Every finding on record at Wisconsin Dells Health Services

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 9 residents who reside on the memory care unit at the facility.Surveyor observed the microwave and refrigerator in the kitchenette to be unkept. The microwave had food splatters all over the inside of the microwave. The refrigerator had crumbs and food spilled on the inside of the refrigerator.Evidenced by:The facility policy, Microwave Oven, dated, 7/21/22, states in part;.The microwave oven will be kept clean, sanitized, and odor free. The microwave oven interior should be cleaned after each use as needed, and at a minimum, after each meal service.The facility policy, Cleaning Instructions: Refrigerators, dated, 7/21/22, states in part;.The refrigerator will be cleaned thoroughly inside and outside with a detergent and followed by a sanitizer at least once every month, or as needed. Spills and leaks will be cleaned as they occur.On 4/29/26 at 10:35 AM, Surveyor observed the kitchenette in the memory care unit. Surveyor observed the microwave to have food splatters on the inside of the microwave and the refrigerator to have crumbs and spills on the inside.On 4/29/26 at 10:39 AM, Housekeeper F indicated she does not know who is responsible for cleaning the refrigerator. Housekeeper F indicated housekeeping is responsible for cleaning the microwave. Housekeeper F and Surveyor observed the microwave and the refrigerator. Housekeeper indicated the microwave and refrigerator should be kept clean.On 4/29/26 at 10:45 AM, CNA G (Certified Nursing Assistant) indicated she thinks housekeeping is responsible for cleaning the kitchenette.On 4/29/26 at 10:56 AM, DM E (Dietary Manager) indicated he would assume the people who work back in memory care would be responsible for cleaning the refrigerator and microwave. DM E indicated it does look like someone is using the microwave. DM E followed back up with Surveyor and indicated it would be the CNA's responsibility to clean the kitchenette because they are the ones doing the logging of the temperatures on the refrigerator and freezer back in memory care.On 4/29/26 at 12:15 PM, NHA A (Nursing Home Administrator) indicated it is the kitchen staff's responsibility to keep the refrigerator and microwave clean. NHA A indicated there was miscommunication between the different departments. NHA A indicated she would expect the microwave and the refrigerator to be kept clean and when spills or splatters occur staff clean up the mess.The facility failed to maintain a safe and sanitary environment in which food is prepared, stored, and distributed in.

Based on interview and record review, the facility failed to ensure that residents advanced directive was signed by the resident or resident representative for 1 (R28) of 12 residents reviewed for advance directives.R28 did not have an advanced directive signed by their Power of Attorney. Evidenced by:The facility policy, Obtaining and Communicating Code Status, dated, [DATE], states in part;.It is the policy of this facility to adhere to residents rights to direct their code status. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information.R28 was admitted to the facility on [DATE] and R28 has an activated power of attorney in place. R28's Cardiopulmonary Resuscitation/Do Not Resuscitate (CPR/DNR) Preference Form indicates, R28 wishes to be DNR. The document is dated [DATE] and does not have the Power of Attorney's signature.On [DATE] at 1:15 PM, NHA A (Nursing Home Administrator) indicated the facility does not have a signed form from the Power of Attorney (POA) because the POA called in to R28's care conference meeting so the form was completed and verbal agreement was obtained by the POA. NHA A indicated the form should have the POA's signature.The facility failed to ensure that resident's advanced directive was signed by the resident's representative.

Based on observation, interview, and record review the facility did not ensure proper use of bed rails for 1 (R5) of 1 Residents reviewed for bed rails.R5 is care planned for side rails up with cares only. R5 was observed in bed, with side rails raised and no staff present.Evidenced by:The facility's Proper Use of Side Rails policy, dated 9/23/22, states, in part: It is the policy of this facility to utilize a person-centered approach when determining the use of side rails, also known as bed rails.If used, the facility ensures correct installation, use, and maintenance of the rails.5. The use of side rails will be specified in the resident's plan of care.c. Parameters for use shall be clearly defined, such as quarter rails or at certain times. 6. The facility will provide ongoing monitoring and supervision of side rail/bed rail use for effectiveness, assessment of need and determination when or if the side rail/bed rail will be discontinued. Responsibilities are specified as follows: a. Direct care staff will be responsible for care and treatment in accordance with the plan of care.c. The interdisciplinary team will make decisions regarding when the side/bed rail will be used or discontinued, or when to revise the care plan to address any residual effects of the rail.R5 admitted to the facility 12/10/25 and has diagnoses that include: Parkinson's Disease without dyskinesia, without mention of fluctuations (progressive neurodegenerative disorder that affects movement, balance, and muscle control); muscle wasting and atrophy (thinning or loss of muscle tissue); dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (progressive syndrome causing cognitive decline-memory loss, confusion, and language issues)R5's Physician Orders include *Bilateral side rails while resident is in bed, per resident request, to assist with independent mobility and repositioning. FOR CARES ONLY every shift Order Date: 3/6/26.R5's Risk vs (versus) Benefit, dated, 3/6/26, states, in part: .5. Conclusion.Resident understands that the use of bedside rails is not a standard practice and may carry certain risks, including the potential for entrapment, injury, or increased fall risk if used improperly.R5's Side Rail Assessment, dated 3/10/26, states, in part: .I. Risk vs benefits in place. Can use bilateral side rails during cares only and must be put back down when cares are not being performed.R5's Care Plan Report states, in part: Focus *ADL (Activities of Daily Living) self-care deficit as evidenced by: increased weakness and decreased mobility related to: obesity, dementia Date Initiated 12/10/25 .Interventions/Tasks .*Bed Mobility: Assist of 2, Can use bilateral side rails during cares only and must be put back down when cares are not being performed.On 4/29/26 at 9:01 AM, Surveyor observed R5 lying in bed, with side rail up on right upper side of the bed and no staff present. On 4/29/26 at 9:12 AM, Surveyor interviewed CNA D (Certified Nursing Assistant) about side rails. CNA D stated R5 is able to have side rails during cares. Surveyor and CNA D went to R5's room to observe R5's bed. CNA D stated, those rails are not down; they should have only been up while cares were occurring.On 4/30/26 at 7:10 AM, Surveyor observed R5 lying in bed, with side rails up on both right and left side, upper end of bed and no staff present. On 4/30/26 at 7:12 AM, Surveyor interviewed RN C (Registered Nurse) about side rails. RN C stated R5's rails are only up for cares. Surveyor and RN C went to R5's room to observe R5's bed. RN C stated the rails are up and should not be; staff should put them down after cares.On 4/30/26 at 8:51 AM, Surveyor interviewed DON B (Director of Nursing) who stated that R5's rails are for cares only and need to be down prior to staff leaving the room.

Based on observation, interviews, and record review, the facility failed to have an effective pest control program in place to prevent pests and rodents from entering the building through damaged exterior doors which lead into the kitchen. This has the potential to affect the census of 52. Findings include:During an initial inspection of the kitchen, on 08/06/25 at 1:20 PM, the following concerns were observed:1.There were two small black droppings in the dry storage room which appeared to be mouse droppings.2.The exterior door next to the dry storage area was observed to have gaps at the bottom of the door where light from outside was observed providing access to pests and/or rodents. A secondary door in between the exterior and interior of the building, directly in front of the exterior door, was observed to have a gap at the bottom corner of the door.3.The door to the dry storage room was not sealed across the bottom of the door, providing access to pests and/or rodents.4.The exterior door, identified as the door utilized for food service delivery, was observed to have approximately one-inch gaps across the bottom and side of the door and a broken and splintered door frame providing access to pests and/or rodents.The above observations were confirmed by the Dietary Manager (DM) and the Corporate Dietician (CD) at the time of inspection on 08/06/25 at 1:20 PM.On 08/06/25 at 1:30 PM, the DM stated My staff member reported mouse droppings to me last week. I told the Maintenance Director (MD) The MD said they [pest control] will be out this week.Review of the pest control invoices provided by the Administrator, from 02/17/25 to 07/14/25, revealed monthly treatment for exterior bait stations, adding more bait; and treatment for ants in one specific resident room.In an interview on 08/07/25 at 09:35 AM, the MD confirmed that the DM had told him about mouse droppings the previous week and that he said the pest control would be out on Monday, however they did not arrive on Monday.Observation of the exterior doors, with the MD, on 08/07/25 at 9:50 AM confirmed the delivery door frame and door itself had large gaps around the door; the exterior door near the dry storage room had gaps; and the door directly in front of the exterior door had a gap at the bottom corner.The MD confirmed the openings could allow pests and/or rodents into the building stating that he could fix three of the four but would have to order a new food delivery door.On 08/07/25 at 10:27 AM, the Administrator, confirmed by observation and interview, that the identified doors were in need of repair to prevent pests and/or rodents from entering the building.

Based on observation, interview and record review the facility did not maintain a safe and sanitary environment in which food is prepared, stored and distributed. This has the potential to affect all 44 residents who reside in the facility. Surveyor observed the facility's freezer to have frozen condensation attached to the ceiling and fallen pieces of frozen condensation on top of and inside of boxes of unsealed food causing potential for contamination. Surveyor observed a mixer to be stored covered and unclean. Supplements in the medication rooms were not dated. Evidenced by: Example 1 Facility policy, titled Food Storage: Cold Foods, undated, includes: . All . foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of FDA (Food and Drug Administration) Food Code . All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination . On 3/9/25 at 9:04 AM, during initial tour of the facility's kitchen, Surveyor and DM K observed frozen drips suspended from the ceiling in the facility's walk-in freezer. Surveyor and DM K also observed boxes of food to have water damage on them and opened boxes with unsealed food to have shards of ice on and inside of the box. DM K indicated she knocks the drips of ice down with an ice scraper every couple days and it is condensation that builds up and freezes. DM K folded the sides of one of the opened and unsealed boxes out, then Surveyor and DM K observed ice sitting in on the plastic bag inside of the box. DM K indicated she is unsure if the ice got inside of the plastic bag as it is no longer sealed by the manufacturer. DM K indicated she needs to provide a barrier between the frozen dripping and the opened food. DM K indicated she would throw out the egg patties and the potato wedges and other food that could be contaminated by the dislodged ice. On 3/9/25 at 12:19 PM District Manager L indicated the freezer has had this issue for a little while and the facility has tried different things to mitigate the condensation building up. District Manager L indicated there should be a barrier between the food that is no longer sealed by the manufacturer and the frozen dripping condensation to prevent contamination. Example 2 Facility policy, titled Equipment, revised 9/2017, includes: . All food contact equipment will be cleaned and sanitized after every use . On 3/9/25 at 9:04 AM Surveyor and DM K (Dietary Manager) observed a mixer to be stored covered and unclean with dried food particles on it. DM K indicated the mixer should have been cleaned before being covered and stored. On 3/9/25 at 12:19 PM District Manager L indicated equipment should be cleaned before being covered in plastic and stored. 50228 Example 3 On 3/10/25 at 4:29 PM, Surveyor observed an open and used 32 ounce box of Imperial Med Plus 2.0 Vanilla Supplement on top of the 400 hall medication cart. Surveyor asked LPN G (Licensed Practical Nurse) if the supplement has been opened and used. LPN G stated yes. Surveyor asked how long the supplement was good. LPN G stated there should be a date on the supplement indicated when it needs to be used by.

Based on observation, interview and record review the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection, this has the potential to affect the census (44), 1 of 4 residents (R10) wound care observations with hand hygiene concerns, and 1 of 3 residents (R37) medication pass observations with hand hygiene concerns. The facility is not monitoring the temperature of 2 of their 3 water heaters as part of their control measures for Water Management Program. The facilities Policy and Procedure for Pneumococcal Vaccine is not up to date. The facility did not identify an outbreak on the date it started. There was a breach in infection control for R10 when LPN F did not perform appropriate hand hygiene with wound care. There was a breach in infection control for R37 when LPN F did not perform appropriate hand hygiene with medication pass. This is evidenced by: The facility's Hand Hygiene policy, dated 11/2/22, states, in part: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 6. Additional considerations: a The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning (applying) gloves, and immediately after removing gloves. The facility's Clean Dressing Change policy, dated 7/20/22, states, in part: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross contamination.12. Cleanse the wound . 14. Wash hands and put on clean gloves. The facility's Blood Glucose Monitoring policy, dated 8/5/22, states, in part: .4. Perform hand hygiene and don gloves.16. Remove the strip and dispose of it properly.18. Remove and discard gloves and perform hand hygiene. Example 1 Per CDC (Centers for Disease Control and Prevention), 3/15/24 documents, in part: .Cold water guidance: Store and circulate cold water at temperatures below 77 F, although Legionella may grow at temperatures as low as 68 F (20 C). Hot water guidance: Store hot water at temperatures above 140 F (60 C). Ensure hot water in circulation doesn't fall below 120 F (49 C) and recirculate hot water continuously, if possible . The Facilities Water Management Plan dated 2/21/25, documents in part: .Our Hot water system is delivered in a loop. The Water enters the building in the boiler room located adjacent to the kitchen and laundry. There are 3 Hot water heaters in the boiler room that heat the water to 154 degrees .Control Measures and Monitoring, Hot water heater temperatures are checked routinely to ensure they remain with in appropriate parameters .: Logbook Documentation from 2025 includes the following, in part: 12/2/25-2/28/25, Monday-Friday documentation reflects a temperature of 165 degrees in the laundry room where the 1st water heater flows to first. There is not documentation for the other two water heaters. On 3/10/25 at 3:22 PM, Surveyor interviewed MD M (Maintenance Director). Surveyor asked MD M are any of the logged temperatures at the water heaters themselves, MD M said just the laundry one. On 3/11/25 at 3:40 PM, Surveyor interviewed MD M. Surveyor asked MD M can you tell me what temperature the water must heat to kill Legionella, MD M said 130 degrees. Surveyor asked MD M is there any documentation of the water heater temperatures, MD M stated only the laundry water heater, not the 2 for rooms. Of note, 140 degrees is the temperature required to prevent Legionella. On 3/11/25 at 3:55 PM, Surveyor interviewed DON/IP B (Director of Nursing/Infection Preventionist). Surveyor asked DON/IP B should the temperatures of the water heaters be documented as part of the Water Management Plan, DON/IP B said I believe so yes. Example 2 The CDC's Pneumococcal Vaccine Recommendations dated 10/26/24 documents in part: .CDC recommends pneumococcal vaccination for children younger than 5 years and adults [AGE] years or older . The Facilities Policy and Procedure entitled Pneumococcal Vaccine (Series) dated 9/18/24, documents in part: .Clinical guidance for implementing pneumococcal vaccine recommendations for adults aged greater than or equal to [AGE] years .Adults aged greater than or equal to [AGE] years old . On 3/11/25 at 3:55 PM, Surveyor interviewed DON/IP B. Surveyor asked DON/IP B if she was aware of the current guidance for pneumococcal vaccines, DON/IP B stated she was not aware of any changes since the addition of the PCV21, PCV 20, and PCV15 (different versions of pneumococcal vaccine). Example 3 According to CDC guidelines and Wisconsin's Department of Health Policy and Procedures date 2/22/23, documents in part: .Acute onset of vomiting and/or diarrhea (3 or more loose stools in 24-hour period) in a resident or staff member and whose symptoms have no other apparent cause . The Facilities Policy and Procedure entitled Infection Outbreak Response and Investigation dated 2/21/25 documents in part: .1. Prompt recognition of outbreak .ii. A sudden cluster of infections on a unit or during a short period of time (i.e. three or more cases) . Per the Facilities timeline they identified the Norovirus outbreak as beginning on 1/29/25. January 2025 Norovirus Outbreak Timeline documents the following in part: 1/27/25: 1 resident (R344) on 100 hall with loose stools, placed on contact precautions. 1/28/25: CNA called in with GI (gastrointestinal) upset. This CNA worked 1/27/25 on the 400 hall. Stool sample collected for R344 which was negative for C. difficile (inflammation of the colon caused by the bacteria Clostridium difficile). 1 resident (R41) on 100 hall reports multiple emesis but believes he ate something that didn't agree with him when he was out to eat, placed on contact precautions. 2 residents (R345 and R27) on 400 hall during rounds noted to have loose stools and emesis (R345 with loose stools and emesis) (R27 with emesis), both placed on contact precautions. 1/29/25: Facility called outbreak. Of note, during review of outbreak, the Facility actually had outbreak that started on 1/28/25. On 3/11/25 at 3:55 PM, Surveyor interviewed DON/IP B. Surveyor asked DON/IP B how did you determine when to call the symptoms/issues an outbreak, DON/IP B said when 3 or more people on same hall and/or staff had it. Surveyor asked DON/IP B if the outbreak should have been noted on 1/28/25, DON/IP B stated yes. 50228 Example 4 On 3/10/25 at 11:20 AM, Surveyor observed LPN F (Licensed Practical Nurse) perform wound care for R10. DON/IP B (Director of Nursing/Infection Preventionist) was observing and assisting with positioning of R10 during the dressing change. LPN F removed cleansing packing from R10's wound, then LPN F removed gloves and applied a new set of gloves without performing hand hygiene. LPN F prepared and applied the primary dressing to R10's wound bed, then LPN F removed gloves and applied a new set of gloves without performing hand hygiene. LPN F prepared and applied the secondary dressing. On 3/10/24 at 11:27 AM, Surveyor interviewed LPN F and asked when hand hygiene is needed for wound care. LPN F stated when going into resident room/prior to starting treatment and when done with treatment. Surveyor asked if gloves are contaminated after pulling packing from a resident's wound. LPN F stated yes. Surveyor asked if hand hygiene should be completed with change of gloves. LPN F stated yes. On 3/10/24 at 2:50 PM, Surveyor interviewed DON/IP B (Director of Nursing/Infection Preventionist) and asked when hand hygiene is needed for wound care. DON/IP B stated before treatment, after removing dirty dressing, anytime you go from dirty to clean, and at the end of the treatment. DON/IP B stated that DON/IP B would have expected LPN F to perform hand hygiene after removal of gloves, prior to application of new gloves. Example 5 On 3/10/25 at 7:57 AM, Surveyor observed LPN F performing medication administration for R37. LPN F gathered oral medications in a medication cup, medication pens for subcutaneous (SQ-under the skin) administration, and a blood sugar test kit and went to R37's bedside. LPN F donned gloves, with no hand hygiene, and performed a finger-stick blood sugar test. Following the test, LPN F touched the following with contaminated gloves: oral medication cup, the bedside table, and the medication pens. Without changing gloves and performing hand hygiene, LPN F administered the SQ injections. LPN F gathered the medication pens, placed them into the blood sugar test kit, and then removed gloves. LPN F then touched the following items prior to performing hand hygiene: resident bed linens, bed remote control, and bedroom door handle. Surveyor asked R37 about infection control with medication administration. LPN F stated that hands should have been cleansed prior to applying gloves and after administration of SQ medication. Surveyor asked if hand hygiene should be performed after performing a blood sugar test, prior to touching resident items. LPN F stated the items belonged to the same resident. Surveyor asked if gloves are contaminated after performing a blood sugar test. LPN F stated yes. Surveyor asked if resident items like a medication cup, bedside table and medication pens should be touched with contaminated gloves. LPN F stated no. Surveyor asked if hand hygiene should be performed after performing a blood sugar test. LPN F stated yes. Surveyor asked if hand hygiene should be performed after SQ administration of medications. LPN F stated yes. On 3/10/24 at 2:50 PM, Surveyor interviewed DON/IP B and asked when hand hygiene is expected with blood sugar testing. DON/IP B stated before and after the test. Surveyor asked if removal of gloves and hand hygiene would be expected after the blood sugar test, prior to any other task/touching resident objects. DON/IP B stated yes. Surveyor asked if DON/IP B would expect staff to remove gloves and perform hand hygiene after SQ administration of medications. DON/IP B stated yes.

Based on observation and interview the facility did not ensure drugs and biologicals are labeled in accordance with currently accepted professional standards 1 of 1 medication carts observed. The medication cart on the 400 hall had two tubes of open and used medicated ointment with no resident names. Evidenced by: Surveyor observed an open, used tube of muscle rub and an open, used tube of hydrocortisone acetate 1% cream in the drawer of the 400 hall medication cart. Surveyor asked LPN G if the tubes were both open and used. LPN G stated yes. Surveyor asked LPN G what resident the tubes were for. LPN G stated no idea, the tubes are not labeled. On 3/11/25 at 10:35 AM, Surveyor interviewed DON/IP B (Director of Nursing/Infection Preventionist) Surveyor asked how long nutritional supplements are good after being opened. DON/IP B stated 3 days. Surveyor asked how staff would know if a supplement is good if there is no use by date. DON/IP B stated there should be a date. Surveyor asked if tubes of ointment are expected to be labeled with a resident's name. DON/IP B stated yes.

Based on observation, interview, and record review, the facility did not ensure that the residents environment remained free of accidents and hazards for 1 of 3 (R25) reviewed for falls and 1 of 1 (R7) reviewed for accidents and hazards. R25 did not have fall interventions in place after 2 falls. Surveyor observed R7's motorized wheelchair charging in the hallway and not behind a fire safe door. This is evidenced by: The facility's policy titled Fall Prevention and Management Guidelines, revised 7/18/24, states in part: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury. Provide interventions that address unique risk factors measured by the risk assessment tool. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions will be monitored for effectiveness. The plan of care will be revised as needed and should be communicated to the staff, resident and resident's family/responsible party. When any resident experiences a fall, the facility will: .review the resident's care plan and update with any new interventions put in place to try to prevent additional falls. Review ach fall/fall investigation during the next morning meeting/clinical meeting with the interdisciplinary Team (IDT). Actions of the IDT may include: .Review of fall risk care plan and any updates to plan of care completed post-fall. Education of staff as to any care plan revisions. The facility's policy titled Comprehensive Care Plan, revised 9/23/22, states in part: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Resident specific interventions that reflect the resident's needs and preferences . Staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the intervention, initially and when changes are made. Example 1 R7 admitted to the facility on [DATE]. He relies on a motorized wheelchair for mobility. On 3/9/25 at 10:51 AM Surveyor viewed R7's motorized wheelchair charging outside of his doorway, in the hallway. On 3/9/25 at 11:10 AM CNA I (Certified Nursing Assistant) indicated she was told by a member of the facility's corporation that she should charge the wheelchair there. CNA I indicated she has not received education on storing motorized wheelchairs. On 3/9/25 LPN F (Licensed Practical Nurse) indicated she was unaware that motorized wheelchairs should be charged behind a fire safe door. LPN F indicated she did not receive education regarding where to store motorized wheelchairs. On 3/9/25 at 11:15 AM DON B (Director of Nursing) indicated she was unsure if motorized wheelchairs are ok to charge in the hallway. On 3/9/25 at 12:00 PM NHA A (Nursing Home Administrator) indicated motorized wheelchairs need to charge behind a fire safe door. 49436 Example 2 R25 admitted to the facility on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) and unsteadiness on feet. R25's Brief Interview for Mental Status (BIMS) on 12/26/24 has a score of 5, indicating R25 has severe cognitive impairment. R25's Minimum Data Set (MDS) comprehensive admission assessment indicates R25 is at risk for falls and falls would be added to R25's care plan. R25's Mobility/Fall Risk assessment dated [DATE] indicates R25 is at risk for falls. R25 had a fall on 10/8/24. R25's fall reports for 10/8/24 states: Intervention: PT (Physical Therapy) to assess walker and brakes, provide education on brakes and assess for other risks. R25's IDT (Interdisciplinary Team) Clinical Review note states in part: Root cause analysis: .Brake was reported to not be locked on walker. R25's Post Event Observation dated 10/9/24 states in part: Reminders to lock both breaks on walker when in use. R25 had a fall on 2/12/25. R25's fall report states in part: IDT (Interdisciplinary Team) team met to discuss resident. Resident is forgetful but is independent in her room . resident to keep walker by her bed to remind her more to use the walker with ambulating or transferring. R25's Nurses note on 2/12/25 at 9:25 PM states in part: Staff to remind resident to use walker all the time. R25's Post Fall assessment dated [DATE] states in part: New interventions: Staff to remind resident to use her walker all the time. R25's CNA's (Certified Nursing Assistant) Kardex, printed 3/7/25, includes the following: Safety: Ensure that the Resident is wearing appropriate footwear: Gripper socks or shoes on at all times when up OOB (Out of Bed). Place call light or communication device within reach. R25's Comprehensive Care Plan, printed 3/11/25, includes the following: Focus: Resident is at risk for falls r/t (Related to) cognition - unaware of safety needs. Deconditioning/weakness, medication use. Date initiated: 7/5/22 Goal: Fall related injuries will be minimized through care plan review date. Interventions/Tasks: Reminders to lock brakes on walker, initiated 3/11/25. Resident to keep walker by her bed to remind her more to use the walker with ambulating and transferring, initiated 3/11/25. Signs in room for reminder to use walker, initiated 3/11/25. Of note, the 3/11/25 interventions were added to the care plan after Surveyor made DON B (Director of Nursing) aware that R25's fall care plan had not been updated since 2022. On 3/11/25 at 8:50 AM, Surveyor interviewed CNA N (Certified Nursing Assistant) regarding interventions for falls. CNA N indicated any interventions for falls would be on the Kardex. CNA N reviewed R25's Kardex with Surveyor. CNA N indicated the only interventions for R25 was to ensure R25 is wearing proper footwear and the call light is in reach. Surveyor asked CNA N if there were any other interventions for R25 and CNA N indicated there were not. On 3/11/25 at 8:55 AM, Surveyor interviewed RN C (Registered Nurse) regarding interventions for falls. RN C indicated he would review the resident's physician orders for fall interventions. RN C also indicated there is a sign on the outside of the room for residents at risk for falls. RN C indicated R25 has an alarm mat on the floor when she is in bed and her bed is in the low position. On 3/11/25 at 9:00 AM, Surveyor observed R25's room. R25 did not have an alarm mat in her room. On 3/11/25 at 9:45 AM, Surveyor interviewed DON B (Director of Nursing) regarding fall interventions. DON B indicated if a resident falls and new interventions are put in place, the resident's care plan would be updated with the new interventions and the interventions would be communicated to staff. DON B indicated the Kardex would also be updated with the new interventions. DON B indicated the facility does not place signs outside of the resident's room indicating they are a fall risk. DON B indicated the facility does not put fall interventions in the physician orders. DON B indicated the primary place to look for fall interventions would be the resident's care plan. DON B indicated R25's care plan should have been updated with the new interventions and was not.

Based on observation, interview, and record review, the facility did not ensure residents who are fed and receive medication by G-tube (Gastrostomy tube, a thin flexible tube inserted through a small incision in the abdomen and into the stomach, used to provide nutrition and fluids) receive the appropriate treatment and services. This affects 1 of 2 residents (R22) reviewed for tube feedings. The facility did not properly check placement of R22's G-tube prior to administering tube feeding. This is evidenced by: The facility's policy titled Verifying Placement of Tube Feeding, revised 8/10/22, states in part: It is the practice of this facility to ensure proper placement of feeding tubes prior to beginning a feeding, flushing the tube, or before administering medications via feeding tube. Before beginning a feeding, flushing the tube, or administering a medication via the feeding tube, proper placement and functioning will be verified. Verify tube placement: For gastrostomy tubes, check that the enteral retention device is properly approximated to the abdominal wall by gently tugging on the tube and taking note of the marking on the tube. Measure length of tube from insertion site to tip upon new admission to facility or with a new/change in the tube and record the length. Check and record the length of the tube prior to feeing as per facility policy. On 3/10/25 at 8:53 AM, Surveyor observed RN C (Registered Nurse) administer R22's tube feeding. RN C stated I had checked placement this morning, We check with air. RN C indicated he was not going to check with air at this time because R22 does not like air being pushed into his stomach. RN C proceeded to use his stethoscope to listen to R22's abdomen while flushing the G-tube with 60 ml of water. Of note, RN C did not verify placement prior to using R22's G-tube. On 3/11/25 at 8:13 AM, Surveyor interviewed RN E regarding verifying G-tube placement. RN E indicated she instills air and listens for bubbles to ensure the G-tube is correctly placed. On 3/11/15 at 8:15 AM, Surveyor interviewed LPN D (Licensed Practical Nurse) regarding verifying G-tube placement. LPN D indicated she uses a little air and listens for the bubbles and will also check residual by aspirating any stomach contents. On 3/11/25 at 8:48 AM, Surveyor interviewed DON B (Director of Nursing) regarding verifying G-tube placement. DON B indicated staff can verify placement by instilling air, watching the site, and assess that the resident is not in pain or discomfort. DON B also indicated staff can aspirate and see if there is residual. Of note, the facility is not following current standards of practice to verify G-tube placement.

Based on observation, interview, and record review the facility did not ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice for 1 of 2 residents (R39) reviewed for oxygen. R39 did not have oxygen tubing changed on a weekly basis. Evidenced by: R39 admitted to the facility on [DATE] and has diagnoses that include, in part: pneumonia due to other specified infectious organisms (infection that causes inflammation of the lungs); chronic obstructive pulmonary disease (a group of lung diseases that cause ongoing breathing problems); acute on chronic systolic congestive heart failure (a condition that causes the heart to pump less effectively causing shortness of breath, weakness and fatigue. R39's Minimum Data Set (MDS), dated [DATE], indicates R39's Brief Interview of Mental Status (BIMS) is a 15, indicating that R39 is cognitively intact. R39's Physician Orders state, in part: *Oxygen at 1-4 L/min (liters per minute) via nasal cannula to keep sats (oxygen saturation level) at or above 88% for respiratory distress, as needed Start date 11/20/24 *Change oxygen equipment weekly Tuesday. Start date 3/4/25 Important to note: Surveyor requested oxygen protocol/policy. The facility's Oxygen Concentrator policy, dated 6/27/22 was provided. The policy does not include instruction on when to change oxygen tubing. On 3/9/25 at 9:49 AM, Surveyor observed R39 wearing the nasal cannula with oxygen concentrator set to 4L/min. No labeling with date was noted on oxygen tubing. On 3/11/25 at 10:17 AM, Surveyor interviewed LPN C (Licensed Practical Nurse) and asked about protocols for residents on oxygen. LPN C indicated that tubing is to be labeled with date and changed weekly. On 3/11/24 at 10:24 AM, Surveyor observed R39 wearing the oxygen nasal cannula and no labeling with date noted on the oxygen tubing. At that time, Surveyor asked CNA H (Certified Nursing Assistant) if there was labeling with date on R39's oxygen tubing. CNA H checked the tubing and stated no. On 3/11/25 at 10:35 AM, Surveyor interviewed DON/IP B (Director of Nursing/Infection Preventionist) and asked about protocols for residents using oxygen. DON/IP B indicated that tubing is to be changed weekly, labeled with the date of change, and documented on the MAR/TAR (medication administration record / treatment administration record). Surveyor asked if this is not documented on the MAR/TAR, do you know if it has been done. DON/IP B stated no. Surveyor asked if it is known when tubing was changed if the tubing is not labeled with a date. DON/IP B stated no. Surveyor reviewed with DON/IP B R39's order for change of oxygen equipment weekly with start date of 3/4/25 and no notation of order prior to this date. Surveyor asked DON/IP B if the facility would be expected to change R39's tubing weekly, label tubing with date of change, and document this change in the MAR/TAR. DON/IP B stated yes.

Based on observation, interview, and record review the facility did not ensure that a resident who requires dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 2 residents (R39 and R33) reviewed for dialysis. R39 is receiving dialysis services. R39's care plan does not indicate how to handle an emergency situation with R 39's dialysis port and staff were not able to appropriately verbalize how to handle an emergency situation. R33 is receiving dialysis services. R33's care plan does not indicate how to handle an emergency situation with R33's dialysis port and staff were not able to appropriately verbalize how to handle an emergency situation. Evidenced by: The facility's Hemodialysis policy, dated 9/10/23, states, in part: The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing assessment and oversight of the resident before and after dialysis treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices. Important to note: the policy does not indicate interventions for implementation in case of a complication/emergency. Example 1 R39 admitted to the facility on [DATE] and has diagnoses that include end stage renal disease (a condition that occurs when the kidneys are no longer able to function adequately to maintain health and survival) and dependence on renal dialysis (relying on a procedure to filter blood and remove waste products when the kidneys are unable to do so). R39's physician orders state, in part: Dialysis scheduled for Mondays, Wednesdays, and Fridays . Order date 11/21/24. R39's care plan states, in part: Renal insufficiencies .date initiated: 3/9/25. Check access site for lack of thrill/bruit (sound and feeling of adequate blood flow), evidence of infection, swelling, or excessive bleeding per facility guidelines. Report abnormalities to MD. Dated 3/9/25. Dialysis (location) Monday-Wednesday-Friday . Dated 3/9/25. Report any dialysis catheter and site evidence of infection, dislodgement, and leaking. Dated 3/9/25. Important to note: R39's care plan does not include interventions related complications/emergencies with catheter site. On 3/10/25 at 10:59 AM, Surveyor interviewed CNA I (certified nursing assistant) and asked what would be done if a resident was found bleeding from their dialysis port. CNA I stated the nurse would need to be updated through use of the phone in the hallway. Important to note that CNA I indicated that the resident would need to be left in order to access the phone. On 3/10/25 at 11:13 AM, Surveyor interviewed CNA J and asked what would be done if a resident was found bleeding from their dialysis port. CNA J stated that the nurse would need to be updated. CNA J stated that CNA J would peek into the hall and ask for the nurse, without breaking resident privacy, or would leave the room and use the hall phone to page the nurse. On 3/10/25 at 11:30 AM, Surveyor interviewed LPN F (licensed practical nurse) and asked what would be done if a resident was found bleeding from their dialysis port. LPN F stated that the RN (registered nurse) would need to be alerted. LPN F indicated that the resident would be left while the staff accessed the phone in the hallway. LPN F indicated that after alerting the RN, LPN F would see how bad the bleeding was and put something in place to stop the bleeding. LPN F stated that a dry wipe in the room could be used or could ask someone to bring in gauze. On 3/10/25 at 4:00 PM, Surveyor interviewed DON/IP B (Director of Nursing/Infection Preventionist) and asked what staff is expected to do if a resident is found bleeding from their dialysis port. DON/IP B stated the nurse is to be alerted and there is a bag in the resident's room on their cork board (emergency kit) to help stop bleeding. Surveyor asked if anyone could use the emergency kit. DON/IP B stated yes. Surveyor asked how the nurse would be alerted. DON/IP B stated staff is to stay with the resident, activate the call light, and yell for the nurse. Surveyor asked if emergency procedure is part of the resident care plan and facility policy. DON/IP B reviewed care plan and policy and indicated that they did not say what to do in case of an emergency. Surveyor asked if the resident care plan and facility policy should say what to do in case of an emergency. DON/IP B stated yes. On 3/10/25 at 4:17 PM, Surveyor observed R39's room with DON/IP B. No emergency kit noted on the cork board. Surveyor asked if there should be an emergency kit on the cork board. DON/IP B stated yes. 38882 Example 2 R33 admitted to the facility on [DATE] with the following diagnoses: end stage renal disease and dependence on renal dialysis. R33's Comprehensive Care Plan, initiated 7/29/24, includes Renal insufficiencies . 7/29/24 Check access site for lack of bruit and thrill, evidence of infection/swelling/ or excessive bleeding per facility guidelines. Report abnormalities to R33's Medical Doctor. 7/29/24 Confer with Medical Doctor and/or dialysis treatment center regarding changes in medication administration times/dosage pre-dialysis as needed. 7/29/24 Coordinate dialysis care with dialysis treatment center . Monday, Wednesday, Friday . Send midrin to dialysis with container of applesauce and plastic spoon. Make sure he has blanket and pillow, coat and hat sent with also. Needs to be high back wheelchair with foot pedals, mesh Hoyer sling and Roho cushion under him . 7/29/24 Diet per Medical Doctor orders . 7/29/24 Encourage rest after dialysis treatments . 7/29/24 Hemp dialysis (location- Named Dialysis Center 3 times weekly on Monday, Wednesday, Friday 11:00 AM chair time, 10:45 AM pick up). Obtain labs as ordered and notify Medical Doctor of results. 7/29/24 Record dry weights and report significant changes as ordered . 7/29/24 Report any dialysis catheter and site evidence of infection, dislodgement, and leaking . It is important to note R33's Comprehensive Care Plan does not include goals or interventions related to emergency procedures. On 3/10/25 at 10:54 AM CNA I (Certified Nursing Assistant) indicated if she found R33 bleeding out of his dialysis site she would exit the room to retrieve the nurse. CNA I indicated she would go find the nurse or use the phone hanging halfway down the hallway to call for the nurse. It is important to note CNA I would not apply pressure and would leave R33 alone if R33 had bleeding from dialysis site. On 3/10/25 at 3:22 PM LPN G (Licensed Practicing Nurse) indicated there should be an emergency dialysis kit in R33's room, but she was not able to locate the kit for Surveyor. On 3/11/25 at 11:27 AM NHA A (Nursing Home Administrator) indicated there should be an emergency kit in the rooms of residents who have dialysis and on 3/10/25 she added one to R33's room suspended from his cork board. NHA A indicated the resident's care plan, and the facility policy should contain emergency procedures for all staff related to dialysis care.

Based on interview and record review, the facility did not ensure the effective monitoring of psychotropic medications for 1 of 5 residents (R35) reviewed for unnecessary medications. R35 was started on Trazadone (antidepressant) for sleep. R35's comprehensive care plan and medical record does not contain sleep monitoring or tracking to assess the effectiveness of this medication. This is evidenced by: The facility policy entitled, Psychotropic Medications, dated 10/24/2022, states in part: .4. The indications for use of any psychotropic drug will be documented in the medical record .b. For Psychotropic drugs that are initiated after admission to the facility, documentation shall include the specific condition as diagnosed by the physician .ii. Non-pharmacological interventions that have been attempted, and target symptoms for monitoring shall be included in the documentation .13. The resident's response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record. R35 was admitted to the facility on [DATE] with diagnoses that include, in part: unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), type 2 diabetes mellitus, unspecified mood affective disorder (medical condition that can cause intense and persistent changes in mood, energy, and behavior), insomnia (sleep disorder characterized by difficulty falling asleep or staying asleep), hypertension (high blood pressure), and atherosclerotic heart disease (the build-up of fats, cholesterol, and other substances in and on the artery walls). R35's Quarterly Minimum Data Set (MDS) dated [DATE] indicates a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating R35's cognition is moderately impaired. R35's physician orders include, in part: Trazadone 150mg give 1 tablet by mouth at bedtime for sleep 2100 (9:00 PM), order date and start date of 3/6/25. (R35 was previously receiving Trazadone at bedtime 1900 (7:00 PM), 150mg 1 tablet, start date of 12/16/24, discontinue date of 3/6/25). On 3/11/25 at 1:30pm, Surveyor reviewed R35's comprehensive care plan dated 2/27/25. There is no focus area, goal, or interventions for sleep, does not indicate monitoring or tracking for sleep, does not indicate use of an antidepressant to aid with sleep. On 3/11/25 at 1:45 PM, Surveyor reviewed R35's Medication Administration Record (MAR) for February and March 2025. Trazadone is signed out as ordered. On 3/11/25 at 2:09 PM, Surveyor requested sleep monitoring and tracking documentation for R35 as Surveyor was unable to locate sleep documentation in R35's electronic health record. On 3/11/25 at 2:32 PM, NHA A (Nursing Home Administrator) told Surveyor she couldn't find any sleep documentation for R35. On 3/11/25 at 3:09 PM, Surveyor interviewed NHA A and asked if she would expect residents receiving Trazadone for sleep to have a comprehensive sleep assessment, a care plan including sleep, and implement sleep tracking and monitoring. NHA A stated yes.

Based on interview and record review, the facility failed to ensure staff were following the plan of care, failed to complete a root cause analysis, and failed to ensure fall interventions were functioning properly for 1 of 3 residents (R3) reviewed for falls. R3 has severe cognitive impairment. R3's care plan states R3 is assist of 1 for transfer resident was observed transferring and ambulating independently. Staff were not aware R3 required assistance with transfer and ambulation and did not know a fall intervention was not functioning. Evidenced by: The Facility Fall Prevention and Management Guidelines revised 7/18/24, includes, in part: each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury. 3. The nurse will initiate interventions to help prevent falls on the resident's baseline care plan. 6. Each residents risk factors and environmental hazards will be evaluated when developing the residents comprehensive care plan. 8. Review each fall/fall investigation during the next morning meeting/clinical meeting with the IDT (interdisciplinary team). Action of the IDT may include: a. Review of the investigation and determination of potential RCA of fall. b. Review of fall risk care plan and any updates to plan of care completed post fall. c. Additional revisions to the plan of care including any physical adaptation to room, furniture, wheelchair, and /or assistive devices. d. Education of staff as to any care plan revisions. e. Scheduling resident/family conferences. Note: If after the IDT review, it is determined that existing interventions in the care plan are most appropriate, document rationale and describe any additional actions taken. R3 admitted to the facility 4/14/23 with diagnoses including Alzheimer's Disease, weakness, gait disorder and CKD-3 (chronic kidney disease). R3's quarterly Minimum Data Set (MDS), dated [DATE], indicated R3's cognition is severely impaired with a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Section GG indicates R3 requires partial/moderate assistance with toileting, sit to stand is independent, toilet transfer independent, chair bed to chair independent. Walk 10 ft supervision or touch assistance, walk 50 ft supervision or touch assistance with verbal cues or touching/steadying assistance, walk 150 independent. R3 is incapacitated and has an activated power of attorney for healthcare. R3's Assistance for Daily Living (ADL) care plan dated 4/14/23 states in part; ADL self-care deficit r/t (related to) deconditioning/weakness. Interventions: Toileting Assist of 1 stand/pivot and ambulate to bathroom with 4 ww (wheeled walker) revised 4/17/23. Transfer with assist of 1 stand/pivot 4 ww revised 5/5/23. Of note, this is not consistent with R3's most recent MDS. It should be noted besides the mention of assisting to ambulate to the bathroom R3's care plan does not address ambulation in room or hallway. R3's Fall care plan dated revised on 5/2/23 states in part; at risk for fall d/t (due to) deconditioning/weakness, medication use. Resident will self-transfer and attempt to ambulate in halls without waiting for staff assist d/t her cognitive status. Resident likes to rummage with items. Resident frequently forgets to use her 4 WW with ambulation. Goal: Minimize risk for injury r/t falls. Minimize risk for falls. Interventions include anti-skid strips on floor on both sides of bed, initiated 9/11/23, bathroom door alarm, initiated 8/14/23, Bed in low position with resident in bed initiated 4/14/23, bilateral grab bars on bed for positioning/transfers initiated 5/2/23, during periods of restlessness, offer resident items she may rummage through such as a purse, or laundry to fold. Provide with other activity items of interest as needed, initiated 5/4/23. Encourage resident son to assist resident out of car when out of facility near a no curb area, if possible, initiated 9/16/23. Encourage to transfer and change positions slowly, initiated 4/14/23. Ensure that resident is wearing appropriate footwear-gripper socks or shoes on at all times when up OOB (out of bed), initiated 4/18/23. Have commonly used articles and call light within easy reach at all times date initiated, 4/18/23. Offer diversional activity with resident is noted to be rummaging date initiated 5/22/23. Offer to close residents curtains in room after she eats supper date initiated 6/13/23. Offer to walk with resident or provide diversional activity prior to supper date initiated 6/13/23. Reinforce need to call for assistance date initiated 4/14/23. Reinforce wheelchair safety as needed such as locking the brakes date initiated, 4/14/23. Report development of pain, bruises, change in mental status, ADL functioning, appetite, or neurological status post fall date initiate 4/14/23. Sign in room and on walker to remind her to use it at all times when ambulating date initiated 6/25/23. [NAME] at bedside date initiated 6/26/23. Wheel chair removed from room as resident no longer uses this for mobility and stationary chair replaced in room in spot where resident enjoys sitting frequently during the day date initiated 8/29/23. R3's Certified Nursing Assistant (CNA) Kardex (plan of care) as of 8/31/24 states in part; locomotion wheelchair, 4ww 1 AS (1 assist), remind to use walker, anti-skid strips on floor on both sides of bed, bilateral grab bars, bathroom door alarm, proper footwear gripper socks/shoes when out of bed, call light w/i easy reach at all times, sign in room and on resident walker to remind her to use it at all times when ambulating, stationary chair replaced in room in spot where resident enjoys sitting frequently during the day, walker at bedside, transfer with assist of 1 with gait belt and 4 ww, toilet assist of 1 stand/pivot and ambulation to bathroom with 4 ww. Of note, R3's Kardex and plan of care are not consistent with R3's most recent MDS. R3 has a Post Fall assessment dated [DATE] with a lock time of 22:18 (10:18 PM). Category: Low Risk, Score: 5.0 Triggering: Un-witnessed fall 6/13/24. Date and Time: 6/13/24 at 21:00 (9:00 PM). Current Fall Information: Ask resident following question immediately after the fall: why do you think you fell ? Answer: getting ready for bed. What time was resident last seen: 20:55 (8:55 PM). Who was the staff member that last saw the Resident? Answer (CNA Name). What position was the resident in when last seen? Sitting in chair. What footwear was the resident wearing? Gripper Socks. What was the resident doing at the time of the current fall? Walking. Location of current fall? Bedroom. What assistive devices were in use? Walker. Mental/Behavior Status: Mental Status Prior to current fall? Confused/disoriented most of the time. Mental Status after the fall? Confused/disoriented most of the time. Environment? Call light in reach. Care Plan: List new immediate interventions. Keep walker at her side. Education provided to the following: Resident. Of note, there is an intervention to keep walker at bedside that was initiated on 6/26/23. There is no intervention stating to keep walker at her bedside on R3's care plan after this fall, R3 was last seen in her chair. R3 stated, she was getting ready for bed. According to R3's plan of care R3 needs assistance of 1 to transfer, ambulate. The fall assessment states education was provided to R3; R3 has significant cognitive impairment with a BIMS of 3 and it is unlikely R3 would retain any education. Progress notes date 6/13/24 at 21:42 (9:42 PM) state in part; resident found on floor in her room at 21:00 (9:00 PM) history of falls. Assessed by RN and no injuries. Continue to remind to use walker. A Post Fall assessment dated [DATE] with a lock time of 14:59 (2:59 PM). Category: Low Risk, Score: 7.0 Triggering: Witnessed fall 7/9/24. Date and Time: 7/9/24 at 14:59 (2:59 PM). Fall History: Last 1 month (30 days) 1-2 times. Last 3 months (90 days) 1-2 times. Last 6 months (180 days) 1-2 times. Current Fall Information: List any life safety measures in place prior to this current fall: Shoes, walker with reminders to use, call light within reach. Ask resident following question immediately after the fall: why do you think you fell ? Answer: Caught up in my feet. Resident was going to her room. What time was resident last seen: 13:05 (1:05 PM). Who was the staff member that last saw the Resident? Answer (CNA Name). What position was the resident in when last seen? Walking with her walker. What footwear was the resident wearing? Shoes. What was the resident doing at the time of the current fall? Walking. Location of current fall? Hallway. What assistive devices were in use? Walker. Mental/Behavior Status: Mental Status Prior to current fall? Confused/disoriented most of the time. Mental Status after the fall? Confused some of the time. Care Plan: List new immediate interventions. Don't shuffle feet when walking. Education provided to the following: Resident. We will remind (R3's name) to pick up her feet when walking. Progress notes dated 7/9/24 at 15:02 (3:02 PM) SBAR (Situation, Background, Assessment, Response) Nurse heard overhead page and went to 300 hall. Resident was on floor on her stomach with her arms tucked into her chest. Resident stated she got caught up in her feet. Assessed for injuries, vital signs taken, staff rolled onto sling and used Hoyer to lift into bed. LUE (left upper extremity) no range without pain. Recommendation: Pick up feet when walking. Late entry for 7/9/24 16:26 (4:26 PM) unwitnessed fall with injury. Note from Assistant Director of Nursing. History of falls became weak tripped over feet. Resident was using her 4 ww. Sent to ER (emergency room ) d/t pain in L shoulder. Had dislocated shoulder which ER fixed and requiring to wear a sling times 7 days. New Intervention: To remind resident if feeling weak to not ambulate independently and wait for staff member to help. Of note, R3's Physical Therapy notes indicate R3 was independent with transfers and walking 10 feet at the time of the fall however the facility did not update R3 physical care plan to indicate this change. Additionally, remind resident to pick up feet was not placed on the care plan and R3 is likely not able to remember to pick up feet d/t her severe cognitive impairment. R3 is currently working with therapy on strengthening and gait training. R3 has cognitive impairment and is unlikely to remember to ask for assistance. Progress notes 7/9/24 at 20:17 (8:17 PM) resident has been at hospital most of shift d/t unwitnessed fall earlier. Called @ 1900 (7:00 PM) and advised resident has been released and being sent back. Ambulance arrived at 2000 (8:00 PM) and was in good spirts. Sling to L shoulder which she tries to remove. Continue use of APAP (acetaminophen) or ibuprofen and ice area. Progress notes dated 7/26/24 at 18:51 (6:51 PM) SBAR resident sitting in chair watching T.V. at approximately 1725 (5:25 PM), at 1735 (5:35 PM) staff heard resident calling for help. Resident found on floor with walker parked next to stand under T.V. and resident lying on floor with feet (gripper socks) near walker and head towards center of room resting face first on ground. Unwitnessed fall, resident was trying to get up on own power and staff requested that nurse check her our first. Vital signs within normal limits, full ROM noted to all extremities (of note R3 has a dislocated shoulder and does not have full range of motion of the left shoulder), no bruising, deformities noted at this time. Resident laughing and denying pain. Refused help up with Hoyer just wanted to get up. Staff assisted to sitting position and resident and staff assisted for safety. Signage placed on walker within reach of resident. Monitor frequently. Of note, there is no RCA for this fall. On 9/3/24 at 8:40 AM Surveyor noted a sign on R3's bulletin board, bedside table and walker that stated take your walker. Surveyor noted fall anti slip strips on bilateral sides of bed, a door alarm on the bathroom door and call light in recliner, not within R3's reach. Surveyor asked R3 if she could look for a CNA care card in R3's closet. Surveyor reviewed the care card/Kardex and noted the following: as of 8/31/24, locomotion wheelchair, 4ww 1 AS (1 assist), remind to use walker, anti-skid strips on floor on both sides of bed, bilateral grab bars, bathroom door alarm, proper footwear gripper socks/shoes when out of bed, call light w/i easy reach at all times, sign in room and on resident walker to remind her to use it at all times when ambulating, stationary chair replaced in room in spot where resident enjoys sitting frequently during the day, walker at bedside, transfer with assist of 1 with gait belt and 4 ww, toilet assist of 1 stand/pivot and ambulation to bathroom with 4 ww. Of note, these are the exact interventions from R3's care plan dated 4/13/23. On 9/4/24 at 9:00 AM, Surveyor saw R3 stand up independently in her room, grab her walker and walk to the bathroom. When R3 opened the bathroom door, the door did not alarm. On 9/4/24 at 9:05 AM, Surveyor interviewed CNA C regarding R3 and R3's fall interventions. Surveyor asked CNA C how she is made aware of residents fall interventions. CNA C stated the nurses will report fall interventions, she asks other staff, or uses the Kardex on the computer or in the closet. Surveyor asked CNA C regarding R3's fall interventions. CNA C stated R3 has had some falls and staff need to monitor her. Surveyor asked CNA C what monitoring means, CNA C said to observe her when she is up to be sure she is using her walker. Surveyor asked CNA C about R3's call light and if it was in reach if R3 is sitting in the corner in her wheelchair and the call light is in the recliner, CNA C stated R3 would have to get up to use her call light, but she doesn't really use it. Surveyor asked CNA C about R3's bathroom door alarm and if the alarm should ring when the door is opened. CNA C stated yes. Surveyor asked CNA C if she could test the alarm. CNA C opened the door, and the bathroom door did not alarm. CNA C tried to get the alarm to function, and it would not alarm. CNA C stated I think the battery is dead and went to find a new battery. Surveyor asked CNA C to review R3's Kardex, Surveyor asked CNA C based on what is on the Kardex is R3 to be ambulating independently or toileting independently? CNA C stated no, R3 should be 1 staff assist for transfers and ambulation. On 9/4/24 at 9:15 AM, Surveyor interviewed LPN D regarding R3 and R3's falls and interventions. LPN D stated R3 has a history of falls and has several interventions in place. Surveyor asked LPN D if the call light in the recliner would be within reach if R3 is sitting in her w/c in the corner. LPN D stated R3 would have to wheel to the call light or walk to the light so it's not really in reach; however, R3 does not use her light. Surveyor asked LPN D if R3's bathroom door alarm should ring when the door is opened LPN D stated yes. Surveyor asked LPN D what happens when a resident falls. LPN D stated they complete a post fall assessment, complete vital signs, ensure resident is not injured and will add a new intervention any time it is necessary. The IDT will meet later and discuss the fall and add interventions they feel are appropriate. Surveyor asked LPN D if she was aware of R3's interventions, LPN D stated we need to watch her close and make sure she is using her walker. On 9/4/24 at 2:50 PM, Surveyor observed R3 to be ambulating in the hall way independently with a 4ww. R3 walked through the hall and into her room and sat in her wheelchair there were multiple staff in the hall and no staff assisted R3 with ambulation. R3's call light was observed in the recliner. On 9/4/24 at 2:55 PM, Surveyor interviewed CNA E regarding R3's fall interventions. CNA E stated R3 is independent with ambulation using her walker. Surveyor asked CNA E if she could review R3's Kardex. After reviewing the Kardex CNA E stated I guess R3 is to be 1 assist with 4ww and gait belt for transfer and ambulation. Surveyor asked CNA E if R3's call light was in reach of where R3 was sitting CNA E stated no but R3 does not use her call light. Surveyor asked CNA E if she could test R3's bathroom alarm, CNA E opened the bathroom door and the alarm immediately sounded. Surveyor asked CNA E based on R3's Kardex should R3 be up alone? CNA E stated no. On 9/4/24 at 1:50 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked if she would expect care planned interventions such as ambulate or transfer with 1 assist to be followed, NHA A stated yes. Surveyor asked if fall interventions such as door alarms should be functioning and call lights within reach NHA stated she would expect the door alarm to be functioning and call lights within reach. Surveyor discussed observations of R3 ambulating in the hall independently and ambulating in room and going to bathroom independently. NHA A stated she would agree based on the care plan staff should be assisting R3. Surveyor discussed the observation of the door alarm not functioning in R3's bathroom and the call light now within reach. NHA A stated she would expect the alarm to be functioning and the call light within reach.

Based on interview and record review, the facility did not ensure the provision of pharmaceutical services (including procedures that assure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 out of 3 sampled residents (R1 and R3). On 5/19/24, R1 did not receive morning (AM) medications until noon. On 5/19/24, R3 did not receive scheduled 7:30 AM and 8:00 AM medications timely. This resulted in 20 medication timing errors. Evidenced by Facility policy, Medication Administration: General Guidelines, dated 1/23 states, in part; .Policy Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication .1. Medications are administered in accordance with written orders of the prescriber .14.Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration scheduled for the nursing care center Documentation: 1. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medication . Example 1 R1 was admitted to the facility on [DATE] with diagnoses including dementia, weakness, obesity, fibromyalgia, depression, and anxiety. R1's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/19/24, indicates R1 has a Brief Interview for Mental Status (BIMS) score of 11 indicating R1 is moderately cognitively impaired. R1 has an activated power of attorney. R1's AM and noon medications state, in part; . Duloxetine HCI Oral Capsule Delayed Release Particles 60 MG Give 60mg by mouth one time a day related to depression 0730. Indapamide Oral tablet 2.5 MG Give 1 tablet by mouth one time a day related to primary hypertension 0730. Metoprolol Succinate ER Tablet Extended Release 24-hour 25 MG Give 25 mg by mouth one time a day related to polyosteoarthritis 0730. Spironolactone Oral Tablet 25 MG Give 25 mg by mouth one time a day for edema 0730. Albuterol Sulfate HFA Inhalation Aerosol Solution 108 2 puff inhale orally two times a day related to asthma 0900. Bupropion HCI ER Oral Tablet Extended release 12-hour 150 MG Give 1 tablet by mouth two times a day related to depression 0730. Eliquis Oral Tablet 2.5 MG Give 2.5 mg by mouth two times a day related to long term use of anticoagulant 0730. Famotidine Oral Tablet 20 MG Give 1 tablet by mouth two times a day for indigestion 0730. Fluticasone Salmeterol Inhalation Aerosol Powder Breath Activated 1 puff inhale orally two times a day related to asthma 0730. Gabapentin Oral 100MG Give 1 capsule by mouth three times a day related to fibromyalgia 0730. Gabapentin Oral 100MG Give 1 capsule by mouth three times a day related to fibromyalgia 1130. Acetaminophen Oral Tablet Give 500mg by mouth four times a day for headache/pain 0730. Acetaminophen Oral Tablet Give 500mg by mouth four times a day for headache/pain 1130. Tramadol HCI Oral Tablet 50 MG Give .5 tablet by mouth four times a day related to polyosteoarthritis 0730. Tramadol HCI Oral Tablet 50 MG Give .5 tablet by mouth four times a day related to polyosteoarthritis 1130. On 5/21/24 at 11:00 AM, RN C (Registered Nurse) indicated RN C could run a report to see the time R1's medications were administered on 5/19/24. RN C indicated she was made aware of R1 receiving AM medications late on the 19th because the daughter called the facility on 5/20/24. RN C indicated she emailed NHA A (Nursing Home Administrator) and informed her of the concern. RN C indicated she has not gotten around to checking all of R1's AM medications on the 19th, but assumes they were all given late. RN C indicated RN C does not know if the primary physician was notified. RN C provided Surveyor Medication Admin Audit Report. Report states, in part; .all 7:30 AM medications on the 19th were signed out that they were administered at noon. R1's noon medications were signed out that they were administered at noon as well. All three noon medications are ordered to give AM as well. On 5/21/24 at 11:15 AM, Surveyor met with R1, R1's daughter/activated power of attorney, and R1's daughter-in-law. On 5/19/24 R1's AM medications were not administered until noon. R1 and the family are unaware of why this occurred, if the primary physician was notified, and if R1's noon medications were given at the same time. R1 and family indicated that on the 19th family was visiting R1 and witnessed medications being given late. R1's Activated Power of Attorney (APOA) indicated she called the facility on 5/20/24 to voice concern about the late medications. On 5/21/24 at 2:50 PM, NHA A (Nursing Home Administrator) and DON B (Director of Nursing) indicated they were not aware of R1 receiving medications late on 5/18/24 or 5/19/24. On 5/21/24 at 3:03 PM, Surveyor attempted to call nurse that worked on 5/19/24. Surveyor did not receive a call back. Facility informed Surveyor they have attempted to call several times and have not received call back. On 5/21/24 at 3:21 PM, NHA A indicated she just saw an email from RN C from 5/20/24 saying R1 was given AM medications late and that R1's daughter called facility to voice the concern. On 5/21/24 at 4:20 PM, NP D (Nurse Practitioner) indicated she was not notified of medications given late for R1 and R3. NP D indicated she would expect to be notified. 30992 Example 2 R3's Physician Orders, signed 5/9/24, indicate the following: 1. Apixaban Tablet Give 2.5 mg (milligrams) by mouth two times a day related to permanent atrial fibrillation. The Medication Administration Record (MAR) indicates the medication is scheduled at 7:30 AM. The Medication Admin Audit Report documents on 5/18/24 Apixaban administered at 11:23 AM. The Medication Admin Audit Report documents on 5/19/24 Apixaban administered at 12:40 PM. 2. Acetaminophen Oral Tablet (Acetaminophen) Give 500 mg by mouth four times a day for headache/pain/fever The MAR indicates the medication is scheduled at 7:30 AM. The Medication Admin Audit Report documents on 5/18/24 Acetaminophen administered at 11:22 AM. The Medication Admin Audit Report documents on 5/19/24 Acetaminophen administered at 12:36 PM. 3. MiraLAX Power 17 gm (grams)/scoop (Polyethylene Glycol 3350) Give 1 scoop by mouth two times a day for constipation. Mix in 8 oz of fluid of choice. The MAR indicates the medication is scheduled at 7:30 AM. The Medication Admin Audit Report documents on 5/18/24 MiraLAX administered at 11:23 AM. The Medication Admin Audit Report documents on 5/19/24 MiraLAX administered at 12:39 PM. 4. Senna Plus Tablet 8.6-50 mg (Sennosides-Docusate Sodium) Give 2 tablets by mouth two times a day for constipation The MAR indicates the medication is scheduled at 7:30 AM. The Medication Admin Audit Report documents on 5/18/24 Senna Plus administered at 11:23 AM. The Medication Admin Audit Report documents on 5/19/24 Senna Plus administered at 12:38 PM. 5. Spironolactone Tablet Give 50 mg by mouth one time a day related to essential hypertension The MAR indicates the medication is scheduled at 7:30 AM. The Medication Admin Audit Report documents on 5/18/24 Spironolactone administered at 11:24 AM. The Medication Admin Audit Report documents on 5/19/24 Spironolactone administered at 12:41 PM. 6. Furosemide Tablet Give 40 mg by mouth one time a day related to essential hypertension The MAR indicates the medication is scheduled at 7:30 AM. The Medication Admin Audit Report documents on 5/18/24 Furosemide administered at 11:23 AM. The Medication Admin Audit Report documents on 5/19/24 Furosemide administered at 12:40 PM. 7. Duloxetine HCL Oral Capsule Delayed Release Particles Give 60 mg by mouth two times a day related to adjustment disorder with mixed anxiety and depressed mood The MAR indicates the medication is scheduled at 7:30 AM. The Medication Admin Audit Report documents on 5/18/24 Duloxetine administered at 11:23 AM. The Medication Admin Audit Report documents on 5/19/24 Duloxetine administered at 12:39 PM. 8. Allopurinol Tablet Give 300 mg by mouth one time a day related to gout. The MAR indicates the medication is scheduled at 7:30 AM. The Medication Admin Audit Report documents on 5/18/24 Allopurinol administered at 11:23 AM. The Medication Admin Audit Report documents on 5/19/24 Allopurinol administered at 12:39 PM. 9. Atorvastatin Calcium Tablet Give 10 mg by mouth one time a day related to hyperlipidemia The MAR indicates the medication is scheduled at 8:00 AM. The Medication Admin Audit Report documents on 5/18/24 Atorvastatin Calcium administered at 11:24 AM. The Medication Admin Audit Report documents on 5/19/24 Atorvastatin Calcium administered at 12:41 PM. 10. Gabapentin Oral Tablet Give 100 mg by mouth two times a day for pain. The MAR indicates the medication is scheduled at 8:00 AM. The Medication Admin Audit Report documents on 5/18/24 Gabapentin administered at 11:24 AM. The Medication Admin Audit Report documents on 5/19/24 Gabapentin administered at 12:41 PM. On 5/21/24 at 3:03 PM, Surveyor attempted to speak with RN E (Registered Nurse) who administered the medications late. RN E did not return Surveyor's phone call. On 5/21/24 at 5:10 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, do you expect medication to be administered per orders. DON B stated, Yes. Surveyor asked DON B, why is this important. DON B stated, it's important to administer medications per physician orders. DON B added, if a medication is ordered to be administered more than one time per day the doses need to be spread out. Surveyor asked DON B, if the facility scheduled a medication administration time what are acceptable parameters for administration. DON B stated, 1 hour before and 1 hour after the medication is scheduled. Surveyor asked DON B, do you expect medication to be administered timely. DON B stated, Yes. Surveyor asked DON B, what should staff do when there's a medication error. DON B stated, notify the nurse on call, Physician, and power of attorney. DON B stated if it's not documented it's not done. Surveyor shared the Medication Admin Audit Report for R1 and R3 that documents the late medication administrations. Surveyor asked DON B, would you expect staff to administer R1 and R3's medications on time (1 hour before and 1 hour after schedule administration time) DON B stated, yes. DON B stated she was unaware of R1's and R3's late medications and there are no Medication Errors noted for R1 or R3. DON B stated, she was not aware of anything catastrophic that occurred on 5/18/24 and 5/19/24 that would have delayed med pass.

Based on interview and record review, the facility did not make prompt efforts to resolve resident grievances for 1 resident (R1) out of 3 sampled residents. R1's Activated Power of Attorney (APOA) informed the facility that R1 did not receive morning (AM) medications until noon. The facility failed to make prompt efforts to resolve the grievance. Evidenced by: The facility policy, Grievance Policy, dated 7/22, states, in part; Policy: The facility will seek to resolve concerns, complaints or grievances and provide residents, responsible parties, staff and others feedback and resolutions in a timely manner . R1 was admitted to the facility on [DATE] with diagnoses including dementia, weakness, obesity, fibromyalgia, depression, and anxiety. R1's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/19/24, indicates R1 has a Brief Interview for Mental Status (BIMS) score of 11 indicating R1 is moderately cognitively impaired. R1 has an activated power of attorney. On 5/21/24 at 11:00 AM, RN C (Registered Nurse) indicated on 5/20/24 R1's daughter called the facility reporting R1 did not received AM medications late on the 19th. RN C indicated she emailed NHA A (Nursing Home Administrator) and informed her of the concern. RN C indicated she has not gotten around to checking all of R1's AM medications on the 19th, but assumes they were all given late. RN C indicated RN C does not know if the primary physician was notified. On 5/21/24 at 11:15 AM, Surveyor met with R1, R1's daughter/activated power of attorney, and R1's daughter-in-law. On 5/19/24, R1's AM medications were not administered until noon. R1 and the family are unaware of why this occurred, if the primary physician was notified, and if R1's noon medications were given at the same time. R1 and family indicated that on the 19th family was visiting R1 and witnessed medications being given late. R1's APOA indicated she called the facility on 5/20/24 to voice concern about the late medications. R1's APOA indicated she was not offered to file a grievance regarding the concern. R1's APOA indicated this is not the first time this has happened and seems to occur more on the weekends. Surveyor reviewed the facility Grievance Log. R1's late medication concern was not on the log. On 5/21/24 at 2:50 PM, NHA A (Nursing Home Administrator) and DON B (Director of Nursing) indicated they were not aware of R1 receiving medications late on 5/19/24 and the family expressing the grievance. On 5/21/24 at 3:21 PM, NHA A indicated she just saw an email from RN C from 5/20/24 saying R1 was given AM medications late and that R1's daughter called facility to voice the concern. On 5/21/24 at 3:53 PM, NHA A (Nursing Home Administrator) indicated NHA A has now started a grievance for R1's medication concern. NHA A indicated she talked with RN C because DON B and Social Services are both able to complete grievances if NHA A is not in building.

Based on interview and record review, the facility did not ensure residents are free of significant medication errors for 1 of 3 total sampled residents (R3). The facility scheduled R3's Metoprolol Succinate ER to be administered at 7:30 AM and 7:30 PM. On 5/18 and 5/19/24, the facility administered R3's morning dose of Metoprolol late and administered the evening dose of Metropolol less than 12 hours after the morning dose. This resulted in four (4) timing errors. As evidenced by Facility policy, Medication Administration: General Guidelines, dated 1/23 states, in part; .Policy Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication .1. Medications are administered in accordance with written orders of the prescriber .14.Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration scheduled for the nursing care center Documentation: 1. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medication . R3's Physician Orders, signed 5/9/24, indicate the following: (Order Date 7/27/21) Metoprolol Succinate ER (Extended Release) Tablet Extended Release 24 Hour - Give 100 mg (milligrams) by mouth two times a day related to permanent atrial fibrillation. R3's Medication Administration Record (MAR) indicates the facility scheduled R3's Metoprolol Succinate ER to be administered at 7:30 AM and 7:30 PM. On 5/19/22, R3's MAR does not document medication administration times. Surveyor requested a Medication Administration Audit Report for R3's medication administration times. R3's Medication Administration Audit Report documents the following administration times: 5/18/24 7:30 AM dose - Administered at 11:24 AM 7:30 PM dose - Administered at 7:17 PM 5/19/24 7:30 AM dose - Administered 12:40 PM 7:30 PM dose - Administered 6:54 PM This resulted in four (4) significant medication timing errors. On 5/21/24 at 3:03 PM, Surveyor attempted to speak with RN E (Registered Nurse) who administered the medications late. RN E did not return Surveyor's phone call. On 5/21/24 at 5:10 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, do you expect medication to be administered per orders. DON B stated, Yes. Surveyor asked DON B, why is this important. DON B stated, it's important to administer medications per physician orders. DON B added, if a medication is ordered to be administered more than one time per day the doses need to be spread out. Surveyor asked DON B, if the facility scheduled a medication administration time what are acceptable parameters for administration. DON B stated, 1 hour before and 1 hour after the medication is scheduled. Surveyor asked DON B, do you expect medication to be administered timely. DON B stated, Yes. Surveyor asked DON B, what should staff do when there's a medication error. DON B stated, notify the nurse on call, physician, and power of attorney. DON B stated, if it's not documented it's not done. Surveyor asked DON B, should R3's Metoprolol Succinate ER have been administered within 1 hour of 7:30 AM and 7:30 PM and evenly spaced by 12 hours. DON B stated, yes. DON B stated she was unaware of R3's late medication and there are no Medication Errors noted for R3. DON B stated, she was not aware of anything catastrophic that occurred on 5/18/24 and 5/19/24 that would have delayed med pass.

Based on observation, interview, document review, and review of the United States (US) Food Code, Dietary Aide (DA) J failed to test a low temperature dish machine's final rinse chemical level properly. In addition, two drink items were not labeled and located in the dietary reach-in refrigerator. The deficient practice affected 46 out of 48 residents and could cause the potential spread of foodborne illness. Findings include: Review of the US Food Code 2022 indicated, .Explaining correct procedures for cleaning and sanitizing utensils and food-contact surfaces of equipment. Employees are properly sanitizing cleaned multiuse equipment and utensils before they are reused. Review of the US Food Code 2022 indicated, . an employee shall eat, drink.only in designated areas where the contamination of exposed food, clean equipment, utensils, and linens . Review of the ECOLAB .Chlorine test strip container indicated, .Immerse the strip in sample and remove immediately .Hold strip level (do not shake off excess sample) .Evaluate the color between 5 and 10 seconds after removing the test strip from sample .Match the center of the test strip pad to the color chart to determine chlorine concentration . The outside of the ECOLAB test strip container revealed the following colors and corresponding measurements of chlorine content: [NAME] was 0 parts per million (ppm); sky blue 25 ppm; dark green 50 ppm; light green 100 ppm; rust 200 ppm; and orange 300 ppm. Example 1 Observation on 04/14/24 at 8:40 AM, Cook I opened the reach-in refrigerator and there was a glass bottle of Starbucks Frappuccino partially full and a full bottle of Dasani water. There were no names on the bottles. During an interview Cook I stated she did not know if the items belong to dietary staff or residents. Example 2 Observation of the Ecolab dishwasher in the dishwashing area on 4/14/24 at 8:45 AM, DA J was asked to test the dish machine's final rinse sanitation level. DA J grabbed the container labeled Ecolab Test Strips for testing Chlorine level and placed a test strip in an empty cup and then placed a metal food container over the cup and started the dish machine. When the dish machine ran to completion, DA J removed the test strip, and the test strip was white (indicating there were no chemicals present). DA J then took a strip from the container of Hydrion test strips (test strips for quaternary chemical) and placed the strip in the dish machine on a plate and ran the dish machine. DA J pulled the test strip out and it was white. DAJ compared it to the test strip container and the color chart on the Hydrion container did not identify what the color white represented in regard to concentration of chemical. During an interview on 04/14/24 at 11:19 AM, the District Manager E stated the dish machine was a low temperature sanitation and was to be tested with the Ecolab Test Strips and not with the Hydrion test strips since the Hydrion test strips were to be used to test the chemical in the quaternary bucket. During the interview, the District Manager E stated staff food items were not to be in the same refrigerator with food that would be for resident consumption since there was a chance of contamination. The District Manager stated if the Starbucks coffee and the Dasani water was for resident consumption there was a specific refrigerator for resident items and the products would have the name of the resident who owned them. During an interview on 04/15/24 at 1:36 PM, the Ecolab Representative L stated that DA J should have used the Ecolab test strips instead of Hydrion test strips since the chemical in the dish machine's final rinse was chlorine to sanitize the dishware.

Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment this has the potential to affect the census of 48 and 2 of 6 residents observed on EBP protocol. The facility did not have an up-to-date process to ensure all staff have been fit tested annually for use of N95 masks. Enhanced Barrier Precautions were not appropriately implemented and maintained for two residents R27 and R16. This is evidenced by: The Facilities Policy and Procedure entitled N95 Fit Testing dated 10/16/23, documents in part: All staff that work in direct resident care will have an initial and annual fit-test for respirator use in accordance with Occupational Safety Health Administration (OSHA) regulations .The initial fit test will occur prior to initial use of the respirator. The center's Infection Preventionist will authorize the assignments of qualified fit-testers and will implement an annual fit-testing schedule per job requirements . Review of the facility's policy titled Enhanced Barrier Precautions, dated 03/25/24 indicated, .It is the policy of this facility to implement enhance barrier precautions for the prevention of transmission of multidrug-resistant organisms.PPE [Personal Protective Equipment] for enhance barrier precautions is only necessary when performing high-contact care activities.High-contact resident care activities include.Dressing.Bathing.Transferring.Providing hygiene.Changing linens.Changing briefs or assisting with toileting. Example 1 The Facility had a COVID outbreak that began 12/15/23. In review of this outbreak, it was discovered that not all staff were current with their N95 fit testing. The Facility has 42 of 80 staff not up to date with their fit testing. Of these 42 staff, 27 were from the Nursing Department, 1 from Administration, 6 from Housekeeping/Laundry Department, 3 from the Life Enrichment Department, and 5 from the Therapy Department. On 4/17/24 at 1:55 PM, Surveyor interviewed MD N (Maintenance Director). Surveyor asked MD N how often are staff in need of being fit tested , MD N said I learned today, that it is annually. Surveyor asked MD N how the annual fit testing is scheduled, MD N explained that he was given list of staff that needed to be fit tested and he was completing those lists but hadn't realized that others needed the annual fit testing done. Surveyor asked MD N if all staff should be fit-tested , MD N stated yes, one hundred percent and they will be. On 4/17/24 at 2:10 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if she expected all staff to be fit-tested and remain current, NHA A stated yes. 12679 Example 2 Review of R27's electronic medical record (EMR) titled Admission Record under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of proteus mirabilis morganii (bacterial infection identified prior to his admission into the facility). Review of R27's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/10/24 in the EMR under the MDS tab indicated the resident required substantial/maximum assistance with toileting and was dependent on staff for transfers from bed to wheelchair. Review of R27's EMR titled Physician Orders located under the Orders tab dated 04/03/24 revealed an order to place the resident under enhanced precautions. Observation on 04/14/24 at 9:32 AM, CNA D assisted R27 with a sit to stand lift. CNA D was observed wearing a gown and no gloves. CNA D had her hands resting on the mechanical lift. On the outside of the resident's room was an orange poster titled CDC [Centers for Disease Control] .Enhanced Barrier Precautions.Everyone Must.Providers and Staff Must Also.Wear gloves and a gown for the following High-Contact Resident Care Activities.Dressing.Bathing/Showering.Transferring.Providing Hygiene.Changing briefs or assisting with toileting. Example 3 Review of R16's EMR titled Admission Record under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of lymphocytosis. Review of R16's admission MDS with an ARD of 03/20/24 under the MDS tab indicated the resident required partial/moderate assistance with toileting and partial/moderate assistance with staff for transfers. Review of R16's EMR titled Physician Orders located under the Orders tab dated 04/03/24 indicated the resident was placed on enhanced precautions for an indwelling medical device (peripheral inserted central catheter (PICC) Line). Observation on 04/14/24 at 10:26 AM in R16's room, CNA D was wearing no gown or gloves. CNA D placed R16's wash basin in the resident's dresser while R16 was in the restroom. On the outside of the resident's room was an orange poster titled, CDC .Enhanced Barrier Precautions.Everyone Must.Providers and Staff Must Also.Wear gloves and a gown for the following High-Contact Resident Care Activities.Dressing.Bathing/Showering.Transferring.Providing Hygiene.Changing briefs or assisting with toileting. During an interview on 04/14/24 at 10:30 AM, CNA D confirmed she wore gloves while she provided R16's personal care but did not wear a gown. CNA D confirmed she was to wear gloves and a gown when coming in contact with both R27 and R16. During an interview on 04/15/24 at 10:22 AM, the Infection Control Preventionist (ICP) K confirmed both R27 and R16 were recently placed on enhanced precautions due to the CDC recommendations. ICP K stated it was her expectations that CNA D should have donned proper personal protective equipment (gown and gloves) with both residents during high contact encounters.

Based on observation, interview, and record review, the facility did not ensure a resident with a catheter receives appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (R36) reviewed for catheter care out of total sample of 14. Staff did not perform appropriate hand hygiene while providing catheter care. There was no barrier placed under supplies on the bedside table during the catheter care. Staff reused a washcloth after cleansing with it by placing it back in the wash basin and using it for the second time on resident's peri area. Staff placed dirty wash cloths directly on bedside table and did not disinfect bedside table after use. Evidenced by: The facility policy entitled Hand Hygiene, dated 11/2/22, states, in part: . Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility . Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table . Hand Hygiene Table: . After handling items potentially contaminated with blood, body fluids, secretions, or excretions. When during resident care, moving from a contaminated body site to a clean body site . The facility policy entitled Catheter Care, dated 3/15/23, states, in part: . Policy: It is the policy of the facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use . Compliance Guidelines: . Male: 15. Gently grasp penis, draw foreskin back if applicable. 16. Using circular motion, cleanse the meatus with a clean cloth moistened with water and perineal cleaner (soap). 16. With a new moistened cloth, starting at the urinary meatus moving down, cleanse the shaft of the penis. 18. With a new moistened cloth, starting at the urinary meatus moving outward, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter . Both: 21. Bag and gather all supplies used, discarding disposable items in the trash can . R36 was admitted to the facility on [DATE] and has diagnoses that include neuromuscular dysfunction of bladder and benign prostatic hyperplasia with lower urinary tract symptoms. R36's Minimum Data Set (MDS) Quarterly Assessment, dated 2/29/24, shows R36 has a Brief Interview of Mental Status (BIMS) score of 9 indicating R36 has a moderate cognitive impairment. R36's Care Plan, dated 3/22/23, states, in part: . Focus: Use of indwelling urinary catheter related to (r/t) Urinary retention and Lower Urinary Tract Symptoms (LUTS) . Date Initiated: 3/22/23 . Interventions/Tasks: Catheter Care Date Initiated: 3/22/23 Revision on: 6/2/23 . R36's Physician Orders, dated 2/20/24, states, in part: . Indwelling urinary catheter 16 French 10 milliliters (mL) balloon for diagnosis Benign Prostate Hyperplasia (BPH) with LUTS and Obstruction . Date Ordered: 2/8/24 . On 4/15/24, at 9:55 AM, Surveyor observed CNA M (certified nursing assistant) perform catheter cares on R36. CNA M had basin of soapy water with washcloth and towel on bedside table with no barrier underneath. CNA M, with gloves on, rinsed and wrung out washcloth in soapy water basin. Then cleansed catheter tubing and peri area with the washcloth. CNA M then took same washcloth and put it back in soapy water basin and wrung it out. CNA M then proceeded to cleanse R36's meatus and peri area and tubing again. CNA M placed the used washcloth directly on the bedside table. CNA M then took dry towel from bedside table and dried peri area. CNA M placed used towel directly on the bedside table. CNA M fastened R36's brief, then grabbed garbage bag and placed used washcloth and towel in garbage bag. CNA M took basin and emptied in the toilet and put away after drying with paper towels. CNA M doffed PPE (personal protective equipment) performed hand hygiene and left room. Of Note: CNA M did not perform hand hygiene in between cleansing R36's catheter tubing and peri area and drying. CNA M did not use a clean washcloth after cleansing to rinse areas. On 4/15/24, at 10:06 AM, Surveyor interviewed CNA M and asked when should hand hygiene be performed during catheter cares. CNA M indicated after washing and before rinsing. Surveyor asked CNA M should a clean washcloth be used for washing and a clean washcloth be used for rinsing and CNA M indicated yes. Surveyor asked CNA M if she had used two clean washcloths and CNA M indicated no. Surveyor asked CNA M if it is proper to place a used washcloth back in basin of soapy water and reuse it. CNA M indicated no. Surveyor asked if a barrier should be placed between basin, washcloths and towel and the bedside table. CNA M indicated yes, and she did not have one. Surveyor asked CNA M if it is proper to place used washcloths and towel directly on bedside table and CNA M indicated no. Surveyor asked CNA M if bedside table should have been disinfected after removing used washcloths and towel and basin. CNA M indicated she should have disinfected the table after removing supplies. On 4/15/24, at 1:47 PM, Surveyor interviewed IP K (infection preventionist) and asked when she would expect hand hygiene to be performed during catheter cares. IP K indicated before beginning cares and after peri cares. Surveyor asked IP K if she would expect hand hygiene to be performed between the process of cleansing, rinsing, and drying and IP K indicated yes. Surveyor asked IP K if a barrier should be placed under basin, clean washcloths, and towel. IP K indicated yes, under clean washcloths and towel. Surveyor asked if it is acceptable to place used washcloths and towel directly on bedside table and IP K indicated no. IP K indicated the bedside table should have been disinfected after removing used washcloths and towel and basin. Surveyor asked IP K if it is acceptable to reuse the same washcloth during catheter cares and IP K indicated no. IP K indicated the washcloth should not have been put back in clean soapy water after using it to perform catheter cares.

Based on interview and record review, the facility did not ensure that a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder (PTSD), receives appropriate treatment and services to correct the assessed problem or attain the highest practical mental and psychosocial well-being for 1 of 1 residents reviewed for PTSD out of 14 sampled residents (R26). R26 was listed as having a diagnosis of PTSD and his care plan is not person centered, as it does not specify triggers, symptoms to monitor for or interventions to use to ensure R26 is reaching his highest practical mental and psychosocial well-being. This is evidenced by: Per CMS (Centers for Medicare and Medicaid Services), .Although PTSD is commonly viewed as a disorder experienced only by military veterans, it is not exclusively a consequence of combat or war zone exposure. Individuals who have been physically or sexually assaulted or who experienced a terrorist attack or natural disaster, among other things may also be affected by PTSD. The facility's policy titled Trauma Informed Care dated 10/18/22 states in part, .2. The facility will use a multi-pronged approach to identify a resident's history of trauma. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as reviewing documentation such as the history and physical, consultation notes, or information received from family/ responsible party .5. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger- specific interventions will identify ways to decrease the resident's exposure to triggers which re- traumatize the resident and will be added to the resident's care plan . R26 was admitted to the facility on [DATE] with diagnoses that include degenerative diseases of basal ganglia (degenerative changes in the brain that impact a person's ability to speak and causes difficulty with movement and mobility), cognitive communication deficit, and tremor. R26 had a diagnosis of PTSD added to his diagnosis list on 6/14/21, Unspecified Dementia with Agitation added on 12/1/22, and Mood [Affective] Disorder added on 8/14/23. R26's most recent MDS (Minimum Data Set) dated 4/13/24 states that R26 has a BIMS (Brief Interview of Mental Status) of 0 out of 15, indicating that R26 has severe cognitive impairment. R26's MDS section I states that from 7/12/21 until 1/14/23, R26 had a diagnosis of PTSD. *It is important to note that R26's current MDS dated [DATE] was completed on 4/17/24, during this survey, and does not include the diagnosis of PTSD. R26's care plan states in part, .At risk for Behavioral Disturbances r/t (related to): Major neurocognitive disorder- deemed incapacitated, Behavioral and Psychological Symptoms of Dementia, Fahr's Disease, Mood Disorder, PTSD, and Agitation r/t Dementia. Res has hx. (history) of Delirium, Rejection of cares, delusions regarding Men taking Ma as he looks for his wife, and others being in his home running water and having the electricity on. Res has behaviors at times including: Wandering on unit, striking out/ pushing at/ grabbing at staff and peers, yelling/ verbal aggression towards staff or peers, shaking his hands and arms out in front of him during angry outbursts. Interventions: Administer medications per physician order. Attempt psychotropic drug reduction per physician's orders. Direct staff supervision during periods of behaviors (increased anxiety, restlessness, agitation, aggression) until behaviors subside. Labs as ordered. Observe for mental status/behavior changes when new medication started or with changes in dosage. Room change closer to nurse's station on unit. Use consistent approaches when giving care . *It is important to note that R26's care plan does not specifically address R26's PTSD, identify triggers, and implement resident centered and individualized interventions. R26 has the following medications with corresponding diagnoses: 2/24/24 Olanzapine 7.5 mg (milligrams) by mouth one time a day related to Post- Traumatic Stress Disorder. 2/24/24 Escitalopram Oxalate 20 mg by mouth one time a day related to Post- Traumatic Stress Disorder, Unspecified Dementia with Behavioral Disturbance. On 4/15/24 at 2:13 PM, Surveyor interviewed CNA P (Certified Nursing Assistant). Surveyor asked CNA P what R26's triggers are for his PTSD, CNA P stated that some female residents are a trigger, as well as some staff members. CNA P stated that R26 does not tolerate loud noises at all. Surveyor asked CNA P if any of R26's triggers are on his care plan, CNA P stated that she was unsure. On 4/15/24 at 2:18 PM, Surveyor interviewed RN F (Registered Nurse). Surveyor asked RN F if there had been any triggers identified for R26's PTSD, RN F stated that she does not usually work on R26's hall but reported that R26's behaviors have improved with his medication changes. *It is important to note that RN F was the nurse on R26's hall for 3 out of 4 days of the survey. On 4/16/24 at 9:36 AM, Surveyor interviewed SW Q (Social Worker). Surveyor asked SW Q if she was aware that R26 had a diagnosis of PTSD, SW Q stated yes. Surveyor asked SW Q if they had identified what the cause of his PTSD was, SW Q stated R26 was at the facility before she started working at the facility and that the facility has made medication changes. Surveyor asked SW Q if they have identified R26's triggers, SW Q stated that sometimes other males and other ambulatory residents can be triggers. Surveyor asked SW Q if R26 has a care plan specifically for PTSD that identifies his triggers and individualized interventions, SW Q stated no. On 4/16/24 at 1:26 PM, SW Q provided Surveyor a copy of R26's physician note dated 6/14/21 stating in part, .the long-term history is not clear; for now, I take this to be behavioral and psychological symptoms of dementia and consider PTSD . Additionally, after inquiry by Surveyor, the facility MDS Nurse entered a note on 4/16/24 stating, Upon query of diagnosis list and question concerning diagnosis of PTSD, this writer researched MD notes and diagnosis list, also NP (Nurse Practitioner) queried, diagnosis was listed as BPSD (behavioral and physiological symptoms in dementia) as listed in MD note dated 6/14/21 that is attached in PCC (Point Click Care/electronic Health Record). The doctor stated that he might consider PTSD but never diagnosed it. The incorrect diagnosis code was entered by us at the time, listing was carried over a potential for never actually documented. This writer contacted and spoke to NP regarding clarification, she verified the code should have been for BPSD which when defined is unspecified dementia F03 which resident has on diagnosis list further specified. Of note, despite the clarification above R26 is receiving medications per physician order for PTSD. On 4/17/24 at 1:11 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if she would expect a resident's medical record to reflect their actual diagnoses, DON B stated yes. Surveyor asked DON B if a physician wrote a statement consider PTSD what she would expect staff to do with that information, DON B stated that she would question it and have a discussion with the physician. Surveyor asked if it would be considered an actual diagnosis, DON B stated no. Surveyor asked if it should be indicated for use with R26's medications, DON B stated only if the medication is written with that diagnosis, but that it's ultimately up to the physician. Surveyor asked DON B if R26 should have a care plan for PTSD, DON B stated yes.

Based on observation, interview, and record review, the facility did not ensure that each resident was free from abuse, including for 1 of 5 sampled residents (R1) this interaction resulted in psychosocial harm as evidenced by R1 changing her social patterns. This interaction had the potential to affect 4 of 5 residents who overheard the altercation (R2, R3, R4, R5). R1 changed her social habits when she no longer ate her meals in the dining room due to DA C (Dietary Aide) yelling and swearing at/or in front of her, taking her plate of food away, and telling her to get out of the dining room. R2, R3, R4 and R5 witnessed DA C yelling and swearing at R1 in the dining room; the facility failed to monitor these residents for emotional distress after the incident. Evidenced by: The facility policy, entitled Abuse Prevention Program, initiated 3/2018, includes, in part: . Our residents have the right to be free from abuse, neglect . Therefore, the facility has developed for screening and training employees for the protection of residents and for the protection of residents and for the prevention, identification, investigation, and reporting of abuse, mental abuse related to humiliating and demeaning ., neglect, The facility's purpose is to assure that the facility is doing all that is within their control to prevent occurrences . It is the policy of this facility to train employees during orientation and through ongoing in services on issues related to abuse, neglect, . of residents. Care and attention will be given utmost priority to the residents involved in the incident and to the reporter to ensure they are free of reprisal or retaliation . A corrective action plan will be developed . Upon receiving an allegation of abuse, committed against a resident, the staff member receiving the allegation must ensure the safety of the resident . The alleged perpetrator will be asked to leave the facility immediately and be escorted out of the facility . Residents who are identified at risk for similar abuse will be interviewed and/or assessed. Residents who came in close contact with the perpetrator will be interviewed and/or assessed. Interventions will be put into place as needed. The residents will be assessed for any needs every shift for 72 hours or until comfortable regarding incident. Nurses will chart each shift for 72 hours regarding resident's condition. The social services will conduct safe surveys . If the alleged perpetrator is found to be at fault or if there is sufficient doubt about their innocence, the employee will be terminated and the Administrator will follow the states regulations regarding abuse findings . All facility staff will be re- inserviced regarding the abuse prevention program. The resident will be re-assessed for any needs every shift for 72 hours or until comfortable regarding incident. Nurses will chart each shift for 72 hours regarding resident's condition. The resident will receive emotional support and counseling as needed or desired. CMS (Center for Medicare and Medicaid Services) definitions: Abuse - The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful - Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Neglect - Neglect means the failure of the facility, 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. Example 1 R1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) 1/28/22 indicates R1 is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 14 out of 15. R1's Progress Notes, include in part: 11/4/2021: . New orders to encourage R1 to come down to the dining room for meals where she can have increased supervision and typically better meal intakes. Resident reviewed (by Interdisciplinary Team). Registered Dietician to continue monitoring and will follow up as needed. R1's Comprehensive Care Plan, includes, in part: revision date: 12/29/21 R1 . Target date: 3/31/22 Goal: will maintain involvement with ADL performance and social activities. Behavior: rejection of care/diet restrictions . Intervention 1: provide empathic listening Intervention 2: Alert RN and ask if any substitutions could be made for R1's food. Intervention 3: Monitor for signs and symptoms of pain . Intervention 4 offer to come back at a later time. Goal: Will reduce risk of behavioral symptoms revision date: 12/29/21 . Target date: 3/31/22 Behavior: rejection of meals Intervention 1: update Nurse of meal rejection Intervention 2: re-approach R1 at another time Intervention 3: offer to help R1 obtain other meal offerings that work with her diet . revision date: 8/2/21 Focus: cognitive loss as evidenced by effects of [CONDITION(S)] initiated: 4/13/21 Goal: Responds to questions/statements with appropriate verbalization. Revision 12/29/21 Target: 3/31/22 Intervention: allow adequate time to respond. Do not rush or supply words Revision 5/25/21 Approach/speak in a calm, positive/reassuring manner Revision 5/25/21 Focus: At risk for nutritional status changes related to . initiated 4/8/21 Intervention: Honor food preferences . Revision 8/13/21 Intervention: Encourage R1 to go to the dining room for all meals to increase meal supervision. Initiated 11/4/21 . Resolved 2/11/22 (It is important to note this intervention was resolved after the incident which took place on 1/26/22). Facility Self-Reported Incident Report, submitted on 1/27/22, includes, in part: .Summary of Incident, Allegation Type Abuse: Hitting, slapping, threats of harm, assaults, humiliation. Name- Affected Person: R1. Name-Accused Person: DA C (Dietary Aide C). Date occurred 01/26/2022 and Time occurred 12:30 PM. The Brief Summary of Incident includes, in part: Our resident complained to dietary aide that she had ordered two pieces of kielbasa and only received one. The dietary aide pointed out that she hadn't even eaten the one she received. The conversation escalated to where the resident was swearing at the aide. The aide became angry and the argument continued until the aide walked away from the resident while saying the resident was a [OBSCENITY] ing [OBSCENITY] . Whereas we feel that this may not have been said to the residents face, it was said within earshot and heard by the residents. Therefore, we believe it reaches the level where it must be investigated as a possible verbal abuse incident. Under Incident Description: Nursing Description: Resident was sitting at her table in the main dining room for lunch. She requested another kielbasa with her lunch. CNA (Certified Nursing Assistant) approached the kitchen staff DA C to request a second serving. Kitchen reported they were out of kielbasa but could offer her an alternate. CNA reported this to the resident. DA C from the kitchen staff came out to residents table to talk with resident. She reported she explained to resident there were no more left and pointed to her plate to say she hadn't even eaten what she was served. DA C stated the resident then called me a [OBSCENITY] and was saying [OBSCENITY] this and that. She called me a [OBSCENITY] ing [OBSCENITY] . I did not call her a [OBSCENITY] ing [OBSCENITY] . I did tell her that if she wasn't happy with it she could leave the dining room then I went into the kitchen where I was upset and talking with a raised voice. I probably swore in the kitchen. Multiple staff and residents were interviewed with numerous statements indicating that both staff and resident swore and had raised voices. With staff member swearing as she was walking away from resident and closer to the dining room than the resident's table. Resident Description: Resident stated You can't treat me this way, get me out of here! When attempted to talk with resident she stated that she asked for 2 kielbasas and didn't get it. She stated she felt safe and would eat in the dining room again but not right now. She stated that the lady in the kitchen said Get that [OBSCENITY] out of here. Immediate Action Taken Description: Resident removed from dining room and kept with staff until she was calm. Resident ate a McDonalds meal after incident and was smiling and appreciative for it. Staff member was removed from kitchen and escorted to ED (Executive Directors) office where she was interviewed by ED and DON B (Director of Nursing) until she was then escorted to get her belongings and was kept in staff sight until she was outside of the building. Resident was placed on psychosocial monitoring. (It is important to note only one resident that was in the dining room during this exchange was placed on psychosocial monitoring.) Facility Investigation Report, initiated on 1/26/22, includes, in part: Interviews and Written Statements: Cook E - 12:30PM: I was in the kitchen discussing my meal with DA C. I heard raised voices, but nothing I could make out. I stepped into the dining room as DA C was coming into the kitchen. When I was in the dining room R4 was consoling R2. I heard DA C swearing in the kitchen so I reentered the kitchen and closed the doors to contain her yelling. Then ADON F (Assistant Director of Nursing) walked in and escorted DA C out. DA C - 12:40PM: R1 was asking for more kielbasa. I pointed to her plate that she didn't even eat her first one. She said This isn't even a whole one. I told her a serving is half a one. She then called me a [OBSCENITY] and was saying [OBSCENITY] this and that. She called me a [OBSCENITY] ing [OBSCENITY] . I did not call her a [OBSCENITY] ing [OBSCENITY] . I did tell her that if she wasn't happy with it she could leave the dining room then. I then went into the kitchen where I was upset and talking with a raised voice. I probably swore in the kitchen. When asked if she felt her yelling/swearing in the kitchen could have been heard behind the closed doors and she stated I don't know. I don't think so. DA C's written statement, undated, includes: I was cleaning up the dishes in the dining room and stopped by R1 and she didn't eat. I asked if she was done and she said she didn't get what she wanted explained portion size she didn't care she said she ordered 2 so she wasn't gonna eat. I told her you could always ask for more, but fought with me so I said your done and walked away with her plate. She screamed FU. I said get out and kept walking towards kitchen. She said F.U. Make me and I said get out- She called me a F [OBSCENITY] . So I was in the kitchen got asked what happened and said she called me a F [OBSCENITY] - Then I was in kitchen saying how stupid and ridiculous she not even supposed to be there she's pull this all the time! I was telling people in the kitchen what was said then I was escorted to (NHA A's) office told (NHA A) then (DON B) and they said I called her a [OBSCENITY] NEVER just repeating what was said getting wrote up for verbal abuse and had to leave. R2: Lunch smelled good but I didn't eat anything. When asked why she didn't eat today she stated I am trying to slim down. When asked if she enjoys going to the dining room and feels safe in the dining room she excitedly stated Yeah! When asked how her time in the dining room was today she stated Great! I got to visit with others. R3: When asked how lunch was today he stated Good. Plate and both drink cups were empty. When asked how he was doing today he said You mean when that girl said a naughty word? When asked which girl said it he said he didn't know. When asked if it was staff or resident he said Both. Stated he feels safe eating in the dining room. R4: . (DA C) maybe could have swore once . (DA C) was trying to stay calm but I guess if you are called names over and over again you just can't stay calm well. R5: When asked how lunch was stated Eh. Not my cooking. If I was cooking and kept talking about her being a chef and her brother being a chef. When asked if she was okay after the incident in the dining room today she stated Rude staff, but I'm okay. When asked who was rude she stated That lady in the kitchen. Stated she feels safe in the dining room and likes to come do her knitting at the table. Scheduler G: refer to her typed statement. Stated she was standing in MDS office doorway with door open (office is immediately outside of dining room). She heard yelling so she went into the dining room to see ADON F assisting resident out of dining room. She heard DA C saying, Get that [OBSCENITY] out of here. as DA C was walking away from the resident. She was closer to the kitchen door than the resident's table. (Resident's table is the one farthest from the kitchen.) On 2/23/22 at 12:25 PM during an interview with Surveyor DA C stated she was clearing off the tables the day of the incident on 1/26/22 when R1 told her she ordered two kielbasas and she told R1 she could give her another one after she eats what is on her plate. When Surveyor asked if there was kielbasa available, DA C indicated yes there was kielbasa available but wanted R1 to eat what was on her plate before getting her any more. DA C also indicated R1 told her she had asked for two pieces and if she couldn't have them she wasn't going to eat at all. DA C indicated at this point she told R1, You are done, and took R1's plate with the food still on it. DA C stated,R1 was upset and called me a [OBSCENITY] ing [OBSCENITY] . DA C stated she then told R1, Get out. When R1 did not move, DA C stated louder this time, while pointing to the door, Get out! DA C told Surveyor there was approximately 10 residents in the dining room who observed this exchange. DA C also indicated she has seen R1 come to the dining room one time since the incident and at this time, R1 asked DA C for a new paper menu. DA C turned away from R1 and told a nearby coworker, You can deal with her. DA C indicated her actions were maybe not appropriate, but R1 is hard to deal with. DA C stated she would like some training working with residents who have behaviors and/or dementia because her mouth tends to get away from her. On 2/23/22 at 12:50 PM during an interview with Surveyor R1 stated, I don't eat in the dining room anymore because of that lady. She was gone for two weeks and I thought she got fired. I guess not. She should have been fired. R1 reported she has not eaten in the dining room since the incident on 1/26/22 and that she would like to eat in the dining room. When asked how the incident made her feel, R1 stated It made me feel lousy, I was so upset I thought I was going to throw up. R1 stated that DA C threw her towel on the table and told her to Get out of here! R1 stated that she felt really scared and that she was shaking. R1 stated she thought DA C was going to hit her. R1 indicated this is her home and she should be able to go into her dining room as she pleases and she should be able to make changes to her diet when she wants. R1 stated, I know what I should eat, but sometimes I want something different. On 2/23/22 at 1:45 PM during an interview, DON B indicated DA C's actions were not willful so therefore it was not abuse. Surveyor asked if DA C's actions were deliberate. DON B indicated DA C could have walked away, could have just given R1 the additional piece of meat, and/or re-approached R1, but she didn't. DON B indicated staff and residents overheard this exchange, including R2, R3, R4, and R5. DON B indicated R2 and R3 have dementia and could mistake this yelling to be at them or not understand what was going on. DON B indicated staff did not continue to monitor R2 and R3 for 72 hours after the incident, as the facility abuse policy and procedure directs. DON B indicated a staff member swearing and yelling at or in front of a resident could be abuse and that it could cause a resident to feel humiliated, belittled, or intimidated. DON B indicated a staff member should not tell a resident that they are done eating and take their plate away, unless it is a safety concern. DON B indicated this action could be abuse. DON B indicated DA C could get another staff member to assist R1 if she feels she can't do it appropriately, but her actions of saying, You deal with her, in front of R1 were not appropriate and could cause R1 to feel intimidated, belittled, and/or humiliated. DON B indicated the actions of DA C were substantiated but DA C did not intend to cause harm. DON B indicated R1 is a difficult resident with behaviors. DON B stated she has not educated the facility staff, including DA C on abuse since the incident. Director of Clinical Services D indicated she was unaware that other staff members reported to have observed DA C swear in front of the residents. Director of Clinical Services D indicated swearing in front of/or at residents could be abuse and could cause emotional distress to residents. DON B and Director of Clinical Services D indicated R1 has not been to the dining room for meals since the incident and they didn't know why. DON B and Clinical Services D indicated DA C is still working her regular scheduled shifts. The following examples are not at the harm level. Example 2 R2 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's most recent MDS with ARD of 2/25/22 indicates R2's cognition is severely impaired with a BIMS score of 3 out of 15. R2 interview after incident: Lunch smelled good but I didn't eat anything. When asked why she didn't eat today she stated I am trying to slim down. When asked if she enjoys going to the dining room and feels safe in the dining room she excitedly stated Yeah! When asked how her time in the dining room was today she stated Great! I got to visit with others. On 2/23/22 at 12:20 PM during an interview R2 did not recall an incident between a staff member and a resident taking place in the dining room. On 2/23/22 at 1:45 PM during an interview DON B indicated staff did not monitor R2 for 72 hours after the incident and they should have according to the facility abuse policy. (It is important to note R2's Medical Record did not contain evidence the nurses charted every shift for 72 hours after the incident.) Example 3 R3 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's MDS with ARD of 1/13/22 indicates R3's cognition is moderately impaired with a BIMS score of 8 out of 15. R3's interview after incident: When asked how lunch was today he stated Good. Plate and both drink cups were empty. When asked how he was doing today he said You mean when that girl said a naughty word? When asked which girl said it he said he didn't know. When asked if it was staff or resident he said Both. Stated he feels safe eating in the dining room. On 2/23/22 at 1:45 PM during an interview DON B indicated staff did not monitor R3 for 72 hours after the incident and they should have according to the facility abuse policy. (It is important to note R3's Medical Record did not contain evidence the nurses charted every shift for 72 hours after the incident to monitor her for emotional distress.) Example 4 R4 was admitted to the facility on [DATE]. Her most recent MDS with ARD of 2/16/22 indicates she is cognitively intact with a BIMS score of 15 out of 15. R4 interview after incident: . (DA C) maybe could have swore once . (DA C) was trying to stay calm but I guess if you are called names over and over again you just can't stay calm well. On 2/23/22 at 1:45 PM during an interview DON B indicated staff did not monitor R4 for 72 hours after the incident and they should have according to the facility abuse policy. On 2/23/22 at 2:47 PM during an interview R4 indicated she witnessed the incident on 1/26/22 between R1 and DA C. R4 indicated R1 called DA C a [OBSCENITY] 3 times and DA C handled it calmly until the third time and then she yelled at R1. R4 indicated she does not remember how other residents reacted to the incident but she thought it could cause them to be afraid. (It is important to note R4's Medical Record did not contain evidence the nurses charted every shift for 72 hours after the incident to monitor her for emotional distress.) Example 5 R5 was admitted to the facility on [DATE]. Her most recent MDS with ARD of 1/18/22 indicates R5's cognition is intact with a BIMS score of 14 out of 15. R5 interview after incident: When asked how lunch was stated Eh. Not my cooking. If I was cooking and kept talking about her being a chef and her brother being a chef. When asked if she was okay after the incident in the dining room today she stated Rude staff, but I'm okay. When asked who was rude she stated That lady in the kitchen. Stated she feels safe in the dining room and likes to come do her knitting at the table. On 2/23/22 at 1:45 PM during an interview DON B indicated staff did not monitor R5 for 72 hours after the incident and they should have according to the facility abuse policy. (It is important to note Surveyor was unable to complete an interview with R5 and R5's Medical Record did not contain evidence the nurses charted every shift for 72 hours after the incident to monitor her for emotional distress.)

Based on interview and record review, the facility did not ensure the resident's right to request, refuse and/or discontinue treatment, to participate in or refuse to participate in experimental research and to formulate an advanced directive in 1 of 12 total residents reviewed (Resident 11) as Resident 11's chart did not accurately identify his wish for cardiopulmonary resuscitation. The failure to accurately identify R11's (Resident ) code status resulted in an Immediate Jeopardy to the health and safety of R11, who had the potential to not be resuscitated by staff in the case of an emergency, which goes against his expressed wishes. The Immediate Jeopardy began on [DATE]. NHA (Nursing Home Administrator) A and DON (Director of Nursing) B were notified of the Immediate Jeopardy on [DATE] at 11:40 AM. The Immediate Jeopardy was removed on [DATE] at 2:45 PM. The non-compliance of F155 remains at severity and scope level of D (potential for more than minimal harm that is not Immediate Jeopardy / Isolated) as the facility continues to train staff as they report to work. This is evidenced by the following: According to a decision by the Division of Appeals Board, It is crucially important that nursing homes have in place, policies and procedures designed to ensure that the wishes of their residents, both for DNR (do not resuscitate) and CPR (cardio-pulmonary resuscitation), are accurately recorded, made accessible and implemented as desired by the residents. The facility's policy for Cardiopulmonary Resuscitation (CPR) Guidelines, undated, states in part: If a patient / resident is found to be unresponsive, begin evaluation to determine presence or absence of pulse and / or respirations. In the absence of pulse and / or respirations do the following: 4. A staff member, other than the one who is providing the resuscitative effort, must promptly identify / validate current code status. While that step is undertaken, AED (Automated External Defibrillator) should be prepared and [MEDICATION NAME] placed. 5. If DNR (Do Not Resuscitate) status is validated, do not initiate CPR. If CPR / Code Status is undetermined, CPR will be initiated and will continue until arrival of EMS (Emergency Medical Service). R11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R11's record contains a PPACO (Physician - Patient Advance Care Order) which states R11 wishes to have CPR performed in the event he is found to be pulseless and non-breathing. This form was signed by R11 on [DATE] and by the physician on [DATE]. R11's Admission Record face sheet documents that R11 is a Full Code (CPR to be performed in emergent situations). R11's Physician orders [REDACTED]. R11's Comprehensive Care Plan does not address his code status. On [DATE], at approximately 8:35 AM, Surveyor noted a red sheet of paper in the front of R11's record. On this red sheet of paper, in large capital letters, in the center of the page, was the acronym DNR (Do Not Resuscitate). On [DATE] at 8:49 AM, Surveyor spoke with RN (Registered Nurse) D regarding residents' advanced directives. Surveyor asked RN D where she would look, during an emergency, if she needed to know a resident's code status. RN D stated in the resident record. Surveyor asked RN D to show her where in R11's record. RN D opened R11's chart and placed her hand on the red DNR sheet in the front of R11's record and stated: Right there. RN D went on to state, that in the absence of this sheet, facility staff would look for the POLST (Physician order [REDACTED]. On [DATE] at 9:02 AM, Surveyor asked Licensed Practical Nurse (LPN) F where she would look, during an emergency, if she needed to know a resident's code status. LPN F stated as she opened a resident chart: Right there, in front. LPN F touched a red DNR page. LPN F went on to state: If it were green (Full Code) we would get the crash cart, call the doctor and get into action. On [DATE] at 9:10 AM, Surveyor asked LPN E where she would look, during an emergency, if she needed to know a resident's code status. LPN E stated she could look in the computer, but in an emergency, she would go to the chart. Surveyor asked LPN E to show her (Surveyor) what she meant. Together, LPN E and Surveyor walked up to the Nurses Station, where LPN E pulled a chart and opened the chart to the front page where a green Full Code sheet was placed. LPN E stated: We put them there (in front) so the CNAs (Certified Nursing Assistants) could find it. On [DATE] at 9:21 AM, Surveyor asked CNA G where she would look, during an emergency, if she needed to know a resident's code status. CNA G stated: I would look in the chart. Surveyor placed R11's chart in front of CNA G and CNA G opened the chart to the front and tapping the red DNR page stated, Right here. On [DATE] at 9:25 AM, Surveyor asked CNA H where she would look, during an emergency, if she needed to know a resident's code status. CNA H stated: In the chart. Right in the front. CNA H opened a chart, which was at the Nurses Station, and went to the front of the chart and tapped the red DNR sheet that was in the front of the chart. On [DATE] at 9:30 AM, Surveyor interviewed CNA K and CNA L asking about what they would do in an event where a resident became pulseless and not breathing. CNA K stated that she would go to the resident's chart and look at the first page of the chart to see the resident's code status and bring the chart to the nurse. CNA L stated that she would read the first page of the resident's chart to see if the chart was marked with DNR or CPR and do what the nurse instructed her to do to assist. On [DATE] at 11:20 AM, Surveyor interviewed ADON (Assistant Director of Nursing) C about the facility's process for marking residents charts related to code status. ADON C stated that the admitting nurse and UC (Unit Clerk) J work together to complete the resident's Advanced Directive Orders for DNR or CPR and the PPACO (Physician-Patient Advance Care Orders) form. ADON C stated that after the resident's PPACO form is completed, UC J places the colored DNR or CPR form as the first page of the resident's chart as indicated. On [DATE] at 11:40 AM, NHA A told Surveyor that staff are trained to look for the DNR or CPR form in the front of the chart, when it is necessary to identify a resident's code status during emergent situations. On [DATE] at 3:35 PM, Surveyor spoke with R11 regarding his advanced directives. Surveyor asked R11 if his wishes regarding resuscitation in the event of an emergency were discussed at the time of his admission to the facility. R11 told Surveyor that when he first came to the facility he was pretty sick. I remember them doing it (discussing resuscitation) at the hospital. But not here. Surveyor asked R11, if in case of an emergency, would he wish to be resuscitated. R11 told Surveyor: Oh yeah, I want the whole thing done. Everything. On [DATE], at approximately 3:45 PM, Surveyor spoke with UC J regarding residents' advanced directives. UC J stated when the code status order comes back from the doctor, with the doctor's signature; she (Unit Clerk J) will put either the DNR (red) sheet or the Full Code (green) sheet in the front of the resident's chart. Surveyor asked when R11's red DNR sheet would have been placed in his chart. UC J looked at the PPACO sheet in R11's record and seeing the MD's signature, with the date [DATE], stated she would have put the red DNR sheet in R11's record on [DATE]. The facility did not ensure R11's code status was accurately documented in R11's record in the place 3 of 3 floor nurses interviewed and 4 of 4 CNAs interviewed would look for such information during an emergency. The failure to ensure that residents' advanced directives are accurately documented created a finding of Immediate Jeopardy. The Immediate Jeopardy was removed on [DATE] at 2:45 PM, after the facility completed the plan to include: 1) The resident's medical chart involved in the alleged practice was reviewed by the Regional Nurse Consultant and Director of Nursing on [DATE]. The code status form was updated to match the POLST form and physician orders. 2) The Regional Nurse Consultant re-inserviced the Director of Nursing, Social Worker, Unit Clerk and ADON on Code status, sheet system, checking POLST forms, physician orders [REDACTED]. Working nursing staff, on [DATE], were inserviced by DON designee on code status, sheet system, checking POLST forms, physician orders [REDACTED]. Off duty staff were notified by the DON and ADON to meet with the DON and ADON prior to working, to receive training on [DATE]. 3) On coming staff, on each unit, will not be allowed to begin work until they meet with the DON and ADON to receive the in-service training. Reminders were posted at the time clock and employee entrances. The in-services will include education on (sic) the Regional Nurse Consultant re-inserviced (sic) the Director of Nursing and ADON on Code status, sheet system, checking POLST forms, physician orders [REDACTED]. 4) Mock codes will be completed (every) shift for first 24 hours. Mock code will then be completed monthly on every shift, 1 time per month for 3 months, followed by quarterly thereafter. Mock codes will be completed by DON or Designee. 5) [DATE] - The Regional Nurse Consultant, Executive Director, Social Worker and DON reviewed the Code Status procedure to monitor that the AOC (Allegation of Compliance) plan was in compliance and to ensure that the code status procedure is being followed. The DON or Social Worker will review Code status every week for a minimum of 12 weeks to ensure compliance. New admissions will be reviewed for compliance with code status. Any negative findings will be corrected immediately. Education will be ongoing as needed. 6) Facility wide audit has been completed by [DATE]. Any issues identified were corrected immediately. 7) AD HOC QA (Quality Assurance) meeting - On [DATE] the QA / PI (Performance Improvement) Committee (composed of Regional Nurse Consultant, Executive Director, DON, ADON and Medical Director) met to review the code status procedure and audit. Weekly audits will be brought to QAPI monthly for review and further recommendations.

Based on observation, interview and record review, the facility did not ensure a resident who enters the facility without Pressure Injuries does not develop Pressure Injuries, that each resident receives care consistent with current standards of practice to prevent the development of a pressure ulcer (Pressure Injury), promote healing, prevent infection or prevent new sores from developing, for 3 of 6 Residents (R3, R2 & R1) reviewed for Pressure Injuries (PI) out of a total sample of 12 Residents. R3 was identified as being at high risk for PI's upon admission and facility staff was aware R3 was at high risk for Pressure Injuries. Given this risk, the facility did not implement aggressive actions to prevent breakdown, causing a stage IV Pressure Injury to develop, which later on became infected. The facility did not address the resident's alleged refusal to reposition or the fact that she experienced pain when repositioned on her side. Facility failure to provide care, consistent with current standards of practice to prevent the development of a pressure ulcer, and failed to ensure a resident with a pressure ulcer receives treatment and services to promote the healing of a pressure ulcer, created a finding of Immediate Jeopardy that began on 11/9/2016. Nursing Home Administrator (NHA) A, Director of Nursing (DON) B, Assistant Director of Nursing (ADON) C, Corporate Nurse Consultant (CNC) O and Corporate Representative (CR) P, were notified of the Immediate Jeopardy on 05/23/2017 at 4:21 PM. The Immediate Jeopardy was removed on 05/23/2017, however the deficient practice continues at a scope/severity of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as evidenced by: R2 was observed as not having appropriate interventions in place per Care Plan while in recliner chair. R1 is at risk for Pressure Injury. It was not until R1 developed a Stage III Pressure Injury, that a specific Care Plan was developed to address R1's Pressure Injury risk. In addition, the documentation of these wounds is not consistant to accurately assess progression of healing of the wounds. This is evidenced by: The facility policy, entitled Skin Integrity Guideline, states in part: Purpose: . to decrease pressure ulcer and/or wound formation by identifying those Patients/Residents who are at risk and implementing appropriate interventions . Patients/Residents will be assessed or observed for risk of skin breakdown within 24 hours of admission or readmission, quarterly, before transfer or discharge to any setting (unless emergent nature of transfer does not allow) and as necessitated by change in condition. Living center develops a routine schedule to review Patients/Residents with wounds or at risk on a weekly basis and will document findings. The Interdisciplinary Plan of Care will address problems, goals and interventions directed toward prevention of pressure ulcers and/or skin integrity concerns identified . Documentation and Care interventions for skin integrity: evaluation/observation is to be completed within the first twenty-four hours of admission/quarterly/significant change of condition using the weekly skin review and/or Wound Evaluation Flow Sheet. If identified risk present, the interventions will be documented in the Immediate Plan of Care or Comprehensive Care Plan. Patients/Residents utilizing a wheel chair, as a primary mode of transportation, will have a pressure redistribution device in place as indicated by the Individualized Plan of Care. Pressure redistribution mattresses are in place as indicated by the Individualized Plan of Care. If there is decline in skin integrity, pressure redistribution surfaces will be reviewed for appropriateness and implemented as indicated by the Individualized Plan of Care. Patients/Residents will be observed by the CNA (Certified Nursing Assistant) daily for reddened/open areas, [MEDICAL CONDITION] of feet or sacrum. Changes will be reported to the licensed nurse and documented . Documentation of Weekly Skin Evaluation/Observations: Licensed nurse will be responsible for performing a skin evaluation/observation weekly, utilizing the Weekly Skin Review UDA. Licensed nurse to document weekly on identified wounds using the Wound Evaluation Flow Sheet (WEFS) UDA . Care Plan is to be implemented, evaluated and revised based on the needs of the Resident. If Patient/Resident is refusing or choosing not to receive treatment, review risks, benefits and alternatives. Re-evaluate and attempt other interventions . Example 1 R3 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. R3's Admit Skin Condition, dated 8/8/16, shows eschar (Unstageable PI) to Right & Left cheek, Right & Left knee and Left elbow & abrasion to Right elbow. This document had no indication of impaired skin or skin concerns identified to R3's bottom/coccyx/sacrum area or heels upon admission to the facility. R3's Braden Scale indicated a score of 12 (score of 10-12 indicates high risk) indicating R3 was at high risk for skin breakdown. R3's Care Plan indicates the following interventions were in place on 08/09/2016: Transfer assistance of 2 with Hoyer lift, use of broda chair and grab bars, bed mobility assistance of 1 assist, inform resident of risks of refusal of care, inspect skin with care. Report reddened areas, rashes, bruising or open areas to Charge Nurse. Locomotion assistance of 1, toileting assist of bed pan every morning and before and after meals at bedtime and check and change during the night and offer bed pan, turning and repositioning program every 2 hours and per request needed. R3's Care Plan, provided to Surveyor on 05/23/2017, does not indicate that she had an at risk for Pressure Ulcer Care Plan in place on 08/09/2016. R3's Care Plan shows Pressure ulcer actual or at risk due to: assistance required in bed mobility, bed fast, bowel incontinence, obesity, pressure ulcer present. Skin desensitized was initiated on 11/29/2016. Interventions initiated on 11/29/2016 include: complete a Braden Scale per policy, conducting a weekly skin inspection, diabetic foot monitoring. Do not massage over bone prominence, float heels, nutritional and hydration support; offer multiple times turn and reposition and continue to do so as resident allows; provide pressure reduction/relieving mattress, provide thorough skin care after incontinent episodes and apply barrier cream; skin assessment per policy, turning and repositioning schedule per assessment and weekly wound assessment. This Care Plan was initiated a month after R3 developed a Pressure Injury. R3's Pain Care Plan on 05/23/2017 states in part: needs pain management and monitoring related to: personal history of falls, open wound and medical [DIAGNOSES REDACTED]. Interventions on 08/09/2016 included: administer pain medication as ordered, dim lighting/quiet environment, distraction techniques, encourage proper rest, music, relaxation techniques and exercise. Interventions initiated on 03/17/2017 includes: evaluate and establish level of pain on numeric scale/evaluation tool, evaluate characteristics and frequency/pattern of pain, evaluate need for bowel management regimen. Evaluate need for routinely scheduled medications rather than PRN pain med, evaluate need to provide medication prior to treatment or therapy, evaluate what makes the patient's pain worse, implement the patients preferred non-pharmacological pain relief strategies; observe for potential medication side effects, offer spiritual support if desired, repositioning and utilize pain monitoring tool to evaluate effectiveness of intervention. (Please note: repositioning for pain management was not initiated on R3's care plan until 3/17/2017.) R3's admit Minimum Data Set (MDS) assessment, dated 08/15/2016, indicated that R3's BIMS (Brief Interview of Mental Status) was a 15, indicating no cognitive impairment. This assessment indicated that R3 needs extensive 2 person physical assist with bed mobility and transfers between surfaces. R3 is indicated as not being able to ambulate. Section M indicates R3 is at risk for pressure ulcers (Pressure Injuries/PI's) and that she has 5 unhealed Unstageable PI's with eschar present. R3 was hospitalized from [DATE] - 10/11/16. On 10/11/2016, R3's hospital discharge summary indicates R3 has been developing worsening pain in both legs, butt pain, inability to walk or improvement. She uses wheelchair, which hurts her butt. On 10/11/2016, R3 readmitted to the facility with [DIAGNOSES REDACTED]. R3's Skin Condition Form indicated R3 had bruises and scabs to bilateral knees. There is no indication of skin breakdown noted to R3's bottom/coccyx/sacrum area or heels upon re-admission. 10/12/2016 - NP facility visit note states in part: . Patient is complaining that her butt hurts from sitting in her wheelchair . 10/19/2016 - MD facility visit note states in part: .Volunteering overactive bowel and bladder, most frustrated by the frequent position changes required for her [MEDICAL CONDITION] . back and extremities - 2+ [MEDICAL CONDITION]/no ulceration, other - unable to move her legs, as before . (Note: Since readmitting on 10/11/2016 up until 10/28/2016, R3 had multiple days where she complained of leg pain to facility staff.) 10/28/2017 at 10:00 AM, Nurses note indicates that NP U was aware of R3 having a decline in condition and assessed R3 at bedside and that R3 is being admitted to Hospice. 10/28/2016 - NP facility visit note states in part: . has declined over the last few days. She has some congestion and is weaker than normal. She is now bedbound . On 10/28/16, R3 is admitted into Hospice care. 10/29/2016 - Hospice visit note states in part: . wound description: Patient has stage 2 ulcer to sacral/coccyx. Site has one large red/black area that is 4cm x 5cm. 2 smaller areas as well . and soreness to back region/buttocks that she rates as a 5/10 currently . called (physician name) . (Note: Please note that Hospice identified what stage R3's Pressure Injury was and assessed the wound, not the facility staff. There is no documentation of R3's wound prior to Hospice's assessment on 10/29/16.) 10/31/16 - Hospice visit note states in part: . uncovered pt, she was not wearing a tabbed brief and she was sitting in multiple disposable chux pads that were saturated with urine . assisted CNA to do a complete bedding change . soaked with urine from her legs to her upper back . low air loss mattress was then put in leiu of her regular mattress . wound care orders for [MEDICATION NAME] or foam dressing every 3 days and PRN if soiled . (R3's mattress was changed from a regular mattress, which manufacturer guidelines states in part: . designed to prevent and relieve pressure ulcers by distributing weight as uniformly as possible . 3. Any stage pressure ulcer on the trunk or pelvis. Plus one of Numbers 4 - 7 or 4. Impaired nutritional status. 5. Fecal or urinary incontinence. 6. Altered sensory perception. 7. Compromised circulatory status . NOTE: If the facility's standard mattress is good for any stage Pressure Injury, then R3 should not have developed a stage III/ Unstageable pressure injury.) 10/30/16 at 1:52 PM, Nurses note states in part: . coccyx wound cleansed, covered to protect . 10/31/2016 at 7:30 AM, Nurses note states in part: . foam dressing applied to sacral ulcers after gentle cleansing . 11/3/2016 - Hospice visit note states in part: . pt was agreeable to having (nurse) help reposition her as pt often refusing to be repositioned anywhere besides her back . 11/4/2016 - Hospice visit note states in part: . Wound assessment . pressure ulcer - sacrum 4 cm x 6.5 cm x 0 cm Unstageable . Wound description: wound bed covered in black eschar tissue. Measurements taken today. Unstageable due to eschar tissue. Does not appear to be deepening. Sacral [MEDICATION NAME] placed over area. Pt with small satellite pink open areas to the right of eschar tissue . Pt's brief was saturated with urine and BM and had soaked through all the way to the chux pads under her . Chux pads under pt's back also saturated due to clear yellow drainage coming from pt's [MEDICAL CONDITION] burn on her back . conferenced with (NP U) after visit to talk about wound and possible wound care . 11/4/2016 - NP U order indicates: Wound care to coccyx: clean wound, apply foam dressing, change Monday - Wednesday - Friday and as needed. 11/4/2016 at 2:03 PM, Nurses note states in part: . refuses to get OOB (out of bed) . Res incontinent of bowel and bladder - voiding frequently large amounts . continues to have large sacral ulcer covered in yellow adherent slough and areas of black necrotic tissue within - no drainage . (Note: The pressure injury was slightly larger on 11/4/16, measuring 4 x 6.5 cm and covered by black eschar. Per Hospice, the wound was Unstageable.) 11/6/2016 - Hospice Visit note states in part: . writer met with floor nurse and agreed to have this writer change dressing, also asking if a Foley order due to possibility of urine rising up into wound dressings . 11/06/2016 at 1:36 PM, Nurses note states in part: . Res incontinent of bowel and bladder- voids frequently . continues to have large sacral ulcer covered in yellow adherent slough and areas of black necrotic tissue within - large amount of foul smelling drainage noted on old bandage . 11/6/2016 - R3's Verbal order states in part: . indwelling urinary catheter: may insert 14-22 French Foley catheter PRN for [MEDICAL CONDITION] or obstruction; to assist healing of perineal and sacral wounds in incontinent patients; or for end-of-life palliative care comfort 11/8/2016 - NP order indicates: Please sprinkle 500mg of [MEDICATION NAME] (antibiotic) into coccyx wound with every wound care, for odor control . wound care every 3 days and as needed to coccyx to be performed by nurse. Wound care to consist of removal of old dressing, clean with soap and water, cover with 4x4 [MEDICATION NAME] or foam dressing. 11/9/2016 - Hospice visit note states in part: . Discussion with (facility nurse) who reports patient has not gotten out of bed very much over the past 2 weeks . [MEDICATION NAME] for wound . 11/9/2016 at 3:11PM, Nurses note indicates that R3's wound measured 4.5 cm x 6 cm and had greater than 50% of the wound had leathery eschar and moderate amount of dark serous drainage which had a foul odor. 11/10/2016 - Hospice visit note states in part: . She appeared uncomfortable with furrowed brows and reported that her pain was a 7. She requested Tylenol. The facility RN was notified and indicated that when she returns from lunch she will give (R3) medication . 11/11/16 - Physician contact states in part: . coccyx wound: area is a little deeper red today due to patient not wanting to turn from side to side. Patient agrees today to reposition to avoid further breakdown . 11/11/16 - NP U orders indicate: wound care to coccyx: clean wound, use skin prep around wound, apply [MEDICATION NAME] to wound bed, alginate over wound bed and cover with foam dressing change daily and as needed. 11/14/2016 - NP U's facility visit note states in part: . Pressure ulcer of coccygeal region, stage 3 . seen today to assess her wound and debride it. Patient is a Hospice patient with a stage III pressure ulcer to her coccyx. Per Hospice and (facility) staff, the wound has progressively gotten worse. Initially the wound was thought to be a Kennedy Terminal Ulcer but I do not believe that is the case . Exam: Coccyx: Before surgical debridement is performed, the entire wound was covered with hard, black necrotic tissue. There was one tiny spot which you could barely see into the wound bed. I was able to debride most of that and expose the wound bed. Yellow and black slough continue to cover some of the wound bed but it is soft and adherent to the wound bed. Santyl should be able to facilitate faster removal . Plan: New wound care orders written at facility. Santyl will be applied daily. Wound will be covered with alginate followed by foam dressing . will continue to debrided as needed . 11/14/2016 - NP orders indicate: wound care to coccyx: clean wound, Santyl to necrotic parts of wound bed (stop [MEDICATION NAME]), use skin prep around wound, apply alginate over wound bed, cover with foam dressing and change daily and a needed. 11/14/16 - Hospice visit note states in part: . reports strong odor continues with wounds well as drainage that requires it to be changed daily now . pt has been refusing to lay on her sides and prefers to lay on her back. During visit, writer asked if she would be willing to go onto her side and relieve pressure off her bottom but she denied . There is no evidence that the facility, knowing the resident did not like repositioning on her side, addressed this in the care plan and presented her with options that might be acceptable. If the resident was refusing because of pain, there is no evidence the facility looked at the resident's pain regime. Nor is there evidence that the facility addressed risks of not repositioning with the resident. 11/16/2016 at 11:14 AM, Nurses note states in part: . approx. 6 x 4 cm, still >50% necrotic and thick yellow slough, pink wound bed visible, no tunneling . 11/20/16 at 12:56 PM, Nurses note indicates R3's sacral wound has increased black/brown/yellow necrotic tissue covering approx .75% of the wound bed and now has a very foul odor. 11/21/2016 - Hospice visit note states in part: . Patient leaning to right side in bed . repositioned patient. Patient moaned with repositioning, denied pain afterwards . wound on sacrum is 75% necrotic tissue . 11/23/2016 at 3:22 PM, Nurses note states in part: .res has been nonambulatory for months and has an indwelling Foley catheter . 11/28/2016 at 11:00 AM, Nurses note states in part: . (NP U) performed sharp debridement of res sacral ulcer at this time again in res room . large amount of yellow slough and black necrotic tissue in wound bed covering approx. 75% of wound bed. 11/29/2016 - NP orders indicate: Change coccyx wound care to twice daily. 11/29/16 at 11:17 AM, Nurses note states in part: IDT: met to discuss resident's refusal of medications, treatments and staying off her backside to aide in healing her Unstageable sacral wound. Resident's goal is comfort and staff to allow her to make liberal choices as we are honoring her wishes. Again, there is no evidence the facility looked at ways that might make the resident comfortable while repositioned off her backside. 11/29/16 at 2:23 PM, Nurses note states in part: . Res continues to be resistant at times with allowing staff to assist with turning/repositioning/offloading from her sacral wound area . 12/1/2016 Hospice visit note states in part: . Joint visit with CTM, WCC, RN (name) to assess pt's coccyx wound as it continues with strong odor and continues with copious amounts of drainage . dressing from previous night was saturated through by 11am . wound 1 cm larger from last week's measurements. Unable to visualize wound bed as calcium alginate and carboflex dressing was on wound . recommended starting [MEDICATION NAME] with each wound change along with the use of Santyl. Explanation done with R3 that we want to do all we can for her wound, but that she will need to try and be more compliant with repositioning and she stated I'm trying. Teaching also done with R3 that there is some tissue that is dying/decaying on her bottom and that the less pressure put on the area, the better . (Education done by Hospice staff not by the facility) Pressure wound measurements indicated as 9 x 9.8 x 0.5 and has full thickness loss (stage III) with large amount of drainage and foul odor. 12/2/2016 - NP order indicates: Please add the following to the coccyx wound care order: After Santyl, please sprinkle 1 cap of [MEDICATION NAME] 500mg done twice per day. 12/2/2016 at 11:30 AM, Nurses note states in part: . writer noted a 3.0 cm x 3.0 cm irregular shaped red non-blanchable area to res Left heel today during AM care Call placed to (Hospice agency) to update . 12/5/2016 at 1:56 PM, Nurses note states in part: . sacral wound with increased black/brown/yellow necrotic tissue covering approx . 75% of wound bed and has a very foul odor . Resident was found to have an approx . 3.0 cm x 3.0 cm irregular shaped, red non-blanchable area to Left heel recently. Skin to affected area is closed and intact. Periwound pink and also intact, affected area nontender to touch . On 5/24/2017 at 2:55 PM, Surveyor interviewed ADON C regarding R3's left heel. ADON C indicated there were no measurements for R3's heel as it resolved within a few days. 12/7/2016 at 1:27 PM, Nurses note states in part: . Debrided by NP . area measures 10.0 x 8.5 cm x 0.7 cm . undermining . presents as a stage III PU. 12/7/16 - NP order indicates: stop [MEDICATION NAME], change wound care to daily. 12/7/2017 - Wound Evaluation Flow Sheet (WEFS) indicates: Stage III, 10 cm (Length) x 8.5 cm (Width) x 0.7 cm (Depth), with undermining of 0.6 cm at 12 o'clock, 0.8 cm at 3 o'clock, 0.6 cm at 6 o'clock and 1.4 cm at 9 o'clock. Thick, moderate amount of Serosanguineous drainage noted, no odor. Wound bed is 50% slough & 50% moist & pink, periwound is irregular, no warmth or swelling. Current treatment Santyl & cover dressing. (Note: By 12/7/16, the wound had increased in size to 10 x 8.5 cm and now had depth 0.7 cm). There was undermining at 12, 3, 6 and 9:00 and moderate serosanguineous drainage. There was no odor. Staff staged the wound as a stage 3. On 05/22/2017 at 3:00 PM, Surveyor interviews Registered Nurse (RN) T regarding wound measurements. RN T indicated that measurements prior to these sheets (Wound Evaluation Flow Sheet) are in the nurses notes on the computer. RN T indicated that R3's wound happened in October. (Note: the first WEFS measurement is dated 12/7/2016). 12/9/2016 at 9:43 PM, Nurses note states in part: . she does not like to lie on sides and will only stay for short period of time . staff continues to encourage her to lie on sides. 12/11/2016 at 2:52 AM, Nurses note states in part: . was screaming out earlier and was saying her back hurt and she was scared . PRN oxy and [MEDICATION NAME] were given . 12/11/2016 at 3:05 PM, Nurses note states in part: . Dressing is saturated with yellow sero sanguinous(SIC) drainage . 12/12/2016 at 2:24 AM, Nurses note states in part: Resident was restless and she stated she was in pain. She has relief with the medication and was no further moaning . On 12/14/16, R3's Physician visit progress note states in part: . the biggest problem has been a poorly - responsive sacral pressure wound . and that R3 has . back and extremities - 2+ [MEDICAL CONDITION]/ large sacral pressure ulcer wound open to bone, black eschar debrided since my last drop-in visit . Sacral pressure wound - probably inevitable given the context; can't think what else we would have done; patient adherence with positioning is difficult . [MEDICAL CONDITION] (due to) vertebral/spinal canal involvement - observing for skin, bowel, and bladder issues . Pressure ulcer of coccygeal region, stage 3 11/14/2016. 12/14/2016 at 12:32 PM, Nurses note states in part: MD here on rounds . sacral wound with increased brown/yellow slough covering approx . 75% of wound bed and has a very foul odor. Measurements are approximately 10 cm x 8.5 cm x 0.7 cm deep Resident was found to have an approx . 3.0 cm x 3.0 cm irregular shaped, red non-blanchable area to Left heel recently. Skin to affected area is closed and intact periwound pink and also intact, affected area nontender to touch . 12/15/2016 at 4:13 AM, Nurses note states in part: Resident was given pain medication for the pain and yelling out with repositioning . There were two undated wound measurements documented on WEFS, between 12/7 and 12/28/16. The first of these wound measurement documentations indicates R3's coccyx wound is a stage 4, measuring 10 x 9 x 0.8 cm with undermining at 12, 3, 6, and 9:00. There is liquid yellow/brown drainage and a scant amount of odor, wound bed 50-70% slough, periwound irregular with induration (redness) and no warmth. Treatment Santyl and cover with alginate and padded dressing. The second undated wound documentation indicates the wound is a stage 4 measuring 10 x 8.5 x 3 cm. Undermining continued at 12, 3, 6 and 9:00 and there was tunneling of 3 cm between 3 & 6 o'clock towards the center of wound. There was a moderate amount of yellow/sero sanguineous drainage with foul odor. Wound bed 40% slough, periwound irregular, undermining around edges, induration and warmth noted. No improvement, some boney vertebrae were showing, slough 40%, undermining around edges, small area on (Left) (Right) side of tunneling starting, current treatment Santyl, alginate & padded dressing. 12/22/2016 - Hospice visit note indicates R3's pressure wound measures 10 cm x 11.2 cm x 2 cm and is staged as a stage IV. Wound description: wound not with tunneling to Right lower area of wound bed. Yellow slough covering 30-50% of wound bed. Pt's coccyx bone now visible as it is hard to the touch. Copious amounts of drainage noted to old dressing, sangunous (SIC)/brown in color. Santyl applied to slough (NP U) updated with tunneling and she is aware and we will not pack area when removing old dressing, the pad was saturated with drainage, some drainage had also seeped onto cloth chux under pt. Pt's coccyx wound is a stage 4 pressure ulcer now as pt's coccyx is now visible. Pt often refuses to be repositioned and if she is repositioned she finds a way back to her backside . 12/28/16 per WEFS, the wound was a stage 4 measuring 9 x 9 x 3 cm with undermining at 12, 3, 6 and 9:00 with 3 cm tunneling. There was heavy yellow/brown foul drainage. Wound bed had 40% slough, periwound irregular. treatment of [REDACTED]. No improvement, boney vertebrae showing, slough 40%, 3 cm area on (Right) lower side of wound tunneling, undermining around all edges, heavy foul drainage present. 01/01/2017 at 2:25 PM, Nurses note states in part: . copious amounts of odor full tan drainage. No odor noted once cleaned . agreed to lay on side this afternoon. 01/02/2017 at 2:25 AM, Nurses note states in part: Resident was yelling out help me and stated she was in pain. Pain medication was given . 01/04/2017 NP order indicates: Wound care to coccyx: clean wound with Dakins or normal saline, 1-2 sheets of alginate or alginate rope over wound, use skin prep around wound to protect skin and cover with sacral 9x9 comfort foam border (may cut bottom to avoid covering anus) change daily and as needed. On 1/4/17, the wound measured 10 x 9 x 1.5 cm and was a stage 4. There was undermining all around the wound with 2 cm tunneling between 3 and 6 o'clock. There was heavy yellow-brown drainage and a foul odor. Wound bed 30% slough, pain minimal. Slight improvement, less slough, 1 cm down in size. 01/07/2017 at 2:32 PM, Nurses note states in part: . Large amount of drainage present . resident refusing to get up in chair. 01/09/2017 - NP order indicates: wound care to coccyx: remove old dressing, cleanse wound with [MEDICATION NAME] and plain water, use 30 milliliter syringe with 19 gage butterfly and irrigate with 30 mls of 0.5% Dakins solution. Dry wound, cut two 4x4 calcium alginate with silver into a spiral rope and tuck with finger or Q tip into undermining. Cover with plain 4x4 calcium alginate and cover with 9 cm x 9 cm sacral dressing. Cut bottom to avoid covering anus and cut top of dressing to open to air. Change daily and as needed. 1/10/17 - NP order indicates: use plain alginate to cover wound, use alginate with silver in wound (cut into spiral rope and tuck with finger or Q-tip into undermining). 1/11/17 - WEFS wound documentation indicates: wound measures 8.5 x 8.3 x 5.1 with undermining of 0.4 cm, heavy sero sanguineous drainage with odor. Wound bed is 20% slough and 80% moist & pink. Current treatment [MEDICATION NAME]/dakins irrigate, alginate foam. 1/11/2017 at 2:25 PM, Nurses note states in part: . heavy amts of sero/sang/brown odorful (SIC) drainage . 1/13/2017 at 1:43 PM, Nurses note states in part: . mod to heavy brown drainage. Less odor noted today compared to 2 days ago . has agreed to lay on side in bed 2x this shift . 1/18/17 - the wound had decreased in size and depth (8 x 8 x 0.5 cm) continues to have undermining, no other characteristics charted on WEFS for drainage, periwound, wound bed or treatment. 1/21/2017 at 2:45 PM, Nurses note states in part: . Resident has been (complaining of) back and butt pain this shift. Resident says she can feel her coccyx wound more and more each day . 1/25/17 - wound measures 8.5 x 8 x 0.5 with tunneling of 3 cm x 4 cm and 8 cm undermining/tunneling along edges from 6 o'clock past 9 o'clock per WEFS form. Moderate amount of yellow/brown drainage with foul odor. Pain 4-10. Wound bed indicated as having slough and irregular. Slowly decreasing in size and center has regrowth of healthy tissue. Depth is less than 0.5 cm other the area where tunneling is located. 1/27/17 - NP order indicates to start 500 milligrams of Keflex (antibiotic) twice a day for 7 days for Infected Wound. 01/30/2017 at 10:18 AM, Nurses note states in part: . IDT: met to review resident currently being treated for [REDACTED]. She has a large amount of foul smelling drainage, [DIAGNOSES REDACTED] surrounding the wound bed and therefore was started on antibiotics . 2/1/17 - wound measurements 7 cm x 9.2 cm x 0.5 cm with undermining between 9 & 12 o'clock, with tunneling of 4 cm x 1.5 cm x 2 cm between 3 & 6 o'clock. Drainage is yellow/brown in moderate amount with moderate odor. Pain 4-8. Wound depth has almost completely diminished. One 4 cm long area between 4-6 is 2 cm deep. Wound area is 7 cm x 9.2 cm. No slough noted. 2/8/17 - wound measurements: 6 x 8 x 3 cm with undermining and tunneling present. Drainage is yellow/brown in color in moderate amount with foul odor. Pain 4-8, treatment Dakins solution, alginate and padded dressing. Wound has been decreasing in size, depth and length on a slow but steady basis. No s/s of infection, foul odor still present. 03/08/2017 - wound care order indicates: wound care to coccyx: remove old dressing, cleanse with [MEDICATION NAME] & plain water, use 30 ml syringe to irrigate with 30 mls of 0.5% Dakins solution, dry wound, pack packing strip into tunnel/undermining cover with plain 4x4 calcium alginate, cover with 9 cm x 9 cm sacral dressing, cut bottom to avoid covering anus, cut top of dressing to open to air, change daily and as needed. As of 5/23/2017, R3 still has a coccyx Pressure Injury, although it has decreased in size since 2/8/2017. On 05/23/2017 at 8:50 AM, Surveyor interviewed R3, who indicated she does not like to turn on her sides due to pain. On 05/23/2017 at 9:00 AM, Surveyor interviewed DON B and ADON C regarding R3. DON B indicated R3 is at risk for skin break down and that R3's Braden score of 12 on 8/8/16 put her at risk. DON B indicated that she would expect a pressure reducing cushion in chair, mattress on bed to be pressure reducing and would expect to assess mobility, compliance with repositioning, how R3's skin looks and assess need to change interventions. DON B indicated there is no log to indicate when air mattress was officially put on R3's bed and both DON B and ADON C were unable to indicate what stage Pressure Injury the facilities standard mattress is

Based on observation, interview and record review, the facility did not ensure each resident receives adequate supervision and assistive devices to prevent accidents in 1 of 5 residents reviewed for fall concerns (R2). R2 has a history of falls and has been identified by the facility to be at risk for falls. R2 was not wearing non-slip footwear, as indicated on his comprehensive plan of care, when R2 fell and sustained a hip fracture. This is evidenced by the following: R2's [DIAGNOSES REDACTED]. R2 is status [REDACTED]. On 12/20/16 at 8:54 am Surveyor observed R2 sleeping in his bed. R2's bed was against the wall and low to the floor. There were 2 mats / cushions on the floor to the open side of the bed. R2's call light was in reach and his feet, which were uncovered of blankets or bed sheets, were noted to have on gripper socks. R2's MDS (Minimum Data Set) current at the time of his fall on 12/8/16, with an observation end date of 10/17/16, documents that R2 has a BIMS (Brief Interview for Mental Status) of 2 out of 15, needs extensive assistance with locomotion on the unit, transfers, and toileting, and a history of falls, having fallen within the last month before admission. At the time of admission (10/10/16) R2 had a Risk for Falls total score of 12. This document states a total score of 10 or above deems resident at risk. R2's plan of care at the time of his fall on 12/8/16 had a Focus area which stated: At risk for falls related to: fell in the past 30 days. fell in the past 31 - 180 days. History of falls. New environment. Use of medication, crawls to the floor to sleep. (Date initiated 10/11/16) Interventions to this Focus area include: Footwear to prevent slipping gripper socks or shoes. Date initiated 10/11/16. R2's Nursing Progress Notes contain the following documentation: *12/8/16 3:45 am: Situation: At 0030 (12:30 am) Heard door bang and went to residents room. Witnessed resident lose balance and fall to floor on his buttocks. Did not hit head. About half hour prior to fall staff asked resident if he needed to use bathroom and he declined. Resident was awake watching TV in his room. Background: Unsteady gait. Fall risk. Has matt on floor by bed. Has a walker which was not used. Assessment: Able to move all extremities. BP (blood pressure) 132/68, pulse 74, resp (respirations) 18, temp (temperature) 98.2. PERRLA (Pupils Equally Round Reactive to Light and Accommodating). Denied pain. Stated he will be okay. Was assisted to standing position and back to bed. Response: No noted injury. Will monitor. Message left for POA (Power of Attorney) and for NP (Nurse Practitioner) to update in am. Walker placed near bed. Frequent checks being done. Call light was within reach. Matt on floor by bed. Resident did have his shoes on at time of fall. *12/8/16 1:41 pm: Situation: Around 0830 (8:30 am) (R2 - name) was found lying on his right side with his feet by the toilet and his head out of the door with walker at bed side. Background: (R2 - name) has a history of falls. Working with PT (Physical Therapy) / OT (Occupational Therapy) / ST (Speech Therapy) for strengthening. Just started walking with PT and has tried several times to walk without a walker or assistance. Assessment: Resident was able to assist staff get up into w/c (wheel chair). Was able to bend and put weight on all extremities without pain. No bruising note. Response: Once back to bed, (R2 - name) c/o (complained of) severe pain in the left hip and only wanted to lay on his right side. Stating he had to poop. Miralax given as ordered but he only drank half. No results yet. A face to face with NP done and orders received. *12/8/16 9:05 pm: Found resident in severe pain and holding onto L (left) hip at 1430 (2:30 pm). He had received a pain med (medication) earlier but it was not effective. Was seen again by (Name) NP and received order to send him to (Hospital) ER (emergency room ) for eval (evaluation) . He left facility at 1530 (3:30 pm) per ambulance. *12/9/16 10:49 am: IDT (Interdisciplinary Team) met to review resident fall. Resident had 2 falls between 340 (Please note the first fall was at 0030 (12:30 am). 3:45 am was the time the note was documented.) and 830 (8:30) am. Resident had increased pain on the left hip area although landed on the right side. An x-ray was ordered pending (mobile X-ray), then He was prescribed vicodin and ice was applied which were ineffective. APNP (Advanced Practice Nurse Prescribe) did see resident and felt he needed to be sent to the hospital. Therefore he was transferred to (Hospital). R2's hospital Orthopedic Surgery History & Physical note dated 12/9/16 states: He fell yesterday at (Facility), seen by (Hospital) ER and X rays showed a left intertrochanteric hip fracture . He was transferred to (another Hospital) for further treatment She (Guardian) confirms he was ambulatory prior to this fall and agrees he would want surgery . A review of the facility's investigation into R2's fall with fracture on 12/8/16 includes the following: *RN (Registered Nurse) C's written statement dated 12/14/16 states: Regarding recent fall of (R2) 12/11. (Please note, R2's fall was 12/8/16. R2 was in the hospital on [DATE].) I was nearest nurse to area, responded to CNA (Certified Nursing Assistant) finding resident on floor in bathroom doorway. Res (Resident) has self transferred / ambulated to bathroom & fallen. Res was wearing soft sox and incont (incontinent) brief. Res resisted to assistance. Care plan as written was followed. Res had been working with therapy and ambulating with walker. Bed was in low position, matt in place, knee protectors in place. On 12/20/16 at 2:20 pm Surveyor spoke with RN C regarding R2's 12/8/16 fall and the statement she had written on 12/14/16. Surveyor asked RN C what was meant by soft sox. RN C told Surveyor that soft sox were regular socks. Surveyor asked if they were gripper socks. RN C stated they were not gripper socks, just regular soft material socks with no gripper or non-skid properties. RN C stated R2 used his walker to get to the bathroom stating: He wouldn't have gotten there otherwise. Surveyor showed RN C R2's care plan with the intervention dated 10/11/16 which states R2 was to wear Footwear to prevent slipping gripper socks or shoes. Surveyor asked RN C why she had stated the care plan was followed as written when R2 had soft sox in place and not gripper socks. RN C stated He was in bed. I suppose that (intervention) is for when he is up (out of bed). He was not supposed to up at that time. On 12/20/16 at 2:26 Surveyor spoke with RN D regarding R2's fall on 12/8/16 at 8:30 am and her note from 12/8/16 at 1:41 pm. Surveyor asked RN D where she got the information as she had written it as some of the information she wrote (e.g. walker at side of bed) is different than other reports (See interview with RN C from 12/20/16 at 2:20 pm noted above.) RN D stated It was kind of like hearsay. I was taking that information from the previous fall (at 12:30 am). I should have made a correction. The Post Fall Analysis / Plan for R2's fall from 12/8/16 at 8:30 am documents that R2 was wearing gripper socks. The IDT Review and Recommendations state: IDT meet to review res fall with subsequent hip fracture. Res was responding to bathroom needs as he stated poop when asked what he was trying to do. Staff visualized resident sleeping just prior to this and when she came back to room resident was lying on the floor in the bathroom. Bowel meds were adjusted to decrease constipation. Res returned to facility after surgical repair of hip and all care plans were reviewed and adjusted to reflect resident current status. The summary statement written by DON (Director of Nursing) B regarding R2's fall on 12/8/16 at 8:30 am states: I spoke with (CNA- Name) that was providing care to R2 and she stated she was going to work with him shortly but was finishing up with another resident. (CNA name) stated he had been in bed sleeping prior to her checking in on him, but he was next, to provide care to. (CNA) stated she left the room and when she returned he was already in the bathroom on the floor. He had his walker, in the bathroom and was not yet released to be walking on his own. He found (sic) on the floor in the bathroom. His fall care plan was reviewed and was thought to be accurate as previously (R2) would tell you when he had to void or go to the restroom . On 12/20/16 at 2:30 pm Surveyor spoke with DON B regarding R2 and his fall on 12/8/16 at 8:30 am. Surveyor asked DON B why the post fall analysis report stated R2 was wearing gripper socks when RN C's note stated R2 was wearing soft sox. DON B stated she just writes the Review and Recommendations part of the form, and that the other information she received from other staff whom she identified as RN D. DON B told Surveyor that R2 was in transition as far as his activity. DON B stated R2 was working with therapy and was progressing with his ambulation. DON B stated R2 was getting stronger and he probably felt he could do things on his own in that moment. Surveyor asked DON B if and intervention of Footwear to prevent slipping gripper socks or shoes on a care plan would mean that intervention would be for at all times. DON B stated Yes and no. When Surveyor asked DON B to explain further DON B stated sometimes the care plan is specific and will state exactly when the intervention is to be carried out, and other times it will not be specific . DON B went on to state that Technically he should have possibly had them on. Surveyor asked DON B for further clarification asking in the absence of any specification as to when the intervention is to be carried out, would she have expected gripper socks to be on R2 at the time of his fall on 12/8/16 at 8:30 am. DON B stated Yes, they should be on at all times. On 12/21/16 at 1:22 pm Surveyor spoke with CNA E, via phone, regarding R2's fall with fracture on 12/8/16. CNA E was working the day of R2's fall. CNA E stated on 12/8/16 she had just left R2's room, having been working with R2's roommate. CNA E stated she had been gone a matter of minutes, and during that time R2 got up to use the bathroom unassisted and fell . CNA E stated R2 was wearing his crew socks. CNA E stated these socks were not gripper socks and do not have non-slip properties. CNA E told Surveyor that R2 would usually ask for assistance when he got up, and staff would then place his shoes or hard soled slippers on his feet. CNA E states she is not aware that R2 had ever self transferred, but did acknowledge that R2 had just attempted to ambulate independently 8 hours previously (at 12:30 am) and had fallen. CNA E states the care plan that states R2 is to wear footwear to prevent slipping gripper socks or shoes is instruction for when R2 is out of bed, not when in bed sleeping.

Based on record review and interview the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 3 of 15 residents (Resident 6, 15, and 3). Resident 6 desired to receive CPR. Three days after returning from an 8-day hospitalization for [MEDICAL CONDITIONS], and altered mental status, staff found Resident 6 unresponsive with agonal breathing. The facility failed to immediately initiate CPR for Resident 6. CPR was not started until emergency personnel arrived. The failure to provide the necessary care including immediately initiating CPR and not leaving a resident in distress created a finding of immediate jeopardy. The immediate jeopardy began on [DATE]. The Nursing Home Administrator was notified of the immediate jeopardy on [DATE] at 12:15 PM. The facility removed the immediacy on [DATE], however the deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its removal plan. Resident 15 aspirated thin liquids on [DATE]. The facility did not monitor Resident 15's change of condition related to his aspiration or when the chest X-ray results on [DATE] stated effusion or pneumonia with [MEDICAL CONDITION]. Resident 15 was transferred to the hospital with [MEDICAL CONDITION]. Resident 3 receives a daily dressing change to a full thickness tear of the meatus and abraded area to the foreskin. Nursing staff did not follow the physician prescribed orders for treatment. This is evidenced by the following: Example 1 According to the Livestrong website: http://www.livestrong.com/article/ 6-agonal-breathing-definition-Respiration Rate Respiration rate is how many breaths a person takes in one minute. The normal rate of respiration is between 15 and 20 breaths per minute. The more active you are, the more oxygen your muscles need, therefore your rate of respiration increases to meet this demand. At rest, it is considered abnormal to have respiration rates greater than 25 or less than 12. Agonal breaths can be as low as three to four breaths per minute. Agonal Breathing-Agonal breathing is also known as gasping for breath. It is a sign that the body is not receiving the oxygen it needs. It most often occurs when a person is actively dying. They are indicative of [MEDICAL CONDITION] or the process of dying from [MEDICAL CONDITION] or [MEDICAL CONDITION]. The American Heart Association notes that agonal breathing can present as a snorting, gurgling or gasping sound. The duration differs from person to person, [MEDICATION NAME] from a few minutes to sometimes hours. Normal respirations are regular in regards to timing. Agonal breathing is irregular and sporadic. It is important to remember that agonal breathing is not sufficient in delivering oxygen to the body. It is a sign of distress and is therefore not considered breathing. [MEDICAL CONDITION] On a positive note, the American Heart Association cites that a patient who displays agonal breathing when suffering from [MEDICAL CONDITION] has a better chance of survival than one who does not. They also indicate that when agonal breaths are present, the brain is still functioning. When CPR is performed on those who are still gasping, they have a better chance of surviving than those who are not displaying signs of respiration. The facility's CPR policy, effective [DATE], includes: 1. CPR sequence -Check patient for responsiveness -Check for breathing or no normal breathing -Call for help -Check a pulse for no more than 10 seconds. -Give 30 compressions -Open airway and give 2 breaths -Resume compressions -No more than 10 seconds hands off time 2. Compressions should be initiated within 10 seconds or recognition of the arrest. What to do in case of a code: -Announce "Code Blue" and the location of the Code by shouting or paging overhead at least three times. -AED-E-Cart is brought to the site. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 6 was [AGE] years old. Resident 6 requested to have CPR (Cardiopulmonary resuscitation). Resident 6's weight on [DATE] was 372 pounds. Resident 6's physician orders [REDACTED]. -[MEDICATION NAME] HCL 240 mg twice a day (day and evening) for [MEDICAL CONDITION]. -[MEDICATION NAME] 200 mg twice a day for [MEDICAL CONDITION] -[MEDICATION NAME] 100 mg twice a day for [MEDICAL CONDITION] -[MEDICATION NAME] HCL 0.3 mg three times a day for [MEDICAL CONDITION] Resident 6's Medication Administration Record [REDACTED]. (Total of 12 doses missed) He was subsequently hospitalized on [DATE] for low blood pressure, [MEDICAL CONDITION] (slow heart rate), and altered mental status. He returned to the facility on [DATE]. Resident 6's nursing notes include: -[DATE], at 5:29 PM, Vitals taken at 2:30 PM and within normal limits. Resident 6 complains of feeling anxious and upset about [MEDICATION NAME] being reduced. Also complains of upset stomach. [MEDICATION NAME] 2.5 mg given and [MEDICATION NAME] 8 mg given at 2:30 PM. Rechecked and resident was less anxious. -[DATE], at 6:36 PM by Director of Nursing (DON) B, Called to resident room at 5:55 PM by CNA who was bringing resident his supper tray. "Resident unresponsive to sternal rub, agonal breathing, pulseless. Instructed Ward Clerk to call 911 at 1756 (5:56 PM). Writer got the AED but before facility staff could begin CPR, Emergency response personnel arrived at 1759 (5:59 PM). CPR performed by them and faint pulse obtained." Resident transferred to hospital for further treatment. Upon investigation 2 nursing staff in with resident at 5:30 PM and vitals taken. Resident offered no complaints at that time. Note no vitals were documented. On [DATE], at 2:20 PM, Surveyor interviewed CNA P. CNA P stated on [DATE] she went to Resident 6's room to give him his supper tray. When she entered the room Resident 6 did not respond and CNA P thought he was sleeping. CNA P shook Resident 6 to try and wake him but Resident 6 did not respond. CNA P yelled down the hall at DON B to come help. DON B came to the room and tried to get him to respond. DON B left the room and got ADON E. CNA P stated she stayed by the door of Resident 6's room during this time. DON B and ADON E returned to the room. CNA P stated she continued to stand outside Resident 6's room to help direct other residents away. On [DATE], at 11:58 AM, Surveyor interviewed DON B who confirmed she is the nurse that responded to Resident 6 on [DATE]. DON B stated she was in the hallway by the nurse's station getting ready to leave when a Certified Nursing Assistant (CNA) called down the hallway for a nurse. DON B responded to Resident 6's room and noted Resident 6 was having agonal breathing and she called down the hall for help. DON B then felt for a pulse and attempted a sternal rub. DON B stated Resident 6's head was down with his chin on his chest so it was hard to tell if there was a pulse. DON B then left the room and went to the nurse's station to get Assistant Director of Nursing (ADON) E and told Scheduler/Ward Clerk Q to call 911. DON B and ADON E returned to Resident 6's room. DON B stated Resident 6 was up in his wheelchair and they could not get him out of the chair. DON B stated the police arrived in approximately 2 minutes and they pulled him out of the chair to the floor and started chest compressions. DON B stated they applied the AED (automated external defibrillator) but it did not advise a shock. Then the paramedics arrived and worked on Resident 6 for about 20 minutes, were able to get a pulse but lost it again before leaving in the ambulance. In addition DON B did not initiate oxygen or give directions to administer oxygen nor did she assure he had an open airway. Surveyor asked what the process is when a resident is found unresponsive. DON B stated the nurse should assess the resident, call others in for assistance, and check the code status in the chart and if a full code begin CPR. DON B stated she told the aides to get more people as she knew they would need help getting Resident 6 out of the chair but the police arrived before they could do that. The DON did not stay with Resident 6 and assess him, did not immediately get assistance in moving Resident 6 to the floor, did not lift Resident 6 ' s head, which was on his chest, to clear his airway, and did not immediately begin cardiopulmonary resuscitation. Consequently, minutes were lost before the paramedics arrived and began CPR. On [DATE], at 2:58 PM, Surveyor interviewed ADON E. ADON E stated on [DATE] she was at the nurses station talking with a family member when DON B came down and said there was an emergency in Resident 6's room. DON B went to the alcove and got the AED and ADON E went to her office to get her stethoscope and then to Resident 6's room. Surveyor estimated the distance from Resident 6's room to the nurse's station was 55 feet. It is approximately another 30 feet from the nurse's station to ADON E's office. The alcove where the defibrillator is located in next to the nurse's station. There is also a crash cart with oxygen in the alcove. After getting to the room, ADON E stated she listened for heart sounds while DON B checked for a pulse. ADON E states she thought there was a faint pulse but Resident 6 was slouched in the wheelchair. Then the Emergency Medical Technicians (EMTs) came into the room. DON B borrowed scissors from the EMTs and cut Resident 6's shirt. There were multiple people in the room and Resident 6 was lifted to the floor, the AED pads were placed and the police started compressions. ADON E stated compressions were not started sooner because she thought there was a faint pulse and there was agonal breathing. On [DATE], at 3:12 PM, Surveyor interviewed Scheduler Q. Scheduler Q stated on [DATE] she was asked to call 911 by DON B because Resident 6 was unresponsive and had agonal breathing. Scheduler Q called 911. Scheduler Q did not go down to Resident 6's room or call a code overhead on the paging system. Per the police department report the 911 call was received on [DATE] at 5:48 PM. The call was dispatched at 5:50 PM and officers arrived at the facility at 5:52 PM. Per the ambulance report the ambulance was dispatched on [DATE] at 5:50 PM and arrived to Resident 6 at 5:54 PM. Upon arrival in the room were facility staff, rescue squad and police officers. Resident 6 was "sitting in a wheelchair with no shirt AED was being prepped for placement. Personnel inside the room stated that it was unsure if there was a pulse. (Ambulance personnel) stated to (rescue squad and police officer) to get patient on the ground. Patient was breathing agonal at an approximate rate of 8 per minute." Weak pulse was noted at the carotid and once defibrillator pads were in place it was confirmed at a rate of 39 bmp (beats per minute). On reassessment pulse was absent and asystole with no shock administered. Fire Department personnel administered CPR. Resident 6 was transported to the emergency room . Resident 6's emergency room notes: Patient arrived at 6:18 PM unresponsive with external pacing. Aggressive treatment for [REDACTED]. Patient remained in a very bradycardic rhythm with a very slow pulse eventually into PA. At this point labs returned showing a potassium greater than 7 and acute [MEDICAL CONDITION]. The patient was not responding and was pronounced dead at 7:48 PM. On [DATE], at 8:41 AM, Surveyor again interviewed DON B and Nursing Home Administrator (NHA) A. NHA A stated she also responded to Resident 6's room to assist. NHA A stated there was a faint pulse and Resident 6 was breathing at the time and it was difficult to get him out of the chair. Surveyor asked what the current procedure is if this were to happen again how they would get a larger resident out of the wheelchair. DON B stated nothing has been done since the incident. The website http://www.AED.com notes that there "Is a 5 minute survival window for a victim of sudden [MEDICAL CONDITION] with the survival depending upon early CPR and having access to an AED within that 5 minute timeframe ...The " Chain of Survival " steps must all occur within 5 minutes:1. Early Access to get help: Call 9112. Early CPR to buy time: Begin CPR Compressions Immediately3. Early Defibrillation to restart heart: Use AED as soon as possible on victim4. Early ACLS to stabilize: Ambulance arrival time " The failure to immediately assess Resident 6, clear his airway, move him to the floor and to immediately begin CPR delayed the initiation of CPR and created a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when they began education with staff how to remove a resident from a wheelchair if found unresponsive, to never leave a resident alone during the event and to ensure a patent airway and all charts were reviewed to identify who is a full code. Example 2 Resident 15 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Resident 15's medications included [MEDICATION NAME] tablet 5 milligrams (mg) daily, Aspirin 81 mg daily. [MEDICATION NAME] 5 mg daily and Tamulsolin 0.4 mg at bedtime. Resident 15's admission Minimum Data Set with a completion date of [DATE] indicates Resident 15 has a cognitive score of 11 indicating Resident 15 is cognitively impaired. Resident 15 needs set up assist with eating. Resident 15 is on a mechanically altered diet and is edentulous (without teeth). Review of Resident 15's comprehensive care plan in part, dated [DATE], Problem: Requires mechanically altered diet related to Dysphagia. Goal: Will tolerate consistency without sign and symptoms of aspiration. Interventions: Diet consistency per Speech Therapy recommendation. Resident 15's comprehensive care plan, dated [DATE], Risk for dehydration related to wounds to feet and legs. Goal: Patient will remain free of signs and symptoms of fluid deficit. Interventions: Check vital signs and auscultate breath sounds as needed, more frequently if indicated. Notify physician of signs and symptoms of fluid excess or deficit. Review of Resident 15's comprehensive care plan does not address Resident 15's complete heart block or Resident 15's potential for aspiration related to his Dysphagia. Resident 15's nursing note, dated [DATE] at 1:35 PM, Speech Therapy (ST) recommends changing diet to mechanical soft solids, thin liquids, no stringy meats, no chewy breads. Speech therapy report form to nursing, dated [DATE] at 10:20 AM, Resident 15 is very wheezy (raspy) sounding. Speech Therapist (ST) concerned that this coincides with upgrade to mechanical soft. Reported to Registered Nurse on the hall. Speech Therapy report to Nursing, dated [DATE], Oxygen levels decreased from 91% to 88% with swallow of thin liquids. Spoke with Nurse Practitioner and she recommended a swallow study orders requested. Resident 15's nursing note, dated [DATE] at 1:56 PM, Resident urine noted to be malodorous, darker yellow, but clear, Temperature 96.1. No confusion noted. (There is no evidence of a lung assessment for Resident 15.) Resident 15's nursing note in part, dated [DATE], at 11:19 AM, Change of condition: Resident noted to have audible wheezing, Background: [DIAGNOSES REDACTED]. Resident noted to be coughing after thin fluid intake. Order for speech therapy yesterday, resulting in resident now on thickened liquids. Assessment: Audible wheeze noted. Lung sounds expiratory wheeze/course crackles throughout crackles clear somewhat with cough and deep breath. Blood Pressure (BP) ,[DATE], Pulse 38(baseline) Temperature 96 oxygen saturation 87% to 90% on room air. Response: Called Resident 15's Physician. Requesting for Chest X-ray or to be sent to emergency room . (ER). Awaiting call back. Resident 15's nursing note in part, dated [DATE], at 1:46 PM, Scripted interview completed. Resident is more short of breath (SOB) today Physician has been notified by the floor nurse. Urine has a strong odor. Resident scored a ,[DATE], which indicates intact cognition. Resident continues to receive therapy services. Resident 15's Physician order, dated [DATE] at 3:06 PM, May we also have an order for [REDACTED]. Physician order: Oxygen by nasal cannula 1 to 6 liters per minute, aiming to maintain pulse oximetry 88% to 92%. Notify physician if unable to maintain saturation or comfort. Resident 15's nursing note, dated [DATE] at 3:10 PM, Order received for chest X-ray. Resident 15's Radiology final report, dated [DATE] at 9:30 PM, Results: There is moderate [MEDICAL CONDITION] venous congestion. Also modest right lower lobe and modest left lower lobe airspace [MEDICAL CONDITION] with effusions or pneumonia. The osseous structure is unremarkable. Conclusion: Moderate [MEDICAL CONDITION]. Also modest right lower lobe and modest left lower lobe airspace [MEDICAL CONDITION] with effusion or pneumonia. Handwritten note in the bottom right hand corner of the X-ray report. Faxed to Resident 15's Physician [DATE] signed by the Registered Nurse. (It is important to note Resident 15's chest X-ray dated [DATE], results include: Basilar space disease on the left interstitial [MEDICAL CONDITION].) Resident 15's nursing note, dated [DATE] at 1:05 AM, Resident 15 chest X-ray results are in noted moderate [MEDICAL CONDITION] also modest right lower lobe and modest left lower lobe airspace [MEDICAL CONDITION] with effusion or pneumonia. These are faxed to Resident 15's Physician. He has dressing to both left and right feet which are dry and intact. He continues to be on antibiotic therapy, is afebrile at this time. This is for wound infection, no new orders on the results of the X-ray. No confusion and was given thickened liquids at this time with his medication. (It is important to note a lung assessment was not completed on Resident 15.) Resident 15's facsimile, dated [DATE], to: Resident 15's Physician. Nursing concern: Results from chest X-ray any new orders? Fax dated [DATE] at 2:37 AM. Physician response: Noted and signed by the Physician on [DATE]. Resident 15's nursing note, dated [DATE] at 10:00 AM (1st documentation since 1:05 AM) Situation: Resident with declining oxygen saturations and increasing abnormal lung sounds. Assessment: Vital signs: temperature 99.7 axillary, BP ,[DATE], pulse 40. Oxygen saturation (SATs) 78% on 2 liter of oxygen. Resting in bed with loud audible coarse crackles and chest congestion noted. Respiration slightly labored with expiration wheezing present. Oxygen increase to 5 liter and Oxygen SATs increased only to 86% to 88%. Resident nail beds and lips are cyanotic and light purple in color. Lung sounds with coarse wet crackles throughout bilaterally. Resident in agreement to be transferred to local hospital. Response: Call placed to on call Physician and updated on Resident above assessment and gave orders to send to emergency room . A review of Resident 15's vital signs from [DATE] when speech therapy first notified nursing of aspiration of liquids through [DATE] when Resident 15 was sent to the emergency room . *[DATE] -at 7:16 AM Blood Pressure: ,[DATE] (There is no evidence a Pulse, Temperature, Respirations and oxygen saturation were monitored on [DATE].) *[DATE] - at 8:14 AM Blood pressure: ,[DATE]. (There is no evidence a Pulse, Temperature, Respirations and oxygen saturation were monitored on [DATE].) *[DATE] - at 10:00 AM (first indication of vital signs) Blood Pressure ,[DATE]. Temperature 99.7 axillary, Pulse 40 and regular, Respirations 20 and Oxygen saturation 78% on oxygen. In reviewing Resident 15's medical record from [DATE] at 1:56 PM through [DATE] at 11:00 AM, there is no evidence of a respiratory assessment, pulse or oxygen saturation completed by the nursing staff. Resident 15's emergency room note, dated [DATE] at 11:30 AM, Resident 15 presents with [MEDICAL CONDITION] and respiratory distress. Yesterday he was noted to have shortness of breath and decreased oxygen saturations. He was placed on 2 liters of Oxygen overnight. This morning he had oxygen saturation of 70% and was placed on 4 liters of oxygen. This did not cause significant improvement so it was increased to a non-breather on Emergency medical service (EMS) arrival. Patient stated he was had symptoms since yesterday. He states he has been short of breath and has had a cough with clear sputum. Physical exam: Increased work in breathing. Immediately placed on [MEDICAL CONDITION] with some improvement of respiratory effort. Initial Impression: Ill appearing patient with [MEDICAL CONDITION] and severe [MEDICAL CONDITION]. Clinical exam most consistent with [MEDICAL CONDITION] exacerbation. Summary On arrival patient was placed on [MEDICAL CONDITION]. This improved his clinical appearance and pulse oximetry. BNP and chest X-ray were consistent with acute [MEDICAL CONDITION] exacerbation. Patient treated with [MEDICATION NAME] and [MEDICAL CONDITION] after further discussion patient would want a pacemaker placement. Patient was coordinated to transfer to University Hospital Madison. Procedure: Critical care time provided 45 minutes. The high probability of sudden, clinical significant deterioration in the patient's condition required the highest level of preparedness to intervene urgently. On [DATE] at 4:05 PM Surveyor spoke with Speech Therapist (ST) Y regarding Resident 15 and his swallow ability. ST Y stated on [DATE] Resident 15's lungs became congested and there was a recommendation for a swallow study. Resident 15's oxygen saturations were decreasing when Resident 15 would drink liquids. ST Y stated she talked to the Nurse Practitioner (NP) regarding Resident 15's cough with liquids and decided on a swallow study. ST Y also stated she downgraded Resident 15's liquids to thickened liquids. In addition: ST Y stated Resident 15's oxygen saturations dropped to 85% and she got Resident 15 some oxygen. ST Y stated the Register Nurse (RN) was to follow up with a chest X-ray. On [DATE] at 4:05 PM Surveyor asked ST Y if she informed an RN about Resident 15's change in condition and decreased oxygen saturations. ST Y stated she did inform Resident 15's nurse regarding the drop in oxygen. ST Y stated the nurse told ST Y to place oxygen on Resident 15. ST Y stated this is the first time Resident 15 has used oxygen since admission. ST Y stated the nurse did not come to assess Resident 15 or to follow up on the oxygen provided. ST Y stated she would have expected a nurse to come and assess the Resident prior to having therapy apply the oxygen. ST Y stated on [DATE] Resident 15 was in bed. On [DATE] at 5:05 PM Surveyor spoke with Director of Nursing regarding Resident 15's change of condition. DON B stated anytime a resident has a change in condition the nurse is to call the Physician. The nurse should do an assessment right away when a resident is complaining of short of breath or oxygen saturations decrease. DON B stated she would expect the nurse to provide the oxygen and do an assessment of the resident and not inform Therapy to apply oxygen and then not see the resident. DON B also stated the nurse should call the Physician in the night and not fax any lab or chest X-ray results after hours. In addition, DON B stated she would have expected the nurse to do a lung assessment every shift and monitor Resident 15 for signs of aspiration pneumonia or any other respiratory changes. The facility did not show evidence of Resident 15's monitoring of change in condition when Speech therapy notified the nursing department of respiratory changes. There is no evidence of a respiratory assessment from [DATE] when the change in lung sounds was identified through [DATE] when Resident 15 was transferred to the emergency room with [MEDICAL CONDITION]. Example 3 Resident 3 was admitted to the facility with [DIAGNOSES REDACTED]. Resident 3's physician's orders [REDACTED]. Cleanse wounds to penis with soap and water, rinse, dry. Apply [MEDICATION NAME] Ag to wound beds, A & D ointment to periwound, cover with oil [MEDICATION NAME] dressing. Resident 3 has a care planned problem dated [DATE] which states in part; "Altered Skin Integrity related to Foley catheter causing friction to the shaft of the penis." An approach to this care planned problem states in part; "Treatments as ordered." On [DATE] at 11:00 AM Surveyor observed the dressing change and treatment to Resident 3's penis. Licensed Practical Nurse (LPN) J washed Resident 3's penis and foreskin with periwash then patted dry. LPN J then applied A& D to the abraded areas on the foreskin and applied [MEDICATION NAME] Alginate to the penile wound and covered with Vaseline gauze. Surveyor reviewed the packaging to the [MEDICATION NAME] Alginate the [MEDICATION NAME] Alginate did not contain AG (silver). On [DATE] at 11:15 AM Surveyor interviewed LPN J regarding the dressing change and treatment to Resident 3's penis. LPN J stated that the [MEDICATION NAME] Alginate Ag and [MEDICATION NAME] Ag are comparable products LPN J stated she did use the wrong product however the product she used did not contain Ag. LPN J stated she would be updating the doctor. According to [MEDICATION NAME]'s website where it asks the question "Why silver?": Silver is a proven antimicrobial in the management of infected wounds and wounds at risk of infection, when used in a protocol of care. Proactive use of silver dressings " ...can inhibit the progression of bacterial penetration and can be effective [MEDICAL CONDITION] and most other superficial pathogens." On [DATE] at 11:45 AM LPN J stated she completed the dressing change to Resident 3 using the correct product. Nursing notes dated [DATE] at 3:01 pm state in part; treatment done MD updated, Health Care Power of Attorney (HCPOA) updated. Nursing notes dated [DATE] at 3:08 pm state in part; spoke with HCPOA via telephone to update on wrong treatment being done this am. On [DATE] at 4:20 pm Surveyor interviewed Director of Nursing (DON) B regarding the wound treatment for [REDACTED].

Based on record review and staff interviews, the facility did not ensure that 4 of 15 sampled residents and 2 supplemental sample residents (Resident 7, 17, 6, 4, 18, and 10) were free of significant medication errors. Resident 7 returned from a hospital stay on 2/4/15 with an order for [REDACTED]. Resident 7 began receiving the [MEDICATION NAME] on 2/9/15, missing 4 doses of the medication (2/5 - 2/8/15). Resident 7 had an increase in pain, not controlled with [MEDICATION NAME] and [MEDICATION NAME], and required evaluation at the surgeon's office. Resident 17 was not administered her ordered [MEDICATION NAME] ([MEDICATION NAME]) for nine days, from 3/4/15 to 3/12/15. Once the facility identified the concern, staff monitored for signs and symptoms of bleeding and bruising. Monitoring for signs of bleeding would typically be initiated in a resident that received an excessive amount of [MEDICATION NAME]. The facility did not place a preventative measure to ensure that a like error did not re-occur. Resident 6 did not receive [MEDICATION NAME] as ordered for 12 doses. Resident 4 received [MEDICATION NAME] after the physician ordered it to be held. Resident 18 received [MEDICATION NAME] without a physician's orders [REDACTED]. Resident 10 was admitted to the facility with [DIAGNOSES REDACTED]. Resident 10 required Intravenous (IV) antibiotic and antifungal for the treatment of [REDACTED]. Evidenced by: Example 1 Resident 7 was readmitted to the facility following a hospitalization on [DATE]. Resident 7's [DIAGNOSES REDACTED]. Resident 7's hospital Discharge Summary, dated 2/4/15, includes the following: [MEDICATION NAME] 2 gm IV every 24 hours for 5 weeks. Resident 7's progress notes included the following: 2/9/15, 1:42 PM, Type: SBAR - Change of Condition. Situation: Medication omission. Background: Res (Resident) currently receiving IV abx (antibiotics) for right ankle infection. Assessment: Writer noted res medication, "[MEDICATION NAME] 2 gms IV q 24 h (hours)" omitted from MAR (Medication Administration Record). Order reinstated as res original med order noted for duration for 5 weeks. Res VSS (vital signs stable) and does not appear to have sustained any ill effects from medication omission. Response: Res updated on medication omission and that medication was reinstated per original MD order. Call placed to (orthopedic surgeon) office to upate on above also - message left for MD or nurse to return call when available. 2/9/15, 8:15 PM, (orthopedic surgeon) notified of resident complaint of increase in pain in right ankle. (Orthopedic surgeon) wanted resident in his office tomorrow at 8:15 AM...Management also made aware of this and they did speak with (orthopedic surgeon) to answer some of his concerns. Resident 7's orthopedic follow up note, dated 2/10/15, includes the following: Here for right ankle pain. Had surgery on 1/30/15. Has noticed increased pain since yesterday. The patient presents today for re-examination of her right ankle. She had hardware removed and debridement done at the right ankle on 1/30/15. She grew gram negative rods including proteus mirabilis and a [MEDICAL CONDITION] staph. She has been treated with dressing changes and IV antibiotics. In the hospital she received [MEDICATION NAME] and [MEDICATION NAME]. ... Last evening 2/9/15, I received a call from the head nurse at her nursing facility which is (name of facility). They informed me she had increased pain which is not controlled by her oral narcotic therapy which includes 40 mg of [MEDICATION NAME] bid (twice a day) and 5 mg to 10 mg of [MEDICATION NAME] every 4 hours as needed. She had no fevers or chills. The also informed me that she had not received any [MEDICATION NAME] since she was transferred there 5 days earlier. A written order for this was with her discharge instructions to them and also a discharge summary indicated that 5 more weeks of [MEDICATION NAME] and [MEDICATION NAME] was planned. She began again receiving [MEDICATION NAME] IV yesterday. On 3/5/15 at 3:20 PM, Surveyor interviewed Registered Nurse (RN) E. RN E is the Assistant Director of Nursing Services. RN E stated Resident 7's [MEDICATION NAME] was not given until 2/9/15. RN E stated the [MEDICATION NAME] was put onto the MAR indicated [REDACTED]. RN E stated a medication error was completed but that there was no investigation into who discontinued the medication. RN E stated Resident 7 should have received the [MEDICATION NAME], as ordered on the discharge summary, beginning 2/5/15. The facility's policy titled, "Anticoagulant Therapy Guideline" dated 1/22/15 states, "The purpose of the Oral Anticoagulant Therapy Management Guideline is to ensure that the anticoagulant therapy is safely administered. Procedures: Order for anticoagulant should be complete including dose/route and lab monitoring. Code medication in PCC (Point Click Care) as anticoagulant and print anticoagulant MAR (Medication Administration Record) ...Order medication. Verify correct dose upon receipt of medication from the pharmacy ..." According to http://www.nlm.nih.gov/medlineplus/druginfo, "[MEDICATION NAME] is used to prevent blood clots from forming or growing larger in your blood and blood vessels. It is prescribed for people with certain types of irregular heartbeat, people with prosthetic (replacement or mechanical) heart valves, and people who have suffered a [MEDICAL CONDITION]. [MEDICATION NAME] is also used to treat or prevent venous [MEDICAL CONDITION] (swelling and blood clot in a vein) and [MEDICAL CONDITION] embolism (a blood clot in the lung). [MEDICATION NAME] is in a class of medications called anticoagulants ('blood thinners'). It works by decreasing the clotting ability of the blood." Example 2 Resident 17 has [DIAGNOSES REDACTED]." dated 4/15/14. Resident 17's care plan dated 1/29/15 states, "At risk for bleeding bruising related to anticoagulant or antiplatelet medication due to: History [MEDICAL CONDITION]. (Resident 17) has hx (history) of nose bleeds and has had to go to ER for cauterization and packing ...Obtain and monitor lab/diagnostic work as ordered. Report results to physician and follow up as indicated ..." Resident 17's "INR (International Normalization Ratio)/PT ([MEDICATION NAME]) Flow Sheet" states, "2/24/15 INR: 2.50. Anti-coagulant dose: Continue c (with) 2.5 mg (milligrams) daily. Date Next Lab Ordered: 3/3/15. 3/3/15: INR: 1.92, Anti-coagulant dose: 2.5 mg QD (each day). Date Next Lab Ordered: 3/17/15. Date: 3/17/15: INR: 1.07. Anti-coagulant Dose: 5 mg Tue (Tuesday) & Thur (Thursday), 2.5 mg S-M-W-F-S (Sunday-Monday, Wednesday, Friday, and Saturday)." "Physician's Laboratory Order" dated 3/3/15 states, "INR in 2 weeks. 3/17/15 one time only related to phlebitis and [MEDICAL CONDITION] of unspecified site (451.9) until 3/17/15 ...Continue on same [MEDICATION NAME] (SIC) 2.5 mg daily." Resident 17's "PT-INR Final Result" lab dated 3/3/15 states, "INR: 1.92 (H) (High) Ref range: 0.92-1.11. 0.92-1.11 Non anticoagulated. 2.0-3.0 [MEDICATION NAME] monitoring. 3.0-3.5 Mechanical Valve or Recurrent systemic embolism. Forwarded to MD & called in results. Keep same dose recheck 2 weeks 3/17/15. (Handwritten)." Resident 17's MAR for March, 2015 states, "[MEDICATION NAME] Tablet 2.5 mg ([MEDICATION NAME] sodium) Give 2.5 mg by mouth in the evening related to: HEART VALVE REPLACED BY OTHER MEANS until 3/3/2015. Do INR 03/03/2015. Order date: 02/24/2015." Resident 17 was administered this order on 3/1/15, 3/2/15, and 3/3/15, according to this MAR. Resident 17 was not administered [MEDICATION NAME] 2.5 mg from 3/4/15 to 3/12/15. The facility completed a "Medication Error Reporting Form" on 3/13/15. This document states that the error occurred on 3/4/15 and involved "right dose," "documentation error," and "started as a transcription error." "Order was given on 3-3-15 to continue same dose of [MEDICATION NAME] and recheck in 2 weeks. Nursing did not read orders properly in PCC as the dose ended on 3-3-15 from previous order given on 2-24-15. MAR indicated [REDACTED]." The facility did not complete a Root Cause Analysis related to Resident 17's not receiving her ordered [MEDICATION NAME]. Education and preventative measures were not completed. The facility obtained an order for [REDACTED]. The facility completed Resident 17's ordered 3/17/15 INR. This document, "PT-INR Final Result" states "INR Value 1.07; Ref range: 0.92-1.11. 0.92-1.11 Non anticoagulated. 2.0-3.0 [MEDICATION NAME] monitoring. 3.0-3.5 Mechanical Valve or Recurrent systemic embolism. 3/17/15 Start [MEDICATION NAME] 5 mg Tue-Thur. 2.5 mg Sun-Mon-Wed-Fri-Sat. Recheck INR 3/31/15 (handwritten)." Resident 17's INR was 1.07 on 3/17/15. This INR is lower than the suggested reference range on 2.0-3.0 for [MEDICATION NAME] monitoring and lower than the suggested reference range of 3.0-3.5 for mechanical valve replacement. Resident 17's "Progress Notes" state the following; 3/3/15: INR results forwarding/call to MD. Awaiting response. Return call from (MD's) nurse new order to continue 2.5 mg daily X (for) 2 weeks. Recheck on 03/17/15. 3/13/15: Situation: Res (resident) has not received [MEDICATION NAME] dose since 3-3-15. Background: Res has hx of [MEDICAL CONDITION], has mitral and aortic valve disorders. Assessments: VS (vital signs) check Q (every) 15 min (minutes), as res allows, no s/sx (signs and symptoms) of bleeding, bruising noted. Response: MD updated, msg (message) left with dgtr (daughter) to return PC (phone call) for update. Orders given to resume previous dose of [MEDICATION NAME] and recheck INR on Tuesday 3-17-15." This statement was written by Assistant Director of Nursing Services (ADNS) E. 3/17/15 "Progress Notes" state, "Notified by (MD's) office that (MD) has not received note from last week about Resident missing [MEDICATION NAME] doses. Not faxed over to (MD's) office, fax confirmation received." On 3/19/15 at 12:55 PM, Surveyor spoke with Director of Nursing (DON) B about Resident 17's medication error. DON B stated that she would continue to look at the resident's INR if they were discovered to not get [MEDICATION NAME] as ordered. Surveyor asked DON B why it was written in Resident 17's chart that Resident 17 was assessed for signs and symptoms of bleeding. DON B stated that you would not look for signs of bleeding if someone did not get their ordered [MEDICATION NAME]. Surveyor requested additional information related to the facility's response to this error. On 3/19/15 at 1:00 PM, Surveyor spoke with ADNS E. ADNS E stated that she wrote the 3/13/15 note for (Resident 17). ADNS E stated that her assessment should have been the other way around. ADNS E stated that she should have monitored for signs of stroke, like tingling, numbness, or signs of [MEDICAL CONDITION], like warmth in the leg. The facility did not place corrective actions in relation to Resident 17's omission of [MEDICATION NAME] for nine days. Example 3 Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 6 was [AGE] years old. Resident 6's physician orders [REDACTED]. -[MEDICATION NAME] HCL 240 mg twice a day (day and evening) for [MEDICAL CONDITION]. -[MEDICATION NAME] 200 mg twice a day for [MEDICAL CONDITION] -[MEDICATION NAME] 100 mg twice a day for [MEDICAL CONDITION] -[MEDICATION NAME] HCL 0.3 mg three times a day for [MEDICAL CONDITION] Resident 6's Medication Administration Record [REDACTED]. (Total of 12 doses) Per the facility Medication Error Reporting Form, on 2/9/15 at 12:54 PM, the facility noted a medication error for Resident 6. Resident 6's [MEDICATION NAME] HCL 240 mg twice a day was discontinued in error on 2/4/15. No ill effects noted and vitals were blood pressure 158/62, pulse 103, temperature 97 F oral and respiration 18. Physician updated, awaiting response. Resident 6's nursing notes indicate the physician returned the call on 2/9/15 and ordered an EKG to be done tonight and blood pressure to be taken twice a day and update physician tomorrow. Resident's blood pressure and pulse elevated early in shift when resident very upset and agitated, resident calm, pleasant after supper, blood pressure and pulse improved. -There are no actual vital signs documented in the note or the vitals summary. Resident 6's nursing note: -2/10/15, at 2:05 AM, sleeping at this time. Blood pressure (BP)124/72 and pulse (P) was 72. -2/11/15 at 5:54 AM, BP 156/86, P 93. Resident 6's vitals log summary: -1/29/15 at 3:06 PM, BP 130/80, P 90, R 18 (respirations). -2/7/15 at 9:15 PM, BP 153/87, P 82, R 20. -2/11/15 at 1:46 PM, BP 150/80, P 88, R 20. Resident 6 was sent to the hospital on [DATE] for [MEDICAL CONDITION]. Example 4 Resident 4's [DIAGNOSES REDACTED]. Resident 4's desired range for INR (International Normalized Ratio) is 2-3. Resident 4's [MEDICATION NAME] orders starting on 2/8/15 were 3 mg in the evening on Sunday and 4 mg in the evening on Monday, Tuesday, Wednesday, Thursday, Friday and Saturday. On 3/3/15 Resident 4 had an INR laboratory test completed. Resident 4's result was and INR of 3.56 and an indication of high. The reference range in 0.92-1.11. On 3/4/15 Resident 4's physician sent a fax order at 9:44 AM to hold the [MEDICATION NAME] for 1 day (3/4/15) then resume 3 mg Monday and Wednesday and 4 mg remaining days. Repeat INR in 2 weeks. On 3/5/15, Surveyor reviewed Resident 4's Medication Administration Record [REDACTED]. On 3/5/15, at 5:35 PM, Surveyor interviewed Assistant Director of Nursing (ADON) E. ADON E stated that Resident 4's [MEDICATION NAME] should have been held on 3/4/15. ADON E stated she would call the physician for follow up and instructed the nurse to hold that evenings dose until ADON E has spoken with the physician. On 3/5/15, at 5:42 PM, ADON E informed Surveyor that Resident 4's physician ordered to hold the [MEDICATION NAME] tonight and to recheck his INR tomorrow. Resident 4's INR results on 3/6/15 were 3.32 and an indication of high. On 3/6/15, the facility received an order from the on-call physician to hold Resident 4's [MEDICATION NAME] today, then resume medication and recheck the INR on 3/9/15. Resident 4's INR results on 3/9/15 were 2.20 which is in the desired range for Resident 4. Example 5 Resident 18's [DIAGNOSES REDACTED]. On 2/12/15 Resident 18's [MEDICATION NAME] orders were: 4.5 mg on Sunday, Tuesday, Thursday and Saturday and 5 mg on Monday, Wednesday, and Friday. On 3/3/15 (Tuesday) Resident 18 had orders for a INR laboratory (lab) test done. Resident 18's INR was 1.79. On 3/3/15 Resident 18 received 4.5 mg of [MEDICATION NAME]. The facility did not receive an updated order for Resident 18's [MEDICATION NAME] until 3/4/15. On 3/4/15 Resident 18's physician changed the [MEDICATION NAME] order to 4.5 mg on Saturday and Sunday, and 5 mg on Monday, Tuesday, Wednesday, Thursday and Friday. The facility did complete a medication error report on 3/9/15 for administering the medication without an order on 3/3/15. On 3/19/15, at 3:50 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated it is the facility's policy that when a resident is on [MEDICATION NAME] labs are typically drawn on Tuesday or Thursday unless ordered otherwise. The labs are drawn in the morning and the evening shift nurse is not to administer the evening dose of [MEDICATION NAME] until the physician has addressed the lab results. DON B stated if the nurse does not get a reply by the time the medication is scheduled they should be calling the physician. DON B confirmed that for Resident 18 the nurse should have not given the [MEDICATION NAME] on 3/3/15 and should have called and followed up with her physician to get an order. Example 6 Resident 10 was admitted to the facility on [DATE]. Resident 10's [DIAGNOSES REDACTED]. Resident 10's signed Physician order [REDACTED]. Resident 10's signed POS dated 2/22/15 states in part; [MEDICATION NAME] 3 grams (gm) IV every 6 hours for infection. Nursing notes dated 3/3/15 at 1:07 pm state in part; received order from Alixa Pharmacy they are unable to get [MEDICATION NAME] from manufacturer at this time. Telephone call placed to physician to inquire if there is anything else to give resident. Nursing notes dated 3/3/15 at 2:20 pm states in part; refer question of antibiotic usage to infectious disease pm Registered Nurse (RN) on phone with infectious disease at this time. Resident 10's signed telephone order sheet dated 3/3/15 states [MEDICATION NAME] 500 mg give 1 tablet by mouth three times a day for infection. Resident 10's signed telephone order sheet dated 3/3/15 states [MEDICATION NAME] 500 mg give 1 tablet by mouth three times a day for infection. Stop IV [MEDICATION NAME]/start oral antibiotics keep giving IV Micafungin. Resident 10's Medication Administration Record [REDACTED]. This medication is not signed out on the MAR indicated [REDACTED] Resident 10's MAR indicated [REDACTED]. Stop IV [MEDICATION NAME]/start oral antibiotics keep giving IV Micafungin. These oral antibiotics were ordered on [DATE] and to begin on 3/3/15 these medications have not been administered. On 3/4/15 at 5:30 PM, Surveyor interviewed Registered Nurse (RN) L regarding administering Resident 10's IV antifungal medication on 3/3/15. RN L stated Resident 10 got all his medications it may have been earlier or later than he wanted he received them it was more of a timing factor. I ran a little bit late - everyone just expects them at a certain time. Surveyor asked RN L if she has a system to check to assure she has given her medications. RN L stated if her drawer in her medication cart is empty then she has given her medications. Of note, the facility has medications that come in a variety of methods bulk, bubble pack; Alixa packaging and individual orders i.e. inhalers, eye drops, and narcotics. Surveyor asked RN L if all medications she administers should be signed out in the MAR indicated [REDACTED]. RN L stated all her medications for the 3/3/15 were signed off on the MAR. On 3/5/15 at 4:20 PM Surveyor interviewed Director of Nursing (DON) B regarding medication administration for Resident 10. DON B stated it is her expectation that Resident's receive their medications as ordered and that nurses should sign out their medications after administration of medication. DON B stated she would expect nurses to review the electronic Medication Administration Record [REDACTED]. Surveyor asked DON B regarding receiving orders from the physician DON B stated she would expect that the orders start the date the order is received unless a specific start date is ordered by the physician. Cross Reference F 425

Based on record review and interview, in 2 of 7 total residents reviewed (Residents 1 and 2), the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Resident 1 is on the blood thinning medication [MEDICATION NAME] ([MEDICATION NAME]). The facility did not consult with a physician timely when it was noted that Resident 1's INR (International Normalized Ratio - a blood test to measure the efficacy of the [MEDICATION NAME]) was elevated. Despite having knowledge of this elevated INR, the facility administered Resident 1's [MEDICATION NAME] as ordered on the evening of 12/9/14. The following day the facility received an order to decrease Resident 1's [MEDICATION NAME] dosage, however Resident 1 was admitted to the hospital on this day for [MEDICAL CONDITIONS] with Urinary Obstruction and Prostatitis before this new [MEDICATION NAME] order could be initiated. Upon arrival to the hospital, Resident 1's INR was elevated even higher. This necessitated the need for Resident 1 to receive 2 units of fresh frozen plasma to reduce the chances for bleeding from his recent Foley catheter placement. Resident 2's wound care was not provided as ordered by the Physician. This is evidenced by the following: Example 1 Resident 1's [DIAGNOSES REDACTED]. Resident 1's physician's orders [REDACTED]. Resident 1 had an INR lab (laboratory) test drawn on 12/9/14 with a documented result of 3.55. This lab report documents that for [MEDICATION NAME] monitoring the lab value should be 2.0 - 3.0. Hand written on this lab report is a note, written by facility staff, which states: "forwarded, also called to MD 1500 (3:00 pm) 12/9." Resident 1's Nurse's Notes for 12/9/14 at 3:08 pm documents: "...INR lab results forwarded to (Physician). Also called and left message for his nurse (name) RN (Registered Nurse) to look for updates to come through. Awaiting call back. Will continue to monitor." Resident 1's record shows no evidence that facility staff received a call back from, or consulted with, a physician regarding Resident 1's elevated INR. Resident 1's MAR (Medication Administration Record) for 12/2014 documents that Resident 1 received his scheduled [MEDICATION NAME] 4 mg on the evening of 12/9/14 despite having an elevated INR. Resident 1's Nurses Notes for 12/10/14 at 1:18 pm documents: "... spoke with (name) RN at (physician's) office again re (regarding): UA (Urinalysis) results, hematuria, pain, abd (abdominal) guarding. Appt (appointment) with MD scheduled for 1415 (2:15 pm) today. Also new [MEDICATION NAME] dosing orders recheck (INR) 12/23... " Resident 1's physician's orders [REDACTED]. (Resident 1's 12/9/14 lab test of the INR of 3.55, and the initial call out to the physician was on a Tuesday.) Resident 1's record documents that Resident 1 was admitted to the hospital from his physician's office on 12/10/14 before the new [MEDICATION NAME] order had been initiated. Documentation from Resident 1's hospital stay from 12/10/14 - 12/15/14 states: "... he was brought to the emergency room and found to have a distended bladder. He had a Foley catheter placed and was admitted . He was also noted to have a (sic) INR of 4.69.... because of his elevated INR he was given 2 units of fresh frozen plasma to reduce the chances of bleeding from his recent Foley catheter placement. Patient's INR was gradually controlled...." On 12/30/14 at 2:13 pm Surveyor spoke with DCE (Director of Clinical Education) C (DCE C was the DNS (Director Nursing Services) at the time of this incident) regarding several topics including Resident 1 and his elevated INR on 12/9/14. Surveyor and DCE C discussed that RN G did place a call to the physician about Resident 1's elevated INR on 12/9/14, but that there is no evidence that facility staff actually consulted with a physician. DCE C noted the time RN G called the physician on 12/9/14 was 3:08 pm. DCE C stated RN G worked the day shift and stated she would have expected the pm staff to follow up on the call out to the physician, or contacted the on call physician that evening (12/9/14), regarding Resident 1's elevated INR and [MEDICATION NAME]. Surveyor placed phone calls out to RN G for additional information but received no response back. Example 2 Resident 2 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Residents 2's initial Minimum Data Set (MDS) assessment dated , 12/23/14 lists a Brief Interview for Mental Status (BIMS) score of 14 which indicates no cognitive impairment. On 12/30/14 at 8:45 AM, Surveyor interviewed Resident 2 who stated, "My wound treatments don't always get done. The nurse will say to me, I will be right back to do your treatment and then the next shift arrives. They pass the buck. I have to stay on them to get my treatment done." On 12/30/14 at 8:50 AM, Surveyor interviewed Registered Nurse (RN) F who stated, "It is very difficult to do everything. It is hard to complete assessments, treatments, take off physician orders, and get the medications passed on time." On 12/30/14 at 8:50 AM, Surveyor interviewed Assistant Director of Nursing (ADON) E who stated, "The floor nurses do all the treatments. We have a wound nurse on Monday's who will do the treatments and measure the wounds." Resident 2's signed Physician order [REDACTED]. (Start date 12/16/14) and "Cleanse BLE (Bilateral Lower Extremities) wounds with saline and pat dry. Apply Vaseline to peri wound. [MEDICATION NAME] to intact skin. Cover wounds with [MEDICATION NAME], secured with kerlix and coban every day shift." A review of December 2014 treatment sheets indicates that Resident 2 was to have his leg wound dressing changed daily. Three times (12/19, 12/24, and 12/26) the boxes are blank meaning the treatment was not completed. A review of the December 2014 treatment record indicates that Resident 2 did not have the [MEDICATION NAME] cream to be applied to his abdomen and groin twice daily. Fourteen times (12/17 PM, 12/18 AM, 12/19 AM and PM, 12/20-12/25 PM, 12/26 AM and PM, 12/27 PM, and 12/28 PM, and 12/29 AM and PM. A review of nursing documentation does not indicate the wound care was completed. On 12/30/14 at 11:00 AM, Surveyor interviewed Resident 2 who confirmed that the wound care was not completed on 12/19/14, 12/24/14 and 12/26/14. Resident 2 stated, "My Physician was in to see me on 12/18/14, he took off my dressings with the nurse present in the room at 11:30 AM. My physician told the nurse to redress my wounds. The nurse did not put bandages on my wounds until 4:00 PM. On 12/30/14 at 12:30 PM, Surveyor interviewed Director of Clinical Education (DCE) C who stated, "Yes, the treatments should be done." DCE C indicated that she reviews the treatment records on a weekly basis.

Based on record review and interview the facility did not provide each resident with sufficient fluid intake to maintain proper hydration and health for 1 of 5 residents (Resident 3) reviewed for hydration. Resident 3 was admitted to the Veterans hospital on [DATE] with a change in mental status. Labs performed indicated that Resident 3 had a critical Sodium level of 170 (Normal range is 136-145), BUN (Blood Urea Nitrogen) level of 117 (normal range is 7-21) and a Creatinine level of 3.3 (normal range is .67-1.17), and the [DIAGNOSES REDACTED]. The facility did not have a system in place to adequately monitor that Resident 3 was receiving the assessed daily recommended amount of fluids to maintain proper hydration. This is evidence by: According to a study published by the National Institute of Health (<http://www.ncbi.nlm.nih.gov/pubmed/ 084> ), an overall mortality rate of 29.8% was found in elderly persons who were hospitalized with dehydration. This increased to 33.3% for those whose sodium levels were 151-153 and to 71.4% whose sodium level exceeded 154. According to Medscape (www.medscape.com/view article/ 8 <http://www.medscape.com/view article/ 8>) Dehydration in Geriatrics from Geriatrics and Aging 2007:10(9) 590-596: Dehydration is a common and serious condition in older adults. Mortality of patients with dehydration is high if not treated adequately... In the older adult dehydration often causes atypical symptoms such as confusion, constipation, or falls.... Body weight proved to be the most responsive to changes in hydration.... Patients consuming less than 50% of meals are at high risk for dehydration. Caregivers should be aware of and anticipate this hazard. Diagnosing dehydration and monitoring fluid balance requires repeated measurement of weight, Creatinine, and physical signs such as tongue hydration. The facility's policy titled "Hydration Protocol," updated 12/08, states the following: *Hydration Assessment: All residents will have a hydration assessment completed upon admission, readmit, then weekly for four weeks, by nursing as part of their weekly summary or more often if condition change occurs. The assessment includes but is not limited to the assessment of: Urine output, skin turgor, mucous membranes of eyes, lips and mouth. *Intake and Output: The interdisciplinary team will work together to identify those residents at risk for dehydration. Each morning at Clinical Startup the following will be reviewed. Dietary will review reports for those leaving 50% or more at meals and or for changes in normal intake for residents. Weight Changes. 24 hour reports for changes of condition that could affect hydration status..... If a resident is identified by the interdisciplinary team as being at risk for dehydration based on a new diagnosis, or changes as indicated above, the resident will have a hydration assessment completed by nursing and/or dietary. Example Resident 3 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident 3's MDS (Minimum Data Set) dated 9/17/14 indicates that Resident 3 had severely impaired cognition, able to make self understood and sometimes understands others. Resident 3's short and long term memory was intact. Resident 3 was independent with bed mobility, and required supervision/or assistance of 1 for transfers and ambulation. Resident 3 required limited assistance of 1 for toileting, and personal hygiene, for eating Resident 3 required supervision with set up help only. Resident 3's care plan with a review date of 10/7/14 titled, "Resident at risk for nutrition/hydration alterations r/t (related to) self monitoring deficits as evidenced by dementia," with a goal of "No s/s (signs and symptoms) of dehydration" under interventions states," Monitor weights weekly, Monitor PO (oral) intake." On 6/17/14, an admission nutritional assessment was completed that indicates Resident 3's estimated fluid need are 1625-1950 ml/d (milliliters per day), under Section 5. Dehydration Risk Factors, box 1h, indicating Dementia is checked. Resident 3's laboratory tests include the following results: 6/2014--BUN (blood urea nitrogen) 15, Creatinine 1.16, Sodium 135, and BUN/Creatinine Ratio: 12.9 (ratio 10-20) 10/31/14--BUN 36, Creatinine 1.44, BUN/Creatinine Ratio: 25, and Sodium 141. 11/14/14 (Hospital ER admission labs) -- BUN 117, Creatinine 3.3, BUN/Creatinine Ratio: 36, and Sodium 170 (Critical Level). Resident 3's physician orders [REDACTED]. - An Email order dated 11/10/14 for Speech Therapy to evaluate and treat, for oropharyngeal dysphagia. Review of Resident 3's nurses notes from 11/9/14 through 11/14/14 state the following; but not all inclusive, 11/9/14 Weekly Nursing Summary: "Appetite has decreased with meal intake 78% this past week, 13 week average of 82%. Current weight 127.7 taken on 11/4/14, this is a loss for him." 11/13/14: "Was up in high back wheelchair as he leans to the side. Ate 25% of meal and drank fluids. Is more tired tonight and not trying to get out of w/c. Was put to bed at 19:30 and has been sleeping with eyes open. B/P (blood pressure) 100/51, P (pulse) 88, R (Respirations) 18, T (temperature) 97.2 ax(axillary). Has not pulled brief off this shift." 11/14/14: "Cares done and resident dressed assisted of two into w/c very little assist from resident is able to answer questions with head nod or shake. asked him if he was hungry nodded yes ate one container of strawberry yogurt. no difficulty swallowing. dau called and informed of condition she will be here at 6 am, tylenol given for comfort due to long ride." 11/14/14: "daughter here at 5:45 am to take to VA appts. body check done skin intact resident assisted into car did well." 11/14/14:"Received call from daughter, daughter stated she took resident to the ER at the VA after his appt and he (resident) was admitted to the VA Hospital with dehydration, elevated NA+(Sodium), and possible UTI(Urinary Tract Infection)." *Please note that nurses notes reviewed from 11/9/14-11/14/14 do not include assessment/documentation of Resident 3's fluid intake, mucous membrane status, skin turgor, or physician/IDT (Interdisciplinary Team) notification of weight loss. Resident 3's document titled "Meal Log" from 11/4/14 - 11/14/14 were as follows: 11/4/14: Breakfast Intake 100%, Lunch Intake 75%, Dinner Intake 25%, Evening Snack 50%, 11/5/14: Breakfast Intake 75%, Lunch Intake 100%, Dinner Intake 75%, Evening Snack 100%, 11/6/14: Breakfast Intake 75%, Lunch Intake 25%, Dinner Intake 100%, Evening Snack 100%, 11/7/14: Breakfast Intake 100%, Lunch Intake 100%, Dinner Intake 50%, Evening Snack 100%, 11/8/14: Breakfast Intake 100%, Lunch Intake 25%, Dinner Intake 100%, Evening Snack 100%, 11/9/14: Breakfast Intake 100%, Lunch Intake 100%, Dinner Intake 50%, Evening Snack 100%, 11/10/14: Breakfast Intake 75%, Lunch Intake 50%, Dinner Intake 100%, Evening Snack 0%, 11/11/14: Breakfast Intake 100%, Lunch Intake 100%, Dinner Intake 25%, Evening Snack 75%, 11/12/14: Breakfast Intake 100%, Lunch Intake 75%, Dinner Intake 0%, Evening Snack 50%, 11/13/14: Breakfast Intake 100%, Lunch Intake 75%, Dinner Intake 50%, Evening Snack 0%, 11/14/14: Breakfast Intake OF (Out of Facility), Lunch Intake OF. *Please note that the percentage of meal intake does not break down the actual amount of fluid or food the resident takes in at each meal. The percentage is for both fluids and food.* Review of Resident 3's weights: 10/7/14- 136.8, 11/4/14- 127.7 and, 11/11/14- 127.7. *Please note that Resident 3 experienced a 6% weight loss in a 30 day period. Resident 3's physician and dietary were not notified regarding the 6% weight decline. The hospital emergency room note, dated 11/14/14, indicates: Chief Complaint: [MEDICAL CONDITION], Objective Data: "Pt's (patients) skin warm pink and dry. Mucous membranes extremely dry. Pt's incontinent brief has moderate amount of diarrhea stool- no urine present. (pt's brief last changed at 5 am) 16 French Foley catheter inserted, free flowing hazy, dark urine. Pt appearing more alert and tracking writer with eyes. Responds briefly and shakes head yes, but not answering other questions at this time. When offered water patient drinks eagerly." ED Admission and Plan of Care Physical Exam: ENT (Ear, Nose, Throat) Nasal mucosa abnormal, Oral Cavity Abnormal, Comment: Mouth and Nasal Mucosa Extremely Dry. Skin Turgor: Abnormal, ED Course and Medical Decision Making: Concern for worsening mental status in past several weeks, now [MEDICAL CONDITION] (fast heart rate). Electrolytes remarkable for NA(Sodium)=170, CL(Chloride)= 137 and AKI(Acute Kidney Injury) with tripling of Creatinine since prior admission. Patient was given 1L(liter) NS(Normal Saline) bolus, with improvement in mental status and [MEDICAL CONDITION] admitted to general care service on 250 ml/hr (milliliters per hour) NS infusion for slow lowering of sodium. Diagnosis: [REDACTED]. Disposition: Inpatient, Condition at Disposition: Improved On 12/2/14 at 1:40 PM, Surveyor spoke with RD (Registered Dietician) C regarding how the facility monitored the fluid intakes for Resident 3 and if a hydration assessment was completed for the weight loss noted on 11/4/14. RD C stated, "I was not aware of the weight loss." Surveyor then asked RD C how fluids needs were monitored for Resident 3, RD C stated, "We monitor the fluid intake with the food intake documentation." Surveyor then asked RD C if a resident had a meal intake of 75% how much of the intake was fluids, RD C stated, "I don't think you can tell." On 12/2/14 at 2:35 PM, Surveyor spoke with CNA (Certified Nursing Assistant) G regarding how the CNA's document food and fluid intakes. CNA G stated, "Yes, we do percentages. The percentage is for food and fluid together, so, if a resident drank 100% but did not eat any food we would document 50%." On 12/2/14 at 2:45 PM, Surveyor spoke with LPN (Licensed Practical Nurse) E regarding hydration assessments for residents. LPN E stated the nurses get a record of intakes daily and if meal intakes trigger need to do a hydration assessment. Surveyor asked LPN E if a fever or weight loss would trigger for hydration concerns, LPN E stated, "Yes, if it was weight loss would ask for a reweigh and talk to the RN (Registered Nurse) and as a team would do a hydration assessment. We would look at the intakes, if out of norm would ask the aides. The meal intakes are for food and fluid together; we have no way to tell how much fluids are taken in." On 12/2/14 at 2:53 PM, Surveyor interviewed CNA F how food and fluids are documented for residents. CNA F stated, "We record the percentage for supper and snacks, it is one big total, food and drinks are combined. If a resident eats 100% of the food and does not drink anything we would document the meal intake of 75% in the computer." On 12/2/14 at 3:00 PM, Surveyor spoke with ACU (Alzheimer's Care Unit) Director D regarding how the facility was monitoring the fluid intake for Resident 3 and if a hydration assessment was completed. ACU Director D stated, "We go by the meal intake, food and fluids together. We do not enter fluid intakes in CC's." Surveyor then asked ACU Director D if a hydration assessment was completed when Resident 3 had a change of condition, ACU Director D stated, "I thought a hydration assessment was completed for (Resident 3). There should have been one done." On 12/2/14, at 3:30 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated, "The meal intakes percentages include both food and fluids taken in at each meal, there is no separate documentation for fluids. That is the standard that is followed by care tracker and we do have guidance for the breakdown of the percentages." Surveyor then asked DON B how the facility ensured that when Resident 3 had the weight loss and overall decline, they assessed daily recommended fluid needs were being met for Resident 3. DON B stated, "We talked about (Resident 3) in the daily clinical meeting but felt that the changes did not warrant completing a hydration assessment or putting (Resident 3) on I&O (Intake and outputs). I looked in (Resident 3's) chart to see if the doctor was made aware of the weight loss and could not find any documentation related to that." The facility did not monitor, or have a process in place to adequately monitor Resident 3's hydration when a change in condition occurred, despite being a risk on admission. Resident 3 was taken to the emergency room by family due to decline in mental status and admitted with a primary [DIAGNOSES REDACTED].