes [REDACTED].#2 was seen was on [DATE]. The Resident denied nausea and vomiting in the note, and was being seen for a decrease in appetite. Review of the physician's orders [REDACTED].#2 was ordered to be given [MEDICATION NAME] suppository rectally for nausea and vomiting on [DATE], and [MEDICATION NAME] 8 milligram tablet orally on [DATE] at 6:28 p.m., for nausea and vomiting. Review of the nursing notes revealed that no nursing notes existed between [DATE], and [DATE]. On [DATE] the Resident was experiencing persistent vomiting, and the physician ordered via the telephone IV 0.9% normal saline at 60 ml per hour for 1000 ml related to dehydration. The nurse was unable to establish an IV access catheter to infuse the fluids, and they were never given. There is no indication that the physician was ever notified that the order was not carried out. There are no further nursing or physician notes until [DATE], when new verbal/telephone physician orders [REDACTED]. The Resident received the fluid from 2:00 p.m. on [DATE], until 11:00 a.m., on [DATE] when it was abruptly stopped. The Medication administration record (MAR) documentation showed at 12:00 noon on [DATE] that the fluids were not infusing, and Other/see nursing note, however, there was no note. The IV fluids were not given after 11:00 a.m., on [DATE] even though the Resident received [MEDICATION NAME] 8 milligram tablet orally on [DATE] at 6:28 p.m., for continuing nausea and vomiting. The fluid infusion order was Discontinued on [DATE] at 9:38 a.m. with no note from the physician or nurses to indicate the reason. LPN A was the nurse for the 11:00 p.m. to 7:00 a.m. shift on the nights of [DATE], and [DATE]. LPN A was interviewed, and stated We didn't have any fluids in the building to give the patient. When asked why no note was written, she stated she had written a note documenting that the fluids were unavailable, and that the nurse on ,[DATE] p.m. shift on [DATE] reported to her that she had not had any in the building either, and the family was angry, so she put the fluids on hold until the pharmacy could deliver them. The fluids never arrived, and the order was discontinued. The facility was asked for a copy of the IV stat box contents which contained extra bulk dose medications that could be administered until supplies for the individual could be received. The document was received, and stated the normal saline needed for Resident #2's infusion was contained in the box. LPN A stated that during the stay of Resident #2, the box was not filled and sent out to the pharmacy for refill as it should have been. The ,[DATE] nurse for [DATE] was identified, and found to be a short term contract employee who no longer worked at the facility. There were no nursing notes in the record for [DATE], and [DATE] to explain why the fluids were not completed through [DATE], and were discontinued on [DATE]. There were no nursing notes from [DATE] until [DATE], which documented that the resident had refused all treatments and care. On [DATE] the first identification of a wound with green yellow slough was documented. On [DATE] the Resident was sent to the hospital for nausea/vomiting and suspected dehydration at 6:35 p.m., which was requested by the family. The Resident never returned. Hospital records were reviewed and revealed the normally oriented and alert Resident was Disoriented and unable to identify complaints. The Resident arrived in the ER (emergency room ) at 7:09 p.m The Resident was seen by critical care staff who surgically placed an IV catheter in the Residents External Jugular neck vein. The ER Critical care note documented System at risk for life threatening failure: Central nervous system, cardiac and circulatory. Associated problems: [MEDICAL CONDITION] (low blood pressure) Dehydration, Arrhythmia and infection. The hospital documents go on to say that emergency medical services ambulance first responders recorded the Resident's blood pressure to be ,[DATE] mmHg (millimeters mercury) at the nursing home, and at the ER measured ,[DATE]. The Resident was admitted with dehydration,[MEDICAL CONDITION], acute [MEDICATION NAME] with bloody urine (urinary tract infection), intractable nausea and vomiting, [DIAGNOSES REDACTED] (critically low potassium 2.2) (normal is 3.5 to 5.5) ), and [DIAGNOSES REDACTED] (critically low magnesium 0.8) (normal is 1.6 to 2.5), and lactic acidosis (critically high 6.96) (normal is 0.9 to 1.7). After placing an IV catheter the Resident was immediately placed on fluid and potassium replacement infusions in the emergency room , and was later admitted to the ICU (intensive care unit), where she expired on [DATE] (5 days later). The Resident was not supplied with ordered fluid infusions, as they were unavailable, she became dehydrated, and was sent to the hospital at the behest of the family. The Resident expired in the hospital on [DATE] (5 days later) with the [DIAGNOSES REDACTED]. The facility Administrator and Director of nursing were made aware of findings on [DATE]. The facility stated they had no further information to provide. COMPLAINT DEFICIENCY 5. Resident #180 did not receive significant medications on the evening of [DATE] after being hospitalized for [REDACTED]. Resident #180, was admitted to the facility on [DATE], and discharged on [DATE]. [DIAGNOSES REDACTED]. Resident #180's most recent Minimum Data Set (MDS) was dated [DATE], and was an admission assessment Cognitive skills for daily decision-making were coded as no impairment. Functional status for bed mobility, transfers, eating, dressing, and personal hygiene were all coded as limited to extensive dependence on staff. The hospital discharge, and nursing home entire closed record review revealed that the Resident was admitted to the facility on [DATE] at approximately 5:00 p.m. The physician's orders [REDACTED]. Those records revealed that the Resident did not receive the following medications in the evening of [DATE]. The medications were ordered, by the physician on [DATE], before his discharge from the hospital, and communicated to the facility on [DATE], the day before he arrived at the facility: 9:00 p.m. Elicitor 40 mg (milligrams) at bedtime for high cholesterol. 9:00 p.m. [MEDICATION NAME] 0.5 mg at bedtime for high cholesterol (anxiety medication) 9:00 p.m. [MEDICATION NAME] 0.5 mg at bedtime for [MEDICAL CONDITION] ([MEDICAL CONDITION] medication) 5:00 p.m. Calcium [MEDICATION NAME] plus Vitamin D ,[DATE] mg twice per day (heart supplement) 5:00 p.m. Carvedilol 6.25 mg twice per day (for [MEDICAL CONDITION]) 5:00 p.m. [MEDICATION NAME]/Salmeterol inhalant ,[DATE] mcg (micrograms) twice per day (for [MEDICAL CONDITION]/[MEDICAL CONDITION]) 5:00 p.m. [MEDICATION NAME] 400 mg three times per day (for [MEDICAL CONDITION]) 6:00 p.m. Duo-neb 0XXX,[DATE].5 inhale 3 ml (milliliters) via hand held nebulizer every 6 hours (for [MEDICAL CONDITION]/[MEDICAL CONDITION]). The DON, and Administrator were made aware of findings, and stated they had no further information to present. COMPLAINT DEFICIENCY 6. Resident #98's significant medications, that were ordered for multiple doses per day, were given late. Resident #98, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #98's most recent Minimum Data Set (MDS) Cognitive skills for daily decision-making were coded as impaired. Functional status for bed mobility, transfers, eating, dressing, and personal hygiene were all coded as extensive to total dependence on staff. On [DATE] at 12:30 p.m., after lunch, LPN A was observed at a medication cart preparing to administer medications to Resident #98. The medications that LPN A prepared to administer were; [MEDICATION NAME] sulfate (Iron), aspirin, sodium chloride, and a multivitamin. LPN A was asked why so many pills were being given at lunch time, and she replied these are all the 9:00 a.m., morning pills. We don't have enough staff to get it all done. The current physician's orders [REDACTED]. The following is a list of the errors noted which were all given at least 2 hours late, and or omitted; 12:00 p.m. Resident #98 - [MEDICATION NAME] 10 mg (milligrams) one tablet 3 times per day at 9:00 a.m., 1:00 p.m., and 5:00 p.m. for low blood pressure, Iron 325 mg twice per day at 9:00 a.m., and 5:00 p.m. for [MEDICAL CONDITION], Pro-stat (protein) liquid 30 ml (milliliters) twice per day at 9:00 a.m., and 5:00 p.m. for supplement for a stage 3 pressure ulcer and protein malnutrition, and sodium chloride 1 gram twice per day at 7:30 a.m., and 5:30 p.m. for low sodium, which can lead to dehydration. On [DATE] at approximately 12:05 p.m., the DON (director of nursing) was asked what references are utilized for professional practice standards and she stated, CMS (Centers for Medicare and Medicaid Services), CDC (Centers for Disease Control and Prevention), AMA (American Medical Association), and for nurses: Potter Perry. On [DATE] at approximately 3:45 p.m., the DON was asked about the expectation of nurses when administering medications and she stated that the nurse should administer the medications on time, and that if given late the resulting dose would be late, and may have to be omitted all together so as to not double dose the patient, which could lead to symptoms of the illness that the medications were necessary for, to prevent and treat. On [DATE] at approximately 4:00 p.m., the Administrator and DON were notified of findings and they offered no further documentation or information. Complaint DEFICIENCY 7. Resident #47's significant medications, that were ordered for multiple doses per day, were given late. Resident #47, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #47's most recent Minimum Data Set (MDS) Cognitive skills for daily decision-making were coded as severely impaired. Functional status for bed mobility, transfers, eating, dressing, and personal hygiene were all coded as extensive to total dependence on staff. On [DATE], after Resident #98's medications were administered at 12:30pm, LPN A was observed preparing to administer medications to Resident #47. They were; aspirin, vitamin B complex, [MEDICATION NAME], and carvedilol. The current physician's orders [REDACTED]. The following is a list of the errors noted which were all given at least 2 hours late, and or omitted; 12:10 p.m. Resident #47 - [MEDICATION NAME] F/C 50 mg twice per day at 9:00a.m., and 5:00 p.m. for migraine headache prevention after a stroke, [MEDICATION NAME] 500 mg twice per day at 9:00 a.m., and 9:00 p.m. for mood disorder [MEDICATION]), and Carvedilol F/C 3.125 mg twice per day at 9:00 a.m., and 5:00 p.m., for high blood pressure. for a Resident with a history of stroke. On [DATE] at approximately 12:05 p.m., the DON (director of nursing) was asked what references are utilized for professional practice standards and she stated, CMS (Centers for Medicare and Medicaid Services), CDC (Centers for Disease Control and Prevention), AMA (American Medical Association), and for nurses: Potter Perry. On [DATE] at approximately 3:45 p.m., the DON was asked about the expectation of nurses when administering medications and she stated that the nurse should administer the medications on time, and that if given late the resulting dose would be late, and may have to be omitted all together so as to not double dose the patient, which could lead to symptoms of the illness that the medications were necessary for, to prevent and treat. On [DATE] at approximately 4:00 p.m., the Administrator and DON were notified of findings and they offered no further documentation or information. Complaint DEFICIENCY 8. Resident #68's significant medications, that were ordered for multiple doses per day, were given late, and 2 medications were omitted. Resident #68, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #68's most recent Minimum Data Set (MDS) Cognitive skills for daily decision-making were coded as impaired. Functional status for bed mobility, transfers, eating (tube feedings), dressing, and personal hygiene were all coded as limited to extensive dependence on staff. On [DATE] after Resident #98's and 47's medications were administered at 12:30pm LPN A was observed at a medication cart preparing to administer medications to Resident #68. The medications that LPN A prepared to administer to Resident #68 were; [MEDICATION NAME], aspirin, [MEDICATION NAME], and wixela ([MEDICATION NAME] inhaler). LPN A stated Oh, his [MEDICATION NAME] and [MEDICATION NAME] are missing, I ordered those yesterday, I guess I will have to order them again, they must not have been delivered. She then administered the medications. The current physician's orders [REDACTED]. The following is a list of the errors noted which were all given at least 2 hours late, and or omitted; 12:15 p.m. Resident #68 - [MEDICATION NAME] 0.5 mg twice per day at 9:00a.m., and 5:00 p.m. for anxiety and for a Resident who suffers from [MEDICAL CONDITION], [MEDICATION NAME] 100 mg twice per day at 9:00 a.m., and 5:00 p.m. for high blood pressure, [MEDICATION NAME] 1000 mg twice per day at 9:00 a.m., and 5:00 p.m., of diabetes, and Wixela ([MEDICATION NAME] inhaler) one puff every 12 hours at 9:00 a.m., and 9:00 p.m., for shortness of breath with ([MEDICAL CONDITION]). On [DATE] at 3:30 p.m. LPN A was preparing to leave for the day, and was asked if the [MEDICATION NAME] and [MEDICATION NAME] for Resident #68 had arrived from the pharmacy, and she replied no, it will probably come in tonight. Both medications were documented on the MAR as having not been given. On [DATE] at approximately 12:05 p.m., the DON (director of nursing) was asked what references are utilized for professional practice standards and she stated, CMS (Centers for Medicare and Medicaid Services), CDC (Centers for Disease Control and Prevention), AMA (American Medical Association), and for nurses: Potter Perry. On [DATE] at approximately 3:45 p.m., the DON was asked about the expectation of nurses when administering medications and she stated that the nurse should administer the medications on time, and that if given late the resulting dose would be late, and may have to be omitted all together so as to not double dose the patient, which could lead to symptoms of the illness that the medications were necessary for, to prevent and treat. On [DATE] at approximately 4:00 p.m., the Administrator and DON were notified of findings and they offered no further documentation or information. Complaint DEFICIENCY 9. For Resident #15, the facility staff failed to administer medication in a timely manner. Resident #15 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #15's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of [DATE] was reviewed. Resident #15 was coded as having a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. On [DATE] at 1:19 P.M. an interview was conducted with Resident #15. He complained of not receiving care, and medications in a timely manner. He stated The facility is always short of staff, and they can't keep the one's they have because they work them to death. Resident #15's signed physician orders [REDACTED]. Inject 15 unit subcutaneously three times a day related to Type 2 Diabetes. His doses were scheduled for specific times of administration. On [DATE] a review was conducted of Resident #15's clinical record, revealing Resident #15's Medication Audit Report. Resident #15 received his insulin between approximately 2 to 5 hours late on the following days: [DATE] Scheduled for 4:00 P.M. Administered at 7:27 P.M. [DATE] Scheduled for 11:00 [NAME]M. Administered at 1:04 P.M. [DATE] Scheduled for 4:00 P.M. Administered at 9:52 P.M. [DATE] Scheduled for 4:00 P.M. Administered at 9:17 P.M. [DATE] Scheduled for 4:00 P.M. Administered at 7:50 P.M. On [DATE] at approximately 3:00 P.M., an interview was conducted with the Director of Nursing (Employee B). When asked to describe the possible consequences of Residents not receiving insulin as ordered, she stated, They can either have a adverse reaction, including a diabetic coma or [MEDICAL CONDITION]. No further information was received. 10. For Resident #181, the facility staff failed to document the administration of medication. Resident #181 was a [AGE] year old who was admitted to the facility on [DATE], and discharged to the hospital on [DATE]. Resident # 181's [DIAGNOSES REDACTED]. The Minimum Data Set, which was an Admission Assessment with an Assessment Reference Date of [DATE], coded Resident #181 as having a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. On [DATE] a review was conducted of Resident #181's clinical record, revealing his Medication Administration Record (MAR) for February, (YEAR). Medication administration was not documented as having been administered as follows: [MEDICATION NAME]/[MEDICATION NAME] Extended Release 60 MG. every 8 hours - [DATE] at 10 P.M. [DATE] at 6 [NAME]M., 2 P.M., 10 P.M. [MEDICATION NAME] Capsule 0.4 MG 1 time daily [DATE] at 9 P.M. [DATE] at 9 P.M. [MEDICATION NAME] Suspension 0.25 MG/2 ML. 2 ML inhale orally via nebulizer 2 x daily [DATE] at 5 P.M. [DATE] at 9 [NAME]M., 5 P.M. Check lung sounds pre-admission 2 x daily for monitoring lung sounds [DATE] at 5 P.M. [DATE] at 9 [NAME]M., 5 P.M. On [DATE] at approximately 3:00 P.M., an interview was conducted with the Director of Nursing (Employee B). She said that she was unable to state why the medications had not been documented as having been administered. She said that the facility's policy was to document the administration of medications immediately after the administration is completed. 11. For Resident #42, the facility staff failed to document the administration of medication. Resident #42 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #42's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of [DATE] was reviewed. Resident #42 was coded as having a Brief Interview of Mental Status Score of 14, indicating no cognitive impairment. On [DATE] a review was conducted of Resident #42's clinical record, revealing his Medication Administration Record for May, 2019. The following medication had not been documented as having been administered: [MEDICATION NAME] 500 MG/2ML. Inject 3 ML intramuscularly every 8 hours related to Urinary Tract Infection. [DATE] at 6 [NAME]M. On [DATE] at approximately 3:00 P.M., an interview was conducted with the Director of Nursing (Employee B). She said that she was unable to state why the medications had not been documented as having been administered. She said that the facility's policy was to document the administration of medications immediately after the administration is completed. 12. For Resident #60, the facility staff failed to document the administration of medication. Resident #60 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #60's [DIAGNOSES REDACTED]. The Minimum Data Set, which was an Annual Assessment with an Assessment Reference Date of [DATE] was reviewed. Resident #60 was coded as having a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. On [DATE] a review was conducted of Resident #60's clinical record, revealing a signed physician order [REDACTED]. Give 1 by mouth once daily. In addition, his Medication Administration Record was reviewed for April, 2019. The following diabetic management medications had not been documented as having been administered: GilpiZIDE Extended Release Tablet 10 MG. Give one tablet by mouth once daily for Diabetes Mellitus [DATE] at 9 [NAME]M. [MEDICATION NAME] HCI Tablet 1000 MG. Give one tablet by mouth every 12 hours related to Type 2 Diabetes Mellitus [DATE] at 9 [NAME]M. On [DATE] at approximately 3:00 P.M., an interview was conducted with the Director of Nursing (Employee B). She said that she was unable to state why the medications had not been documented as having been administered. She said that the facility's policy was to document the administration of medications immediately after the administration is completed. No further information was received. 13. For Resident #57, the facility staff left 2 white pills in a medicine cup at the bedside on [DATE]. Resident #57, a [AGE] year old male, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #57's most recent Minimum Data Set with an Assessment Reference Date of [DATE] was coded as a quarterly review. The Brief Interview for Mental Status was 4 out of possible 15 indicative of severe cognitive impairment. On [DATE] at approximately 12:00 PM, Resident #57 was not in his room but there were 2 white pills observed in a med cup on his tray table by his bed. On [DATE] at 12:02 PM, an interview with LPN B was conducted. When asked if she gave Resident #57 his medications today, she stated, Yes. LPN B and this surveyor went to Resident #57's bedside to observe the 2 white pills in the med cup. The pills appeared whole an

Based on Resident interview, Family interview, staff interview, clinical record review, facility record review, and in the course of a complaint investigation, the facility staff failed to investigate, prevent further occurrences, and correct allegations of abuse, neglect, and misappropriation for 2 residents (Resident #2, #97), resulting in harm for Resident #2, in a survey sample of 76 Residents. The findings included: 1. For Resident #2, the facility Director of Nursing (DON), and nursing staff neglected to report and investigate an allegation of neglect, and the family reported neglect to them on 2-13-19. Resident #2 was visited by family on 2-13-19, and found that the Resident had been vomiting all day on 2-12-19, and the emesis basin full of emesis was still on the bedside table. Also found were medications in a cup which had not been administered. The family went to the nurses station and spoke to the nurse who stated she would get the DON for them to speak to. The family waited for the nurse for 15 minutes, and when she did not return, went immediately to the DON and reported their findings of neglect. The DON told them she was leaving and not returning to the position, and would report it to the new DON. On 6-11-19, the Administrator was asked to provide any and all documentation of an abuse or neglect report and investigation for this Resident during her entire stay. She returned, and stated there were none, however, she had received calls from the Residents daughter about concerns, but had not felt it was neglect. She did not report nor investigate an allegation of neglect per federal regulation. The facility Administrator and Director of nursing were made aware of findings on 6-20-19. The facility stated they had no further information to provide. COMPLAINT DEFICIENCY 2. For Resident #97, the facility staff failed to prevent further potential abuse after an allegation of abuse by a nurse on 05/11/2019. Resident #97, a [AGE] year old female, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #97's most recent Minimum Data Set with an Assessment Reference Date of 05/02/2019 was coded as a quarterly review. The Brief Interview for Mental Status was coded as 15 out of possible 15 indicative of intact cognition. Functional status for transfers and locomotion on and off unit were coded as limited assistance from staff. Mobility devices were walker or wheelchair. On 06/05/2019 at approximately 12:10 PM, an interview with Resident #97 was conducted in her room. When asked if she had any concerns about how the staff treats her, Resident #97 stated she had a problem with a nurse a few weeks ago. Resident #97 stated, It was a Saturday morning. Resident #97 stated she was in the lobby waiting for her ride to [MEDICAL TREATMENT] when a nurse came and told her she couldn't wait in the lobby because it wasn't safe. Resident #97 stated she always waits in the lobby for her ride to [MEDICAL TREATMENT] and locked her wheelchair in place. Resident #97 stated the nurse was rude when talking to her and began pushing/pulling on the wheelchair trying to get it to move. As a result, Resident #97 stated that she slid out of her wheelchair to the floor. Resident #97 stated that her whole right side was still sore from the incident. Resident #97 stated she told the administrator about what happened that same day and has not seen the administrator since that day. Resident #97 stated she did not remember the nurse's name. When asked if she has seen the nurse again since the incident, Resident #97 stated that the Thursday following the incident, that same nurse came in her room to give medications and Resident #97 stated she refused her meds and told the nurse, I don't even want a cup of water from you. Resident #97 denies feeling anxious or fearful and stated she had since talked to the nurse like she was my own daughter. Resident #97 stated she told her Don't hassle people in a wheelchair. On 06/05/2019 at approximately 1:00 PM, the administrator was notified of this allegation of abuse and entered Resident #97's room with this surveyor. Resident #97 repeated her statements to the administrator. On 06/05/2019 at approximately 1:15 PM, the administrator and this surveyor met to discuss the incident. When asked for notes of the investigation and statements, the administrator looked through her electronic files and stated she could not find notes about the investigation. The administrator stated she asked the nurse to write a statement but was unable to locate it. The administrator did locate an incident report dated 05/14/2019 and provided a copy to this surveyor. The incident report dated 05/14/2019 was completed by Licensed Practical Nurse F (LPN F). Under the header, Describe objectively what was observed, it was documented, Resident was in the front lobby with no supervision. Nurse asked president how she got out there. Resident stated she knows the code to get out. Nurse informed resident of the dangers that can happen because she is off the unit and we are unaware of who is picking her up. Nurse also informed her she care about her well-being that if someone comes into the facility they could harm her and we would be unaware. Resident got upset stating no one cares about her. I informed her that I don't know what normally goes on but I care and I can't allow her to sit out there. Nurse started taking resident back to the unit and Resident grow I told to the side rail next to the administrator door and pulled herself out of chair. Resident did not hit floor immediately. Resident lowered herself to the floor. Nurse tried to assist resident back in wheelchair that is when resident started yelling leave her alone. Resident put herself back in chair. Under the header, Management Review dated 05/16/2019 at 7:49 a.m., it was documented by the administrator I have met with resident on 05/11/2019 (Saturday) morning. She was able to stand up and walking with her W/C (wheelchair). On 06/17/2019, the facility staff provided a list of days LPN [NAME] was assigned to care for Resident #97 since 05/11/2019. There were 3 dates when LPN [NAME] was assigned to care for Resident #97 after the allegation of abuse incident (05/26/2019, 05/30/2019, and 06/02/2019). On 06/20/2019 by the end of the survey, the interim administrator had no further information or documentation to offer.

Based on family interview, staff interview, clinical record review, facility document review, hospital record review, and in the course of a complaint investigation, the facility staff failed to provide intravenous fluids ordered by a physician for one Resident (Resident #2) resulting in harm, in a sample of 76 Residents. The findings included: Resident #2 did not receive a physician ordered IV (intravenous fluid infusion) on [DATE] due to staff inability to access a vein to infuse the fluids, and, the Resident failed to receive Hypodermoclysis fluid infusion in the subcutaneous tissue as ordered due to unavailability of the IV fluids in the facility on [DATE]. Resident #2 was admitted to the facility on [DATE], after treatment for [REDACTED]. Resident #2's [DIAGNOSES REDACTED]. Resident #2's most recent Minimum Data Set (MDS) was an admission assessment dated [DATE]. Cognitive skills for daily decision-making were coded as 13 of 15, and no cognitive impairment. Functional status for bed mobility, transfers, eating, dressing, and personal hygiene were all coded as extensive dependence on staff. Review of the closed record physician progress notes [REDACTED].#2 was seen was on [DATE]. The Resident denied nausea and vomiting in the note, and was being seen for a decrease in appetite. Review of the physician's orders [REDACTED].#2 was ordered to be given [MEDICATION NAME] suppository rectally for nausea and vomiting on [DATE], and [MEDICATION NAME] 8 milligram tablet orally on [DATE] at 6:28 p.m., for nausea and vomiting. Review of the nursing notes revealed that no nursing notes existed between [DATE], and [DATE]. On [DATE] the Resident was experiencing persistent vomiting, and the physician ordered via the telephone IV 0.9% normal saline at 60 ml per hour for 1000 ml related to dehydration. The nurse was unable to establish an IV access catheter to infuse the fluids, and they were never given. There is no indication that the physician was ever notified that the order was not carried out. There are no further nursing or physician notes until [DATE], when new verbal/telephone physician orders [REDACTED]. The Resident received the fluid from 2:00 p.m. on [DATE], until 11:00 a.m., on [DATE] when it was abruptly stopped. The Medication Administration Record [REDACTED]. The IV fluids were not given after 11:00 a.m., on [DATE] even though the Resident received [MEDICATION NAME] 8 milligram tablet orally on [DATE] at 6:28 p.m., for continuing nausea and vomiting. The fluid infusion order was Discontinued on [DATE] at 9:38 a.m. with no note from the physician or nurses to indicate the reason. Licensed Practical Nurse-LPN A was the nurse for the 11:00 p.m. to 7:00 a.m. shift on the nights of [DATE], and [DATE]. Licensed Practical Nurse-LPN A was interviewed, and stated We didn't have any fluids in the building to give the patient. When asked why no note was written, she stated she had written a note documenting that the fluids were unavailable, and that the nurse on 3 p.m.-11 p.m. shift on [DATE] reported to her that she had not had any in the building either, and the family was angry, so she put the fluids on hold until the pharmacy could deliver them. The fluids never arrived, and the order was discontinued. The facility was asked for a copy of the IV stat box contents which contained extra bulk dose medications that could be administered until supplies for the individual could be received. The document was received, and stated the normal saline needed for Resident #2's infusion was contained in the box. LPN A stated that during the stay of Resident #2, the box was not filled and sent out to the pharmacy for refill as it should have been. The ,[DATE] nurse for [DATE] was identified, and found to be a short term contract employee who no longer worked at the facility. There were no nursing notes in the record for [DATE], and [DATE] to explain why the fluids were not completed through [DATE], and were discontinued on [DATE]. There were no nursing notes from [DATE] until [DATE], which documented that the resident had refused all treatments and care. On [DATE] the first identification of a wound with green yellow slough was documented. On [DATE] the Resident was sent to the hospital for nausea/vomiting and suspected dehydration at 6:35 p.m., which was requested by the family. The Resident never returned. Weight records were reviewed and revealed a weight loss of 45 pounds in 38 days. The care plan was reviewed and had no interventions care planned for continued nausea, and vomiting. Hospital records document that it was reported to the hospital staff that [MEDICATION NAME] ([MEDICATION NAME]) 8 mg was given to the Resident prior to leaving the nursing home on [DATE], however, the nursing notes and MAR indicated [REDACTED]. Hospital records were reviewed and revealed the normally oriented and alert Resident was Disoriented and unable to identify complaints. The Resident arrived in the ER (emergency room ) at 7:09 p.m The Resident was seen by critical care staff who surgically placed an IV catheter in the Residents External Jugular neck vein. The ER Critical care note documented System at risk for life threatening failure: Central nervous system, cardiac and circulatory. Associated problems: [MEDICAL CONDITION] (low blood pressure) Dehydration, Arrhythmia and infection. The hospital documents go on to say that emergency medical services ambulance first responders recorded the Resident's blood pressure to be ,[DATE] mmHg (millimeters mercury) at the nursing home, and at the ER measured ,[DATE]. The Resident was admitted with dehydration,[MEDICAL CONDITION], acute [MEDICATION NAME] with bloody urine (urinary tract infection), intractable nausea and vomiting, [DIAGNOSES REDACTED] (critically low potassium 2.2-normal is 3.5 to 5.5), and [DIAGNOSES REDACTED] (critically low magnesium 0.8-normal is 1.6 to 2.5), and lactic acidosis (critically high 6.96-normal is 0.9 to 1.7). After placing an IV catheter the Resident was immediately placed on fluid and potassium replacement infusions in the emergency room , and was later admitted to the ICU (intensive care unit), where she expired on [DATE] (5 days later). The Resident was last seen by the physician on [DATE], and had recurrent nausea and vomiting from [DATE] until her discharge [DATE]. The Resident was not supplied with ordered fluid infusions, as they were unavailable, she became dehydrated, and was sent to the hospital at the behest of the family. The Resident expired in the hospital on [DATE] (5 days later) with the [DIAGNOSES REDACTED]. The facility Administrator and Director of nursing were made aware of findings on [DATE]. The facility stated they had no further information to provide. COMPLAINT DEFICIENCY

Based on resident interview, staff interview, clinical record review and facility documentation the facility staff failed to provide adequate pain management for 1 Resident (Resident #125) in a survey sample of 76 Residents. The findings include: For Resident #125 the facility staff failed to address the Resident's back pain resulting in Resident #125 calling 911 himself to get help. Resident #125, a [AGE] year old man was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Resident #125's most recent MDS dated [DATE], coded as a PPS 5 Day, the Resident had a BIMS (Brief Interview of Mental Status) score of 15 indicating no cognitive impairment. The MDS also coded him as Extensive Assist with 1 person physical assist needed for Bathing, Dressing, Toileting, Bed Mobility, and Transfers. On 6/7/19 at 9:15 AM, Resident #125 stated that he called 911 to go to the ER because he was in so much pain in his back. He stated I rang that call bell and no one answered, I needed help getting to the bathroom. I had been on a metal table getting a scan today and I was hurting so bad I couldn't even sit up by myself. I kept trying to get help and get my [MEDICATION NAME] for muscle spasms but no one would come. I couldn't hold it any longer and I ended up peeing on myself that was so humiliating. He further stated that he waited so long for someone to answer that he called 911 himself around 1:30 AM. He said A nurse finally came in and I told her I called 911 and she said we better get you cleaned up so they don't think we neglected you. According to the EMS Report the Rescue Squad arrived at the facility at 1:36 AM. In an interview with the DON on 6/7/19 at 1030 AM she stated that she had a call out and asked the 3 PM-11 PM nurse to stay and that nurse got angry, left her keys and left the building. She left at 11:41 PM according to her time clock report. The DON stated she spoke with her and told her she couldn't leave her patients. The nurse did not return until 1:30 AM. In an interview with Registered Nurse-RN F she stated she did not abandon her patients that she left and came back a couple of hours later. She stated she had something to do that couldn't wait. She further stated that her coworkers were aware of her leaving and the need to cover her patients. An excerpt from a written statement provided by the Administrator included: He used his cell phone to call EMS himself. Nurse assisted EMS staff and (name redacted) was transferred to the ER per his request. Nursing Progress Notes dated 6/7/19 at 7:07 AM read Resident called 911 because of back pain refused to take medicine. Sent via Ambulance Resident is own RP. MD made aware. Nursing Progress Notes dated 6/7/19 at 2:30 PM Resident stated that he called 911 due to increased pain. Resident stated the pain was unbearable and he felt he needed to go to the ER. An excerpt from the Hospital ER Report reads Hx of [MEDICAL CONDITION] and chronic back pain States had a DaT Scan today at (hospital name redacted) 1:00 PM -and his chronic back pain began to hurt .has asked the Staff at (facility name redacted) for his [MEDICATION NAME] and they wouldn't give him any .thus he called 911. On 6/11/19 at 10:00 AM in an interview with the DON she stated A resident should never have to call the EMS by themselves. During the end of day meeting on 6/20/19 the Administrator was made aware of the issues and no further information was provided.

Based on observation, family interview, staff interview, clinical record review, facility document review, hospital record review, and in the course of a complaint investigation, the facility staff failed to ensure medications were available for 3 residents (Residents #2, #180, #68), resulting in harm for Resident #2, in a sample size of 76 residents. The findings included: 1. Resident #2 did not receive a physician ordered IV (intravenous fluid infusion) on [DATE] due to staff inability to access a vein to infuse the fluids, and, the Resident failed to receive Hypodermoclysis fluid infusion in the subcutaneous tissue as ordered due to unavailability of the IV fluids in the facility on [DATE]. This is harm. Resident #2 was admitted to the facility on [DATE], after treatment for [REDACTED]. Resident #2's [DIAGNOSES REDACTED]. Resident #2's most recent Minimum Data Set (MDS) was an admission assessment dated [DATE]. Cognitive skills for daily decision-making were coded as 13 of 15, and no cognitive impairment. Functional status for bed mobility, transfers, eating, dressing, and personal hygiene were all coded as extensive dependence on staff. Review of the closed record physician progress notes [REDACTED].#2 was seen was on [DATE]. The Resident denied nausea and vomiting in the note, and was being seen for a decrease in appetite. Review of the physician's orders [REDACTED].#2 was ordered to be given [MEDICATION NAME] suppository rectally for nausea and vomiting on [DATE], and Odansetron 8 milligram tablet orally on [DATE] at 6:28 p.m., for nausea and vomiting. Review of the nursing notes revealed that no nursing notes existed between [DATE], and [DATE]. On [DATE] the Resident was experiencing persistent vomiting, and the physician ordered via the telephone IV 0.9% normal saline at 60 ml (milliliters) per hour for 1000 ml related to dehydration. The nurse was unable to establish an IV access catheter to infuse the fluids, and they were never given. There is no indication that the physician was ever notified that the order was not carried out. There are no further nursing or physician notes until [DATE], when new verbal/telephone physician orders [REDACTED]. The Resident received the fluid from 2:00 p.m. on [DATE], until 11:00 a.m., on [DATE] when it was abruptly stopped. The Medication Administration Record (MAR) documentation showed at 12:00 noon on [DATE] that the fluids were not infusing, and Other/see nursing note but there was no note. The IV fluids were not given after 11:00 a.m. on [DATE] even though the Resident received Odansetron 8 milligram tablet orally on [DATE] at 6:28 p.m., for continuing nausea and vomiting. The fluid infusion order was Discontinued on [DATE] at 9:38 a.m. with no note from the physician or nurses to indicate the reason. Licensed Practical Nurse-LPN A was the nurse for the 11:00 p.m. to 7:00 a.m. shift on the nights of [DATE], and [DATE]. LPN A was interviewed, and stated We didn't have any fluids in the building to give the patient. When asked why no note was written, she stated she had written a note documenting that the fluids were unavailable, and that the nurse on 3 p.m.-11 p.m. shift on [DATE] reported to her that she had not had any in the building either, and the family was angry, so she put the fluids on hold until the pharmacy could deliver them. The fluids never arrived, and the order was discontinued. The facility was asked for a copy of the IV stat box contents which contained extra bulk dose medications that could be administered until supplies for the individual could be received. The document was received, and stated the normal saline needed for Resident #2's infusion was contained in the box. LPN A stated that during the stay of Resident #2, the box was not filled and sent out to the pharmacy for refill as it should have been. The ,[DATE] nurse for [DATE] was identified, and found to be a short term contract employee who no longer worked at the facility. There were no nursing notes in the record for [DATE], and [DATE] to explain why the fluids were not completed through [DATE], and were discontinued on [DATE]. There were no nursing notes from [DATE] until [DATE], which documented that the resident had refused all treatments and care. On [DATE] the first identification of a wound with green yellow slough was documented. On [DATE] the Resident was sent to the hospital for nausea/vomiting and suspected dehydration at 6:35 p.m., which was requested by the family. The Resident never returned. Hospital records document that it was reported to the hospital staff that [MEDICATION NAME] (Odansetron) 8 mg was given to the Resident prior to leaving the nursing home on [DATE], however, the nursing notes and MAR have no documentation of the medication ever having been given on [DATE]. Hospital records were reviewed and revealed the normally oriented and alert Resident was Disoriented and unable to identify complaints. The Resident arrived in the ER (emergency room ) at 7:09 p.m The Resident was seen by critical care staff who surgically placed an IV catheter in the Residents External Jugular neck vein. The ER Critical care note documented System at risk for life threatening failure: Central nervous system, cardiac and circulatory. Associated problems: [MEDICAL CONDITION] (low blood pressure) Dehydration, Arrhythmia and infection. The hospital documents go on to say that emergency medical services ambulance first responders recorded the Resident's blood pressure to be ,[DATE] mmHg (millimeters mercury) at the nursing home, and at the ER measured ,[DATE]. The Resident was admitted with dehydration,[MEDICAL CONDITION], acute [MEDICATION NAME] with bloody urine (urinary tract infection), intractable nausea and vomiting, [DIAGNOSES REDACTED] (critically low potassium 2.2) (normal is 3.5 to 5.5) ), and [DIAGNOSES REDACTED] (critically low magnesium 0.8) (normal is 1.6 to 2.5), and lactic acidosis (critically high 6.96) (normal is 0.9 to 1.7). After placing an IV catheter the Resident was immediately placed on fluid and potassium replacement infusions in the emergency room , and was later admitted to the ICU (intensive care unit), where she expired on [DATE] (5 days later). The Resident was last seen by the physician on [DATE], and had recurrent nausea and vomiting from [DATE] until her discharge [DATE]. The Resident was not supplied with ordered fluid infusions, as they were unavailable, she became dehydrated, and was sent to the hospital at the behest of the family. The Resident expired in the hospital on [DATE] (5 days later) with the [DIAGNOSES REDACTED]. The facility Administrator and Director of nursing were made aware of findings on [DATE]. The facility stated they had no further information to provide. COMPLAINT DEFICIENCY 2. Resident #180, was admitted to the facility on [DATE], and discharged on [DATE]. [DIAGNOSES REDACTED]. Resident #180's most recent Minimum Data Set (MDS) was dated [DATE], and was an admission assessment Cognitive skills for daily decision-making were coded as no impairment. Functional status for bed mobility, transfers, eating, dressing, and personal hygiene were all coded as limited to extensive dependence on staff. The hospital discharge, and the entire nursing home closed record review revealed that the Resident was admitted to the facility on [DATE] at approximately 5:00 p.m. The physician's orders [REDACTED]. Those records revealed that the Resident did not receive the following medications in the evening of [DATE]. The medications were ordered, by the physician on [DATE], before his discharge from the hospital, and communicated to the facility on [DATE], the day before he arrived at the facility: 9:00 p.m. [MEDICATION NAME] 40 mg (milligrams) at bedtime for high cholesterol. 9:00 p.m. [MEDICATION NAME] 0.5 mg at bedtime for high cholesterol (anxiety medication) 9:00 p.m. [MEDICATION NAME] 0.5 mg at bedtime for [MEDICAL CONDITION] (supplement used to regulate sleep-wake cycles) 5:00 p.m. Calcium [MEDICATION NAME] plus Vitamin D ,[DATE] mg twice per day 5:00 p.m. Carvedilol 6.25 mg twice per day (for [MEDICAL CONDITION]) 5:00 p.m. [MEDICATION NAME]/Salmeterol inhalant ,[DATE] mcg (micrograms) twice per day (for [MEDICAL CONDITION]/[MEDICAL CONDITION]) 5:00 p.m. [MEDICATION NAME] 400 mg three times per day (for [MEDICAL CONDITION]) 6:00 p.m. Duo-neb 0XXX,[DATE].5 inhale 3 ml (milliliters) via hand held nebulizer every 6 hours (for [MEDICAL CONDITION]/[MEDICAL CONDITION]). The Director of Nursing (DON), and Administrator were made aware of findings, and stated they had no further information to present. COMPLAINT DEFICIENCY 3. Resident #68, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #68's most recent Minimum Data Set (MDS) Cognitive skills for daily decision-making were coded as impaired. Functional status for bed mobility, transfers, eating (tube feedings), dressing, and personal hygiene were all coded as limited to extensive dependence on staff. On [DATE] at 12:30 p.m., after lunch, Licensed Practical Nurse-LPN A was observed at a medication cart preparing to administer medications, and was asked why so many pills were being given at lunch time, and she replied these are all the 9:00 a.m., morning pills. We don't have enough staff to get it all done. After administering pills for 2 other residents, and administering them, she continued on to Resident #68. The medications that LPN A prepared to administer to Resident #68 were; [MEDICATION NAME], aspirin, [MEDICATION NAME], and wixela ([MEDICATION NAME] inhaler). LPN A stated Oh, his [MEDICATION NAME] and [MEDICATION NAME] are missing, I ordered those yesterday, I guess I will have to order them again, they must not have been delivered. She then administered the medications that she did have available. The current physician's orders [REDACTED]. The following is a list of the errors noted for Resident #68 who received his medications over 2 hours late, and the 2 medications which were omitted on [DATE]; 12:15 p.m., was the administration time for Resident #68 for [MEDICATION NAME] 0.5 mg twice per day at 9:00 a.m., and 5:00 p.m. for anxiety, [MEDICATION NAME] 100 mg twice per day at 9:00 a.m., and 5:00 p.m. for high blood pressure, [MEDICATION NAME] 1000 mg twice per day at 9:00 a.m., and 5:00 p.m., of diabetes, and Wixela ([MEDICATION NAME] inhaler) one puff every 12 hours at 9:00 a.m., and 9:00 p.m., for shortness of breath ([MEDICAL CONDITION]). On [DATE] at 3:30 p.m. LPN A was preparing to leave for the day, and was asked if the [MEDICATION NAME] and [MEDICATION NAME] for Resident #68 had arrived from the pharmacy, and she replied no, it will probably come in tonight. Both medications were documented on the MAR as having been omitted. On [DATE] the nursing notes, MAR, and the Medication Administration Audit Report were requested, and copies were delivered for Resident # 68's medication administration errors. The reports were reviewed and documented the approximate time the medications were observed as given for [DATE], with one exception, the [MEDICATION NAME] which was unavailable and omitted on [DATE] for Resident #68 was marked as administered on the audit report. The MAR received on [DATE] showed the [MEDICATION NAME] and [MEDICATION NAME] documented as not given. Nursing notes revealed that the medication was unavailable. On [DATE] at approximately 3:45 p.m., the DON was asked about the expectation of nurses when administering medications and she stated that the nurse should administer the medications on time, and that if given late the resulting dose would be late, and may have to be omitted all together so as to not double dose the patient, which could lead to symptoms of the illness that the medications were necessary for, to prevent and treat On [DATE] at approximately 4:00 p.m., the Administrator and DON were notified of findings and they offered no further documentation or information. COMPLAINT DEFICIENCY

Based on observation, staff interview, Family interview, Resident interview, clinical record review, facility document review, Hospital record review, and in the course of a complaint investigation, the facility staff failed to ensure Resident were free from significant medication errors for 10 residents in a sample size of 76 residents. (Residents #2, #180, #98, #47, #68, #76, #68 and separate issues for #111, #29 & #15 ) resulting in harm for Resident #2. The findings included: 1. Resident #2 did not receive a physician ordered IV (intravenous fluid infusion) on [DATE] due to staff inability to access a vein to infuse the fluids, and, the Resident failed to receive Hypodermoclysis fluid infusion in the subcutaneous tissue as ordered due to unavailability of the IV fluids in the facility on [DATE]. This is harm. Resident #2 was admitted to the facility on [DATE], after treatment for [REDACTED]. Resident #2's [DIAGNOSES REDACTED]. Resident #2's most recent Minimum Data Set (MDS) was an admission assessment dated [DATE]. Cognitive skills for daily decision-making were coded as 13 of 15, and no cognitive impairment. Functional status for bed mobility, transfers, eating, dressing, and personal hygiene were all coded as extensive dependence on staff. Review of the closed record physician progress notes [REDACTED].#2 was seen was on [DATE]. The Resident denied nausea and vomiting in the note, and was being seen for a decrease in appetite. Review of the physician's orders revealed that Resident #2 was ordered to be given [MEDICATION NAME] suppository rectally for nausea and vomiting on [DATE], and Odansetron 8 milligram tablet orally on [DATE] at 6:28 p.m., for nausea and vomiting. Review of the nursing notes revealed that no nursing notes existed between [DATE], and [DATE]. On [DATE] the Resident was experiencing persistent vomiting, and the physician ordered via the telephone IV (intravenous) 0.9% normal saline at 60 ml (milliliters) per hour for 1000 ml related to dehydration. The nurse was unable to establish an IV access catheter to infuse the fluids, and they were never given. There is no indication that the physician was ever notified that the order was not carried out. There were no further nursing or physician notes until [DATE], when new verbal/telephone physician orders were received for Hypodermoclysis fluid infusion in the subcutaneous tissue 0.9% normal saline at 60 milliliters per hour for 1 liter every hour, which is also used to treat dehydration. The Resident received the fluid from 2:00 p.m. on [DATE], until 11:00 a.m., on [DATE] when it was abruptly stopped. The Medication administration record (MAR) documentation showed at 12:00 noon on [DATE] that the fluids were not infusing, and Other/see nursing note and there was no note. The IV fluids were not given after 11:00 a.m., on [DATE] even though the Resident received Odansetron 8 milligram tablet orally on [DATE] at 6:28 p.m., for continuing nausea and vomiting. The fluid infusion order was Discontinued on [DATE] at 9:38 a.m. with no note from the physician or nurses to indicate the reason. LPN A was the nurse for the 11:00 p.m. to 7:00 a.m. shift on the nights of [DATE], and [DATE]. LPN A was interviewed, and stated We didn't have any fluids in the building to give the patient. When asked why no note was written, she stated she had written a note documenting that the fluids were unavailable, and that the nurse on 3 p.m-11 p.m. shift on [DATE] reported to her that she had not had any in the building either, and the family was angry, so she put the fluids on hold until the pharmacy could deliver them. The fluids never arrived, and the order was discontinued. The facility was asked for a copy of the IV stat box contents which contained extra bulk dose medications that could be administered until supplies for the individual could be received. The document was received, and stated the normal saline needed for Resident #2's infusion was contained in the box. LPN A stated that during the stay of Resident #2, the box was not filled and sent out to the pharmacy for refill as it should have been. The ,[DATE] nurse for [DATE] was identified, and found to be a short term contract employee who no longer worked at the facility. There were no nursing notes in the record for [DATE], and [DATE] to explain why the fluids were not completed through [DATE], and were discontinued on [DATE]. There were no nursing notes from [DATE] until [DATE], which documented that the resident had refused all treatments and care. On [DATE] the first identification of a wound with green yellow slough was documented. On [DATE] the Resident was sent to the hospital for nausea/vomiting and suspected dehydration at 6:35 p.m., which was requested by the family. The Resident never returned. Weight records were reviewed and revealed a weight loss of 45 pounds in 38 days. The care plan was reviewed and had no interventions care planned for continued nausea, and vomiting. Hospital records document that it was reported to the hospital staff that [MEDICATION NAME] (Odansetron) 8 mg was given to the Resident prior to leaving the nursing home on [DATE], however, the nursing notes and MAR have no documentation of the medication ever having been given on [DATE]. Hospital records were reviewed and revealed the normally oriented and alert Resident was Disoriented and unable to identify complaints. The Resident arrived in the ER (emergency room ) at 7:09 p.m The Resident was seen by critical care staff who surgically placed an IV catheter in the Residents External Jugular neck vein. The ER Critical care note documented System at risk for life threatening failure: Central nervous system, cardiac and circulatory. Associated problems: [MEDICAL CONDITION] (low blood pressure) Dehydration, Arrhythmia and infection. The hospital documents state that emergency medical services ambulance first responders recorded the Resident's blood pressure to be ,[DATE] mmHg (millimeters mercury) at the nursing home, and at the ER measured ,[DATE]. The Resident was admitted with dehydration,[MEDICAL CONDITION], acute [MEDICATION NAME] with bloody urine (urinary tract infection), intractable nausea and vomiting, [DIAGNOSES REDACTED] (critically low potassium 2.2-normal is 3.5 to 5.5) ), and [DIAGNOSES REDACTED] (critically low magnesium 0.8-normal is 1.6 to 2.5), and lactic acidosis (critically high 6.96-normal is 0.9 to 1.7). After placing an IV catheter the Resident was immediately placed on fluid and potassium replacement infusions in the emergency room , and was later admitted to the ICU (intensive care unit), where she expired on [DATE] (5 days later). The Resident was last seen by the physician on [DATE], and had recurrent nausea and vomiting from [DATE] until her discharge [DATE]. The Resident was not supplied with ordered fluid infusions, as they were unavailable, she became dehydrated, and was sent to the hospital at the behest of the family. The Resident expired in the hospital on [DATE] (5 days later) with the [DIAGNOSES REDACTED]. The facility Administrator and Director of nursing were made aware of findings on [DATE]. The facility stated they had no further information to provide. COMPLAINT DEFICIENCY 2. Resident #180 did not receive significant medications on the evening of [DATE] after being hospitalized for [REDACTED]. Resident #180, was admitted to the facility on [DATE], and discharged on [DATE]. [DIAGNOSES REDACTED]. Resident #180's most recent Minimum Data Set (MDS) was dated [DATE], and was an admission assessment Cognitive skills for daily decision-making were coded as no impairment. Functional status for bed mobility, transfers, eating, dressing, and personal hygiene were all coded as limited to extensive dependence on staff. The hospital discharge record and nursing home entire closed record review revealed that the Resident was admitted to the facility on [DATE] at approximately 5:00 p.m. The physician's orders, nursing notes, and Medication Administration records (MARs) for the time period from admission to discharge (19 days), were reviewed. Those records revealed that the Resident did not receive the following medications in the evening of [DATE]. The medications were ordered, by the physician on [DATE], before his discharge from the hospital, and communicated to the facility on [DATE], the day before he arrived at the facility: 9:00 p.m. [MEDICATION NAME] 40 mg (milligrams) at bedtime for high cholesterol. 9:00 p.m. [MEDICATION NAME] 0.5 mg at bedtime for high cholesterol (anxiety medication) 9:00 p.m. [MEDICATION NAME] 0.5 mg at bedtime for [MEDICAL CONDITION] ([MEDICAL CONDITION] medication) 5:00 p.m. Calcium [MEDICATION NAME] plus Vitamin D ,[DATE] mg twice per day 5:00 p.m. Carvedilol 6.25 mg twice per day (for [MEDICAL CONDITION]) 5:00 p.m. [MEDICATION NAME]/Salmeterol inhalant ,[DATE] mcg (micrograms) twice per day (for [MEDICAL CONDITION]/[MEDICAL CONDITION]) 5:00 p.m. [MEDICATION NAME] 400 mg three times per day (for [MEDICAL CONDITION]) 6:00 p.m. Duo-neb 0XXX,[DATE].5 inhale 3 ml (milliliters) via hand held nebulizer every 6 hours (for [MEDICAL CONDITION]/[MEDICAL CONDITION]). The DON, and Administrator were made aware of findings, and stated they had no further information to present. COMPLAINT DEFICIENCY. 3a. Resident #98's significant medications, that were ordered for multiple doses per day, were given late. 3b. Resident #47's significant medications, that were ordered for multiple doses per day, were given late. 3c. Resident #68's significant medications, that were ordered for multiple doses per day, were given late, and 2 medications were omitted. On [DATE] at 12:30 p.m., after lunch, LPN A was observed at a medication cart preparing to administer medications to Resident #98. The medications that LPN A prepared to administer were; [MEDICATION NAME] sulfate (Iron), aspirin, sodium chloride, and a multivitamin. LPN A was asked why so many pills were being given at lunch time, and she replied these are all the 9:00 a.m., morning pills. We don't have enough staff to get it all done. After administering the pills, she continued to Resident #47. The medications that LPN A prepared to administer to Resident #47 were; aspirin, vitamin B complex, [MEDICATION NAME], and carvedilol. After administering the pills, she continued on to Resident #68. The medications that LPN A prepared to administer to Resident #68 were; [MEDICATION NAME], aspirin, [MEDICATION NAME], and wixela ([MEDICATION NAME] inhaler). LPN A stated Oh, his [MEDICATION NAME] and [MEDICATION NAME] are missing, I ordered those yesterday, I guess I will have to order them again, they must not have been delivered. She then administered the medications. A fourth resident was also observed to receive medications with no error noted. The current physician's orders and medication administration record (MAR) were reviewed in the computerized program for the 4 Residents observed during the medication pour and pass observation. The last resident was found to have no error in administration of her medications, which were all due at lunch time. The following is a list of the errors noted for the other 3 Residents significant medications which were all given at least 2 hours late, and or omitted; 3a. 12:00 p.m. Resident #98-[MEDICATION NAME] 10 mg (milligrams) one tablet 3 times per day at 9:00 a.m., 1:00 p.m., and 5:00 p.m. for low blood pressure, Iron 325 mg twice per day at 9:00 a.m., and 5:00 p.m. for [MEDICAL CONDITION], Pro-stat (protein) liquid 30 ml (milliliters) twice per day at 9:00 a.m., and 5:00 p.m. for supplement for a stage 3 pressure ulcer and protein malnutrition, and sodium chloride 1 gram twice per day at 7:30 a.m., and 5:30 p.m. for low sodium, which can lead to dehydration. 3b. 12:10 p.m. Resident #47-[MEDICATION NAME] F/C 50 mg twice per day at 9:00 a.m., and 5:00 p.m. for migraine headache prevention after a stroke, [MEDICATION NAME] 500 mg twice per day at 9:00 a.m., and 9:00 p.m. for mood disorder [MEDICATION]), and Carvedilol F/C 3.125 mg twice per day at 9:00 a.m., and 5:00 p.m., for high blood pressure. for a Resident with a history of stroke. 3c. 12:15 p.m. Resident #68-[MEDICATION NAME] 0.5 mg twice per day at 9:00 a.m., and 5:00 p.m. for anxiety and for a Resident who suffers from [MEDICAL CONDITION], [MEDICATION NAME] 100 mg twice per day at 9:00 a.m., and 5:00 p.m. for high blood pressure, [MEDICATION NAME] 1000 mg twice per day at 9:00 a.m., and 5:00 p.m., of diabetes, and Wixela ([MEDICATION NAME] inhaler) one puff every 12 hours at 9:00 a.m., and 9:00 p.m., for shortness of breath with ([MEDICAL CONDITION]). On [DATE] at 3:30 p.m. LPN A was preparing to leave for the day, and was asked if the [MEDICATION NAME] and [MEDICATION NAME] for Resident #68 had arrived from the pharmacy, and she replied no, it will probably come in tonight. Both medications were documented on the MAR as having not been given. On [DATE] the nursing notes, MAR, and the Medication Administration Audit Report were requested, and copies were delivered for the 3 Residents with found medication administration errors. The reports were reviewed and documented the approximate time the medications were observed as given for [DATE], with one exception, the [MEDICATION NAME] which was unavailable and omitted on [DATE] for Resident #68 was marked as administered on the audit report. The MAR received on [DATE] showed the [MEDICATION NAME] and [MEDICATION NAME] documented as not given. Nursing notes revealed that the medication was unavailable. On [DATE] at approximately 12:05 p.m., the DON (director of nursing) was asked what references are utilized for professional practice standards and she stated, CMS (Centers for Medicare and Medicaid Services), CDC (Centers for Disease Control and Prevention), AMA (American Medical Association), and for nurses: Potter Perry. On [DATE] at approximately 3:45 p.m., the DON was asked about the expectation of nurses when administering medications and she stated that the nurse should administer the medications on time, and that if given late the resulting dose would be late, and may have to be omitted all together so as to not double dose the patient, which could lead to symptoms of the illness that the medications were necessary for, to prevent and treat. On [DATE] at approximately 4:00 p.m., the Administrator and DON were notified of findings and they offered no further documentation or information. COMPLAINT DEFICIENCY 4. For resident #76 the facility staff failed to document IV antibiotic X 1 dose and failed to notify MD of the resident refusing IV antibiotics for 6 consecutive days after returning to the facility after a hospital stay [MEDICAL CONDITION]. Resident #76, was a [AGE] year old man who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] during clinical record review it was noted that the Resident went to the hospital [MEDICAL CONDITION] from beta strep infected pressure wounds. Documentation included: Pt was placed in the hospital [MEDICAL CONDITION] to pressure areas from [DATE] to [DATE] and according to Hospital Discharge summary the Resident had LARGE decubitis to left posterior thigh and Multiple Areas of skin breakdown. Resident was discharged back to the facility with a PICC (Peripherally Inserted Central Catheter) line and orders for IV (intravenous) Antibiotics. He began the treatment while he was in the hospital and it was ordered daily until [DATE]. Physician order sheet read [MEDICATION NAME] Sodium Solution Reconstituted 2 gm (grams) intravenously one time a day. The (Medication Administration Record) MAR showed that the Resident was on [MEDICATION NAME] Sodium Solution Reconstituted 2 gm (grams) intravenously one time a day. It was to begin on [DATE] at 9:00 AM. The MAR revealed that the medication was administered on [DATE] and [DATE] and was also documented as follows: On [DATE] it is coded 2 which means Refused. On [DATE] it is coded as 5 which means see nurses note. On [DATE] it is coded as 2 which means Refused On [DATE] it is not signed or coded. On [DATE] it is coded as 2 which means Refused On [DATE] it is coded as 2 which means Refused Upon review of Progress notes there is no mention of medication refusal or MD notification. On [DATE] and [DATE] there is no nurses note at all only notes from Activities and Staff Development RN. On ,[DATE] /19 and [DATE] there are no nurses notes at all On [DATE] The Skilled nurses note states Resident accepted and tolerated skilled care with 0 adverse med effects. The IV antibiotic began in the hospital however the Resident missed 6 days of the 8 remaining days of ordered antibiotic therapy On [DATE] at 11:00 AM the Director of Nursing was asked what the expectation is of the nurses when Resident refuse medications. She answered The nurse should find out why they are refusing, document the refusal, and notify the MD of the refusal. When asked should she document physician notification she stated that they should make a note in the progress notes that they have notified the physician and nay new orders When asked if that was done in this case she stated No it was not. During end of day meeting on [DATE] the Administrator was made aware of the findings and no further information was provided. 5. For resident #68 the facility failed to clarify an order for [REDACTED]. Resident #68, a [AGE] year old man admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] during clinical record review it was noted that the resident had 2 co-existing orders for [MEDICATION NAME] (a [MEDICAL CONDITION] medication). The first order read: [MEDICATION NAME] XR Tablet Extended Release 12 hour 100 mg (milligrams). Give 1 tablet by mouth in the evening related to Major [MEDICAL CONDITION] Unspecified (f 33.9) -Start date-[DATE] at 5:00 PM The second order read: [MEDICATION NAME] XR Tablet Extended Release 12 hour 200 mg. Give 1 tablet by mouth at bedtime related to Major [MEDICAL CONDITION] Unspecified (f 33.9) -Start date-[DATE] at 9:00 PM Excerpts from the psych consult: [DATE]-This is an (sic) [AGE] year old male with a history of [MEDICAL CONDITION] being seen for a routine follow up visit. Per staff pt. is having increased aggression and making threats. Pt is currently taking [MEDICATION NAME] 0.5 mg PO (by mouth) Q (every) 8 hrs. As needed, [MEDICATION NAME] 0. 5mg po BID (twice a day) [MEDICATION NAME] 1 mg po bid [MEDICATION NAME] XR 100 mg Q HS (bedtime) and [MEDICATION NAME] 20 mg po QD (every day) Pt has been taking [MEDICATION NAME] since [DATE] and has not had a reduction in aggression/ behaviors Will D/C (discontinue) [MEDICATION NAME] and initiate [MEDICATION NAME] will also increase [MEDICATION NAME] to help with has mood. Medication: D/C [MEDICATION NAME] 1 mg PO BID, start [MEDICATION NAME] 10 mg qhs, D/C [MEDICATION NAME] XR 100 mg Start [MEDICATION NAME] XR 200 mg qhs On [DATE] the Psych consult read: Medication: Continue [MEDICATION NAME] 5mg PO QD, [MEDICATION NAME] ER 100 mg QAM (every morning) and 200 mg PO Q HS [MEDICATION NAME] 0.5 mg Q 8H PRN anxiety and [MEDICATION NAME] 0.5mg BID. The MAR (Medication Administration Record) showed the Resident as receiving [MEDICATION NAME] ER 100 mg at 5:00 PM [MEDICATION NAME] ER 200 mg at 9:00 PM On [DATE] at 2:00 PM in an interview with Unit Manager when asked are 12 hour extended release tablets usually given 4 hours apart, she stated that they would not be administered that way. When shown the copy of the MAR she stated she would look into it and get back to me. On [DATE] at 9:45 AM Unit in an interview with the unit manager she stated that she had spoken with the Nurse practitioner and the Psych NP's and that there was an error in the order and it should have read: [MEDICATION NAME] 100 mg Q AM and 200 mg Q Hs however since the reassigned was doing ok with the dose she would give him 300 mg at hs. [DATE] 4:35 PM Writer contacted NP regarding resident per Psych note to D/C [MEDICATION NAME] XR 100 mg Q HS and start [MEDICATION NAME] 200 mg at QHS dated [DATE]. NP state to contact psych NP. Writer contacted Psych NP for (name of psych practice redacted) and was informed of above. N.O. Give [MEDICATION NAME] XR 300 mg One PO QHS and will see resident on next visit. Resident shows no obvious signs or symptoms of injury. VS ,[DATE] ,[DATE] 98.1 O2 sat 97% Alert and oriented X ,[DATE]. Resident propel (sic) self in wheel chair as desired. Participates in choice activities. Denies abd (abdominal) discomfort, headaches or nausea/vomiting. Tolerates meal self fed after set up. No adverse reactions noted at this time. During end of day meeting on [DATE] the Administrator was made aware of the findings and no further information was provided. 6. For Resident #111, the facility staff failed to administer insulin as scheduled. Resident #111, a [AGE] year old female, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. On [DATE] during initial tour, Resident #111 expressed concerns regarding the nursing care she was receiving by stating, .the nurses here are also not giving me my insulin like I am supposed to get, it is never on time and my blood sugars are all over the place, I have had problems in the past and have been in ICU before because of my blood sugars and I am sitting here constantly worried that something is going to happen to me, I don't even go outside my room, I wish I wasn't here, I will never come back to this place. On [DATE], a review the Medication Administration Record (MAR) and Medication Administration Audit Report regarding insulin administration to Resident #111 was conducted and revealed that from date of admission on [DATE] to [DATE] there were 78 scheduled doses of insulin to be given per physician order. Only 27 insulin doses (33%) were given that met professional and facility guidelines to administer medication at the correct time. A staff interview was conducted with the Regional Clinical Director (Employee H) who stated, An acceptable time range to give a scheduled medication dose is within an hour before or an hour after a scheduled time on the MAR, anything other than that is not acceptable as it does not meet our expectations or comply with professional practice and more importantly with insulin, the right time is essential to controlling blood sugar, if not given at the right time it can be detrimental to the resident, it can cause serious harm. COMPLAINT DEFICIENCY 7. For Resident #29 the facility staff administered insulin that was expired. On [DATE] at 1:05 p.m. during review of the Liberty 1 medication cart the following was observed: A multi-dose vial of Humalog belonging to Resident #29 was noted with an open date of [DATE]. This Humalog should have been discarded 28 days after opening. Review of the Medication administration record (MAR) for Resident #29 revealed that Resident #29 had received 8 doses of Humalog after the date it should have been discarded. An interview was conducted with LPN A, who was present during the review of the Liberty 1 medication cart. LPN A stated, it should have been thrown out after 28 days. On [DATE] at 2:40 p.m. when LPN A was asked if the expired insulin had been administered to Resident #29, LPN said, I am going to say yes. On [DATE] at 2:19 p.m. an interview was conducted with the facility Director of Nursing (DON). The DON stated her expectation is, insulin is discarded 28 days after opened, when they open it they are to put the date on it. Review of the facility policy titled 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles with a revision date of [DATE] read, Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. Review of the facility policy titled, 6.0 General Dose Preparation and Medication Administration with a revision date of [DATE] read under the number 3.11, facility staff should enter the date opened on the label of medications with shortened expiration dates (e.g., insulins) Review of the Medication Storage Guidance provided by the facility on [DATE] read, multiple-dose vials for injection: date when opened and discard unused portion after 28 days. Page 10 of this document addressed insulin storage and stated, Humalog, Humalog mix, and [MEDICATION NAME] all have a storage recommendation of 28 days after opening. The drug information sheets and manufacture recommendations were reviewed and indicate to discard any unused product 28 days after opening. COMPLAINT DEFICIENCY 8. For Resident #15, the facility staff failed to ensure that he was free of Significant Medication Errors related to diabetic management. Resident #15 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #15's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of [DATE] was reviewed. Resident #15 was coded as having a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. On [DATE] at 1:19 P.M. an interview was conducted with Resident #15. He complained of not receiving care, and medications in a timely manner. He stated The facility is always short of staff, and they can't keep the one's they have because they work them to death. On [DATE] a review was conducted of Resident #15's clinical record, revealing a A1C lab test result which is obtained for diabetic management. The test was dated [DATE]. The Reference Range of normal levels was 4.0 - 6.0. Resident #15's level was 11.2, which was coded as being High. Resident #15's care plan was reviewed. An excerpt from the care plan read, [DATE]. The resident has Suprapubic catheter. The resident will remain free from catheter-related trauma. Catheter care as ordered. The Resident is at risk for Metabolic Complications r/t (related to) Diabetes. Medications as ordered. Resident #15's signed physician orders dated [DATE] read, [MEDICATION NAME] Solution Pen-Injector 100 UNIT/ML. Inject 15 unit subcutaneously three times a day related to Type 2 Diabetes. His doses were scheduled for specific times of administration. On [DATE] a review was conducted of Resident #15's clinical record, revealing Resident #15's Medication Audit Report. Resident #15 received his insulin between approximately 2 to 5 hours late on the following days: Date [DATE], Time Scheduled 4:00 P.M., Time Administered 7:27 P.M. Date [DATE], Time Scheduled 11:00 [NAME]M., Time Administered 1:04 P.M. Date [DATE] Time Scheduled 4:00 P.M., Time Administered 9:52 P.M. Date [DATE] Time Scheduled 4:00 P.M., Time Administered 9:17 P.M. Date [DATE] Time Scheduled 4:00 P.M., Time Administered 7:50 P.M. On [DATE] at approximately 3:00 P.M., an interview was conducted with the Director of Nursing (Employee B). When asked to describe the possible consequences of Residents not receiving insulin as ordered, she stated, They can either have a adverse reaction, including a diabetic coma or [MEDICAL CONDITION]. No further information was received.

Based on Observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure that one resident was free from abuse (Resident #14) in the survey sample of 26 residents, resulting in psychological harm for Resident #14. For Resident #14, one facility staff member jerked clothing off of the sleeping Resident, turned the Resident in bed banging his head into the side rail, and pushed the Resident from side to side without speaking to the Resident, while the Resident cried and pleaded for the staff member to stop, causing the Resident psychological harm. The Findings included: Resident #14 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment was a 14 day admission Assessment with an Assessment Reference Date of 4-8-16. The MDS coded Resident #14 as having moderate cognitive impairment. A Brief Interview for Mental Status was not conducted. The Resident was also coded as requiring extensive to total assistance of one to two staff members for all ADL's. The only exception to this was eating, which the Resident was able to accomplish previously with only tray set up help. The Resident was frequently incontinent of bowel and bladder. On 6-21-16 during initial tour of the facility at 2:50 p.m., Resident #14 was observed to be sitting in a reclining Geri Chair with wheels, and with wandergards on both ankles. The reclining chair was fully reclined to a lying position. On 6-21-16 at 3:25 p.m. Licensed Practical Nurse (LPN) E was interviewed at the nursing station. Resident #14 was still seated in the Geri Chair recliner at the nursing station. LPN E stated that he kept Resident #14 at the nursing station by him, as the Resident was a real fall risk. LPN E went on to say that the reason the Resident had 2 wandergard alarm bracelets (1 on each ankle) was that the family had purchased one of the devices through the police department and did not want it removed. This wandergard could locate the Resident if he left the facility and wandered into the community. The other wandergard bracelet was only connected to the facility and would alarm if the resident tried to leave via one of the exit doors in the facility. On 6-21-16 at 4:11 p.m. the Resident remained at the nursing station in the recliner in lying position. On 6-22-16 at 8:10 a.m. the Resident was again observed, alone in the room, and was found lying in bed, in the back of the room closest to the window. The Resident was on his back with an open unbuttoned pajama shirt on, uncovered in an incontinent brief, no pajama pants, and the door to the Resident's room was open leaving the Resident open to public view with other residents, staff, and visitors moving freely up and down the hallway outside of the room. On 6-22-16 observations of the Resident continued throughout the day and occurred at 9:15 a.m., 10:15 a.m., 11:15 a.m., 12:15 p.m., and 2:00 p.m. The Resident remained alone in the room and in bed all day in the open unbuttoned pajama shirt and incontinent brief, without being covered from view. The bed room door remained open to the hallway, with the Resident in view of the public, and no staff were viewed entering the room during these times. On 6-22-16 at 2:00 p.m. an observation of Resident #14's room was conducted with the Resident remaining in bed, alone in the room, as on all of the other observations. On 6-22-16 at 2:10 p.m. while the surveyor was still in Resident #14's room, a clean incontinence brief was observed lying open on the bed of Resident #14's roommate. Resident #14 was sleeping with eyes closed and softly snoring. Certified Nursing Assistant (CNA) B entered Resident #14's room, and was asked if CNA B was going to provide care to Resident #14, and she replied yes. The room door remained open. The following 12 paragraphs contain that observation. 1. CNA B took the incontinent brief off of Resident #14's roommate's bed and laid it at the foot of Resident #14's bed. CNA B exited the room and returned with a 3 section rolling dirty linen cart from the hallway and pulled it into Resident #14's room, placing it by the roommate's bed, which was closest to the hallway door, and beside the sink area. CNA B walked over to Resident #14's bed alone, and placed a cloth chux incontinent pad inside a clean fitted sheet, and rolled them length wise together to be unrolled under the Resident when she needed them. She also placed a clean hospital gown on the foot of the Resident's bed. 2. CNA B then with ungloved hands, grabbed the left sleeve of Resident #14's unbuttoned pajama top and began to yank on the sleeve so as to remove the Resident's arm from it. The resident was sleeping. The Resident woke, was startled and cried out where am I?. The Resident kept asking Where am I?, Where am I?, and CNA B stated in a loud abrupt manner You are ok., (this was the only time she directly spoke to the Resident) and she continued to handle the Resident without ever explaining to the Resident what she was doing to him. 3. CNA B then, stated to the surveyor, He, (Res #14) is a fighter, he will bite and swing his arms at you, you have to watch him. After removing the pajama shirt by finally pulling it over the Resident's head, CNA B pushed the Resident from behind him, onto his right side, with one hand on his left shoulder. CNA B then pushed the soiled sheet and soiled cloth chux incontinent pad under the Resident's right buttock. The center of the sheet and chux pad were dripping wet with urine, and a dark yellow dried halo of urine was noted around the outer edges of the sheet. The soiled incontinence brief that Resident #14 was wearing was soaked with urine, and it could no longer contain the liquid, so that when CNA B pushed the Resident onto his side urine flowed out of the brief onto the bed. 4. CNA B then pushed the clean rolled sheet and chux pad together under the Resident and attached the corners of the sheet to the head and foot of the bed on that side by changing hands, and let go of the Resident's shoulder, which caused him to flop back on his back. Resident #14 began moaning and repeating over and over no more, no more, please no more, oh God please no more. CNA B stated twice loudly and abruptly, while shaking her head, and frowning, during this portion of the care Lord have mercy, please give me patience to get through this mess. 5. CNA B then walked around the bed to the opposite side and lifted then pushed on the Resident's right shoulder from behind him, so as to turn him onto his left side facing the window. CNA B pushed Resident #14 onto his side and the resident banged his forehead into the raised side rail. This made a thudding sound, and she held him there against the rail with one hand until she could pull the dirty linen out, and pull the rolled clean sheet and chux under him. One half of the bed had clean linens, and the dirty linens were still on the edge of the bed behind the Resident. 6. CNA B then removed her hand and allowed the Resident to fall back onto his back. The door to the room had been left open during all of the care. Resident #14 was now lying on his back exposed, and uncovered in the soiled incontinent brief only, and in a half soiled and half clean bed, and he was weeping softly. The Resident was not combative at any time during this portion of the care. CNA B then exited the room and in a few minutes returned with CNA C. 7. CNA B went to the dirty soiled sink and got a cloth wash cloth wet, and applied some of the shampoo that had been sitting on the sink without knowing who it belonged to, as there were 2 bottles of open and used shampoo on the sink top with no name or open date on them, in the shared room. CNA B then returned to the bedside and started to roughly and briskly wash Resident #14's underarms and chest. Resident #14 began repeatedly asking What are you doing?, What are you doing? CNA B never answered him nor did she at any time explain to him what she was doing to him. 8. CNA B gruffly stated to CNA C Let's get his diaper on. CNA B now donned gloves, and unfastened the tape tabs which held it in place and proceeded to wash the Resident's genital area with the same soapy wash cloth. The glans penis was not cleansed, and not accessed by retracting the foreskin. CNA B pulled Resident #14 toward her by his right shoulder, as CNA C helped to push him from behind. The wet soiled linens were pulled off of the edge of the bed and placed in the soiled linen cart. 9. The clean incontinence brief (which had been on his roommate 's bed) was placed under the Resident and he was lowered back onto his back, and the sheet was secured on the other side of the bed at the head and foot by CNA C. During the limited bathing procedure and removal of the soiled incontinence brief, the clean sheet and chux incontinence pad which were now under the Resident, were soiled with urine from the old soiled and dripping incontinence brief. 10. CNA C remarked that the Resident had feces smeared on the back of his right leg behind the knee. CNA B stated she had not had time to wash or change the Resident's incontinence brief during this day shift until now, because they were so short staffed. All present had observed that the Resident had not had a bowel movement in the incontinence brief that had just been changed, so CNA B felt the feces must have been left on the Resident from the previous night shift staff. 11. CNA B took the soiled wash cloth and cleaned the feces off of the Resident's leg, smearing it on the clean sheet. CNA B then took the soiled wash cloth and placed it in the soiled linen cart and left the room. The Resident by this time had become combative and was saying Stop, Stop, Stop. While swinging his arms slowly, and trying to bite. He was easily avoided. At no time was the room door closed, and the new clean sheet which had been soiled during the procedure with urine and a smear of feces during incontinence care, was never changed. 12. CNA C was asked what she thought of the care that Resident #14 had received from CNA B. She stated that the door should have never been left open, and she had felt very uncomfortable with observing how rough CNA B was with the Resident. She further stated she was going to report it to her supervisor, and that the Resident only acted out when he was afraid, and if you talk to him, and tell him what you are going to do, and are gentle, he never gets combative. She went on to say she had cared for him previously, and had not had any problems with him being combative. At 2:30 p.m. on 6-22-16 an interview was conducted with CNA B, in the conference room with 4 surveyors present. CNA B was loud, abrupt and frowning. She stated that her usual assignment was either assignment 3 or 4, but today she had to do this assignment because there was only her and one other CNA to give all ADL care to 29 residents on the Liberty unit in rooms 105 to 128 on day shift (7:00 a.m. to 3:00 p.m.). She went on to say that Resident #14 was a fighter. CNA B was asked if she had been trained to tell a Resident what care she was going to perform before she gave the care, and she answered Yes, but went on to say that it didn't matter if you told the resident what you were going to do, or didn't tell the resident, it would not change anything. CNA B went on to say that Resident #14's care depended on if the facility was fully staffed or not, and that she didn't have time to fight the residents and get her job done too. She went on to say that the Assistant Director of Nursing worked like a slave in this building, and the CNA's never saw the Director of Nursing. CNA B stated that the whole building last weekend only had 3-4 CNA's, and that they had been short staffed the last 3 days also. She stated that Resident #14 had not received any care until the 2:00 p.m. observation today, because the CNA's could only give ADL care one time per day, because there were so many to take care of, and some of the residents had to wait until after lunch because they were so short staffed. CNA B stated that Administration keeps Colonial (skilled unit) more staffed, and lets Liberty, and Freedom be short. CNA B was interviewed and she felt that the facility staffing was the reason for her treatment of [REDACTED]. The Staffing schedule for this shift was requested, and found that CNA B's statements about staffing were correct, and indeed only 2 CNA's were assigned to Liberty unit to provide care for the 29 Residents in an 8 (30 minutes for lunch) hour shift. This provides for an equation of 7.5 hours x 60 minutes for each hour, equaling 450 minutes in the shift. This 450 minutes is then divided by 14.5 residents for each of the 2 CNA ' s, to care for each shift. This allows only 31 minutes for each Resident to get care on each shift. Care includes, incontinence care, feeding, bathing, linen changes, transferring, bed mobility, toileting, ambulation, and dressing. Freedom unit had 3 CNA's assigned, with a fourth who came in at lunch time to float between Liberty and Freedom units, and Colonial was assigned to have 5 full time CNA's. Further Review of the as worked schedule since April, 2016, revealed the Director of Nursing (DON) functioned as a floor nurse, performing Resident care and administering medications, on 6-9-16 (11-7) shift, and 6-13-16 (3-11) shift. The DON also stated on 6-23-16 at 3:46 p.m., that she had also worked Mother's day, 5-8-16 to assist the staff with Resident care. At 3:00 p.m. on 6-22-16, after the interview with CNA B was completed, the Administrator and Director of Nursing (DON) were called to the conference room by surveyors who are mandated reporters, and notified of the Observed abuse involving Resident #14's care administered by CNA B. The DON stated she was already aware of the allegation of abuse, as CNA C, (who had come from Freedom unit to help CNA B) had reported it to her supervisor, the unit manager on Freedom unit, who in turn reported it to the DON, and Administrator. On 6-22-16 at 5:00 p.m. the Administrator stated he had called CNA B back in to the facility, as she had left for the day, and had taken her statement. The Administrator stated that CNA B denied all of the allegations, however, CNA C had made a report of abuse to her supervisor in keeping with her observation of the events, and CNA B had been suspended. On 6-24-16 at 10:00 a.m. the administrator was interviewed regarding the abuse policy as he was the Abuse Coordinator. He described a facility reported incident of an injury of unknown origin, as an example of the facility program for abuse prohibition. This topic, however, revealed that no description of Injuries of unknown origin identification, reporting or investigation was documented in the 10 page facility policy. The administrator stated that Rounding and direct observation was used to monitor staff that were providing care to assure that abuse and neglect do not occur. This rounding, however, was not witnessed during survey as the shortage of staffing required supervisory staff to fill in providing direct care to Residents. The facility policy on Resident Abuse instituted on 11-30-14, and revised on 6-1-15 was requested, received, and reviewed. The areas in bold lettering below are directly related to the care observation of Resident #14 on 6-22-16. The policy stated that physical abuse is defined as: .Non-therapeutic shoving, pushing, pulling or twisting any part of the resident's body, .Physical contact intentionally or through carelessness that results in, or is likely to result in, death, physical injury, or psychological harm to the resident. Indications of psychological harm include a noticeable level of fear, anxiety, agitation or emotional distress in the resident. Verbal abuse is statements made to a resident which result in ridicule or humiliation of the resident. Neglect is defined in the policy as: Intentional lack of attention to physical needs including, but not limited to, toileting and bathing. The document did not specify any reporting time frames to state agencies, or law enforcement. The document did have blank spaces for the phone contact information for Adult protective services, The Agency for Health Care Administration, and the Ombudsman Council, however, no phone numbers had been placed in the blank spaces, and the last line on page 10 of 10 read: NOTE: See state specific guidelines for abuse reporting. No state specific guidelines were given. The DON also provided the Abuse Education text instituted January 2007. The areas in bold lettering below were taught to staff, and were directly related to the care observation of Resident #14 on 6-22-16. Resident #14 experienced, and exhibited the signs of Catastrophic Reaction, which had been taught in the abuse program at the facility, and was not followed. The document contained the following; Catastrophic Reactions - are extraordinary reactions of residents to ordinary stimuli, such as the attempt to provide care .defined as reactions or mood changes of the resident in response to what may seem to be minimal stimuli (e.g.: bathing, dressing, having to go to the bathroom .) that can be characterized by weeping, blushing, anger, agitation, or stubbornness. Under examples of Potential or actual injury related to failure to meet requirements, is included Loss of dignity due to lying in a urine saturated bed for a prolonged period. In the Abuse Education package Abuse Prevention Techniques are listed on page 6 of 7, and page 7 of 7. The techniques are summarized below; Identify Residents at risk. 1. Residents with aggressive behavior. 2. Residents with communication deficits (cognitive) 3. Residents with adjustment problems (Res #14 was a new admission of 3 months). 4. Residents requiring heavy nursing care or are totally dependant. 5. Bed bound residents. Interventions. 1. Know care plan approaches for each resident 2. Offer reassurance. 3. Try distraction. 4. Avoid arguing. 5. Task sequencing. 6. Consistency, establish a routine. 7. Be realistic about resident abilities, concentrate on remaining resident skills. 8. Be mindful of your tone of voice and body language. 9. Do not talk about the resident as if he were not there. 10. Use a friendly, warm approach, but be dignified and respectful. 11. Do not shout, they may view loud voices as threatening. 12. Assess for physical problems which may be causing pain or discomfort. 13. Attend classes to learn behavioral techniques to share with co-workers. 14. Use appropriate assistive devices. In the same document Staff stress factors in which abuse was likely to occur, were also listed and are as follows: 1. Environment. 2. Training deficits. 3. Lack of supervision. 4. Staffing level and call outs. 5. Learned patterns that are inappropriate. 6. Definition of stress is a physical, mental or emotional factor that causes tension. 7. Reactions to stress: Tearfulness, forgetfulness, anger, inappropriate laughter, inability to speak, Not caring, inappropriate behavior like screaming, yelling, striking or hitting, indifference, not feeling good about oneself. The Administrator and DON supplied the Facility reported incident report which was sent to the State agency Virginia Department of Health (Office of Licensure and Certification), along with proof of notification of an allegation of abuse and neglect to the family and doctor for Resident#14, to the Ombudsman office, and to Adult Protective Services. The Administrator also stated that he had contacted local law enforcement, and the Department of Healthcare Professions. On 6-22-16, 6-23-16, and 6-24-16, the Administrator, and DON were notified that Resident #14 did not receive services to meet the Resident needs, and to ensure that he was free from abuse, and neglect. The lack of Administrative oversight by the DON, and other supervisory nurses, who were working on the floor providing care to residents, impaired Administrative staff's ability to recognize or identify the signs of burn out, frustration and stress compounded by understaffing. The facility Administration did not intervene, or correct the lack of adequate staffing, even though it was identified as a problem. Further, no mention of identifying, educating on, or reporting and investigating injuries of unknown origin appeared in the 10 page abuse policy. No further information was provided by the facility during the 3 day period from 6-22-16 through 6-24-16.

Based on staff interview, observation, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to identify and treat pressure injuries in a timely manner for three Residents (Residents' #5, #1, and #4) in a survey sample of 25 Residents, resulting in harm for two Residents (Residents' #5 and #1). 1. For Resident #5, the facility staff failed to identify a pressure injury prior to discovery at unable to stage and failed to perform pressure injury wound care in a manner to prevent the spread of infection. The pressure injury identified 6/15/16 as an unable to stage, wound base covered with eschar and slough was located on Resident #5's right buttock area, sized at 1.0 cm by .5 cm (centimeters) at the time of discovery resulting in harm for Resident #5; 2. Resident #1's pressure injury to the coccyx was not identified until it had reached a stage 3 injury with slough, resulting in harm; and 3. For Resident #4, the facility failed to identify a pressure ulcer prior to it developing into Stage Two. The findings included: 1. For Resident #5, the facility staff failed to identify a pressure injury prior to discovery at unable to stage and failed to perform pressure injury wound care in a manner to prevent the spread of infection. The pressure injury identified 6/15/16 as an unable to stage, wound base covered with eschar and slough was located on Resident #5's right buttock area, sized at 1.0 cm by .5 cm (centimeters) at the time of discovery resulting in harm for Resident #5; Resident #5, a female, was initially admitted to the facility 3/10/09 and readmitted after a hospitalization [DATE]. Her [DIAGNOSES REDACTED]. Resident #5's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4/18/16 was coded as a quarterly assessment. Resident #5 was coded as having no memory deficits and was able to make her own daily life decisions. She was coded as needing extensive to total assistance of one to two staff members to perform her activities of daily living with the exception of eating. For eating she was coded as needing limited assistance. Resident #5 was coded as being at risk for the development of pressure areas. No pressure areas were coded. Resident #5 was also coded as being incontinent of urine and bowels. Resident #5 was observed 6/21/16 at 4:12 p.m. She was alert and verbal. Resident #5 was sitting in her wheelchair with her feet on the foot pedals. She was also observed 6/22/16 at 8:12 a.m. She was lying in bed with the head of bed elevated. Resident #5 appeared to be sleeping. Review of Resident #5's clinical record revealed on 6/15/16 the facility staff completed an SBAR Assessment. The SBAR (a means of communication meaning situation, background, assessment, recommendation) informed Resident #5's physician and the rest of the staff that Resident #5 was found to have a new wound on 6/15/16. Included on the SBAR was the following description: To have a area under right buttock cheek that's painful when touched. Was brought to undersigned attention during care that Resident has area under right buttock cheek, went in to assess. Area noted to be 1.0 x .5 (cm centimeters). Black in color with yellow slough surrounding the wound. Area noted to started by pressure from brief cutting into her. The physician was notified of the development of the pressure injury and a treatment was ordered 6/15/16, cleanse area with NS (normal saline), pat dry, apply Santyl and dry dressing Q (every) day, Guidance by www.npuap.com defines an unable to stage pressure injury: Unstageable Pressure Injury: Obscured full-thickness skin and tissue lossFull-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on an ischemic limb or the heel(s) should not be removed. When interviewed 6/22/16 at 11:32 a.m., , RN (registered nurse) A, the ADON (assistant director of nursing), stated, Residents should have a weekly skin assessment completed by a licensed nurse. Additionally all staff should be assessing Residents' skin whenever care is performed, including incontinence care, bathing, or showering. If a CNA (certified nursing assistant) identifies something unusual on a Resident's skin, they are to complete a form and inform the nurse. RN A stated 6/22/16 at 3:10 p.m. that was how Resident #5's unable to stage area was discovered. The CNA informed the nurse of the area during Resident #5's shower; the nurse assessed the area and completed the SBAR. The nurse also notified the physician and obtained an order for [REDACTED].#5 resides on did not have a unit manager; therefore the ADON was assessing wounds on that unit. RN A stated the wound was coded as an unable to stage wound and areas should be found with any changes in skin, not when the damage has already occurred. Review of Resident #5's clinical record revealed the only weekly skin assessments that occurred for Resident #5 since April, 2016 were on 4/7/16, 4/10/16, 4/22/16, 5/21/16, and 6/12/16. Review of the facility ' s policy entitled General Wound Care Principles included: Application for all wound types: *Assess skin daily unless otherwise indicated. *Update the Care Plan reflecting interventions that have been implemented. *DOCUMENT no less than WEEKLY. RN A stated the facility has been short on staff and that the administrative staff, DON (director of nursing), unit managers, and ADON (assistant DON) had been working on the units and administering medications. RN A stated the unit managers and ADON were supposed to be auditing the staff to ensure weekly skin assessments were completed on time, however due to short staffing the audits had not been completed. Review of Resident #5's care plan revealed the care plan was revised on 6/2/16 and included as a Focus The resident has the potential for impaired skin integrity r/t (related to) impaired mobility, incontinence, diabetes, history of [MEDICAL CONDITION], refuses care at times, history of rashes. Included in the interventions: Incontinence care post episode Keep skin clean and dry Monitor blood sugars as ordered Notify nurse of any new areas of skin breakdown: Redness, blisters, bruises, discoloration noted during bath or daily care Nutritional evaluation quarterly and PRN (as needed) Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated Offer snack prn Placement of adaptive devices pressure relieving/reducing while in bed Placement of adaptive devises pressure relieving/reducing wheelchair cushion Administer medications as ordered. Monitor & report for side effects and effectiveness Apply barrier cream post incontinence care Braden Scale quarterly (a device used to determine risk of development of pressure injury) Encourage adequate nutrition and hydration in order to promote healthier skin Encourage appropriate fluid intake Float heels while in bed as resident allows Follow policies /protocols for the prevention/treatment of [REDACTED].>Handle and position to reduce friction Identify/document potential causative factors and eliminate/resolve where possible. If Resident refuses treatment, attempt to determine why and try alternative methods to gain compliance. A thorough review of the clinical record revealed no evidence Resident #5 refused to have skin assessments, incontinence care or wound care performed. An entry was placed on the care plan by RN A, 6/15/16 pressure ulcer under right buttock. The revision was not entered until 6/22/16, seven days after the identification of the Unstageable pressure injury. No new interventions were developed after the identification of the area. LPN (licensed practical nurse) A was interviewed 6/23/16 at 9:12 a.m. LPN A stated she assessed the area after the CNA notified her of the area 6/15/16. LPN A stated the edges of the pressure injury were well defined and there was minimal serous drainage. LPN A stated she could not see the wound bed as it was covered by tissue that was tan to dark brown, spongy and firm to touch. LPN A stated At the time I thought it was an unable to stage pressure injury. The facility definitions on Pressure Ulcer Prevention/National Pressure Ulcer Advisory Panel (npuap) included: Eschar-Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab like. Necrotic tissue and eschar are usually firmly adhered to the base of the wound and often the sides/edges of the wound. Guidance is provided at the following sites: www.ahqr.gov Pressure ulcers develop when capillaries supplying the skin and subcutaneous tissues are compressed enough to impede perfusion, leading ultimately to tissue necrosis. Since 1930, we have understood that normal blood pressure within capillaries ranges from 20 to 40 mm Hg (millimeters of mercury) ; 32 mm Hg is considered the average.17 Thus, keeping the external pressure less than 32 mm Hg should be sufficient to prevent the development of pressure ulcers. However, capillary blood pressure may be less than 32 mm Hg in critically ill patients due to hemodynamic instability and comorbid conditions; thus, even lower applied pressures may be sufficient to induce ulceration in this group of patients. Therefore, the key to preventing pressure ulcers is to accurately identify at-risk individuals quickly, so that preventive measures may be implemented. www.nursingceu.com <http://www.nursingceu.com> The compression of soft tissue interferes with the tissue blood supply, leading to vascular insufficiency, tissue anoxia, and cell death. Pressure ulcers usually occur over bony prominences such as the sacrum, ischium, heel, and trochanter, where there is less tissue to compress. Other factors previously mentioned also contribute to the tissue breakdown. Pressure ulcers can develop within 24 hours of the initial pressure but take as long as 5 days to present themselves. After the initial assessment of Resident #5's pressure injury on 6/15/16, no ongoing assessment had occurred. RN A, the ADON, stated 6/22/16 at 11:32 a.m. she was supposed to assess wounds after they have been identified, however she had not assessed Resident #5's wound as of 6/23/16. On 6/23/16 at 2:10 p.m., RN B, the unit manager for one of the other units, stated she was wound care certified. RN B stated she had not been unaware of Resident #5's pressure injury and had not assessed it as of the interview. Resident #5 was observed during wound care 6/22/16 at 1:26 p.m. LPN A donned a pair of gloves. LPN A cleaned the over bed table and placed clean paper towels on the table. She put her supplies on the paper towels and labeled the new dressing. LPN A removed her gloves and donned a new pair of gloves. After assisting Resident #5 to bed and positioning her, LPN A removed Resident #5's incontinent brief. As Resident #5 had a small bowel movement, the CNA assisting performed incontinence care. LPN A removed Resident #5's old dressing and discarded the dressing. The wound bed appeared to be pale pink in color, no redness, [MEDICAL CONDITION], or discoloration was noted. LPN A stated after the eschar came off the wound, it was staged as a II. www.npuap.com defines a stage II pressure injury as: Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermisPartial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). LPN A removed her gloves and donned a new pair of gloves. She cleaned the area with normal saline and dried it with a 4 x 4. LPN A applied a [MEDICATION NAME] dressing, being sure the edges were well sealed. LPN A was noted to not have cleaned or washed her hands during the entire wound care observation, especially after removing her gloves and prior to donning a new pair. LPN A stated 6/23/16 11:45 a.m., she was unaware she had not cleaned her hands after changing her gloves during the wound care observation done 6/22/16. Review of the facility's policy entitled Dressing Change included: Perform Hand Hygiene Put on disposable gloves Untie tape or loosen disposable tape. Remove soiled dressings and dispose of per Exposure Control policy Remove gloves. Perform Hand Hygiene. Apply new disposable gloves Assess wound for type, color, amount of drainage. Obtain wound culture if indicated Cleanse wound as ordered. Using gauze cleanse the wound. Dry the wound with dry gauze. Apply clean dressing and secure. Discard gloves per Exposure Control policy and Perform hand hygiene. Document in medical record. The administrator, DON, and corporate consultant were informed of the failure of the staff to identify Resident #5's pressure injury in a timely manner, prior to the development of an Unstageable pressure injury resulting in harm and failure of LPN A to perform hand hygiene after removing her gloves and prior to donning a new pair of gloves during wound care, 6/23/16 at end of day conference. 2. Resident #1's pressure injury to the coccyx was not identified until it had reached a stage 3 injury with slough on 1/11/16, resulting in harm. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's most recent Minimum Data Set (MDS) assessment was an annual assessment with an Assessment Reference Date (ARD) of 3/28/16. She was coded with a Brief Interview of Mental Status score of 15 out of a possible 15 indicating no cognitive impairment. She required total assistance of one to two staff members for bed mobility and toileting. The resident was coded as having limitations of range of motion both in the upper and lower extremities. The resident was incontinent of bowel and bladder. The resident did have recent significant weight loss. She was fed by gastrostomy tube and took some food by mouth. The resident was coded with a stage 2 pressure ulcer with granulation tissue. The resident was coded as being at risk for pressure sores. On 6/22/16 at 8:40 AM, Resident #1 was observed in the bed on her back. A right sided neck contracture was present. She was on a low air loss specialty mattress; her heels were not floated. On 6/22/16 at 2:00 PM, Resident #1 was observed in bed, awake and alert. The room smelled strongly of bowel movement. On 6/22/16 at 3:00 PM, Resident #1 remained in bed, still smelled strongly of bowel movement. On 6/22/16 at 4:15 PM, CNA (certified nursing assistant) A was asked to come to the resident's room. When checked for incontinence, the resident's brief was very wet and had had a very soft, runny bowel movement. The resident's labia and groin creases were reddened. There was no dressing on the coccyx wound. On 6/22/16 at 5:40 PM, Resident #1 was asked if her brief had been changed since lunch. Resident #1 stated, No, I don't think so. On 1/5/16, a weekly skin review done by licensed nursing, showed only a gastrostomy tube site. Documentation showed: Had no other areas. Review of the clinical record revealed a nurse's note dated 1/11/16 by the certified wound nurse, RN (registered nurse) B. The note revealed: Resident has a small open area on her coccyx measuring 0.6 cm (centimeters) by 0.5 cm with a depth of 0.1 cm. Area is covered with a thin layer of slough (dead, devitalized tissue). [MEDICATION NAME] dressing applied to area. The (name of facility) Pressure Ulcer Record dated 1/11/16 detailed the same measurements. The wound was staged as a stage 3. Zinc Oxide was ordered 1-13-16 and Santyl (a [MEDICATION NAME] agent) was ordered 1-28-16 with a dry dressing daily and prn. On 3/7/16, a physician's note documented a stage 3 decubitus ulcer, coccyx. The NPUAP (National Pressure Ulcer Advisory Panel) defines a stage III pressure ulcer as: Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a Stage III pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue, and Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Review of the care plan dated 1/9/16 revealed the following: The resident has the potential for impaired skin integrity due to [MEDICAL CONDITION], multiple contractures and history of pressure. Interventions included: Serve diet as ordered, assist as needed, monitor intake, offer snacks as needed. Administer medication as ordered. Assist with turning and positioning every two hours and as needed while in bed. Inform physician of any new area of skin breakdown. Inform the resident, family/caregiver of any new area of skin breakdown. Obtain and monitor lab/diagnostic work as ordered. Review of the January, 2016 TAR (treatment administration record) revealed the resident had the following interventions in place: carrot splints for hand contractures and a pressure relief mattress. Zinc oxide and a low air loss mattress were initiated after the development of the pressure injury. On 6/8/16, a [MEDICATION NAME] dressing was ordered, apply every 72 hours and as needed. On 6/23/16 at 10:10 AM, the unit manager and certified wound nurse, RN (B) was interviewed. She stated, It was a little bigger than now; it had a thin layer of slough like a spider web. She went on to state that was why the wound was staged as a 3, because I could see the wound bed. Wound care was then done by LPN (licensed practical nurse) B. The wound bed was clean without slough or eschar. The area measured 0.3 cm by 0.6 cm by 0.1 cm depth. The wound was covered with a [MEDICATION NAME] dressing. On 6/23/16 at 10:35 AM, RN (B) was again interviewed. RN (B) shook her head no when asked if the wound should have been found at a stage 3. She went on to state that a pressure wound would start as redness, then it opens. On 6/22/16 at 5:30 PM, the Administrator and DON (director of nursing) were notified of above findings at harm level. 3. For Resident #4, The facility staff failed to identify a pressure ulcer prior to it becoming Stage 2. Resident #4 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #4's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 5/9/16, coded Resident #4 as requiring the extensive assistance of 2 persons for transfers, and as having Range of Motion limitations of her upper and lower extremities. On 6/21/16 a review was conducted of Resident #4's clinical record, revealing the following Nursing Note: 6/19/16 Staff member notified this nurse of open areas to patient's buttocks, this nurse dressed and entered medication and dressing change into PCC (computerized clinical record), but current nurse notified of treatment initiated and that RP (Responsible Party) needed to be notified and as SBAR (assessment) and risk needed to be completed. The clinical record also contained the following document 6/21/16 Pressure Ulcer Record - State 2 Length 1 x width 1.6 Depth 0.1 The location was not mentioned. The clinical record contained a Weekly Skin Review dated 6/16/16. It read, No issues. A review of Resident #4's Care Plan was done, revealing that the wound had not been care planned as of 6/21/16. Resident Treatment Administration Record for June, 2016 was done. I tread, [MEDICATION NAME] apply 1 x day every 3 days for wound cleanse upper thigh with Normal Saline. The treatment was not documented as having been administered on 6/21/16. There were no documented treatments since the wound was discovered on 6/19/16. On 6/21/16 at 10:05 A.M. an interview was conducted with the Director of Nursing. She was unable to state why the pressure ulcer was not identified prior to it becoming Stage 2. She stated, It was reassessed, the area is not to buttocks but to left posterior thigh. Hydrogel order was changed to [MEDICATION NAME] to be changed every 3 days. ([MEDICATION NAME] is a cotton dressing with gel on it to promote healing. According to the WoundcareAdvisor.com, A [MEDICATION NAME] dressing is a wafer type of dressing that contains gel-forming agents in an adhesive compound.) On 6/22/16 at 10:00 A.M. an observation was made of Resident #4's wound on her left rear thigh. Registered Nurse D, who was the Unit Manager was asked to describe the wound. She stated, It is a Stage 2 pressure ulcer, wound bed covered, 100% by [MEDICATION NAME] tissue. No [MEDICAL CONDITION] or maceration noted, edges distinct. ([MEDICATION NAME] tissue is skin that covers an area as it heals. According to The National Institutes of Health at www.science.nichd.nih.gov <http://www.science.nichd.nih.gov>, [MEDICATION NAME] cells serve as a barrier between the body interior and the external environment. ). On 6/22/16 at 4:00 P.M. the facility Administrator (Employee A) was informed of the findings. No further information was received.

Based on staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to notify the physician when one resident (Resident #1) in the survey sample of three residents had a change in condition. Facility staff failed to notify physician/transport to ER (emergency room ) when Resident #1's O2 sats (oxygen saturation) dropped below 96% per physician's orders [REDACTED].>Facility staff failed to notify physician when Resident #1 did not receive his scheduled medications. Facility staff failed to notify physician in a timely manner when Resident #1 was unresponsive. Certified Nurse Aid (CNA) informed nursing staff that Resident #1 was unresponsive during the ,[DATE] (3:00 p.m.-11:00 p.m.) shift on [DATE]. Resident #1 was not sent out until the next morning during ,[DATE] (7:00 a.m.-3:00 p.m.) shift. Resident #1 expired on [DATE]. The findings included: Resident #1 was admitted to the facility on [DATE] and expired on [DATE]. [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of [DATE] coded Resident #1 with ability to express ideas and wants; and ability to understand others. physician's orders [REDACTED]. physician's orders [REDACTED]. Radiology Report for Resident #1 dated [DATE] documented, Examination: Chest-Results: Increased linear densities at the right base are consistent with linear atelectasis however developing early pneumonia may produce a similar appearance. The heart is normal. The trachea is in the midline. The appearance of the bony structures is consistent with the patient's age. No definite infiltrate or [MEDICAL CONDITIONS] is seen at this time. physician progress notes [REDACTED]. physician progress notes [REDACTED]. CXR (chest x-ray) PA/LAT (posterioranterior)/(lateral), O2 continuous via NC to maintain saturation above 96%, if saturation drops below 96% notify on-call M.D. immediately and transport pt to ED. Nurses to feed pt x 5 days to avoid aspiration. physician's orders [REDACTED]. Aspiration risk. physician's orders [REDACTED]. Medication Administration Record [REDACTED]. Staff failed to notify MD/transport pt to ED at this time per physician's orders [REDACTED].>MAR for Resident #1 dated [DATE] indicated Resident #1 did not receive his 5:00 p.m. scheduled po medications ([MEDICATION NAME], Pro-Stat, and [MEDICATION NAME]). Nurse's Notes for Resident #1 dated [DATE] at 1930P (7:30 p.m.) documented, Resident temp. (temperature) 102.5 (degrees Fahrenheit). MD notified, PRN order for MD on call. Rechecked temp 1 hour later. Will cont (continue) to monitor. physician's orders [REDACTED]. MAR for Resident #1 dated [DATE] indicated Resident #1 received Tylenol 650 suppository at 10:00 p.m., and 2:00 a.m. MAR for Resident #1 dated [DATE] (,[DATE] shift), documented O2 sats 91%. Staff failed to notify MD/transport pt to ED at this time per physician's orders [REDACTED].>SBAR (Situation-Background-Assessment-Request) Communication Form for Resident #1 dated [DATE] at 8:05 a.m. documented, Resident noted with increased Resp (respiration) @ (at) 40 min (breaths per minute). Resident unresponsive, but responding to sternum rub. Full vitals taken ,[DATE] (blood pressure) 137 (pulse) 40 (respiration) 101.9 (temperature) 87% O2 on 3 L via NC. MD on call phoned. N.O. (new order) send to ER (emergency room ). Hospital Record for Resident #1 dated [DATE] documented, Time of Death 1016 (10:16 a.m.). Hospital Record for Resident #1 dated [DATE] documented, Death Summary-Final Diagnoses: [REDACTED]. Hospital Record for Resident #1 dated [DATE] documented, (Resident #1) is a [AGE] year-old male with a past medical history of [REDACTED]. The sister and cousin state that he had some altered mental status yesterday and increased respiratory rate with fever. Apparently today he was found unresponsive and brought via EMS (emergency medical services) to the emergency department. He was found to have a temperature of 40.2 (40.2 Celsius=104.36 Fahrenheit), heart rate of 143, respiratory rate of 29, oxygen saturation of 60% on oxygen, with a blood pressure of ,[DATE]. Laboratory workup revealed he had a blood glucose greater than 800, with an elevated white blood cell count at 15.5 and a sodium of 169.Chest x-ray revealed bilateral patchy infiltrates on both lower lobes of his lung [MEDICAL CONDITION] due to pneumonia with diabetic ketoacidosis was likely cause of his unresponsiveness. On [DATE] at 2:33 p.m., an interview was conducted with Licensed Practical Nurse-A (LPN-A). LPN-A was the nurse who sent Resident #1 to theER on [DATE]. LPN-A stated Resident #1 was in that condition when she received him. Reviewed Resident #1's medical record with LPN-A. LPN-A also questioned as to why Resident #1 did not receive his 5:00 p.m. po medications; and reason for administering suppository Tylenol instead of po. On [DATE] at 3:36 p.m., an interview was conducted with LPN-B via phone. Director of Clinical Services (DCS) and Assistant Director of Clinical Services (ADCS) sat in for this phone interview. LPN-B was Resident #1's nurse from [DATE] -3:00 p.m. to [DATE]-7:00 a.m. Surveyor asked LPN-B if she notified the doctor when Resident #1's O2 sats dropped below 96%. LPN-B stated You don't need to call the doctor. On [DATE] at 4:25 p.m., an interview was conducted with LPN-C. LPN-C stated staff should notify physician when Resident #1's O2 sats dropped below 96%. On [DATE] at 1:32 p.m., an interview was conducted with DCS. DCS stated there's no nursing assessment/vitals on Resident #1 from [DATE] (7:30 p.m.) to [DATE] (8:05 a.m.); approximately 12.5 hours since change in condition. DCS also stated there's no documentation as to why Resident #1 did not receive his 5:00 p.m. po medications on [DATE]. DCS stated staff should document when medications were not given. On [DATE] at 1:50 p.m., an interview was conducted with LPN-D. LPN-D stated staff should follow physician's orders [REDACTED].#1's O2 sats dropped below 96%; when medications were not given; and when resident was unresponsive. On [DATE] at 1:55 p.m., an interview was conducted with LPN-E. LPN-E stated staff should follow physician's orders [REDACTED].#1's O2 sats dropped below 96%; when medications were not given; and when resident was unresponsive. On [DATE] at 2:06 p.m., an interview was conducted with LPN-A. LPN-A stated staff should conduct a full nursing assessment/full set of vitals on Resident #1 when there's change in condition. LPN-A also stated Resident #1 should be send out to ER (emergency room ) earlier due to the following reasons. Resident #1 had a temperature while on last day of his antibiotic. I am thinking septic. Resident #1 had an order in place to be send out when O2 sats dropped below 96%. On [DATE] at 2:22 p.m., an interview was conducted with DCS. DCS stated staff should follow physician's orders [REDACTED]. Staff should assess/monitor/follow up in the above incident. On [DATE] at 3:43 p.m., an interview was conducted with Certified Nurse Aid-A (CNA-A). CNA-A was Resident #1's aid on [DATE], ,[DATE] shift. CNA-A stated Resident #1 was unresponsive during her shift. According to CNA-A, Resident #1 did not open his eyes when his name was called. He normally would. CNA-A stated she notified LPN-B around 4:30 p.m. or 5:00 p.m. of her findings. CNA-A also stated Resident #1 was not on any oxygen during this shift. On [DATE] at 1:21 p.m., an interview was conducted with CNA (certified nursing assistant)-B via phone. CNA-B was Resident #1's aid on [DATE] (,[DATE] shift). CNA-B stated Resident #1 was having a hard time breathing and unresponsive during her shift. According to CNA-B, Resident #1 did not follow directions. Normally, he would follow my command. CNA-B stated she notified LPN-B around 11:00 p.m. of her findings. On [DATE] at 2:16 p.m., an interview was conducted with Resident #1's physician. Resident #1's physician stated he expected staff follow his order. According to physician, Resident would show symptoms when O2 sats less than 96%. It's a way to alert staff. Resident #1's physician was not the on-call doctor on [DATE]. Facility Policies/Procedure titled Change in Resident Condition dated [DATE] stated, The Clinical Nurse will recognize and appropriately intervene in the event of a change in resident condition. The Physician/Family/Responsible Party will be notified as soon as possible. The Administrator and Director of Clinical Services were made aware of these findings on [DATE] at 4:30 p.m., no further information provided. Complaint Deficiency

Based on staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to provide services that meet professional standards for one of three residents in the survey sample, Resident #1. Facility staff failed to transport Resident #1 to ER (emergency room ) when O2 sats (oxygen saturation) dropped below 96% per physician's orders [REDACTED].>Facility staff failed to administered Resident #1's scheduled medications. Facility staff failed to check Resident #1's blood pressure per physician's orders [REDACTED].>Facility staff failed to assess/monitor/follow up/notify physician in a timely manner, when Resident #1 was unresponsive. Certified Nurse Aid (CNA) informed nursing staff that Resident #1 was unresponsive during the ,[DATE] (3:00 p.m.-11:00 p.m.) shift on [DATE]. Resident #1 was not send out until the next morning during ,[DATE] (7:00 a.m.-3:00 p.m.) shift. Resident #1 expired on [DATE]. The findings included: Resident #1 was admitted to the facility on [DATE] and expired on [DATE]. [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of [DATE] coded Resident #1 with ability to express ideas and wants; and ability to understand others. physician's orders [REDACTED]. physician's orders [REDACTED]. Medication Administration Record [REDACTED]. MAR for Resident #1 dated [DATE] documented, Pro-Stat 30 ml (milliliter) by mouth two times a day for 30 days. It was scheduled at 8:00 a.m. and 5:00 p.m. physician's orders [REDACTED]. physician's orders [REDACTED]. Radiology Report for Resident #1 dated [DATE] documented, Examination: Chest-Results: Increased linear densities at the right base are consistent with linear atelectasis however developing early pneumonia may produce a similar appearance. The heart is normal. The trachea is in the midline. The appearance of the bony structures is consistent with the patient's age. No definite infiltrate or [MEDICAL CONDITIONS] is seen at this time. physician progress notes [REDACTED]. physician progress notes [REDACTED]. CXR (chest x-ray) PA/LAT (posterioranterior)/(lateral), O2 continuous via NC to maintain saturation above 96%, if saturation drops below 96% notify on-call M.D. immediately and transport pt to ED. Nurses to feed pt x 5 days to avoid aspiration. physician's orders [REDACTED]. Aspiration risk. physician's orders [REDACTED]. Medication Administration Record [REDACTED]. Staff failed to notify MD/transport pt to ED at this time per physician's orders [REDACTED].>MAR for Resident #1 dated [DATE] indicated Resident #1 did not receive his 5:00 p.m. scheduled po medications ([MEDICATION NAME], Pro-Stat, and [MEDICATION NAME]). Nurse's Notes for Resident #1 dated [DATE] at 1930P (7:30 p.m.) documented, Resident temp. (temperature) 102.5. MD notified, PRN order for MD on call. Rechecked temp 1 hour later. Will cont (continue) to monitor. physician's orders [REDACTED]. MAR for Resident #1 dated [DATE] indicated Resident #1 received Tylenol 650 suppository at 10:00 p.m., and 2:00 a.m. MAR for Resident #1 dated [DATE] (,[DATE] shift), documented O2 sats 91%. Staff failed to notify MD/transport pt to ED at this time per physician's orders [REDACTED].>SBAR (Situation-Background-Assessment-Request) Communication Form for Resident #1 dated [DATE] at 8:05 a.m. documented, Resident noted with increased Resp (respiration) @ (at) 40 min (breaths per minute). Resident unresponsive, but responding to sternum rub. Full vitals taken ,[DATE] (blood pressure) 137 (pulse) 40 (respiration) 101.9 (temperature) 87% O2 on 3 L via NC. MD on call phoned. N.O. (new order) send to ER (emergency room ). Hospital Record for Resident #1 dated [DATE] documented, Time of Death 1016 (10:16 a.m.). Hospital Record for Resident #1 dated [DATE] documented, Death Summary-Final Diagnoses: [REDACTED]. Hospital Record for Resident #1 dated [DATE] documented, (Resident #1) is a [AGE] year-old male with a past medical history of [REDACTED]. The sister and cousin state that he had some altered mental status yesterday and increased respiratory rate with fever. Apparently today he was found unresponsive and brought via EMS (emergency medical services) to the emergency department. He was found to have a temperature of 40.2 (40.2 Celsius=104.36 Fahrenheit), heart rate of 143, respiratory rate of 29, oxygen saturation of 60% on oxygen, with a blood pressure of ,[DATE]. Laboratory workup revealed he had a blood glucose greater than 800, with an elevated white blood cell count at 15.5 and a sodium of 169.Chest x-ray revealed bilateral patchy infiltrates on both lower lobes of his lung [MEDICAL CONDITION] due to pneumonia with diabetic ketoacidosis was likely cause of his unresponsiveness. On [DATE] at 2:33 p.m., an interview was conducted with Licensed Practical Nurse-A (LPN-A). LPN-A was the nurse who sent Resident #1 to theER on [DATE]. LPN-A stated Resident #1 was in that condition when she received him. Reviewed Resident #1's medical record with LPN-A. LPN-A also questioned as to why Resident #1 did not receive his 5:00 p.m. po medications on [DATE]; and reason for administering suppository Tylenol instead of po. On [DATE] at 3:36 p.m., an interview was conducted with LPN-B via phone. Director of Clinical Services (DCS) and Assistant Director of Clinical Services (ADCS) sat in for this phone interview. LPN-B was Resident #1's nurse from [DATE] -3:00 p.m. to [DATE]-7:00 a.m. Surveyor asked LPN-B if she notified the doctor when Resident #1's O2 sats dropped below 96%. LPN-B stated You don't need to call the doctor. On [DATE] at 4:25 p.m., an interview was conducted with LPN-C. LPN-C stated staff should notify physician when Resident #1's O2 sats dropped below 96%. On [DATE] at 1:32 p.m., an interview was conducted with DCS. DCS stated there's no nursing assessment/vitals on Resident #1 from [DATE] (7:30 p.m.) to [DATE] (8:05 a.m.); approximately 12.5 hours since change in condition. DCS also stated there's no documentation as to why Resident #1 did not receive his 5:00 p.m. po medications on [DATE]. DCS stated staff should document when medications were not given. According to DCS, staff did not check/monitor Resident #1's blood pressure per physician's orders [REDACTED].>On [DATE] at 1:50 p.m., an interview was conducted with LPN-D. LPN-D stated staff should follow physician's orders [REDACTED].#1's O2 sats dropped below 96%; when medications were not given; and when resident was unresponsive. On [DATE] at 1:55 p.m., an interview was conducted with LPN-E. LPN-E stated staff should follow physician's orders [REDACTED].#1's O2 sats dropped below 96%; when medications were not given; and when resident was unresponsive. On [DATE] at 2:06 p.m., an interview was conducted with LPN-A. LPN-A stated staff should conduct a full nursing assessment/full set of vitals on Resident #1 when there's change in condition. LPN-A also stated Resident #1 should be send out to ER earlier due to the following reasons. Resident #1 had a temperature while on last day of his antibiotic. I am thinking septic. Resident #1 had an order in place to be send out when O2 sats dropped below 96%. On [DATE] at 2:22 p.m., an interview was conducted with DCS. DCS stated staff should follow physician's orders [REDACTED]. Staff should assess/monitor/follow up in the above incident. On [DATE] at 3:43 p.m., an interview was conducted with Certified Nurse Aid-A (CNA-A). CNA-A was Resident #1's aid on [DATE], ,[DATE] shift. CNA-A stated Resident #1 was unresponsive during her shift. According to CNA-A, Resident #1 did not open his eyes when his name was called. He normally would. CNA-A stated she notified LPN-B around 4:30 p.m. or 5:00 p.m. on [DATE] of her findings. CNA-A also stated Resident #1 was not on any oxygen during this shift. On [DATE] at 1:21 p.m., an interview was conducted with CNA-B via phone. CNA-B was Resident #1's aid on [DATE] (,[DATE] shift). CNA-B stated Resident #1 was having a hard time breathing and unresponsive during her shift. According to CNA-B, Resident #1 did not follow directions. Normally, he would follow my command. CNA-B stated she notified LPN-B around 11:00 p.m. on [DATE] of her findings. On [DATE] at 2:16 p.m., an interview was conducted with Resident #1's physician. Resident #1's physician stated he expected staff follow his order. According to physician, Resident #1 would show symptoms when O2 sats less than 96%. It's a way to alert staff. Resident #1's physician was not the on-call doctor on [DATE]. Facility Policies/Procedure titled Change in Resident Condition dated [DATE] stated, The Clinical Nurse will recognize and appropriately intervene in the event of a change in resident condition. The Physician/Family/Responsible Party will be notified as soon as possible. Facility Policies/Procedures titled Medications-Oral Administration Of dated [DATE] stated, It is the policy that the resident can expect safe and accurate administration of oral medication. Facility Policies/Procedures titled Medications/Physician order [REDACTED]. In Fundamentals of Nursing 6th edition, 2005; Patricia A. Potter and Anne Griffin Perry; Mosby, Inc; Page 419. The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders [REDACTED]. The Administrator and Director of Clinical Services were made aware of these findings on [DATE] at 4:30 p.m., no further information provided. Complaint Deficiency

Based on staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to follow physician's orders [REDACTED].#1. Facility staff failed to transport Resident #1 to ER (emergency room ) when O2 sats (oxygen saturation) dropped below 96% per physician's orders [REDACTED].>Facility staff failed to administered Resident #1's scheduled medications. Facility staff failed to check Resident #1's blood pressure per physician's orders [REDACTED].>Facility staff failed to assess/monitor/follow up/notify physician in a timely manner, when Resident #1 was unresponsive. Certified Nurse Aid (CNA) informed nursing staff that Resident #1 was unresponsive during the ,[DATE] (3:00 p.m.-11:00 p.m.) shift on [DATE]. Resident #1 was not sent out until the next morning during ,[DATE] (7:00 a.m.-3:00 p.m.) shift. Resident #1 expired on [DATE]. The findings included: Resident #1 was admitted to the facility on [DATE] and expired on [DATE]. [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of [DATE] coded Resident #1 with ability to express ideas and wants; and ability to understand others. physician's orders [REDACTED]. physician's orders [REDACTED]. Medication Administration Record [REDACTED]. MAR for Resident #1 dated [DATE] documented, Pro-Stat 30 ml (milliliter) by mouth two times a day for 30 days. It was scheduled at 8:00 a.m. and 5:00 p.m. physician's orders [REDACTED]. physician's orders [REDACTED]. Radiology Report for Resident #1 dated [DATE] documented, Examination: Chest-Results: Increased linear densities at the right base are consistent with linear atelectasis however developing early pneumonia may produce a similar appearance. The heart is normal. The trachea is in the midline. The appearance of the bony structures is consistent with the patient's age. No definite infiltrate or [MEDICAL CONDITIONS] is seen at this time. physician progress notes [REDACTED]. physician progress notes [REDACTED]. CXR (chest x-ray) PA/LAT (posterioranterior)/(lateral), O2 continuous via NC to maintain saturation above 96%, if saturation drops below 96% notify on-call M.D. immediately and transport pt to ED. Nurses to feed pt x 5 days to avoid aspiration. physician's orders [REDACTED]. Aspiration risk. physician's orders [REDACTED]. Medication Administration Record [REDACTED]. Staff failed to notify MD/transport pt (patient) to ED at this time per physician's orders [REDACTED].>MAR for Resident #1 dated [DATE] indicated Resident #1 did not receive his 5:00 p.m. scheduled po medications ([MEDICATION NAME], Pro-Stat and [MEDICATION NAME]). Nurse's Notes for Resident #1 dated [DATE] at 1930P (7:30 p.m.) documented, Resident temp. (temperature) 102.5. MD notified, PRN (as needed) order for MD on call. Rechecked temp 1 hour later. Will cont (continue) to monitor. physician's orders [REDACTED]. MAR for Resident #1 dated [DATE] indicated Resident #1 received Tylenol 650 suppository at 10:00 p.m., and 2:00 a.m. MAR for Resident #1 dated [DATE] (,[DATE] shift), documented O2 sats 91%. Staff failed to notify MD/transport pt to ED at this time per physician's orders [REDACTED].>SBAR (Situation-Background-Assessment-Request) Communication Form for Resident #1 dated [DATE] at 8:05 a.m. documented, Resident noted with increased Resp (respiration) @ (at) 40 min (breaths per minute). Resident unresponsive, but responding to sternum rub. Full vitals taken ,[DATE] (blood pressure) 137 (pulse) 40 (respiration) 101.9 (temperature) 87% O2 on 3 L via NC. MD on call phoned. N.O. (new order) send to ER (emergency room ). Hospital Record for Resident #1 dated [DATE] documented, Time of Death 1016 (10:16 a.m.). Hospital Record for Resident #1 dated [DATE] documented, Death Summary-Final Diagnoses: [REDACTED]. Hospital Record for Resident #1 dated [DATE] documented, (Resident #1) is a [AGE] year-old male with a past medical history of [REDACTED]. The sister and cousin state that he had some altered mental status yesterday and increased respiratory rate with fever. Apparently today he was found unresponsive and brought via EMS (emergency medical services) to the emergency department. He was found to have a temperature of 40.2 (40.2 Celsius=104.36 Fahrenheit), heart rate of 143, respiratory rate of 29, oxygen saturation of 60% on oxygen, with a blood pressure of ,[DATE]. Laboratory workup revealed he had a blood glucose greater than 800, with an elevated white blood cell count at 15.5 and a sodium of 169.Chest x-ray revealed bilateral patchy infiltrates on both lower lobes of his lung [MEDICAL CONDITION] due to pneumonia with diabetic ketoacidosis was likely cause of his unresponsiveness. On [DATE] at 2:33 p.m., an interview was conducted with Licensed Practical Nurse-A (LPN-A). LPN-A was the nurse who sent Resident #1 to theER on [DATE]. LPN-A stated Resident #1 was in that condition when she received him. Reviewed Resident #1's medical record with LPN-A. LPN-A also questioned as to why Resident #1 did not receive his 5:00 p.m. po medications on [DATE]; and reason for administering suppository Tylenol instead of po. On [DATE] at 3:36 p.m., an interview was conducted with LPN-B via phone. Director of Clinical Services (DCS) and Assistant Director of Clinical Services (ADCS) sat in for this phone interview. LPN-B was Resident #1's nurse from [DATE] -3:00 p.m. to [DATE]-7:00 a.m. Surveyor asked LPN-B if she notified the doctor when Resident #1's O2 sats dropped below 96%. LPN-B stated You don't need to call the doctor. On [DATE] at 4:25 p.m., an interview was conducted with LPN-C. LPN-C stated staff should notify physician when Resident #1's O2 sats dropped below 96%. On [DATE] at 1:32 p.m., an interview was conducted with DCS. DCS stated there's no nursing assessment/vitals on Resident #1 from [DATE] (7:30 p.m.) to [DATE] (8:05 a.m.); approximately 12.5 hours since change in condition. DCS also stated there's no documentation as to why Resident #1 did not receive his 5:00 p.m. po medications on [DATE]. DCS stated staff should document when medications were not given. According to DCS, staff did not check/monitor Resident #1's blood pressure per physician's orders [REDACTED].>On [DATE] at 1:50 p.m., an interview was conducted with LPN-D. LPN-D stated staff should follow physician's orders [REDACTED].#1's O2 sats dropped below 96%; when medications were not given; and when resident was unresponsive. On [DATE] at 1:55 p.m., an interview was conducted with LPN-E. LPN-E stated staff should follow physician's orders [REDACTED].#1's O2 sats dropped below 96%; when medications were not given; and when resident was unresponsive. On [DATE] at 2:06 p.m., an interview was conducted with LPN-A. LPN-A stated staff should conduct a full nursing assessment/full set of vitals on Resident #1 when there's change in condition. LPN-A also stated Resident #1 should be send out to ER earlier due to the following reasons. Resident #1 had a temperature while on last day of his antibiotic. I am thinking septic. Resident #1 had an order in place to be send out when O2 sats dropped below 96%. On [DATE] at 2:22 p.m., an interview was conducted with DCS. DCS stated staff should follow physician's orders [REDACTED]. Staff should assess/monitor/follow up in the above incident. On [DATE] at 3:43 p.m., an interview was conducted with Certified Nurse Aid-A (CNA-A). CNA-A was Resident #1's aid on [DATE], ,[DATE] shift. CNA-A stated Resident #1 was unresponsive during her shift. According to CNA-A, Resident #1 did not open his eyes when his name was called. He normally would. CNA-A stated she notified LPN-B around 4:30 p.m. or 5:00 p.m. on [DATE] of her findings. CNA-A also stated Resident #1 was not on any oxygen during this shift. On [DATE] at 1:21 p.m., an interview was conducted with CNA-B via phone. CNA-B was Resident #1's aid on [DATE] (,[DATE] shift). CNA-B stated Resident #1 was having a hard time breathing and unresponsive during her shift. According to CNA-B, Resident #1 did not follow directions. Normally, he would follow my command. CNA-B stated she notified LPN-B around 11:00 p.m. on [DATE] of her findings. On [DATE] at 2:16 p.m., an interview was conducted with Resident #1's physician. Resident #1's physician stated he expected staff follow his order. According to physician, Resident #1 would show symptoms when O2 sats less than 96%. It's a way to alert staff. Resident #1's physician was not the on-call doctor on [DATE]. Facility Policies/Procedure titled Change in Resident Condition dated [DATE] stated, The Clinical Nurse will recognize and appropriately intervene in the event of a change in resident condition. The Physician/Family/Responsible Party will be notified as soon as possible. Facility Policies/Procedures titled Medications-Oral Administration Of dated [DATE] stated, It is the policy that the resident can expect safe and accurate administration of oral medication. Facility Policies/Procedures titled Medications/Physician order [REDACTED]. In Fundamentals of Nursing 6th edition, 2005; Patricia A. Potter and Anne Griffin Perry; Mosby, Inc; Page 419. The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders [REDACTED]. The Administrator and Director of Clinical Services were made aware of these findings on [DATE] at 4:30 p.m., no further information provided. Complaint Deficiency

Based on observation, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility failed to prevent, assess, identify, and timely treat residents with pressure ulcers, for five residents (Resident #16, 3, 22, 24, and #11), resulting in harm for Resident #16, in a survey sample of 27 residents. 1. Resident #16's heel ulcer was not identified by the facility (assessed) until it was identified as unstageable wound during a regular podiatry consult, and by the podiatrist at "Eschar", (necrotic or dead tissue) on the left heel. Weekly skin assessments were not completed, and wound assessments and measuring were only completed for the month of June 2014, from identification on April, 22nd 2014 to the time of survey in July 2014. Treatment interventions were not implemented timely, and consistently. 2. For Resident # 3, the facility staff failed to provide physician ordered care and service for the prevention and treatment of [REDACTED]. 3. For Resident #22, the facility staff failed to consistently provide physician ordered care and treatment for [REDACTED]. 4. For Resident #24, the facility staff failed to consistently document interventions for the prevention of pressure sores. There were multiple omissions in documentation of turning and repositioning. In addition, the sacral wound was not tracked for two weeks. 5. For Resident #11, facility staff failed to perform weekly skin assessments and monitor pressure ulcers. The findings included: 1. Resident #16 was admitted to the facility 4-4-14. [DIAGNOSES REDACTED]. Resident #16's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4-11-14 was coded as a full admission assessment. Resident #16 was coded as having dementia. The resident was able to understand others and make self understood. Resident #16 was also coded as requiring extensive total assistance of two staff members to perform activities of daily living, such as bed mobility. Resident #16 was coded as being at risk for the development of pressure ulcers and also coded as having no pressure ulcers upon admission, and no vascular ulcers upon admission. On 7-8-14 at 12 noon, Resident #16, was observed with a large bulky King wrap applied to the Resident's left heel and ankle. The Resident was sitting in a wheel chair with bare feet resting on the floor. No boots or protective foot coverings were present, other than the dressing that was in place. Clinical record review revealed admission physician's orders which included: Float heels when in bed, turn and reposition frequently each shift, pressure reducing mattress to bed, moisture barrier apply every shift and as needed, pressure reducing cushion to wheel chair and check placement every shift, and a multivitamin for supplement. Float heels when in bed was not denoted or signed as administered on the treatment administration record (TAR) from admission on 4-4-14 until May 2014 (8 days after the pressure ulcer was identified by the podiatrist), Further review of the clinical record revealed that on 4-15-14 a physician's order was issued for a regular podiatry consult for routine foot care. The consultation occurred on 4-22-14 and the doctor provided a progress note to the facility diagnosing multiple areas of eschar (dead necrotic tissue) on the Residents feet, to include the Left heel. The Podiatry doctor recommended a vascular surgeon consultation, which was ordered the same day on 4-22-14. The Resident was scheduled to see the vascular surgeon on 4-29-14. No further orders were received for the Resident's heel ulcer until 4-26-14 when "Skin prep to bilateral heels every shift" was ordered. Resident #16 went to the vascular surgeon consultation on 4-29-14 and the doctor wrote a progress note which stated the Resident's wounds were from pressure, and not from ischemia related to poor circulation. The vascular surgeon recommended to "clean" the Resident's "feet with soap and water, cover with [MEDICATION NAME] topical and cover with gauze every day." He also recommended "avoid footwear that rubs the areas, slippers are a good idea," and "need podiatry for toenail and good foot care." The new left heel dressing recommendation was not ordered until 5-20-14, (21 days later). The skin prep treatment was continued through 5-20-14, and then on 5-20-14 it was combined with the new order to read "Cleanse Left heel with normal saline, apply skin prep and 1% [MEDICATION NAME] cream every day and as needed." The treatment was started on 5-21-14. On 5-27-14 Resident #16 was again seen by the vascular surgeon for consultation, and his progress notes revealed new recommendations of "Continue current wound care with [MEDICATION NAME] cream over all wounds," and "Needs pressure boots on both legs to help with Left heel and to prevent anything on the right heel from happening especially since blood flow is diminished." The pressure boots were ordered via a telephone order, the same day at the facility on 5-27-14. The order did not appear on the monthly physician's order sheet nor on the TAR's for the months of May, and June. There was no documentation that the boots were applied for those months. Resident #16 was seen for the first time by a wound care specialist doctor on 6-25-14 (over 2 months after identification) who ordered [MEDICATION NAME] once a day and off loading. The wound specialist saw the Resident again on 7-2-14, and did not change orders. The TAR for July 2014 documented the pressure boots signed for by the nursing staff as being applied from 7-1-14 through the time of survey, however, from the 5-27-14 order until 7-1-14, there was no documentation that the boots were used. During observations of Resident #16 on 7-8-14 at noon, 7-9-14 at 1:15 p.m., and 7-10-14 at 11:00 a.m., the boots were not being worn by the Resident. Further review of the TARs evidenced treatments that were not documented as being done. One the May and June TARs, the 5-20-14 order "Cleanse Left heel with normal saline, apply skin prep and 1% [MEDICATION NAME] cream every day and as needed" that was begun on 5-21-14 was not signed off as administered on the Treatment Administration Record (TAR) on 5-25-14, 5-26-14, 5-27-14, 5-30-14, 6-1-14, 6-2-14(patient refused), and 6-15-14. The order was discontinued on 6-25-14, at which time a new treatment order was issued for "[MEDICATION NAME] to left heel wound daily, which was begun 6-26-14, however, the treatment was not signed as administered on 6-27-14. On the July TAR, the dates of 7-1-14, 7-2-14, 7-5-14, and 7-6-14 revealed circled signatures which indicated the treatment was withheld, with no notation on the reverse side of the form indicating why the treatment was not provided. The clinical record revealed a nurse's note dated 4-25-14 documenting dressings to feet. This was the first note by facility staff denoting a wound after first identification by the podiatrist on 4-22-14 of the eschar to the heel. There was no assessment or nursing note to identify the wound prior to it being found by the podiatrist. The Braden scale for predicting pressure sore risk was completed upon admission and Resident #16 scored a 12 placing the Resident at "high risk", with no sores or ulcers present on admit. Weekly skin integrity review sheets revealed only 4 weekly assessments being completed for the Resident since admission: 4-12-14 surgical incision documented on the Left hip, and no other areas of concern. 4-26-16 surgical incision, and bilateral feet including the left heel, 4 days after the identification by the podiatrist. 6-7-14 eschar right heel and top of left foot, (the right heel was not necrotic and had no wound, it is assumed this was an error). 6-21-14 vascular areas to top of right and left foot. Eschar to left heel. No other skin assessments were performed. Weekly Pressure Ulcer Record reports revealed the following: 6-9-14 Left heel unable to stage 5.2 cm (centimeters) long x 9 cm wide x unknown depth. 6-16-14 Left heel unable to stage 5 cm (centimeters) long x 9 cm wide x unknown depth. 6-23-14 Left heel unable to stage 5 cm (centimeters) long x 9 cm wide x unknown depth. 6-30-14 Left heel unable to stage no measurements were documented. No other wound assessments or measurements were completed before 6-9-14, nor after 6-30-14 until the time of survey. Review of the admission care plan dated 4-4-14, and revised on 4-15-14 revealed, under the heading of "pressure sores/skin care; follow facility skin care protocol, turn every two hours and as needed, and preventive measures: immediately report any redness or skin breakdown to charge nurse." Other areas included: Provide supplement for weight loss, assistance of 1-2 staff members for turning and repositioning in bed every 1-2 hours, serve diet as ordered assist as needed, monitor intake, administer treatments as ordered and monitor for effectiveness, do not cross lower extremities, float heels, weekly skin checks, skin prep to bilateral heels every shift 4-26-14. Treatment as ordered 4-29-14. There was no mention in the care plan of protective measures for the heels, such as heel boots. The last revision to the care plan was made on 4-29-14 (72 days since the last revision). On 7-8-14 the ADON (Assistant Director of Nursing) was interviewed and she stated, "I keep the wound measurements in my office to help out the floor nurses, they have so much to do, that I do these myself." She supplied the Pressure ulcer record for June 2014. When asked where the rest of the measurements were from identification on 4-22-14, the month of May 2014, and the first week of July, the ADON stated "this is all there is." The ADON further stated that there were no further measurements and skin checks done other than the June documents which were provided. On 7-9-14 at 1:15 p.m., wound care observation was conducted with LPN (B). The left Heel soiled dressing was removed, and revealed a circular area of black, leather like, dead, necrosed tissue (eschar) of approximately 4-5 cm (centimeters) present. On 7-9-14 at 1:15 p.m., LPN (B), the wound nurse was interviewed. She stated, "The left heel wound started off as an unable to stage wound." She went on to state it was "necrotic" and that "the base of the wound could not be seen, and that was why it was unstageable." Regarding why the orders from the vascular surgeon were not implemented until 3 weeks after the consultation, LPN (B) stated she did not know why orders were not carried out as written. Guidance provided at www.NPUAP.com defined an unstageable pressure ulcer as follows: "The goal for revising the definition of unstageable ulcers was to reduce the tendency to classify an ulcer with any necrotic tissue as unstageable, when the depth of the ulcer can be seen. The new definition is "Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed." Note the phrase "the base of the ulcer" is used to denote the inability to determine the depth. If necrotic tissue is present, for example, on the edge of the ulcer, but the base is bone, the ulcer should be staged as a Stage IV. Further description of Stage IV ulcers include these phrases: "Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed." The NPUAP (National Pressure Ulcer Advisory Panel) advises "Use devices that eliminate pressure on the heels. For short-term use with cooperative patients, place pillows under the calf to raise the heels off the bed. Place heel suspension boots for long-term use." Review of the facility's policy for "Wound Care Prevention and Treatment Objectives," under Policy Objectives, read as follows "1.) identify at risk residents. 2.) prevention of the development of pressure sores ulcers by performing routine skin and risk assessments. 3.) Accurately identify existing pressure ulcers and appropriate stages to optimize healing by utilizing consistent standardized treatment. 4.) maintain and improve tissue tolerance. 5.) protect against adverse effects of external forces. 6.) provide proactive intervention and education. Weekly documentation of skin assessments." On 7-9-14 at end of day debrief the Administrator and Director of Nursing (DON) were made aware of the harm level findings for this this Resident. When asked if it is usual for wounds to be discovered with eschar, the DON stated, "no, this was an error," and went on to state her expectation was for "CNA's and nurses to report any changes in the skin." No further information was provided by the facility. The DON further stated if it wasn't documented it wasn't done. 2. Resident #3, a female, was admitted to the facility 3/12/14 and readmitted after a hospitalization , 5/7/14. Her [DIAGNOSES REDACTED]. Resident #3's most recent MDS (minimum data set) with an ARD (assessment reference date) of 3/19/14 was coded as an admission assessment. Resident #3 was coded a BIMS (Brief Interview of Mental Status) score of 13, cognitively intact. She was coded as requiring total assistance of one to two staff members to perform her activities of daily living. She was also coded as having limited range of motion of her lower extremities. Resident #3 was coded on admission as having one stage II pressure ulcer and two unstageable wounds related to her [MEDICAL CONDITION]. On 7/8/14 at 11:10 a.m. a wound care observation was conducted with LPN (licensed practical nurse) E, unit nurse. LPN E performed dressing changes on two large surgical wounds to the right lateral thigh and the right inner thigh. During these non-pressure related wound changes, Resident #3 said, "I have trouble moving off my bottom and my bottom kinda be hurting me." LPN E told Resident #3 she would check her buttocks after her dressing changes. On 7/8/14 at 1:40 p.m. LPN E said she was going to assess Resident #3's skin. Assisted by two CNAs (certified nursing assistants), LPN E was able to position Resident #3 on her left side to inspect her buttocks. There was a quarter size superficial open area visible on the right buttock. LPN E stated she would notify the physician of the open area to Resident#3's right buttock. Review of Resident #3's clinical record was conducted and revealed no weekly skin assessments. Further review of the clinical record revealed no documentation the following treatments were administered per physician's orders: Treatment to Cleanse R (right) hip with NS (normal saline) apply Santyl to wound bed and dry dressing daily and PRN (as needed) :7-3 shift on 5/16, 5/17, 5/18, 5/25, 5/26, 5/28, 5/29, 5/30. Treatment to clean wound to inner thigh with NS, moisten gauze with Dakins, apply to wound and cover with ABD (abdominal) pad, secure with paper, tape q 12 hours: 7-3 shift on 5/12, 5/14, 5.5/16, 5/22, 5/25, 5/28, 5/29, 5/30. On 3-11 p.m. shift 5/10, 5/11, 5/12, 5/13, 5/14, 5/20, 5/27, 5/29, 5/30. treatment for [REDACTED]. No Dressing: For May- treatment only administered once a day on the 7 a.m. - 3 p.m. shift and treatments were not documented as administered on 5/12, 5/14, 5/16,5/18, 5/25, 5/26, 5/28, 5/29, 5/30. Valid physicians' orders were evident for the treatments not documented as having been administered. On 7/9/14 at 1:40 p.m., an interview was conducted with LPN C, unit manager, regarding the treatments that were not documented as administered and the lack of any weekly skin assessments. After reviewing the clinical record, LPN C said the [MEDICATION NAME] treatment for [REDACTED]. LPN C also stated, "There are no weekly skin assessments for her (Resident #3)." LPN C said she was aware of the open area identified during the wound care observation performed on 7/8/14. On 7/9/14 at 3:30 p.m., the administration was informed of the facility staff's failure to provide pressure ulcer preventative and physician order care and treatments for Resident #3. 3. Resident #22, a male, was admitted to the facility 11/25/13 and readmitted to the facility following a hospitalization on [DATE]. His [DIAGNOSES REDACTED].. Resident #22's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4/17/14 was coded as a quarterly assessment. Resident #22 was coded a BIMS (Brief Interview of Mental Status) score of 15, cognitively intact. He was coded was being totally dependent on one to two staff members to perform all activities of daily living except eating. Resident #22 was coded as being impaired on both sides of his lower extremities and as being incontinent of bladder and bowel. Resident #22 was coded as having one stage two and two unstageable pressure ulcers that were coded as being present on admission. Review of Resident #22's prior MDSs revealed a readmission MDS with ARD of 1/15/14. Resident # 22 was coded as having two (2) stage two pressure ulcers. Resident #22's initial admission MDS with an ARD of 12/2/13 was not coded for any pressure ulcers. On 7/7/14 a review of Resident #22's closed clinical record was conducted and revealed TARs (Treatment Administration Records) with the following physician ordered pressure ulcer care and treatments that were not documented as having been provided or administered: "Turn and Reposition Resident Frequently every Shift: On 11-7 shift 11/28, 11/29 12/6, 12/9, 12/10, 12/15, 12/16, 12/20 12/24, 12/28, 1/12, 1/21, 1/25, 1/26, 1/29, 1/30, 1/31, 2/10, 3/12 4/5, 4/6, 4/14, 4/26, 4/27, 4/28 , 5/12. On 7-3 shift 12/3, 12/3, 12/7, 12/8, 12/9, 12/20, 12/21, 12/25, 12/26, 12/27, 12/30, 12/31, 1/1, 1/9, 1/10, 1/11, 1/12, 1/14, 1/18, 2/14, 2/15, 2/25, 3/2, 3/14, 3/15, 3/21, 3/22, 3/23, 3/24, 3/27, 3/28, 3/29, 4.25, 4/27, 4/28, 4/29, 4/30, 5/16. On 3-11 shift 12/2, 12/3, 12/4, 12/5, 12/7, 12/9, 12/15, 12/17, 12/18, 12/19, 12/20, 12/23, 12/24, 12/25, 12/26, 12/28., 1/10, 1/11, 1/12, 1/14, 1/19, 1/20, 1/22, 1/23., 2/11, 2/12, 2/1, 2/20, 2/27, 3/13, 3/26, 3/27, 3/30, 4/11, 5/3, 5/4, 5/9. Therapeutic Mattress to Bed - Check Placement/function every Shift: On 11-7 shift 5/2. On 7-3 shift 5/16. On 3-11 shift 5/3, 5/4 Pressure reducing mattress at all times-check placement every shift: On 11-7 shift 11/27, 11/28, 11/29, 12/2, 12/13, 12/16, 12/17,12/18, 12/22, 12/23, 12/24, 12/25, 5/12. On 7-3 shift 12/4, 5/16. On 3-11 shift 12/20, 12/21, 12/22, 12/24, 12/26, 5/3, 5/4, 5/9. Pressure reducing cushion to chair/wheelchair at all times-check placement every shift: On 11-7 shift 11/27, 11/28, 11/29, 12/2, 12/6, 12/16, 12/17, 12/21, 12/22, 12/24,2/9, 5/12. On 7-3 shift 5/16. On 3-11 shift 12/9, 12/10, 12/21, 12/22, 12/23, 12/24, 12/26, 5/3, 5/4, 5/9. Apply Skin Prep to Bilateral Heels Every Shift for Prevention: On 11-7 shift 11/22, 11/23, 11/24, 11/25, 1/16, 1/27, 4/7, 5/12. On 7-3 shift 4/4, 5/16. On 3-11 shift 11/20, 11/21, 11/22, 11/23, 11/24, 11/26, 2/7, 2/8, 2/9, 2/25, 3/13, 3/27, 4/16, 4/20, 4/27, 5/3, 5/4, 5/9. Apply barrier cream to L (left) buttock and coccyx wounds q (every) shift: On 11-7 shift 12/6, 12/9, 12/10, 12/22, 12/23,12/24, 12/25. On the 3-11 shift 12/20, 12/21, 12/22, 12/24, 1/15, 1/21, 1/31, 1/31 . Float Heels when in Bed every Shift: On 11-7 shift 1/13, 1/16, 1/20, 5/12. On 7-3 shift 5/16. On 3-11 shift 1/12, 1/13, 1/14, 1/16, 1/21, 1/23, 1/26, 1/315/3, 5/4, 5/9. Cleanse Coccyx with NS, Pat dry, Apply Optiform AG - Change everyday: 4/4 and 4/21 Cleanse Coccyx with NS (normal saline). Apply Santyl and dry dressing daily: 5/10, 5/11. Cleanse R (right) Heel with NS. Apply Santyl and dry dressing daily: 3/13, 3/15, 5/1, 5/6, 5/11. Santyl to r. heel q AM, then cover with [MEDICATION NAME] Kerlix: 3/31. Cleanse coccyx with NS wet to dry dressing and apply border gauze daily: 5/16. Cleanse coccyx with NS. apply [MEDICATION NAME] and border gauze twice daily: On 3-11 shift 2/21, 2/25. Cleanse coccyx with NS, pat dry, apply [MEDICATION NAME] AG, change daily: 3/31. [MEDICATION NAME] Cream to Bilateral Feet two times a day: On 7-3 shift 5/16. On 3-11 shift 2/1, 2/25 5/3, 5/4. Elevate R leg/foot off bed Contact Q Shift: 4/8, 4/28, 4/30 on 11-7 shift. 4/6 on 7-3 shift." Valid physicians' orders were evident for the treatments not documented as having been administered. Review of the MAR, nurses' notes and interdisciplinary notes throughout Resident#22's stay in the facility revealed numerous episodes of non-compliance and refusal of care in conjunction with care and treatments that were not documented as having been administered. A review of Resident #22's weekly skin assessments from the time of his initial admission 11/22/13 until he was discharged on [DATE] revealed inconsistent performance of weekly skin assessments. Evidence of weekly skin assessments were provided for the following dates: "11/4/13, 12/9/13, 12/15/13, 12/22/13, 1/12/14, 1/13/14, 1/20/14, 1/26/14, 2/2/14, 3/2/14, 3/24/13, 3/30/14." Requests for any additional evidence of the performance of weekly skin assessments were made on 7/8/14 at 4:15 p.m. during an end of day briefing. No additional weekly assessment documentation was presented. A review of Resident #22's Pressure Ulcer Records revealed measurements and wound monitoring for a right heel and coccyx pressure ulcer. Resident #22 was readmitted to the facility after hospitalization on [DATE]. Resident #22's PRESSURE ULCER RECORD revealed wound measurements were initiated on 1/15/2014. At this time, Resident #22 was documented as having one coccyx stage II pressure ulcer that was 5.2 x 4.0 x 0.2 with granulation, no odor, and no drainage. The final measurements for the coccyx wound was documented on 5/13/14 at [MEDICAL CONDITION] with slough, redness on the wound edges, odor and serous drainage. Resident #22's right heel was initially documents as a stage III pressure ulcer at 10.8 x 1.8 x .2 with granulation and no odor. The final measurements taken on 5/13/14 documented the right heel as an unstageable pressure ulcer measuring 8.3 x 8.1 x 1.3 with slough, large amounts of sero-sanguineous drainage and the presence of odor. Review of the physician orders dated 5/1/14 further revealed the worsening the right heel, "Plastic Surgery Consult - DX (diagnosis) R. Heel Pressure Ulcer Stage IV." Review of Resident #22's care plan revealed a Pressure Ulcer careplan dated 1/8/14 that identified the right heel and left coccyx and a Skin Prevention Care Plan. Interventions for this care plan included the following: "-Skin Prep to Heels as ordered. -Weekly skin checks by licensed nurse. -Turn and Position Q (every) 2 hours. -Apply Skin Barrier." Review of a form entitled GUIDELINES FOR UNAVOIDABLE WOUNDS, signed by the physician of 1/8/14, identified the following interventions that were expected to be implemented: "-Weekly skin assessments -Turn/Reposition, as required -Pressure reducing/relieving mattress -Use of barrier ointments/creams -Administer Treatments as ordered." Review of the facility policy and procedures entitled Wound Care Prevention and Treatment was conducted. Under Policy read, "Use of a standardized skin assessment to determine risk factors and current status. Weekly documentation of the above findings." Under Objectives read:: "Accurately identify existing pressure ulcers and appropriate stages to optimize healing by utilizing consistent, standardized treatment." On 7/8/2014 at 4:30 p.m., during the end of day briefing the administrator, and the director of nursing were informed of the worsening and lack of consistent care and treatment to Resident #22's pressure ulcers as evidenced by the treatment and care that was not documented as administered per the physician orders. On 7/9/14 at 3:30 p.m. the administration was informed of the above findings. No additional documentation to address the care and treatments that were not documented as administered to Resident 22's worsening pressure ulcers was provided. COMPLAINT DEFICIENCY 4. Resident #24 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed most recent MDS (minimum data set) with an ARD (assessment reference date) of 1/29/14. The resident was coded as having a BIMS (brief interview of mental status) of "7" out of a possible 15, or moderate cognitive impairment. The resident was coded as requiring total assistance for ADLs (activities of daily living), such as bathing. The resident did not have any pressure sores coded. On 2/10/14 an SBAR (situation, background, assessment and request form) was completed for "open areas" of a stage 2 to the sacrum, and left and right buttocks. The MD (medical doctor) and RP (responsible party) was documented as being notified. Moisture barrier cream every shift had been ordered every shift since admission. A [MEDICATION NAME] (a gel containing dressing) for the open areas. Review of the resident's care plan dated 1/22/14 contained the following regarding pressure sores: "Turn every two hours and prn (as needed), barrier cream, float heels." Review of the TAR (treatment administration record) for February, 2014, revealed multiple omissions in documentation for turning and repositioning (2/10, 2/17-23, 2/26, 2/27). On 2/24/14, an SBAR was completed for "open areas to sacrum and right and left buttock have not shown improvement and continue to deteriorate." The MD and RP were notified, and the treatment was changed on 2/18/14 to Santyl (a [MEDICATION NAME] agent). Wound tracking for the sacrum during the month of February through April 2014 revealed the following: 2/2/14: Stage 2: 1.0 by 1.0 cm (centimeters), no depth 2/10/14: Stage 2: 3.0 by 1.2 by 0.1 cm 2/17/14: Stage 2: 3.9 by 2.0 by 0.2 2/18/14: Stage 3: 7.0 by 2.0 by 3.0 with slough and tunneling 3/4/14: Stage 4: 6.7 by 5.0 by 5. 3/11/14: Stage 4: 7.5 by 5.0 by 5.0 3/17/14: Stage 4: 7.0 by 5.6 by 4.3 3/24/14: Stage 4: 6.7 by 5.9 by 3.6 3/31/14: Stage 4: 6.5 by 4.4 by 3.1 4/7/14: Stage 4: 6.6 by 4.7 by 5.3 4/14/14: Stage 4: 2.2 by 5.8 by 2 4/21/14: Stage 4: 2.4 by 5.6 by 2.1 4/28/14: Stage 4: 6.1 by 4.1 by 1.9 There were no measurements recorded for 5/1/4, 5/7/14. The next measurement was 5/21/14 with measurements of 5.8 by 8.2 by 2.4 cm. The Minimum Data Set 3.0 defines the four stages of pressure ulcers. STAGE I Intact skin with non-blanchable redness of a localized area usually over a bony prominence. STAGE II Partial thickness of skin loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact blister. STAGE III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. STAGE IV Full thickness loss with exposed bone, tendon or muscle. Slough or eschar may be present on some part of the wound bed. Often includes undermining or tunneling. On 7/9/14 at 10:00 AM, an interview with LPN (licensed practical nurse) D. LPN (D) stated, "We are supposed to measure wounds weekly." She went on to state that all the nurses measure wounds, there is no wound care nurse. On 7/9/14, the Administrator and DON (director of nursing) were notified of above findings. 5. Resident #11, a [AGE] year old, was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #11's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 5/9/14. She was coded with a Brief Interview of Mental Status score of 9 indicating moderate cognitive impairment. She required extensive assistance with her activities of daily living. Upon completion of the clinical record review, it was determined that Resident #11 received treatment to several different pressure ulcers while at the facility. The following information includes the pressure ulcer areas and the date on which treatment was ordered: 2/10/14- Left buttock (acquired). Treatment order read "L (left) buttock cleanse with NS (normal saline). Apply Hydrogel daily cover with dressing. Change daily and PRN (as needed) until healed." 5/24/14- Left heel blister (acquired). Treatment ordered read "Skin prep to blister on L heel q (every) shift until healed." 5/24/14- Left and right buttocks wound (acquired). Treatment ordered read "Cleanse L/R (left/right) buttocks with NS (normal saline), apply [MEDICATION NAME] Q (every) 3 days until healed and PRN (as needed)." In the afternoon of 7/8/14, Unit Manager (LPN C) was asked to provide all skin related documents, to include weekly skin assessments and pressure wound tracking sheets, for Resident #11. LPN C stated that Resident #11's left heel pressure wound had just healed that day. LPN C stated that Resident #11 had not had any other pressure wounds. It was reviewed with LPN C that Resident #11 had been treated for [REDACTED]. LPN C stated that those areas were not pressure wounds. It was reviewed with LPN C that the products ordered by the physician to treat the open areas on the skin were products designed to heal pressure wounds. In addition to any wound tracking documentation, LPN C was also asked for all of Resident #11's weekly skin assessments since her admission. On 7/9/14 at 1:50 p.m., another Unit Manager (LPN D), was interviewed regarding the facility's skin assessment process. LPN D stated that if an area was identified on the skin, a treatment would be ordered and a tracking form for either a pressure ulcer issue or a non-pressure issue would be started. Resident #11's record, to include the thinned chart, was reviewed for skin assessment documentation and pressure ulcer monitoring documents. Resident #11 had been at the facility for almost six months. No weekly skin assessments were found in the clinical record. In addition, no pressure ulcer tracking forms were found in the clinical record. LPN C provided a "Pressure Ulcer Record" for Resident #11's left heel wound. The form was initiated on 5/24/14 and the wound was documented as Stage II. She was also able to provide a Pressure Ulcer Record for the left buttock dated 2/10/14 and the wound was documented as Stage II. No Pressure Ulcer Records were provided for the right buttock wound or the left buttock wound (re-opened 5/24/14). It is unclear at what stage these wounds were upon identification. Resident #11's Skin Prevention Care Plan dated 2/11/14 was reviewed. The "Interventions/ Approaches" section was reviewed. The following were some of the interventions checked: -Document change in skin color, turgor, etc. -Pressure reducing mattress per facility protocol -Utilize pillows to the entire lower legs to keep heels off mattress as needed -Turn and position every 2 hours A second care plan for "Skin/wound" dated 5/26/14 was reviewed. This care plan addressed "Skin/wound left heel, right buttock/left buttock." The "Interventions/ Approaches" section included: -Assist resident with turning and positioning -Inform physician of any new area of skin breakdown -Notify nurse of any new areas of skin breakdown -Float heels -Weekly skin checks Resident #11 was observed on 7/9/14 at 10:10 a.m.. She was laying in bed, with the head of the bed elevated. Her heels were flat on the mattress, with pillows and heel floating device positioned behind her upper calves. Resident #11's left heel was observed with dry, flaky patches, with closed tender pink skin. At this time, LPN M was preparing

Based on observation, staff interview, facility documentation and clinical record review, and in the course of a complaint investigation, the facility failed to for four residents (Resident #1, #6, #2 and #4) in a survey sample of 12 residents, to provide treatment and services to prevent and heal pressure ulcers, resulting in harm for Residents #1, #6 and #2. 1. Resident #1's post operative instructions for sacral wound care after surgical closure of the wound were not obtained timely and when obtained, antibiotics were not initiated. The surgeon was not notified of the surgical wound dressing coming off, the wound and/ or dressing was not assessed during the weekend. The wound dehisced (wound opening up) and deteriorated. 2. For Resident#6, the facility staff failed to accurately and consistently assess and monitor Resident #6's skin. Resident #6 developed a stage III pressure ulcer, resulting in harm. 3. For Resident #2, the staff failed to; a. Implement weekly skin checks, b. administer ordered medications, treatments & supplements daily, and c. To implement in a timely manner Physical therapy interventions, which cumulatively resulted in harm, specifically the development of two stage (3) pressure ulcers. 4. For Resident #4 the facility staff failed to assess and treat a pressure ulcer on the right hip. The findings included: Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (MDS) (an assessment protocol) with an Assessment Reference Date of 3/9/13 coded Resident #1 as having a BIMS (brief interview of mental status) score of "15" out of a possible 15, or no cognitive impairment. In addition, the MDS coded Resident #1 as requiring total staff assistance of 1 to 2 staff members for Activities of Daily Living care such as toileting, dressing and bathing. Resident #1 was coded as always incontinent of bowel and bladder. Resident #1 was also coded with two stage 1 pressure ulcers, three stage 2 pressure ulcers, and one stage 4 pressure ulcer, measuring 1.2 cm (centimeters) by 0.6 cm by 0.2 cm depth. The stage 4 wound was present on admission. Currently, Resident #1 has 8 wounds, with two new pressure wounds on the left foot, which were acquired on 4/9/13, and have deteriorated. Resident #1 also acquired two new wounds in May, one on the right back, and the other on the right thigh, which were improving. Review of the clinical record revealed on 4/25/13, Resident #1 went to outpatient surgery for [REDACTED]. 4/25/13- Resident #1 was sent to local hospital for surgical debridement of the sacrum and left foot, as well as closure of the sacral wound with sutures. A pressure dressing was applied. There was no nurse ' s note of the resident being transferred to the hospital until a late note on 4/26/13. 4/26/13 (Friday): discharged back to the facility. Wound nurse stated of the post operative instructions, " None were present on the desk. " An attempt was made to notify the surgeon, with the message he would call back after finishing surgery, and was to talk with a 3-11 (name was given). No additional notes were evident that further attempts were made to notify the surgeon, who did not call back. 4/27/13- 4/28/13 (weekend): No nurses notes describing condition of wound dressing (bleeding or drainage) were on the chart during this time. 4/29/13 (Monday) Wound care nurse discovered the wound care instructions had not been obtained. The surgical dressing was off, and the wound care nurse put a foam dressing on it. The surgeon was not notified the dressing had come off. Post operative instructions were faxed to the facility, which included the following: ? [MEDICATION NAME](antibiotic) 250- 62.5 milligrams (10 cubic centimeters) every 12 hours for seven days. Review of the MAR (medication administration record) for April revealed the antibiotic was not started as ordered. ? Leave dressings on until follow up appointment in clinic. ? Patient needs to avoid excessive time on her back due to surgery. She needs every 2 hour turning and off loading of the heel and sacrum. 5/1/13 (Wednesday) Resident #1 returned to the wound clinic for follow up of postoperative wound. According to the surgeon ' s note: "Unfortunately the patient has regressed after her surgical intervention. Strict instructions were given that the patient needed aggressive offloading post operatively and it appears that the patient has unfortunately opened her sacral wound closure. The sutures were removed. The patient also has signs of a new pressure ulcer on the right lateral rib. She recently within the past two weeks has had two new pressure ulcers develop on her left lateral foot. On the foot the wounds are down to the bone and I feel she will likely be looking at amputation below the knee. She was given a prescription for antibiotics which were not started on discharge from her operation. We have documentation from our staff that the instructions were called to (name of facility), but not followed through. In addition, most importantly appears that the patient is not being off loaded aggressively." Under history and physical the note read, "She has not received post operative care and presented today with wounds open to air." [DEVICE] therapy was started. Measurements of the sacral wound preoperatively to current were: 4/23/13: 1.6 cm by 1.9 cm by 0.9 cm 4/25/13(Day of surgery) 2 cm (centimeters) by 2 cm by 0.4 cm (depth) 4/26/13: 1.6 by 1.9 cm (according to interview with the wound nurse, the dressing was intact on 4/26/13). 5/1/13 (post op visit) 3.0 cm by 4.1 by 1.5 cm (depth) 5/6/13: 2.6 cm by 3.8 cm by 2.7 cm) On 5/22/13, the DON (director of nursing) stated, "Both nurses (wound care nurse and 3-11 nurse) were counseled on wound care and not following up on orders." On 5/22/13 at 11:05 AM, wound care was observed with Resident #1. On observation of the sacral wound, the resident did not have a dressing on the sacrum. The wound nurse stated, "It's very difficult to keep the wound vac (vacuum) on because she urinates very often, and she refuses to have a catheter, so the dressing comes off." The resident had on heel boots and was on an alternating pressure mattress. Wound care was performed according to the current orders. On 5/22/13 at 2:35 PM, an interview with the wound care nurse was conducted. She stated, "I have been doing this for a month and a half." She went on to state that after the resident's discharge from surgery on 4/26/13, she went to the unit to check on her orders, but "none were present on the desk". After calling the hospital, she called the wound clinic, and was told the physician was in surgery and would contact the 3-11 nurse. As of Monday, 4/29/13, the orders had not been obtained, but were finally obtained on 4/29/13. Physician ordered antibiotics were not initiated at this time. The wound nurse went on to state that on 4/29/13 (Monday), the dressing had come off, and "I put a foam dressing on it." When asked if she had notified the surgeon of the dressing being off, the wound nurse stated, "I should have called the doctor." The DON (director of nursing) stated, "Both nurses were counseled on wound care and not following up on orders." The facility did provide a clean dressing competency test results, dated 5/8/13 for the wound care nurse. On the competency test results section, the last step included to notify RP (responsible party) of condition of wound; there was nothing in the competency test section to notify the physician of changes in the wound. The above measurements showed deterioration of the wound after surgical intervention. On 5/22/13 at the end of the day exit, the Administrator and DON were notified of harm level findings. 2. For Resident #6, the facility failed to accurately and consistently assess and monitor Resident#6's skin. Resident#6 developed a stage III pressure ulcer on the sacrum which was identified on 5/16/13. Resident #6, an [AGE] year old female, was admitted to the facility 4/18/13. Her [DIAGNOSES REDACTED]. Resident #6 was hospitalized during the time of the survey. Resident #6's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4/25/13 was coded as an admission assessment. She was coded as having short and long term memory problems or moderately impaired cognitive loss. She was coded as having signs and symptoms of [MEDICAL CONDITION]. Resident #6 was coded as being totally dependent on staff physical assistance with her activities of daily living and two person assistance with bed mobility and transfers. Resident #6 was coded as always incontinent of bladder and bowel. There was one stage II and two unstagable pressure ulcers coded during this ARD period. On 5/22/13, at 11:00 AM Resident #6's facility medical record was reviewed. A nurse practitioner's progress note, written 5/17/13 read, "New decubitus to sacrum stage III. A physician telephone order, written 5/17/13, read "Cleanse sacrum with NS (normal saline) apply nickel thick Santyl to wound bed cover with dry dressing daily." Santyl ointment is an enzymatic [MEDICATION NAME] ointment that is used for removing dead skin from wounds. http://www.drugs.com/cdi/santyl-ointment.html Review of the Resident #6's Pressure Ulcer Records revealed on 5/16/13 a stage III to the sacrum was first observed. The wound size was documented as 3.0 cm (centimeters) by 2.6 cm with no drainage and no odor. The current treatment plan was Santyl. The Stage III pressure decubitus was initially identified on 5/16 by a CNA that reported it to the Nurse Practitioner. The wound care nurse stated the Stage II on admission was not the Stage III that was later acquired. A review of the hospital Wound Care Nurses assessment, revealed the two sacral ulcers as being separate. According to the National Pressure Ulcer Advisory Panel, a stage III is defined as "Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling." Resident #6's plan of care updated 5/7/13 included a Skin Prevention Care Plan that read, "Resident remains at risk for skin breakdown related to [DIAGNOSES REDACTED]. The Pressure Ulcer Care Plan was checked to continue current Skin Prevention Care Plan to assure there was no further breakdown. Interventions/Approaches included the following: "-Braden on admission, quarterly,and change in cognitive status,-Nutritional assessment on admission and quarterly, treatments per MD orders,-Assess for history of pressure ulcers,-Document change in skin color, tutor,-Weekly skin checks by licensed nurse,-Report any red areas to nurse immediately,-Pressure reducing mattress,-Turn and position frequently each shift,-Use lift device to prevent shearing and friction,-Keep linen wrinkle free,-Pressure reducing cushion to W/C(wheel chair), -Free of perspiration,-Free of wound drainage,-Keep linen clean and dry,-Incontinence care every 2 hours and prn (as needed) each shift,-Complete a skin assessment before and after out of facility appointments,-Complete a skin assessment before and after leave of absence,-Completed a head to toe assessment to assure skin is intact". Review of Resident#6's facility medical record revealed Pressure Ulcer Records for three of Resident#6's four pressure ulcers with the following recent measurements: "Sacrum -first observed on admission, 4/18/13, measured on 5/11/13 as a stage II, [MEDICAL CONDITIONS] with no drainage, odor, or tunneling. L. Heel-first observed on admission, 4/18/13, measured on 5/11/13 as a UTS (unable to stage) , 3.6x3.4cm, no depth, no drainage, no tunneling. Sacrum-first observed 5/16/13, measured as a Stage III, 3.0x2.6cm, no drainage, no odor. Review of the May 2013 physician orders [REDACTED]. Resident #6's facility medical record did not have a pressure ulcer record for Resident#6's right heel. On 5/19/13 at 9:30 PM a Physician Telephone order was written, "Send to ED (emergency room ) for increased K+ (potassium) 6.9 and Na (sodium) 112." Review of Resident#6's hospital medical record revealed she was initially seen by an attending provider on 5/19/13 at 2217 (10:17 PM). Under History of Present Illness was documented, "The patient was found to be in septic shock in the ER with [MEDICAL CONDITION] (low sodium), [MEDICAL CONDITION] (high potassium) and acute [MEDICAL CONDITION]. Under Skin read, "She has multiple areas of skin breakdown and excoriations around her groin". Review of Resident #6's Wound Care Note from the hospital dated 5/20/13 11:07 AM revealed in depth descriptions of Resident#6's wounds and skin: "Location: R. heel, Suspected DTI (deep tissue injury) and stage 2 pressure, 1.5x1.5x1.05cm, intact dark purple with open skin flap w/moist red tissue Location: L. heel, Suspected DTI, 3.5x4.0cm, very dark purple/almost black, intact, mushy, no drainage. Location: bilateral bony prominence to top of feet and anterior ankles, Suspected DTI, suspect r/t (related to) footwear. Location: Buttocks/coccyx/sacrum, Unstagable pressure ulcer and moisture assoc skin damage, 8.0x11.0cm. intact firmly adherent yellow tissue and superficial denudement at edges, moderate serosang drainage. Location: R. buttock fold/ischium area, suspected DTI/stage 2 pressure ulcer/moisture related, .5x2.0cm, intact purple and moist red. Location: Bilateral upper inner thighs L>R, Suspected DTI/stage2 pressure ulcer/moisture related, [MEDICAL CONDITION], intact purple and moist red." Under Wound Care Notes-Impression was noted, "Pressure ulcers and moisture associated skin damage on admission". On 5/22/13 at 3:45 PM the DON (director of nursing) was questioned about Resident#6's skin and pressure ulcer care. When asked about the performance and documentation of wound care and monitoring to Resident#6's R. heel, she stated, "Oh, there was never a pressure ulcer to the R heel. That was transcribed incorrectly." Review of the care plan, the admission assessment, and the April and May treatment records revealed the presence of unstagable ulcers to both heels. When asked about the new stage III pressure ulcer that according to Resident#6's facility medical record, was acquired on 5/16/13, the DON stated, "No, that wasn't a new pressure ulcer. The resident was admitted with a stage II to the sacrum and it got worse." When questioned about weekly skin assessments, the DON said she would provide that documentation later. On 5/22/13 at 5:45 PM during the end of day conference, informed the administrator, and DON of missing evidence of consistent and accurate skin care assessments, and wound care monitoring for Resident#6. On 5/23/13 at 10:50 AM met with the DON who provided a copy of the facility's Pressure Ulcer Protocol At-A-Glance and Resident#6's Weekly Skin Integrity Checks form. Review of this form revealed skin care assessments on 5/10/13 and 5/18/13. Noted under the form title was a statement which read, "Weekly head to toe skin integrity checks to be done weekly on all patients". On 5/10/13, there was a check to indicate "Skin clear, no change of condition assessed. On 5/18/13, each of the choices were checked to indicate "Skin clear, no change of condition assessed; New wound/change of condition; and Wound/Skin condition Present/No new change of condition." When asked if there was any other weekly documentation of skin assessments performed by a licensed nurse, the DON responded, "No". The facility's Pressure Ulcer Protocol under Assessment read: "1. On Admission 2. Weekly Skin Integrity Checks 3 Weekly Pressure Ulcer Record 4. Quarter *Anytime a pressure ulcer is identified a Weekly Pressure Ulcer Record must be completed." On 5/23/13 at 1:55 PM, LPN-A (facility designated wound care nurse) and LPN-B were questioned about Resident #6's pressure ulcers. When asked specifically about the stage III pressure ulcer that was documented as date first observed 5/16/13, LPN-A stated she clearly remembered the pressure ulcer. She stated, "It was definitely a new pressure ulcer. I staged it as a stage III because it had a little slough on it and I could see the base of the wound." LPN-B concurred with LPN-A's assessment of the wound and she stated, "I was with her (LPN-A) and because of the wound description, it was a stage III. That's why Santyl was ordered." On 5/23/13 at 3:30 PM, interviewed the DON regarding incontinence care as it related to Resident#6's moisture associated skin damage. The DON provided the facility's policy and procedures entitled, Incontinent Resident Care, which stated, "Incontinent residents will be cared for by nursing personnel to ensure adequate skin care, control odor, and provide personnel hygiene." When asked about the excoriation of Resident#6 buttocks and upper thighs that was documented in the hospital records, the DON stated, "I've seen residents get excoriated in a short period of time." On 5/23/13 at 4:15 PM, spoke with the assistant DON (RN-B) who provided information regarding the pickup time by the ambulance to transport Resident #6 to the ER (emergency room ). RN-B stated, "The order to send her to the ER was written at 9:30 PM. It may have been 30 minutes before she was actually picked up. We sent her out clean and dry." On 5/23/13 at 4:30 PM, surveyor asked the DON to select for interview a CNA (certified nursing assisted) that had worked with Resident#6 during the evening shift hours. She selected CNA-E and CNA-E was interviewed and questioned about Resident#6's incontinence care. CNA-E stated she had performed incontinence care on Resident#6 many times. She stated that before any resident left the facility, they were checked and changed to make sure they were dry and clean. When asked specifically about the condition of Resident#6's buttocks and groin area, she stated, ""Oh, she was red and broke down when she came here. Kind of red and raw." When asked it she reported her skin condition to the nurse, she stated, "No, she (Resident#6) was always like that." Guidance was given, "Medical Surgical Nursing, Vol 1, Ignatavicius and Workman, p. 123, "To maintain healthy skin, the body must have adequate food, water, oxygen intake, intact waste removal mechanisms; sensation; and functional mobility. Changes in any of these variables can lead to rapid and extensive skin breakdown. If the client cannot protect or maintain the skin, the nurse must be able to assess and plan for his or her needs. The nurse monitors the client to determine the risk of skin breakdown before it occurs." Guidance from the National Home Quality Campaign, " Skin changes and pressure ulcers can develop quickly. Routine skin checks are a key to good care.. "http://www.nhqualitycampaign.org/files/factsheets/Consumer%20Fact%20Sheet%20-%20Pressure%20Ulcers.pdf . On 5/23/13 at 5:30 PM, the DON and Administrator were notified of findings. No other documentation was provided. 3) For Resident #2, the staff failed to; 1. Implement weekly skin checks, 2. administer ordered medications, treatments & supplements daily 3. and to implement in a timely manner Physical therapy interventions. All of the above resulted in harm. Resident #2 was originally admitted to the facility 11-8-12 and readmitted on [DATE], 4-16-13, and 5-20-13. The resident had [DIAGNOSES REDACTED]. Resident #2's most recent MDS (minimum data set) with an ARD (assessment reference date) of 2-14-13 was coded as a quarterly assessment. This was compared to the previous admission full assessment with an ARD date of 11-15-12. Resident #2 was coded as having no memory deficits and required no help in making daily life decisions, and received 15 of a possible 15 points on a brief interview for mental status. Resident #2 was also coded as requiring one to two staff members for extensive to total physical dependence in activities of daily living including transferring, bed mobility, bathing, dressing, and toileting. The Resident was coded as of the 2-14-13 MDS as having two stage 2 pressure ulcers that were present on re-admission 2-11-13, and that new tissue was growing into the superficial wound with only [MEDICATION NAME] tissue being involved. Resident #2 was assessed as at risk for skin breakdown, and both wounds were healed, 1 on the right lower lateral leg on 2-25-13, and the second on the left lower lateral leg on 3-18-13. On 3-19-13 the (name of facility) pressure ulcer record filled out by the wound treatment nurse revealed 3 new pressure ulcers, 2 of which were open and 1 which was not open. The locations were; 1. Left posterior heel - measured 1.7 cm(centimeters) x 0.4 cm x 0.1 cm open area surrounded by dark purple discolored tissue, no stage was documented. 2. Right posterior leg 2.6 cmx1.0 cm x 0.1 cm open area, with purulent (pus) drainage, and deep tissue injury, no stage was documented. 3. Right posterior leg 26.5 cmx 2.0 cm purple bruising, deep tissue injury. On 3-24-13 a fourth pressure area was documented on the pressure ulcer record as Right posterior lower leg 3.9 cm x 1.4 cm x 0.1 cm open red area surrounded by dark tissue and no stage was documented. 3-25-13 Resident #2 went to the hospital for diagnosed [MEDICAL CONDITION] and surgical debridement of right lower extremity. The Resident returned 4-16-13 time unknown, as the admission data collection form reveals no time. The form states only 1 wound which is the right lower extremity surgical wound, however, does mention in the [DIAGNOSES REDACTED]. There was no nursing note for the 4-16-13 readmission to the facility. There were no further hospitalization s from 4-16-13 through 5-16-13. Nursing notes on 4-17-13 upon readmission denoted the wounds present on readmission were the following with measurements; 1. Right heel, unable to stage due to black eschar 2.5 cm x 1.8 cm. 2. Right buttocks stage (3) 3.8 cm x 3.7 cm x 0.1 cm. 3. Right buttocks stage (2) 0.3 cm x 0.2 cm x 0.1 cm. 4. Right posterior leg surgical post debridement 13.9 cm x 5.0 cm x 1.4 cm wound vac ordered. On 4-29-13 (13 days after readmission) The following Pressure ulcer record revealed assessments of 2 new areas; 1. Left lateral leg deep tissue injury stage 2 no measurement, with no follow up descriptions or measurements after documentation of this initial entry. 2. Left lower leg deep tissue injury stage 2 no measurement, with only documented follow up on 5-11-13 of deep tissue injury 10.2 cm x 2.3 cm. No further newly found pressure areas were documented until 5-7-13 (21 days after readmission), which revealed the following newly found pressure ulcers; 1. Left Lateral heel stage (3) 1.8 cm x 3.1 cm x 0.1 cm, no slough. 2. Left lateral heel stage (3) 1.1 cm x 0.9 cm x 0.1 cm, no slough. 3. Left lateral heel unable to stage 5.0 cm x 1.9 cm. 4. Left lateral heel unable to stage 2.0 cm x 3.2 cm. Numbers 3 and 4 above had 1 other measurement done 5-11-13, however, still documented as unable to stage. No further documentation on these newly found areas were available at time of survey 5-23-13 (16 days after first finding of 2 stage (3) pressure ulcers on the Left lateral heel). One entry was found in the pressure ulcer record dated 5-20-13 of a Left Lateral heel #3 stage (2) now measuring 0.2 cm x 0.3 cm x 0.1 cm. It was unknown which, if any, of the 4 areas documented on the 5-7-13 assessments matched this follow up entry, as the location and size descriptions of the 5-7-13 and 5-20-13 documents do not match anywhere in Resident #2 ' s clinical records. Facility policy and procedure denoted to " observe skin, evaluate skin after each turning interval, do weekly skin audits, use assistive devices such as over bed trapeze, and do pressure sore progress note and assessment, do wound treatments, administer medications and supplements as ordered." The Resident ' s full care plan with updates 4-16-13 and 5-20-13 denoted; follow skin protocol, turn every 2 hours, specialty mattress, barrier cream, float heels, immediately report any redness or skin breakdown to charge nurse. Also record on the pressure ulcer record weekly the stage of the wound, length x width x depth, odor, progress, lack of progress, current treatment, weekly skin checks by licensed nurse, use assistive devices, do treatments, administer medications and supplements as ordered, encourage resident to off load pressure areas, and review at weekly skin meeting. Weekly skin integrity checks (audits) forms since initial admission were requested and provided by the Director of Nursing (DON) who stated " these are all of the skin checks we have done since admission. " The DON's forms revealed no skin checks being done in the month of April 2013 and 2 weeks were done for the Month of May as of survey 5-23-13, done 5-4-13 and 5-11-13, with no mention of the pressure ulcers found 5-7-13 were made. Physical therapy (PT) notes revealed a doctors order and treatment request from physical therapy for an over bed trapeze to assist the Resident in moving and off loading pressure areas. Therapist notes stated maintenance requested to provide a trapeze and replied there were none in the facility to issue. No trapeze was ever obtained for Resident #2. PT notes also revealed that the [DEVICE] for Resident #2 did not properly seal and the Resident was frustrated because of this. No documents could be provided by DON that the doctor was ever made aware of the failure of the wound vac to seal properly. Thera-gran multivitamin was ordered by a doctor to be given daily on 4-28-13 for weight maintenance and [MEDICAL CONDITION] diagnosed during hospitalization , was not given, and not transcribed onto the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Med pass liquid was ordered 3 times per day on 4-28-13 for weight maintenance and [MEDICAL CONDITION], the supplement was given 4/28/13, 4/29/13, and 4/30/13, only. The supplement was not discontinued by the doctor, and was not given for the month of May, nor was it transcribed onto the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Barrier cream to buttocks was ordered on 4-14-13 and never documented as administered on the treatment administration (TAR) record until 5-1-13 through 5-16-13, when the Resident was hospitalized . Pro- stat protein supplement ordered twice a day 4-21-13 for wound healing was administered until 5-16-13, however, a doctors order to increase the pro-stat to three times a day was received on 4-30-13 at 7:00 PM via a telephone order after the doctor had been to see residents during day shift. The order to increase the Pro-stat supplement was never transcribed onto the MAR for administration, and the Resident continued to receive the supplement twice a day until 5-16-13 when Resident #2 was hospitalized . Observation of wound care was completed 5-23-13 at 9:00 AM with the wound treatment LPN #A, which revealed 4 pressure ulcer areas in various stages of healing on Resident #2 ' s left heel. No infection control breach of practice standards was observed. Resident #2 was briefly interviewed and found to be oriented to person, place, time and situation prior to wound care observation and stated " Yes you can watch her change my dressing if you want to, " the Resident was found to be compliant and agreeable, and talked about " looking forward to being able to leave this room after my infection is gone. " DON and Treatment LPN A were interviewed 5-22-13 at 4:00 PM. One stated wound care record sheets were supposed to be documented on weekly, however, these were not. LPN A stated " I do this assessment and documentation every Monday and Tuesday and update everybody ' s sheets, each time a resident goes out to the hospital, we do a new sheet on readmission. I do all of the treatments Monday through Friday, then the 7a to 3p shift nurse does them on Saturday and Sunday. LPN A stated " there were 4 wounds found on 5-7-13 on his left lateral heel, but I have only been here a little over a month and can not say what happened before that. " When asked why orders were not transcribed correctly, and treatments not completed the DON response was " I will find out. " No further information was submitted at time of exit 5-23-13 at 6:00 PM. The Administrator and DON were made aware of findings at end of day debrief. The investigation revealed no assessment or monitoring prior to the pressure ulcers on the Residents lateral heel being initially found at a stage 3, further, doctor ordered treatments were not administered timely, medications were missed and not correctly administered, and assistive devices ordered by the doctor and the Physical Therapist were not made available to the Resident. 4. For Resident #4 the facility staff failed to assess and treat a pressure ulcer on the right hip. Resident #4 was most recently admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #4's admission minimum data set assessment with an assessment reference date of 11/14/12 coded him with severe cognitive impairment and requiring extensive assistance with his activities of daily living. He was coded with no pressure ulcer areas. During the clinical record review, a physician progress notes [REDACTED]. The progress note read, "Open areas sacrum, right wrist, right hip improving per nurse. Has low air loss mattress." The facility used a form titled "Pressure Ulcer Record" to document and track pressure ulcers. A pressure ulcer record dated 1/2/12 documented that Resident #4 had a stage II wound to the right hip. The size of the wound was documented as 3.3 x 3.9 on the form. There were no other tracking entries made on the form. Upon further review of the clinical record, it was determined that the pressure ulcer record was dated wrong, it should have included the year 2013 rather than 2012. According to the nurse's notes, Resident #4 had been readmitted to the facility on [DATE]. The admission nurse's note dated 1/2/13 documented the right hip wound. The note read "Red open area to right hip measures 3.3 x 3.9." Another nurse's note dated 1/6/13 read "right hip appears to be improving." On 5/22/13 at 6:00 p.m. Resident #4's skin assessment was discussed with the Director of Nursing (DON) and corporate nurse. They stated that weekly skin checks were performed for all residents at the facility. They stated that the weekly skin assessments were kept in the assessment section of the clinical record. The facility used the form titled "Weekly Skin Integrity Checks." This form used check off boxes to describe skin condition. The three check off boxes describing the skin included "clear skin", "new wound", or "wound/ skin condition present." Resident #4 did not have any weekly skin assessments in the assessment section of his clinical record. The facility staff located his skin assessment sheet in a book kept on the unit. According to his skin assessment form, Resident #4's weekly skin check was performed on 1/7/13 and was checked for "wound/skin condition present." His weekly skin integrity check was not performed again until 2/25/13. Resident #4 did go to the hospital in mid January 2013, but returned to the facility on [DATE]. A physician order [REDACTED].