Every finding on record at Wisconsin Rapids Health Services

Based on observation, staff and resident interview, and record review, the facility did not ensure food was stored, prepared, and served in a safe and sanitary manner. This practice had the potential to affect 35 of 36 residents residing in the facility (one resident received nutrition via tubefeeding.)Staff did not complete appropriate hand hygiene.Documentation logs for parts per million (PPM) of the sanitizing solution were not completed correctly.Staff did not follow safe food cooling protocols.Food was not served at an appropriate temperature.Findings include:On 2/23/26 at 9:40 AM, Surveyor and Account Manager (AM)-E began an initial kitchen tour. AM-E stated the facility follows the Food and Drug Administration (FDA) Food Code.Hand Hygiene:The 2022 FDA Food Code documents at 2-301.14: Food Employees shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles.The 2022 FDA Food Code documents at 3-301.11 Preventing Contamination from Hands: (A) Food Employees shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, Food Employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment.The facility's undated Handwashing Policy indicates: Proper handwashing, by far, is the single most important thing you can do to prevent infections and stop the spread of infectious disease. The most important thing to remember is that you can never over wash your hands. You should wash your hands frequently - and at least every 15-20 minutes. Most important times to wash hands: After using the restroom; returning from breaks; sneezing, coughing or blowing your nose; smoking; eating; drinking; using chemicals; handling trash; cleaning; touching your own or someone else's clothing or hair; touching any unsanitized surface .The facility's Food Preparation policy, revised 9/2017, indicates: All food is prepared in accordance with the FDA Food Code. All staff will practice proper hand washing techniques and glove use.On 2/24/26 at 7:40 AM, Surveyor observed Dietary Aide (DA)-I serve food from the second floor kitchenette. DA-I grabbed plates and touched food serving utensils with bare hands. DA-I served food on the plates that DA-I had touched. At 7:43 AM, Surveyor observed DA-I pick up a plastic single-use cup cover off the floor with bare hands and put it in a garbage can. Without completing hand hygiene, DA-I continued to serve food and touch plates with bare hands. At 7:49 AM, Surveyor observed DA-I open the door to the hallway with a bare hand. DA-I then continued to serve food and touch plates with bare hands. The process continued until all residents on both floors were served.On 2/24/26 at 7:54 AM, Surveyor interviewed DA-I who stated DA-I should complete hand hygiene throughout meal service and after picking refuse off the floor and touching door handles.On 2/24/26 at 8:55 AM, Surveyor interviewed AM-E who stated staff should complete hand hygiene throughout meal service, when picking refuse off the floor, and after touching high-touch surfaces.Sanitizing Solution:The 2022 FDA Food Code documents at 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization - Temperature, pH, Concentration, and Hardness: A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under 7-204.11 Sanitizers, Criteria, shall be used in accordance with the Environmental Protection Agency (EPA)-registered label use instructions.The 2022 FDA Food Code documents at 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration: Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device.The Ecolab Oasis 146 Multi-Quat Sanitizer data sheet indicates the sanitizing solution should be tested for effectiveness by measuring the PPM dilution range. Hydrion Quat test strips are the appropriate testing strips. The sanitizing solution temperature needs to be tested and within 65-75 degrees Fahrenheit (F). The effective PPM range is 150-400 PPM.The facility's policy, revised 6/2025, indicates: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition .2. The Dining Services Director will ensure employees are knowledgeable in the proper procedures for cleaning and sanitizing food service equipment and surfaces .The facility's Manual Warewashing Policy, revised 9/2017, indicates: .2. Appropriate test strips will be used to measure the concentration of the sanitizing solution. Results will be recorded on the Three-Compartment Sink log.On 2/24/26 at 9:09 AM, Surveyor observed a container of Ecolab Oasis 146 Multi-Quat Sanitizer in the kitchen and an Ecolab Oasis 146 Multi-Quat Sanitizer data sheet posted above the three-compartment sink. Surveyor also observed a bucket of sanitizing solution inside a bin of ice near the sink.On 2/24/26 at 9:15 AM, Surveyor asked DA-J to test the PPM of the sanitizing solution. DA-J stated the sanitizing solution was put on ice because AM-F told DA-J to cool the solution. DA-J stated it was the first time DA-J had to cool the solution and indicated the solution came out hot and was usually used that way. DA-J left the area and did not test the PPM.On 2/24/26 at 9:18 AM, Surveyor reviewed the facility's Sanitizer Bucket log which contained columns to record the time, PPM, and initials of staff who performed the test 4 times daily (twice on each AM and PM shift). The log did not contain a column to record the temperature of the sanitizing solution. Surveyor noted the bottom of the log indicated the Ecolab Oasis 146 Multi-Quat Sanitizer had an efficacy range of 150-400 PPM. The form also indicated staff should refer to the manufacturer's guidelines along with state and local requirements. The log indicated if the chemical concentration does not meet the manufacturer's established parameters, staff should stop using it and alert a manager or designee. In addition, Surveyor noted 10 columns over 5 shifts in the previous 4 days were blank. The 5:30 AM shift test was also missing on 2/24/26.On 2/24/26 at 9:20 AM, Surveyor interviewed AM-E who stated the sanitizing solution is usually hot when it comes out of the three-compartment sink. AM-E stated an Ecolab professional was at the facility the day before and informed management that staff need to temp the sanitizing solution prior to use. AM-E stated the Ecolab professional stated staff should cool the sanitizing solution on ice to bring it to the appropriate testing and use temperature. AM-E indicated staff should test the sanitizing solution and document the results on the log twice per shift as indicated on the log.On 2/24/26 at 9:24 AM, Surveyor asked [NAME] (CK)-K to test the sanitizing solution. Surveyor observed CK-K dip a Hydrion test strip in the solution and remove the strip after approximately a half second to one second. CK-K held the test strip to the PPM guide on the back of the container. CK-K stated the color guide indicated the PPM were 200. Surveyor observed CK-K test the temperature of the sanitizing solution which was 76 degrees F (and outside of the 65 to 75 degree testing range). Surveyor and CK-K discussed the testing process and reviewed the Hydrion test strip packaging and an Ecolab Oasis 146 Multi-Quat Sanitizer data sheet posted above the three-compartment sink. CK-K indicated CK-K had completed the test wrong. Surveyor observed CK-K redo the test. The temperature was within the appropriate temperature range and the PPM were 400. CK-K stated it was a new process for CK-K who did not know CK-K was supposed to temp the sanitizing solution before that day. When asked if CK-K had ever reviewed the Oasis 146 Multi-Quat Sanitizer data sheet posted above the three-compartment sink, CK-K stated CK-K did not know.On 2/24/26 at 1:49 PM, Survey received a sanitizing log from AM-H who showed Surveyor that the log had a column for the temperature to be tested along with the PPM. AM-H indicated to Surveyor that staff will be trained on the process and will use the sanitizing log moving forward.Food Cooling Temperatures:The 2022 FDA Food Code documents at 3-501.14 Cooling: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 Celcius (C) (135 Fahrenheit (F)) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5 C (41 F) or less.The 2022 FDA Food Code documents at section 3-501.15 Cooling Methods: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods.The facility's Food Preparation policy, revised 9/2017, states: All food is prepared in accordance with the FDA Food Code .4. The Dining Services Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time food items are exposed to temperatures greater than 41 degrees and/or less than 135 degrees F or per state regulation .16. Prepared hot food items that are not intended for immediate service will be cooled using the following guidelines: Place in shallow pans or cut/slice to promote rapid cooling. Time/Temperature Control for Safety (TCS) foods will be cooled from 135 degrees F to 70 degrees F within two hours. TCS foods will be cooled from 70 degrees F to 41 degrees F within four hours. Total cooling time cannot exceed 6 hours. The clock starts at 135 degrees F .During an initial kitchen tour that began at 9:40 AM on 2/23/26, Surveyor interviewed AM-E who indicated the facility saves leftovers and uses a cooling log to document the cooling process. Surveyor and AM-E reviewed the facility's February 2026 food cooling log which contained 17 items. Surveyor noted only 3 of the items were tracked to 41 degress F or less. Fourteen items were listed between 43 degrees F and 67 degrees F which was in the TCS food danger zone. Surveyor also noted 32 of 34 time entries on the form ended in 00 which indicated every test was completed at the top of the hour which AM-E verified was unlikely. AM-E stated follow-up and retraining on food cooling and documentation was needed.On 2/24/26 at 7:37 AM, Surveyor interviewed [NAME] President of Success (VPS)-G who stated VPS-G made an executive decision that morning that the facility would no longer save leftovers and, therefore, would no longer use a food cooling log.Food Holding Temperatures:The facility's Food Preparation policy, revised 9/2017, indicates: All food is prepared in accordance with the FDA Food Code .4. The Dining Services Director/Cook(s) are responsible for food preparation techniques which minimize the amount of time food items are exposed to temperatures greater than 41 degrees and/or less than 135 degrees F or per state regulation .11. When hot pureed, ground, or diced foods drop into the danger zone (below 135 degrees F), the mechanically-altered food must be reheated to 165 degrees F for 15 seconds if holding for hot service .13. All food will be held at an appropriate temperature, greater than 135 degrees F (or as state regulation requires) for hot holding, and less than 41 degrees F for cold holding .On 2/24/26 at 7:40 AM, Surveyor observed DA-I serve residents from the second floor kitchenette. Surveyor noted most of the hot food was served from the steam table. Surveyor observed a pan of ground meat on a rolling cart; the meat was not in the steam table and was not kept warm. At 7:50 AM, Surveyor observed DA-I put a serving of ground meat from the cart on a plate with other food from the steam table. The ticket indicated the meal was for R45. DA-I gave the plate to staff to deliver to R45. DA-I indicated the meat was ground sausage and verified the sausage had not been kept warm. DA-I indicated the cooks put the ground sausage on the rolling cart and DA-I did not know why. When asked if R45 was going to be served room temperature sausage, DA-I stated yes unless staff microwaved it downstairs.On 2/24/26 at 8:55 AM, Surveyor interviewed AM-E who indicated DA-I should have kept the ground sausage hot and not served it to R45 at room temperature. AM-E indicated DA-I should have made room for the sausage in the steam table.On 2/24/26 at 10:28 AM, Surveyor interviewed R45 who stated R45's breakfast was fair. R45 stated the sausage was not warm and R45 did not care for sausage.On 2/24/26 at 12:57 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated kitchen staff should know and follow hand hygiene, sanitizing solution testing, food cooling, and hot holding policies. NHA-A was aware that VPS-G implemented a new protocol for no leftovers. NHA-A indicated staff recently received hand hygiene education from AM-H.

Based on staff interview and record review, the facility did not provide a bed hold or transfer notice and/or notify the state long-term care Ombudsman of hospital transfers for 2 residents (R) (R19 and R21) of 5 sampled residents. R19 was transferred to the emergency room (ER) on 9/25/25, 10/5/25, and 1/8/26. R19 was not provided a written bed hold or transfer notice for the hospital transfers on 9/25/25 and 1/8/26. In addition, the Ombudsman was not notified of any of the transfers.R21 was transferred to the ER twice on 1/18/26. The Ombudsman was not notified of the transfers. Findings include:The facility's Transfer and Discharge policy, revised 7/15/22, indicates: It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except as initiated by the resident, necessary for the health and safety of the resident or other individuals are endangered, or as otherwise permitted by applicable law. Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility .7. Emergency Transfers/Discharges - initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident: .K. The Social Services Director/designee shall provide notice of transfer to a representative of the state long-term care Ombudsman via a monthly list. 1. From 2/23/26 to 2/25/26, Surveyor reviewed R19's medical record. R19 was admitted to the facility on [DATE] and had diagnoses including right below knee amputation, urinary tract infection (UTI), chronic obstructive pulmonary disease (COPD), bladder neck obstruction, peripheral vascular disease (PVD), and neuromuscular dysfunction of the bladder. R19 had an indwelling urinary catheter. R19's Minimum Data Set (MDS) assesment, dated 1/3/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R19 had intact cognition. R19 made R19's own healthcare decisions.A Nurse Practitioner's (NP) note, dated 10/2/25 at 9:00 AM, indicated R19 was sent to the ER on [DATE] due to blood in the urine, decreased urinary output, and possible kidney issues. An NP note, dated 10/23/25 at 10:45 AM, indicated R19 was sent to the ER for UTI and dehydration on 10/5/25.An NP note, dated 1/13/26 at 10:45 AM, indicated R19's indwelling catheter was removed on 10/25/25 for a voiding trial. The catheter was reinserted on 10/28/25. On 1/8/26, R19 saw a Urologist who removed the catheter with instructions to reinsert the catheter if R19 could not void more than 12 hours later. R19 was unable to void and refused to have the catheter replaced. R19 was in pain and had moderate bleeding from the tip of the penis. R19 was sent to the ER.R19's medical record did not indicate bed hold or transfer notices were provided to R19 for the hospital transfers on 9/25/25 and 1/8/26. Surveyor also reviewed a binder that contained monthly reports sent to the Ombudsman and noted the Ombudsman was not notified of R19's hospital transfers on 9/25/25, 10/5/25, and 1/8/26.On 2/25/26 at 9:29 AM and 10:52 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified R19 was not provided bed hold or transfer notices for the hospital transfers on 9/25/25 and 1/8/26. NHA-A also verified the binder did not contain Ombudsman notification for R19's 9/25/25, 10/5/25, and 1/8/26 hospital transfers. 2. From 2/23/26 to 2/25/26, Surveyor reviewed R21's medical record. R21 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following a stroke, diabetes, and nontraumatic hematoma of soft tissue right leg wound. R21's MDS assessment, dated 2/15/25, had a BIMS score of 11 out of 15 which indicated R21 had moderate cognitive impairment. R21 made R21's own healthcare decisions.A nursing progress note, dated 1/18/26 at 3:00 PM, indicated R21 was transferred to the ER around lunch time due to a large round raised hematoma that continued to swell and cause severe pain. R21 returned to the facility with orders to follow-up with R21's primary care provider in 2 weeks and keep R21's bilateral lower extremities elevated and wrapped in ace wraps. A nursing progress note, dated 1/18/26 at 7:44 PM, indicated R21 was transferred to the ER again due to increased swelling of the right lower leg hematoma, uncontrolled pain, restlessness, and small blisters. Surveyor reviewed a binder that contained monthly reports sent to the Ombudsman and noted the Ombudsman was not notified of R21's hospital transfers on 1/18/26.On 2/25/26 at 10:54 AM, Surveyor interviewed NHA-A who verified the Ombudsman was not notified of either of R21's hospital transfers on 1/18/26.

Based on staff interview and record review, the facility did not monitor for adverse reactions to a high risk medication for 1 resident (R) (R32) of 5 sampled residents.R32 had an order for Apixaban (an anticoagulant) 5 milligrams (mg) two times daily for cerebrovascular accident (CVA). The facility did not monitor R32 for adverse reactions to the high-risk medication. In addition, R32 did not have a care plan related to anticoagulant use.Findings include:The facility's High Risk Medication policy, dated 8/30/23, indicates: The resident's care plan should alert staff to monitor for adverse consequences. Risks associated with anticoagulants include but are not limited to: a. Bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, blood in urine or stool); b. Fall in hematocrit or blood pressure; c. Thromboembolism.From 2/2326 to 2/25/26, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] and had diagnoses including long-term (current) use of anticoagulants, history of venous thrombosis and embolism, and cognitive and communication deficit. R32's Minimum Data Set (MDS) assessment, dated 12/10/25, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R32 had moderately impaired cognition. R32 had an activated Power of Attorney for Healthcare (POAHC).R32's medical record contained an order for Apixaban 5 mg two times daily for cerebrovascular accident. R32's medical record did not indicate R32 was monitored for adverse reactions to the high-risk medication and did not contain a care plan for anticoagulant use. On 2/24/26 at 3:05 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who indicated staff should monitor for abnormal bleeding, bruising, or black stools for residents on anticoagulant medication. LPN-D stated anticoagulant monitoring should be on a resident's care plan and Treatment Administration Record (TAR). LPN-D verified R32 did not have monitoring interventions or a care plan for anticoagulant use.On 2/25/26 at 2:16 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R32 did not have monitoring interventions in place or a care plan for the use of anticoagulant medication.

Based on observation, staff interview, and record review, the facility did not ensure food was stored in a safe and sanitary manner and the kitchen was in a clean condition. This practice had the potential to affect 20 of the 36 residents who resided on the second floor. Two cabinets in the kitchenette next to the dining room contained mouse droppings. The facility did not have documentation to indicate the last time the cabinets were cleaned.The refrigerator in the kitchenette next to the dining room contained unlabeled, undated, and/or expired food items.Findings include: The facility's Cleaning and Sanitation of Dining and Food Service Areas policy, revised 7/13/22, indicates: The food and nutrition services staff will maintain the cleanliness and santiation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule.The facility's Use and Storage of Food Brought in by Family or Visitors policy, dated 12/14/22, indicates: .2. All food items that are already prepared by the family or visitor brought in must be labeled with content and date. b. The prepared food should be consumed by the resident within 3 days. c. If not consumed within 3 days, food should be disposed of by facility staff. 1.On 2/3/26 and 2/4/26, Surveyor observed a resident dining area on the second floor of the facility with an adjacent kitchenette. Resident meals were cooked in a central kitchen and transported to the kitchenette for meal service.On 2/3/26 at 1:26 PM, Surveyor interviewed Maintenance Director (MD)-E who indicated the facility had a mouse issue that was resolved. As soon as MD-E became aware of the issue, MD-E contacted the facility's pest control company who had been to the facility several times and set traps. MD-E indicated the facility completed a deep clean of the dining and kitchen areas and had caught approximately 4 mice. On 2/3/26 and 2/4/26, Surveyor reviewed the facility's pest control records which indicated the facility had an ongoing monthly pest control program with visits from a pest control company. The records indicated the following:~ On 12/22/25, the pest control company was at the facility after the facility contacted them about a mouse in the upstairs dining area/kitchenette. The inspection indicated there were mice droppings in the kitchenette under the sink; however, no mice were seen.~ On 12/30/25, an inspection note indicated there were mice droppings under the kitchenette sink. One interior bait station equipped with all-weather bait blocks was placed under the second floor kitchenette sink. A second interior bait station was placed by the kitchenette refrigerator. ~ On 1/12/26, an inspection note advised to clean up any mouse droppings. On 2/4/26 at 12:23 PM, Surveyor entered the kitchenette and observed several mouse traps on the floor next to the refrigerator. Surveyor observed several mouse traps in the cabinet under the sink and what appeared to be mouse droppings. Surveyor also observed what appeared to be mouse droppings in the cabinet to the left of the sink. On 2/4/26 at 12:35 PM, Surveyor entered the kitchenette and observed Housekeeping Supervisor (HKS)-D cleaning the area. When Surveyor showed HKS-D the inside of the cabinet, HSK-D confirmed there were mouse droppings in the cabinet. HKS-D indicated the facility had a mouse problem and several mice were caught. HKS-D confirmed dietary staff were responsible for cleaning the cabinets and serving area and housekeeping staff were responsible for cleaning the floors, dining room counter, and back cabinet counters.On 2/4/26 at 12:49 PM, Surveyor interviewed Dietary Manager (DM)-C who indicated there was not a cleaning schedule that indicated when the interior of the cabinets were last cleaned. DM-C was not sure if the mice droppings were fresh or if they had been there from weeks prior. DM-C confirmed there had been and could still be a mouse problem and verified the cabinets should be inspected and wiped down regularly so the facility can determine if there are current issues.2. On 2/4/26 at 12:42 PM, Surveyor inspected the refrigerator in the kitchenette adjacent to the second floor dining room and noted the following items were either unlabeled, undated, and/or expired:~ A jar of apple butter labeled with a resident named and dated 10/18/25. ~ A bottle of [NAME] thousand island dressing labeled with a resident name and a best-by date of 11/11/25. ~ A jar of Smuckers jam labeled with a room number and a best-by date of 12/16/25. ~ A 16 ounce (oz) bottle of raspberry light vinaigrette with a best-by date of 4/10/25. ~ A 32 oz jar of Milwaukee dill pickles labeled with a resident name and room number and a use-by date of 11/23/24. ~ A 64 oz jar of Zeiglers old fashioned apple cider with a hand-written date of 10/7/25. ~ An unlabeled and undated meat and lettuce sandwich in plastic wrap. ~ A 16 oz bottle of Ken's thousand island steakhouse dressing with a best-by date of 4/10/25. ~ An unlabeled and undated sandwich.~ Three pieces of an undated cream pie labeled with a resident's name. On 2/4/26 at 12:49 PM, Surveyor interviewed DM-C who stated residents and families use the refrigerator and kitchen items. DM-C indicated it is everyone's responsibility to ensure items are labeled and dated and expired items are disposed of. When Surveyor showed DM-C some of the expired and unlabeled items, DM-C confirmed the items should be labeled and/or disposed of.

Based on staff interview and record review, the facility did not ensure an allegation of verbal abuse was reported to the State Agency (SA) for 1 resident (R) (R7) of 2 sampled residents.R8 reported to staff on 9/3/25 that Certified Nursing Assistant (CNA)-E yelled at R7 (who was R8's spouse). The facility did not report the allegation of abuse to the SA.Findings include:The facility's Abuse, Neglect, and Exploitation policy, revised 7/15/22, indicates: .IV. Identification of Abuse, Neglect, and Exploitation: .B. Possible indicators of abuse include, but are not limited to: Verbal abuse of a resident overheard or inappropriate verbal conduct overheard .VII. Reporting Response. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services, and to all other required agencies (e.g., law enforcement when applicable) within specified time frames. B. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. B. The Administrator will follow-up with government agencies to report the results of the investigation when final within 5 working days of the incident, as required by State Agencies. On 10/6/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and dysphagia. A Minimum Data Set (MDS) assessment completed 9/10/25 included a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R7 had moderate cognitive impairment. On 10/6/25, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD). An MDS assessment completed 1/31/22 included a BIMS score of 15 out of 15 which indicated R8 was not cognitively impaired. On 10/6/25, Surveyor reviewed a grievance, reported by R8 and dated 9/3/25, that indicated CNA-E yelled at R7 (who was R8's spouse) on 9/2/25 for getting out of bed. An alarm was activated when R7 was watching TV in a wheelchair and attempted to get the remote. CNA-E entered the room and yelled at R7. The grievance form indicated Nursing Home Administrator (NHA)-A investigated the grievance. Staff had no follow-up or further information and did not confirm or deny the incident. The writer discussed being firm with a resident who puts themself at risk and the perception of coming across as yelling. The form indicated the grievance was resolved on 9/20/25. On 10/6/25 at 1:22 PM, Surveyor interviewed NHA-A who confirmed NHA-A did not report the allegation of abuse to the SA. NHA-A indicated NHA-A knew R7, R8, and CNA-E and felt CNA-E's tone was taken wrong. NHA-A indicated CNA-E is not a soft person and it sounded like CNA-E entered the room with intensity which was perceived as yelling. NHA-A agreed the allegation of abuse should have been reported to the SA.

Based on staff interview and record review, the facility did not ensure an allegation of verbal abuse was thoroughly investigated for 1 resident (R) (R7) of 2 sampled residents.R8 reported to staff on 9/3/25 that Certified Nursing Assistant (CNA)-E yelled at R7 (who was R8's spouse). The facility did not thoroughly investigate the allegation of abuse.Findings include:The facility's Abuse, Neglect, and Exploitation policy, revised 7/15/22, indicates: .IV. Identification of Abuse, Neglect, and Exploitation: .B. Possible indicators of abuse include, but are not limited to: Verbal abuse of a resident overheard or inappropriate verbal conduct overheard .V. Investigation of Alleged Abuse, Neglect, and Exploitation. A. An immediate investigation is warranted when an allegation or suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. VI. Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation.On 10/6/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and dysphagia. A Minimum Data Set (MDS) assessment completed 9/10/25 included a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R7 had moderate cognitive impairment.On 10/6/25, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD). An MDS assessment completed 1/31/22 included a BIMS score of 15 out of 15 which indicated R8 was not cognitively impaired.On 10/6/25, Surveyor reviewed a grievance, reported by R8 and dated 9/3/25, that indicated CNA-E yelled at R7 (who was R8's spouse) on 9/2/25 for getting out of bed. An alarm went off when R7 was watching TV in a wheelchair and attempted to get the remote. CNA-E entered the room and yelled at R7. The grievance form indicated Nursing Home Administrator (NHA)-A investigated the grievance. Staff had no follow-up or further information and did not confirm or deny the incident. Staff had no comment when the writer discussed being firm with a resident who puts themself at risk and the perception of coming across as yelling. The form indicated the grievance was resolved on 9/20/25. On 10/6/25 at 1:22 PM, Surveyor interviewed NHA-A who confirmed NHA-A did not complete a thorough investigation for the allegation of verbal abuse. NHA-A indicated NHA-A knew R7, R8, and CNA-E and thought CNA-E's tone was taken wrong. NHA-A indiated CNA-E is not a soft person and it sounded like CNA-E entered the room with intensity which was perceived as yelling. NHA-A stated NHA-A talks with staff frequently about checking themselves at the door prior to entering a resident's room. NHA-A agreed the allegation of abuse should have been thoroughly investigated, including resident and staff interviews and staff education.

Based on observation, staff interview, and record review, the facility did not ensure 2 residents (R) (R1 and R6) of 2 sampled residents were provided safe and accurate administration of drugs and biologicals. Registered Nurse (RN)-K did not administer R1's Ozempic as ordered. In addition, RN-L documented Ozempic was administered to R1 when it was not administered.During the administration of insulin for R6, RN-C held a lispro injectable pen to R6's skin for less than the recommended 5 to10 seconds.Findings include: The facility's Medication Administration, General Guidelines policy, dated 1/2025, indicates: Medications are administered as prescribed .3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record .2. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at the scheduled dose time, or an initial dose of antibiotics is needed), the nurse shall document either in the electronic Medication Administration Record or the paper MAR that the dose was withheld, refused, or given at other than the scheduled time and enter an explanatory note. The facility's Medication Administration policy, dated 1/2023, indicates: The correct procedure for injectable pens is to insert the needle into the skin at a 90-degree angle, deliver the dose by pressing the injection button all the way in, keep the injection button pressed all the way in and slowly count to 10 before withdrawing the needle from the skin. 1.On 10/6/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including chronic venous hypertension with ulcer of left lower extremity, type 2 diabetes mellitus, morbid obesity, and chronic kidney disease stage 4. A Minimum Data Set (MDS) assessment completed 9/20/25 included Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker. R1's medication orders included the following: ~ Ozempic Subcutaneous Solution Pen-Injector 2 milligrams (MG)/3 milliliters (ML), inject 0.5 mg subcutaneously once daily every Wednesday for weight loss (Start date: 7/16/25; End date: 8/29/25). ~ Ozempic Subcutaneous Solution Pen-Injector 2MG/3ML, inject 0.5 mg subcutaneously once daily every Wednesday for weight loss (Start date: 9/3/25). R1's Medication Administration Record (MAR) indicated Ozempic 0.5 mg was administered by RN-K on 8/27/25 and by RN-L on 9/3/25. On 10/6/25, Surveyor reviewed a Resident Grievance Form filed by R1 on 9/3/25 that indicated staff did not administer an accurate dose of Ozempic and a dose of Ozempic was not administered as ordered. Follow-up by Director of Nursing (DON)-B indicated staff administered an additional dose of Ozempic after the initial dose had leaked from R1's administration site. Surveyor reviewed a Medication Error Report Form, dated 9/3/25, that indicated RN-K administered an Ozempic dose in error. The report was completed by DON-B and indicated the error was discovered on 9/3/25 by RN-L. The provider was notified on 9/4/25. An observation note, documented on 9/10/25 as a late entry by DON-B, indicated R1 and the provider were updated on the Ozempic error. The note indicated the provider advised to give R1 Ozempic as ordered when the facility received the medication from the pharmacy. On 10/6/25 at 10:47 AM, Surveyor interviewed RN-K who indicated RN-K administered R1's Ozempic 0.5 mg pen on 8/27/25. RN-K indicated while administering Ozempic, RN-K noted the medication was leaking down R1's abdomen from the injection site. RN-K then administered an additional 2 clicks of the pen. RN-K did not know the dose of Ozempic that was administered in the 2 clicks of the pen but thought it was comparable to the amount that leaked from the injection site. RN-K did not document a progres note regarding the altered Ozempic dose and did not update the provider or facility administration about the altered dose. RN-K indicated staff later received education regarding medication injection technique, reporting, and what to do if medication is missing. On 10/6/25 at 12:20 PM, Surveyor interviewed DON-B who indicated RN-L verbally informed R1 and DON-B that RN-L did not have Ozempic to administer to R1 on 9/3/25. DON-B discussed Ozempic with R1 who indicated the last time Ozempic was administered, the medication leaked and R1 was administered additional medication. DON-B updated the provider on 9/4/25 but did not enter a provider notification note until 9/10/25 because that was when DON-B completed the staff in-service regarding Ozempic administration, provider notification, and medication ordering. DON-B verified a medication error should have been reported on 8/27/25. DON-B also verified R1's MAR indicated Ozempic was administered on 9/3/25. DON-B thought the Ozempic administration documentation was in error since RN-L verbally communicated to DON-B on 9/3/25 that RN-L did not have the medication to administer. On 10/6/25 at 1:02 PM, Surveyor interviewed RN-L who indicated RN-L did not have R1's Ozempic to administer on 9/3/25. RN-L attempted to reorder the medication, however, it had been ordered from the pharmacy on 9/1/25 by another staff. RN-L thought RN-L documented that the medication was not administered and wrote a progress note. When Surveyor indicated R1's MAR indicated Ozempic was administered by RN-L on 9/3/25, RN-L stated RN-L did not know why Ozempic was documented as administered when RN-L did not administer it. RN-L stated RN-L told DON-B that RN-L did not administer R1's Ozempic on 9/3/25 because R1's Ozempic pen was not available. 2. On 10/6/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis, diabetes, chronic obstructive pulmonary disease (COPD), aphasia, and long term use of insulin. An MDS assessment completed 8/14/25 included a BIMS score of 5 out of 15 which indicated R6 had severely impaired cognition. R6 had an order for Lispro sliding scale insulin: 150-200=2 units; 201-250=4 units; 251-300=6 units; 301-350=8 units; 351-400=10 units; 401 + give 12 units and notify MD, administered subcutaneously three times daily related to diabetes (Start date: 3/10/25). On 10/6/25 at 10:45 AM, Surveyor observed RN-C insert a needle in a Lispro injectable pen, prime the needle, and dial 8 units of Lispro. RN-C then wiped R6's right abdomen with an alcohol pad, inserted the pen needle at a 90-degree angle, pressed the injection button, and removed the needle from R6's right abdomen in less than 2 seconds. On 10/6/25 at approximately 10:50 AM, Surveyor interviewed RN-C who indicated RN-C held the pen to R6's right abdomen for 3 seconds. On 10/6/25 at approximately 2:00 PM, Surveyor interviewed DON-B who verified when administering insulin with an injectable pen, the pen should be held to the skin for 10 seconds after pressing the injection button.

Based on observation, staff interview, and record review, the facility did not ensure mechanical lifts were in safe operating condition which affected 1 resident (R) (R1) of 2 sanpled residents. R1 required a bariatric lift to transfer to an electric wheelchair. From 9/20/25 to 9/23/25, R1 was unable to transfer out of bed when the facility's bariatric Hoyer lift was out of service. In addition, staff had shared remotes between bariatric lifts for 2 weeks prior and a bariatric EZ stand lift was not in working order.Findings include:The facility's Safe Lifting and Movement of Residents policy, revised 11/28/22, indicates: .9. Mechanical lifts shall be made readily available and accessible to staff 24 hours per day. Back-up battery packs on remote chargers shall be provided as needed so that lifts can be used 24 hours per day .11. Maintenance staff shall perform routine checks and maintenance of equipment used for lifting, consistent with manufacturer's guidance, to ensure it remains in good working order. On 10/6/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including chronic venous hypertension with ulcer of left lower extremity, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), morbid obesity, chronic respiratory failure with hypoxia, and chronic kidney disease stage 4. A Minimum Data Set (MDS) assessment completed 9/20/25 included a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 was not cognitively impaired. A care plan, revised 5/8/23, indicated R1 had limited physical mobility related to activity intolerance, fatigue, impaired balance, limited mobility, arthritis, muscle spasms, lymphedema, obesity, pain, congestive heart failure (CHF), and COPD. The care plan contained an intervention, revised 5/12/25, that indicated R1 required the assistance of 2 staff and a Hoyer lift with an Arjo white 2 XL sling for transfers to R1's electric wheelchair. On 10/6/25 at 12:50 PM, Surveyor interviewed R1 who indicated staff use a bariatric Hoyer lift to transfer R1 to R1's electric wheelchair. R1 indicated R1 does not choose to get out of bed every day; however, there was a 4 day period when R1 couldn't get out of bed if R1 wanted to. R1 stated the bariatric Hoyer lift broke on Saturday (9/20/25) but R1 did not want to get out of bed that day. R1 indicated R1 wanted to get out of bed on 9/21/25 but couldn't because the lift was still broken. R1 indicated staff had been swapping remotes between the bariatric Hoyer lift and bariatric EZ stand lift for approximately 2 weeks because one of the remotes didn't work. R1 spoke with Maintenance Director (MD)-F who had ordered a new remote. R1 stated all of a sudden nothing worked and the facility had a new lift delivered on 9/23/25. On 10/6/25 at 9:26 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who confirmed the bariatric Hoyer lift R1 used for transfers broke on 9/20/25. LPN-D indicated R1 didn't want to get out of bed every day and couldn't recall if R1 wanted to get out of bed during that timeframe. On 10/6/25 at 9:33 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-G who didn't work the weekend the lift broke; however, R1 mentioned to CNA-G that R1 couldn't get out of bed. CNA-G confirmed staff had been swapping out remotes because one of the hand remotes stopped working. On 10/6/25 at 11:57 AM, Surveyor interviewed CNA-H who showed Surveyor a rented bariatric EZ stand lift which did not work. CNA-H indicated the battery must be dead and plugged in the lift. CNA-H indicated CNA-H did not work the weekend when the lift broke but came back to work on 9/22/25 and both lifts were not working. CNA-H indicated staff had been switching remotes between the 2 lifts prior to when the lift broke. CNA-H could not recall if R1 asked to get out of bed during CNA-H's shifts on 9/22/25 and 9/23/25. CNA-H indicated Nursing Home Administrator (NHA)-A was dealing with the lift when CNA-H arrived at work on 9/22/25. NHA-A indicated a new lift would be coming.On 10/6/25 at 10:20 AM, Surveyor interviewed MD-F who indicated the facility rents the bariatric lifts and has some some lifts in house. MD-F indicated MD-F does not do much with rented lifts but occasionally gives them a quick look over. MD-F stated the lookover is not documented on MD-F's spreadsheet for inspections or battery rebuilds. MD-F was aware staff were sharing a remote between lifts and indicated the rented bariatric EZ stand and bariatric Hoyer lift could share a remote. MD-F indicated it doesn't take long to get a remote and was not sure why a new remote did not arrive right away. MD-F verified MD-F was notified that the bariatric Hoyer lift didn't work but could not recall the date. MD-F indicated the rental company came in and swapped the bariatric Hoyer lift. In a subsequent interview at 12:55 PM, MD-F confirmed the issue with the lifts started approximately 2 weeks prior when a remote stopped working. MD-F confirmed NHA-A got involved when the lift stopped working entirely. Surveyor and MD-F then went to the storage room. When Surveyor indicated the rented bariatric EZ stand lift did not work, MD-F tried to turn on the lift. MD-F verified the lift did not work and was not sure why.On 10/6/25 at 11:08 AM, Surveyor interviewed Rental Company Staff (RCS)-I who stated NHA-A contacted the company on 9/22/25 and indicated the lift battery was fully charged but the lift didn't work. RCS-I indicated the company picked up the lift that day at 5:42 PM and a new bariatric lift was delivered on 9/23/25 at 5:43 PM. On 10/6/25 at 4:30 PM, Surveyor interviewed CNA-J via phone. CNA-J indicated the bariatric Hoyer lift did not work on 9/21/25 which affected one resident who was no longer at the facility. CNA-J could not recall the resident's name. CNA-J stated the resident usually got up to eat but had to stay in bed because the lift didn't work. CNA-J did not recall if R1 asked to get up. CNA-J informed the nurse when the lift stopped working and stated CNA-J probably should have initiated a work order.On 10/6/24 at 1:24 PM, Surveyor interviewed NHA-A who confirmed a rented bariatric lift stopped operating on the weekend of 9/21/25. NHA-A contacted the company and thought it only affected one resident. NHA-A was not aware that R1 was affected and stated R1 did not choose to get up every day. When NHA-A learned staff had been sharing a controller and asked why the company did not send a new controller for the lift, the company brought a new lift to the facility. NHA-A had not completed staff education on how to report issues so they are resolved timely. Surveyor informed NHA-A that there was a broken bariatric EZ stand lift in the storage room on R1's unit and confusion between staff regarding which lifts worked.

Based on staff interview and record review the facility did not ensure a physician was notified regarding a change in condition for 1 resident (R) (R1) of 3 sampled residents. R1's medical record indicated R1 refused at least 2 meals per day multiple days in March 2025. The facility did not notify R1's physician of the refusals. Findings include: The facility's Change in Condition of the Resident policy, dated 9/20/22, indicates: When a resident presents with a possible change of condition, after a fall or other possible injury, trauma, or noted changes in mental or physical functioning: 1. Assess the resident's needs for immediate care/medical attention. Provide emergency care as needed .3. Notify resident's physician - use INTERACT Change in Condition. The Interact Version 4.5 tool 2014-2021, Change in Condition: When to report to the Medical Doctor (MD)/Nurse Practitioner (NP)/Physician Assistant (PA) indicates: Symptom or Sign: Appetite, Diminished: No oral intake 2 consecutive meals (immediate notification). Significant decline in food and fluid intake in resident with marginal hydration and nutritional status (non-immediate notification) . On 4/22/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including paraplegia, protein calorie malnutrition, pressure ulcer of sacral region stage 4, pressure ulcer of right heel unstageable, pressure ulcer of left heel unstageable, ileostomy, and monoplegia of upper limb following cerebral infarction affecting the right dominant side. R1's Minimum Data Set (MDS) assessment, dated 2/18/25, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R1 had moderate cognitive impairment. R1 was hospitalized on [DATE]. R1 was admitted to another facility on Hospice services following discharge from the hospital. R1 had a revised care plan, dated 2/17/25, that indicated R1 was at risk for nutritional status change related to protein-calorie malnutrition, hypertension, hyperlipidemia, tremors, weight loss, pressure areas, depression, poor oral intake, and paraplegia. The care plan contained the following interventions: Eating - Independent. Please cut up foods as needed and set-up (revised 2/17/25); Encourage and assist as needed to consume foods and/or supplements and fluids offered (revised 3/7/24). A note by Advance Practice Nurse Practitioner (APNP)-C, dated 2/7/25, indicated APNP-C saw R1 who was resting in bed. R1 was alert and oriented and denied shortness of breath, chest pain, nausea, vomiting or diarrhea. Nursing staff indicated R1 has not been eating well and had a 13 pound weight loss. APNP-C spoke to R1 about not eating well which R1 confirmed. R1 reported feeling more depressed since R1's spouse does not visit on a daily basis. R1 did not want an increase in any depression medication, however, R1 agreed to try an increase in mirtazapine to help R1's appetite. APNP-C asked the facility's Social Worker to reach out to R1's spouse to see if R1's spouse could visit R1 or do something through telehealth. A discussion was had with the Hospice nurse who indicated R1 did not qualify for Hospice care at that time. A note written by APNP-D, dated 3/3/25, indicated R1 was evaluated that morning. R1's spouse noted increased confusion and requested a capacity evaluation. R1 stated R1's date of birth correctly, but was unable to appropriately answer questions regarding place, time, and situation. APNP-D indicated R1 was not able to make complex medical decisions and agreed with activating R1's Power of Attorney for Healthcare (POAHC). The note indicated an MD would evaluate R1 the following day and indicated R1 complained of depression symptoms A Nutrition/Dietary note, dated 3/19/25, indicated an unstageable deep tissue injury (DTI) on R1's left heel was resolved as 3/19/25. R1 continued with an unstageable DTI on the right heel and had a stage 2 on the right heel. The note indicated to continue with liquid protein 2 times daily (BID) to support wound healing as well as vitamin C and a multi-vitamin injection. R1's meal intake was poor with an average of 0-25%. R1 was offered foods of preference including sandwich's and 2 glasses of chocolate milk with meals. R1 complained of depression symptoms. R1's depression medication was increased and R1 was followed by psych. The note indicated to continue to provide oral intake encouragement. On 3/23/25 at 2:05 PM, a Registered Nurse (RN) messaged the on-call physician via an app the facility uses for physician communication. The note indicated R1 had an acute change in condition and noted R1: refused to drink; had sunken eye sockets; had poor skin turgor; had dry lips; and wouldn't open R1's mouth so the RN could inspect R1's tongue for furrowing. The note indicated the skin along R1's left inner cheek looked like a hanging sheet. R1's mouth was dry and R1 had difficulty or refused to drink from a straw which R1 usually did. R1 was given fluids direct from cup to mouth but only took approximately 5-10 cubic centimeters (cc). The note indicated R1 was very depressed but denied making R1's self intentionally dehydrated. The note asked permission to send R1 to the emergency room (ER) for evaluation and treatment. A change of condition note, dated 3/23/35 at 2:09 PM, indicated nursing staff indicated R1 was unable to draw up fluid through a straw due to dry oral mucosa. R1's lips were chapped and orbital sockets were sunken. R1's eyes were matting shut and R1 had poor skin turgor. R1's Foley catheter output contained medium yellow urine with a brown tint. Charting over last few days indicated R1 had an average output of 700 milliliters (ml) or less. An NP was notified and ordered a stat (emergency) basic metabolic panel (BMP) and complete blood count (CBC) and a bag of normal saline (NS) 75 ml/hour and re-evaluate after administration. The NP also ordered Refresh eye drops as needed (PRN) four times daily (QID). R1's spouse was notified and agreed with the plan of care A progress note, dated 3/23/25 at 2:43 PM, indicated R1 frequently spilled drinks in bed lately. Nursing staff trialed cups with straws to decrease the likelihood of spilling. On 3/23/25, the writer noted R1 was not drinking and attempted to provide fluids directly, however, R1 cannot drink more than 5-10 cc at a time. R1 was unable to draw up fluid through the straw due to dry oral mucosa. R1's lips were chapped and orbital sockets were sunken. R1's eyes were matting shut and R1 had poor skin turgor. R1's Foley output contained medium yellow urine with a brown tint. Charting over last few days indicated R1 had an average output 700 ml or less. An NP ordered a stat BMP and CBC and a bag of NS 75 ml/hour and to re-evaluate after administration. The NP also ordered Refresh eye drops PRN QID. The NP wanted treatment in the facility at that time, however, an RN was not available until 6:00 PM. The writer contacted the Assistant Director of Nursing (ADON) to see if the concern could be addressed sooner. The NP said it was okay to wait until 6:00 PM if the ADON was unavailable. R1's spouse was notified and agreeable to the plan of care. A progress note, dated 3/23/25 at 6:36 PM, indicated R1 had difficulty swallowing whole pills and requested R1's medication be crushed. The NP agreed to order the appropriate medications crushed as needed. R1 could swallow medication and drink 30 cc of water but stated R1 was unable to drink any more than that A note, dated 3/23/25 at 9:53 PM, indicated R1's lab results were received at 8:20 PM and indicated R1 had a high sodium (NA) level and a low glomerular filtration rate (GFR). R1's physician was notified and sent R1 to the ER. R1's spouse was contacted and agreeable. R1 was transported to the ER via ambulance. When the write attempted to give R1 bedtime (HS) medications, R1 was mostly unresponsive and would not open eyes or mouth when asked. R1 would not open R1's eyes even to painful stimuli. Surveyor reviewed R1's food and fluid intake for March 2025 and noted the following: -On 3/19/25, R1 refused breakfast and lunch and drank 720 ccs of fluid. -On 3/20/25, R1 had refused all meals. R1 refused fluids at 7:30 AM and 11:30 AM. R1 consumed 240 ccs of fluid at 6:00 PM. -On 3/21/25, R1 refused breakfast and lunch. (Of note: R1 refused 5 meals in a row between 3/20/25 and 3/21/25. In addition, there was no fluid intake documented on 3/21/25 (7:30 AM refusal, not applicable (NA) at 11:30 AM, and nothing documented at 6:00 PM.) -On 3/22/25, R1 ate 0-25% for breakfast, refused lunch, and there was no documentation for dinner. R1 consumed 360 ccs of fluid. -On 3/23/25, R1 consumed 480 ccs of fluid at 7:30 AM and 0 ccs at 11:30 AM. R1's change in condition was communicated to an APNP at 2:05 PM on 3/23/25. Surveyor noted that prior to 3/20/25, R1 had 13 other meal refusals including the following dates where R1 also had 2 meal refusals in a row: 3/6/25, 3/10/25, and 3/13/25. R1's medical record did not indicate R1's physician was notified of the meal refusals. Surveyor also noted R1 ate 0-25% of meals provided. With regard to fluids, R1 had only 1 other documented refusal of fluids during the month. On 4/22/25 at 11:55 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated R1 refused meals regularly. DON-B confirmed R1 had multiple refusals prior to going to the hospital on 3/23/25. DON-B indicated Certified Nursing Assistants (CNAs) should communicate shift to shift and with nurses when they notice things so clinical judgement can then be used based on how the resident presents. On 4/22/25 at 1:08 PM, Surveyor interviewed APNP-D who completed telehealth at the facility on Mondays. APNP-D indicated APNP-D met with R1 for the first time on 3/3/25. APNP-D did an evaluation for capacity because R1's spouse noted increased confusion. APNP-D indicated if a resident refused 5 meals in a row, APNP-D would want to be notified. On 4/22/25 at 1:44 PM, Surveyor interviewed APNP-C via phone. APNP-C indicated APNP-C last saw R1 on 2/7/25 and spoke with R1 about depression and lack of appetite. APNP-C indicated APNP-C is in the building on Fridays to see residents. APNP-C talks with nurses and the DON to see if there are concerns with residents. APNP-C did not recall hearing a concern that R1 refused multiple meals on 3/21/25 (Friday) which was a date that APNP-C would have been at the facility. APNP-C indicated in addition to coming in, APNP-C takes call and covers multiple facilities. APNP-C indicated if APNP-C was notified that R1 refused five meals in a row, APNP-C would have talked with R1 to figure out why. APNP-C indicated APNP-C would order basic lab work to see if R1 was dehydrated or had an infection and might have ordered a speech evaluation pending the findings after talking with R1. If R1's lab work showed dehydration, APNP-C would make a decision based on the severity of the lab work. If intravenous (IV) fluids could be administered in the facility, APNP-C was order IV fluids in the building and re-run lab work or would possibly send R1 to the ER for evaluation if that's what R1's family wanted. APNP-C recalled a conversation with R1 about Hospice services and indicated R1 did not qualify for Hospice services at that time on 2/7/25.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R3 and R4) of 3 residents observed during the provision of cares. Certified Nursing Assistant (CNA)-G did not complete appropriate hand hygiene during the provision of care for R4. Licensed Practical Nurse (LPN)-E and CNA-F did not wear the appropriate personal protective equipment (PPE) during a transfer for R3 who was on enhanced barrier precautions (EBP). Findings include: The facility's Hand Hygiene policy, dated 11/2/22, indicates: .1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand Hygiene Table: After handling contaminated objects (either soap and water or alcohol-based hand rub (ABHR) is preferred); Before and after handling clean or soiled dressings, linens, etc; 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's Enhanced Barrier Precautions policy, dated 8/8/24, indicates: .a. 4. High-contact resident care activities include: .c: transferring, f. changing briefs or assisting with toileting .8. Additional epidemiologically important multidrug-resistant organisms (MDROs) may include: methicillin-resistant Staphylococcus aureus (MRSA). The facility's Transmission Based Precautions policy, dated 9/24/24, indicates: .10. Contact Precautions: Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment .F. Contact precautions will be used for residents infected or colonized with MDROs in the following situations: .i. when a resident has wounds, secretions, or excretions that are unable to be covered or contained . 1. On 4/22/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including seizure disorder and malnutrition. On 4/22/25 at 5:50 AM, Surveyor observed CNA-G provide morning cares for R4. When CNA-G approached R4 to get dressed, CNA-G noted R4 had urinated through R4's clothing and Chux pad. CNA-G completed hand hygiene and donned gloves. CNA-G began removing R4's sheet and Chux pad and also noted R4 had a bowel movement. CNA-G indicated CNA-G did not have wipes or a garbage can nearby. CNA-G walked around the R4's bed and touched R4's bed with soiled gloves. CNA-G then entered R4's bathroom and removed gloves. Without completing hand hygiene, CNA-G donned clean gloves and retrieved wipes. CNA-G then cleansed R4's bottom of stool. With the same soiled gloves, CNA-G fluffed R4's pillow and removed R4's shirt. Throughout the observation, Surveyor observed CNA-G change gloves 4 times without completing hand hygiene between glove changes. Surveyor observed CNA-G wash hands with soap and water once during the care observation and noted CNA-G did not have hand sanitizer available while providing cares. On 4/22/25 at 6:40 AM, Surveyor interviewed CNA-G who acknowledged CNA-G did not complete hand hygiene during glove changes. CNA-G also acknowledged CNA-G touched multiple items in R4's room with soiled gloves. CNA-G also verified there was not hand sanitizer readily available in any of the resident rooms. 2. On 4/22/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including diabetes mellitus, MRSA, and cellulitis. R4's care plan, dated 2/12/25, indicated R4 had venous wounds on the left lower extremity and a MRSA infection/cellulitis in the left lower leg. On 4/22/25 at 5:00 AM, Surveyor observed CNA-G and LPN-E enter R4's room to transfer R4 from bed to toilet with an EZ stand lift. Surveyor observed a sign on R4's door that indicated R4 was on EBP and providers must wear gloves and gowns for the following high-contact resident care activities: Transferring; Changing briefs or assisting with toileting. Surveyor noted a set a drawers to the right of R4's door that contained PPE. A sign on top of the drawers indicated: Contact Precautions: Providers and staff must also: Put on gown before room entry. Discard gown before room exit. Surveyor observed CNA-G and LPN-E don gloves, enter R4's room, and transfer R4 to the toilet. CNA-G and LPN-E remained in R4's room and then transferred R4 from the toilet to R4's wheelchair. When LPN-E exited R4's room, Surveyor interviewed LPN-E and referenced the signage on R4's door. LPN-E indicated LPN-E did not know which sign LPN-E should follow. LPN-E verified LPN-E did not wear a gown during the transfer. CNA-G then exited R4's room. When Surveyor referenced the two signs on R4's door, CNA-G indicated CNA-G thought R4 was on contact precautions. CNA-G acknowledged CNA-G did not wear a gown during the transfer. On 4/22/25 at 11:06 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should complete hand hygiene when going from dirty to clean and when donning new gloves. Surveyor informed DON-B that hand sanitizer was not accessible for staff in resident rooms. With regard to wearing PPE during a transfer for a resident with EBP and Contact Precautions signs on their door, DON-B indicated staff should have followed the signs and donned a gown for the transfer. DON-B indicated the facility was completing hand hygiene and EBP audits and recognized both of the observations were on the night (NOC) shift, however, the audits were done mostly on the AM and PM shifts.

Based on staff and resident representative interview and record review, the facility did not ensure a medical record contained signed COVID-19 vaccination documentation for 1 resident (R) (R2) of 5 sampled residents. R2's medical record did not contain a signed authorization from R2's Power of Attorney for Healthcare (POAHC) for the facility to administer a COVID-19 vaccine. Findings include: The facility's COVID-19 Vaccination policy, dated 9/13/24, indicates: 14. Consent will be signed prior to administration of the COVID-19 vaccine. This information will be retained in the resident's medical record . On 4/22/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD), dysphagia, schizoaffective disorder, and bipolar disorder. On 3/20/25, R2's Minimum Data Set (MDS) assessment, dated 3/20/25, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R2 had moderate cognitive impairment. R2 had an activated POAHC. R2's medical record contained a COVID-19 consent form, dated 2/1/25, that indicated R2's POAHC gave verbal consent for R2 to receive a COVID-19 vaccine. On 4/22/25 at 9:47 AM, Surveyor interviewed Registered Nurse (RN)-H who indicated RN-H called R2' POAHC on 2/1/25 and obtained verbal authorization for R2 to receive a COVID-19 vaccine. RN-H indicated RN-H mailed the authorization form to R2's POAHC with a note to return the signed document to the facility within two weeks. RN-H indicated R2's POAHC had not returned the signed document. RN-H did not document the verbal conversation with R2's POAHC in R2's medical record and indicated RN-H usually documented communications in nursing notes. RN-H indicated RN-H obtained authorization from R2 on 2/14/25 to administer a COVID-19 vaccine. On 4/22/25 at 2:23 PM, Surveyor interviewed R2's POAHC who indicated RN-H called and left a message regarding authorization for vaccines. R2's POAHC indicated they attempted to return RN-H's call but did not get through. R2's POAHC then phoned the former Director of Nursing (DON) and left a message authorizing all vaccines except COVID-19. R2's POAHC indicated R2 authorized COVID-19 vaccination on 2/14/25, however, R2's POAHC had been activated for R2's POAHC to make medical decisions. R2's POAHC indicated they spoke with the former DON who stated there was a miscommunication regarding R2's COVID-19 vaccine and that RN-H would be further educated on the process for the future. On 4/22/25 at 3:42 PM, Surveyor interviewed DON-B who verified a COVID-19 vaccine was administered to R2. DON-B indicated the facility works off of verbal consents. DON-B verified the language in the facility's policy regarding having a signed consent prior to administration of a COVID-19 vaccine. DON-B was not aware of R2's POAHC and the former DON's conversation. DON-B provided Surveyor with COVID-19 education that was provided to R2.

Based on staff interview and record review, the facility did not make a prompt effort to investigate and resolve a grievance for 1 resident (R) (R1) of 5 sampled residents. A grievance was emailed to the facility on [DATE] that indicated certain medications were not administered to R1 during R1's respite stay. The grievance was not investigated and a resolution was not provided. Findings include: The facility's Grievance Policy, revised 7/2022, indicates: The facility will seek to resolve concerns, complaints, or grievances and provide residents, responsible parties, staff, and others feedback and resolution in a timely manner . On 3/13/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] for a Hospice respite stay and had diagnoses including congestive heart failure, end-stage renal disease, hypothyroidism, and anxiety disorder. R1's Minimum Data Set (MDS) assessment, dated 11/27/24, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R1 had moderate cognitive impairment. R1 was responsible for R1's healthcare decisions and was discharged from the facility on 11/27/24. R1's medical record indicated R1 was administered (as ordered by the physician) levothyroxine (used to treat hypothyroidism) 75 micrograms (mcg) daily, furosemide (a diuretic medication used to treat fluid retention) 40 milligrams (mg) daily, and spironolactone (a diuretic medication used to treat fluid retention) 50 mg daily in addition to other medications during R1's respite stay. R1's medication administration record (MAR) did not indicate any doses were refused or not administered. The MAR indicated Licensed Practical Nurse (LPN)-C, Registered Nurse (RN)-D, and LPN-E were among the nurses who administered medication to R1. On 3/13/25 at 10:03 AM, Surveyor interviewed LPN-C who indicated LPN-C did not recall R1. LPN-C indicated residents on respite stays are usually administered medication provided by the facility's pharmacy, however, sometimes families bring medication. On 3/13/25 at 10:14 AM, Surveyor interviewed RN-D via phone. RN-D recalled R1 and indicated RN-D administered levothyroxine to R1 in the early morning hours when levothyroxine was scheduled to be given. RN-D indicated R1 asked what the medication was for. RN-D indicated the pharmacy delivered medication daily between 10:00 PM and 11:00 PM and 4:30 AM and 6:30 AM. RN-D did not recall concerns with R1's medication supply. RN-D indicated residents on respite stays are usually administered medication provided by the pharmacy. RN-D indicated if medications are brought from a resident's home, the medications might be administered until the pharmacy supply arrives. RN-D also indicated nurses can pull medication from contingency. On 3/13/25 at 10:22 AM, Surveyor interviewed LPN-E via phone. LPN-E indicated R1's name sounded familiar. LPN-E indicated residents on respite stays are usually administered medication provided by the pharmacy. LPN-E indicated if medications are available over-the-counter, nurses can use the facility's stock supply. LPN-E indicated if a resident is prescribed an unusual medication, the resident's family needs to bring in the medication. LPN-E indicated medication can be obtained from contingency if the pharmacy delivery has not yet arrived. LPN-E indicated a family member was upset about a resident not receiving certain medications, however, LPN-E was not sure if the situation involved R1. On 3/13/25 at 11:39 AM, Surveyor interviewed Social Worker (SW)-F who indicated the pharmacy provides medication for respite stay residents. On 3/13/25 at 12:17 PM, Surveyor interviewed Director of Nursing (DON)-B who provided Surveyor with a delivery manifest and invoice from the pharmacy that included information on medications delivered/billed to the facility for R1's respite stay. The documents listed furosemide and levothyroxine and a medication used to treat breathing conditions via a nebulizer. DON-B indicated as far as DON-B could tell, R1's other medications did not come from the pharmacy. DON-B indicated DON-B was not in the facility during R1's respite stay. On 3/13/25, Surveyor reviewed a delivery manifest and invoice from the pharmacy that indicated the facility was charged for fourteen tablets of furosemide and levothyroxine related for R1 with a service date of 11/23/24. No other medications for R1 were listed as received from the pharmacy. On 3/13/25 at 1:18 PM, Surveyor interviewed Hospice Administrator (HA)-G who indicated R1 was admitted to the facility on [DATE] for a Hospice respite stay of five days. HA-G indicated the contract between the Hospice company and the facility allowed for medications to be brought from home for administration at the facility. HA-G indicated Hospice pays the facility an overall rate for care during respite stays which covers any medications administered. HA-G indicated Hospice notes indicated R1's family was upset about the possibility that R1 did not receive certain medications. On 3/13/25, Surveyor reviewed medical records provided by R1's Hospice provider that indicated a family member informed R1's Hospice nurse during a home visit on 11/27/24 that the family member sent six tablets of each of R1's medications with R1 when R1 was admitted to the facility on [DATE]. The family member reported to the Hospice nurse that all six of R1's levothyroxine and furosemide tablets came home with R1 along with three spironolactone tablets. The note indicated the Hospice nurse attempted to call the facility but could only leave a voicemail message for SW-F. The note indicated the Hospice nurse also emailed SW-F on the same date regarding the medication concerns. On 3/13/25 at 2:10 PM, Surveyor interviewed DON-B who indicated the facility could not find any indication that R1's medications were at the facility. DON-B indicated the facility did not have documentation that R1 brought medication from home or left with medications when R1 discharged home. When asked where R1's administered medications came from, DON-B stated, I don't know. On 3/13/25 at 2:15 PM, Surveyor interviewed SW-F who verified SW-F received an email from R1's Hospice nurse. SW-F indicated SW-F would have followed-up with nursing staff but could not find documentation that that occurred. SW-F verified the facility should have used the grievance process for the emailed concerns. On 3/13/25, Surveyor reviewed the email sent from the Hospice nurse to SW-F on 11/27/24. The email indicated the Hospice nurse attempted to call SW-F but was unable to get through. The Hospice nurse asked for a call back due to medication concerns and indicated R1 returned home from respite care that day. The email indicated a family member sent six tablets plus an extra of each of R1's medications, however, R1 returned home with medication that should have been administered during R1's stay. The email indicated six tablets of one medication were sent home and six tablets of another medication were sent home, however, staff ordered fourteen tablets from the pharmacy. On 3/13/25 at 2:43 PM, Surveyor interviewed SW-F who indicated SW-F contacted Hospice staff via phone to let them know R1's medications came from the pharmacy. When asked how SW-F knew R1's administered medications came from the pharmacy, SW-F indicated nurses told SW-F. SW-F verified a thorough investigation was not completed and the facility's grievance process was not followed.

Based on observation, interview and record review, the facility did not ensure 2 of 4 residents (R) reviewed for pressure injuries (PI) (R151 and R32) received care consistent with professional standards of practice to prevent the development of a new pressure injury and promote healing of existing PIs. R151 was admitted to the facility with a sacral PI and was assessed to be at risk for PI development. R151 developed one unstageable PI on 10/16/24 and three unstageable PIs on 10/18/24. R151's care plan for PI interventions was not developed until 10/18/24 and not updated until 10/23/24 with interventions to off-load pressure areas to R151's bilateral lower extremities and sacral wound. The facility's failure to develop a care plan and implement interventions to off-load pressure to a resident's bilateral lower extremities and sacral wound created a finding of immediate jeopardy that began on 10/18/24. Nursing Home Administrator (NHA) A was notified of the immediate jeopardy on 10/28/24 at 3:30 PM. The immediate jeopardy was removed on 10/28/24; however, the deficient practice continues at a scope/severity level G (actual harm/isolated) as evidenced by the following example for R32. R32 had an existing stage IV pressure injury that developed 8.5 centimeters (cm) tunneling on the left hip and a stage IV pressure injury on the coccyx. R32 had wound vac therapy and multiple surgical debridements. The facility did not complete weekly pressure injury assessments, did not complete multiple treatments, and did not offload R32 as the care plan instructed. In addition, R32 missed wound clinic appointments on 8/14/24, 9/11/24, and 10/8/24. This is evidenced by: Guidelines from the National Pressure Injury Advisory Panel (NPIAP) Quick Reference Guide 2019 indicate in part: 2.1 Conduct a comprehensive skin and tissue assessment for all individuals at risk of pressure injuries: As soon as possible after admission/transfer to the health care service .5.1 Reposition all individuals with or at risk of pressure injuries on an individualized schedule, unless contraindicated .5.5 Reposition the individual in such a way that optimal offloading of all bony prominences and maximum redistribution of pressure is achieved .6.3 For individuals with a Category/Stage III or greater heel pressure injury, elevate the heels using a specifically designed heel suspension device offloading the heel completely in a way as to distribute the weight of the leg along the calf .NPIAP Classification Unstageable Pressure injury: Obscured full thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed . Example 1 R151 was admitted to the facility on [DATE] with diagnoses including multiple fractures of ribs, left side, chronic obstructive pulmonary disease (COPD), emphysema, anemia, hypo-osmolality and hyponatremia, atrial fibrillation, chronic kidney disease stage 3, anticoagulants, personal history of transient ischemic attack, atherosclerotic heart disease, peripheral vascular disease, congestive heart failure, prediabetes, and cardiac pacemaker. Hospital patient demographics, dated 10/10/24, documented an active wound on the posterior sacrum first assessed on 10/03/24 with the primary wound being a skin tear. An admission evaluation completed on 10/10/24 documented no skin impairments were present. The comments section documented, Bandage on lower back clean and dry. Bruising on (right) arm. Large Bruising noted to (left) hip area. Coban on (right) FA. R151's Admission Minimum Data Set (MDS) assessment, dated 10/16/24, documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated R151 had moderately impaired cognition. The MDS documented R151 had impairment to both lower legs and required partial/moderate assistance of staff for toileting, and upper and lower body cares. The MDS documented R151 was at risk for pressure injuries and had 2 unstageable pressure injuries with slough and or eschar. The MDS indicated R151 did not have a turning or repositioning schedule and did not refuse cares. R151 was discharged home on 10/26/24. The facility completed a Braden scale pressure risk skin assessment on 10/11/24 with a score of 18 which indicated R151 was at risk. (The Braden scoring scale is: 15-18 at risk, 13-14 moderate risk, 10-12 high risk, 9 or below very high risk.) The facility completed a Braden assessment on 10/23/24 with a score of 20 which indicated R151 was not at risk. The facility did not develop a care plan addressing this risk until 10/18/24. A pressure injury weekly tracker, dated 10/13/24, documented an unstageable pressure injury on the left buttock that measured 3.5 cm x 4.5 cm with slough and light serosanguinous drainage. A physician order, dated 10/13/24, documented, Reposition every 2 hours and prn (as needed). The order did not mention offloading the buttock PI when repositioning R151. A wound clinic note, dated 10/16/24 at 9:56 AM, documented, Pressure sacrum unstageable due to necrosis, measuring 3.0 cm X 3.5 cm x 0.1 cm with moderate serous drainage. Pressure left lateral foot unstageable DTI (deep tissue injury) with intact skin undetermined thickness. Noted to be present on admission per staff. The PI measured 1.3 cm x 1.5 cm and the depth not measurable. Skin is intact with purple/maroon discoloration. Apply skin prep twice daily for 30 days. This is the first documentation of the wound. A Pressure Injury Weekly Tracker, dated 10/16/24 at 2:07 PM, indicated: Sacrum PI measured 3 cm x 3.5 cm x 0.1 cm, unstageable with necrotic tissue, 20% granulation tissue, 80% slough, 100% necrotic tissue, and had moderate serous drainage. On 10/16/24 at 2:30 PM, date acquired 10/16/24 in-house, R151's left lateral foot PI measured 1.3 cm x 1.5 cm unstageable with 100% necrotic tissue with no drainage, dark red or purple and/or non-blanchable. R151 had the following physician orders: 10/16/24: Heel protectors to be on while in bed. 10/16/24: Air mattress needed for resident. 10/16/24: Wound type: Pressure wound. Location: left buttock/sacrum. Wound cleansing agent: normal saline or wound cleanser. Primary dressing type: Calcium alginate with silver, zinc to peri-wound. Cover dressing: Foam dressing. Frequency of dressing changes: Three times per week Monday-Wednesday-Friday and PRN. Expected duration of need: TBD (to be determined) one time a day every Mon, Wed, Fri for Wound Care and PRN AND as needed for if dressing is soiled or no longer intact. The facility ordered an alternating low air loss mattress on 10/16/24 which was placed on R151's bed on 10/17/24. On 10/16/24, the facility ordered liquid protein 30 milliliters (mls) two times per day. A Pressure Injury Weekly Tracker, dated 10/18/24, indicated: Left lateral foot (acquired on admission), unstageable PI measured 4.3 cm x 2.2 cm with 50% necrotic tissue with no drainage. The first PI weekly tracker assessment of the left lateral foot on 10/16/24 documented the PI was acquired in the facility. On 10/18/24, left plantar foot (acquired on admission), unstageable PI measured 2.2 cm x 1.7 cm, with necrotic tissue and no drainage. This is the first documentation of this PI. On 10/18/24, left heel (acquired admission), unstageable PI measured 1.6 cm x 0.7 cm with necrotic tissue and no drainage. This is the first documentation of this PI. On 10/18/24, right plantar foot (acquired on admission), unstageable PI measured 3.5 cm x 6.5 cm with necrotic tissue and no drainage. This is the first documentation of this PI. R151's care plan was first developed on 10/18/24 with the focus area: The resident has unstageable to heel and unstageable to sacrum pressure ulcer or potential for pressure ulcer development (related to) immobility. Interventions implemented on 10/18/24 included: Administer medications as ordered; Administer treatments as ordered; and Monitor for effectiveness. Interventions implemented on 10/23/24 included: Elevate bilateral lower extremities up on pillow to off load pressure area; Reposition to right side with pillow to off load sacral wound; Please chart refusals from resident; Follow facility policies/protocols for the prevention/treatment of skin breakdown. (The repositioning and heel interventions were added 13 days after R151's admission.) A physician order, dated 10/19/24, stated to apply skin prep to right plantar foot, left plantar foot, left heel, and left lateral foot for wound care two times a day. A nursing note, dated 10/19/24 at 10:00 PM, stated, Behavior Note: Note Text: Resident refused to be turned and repositioned on the evening shift. Went in at least every 2 hours but was in there more than that to ask him to be repositioned and he was refusing. Talked to him about the importance of being repositioned and he said that he already has a sore bottom so what is going to make the difference now. Explained to him that if he just stays in one position then the sore is going to get worse. He said for right now he does not want to be turned or repositioned. R151's medical record did not contain a risk versus benefits statement for refusals of repositioning. R151's behavior monitoring charting indicated no refusals of cares and no documented behaviors. R151's nursing documentation did not indicate R151 refused care or treatments. On 10/21/24 at 11:22 AM, Surveyor interviewed R151's family member about his care. The family member stated R151 came into the facility with one PI on the butt and developed one PI on his foot. The facility changed R151's mattress, but the pillows are on the chair and staff don't elevate his heels. The wound doctor comes in to do the dressing. On 10/22/24 at 5:20 AM, Surveyor observed R151 in bed with his feet directly on the mattress and the pillows on his dresser. On 10/22/24 at 5:39 AM, Surveyor interviewed Registered Nurse (RN) P about R151's positioning and heel protectors. When Surveyor asked RN P to verify if heel protectors were on R151, RN P verified R151 did not have heel protectors on and there were none in the room. RN P checked R151's feet which were pressing on the foot board of the bed and directly on the mattress. When RN P asked R151 if he remembered if he had been wearing the heel boots, R151 said no. When RN P asked if R151 wanted a pillow under his legs, R151 willfully lifted his legs. RN P placed a pillow under R151's legs and stated she would get Certified Nursing Assistant (CNA) Q to assist with a boost. At 5:44 a.m., RN P and CNA Q boosted R151 so his feet were not touching the foot board. On 10/22/24 at 9:22 AM, Surveyor observed RN H provide wound care to R151's feet which were pressing on the foot board. RN H removed R151's socks and applied skin prep to the right foot plantar area, left foot plantar, lateral, and heel. Surveyor noted an area on the right foot that was small and dark with a callused area, the left lateral foot just below 5th digit was black and dry, the left plantar was small, dark, and callused, and the left heel had a small dark area. On 10/22/24 at 10:10 AM, Surveyor interviewed R151 about his feet pressing on the foot board and asked if staff elevated his heels with pillows or if he wore boots. R151 indicated staff have not put the pillows under his legs and the pillows are always sitting on the shelf. R151 indicated someone told him that he shouldn't wear the boots and his feet would heal better without them. R151 could not remember who told him. R151 stated his feet didn't hurt but they press on the foot board when the head of the bed is up and he slides down in bed. Staff boost R151 up when asked. On 10/23/24 at 1:15 PM, Surveyor observed RN M remove Mepilex from R151's buttock. The area had 100% slough and a red peri-wound. RN M stated the area was unstageable with 100% slough. The area measured 2.9 cm x 3.2 cm. RN M assessed R151's left lateral foot below the 5th digit on the pad of the foot and measured 1.8 cm x 1.3 cm. The area appeared dark in color and dry with no raised area or appearance of being open. RN M measured the left foot plantar area to be 2 cm x 1.8 cm. Surveyor observed a small red DTI area with hard skin. RN M measured the left heel to be 0.6 cm x 1.3 cm. Surveyor observed a small red DTI area with hard skin. RN M measured the right foot plantar area to be 3.0 cm x 3.0 cm. Surveyor observed a small red DTI area with hard skin. RN M indicated all the areas were unstageable. RN M looked for boots for R151. When RN M asked if he had been wearing the boots, R151 stated no. Surveyor told RN M that Surveyor observed boots in R151's closet on the top shelf. When RN M got the boots, R151 refused. When RN M asked why R151 didn't want the boots and if they were hot, R151 stated he could not remember who told him that he would be better off not wearing the boots. RN M educated R151 that wearing the boots would help his feet from hitting the foot board and causing more issues. R151 agreed to wear the boots. RN M applied the boots and placed a pillow under R151's calves. On 10/23/24 at 1:40 PM, Surveyor interviewed RN M about R151's documentation of PIs and asked if the PIs were facility-acquired. RN M indicated that she was not sure if the PIs were facility-acquired and thought the PIs were initially assessed upon admission. Surveyor stated the left lateral foot was initially noted to be facility-acquired but the assessments after that documented the PIs were present upon admission. RN M indicated she wasn't sure when she did the assessment so she marked the wounds as present upon admission. RN M indicated she would change the assessments to indicate the PIs were facility-acquired. On 10/24/24 at 8:24 AM, Surveyor interviewed Director of Nursing (DON) B and asked if R151's PIs were avoidable or unavoidable. DON B indicated all PIs are avoidable. On 10/28/24 at 11:57 AM, Surveyor interviewed RN O (the facility's MDS Coordinator) about R151's 10/16/24 Admission MDS assessment that coded 2 PIs on admission. RN O indicated the coding was based on information in the chart from admission and the wound clinic note. Surveyor and RN O reviewed the facility's admission evaluation documentation that indicated R151 did not have any skin impairments. There was a PI weekly tracker completed on 10/13/24 of the left buttock and a non-pressure injury to the right buttock. On 10/16/24, the PI weekly tracker assessments stated a sacrum PI and left lateral foot PI were acquired on 10/16/24 in house. A hospital demographics note on 10/10/24 documented the sacrum but did not document the left lateral foot. RN O indicated the wound clinic note documented the left lateral foot was present upon admission. Surveyor stated the wound note documented noted to be present on admission per staff but there was no documentation that staff assessed a left lateral foot PI until 10/16/24 after the wound clinic evaluation. RN O indicated she understood and stated the MDS should have been coded with 1 PI to the sacrum on admission and 1 PI to the left lateral foot facility-acquired and indicated the MDS would be updated. On 10/28/24 at 12:46 PM, Surveyor interviewed Nurse Practitioner (NP) N about R151 having PIs on admission. NP N reviewed R151's admission notes and did not see any documentation of R151 having PIs on his feet. NP N indicated she would have reviewed the hospital discharge note and would follow-up with R151 when next seen. NP N reviewed the hospital discharge note and noted there were no PIs on R151's feet and the only skin area noted was the sacrum. NP N indicated she should be notified by the facility if there was a change in condition and expected to be notified of the start of a PI. NP N reviewed her communication with the facility and dictation and stated there was no documentation of R151 having any PIs. NP N indicated she was not aware that R151 had any PIs on his feet. NP N indicated she would have reviewed the wound clinic orders, ensured the facility was following the orders, and would have assessed R151 on her next visit. NP N indicated the only time R151 refused care was related to the use of oxygen upon discharge. NP N indicated R151 told her everything was fine and he had no pain or concerns. The failure to initiate a care plan and implement interventions to prevent pressure injuries resulted in serious harm for R151 and led to a finding of immediate jeopardy. The facility removed the jeopardy on 10/28/24 when it completed the following: 1. Completed wound assessments for residents with pressure injuries and skin assessments for all in-house residents. 2. Updated care plans with pressure prevention interventions. 3. Educated licensed nursing staff on the facility's policy, assessing residents upon admission, implementing pressure injury prevention interventions, implementing treatment orders, documentation, and provider notification. 4. Educated nursing and therapy staff on implementing pressure injury prevention interventions. 5. Implemented audits to ensure compliance. 40590 Example 2 R32 had diagnoses including fracture of left pubis (admission diagnosis), moderate protein calorie malnutrition, and diabetes mellitus type 2. R32's MDS assessment, dated 9/5/24, indicated R32 had no behaviors or rejection of care and had two stage 4 unhealed pressure injuries. R32 had a BIMS score of 14 which indicated R32 was cognitively intact; however, R32 was a poor historian. R32's care plan, initiated 4/11/24, indicated R32 had potential/actual impairment to skin integrity and was at high-risk due to multiple open wounds (revised 10/22/24). Care plan interventions on admission included: The resident will maintain or develop clean and intact skin by the review date; Keep skin clean and dry. Use lotion on dry skin as ordered/desired/needed; Meds/labs/treatments as ordered. An active physician order with a start date of 5/23/24 stated, Reposition every hour, document refusals, three time a day for repositioning. A Braden Scale assessment, dated 9/1/24, had a score of 12.0 which indicated R32 was at high risk for pressure injuries. R32 had wound care to be done every Monday and Friday by the facility and every Wednesday in the wound clinic. On 7/24/24, R32 was noted to have stage 4 pressure injuries on the coccyx/sacrum and left trochanter/hip. A facility Pressure Injury Weekly Tracker showed: Sacrum 2.4 x 1.4 x 4.2 stage 4, necrotic Left hip: No wound measurements on assessment by the facility Wound Clinic (WC) measurements indicated: Coccyx: 2.4 x 1.4 x 4.2, foul odor, exposed bone and muscle, stage 4 Left hip: 4.0 x 3.7 x 5.1, with tunnel, stage 4 (there was no measurement of the tunnel) WC treatment orders indicated: Wash with Dakin's 0.25% solution. Skin prep to peri-wounds. Bridge wound vac to cover both wounds. Wound vac set to -125 mmHg (millimeters of mercury). To be changed Monday and Friday at the nursing home and Wednesdays in the wound clinic. A WC physician note indicated: No wound vac was applied or came with the patient today. We will do a dakin's wet to dry covered with 4x4 Allevyn in clinic but Nursing Home, please get the wound vac applied today. R32's Treatment Administration Record (TAR) indicated: Wet to dry dressing with normal saline and Kerlix. Skin prep around wound to protect healthy skin and cover with foam adherent dressing. To be completed TID (three times daily) and as needed until wound vac supplies arrive. The treatment was not signed out on 7/22 noon, 7/23 PM, or 7/24 PM. R32's medical record did not indicate the WC physician was updated that R32's wound vac was removed. On 7/31/24, a Pressure Injury Weekly Tracker indicated: Sacrum: 2.2 x 1.4 x 2.5 stage 4, granulation Left hip: 3.2 x 3.2 x 6.3 stage 4, granulation (increased depth of left hip) There were no new interventions on R32's care plan. WC treatment orders indicated: Wound vac-wash with Dakin's 0.25% solution. Apply vacuum-assisted closure device at -125 mmHg. With green foam to left hip and coccyx (note change in treatment to green foam). With bridge dressing to cover both wounds. Apply skin prep to peri-wound and transparent semi-permeable cover dressing. One time a day every Monday, Wednesday, Friday for wound care. Wound clinic to change wound vac on Wednesdays. On 8/7/24, WC measurements indicated: Coccyx: 2.2 x 1.9 x 2.8, with foul odor Left hip: 3.3 x 3.4 x 3.5, with tunnel 8.0 cm A nurses note, dated 8/11/24 at 5:40 PM, stated, Resident refused repositioning at 1600 (4:00 PM); agreed to lift up on arms to give buttocks a break from sitting but refused to lay down and get off buttocks. This was the first documented refusal by R32 since admission on 4/11/24. There were no facility weekly wound assessments with measurements or wound clinic notes in R32's record for 8/14/24. R32 was supposed to have a wound clinic appointment on 8/14/24. A Nursing Skin/Wound Note, dated 8/15/24, stated, Note Text: wound care completed by wound care nurse. Wound vac dressing to hip and coccyx changed. Measurements taken. Coccyx measures 2.3 cm x 3.5 cm x 2.0 cm. Left hip measures 3.1 cm x 3.1 cm x 8.4 cm. (increased depth) On 8/21/24, a Pressure Injury Weekly Tracker indicated: Sacrum: 2.2 x 1.9 x 2.8 stage 4, granulation Left hip: 3.3 x 6.4 x 3.5 stage 4, granulation, necrotic fat, necrotic muscle, debrided, with tunnel at 11:00, strong odor (increased width) WC measurements indicated: Coccyx: 1.8 x 1.3 x 2.5 with foul odor Left hip: 2.5 x 2.6 x 3.5 with tunnel 6 cm (Inconsistent measurements from wound clinic compared to facility weekly PI tracker) A WC treatment order on 8/21/24 indicated: Wash with Dakin's 0.25% solution. Skin prep peri-wounds. Apply Puracol collagen to the base of the wounds (whole pack to each wound). [NAME] foam to areas that are visible. Black foam on top of white foam (foams must be touching within the wound). Bridge vac to cover both wounds. Wound vac set to -125 mmHg. To be changed Monday and Friday at the nursing home and Wednesdays in the wound clinic. The wound care treatment was changed on 8/21/24 when the wound increased in size. Puracol collagen was added. R32's treatment was not signed out on 8/23/24. A Nursing Skin/Wound Note, dated 8/25/24,stated, Note Text: Wound vac alarming with a leak alert. Wound vac removed and wounds to right hip and coccyx packed with dakins soaked gauze and to be changed BID (twice daily). Wound vac canisters ordered. There was no evidence the wound physician was updated. On 8/28/24, Pressure Injury Weekly Tracker measurements were the same as the wound clinic and indicated: Coccyx: 2.2 x 1.6 x 2.5 foul odor Left hip: 2.7 x 2.7 x 3.5 with tunnel 8.5 cm The wound care treatment order was the same as 8/21/24. R32's TAR indicated: Pack coccyx and right hip wounds with Kerlix damp with quarter strength Dakin's BID until wound vac is able to be put back on. The treatment was not signed out on the 8/30 PM shift and the order identified the wrong hip. A Nursing Skin/Wound Note, dated 8/29/24, stated, Note Text: Wound care completed by wound care nurse. Wound Vac not on, waiting on white foam, wet to dry applied. A Nursing Skin/Wound Note, dated 8/31/24, stated, Note Text: Wound care completed by this writer. Wound Vac applied. On 9/4/24, a Pressure Injury Weekly Tracker indicated: Sacrum 2.4 x 2.1 x 2.5 stage 4, granulation Left hip: 2.3 x 2.4 x 6.0 stage 4, undermined 6 cm (improved) A WC physician note indicated: Left hip with undermining has a 6 cm tunnel going cranially. The ulcer is stage 4 with necrotic muscle, necrotic fat, necrotic connective tissue. The coccygeal ulcer has some necrotic muscle, necrotic fat present but improved and does not probe to bone but only muscle. A Wound Debridement physician note indicated: Wound debridement to remove necrotic fat, necrotic muscle, necrotic connective tissue, tenacious yellowish slough, necrotic fascia, and fibrin from base of coccyx and left ischium wound. Coccyx pre-debridement measurement: 2.4 x 2.1 x 2.5 with foul odor Left hip pre-debridement measurement: 2.3 x 2.4 x 6.0 with tunnel. WC measurements post debridement indicated: Coccyx: 2.1 x 1.9 x 2.5 stage 4 with foul odor Left hip: 2.1 x 2.1 x 9.0 with tunnel The WC treatment order was the same as 8/21/24. R32's treatment was not signed out on 9/2, 9/6, 9/11, or 9/16. A nurses note, dated 9/7/24 at 5:08 AM, stated, Resident refused to be toileted or repositioned on last rounds. This was the second documented refusal and last documented refusal R32's medical record. On 9/11/24, there were no weekly in-house wound assessments or at the wound clinic. On 9/18/24, a Pressure Injury Weekly Tracker indicated: Sacrum 2.1 x 1.9 x 2.5 stage 4 Left hip: 2.1 x 2.1 x 9.0 stage 4, granulation with foul odor, tunnel 9 cm deep R32's treatment was not signed out on 9/20, 9/23, or 9/25. On 9/25/24, a Pressure Injury Weekly Tracker showed same measurements as the wound clinic: Coccyx: 2.1 x 1.9 x 2.0 with foul odor (improved) Left hip: 1.9 x 2.0 x 9.0 with tunnel (improved) On 9/30/24, a Pressure Injury Weekly Tracker indicated: Sacrum 1.0 x 0.9 x 3.0 stage 4, granulation 34-66%, necrotic 34-66% Left hip: 1.2 x 1.5 x 9.0 stage 4, granulation tissue 34-66%, necrotic tissue 34-66% WC measurements indicated: Coccyx: 1.0 x 0.9 x 3.0 with foul odor (improved length x width) Left hip: 1.2 x 1.5 x 9.0 with tunnel (improved length x width) A WC treatment order indicated: Left hip wound vac is on hold for left hip 9/25/24. Wash with Dakin's 0.25% solution. Pack with gauze soaked in Dakin's 0.25% solution (wring out so it's damp but not dripping). Apply 6 x 6 Allevyn or similar dressing over the wound. Clean and change dressing daily. On 10/2/24, WC measurements indicated: Coccyx: 1.1 x 1.2 x 2.5 with foul odor Left hip: 3.6 x 3.1 x 4.0 with 7.5 cm tunnel R32's treatment was not signed out on 10/3, 10/5, 10/9, or 10/10. On 10/9/24, there was no in-house weekly wound assessment or wound clinic note in R32's medical record. R32 was supposed to have a wound clinic appointment on 10/9/24. On 10/16/24, WC measurements indicated: Coccyx: 0.9 x 0.6 x 1.5 foul odor (improved) Left hip: 2.2 x 2.1 x 3.2 with tunnel 6.0 cm (improved) A WC physician note indicated: Continue wound vac for both wounds but the hip ulcer may have to be opened up further. On 10/22/24, DON B was made aware that Surveyor wanted to observe R32's dressing change on 10/23/24. DON B stated the dressing change would not done in-house on 10/23/24 because R32 had a wound clinic appointment. On 10/23/24, WC measurements indicated: Coccyx: 0.7 x 0.8 x 2.0 foul odor Left hip: 3.1 x 1.9 x 3.5 with tunnel 6.5 cm A WC Surgical Debridement note indicated: Sacrum: Necrotic muscle, necrotic fat, necrotic connective tissue, tenacious yellowish slough, necrotic fascia, and fibrin from the base of the wound removed. Left Hip: Necrotic muscle, necrotic fat, necrotic connective tissue, yellowish slough, and fibrin from the base of the wound removed. Has tunneling at 7.5 cm deep. Left hip measurement pre-debridement: 3.1 x 1.9 x 3.5 Coccyx measurement pre-debridement: 0.7 x 0.8 x 2.0 A WC treatment order indicated staff should continue the same left hip/coccyx treatment. On 10/22/24 at 7:03 AM, Surveyor observed R32 in bed asleep. R32 was positioned on the right side facing the doorway. At 7:37 AM, Surveyor observed Certified Nursing Assistant (CNA) L exit R32's room with R32 in a wheelchair and take R32 to the dining area for breakfast. At 7:42 AM, Surveyor observed R32 in the dining room eating breakfast independently. At 8:05 AM, Surveyor observed staff take R32 to therapy. At 9:10 AM, R32 returned from therapy. At 9:16 AM, Surveyor observed CNA L enter R32's room and ask if she needed anything. R32 stated she needed to go to the bathroom. CNA L retrieved gloves from a bin in the hallway. At 9:18 AM, Surveyor observed CNA L exit R32's room and don personal protective equipment (PPE) in the hallway. R32 was not repositioned during those 2 minutes. At 9:21 AM, Surveyor observed CNA L state to R32, I will come back for you and exit R32's room. At 9:44 AM, Surveyor observed staff take R32 to a resident council meeting. At 11:00 AM, Surveyor observed R32 in a wheelchair watching TV in her room. At 11:15 AM, Surveyor observed a CNA take R32 to the dining room. At 12:19 PM, Surveyor observed a CNA take R32 back to her room. Surveyor observed R32 in her wheelchair watching TV from 12:20 PM to 2:45 PM and noted R32 was sitting in her chair from 7:37 AM until she was last observed at 2:45 PM which was approximately 7 hours. An observation of R32's wheelchair cushion on 10/24/24 at 6:49 AM indicated R32 did not have a pressure reducing cushion. The cushion was labeled Comfort Curve. Key specs of Comfort Curve cushion use state, Your Risk of Skin Breakdown: Low. The cushion was not a pressure relieving cushion for the prevention of or promotion of healing pressure injuries. On 10/24/24 at 7:55 AM, Surveyor interviewed R32 regarding wound care and repositioning. R32 stated, The wound is on my butt, and they are changing the bandages on my butt. R32 also stated, They change the bandage on Wednesday, and they use a ruler to take measurements. When asked if staff educated R32 on the risks and benefits of repositioning, R32 stated, Yes. R32 had a poor memory and could not distinguish between facility and wound clinic staff regarding measurements and dressing changes. R32 also could not recall how staff repositioned her in bed or how often. On 10/24/24 at 8:05 AM, Surveyor interviewed CNA L and CNA K regarding R32's wound care and repositioning. CNA L stated, We wash her up. We lotion her and reposition her every 2 hours. CNA K stated, We wash her and lotion her skin, do skin inspections on her bottom to make sure she doesn't have pressure sores. We reposition her from her left side to her right side and keep her dry. On 10/28/24 at 3:35 PM, Surveyor interviewed DON B and Assistant Director of Nursing (ADON) J regarding R32's wound care and assessments. Surveyor shared concerns that the facility's PI measurements were identical to the wound clinic's measurements each week. ADON J stated the facility used the wound clinic physician's wound assessments and measurements for their weekly wound assessments and indicated they had not been doing their own weekly PI assessments on Mondays or Fridays with dressing changes. On 10/29/24 at 12:00 PM, Surveyor interviewed Registered Nurse (RN) Q who was R32's wound clinic case manager. RN Q confirmed R32 saw the wound clinic physician every Wednesday for wound care and debridement. RN Q stated there were three wound physicians and they rotated for R32's wound care. RN Q stated R32 missed wound care appointments on 8/14, 9/11, and 10/8. RN Q stated she felt R32's wounds had gotten better recently but had concerns about wounds in the past. RN Q stated the wound clinic was not updated by the facility that R32's wound vac was removed or that there were concerns with R32's wound care. RN Q stated she could not give an opinion on why the wounds had worsened from 7/24 to 9/18. RN Q stated she put suggestions for better off-loading on R32's wound clinic follow-up instructions.

Based on interview and record review, the facility did not ensure food was prepared in a clean and sanitary environment which had the potential to affect over 75% of the 48 residents (R) in the facility as 2 of the residents received tube feeding. Staff did not consistently test or document parts per million (PPM) of the sanitizing solution. Staff did not consistently document refrigerator temperatures. This was evidenced by: Sanitization Solution: The 2022 Federal Food and Drug Administration (FDA) Food Code documents at 4-302.13 Temperature Measuring Devices, Manual Warewashing: Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. The effectiveness of cleaners and chemical sanitizers is also determined by the temperature of the water used. A temperature measuring device is essential to monitor manual warewashing and ensure sanitization. The 2022 FDA Food Code documents at 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration: Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. On 10/21/24 9:12 AM, during an initial tour with Dietary Manager (DM) G, Surveyor asked to review the facility's sanitization logs. Surveyor noted the sanitization logs were missing PPM for the sanitization bucket, sink wash temperature, and for testing on October 11th and between October 13th and 21st. Surveyor asked to view the sanitization logs from August and September of 2024. The August sanitization log was missing PPM and sink wash temperatures for the 22nd, 29th and the 31st. The September sanitization log was missing sink wash temperatures on the 21st and 25th. Refrigerator/Freezer Temperatures: The 2022 FDA Food Code documents at 3-501.14 Cooling: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 Celsius (C) (135 Fahrenheit (F)) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5 C (41 F) or less. On 10/221/24 at 9:13 AM, during an initial tour of the kitchen with DM G, Surveyor noted missing cold storage temperatures. The temperature log for October 2024 was missing temperatures on the 15th, 16th, 18th, 19th, and 21st. Surveyor asked to view the August and September 2024 temperature logs. The August temperature log was missing temperatures on the 1st, 29th, and 31st. The September temperature log was missing temperatures from the 15th through the 18th and on the 27th.

Based on interview and record review, the facility did not send a copy of the discharge notice to the Office of the State Long Term Care Ombudsman for 4 of 4 residents (R) reviewed who were discharged to hospital (R12, R35, R50, and R4). The Ombudsman was not notified when R12, R35, R50, and R4 were discharged /transferred to the hospital. This was evidenced by: Example 1 R12 was hospitalized from 7/17/24 to 7/22/24, 7/29/24 to 8/2/24, and 8/7/24 to 8/16/24 for a change in condition. On 10/23/24 at 1:42 PM, Surveyor requested information of notification to the State Long Term Care Ombudsman for R12's discharges to the hospital. Director of Nursing (DON) B stated the facility did not have documentation of the notices. 31086 Example 2 R35 was admitted to the facility on [DATE] with diagnoses including Crohn's disease, chronic kidney disease stage 4, osteoporosis, type 2 diabetes mellitus, atherosclerotic heart disease, and transient ischemic attack. A Quarterly Minimum Data Set (MDS) assessment, dated 9/10/24, documented R35 had no impairments to the extremities, and required partial to moderate assist of staff for activities of daily living (ADLs) including toileting, dressing, and hygiene. A Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicated R35 was cognitively intact. A review of MDS records documented on 5/15/24, R35 was discharged with return anticipated and returned to the facility on [DATE]. On 5/26/24, R35 was discharged with return anticipated and returned to the facility on [DATE]. On 10/21/24 at 10:51 AM, Surveyor interviewed R35 about her transfers to hospital. R35 indicated in June she had complications from surgery for colon cancer, was sent to [NAME] to have surgery, and was able to come back to the same room. On 10/23/24, Surveyor requested from Director of Nursing (DON) B copies of the May 2024 notices given to the Ombudsman for R35's transfers to the hospital. On 10/25/24, Nursing Home Administrator (NHA) A provided Surveyor with an e-mail of the notice sent to the Ombudsman. The e-mail documented admissions, discharges from the facility, and deaths. The e-mail did not contain residents that were transferred to the hospital. Example 3 R50 was admitted to the facility on [DATE] with diagnoses including duodenal ulcer with hemorrhage, muscle weakness, type 2 diabetes mellitus, pressure ulcer of left heel stage 3 (dated 3/28/24), pressure ulcer sacral region stage 3 (dated 3/28/24), sleep apnea, posthemorrhagic anemia, restless legs syndrome, chronic kidney disease stage 3, depression, personal history of transient ischemic attack and cerebral infarction without residual deficits. An Admission MDS assessment, dated 2/25/24, documented a BIMS score of 13 out of 15 which indicated R50 was cognitively intact. A review of MDS records documented on 3/16/24, R50 was discharged with return anticipated and returned to the facility on [DATE]. A progress note documented on 3/16/24 at 12:11 AM indicated R50 was transferred to the hospital for a gastrointestinal (GI) bleed. An Interact tool documented R50 was aware of the clinical situation and notified of the transfer. On 10/23/24, Surveyor requested from DON B the March 2024 notices given to the Ombudsman of R50's transfers to the hospital. On 10/25/24, NHA A provided Surveyor with an e-mail of the notice sent to the Ombudsman. The e-mail documented admissions, discharges from the facility, and deaths. The e-mail did not contain residents who were transferred to the hospital. 40590 Example 4 R4 was admitted to the facility on [DATE] and had diagnoses including diabetes mellitus type 2 with foot ulcer. R4 had an unplanned discharge to the hospital on 7/5/24 and returned to the facility on [DATE]. R4 had another unplanned discharge on 9/23/24 and returned to the facility on [DATE]. The facility did not notify the Ombudsman of R4's discharges to the hospital. On 10/23/24 at 11:16 AM, Surveyor received a copy of an e-mail from Social Services Director (SSD) I that was sent on 10/23/24 to the Ombudsman notifying the Ombudsman of unplanned discharges from May-October 2024. On 10/28/24 at 4:40 PM, Surveyor conducted an exit interview with NHA A, DON B and [NAME] President of Success (VP) R about Ombudsman notification. VP R indicated the Ombudsman notices did not contain residents who were transferred to the hospital and education was provided to the Social Worker.

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 to help prevent the development and transmission of communicable disease and infection. This had the potential to affect 7 of 15 sampled residents (R) (R23, R40, R32, R151, R9, R35, and R26). Staff provided care to residents on enhanced barrier precautions (EBP) and contact precautions without the proper personal protective equipment (PPE) usage (R23, R40, R32, and R151). Staff did not follow appropriate hand hygiene when providing personal cares and wound care (R9, R35, and R26). Staff emptied a contaminated basin of water in R9's sink. This was evidenced by: The facility's policy titled Transmission-Based (Isolation) Precautions, revised 9/24/24, states in part: Contact Precautions: a. Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment. b. Make decisions regarding private room on case-by-case basis, balancing infection risks to other residents, the presence of risk factors that increase the likelihood of transmission, and the potential adverse psychological impact on the infected or colonized resident. c. Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. e. Residents experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen, should be placed on contact precautions even before a specific organism has been identified. f. Contact precautions will be used for residents infected or colonized with multidrug-resistant organisms (MDROs) in the following situations: a. When a resident has wounds, secretions, or excretions that are unable to be covered or contained: and b. On units or in facilities where, despite attempts to control the spread of the MDRO, ongoing transmission is occurring. The facility's policy titled Enhanced Barrier Precautions, revised 8/8/24, states in part: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care activities .3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray. b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities (described below) and may not need to be donned prior to entering the resident's room . 4. High-contact resident care activities include: a. Dressing; b. Bathing; c. Transferring; d. Providing hygiene; e. Changing linens; f. Changing briefs or assisting with toileting; g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tube; h. Wound care: any chronic skin opening requiring a dressing .9. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. The facility's policy titled Hand Hygiene, with a reviewed/revised date of 11/2/22, reads in part: 5. Hand hygiene technique when using soap and water: .d. Rinse hands with water. e. Dry thoroughly with a single-use towel. f. Use clean towel to turn of the faucet .Hand Hygiene Table: .After handling items potentially contaminated with blood, body fluids, secretions, or excretions use either soap and water or alcohol based hand rub . Example 1 R23 was admitted to the facility on [DATE] with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R23 was cognitively intact. R23 had a diagnosis of venous insufficiency (a condition in which the leg veins don't allow blood to flow back to the heart). R23's physician orders included: (Medical Doctor) follows resident for wound care; Wound care team to complete wound care. If wound care team is not here, floor nurses are to complete treatments; Enhanced barrier and contact precautions due to methicillin susceptible staph aureus (MSSA). A non-pressure weekly wound tracker started on 2/2/24 stated in part: Type of wound: venous stasis Length 11.6, width 12.0, depth 0.2 Granulation 70%, slough 39% Serous drainage moderate R23's latest non-pressure weekly wound tracker dated 10/16/24 stated in part: Type of wound: venous stasis ulcer to inner right ankle Length 0.7, width 0.7, depth 0.1 Wound edges healed Summary of findings healed. On 10/21/24 at 10:39 AM, Surveyor noted a wound on R23's right inner ankle with no dressing and blood stains on R23's left sock. R23 stated, That is because I have my legs crossed and the wound on my right ankle got my left sock dirty. On 10/21/24 at 11:30 AM, Surveyor observed Certified Nursing Assistant (CNA) C enter R23's room without a gown and gloves and deliver a meal tray. Surveyor observed CNA C touch R23's over-the-bed table, grab bar on the bed, and bed control. When CNA C exited R23's room, Surveyor asked CNA C if a gown and gloves were needed to deliver a meal tray for a resident on contact precautions. CNA C replied, I usually do. I would put the tray down here, gown and glove, then take the tray into this room. On 10/22/24 at 9:29 AM, Surveyor observed Social Services (SS) I enter R23's room without a gown or gloves and touch R23's over-the-bed table. When Surveyor asked SS I if it was necessary to gown and glove when entering R23's room, SS I replied, Not if I am not doing personal cares. On 10/22/24 at 11:29 AM, Surveyor observed Dietary Manager (DM) G enter R23's room without a gown or gloves and touch R23's over-the-bed table when delivering a lunch tray. When Surveyor asked DM G if a gown and gloves were necessary when delivering a tray to a resident on contact precautions, DM G replied, If you are just passing the tray then you do not need to put on a gown. On 10/23/24 at 7:23 AM, Surveyor asked Director of Nursing (DON) B what guidance the facility follows for infection control. DON B indicated the facility has policies that staff follow. When Surveyor asked DON B, What guidance does your policy follow? DON B replied, CDC's (Center for Disease Control and Prevention's) guidance. When Surveyor asked DON B, What is the difference between contact precautions and EBP? DON B replied, With contact precautions, they have an MDRO. When Surveyor asked DON B, Is there any difference regarding PPE usage between contact precautions and EBP? DON B paused. Surveyor pulled out the CDC's transmission-based precautions reference guide printed from the Wisconsin Department of Health Services (DHS) website and showed DON B (who was the facility's Infection Preventionist) with contact precautions, You wear a gown and gloves for all interaction that may involve contact with the patient or potentially contaminated areas in the resident's environment. Example 2 R40 was admitted to the facility on [DATE] with diagnoses of dysphagia (swallowing difficulties) following a stroke and esophageal obstruction (a malformation in which the esophagus is interrupted and forms a blind-ending pouch rather than connecting normally to the stomach). R40's physician orders included enhanced barrier precautions due to a gastronomy (G)-tube. On 10/22/24 at 9:21 AM, Surveyor observed CNA C and Registered Nurse (RN) D enter R40's room with a Hoyer lift. CNA C and RN D were not wearing gowns. On 10/22/24 at 9:25 AM, Surveyor interviewed RN D about the observation. RN D replied, Yeah, we probably should have placed a gown when we assisted (R40) with the Hoyer to the shower chair. CNA C exited R40's room and replied, I put a gown on when I showered (R40) in the bathroom. 40590 Example 3 R32 was admitted to the facility on [DATE] and had a diagnosis of fracture of left pubis. A Minimum Data Set (MDS) assessment, dated 9/5/24, indicated R32 had two stage 4 unhealed pressure ulcers. R32's care plan, dated 4/11/24 with a target date of 11/20/24, stated, At risk/actual for infection r/t (related to) wounds. Will remain free of complications through review date. An intervention initiated on 5/23/24 stated, Enhanced barrier precautions when performing high-contact care activities. On 10/21/24 at 1:47 PM, Surveyor observed an EBP sign on R32's door and a PPE bin with gloves and gowns in the hallway outside R32's room. The EBP sign indicated: Everyone must: clean their hands, including before entering and when leaving the room. Providers and Staff must also: wear gloves and gown for the following high-contact resident care activities, dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tubes, tracheostomy, wound care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. On 10/21/24 at 7:18 AM, CNA L knocked on R32's door. CNA L entered R32's room without donning PPE and stated, Good morning (R32) and closed the door. At 7:37 AM, CNA L exited the room with R32 fully dressed in a wheelchair and took R32 to the dining area. At 7:40 AM, Surveyor noted there was no PPE in R32's room for staff to don while in the room. On 10/22/24 at 9:21 AM, Surveyor interviewed CNA L regarding R32 and EBP. CNA L stated EBP was for wounds on R32's bottom and left hip wound vac. CNA L stated the wound on R32's coccyx was covered. When Surveyor asked CNA L when it was appropriate to use PPE for R32, CNA L stated, Anytime we do anything hands on; personal care, bathroom, and, We do everything for her, clean her up, but she can eat independently. 31086 Example 4 R151 was admitted to the facility on [DATE] with diagnoses including multiple fractures of ribs, left side, chronic obstructive pulmonary disease (COPD), chronic kidney disease stage 3, personal history of transient ischemic attack, peripheral vascular disease (PVD), congestive heart failure, prediabetes, and cardiac pacemaker. An Admission MDS assessment, dated 10/16/24, documented a BIMS score of 12 out of 15 which indicated R151 had moderately impaired cognition. The MDS documented R151 had impairment to both lower legs and required partial/moderate assistance of staff for toileting and upper and lower body cares. R151 had a physician order dated 10/13/24 for Enhanced barrier precautions d/t (due/to) open wounds. Every shift for wound care. On 10/22/24 at 9:22 AM, Surveyor observed Registered Nurse (RN) H provide wound care for R151's feet. RN H entered R151's room, sanitized hands, and applied gloves. RN H completed treatments to both of R151's feet, removed gloves, and sanitized hands. RN H did not wear a gown while providing care. Example 5 R9 was admitted to the facility on [DATE] with diagnoses of dementia, without behavioral disturbance, pneumonia, acute kidney failure, ulcer of esophagus, and osteoporosis. R9 was enrolled in Hospice care. An MDS Part A discharge assessment, dated 10/16/24, documented a BIMS assessment was not completed. R9 required partial/moderate assistance of staff for toileting, bathing, dressing, and bed mobility. On 10/22/24 at 6:43 AM, Surveyor observed CNA K and CNA L provide personal cares for R9. CNA K and CNA L sanitized hands and applied gloves. CNA L filled a basin with warm water and placed the basin on a barrier on R9's table. CNA L unfastened R9's brief and CNA K completed frontal peri care using wipes. CNA L and CNA K rolled R9 to the right side. CNA L removed R9's brief, cleaned R9's buttocks and peri area with wipes, and placed a clean brief on R9. CNA K and CNA L did not remove gloves and complete hand hygiene. With the same gloved hands, CNA K wet a wash cloth in the basin and gave the wash cloth to R9 to wash R9's face. With the same gloved hands, CNA K put soap on the wash cloth to wash R9's upper body and then put the wash cloth in the basin of water. CNA K used another wash cloth from the basin to rinse R9's upper body. CNA K used the same wash cloth to wash R9's frontal peri area and put the wash cloth back in the basin. CNA K used the other wash cloth in the basin of water to rinse R9's peri area. CNA K squeezed out the wash cloths in the basin, emptied the basin in the bathroom sink, rinsed the basin, and emptied the basin again in the sink. With the same gloved hands, CNA L and CNA K transferred R9 from bed to recliner. CNA L touched R9's hairbrush and brushed R9's hair. Example 6 R35 was admitted to the facility on [DATE] with a re-admission after hospital stay date of 6/4/24. R35's diagnoses included Crohn's disease, chronic kidney disease stage 4, type 2 diabetes mellitus, transient ischemic attack, and fibromyalgia. A Quarterly MDS assessment, dated 9/10/24, documented R35 had no impairments to the extremities and required partial to moderate assist of staff for activities of daily living (ADLs) including toileting, dressing, and hygiene. A BIMS score of 15 out of 15 indicated R35 was cognitively intact. On 10/22/24 at 1:31 PM, Surveyor observed RN H provide wound care to R35. RN H sanitized hands and applied a gown and gloves. After RN H removed R35's dressing, RN H removed gloves, washed hands in R35's bathroom sink, and turned off the faucet with clean hands. RN H applied clean gloves, applied gauze with Dakin's solution to R35's wound, and then removed the gauze. RN H removed gloves, washed hands, turned off the faucet with clean hands, and applied clean gloves. RN H placed a plain packing strip in the wound with a cotton swab. RN H removed RN H's gown and gloves, washed hands in R35's bathroom sink, and turned off the faucet with a bare arm. RN H then left the room to find the tape R35 requested. On 10/24/24 at 8:24 AM, Surveyor interviewed Director of Nursing (DON) B about infection control, hand hygiene, and EBP. DON B indicated staff were provided education and audited for infection control practices. DON B indicated the basin of water should have been emptied in the toilet. DON B also indicated a gown must be worn during wound care and the faucet should be turned off with a paper towel after hand washing. 47657 Example 7 On 10/23/24 at 10:09 AM, Surveyor observed CNA C complete incontinence care for R26. CNA C gathered supplies, completed hand hygiene, and donned clean gloves. CNA C unfastened R26's urine-filled brief, cleansed R26's frontal peri area, assisted R26 onto the left side, and cleansed R26's buttocks. Without removing gloves and completing hand hygiene, CNA C positioned and secured R26's clean brief and pulled down R26's shirt. CNA C then removed gloves. Without completing hand hygiene, R26 picked up R26's pillow to reposition R26 on the left side, picked up additional pillows to elevate R26's feet, and adjusted the bed covers for warmth. CNA C then touched the bed remote, adjusted R26's hair and head, moved the bedside table within reach, and picked up the garbage. On 10/23/24 at 10:14 AM, Surveyor interviewed CNA C regarding the facility's expectation of when to complete hand hygiene and remove gloves. CNA C stated when going from dirty to clean areas.

Based on observation, interview and record review, the facility did not ensure each resident (R) was treated with dignity and respect and cared for in a manner that enhanced their quality of life for 2 residents (R16 and R24). Staff were observed feeding R16 and R24 part of their meals while standing over them. This was evidenced by: The facility policy titled The Dining Experience: Staff Responsibilities, dated 4/10/20, states in part: The dining experience will enhance each individual's quality of life through person centered dining. Example 1 R24 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease and anemia. R24's care plan states in part: Eating - assist with set up. Encourage and assist as needed to consume foods and/or supplements and fluids offered. On 10/22/24 at 8:39 AM, Surveyor observed R24 trying to eat her meal. R24 had been using a knife to eat with when Certified Nursing Assistant (CNA) F approached, gave R24 a spoon instead of a knife, and stated this might be easier. CNA F then stood over R24 and began feeding her. CNA F stood and fed R24 the rest of her meal. Example 2 R16 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease and legal blindness. R16's care plan states in part: Eating - independent after set up, uses a lip plate, Clock method to make aware of where food is, Assist of 1 as needed. On 10/22/24 at 12:36 PM, Surveyor observed CNA F feed R16 some bites of asparagus and an entire bowl of fruit while standing. On 10/24/24 at 11:07 AM, Surveyor interviewed Director of Nursing (DON) B. When Surveyor relayed the above observations to DON B, DON B stated, Staff should not do that; staff should be sitting when assisting residents with their meals.

Based on interview and record review, the facility did not complete and submit a Significant Change in Status Minimum Data Set (MDS) assessment within 14 days after determining a SCS had occurred for 1 of 15 residents (R) (R48) reviewed. R48 was admitted to Hospice services on 6/24/24. A Significant Change MDS assessment was not completed. This was evidenced by: R48 was admitted to the facility on [DATE] with diagnoses including cardiomyopathy ischemic, hypertension, and congestive heart failure. In reviewing the medical record of R48, Surveyor noted the most recent MDS assessment completed was a Medicare - 5 day assessment dated [DATE]. R48 was admitted to Hospice services on 6/24/24. A Significant Change MDS assessment had not been completed. On 10/22/24 at 2:41 PM, Surveyor interviewed Director of Nursing (DON) B to provide evidence of a Significant Change MDS assessment completed when R48 transitioned to Hospice services. DON B stated DON B confirmed with the MDS Coordinator that a Significant Change MDS assessment was not completed for R48. On 10/23/24 at 1:42 PM, Surveyor requested a policy on Significant Change MDS assessments from DON B who stated the facility did not have a policy.

Based on interview and record review, the facility did not ensure a baseline care plan was developed and implemented for each resident (R) within 48 hours of admission for 1 of 14 residents reviewed (R49). R49 was admitted to the facility on [DATE]. A baseline care plan was not implemented in a timely manner. This was evidenced by: R49 was admitted to the facility on [DATE] and was discharged on [DATE]. R49's diagnoses included encounter for other orthopedic aftercare, diabetes mellitus type 2, weakness abnormalities of gait and mobility, emphysema, cervical disc disorder with myelopathy, hypertension, paroxysmal atrial fibrillation, anxiety disorders, behavioral and emotional disorder, social phobia, stress incontinence, history of malignant neoplasm of breast, and nicotine dependence. Surveyor reviewed R49's medical record and was not able to identify that a baseline care plan was developed. On 10/24/24 at 1:43 PM, Surveyor interviewed Director of Nursing (DON) B about the development of R49's baseline care plan. DON B indicated she could not find the documents. When Surveyor asked if a baseline care plan should have been completed within 48 hours, DON B indicated a baseline care plan should have been completed.

Based on interview and record review, the facility did not develop and implement a comprehensive care plan for each resident (R) to meet medical, nursing, and psychosocial needs identified for 2 of 15 sampled residents (R35 and R23). R35 did not have a sleep hygiene care plan developed when R35 was prescribed medication to promote sleep. R23 did not have a comprehensive care plan for skin integrity. This was evidenced by: The facility's policy titled Comprehensive Care Plan, revised 9/23/22, states in part: .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment .5. The comprehensive care plan will be reviewed and revised as appropriate by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and as needed with changes in condition. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. Example 1 R35 was admitted to the facility on [DATE] with diagnoses of Crohn's disease, chronic kidney disease stage 4, osteoporosis, type 2 diabetes mellitus, atherosclerotic heart disease, and transient ischemic attack. A Quarterly Minimum Data Set (MDS) assessment, dated 9/10/24, documented R35 had no impairments to extremities and required partial to moderate assist of staff for activities of daily living (ADLs), including toileting, dressing, and hygiene. A Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicated R35 was cognitively intact. R35's physician orders documented an order written 6/3/24 for trazadone HCl Oral Tablet (Trazodone HCl) Give 100 mg by mouth one time a day for Insomnia. Surveyor reviewed a sleep assessment from 11/29/23 that did not contain a score or section for teaching and care planning. Surveyor reviewed R35's comprehensive care plan and was unable to identify a sleep hygiene care plan with interventions to promote sleep. On 10/23/24 at 4:30 PM, Surveyor interviewed Director of Nursing (DON) B about a sleep hygiene care plan for R35 with interventions to promote sleep. DON B indicated the 11/29/23 sleep assessment was not completed with care plan interventions. Surveyor reviewed with DON B that a care plan for sleep hygiene was not developed with non-pharmacological interventions to promote sleep when trazadone was prescribed for sleep. 46694 Example 2 R23 was admitted to the facility on [DATE] with a BIMS assessment score of 15 out of 15 which indicated R23 was cognitively intact. R23 had diagnoses including venous insufficiency (a condition in which the leg veins don't allow blood to flow back to the heart). R23 had physician orders that included: (Medical Doctor) follows resident for wound care. Wound care team to complete wound care. If wound care team is not here, floor nurses are to complete treatments; and enhanced barrier and contact precautions due to methicillin susceptible staph aureus (MSSA). A non-pressure weekly wound tracker started on 2/2/24 stated in part: Type of wound: venous stasis Length 11.6, width 12.0, depth 0.2 Granulation 70%, slough 39% Serous drainage moderate. R23's latest non-pressure weekly wound tracker dated 10/16/24 stated in part: Type of wound venous stasis ulcers to inner right ankle Length 0.7, width 0.7, depth 0.1 Wound edges healed Summary of findings healed. On 10/21/24 at 10:39 AM, Surveyor noted a wound on R23's right inner ankle with no dressing and blood stains on R23's left sock. R23 stated, That is because I have my legs crossed and the wound on my right ankle got my left sock dirty. On 10/23/24 at 8:06 AM, Surveyor asked DON B for a skin integrity care plan for R23 who had venous stasis dermatitis and open leg wounds. DON B replied, I will get that for you. On 10/23/24 at 11:00 AM, Surveyor reviewed R23's care plans and did not see a skin integrity care plan for R23. On 10/23/24 at 11:07 AM, Surveyor asked DON B to show R23's skin integrity care plan to Surveyor. When DON B went on the computer, DON B realized R23's skin integrity care plan was a temporary care plan and was resolved and removed from R23's plan of care. DON B replied, That is our oversight. I will put one (care plan) in now.

Based on staff interview and record review, the facility did not ensure code status was determined for 1 Resident (R) (R1) of 2 sampled residents which led to the failure to perform cardiopulmonary resuscitation (CPR) for the resident after the resident was found pulseless and non-breathing (PNB). R1's Power of Attorney for Healthcare (POAHC) document indicated R1 wished to be resuscitated. On [DATE], staff did not initiate resuscitation efforts when R1 was found PNB. R1 passed away at the facility on [DATE]. The facility's failure to ensure code status was determined and perform CPR when R1 was found PNB created a finding of Immediate Jeopardy (IJ) which began on [DATE]. The State Agency (SA) notified Nursing Home Administrator (NHA)-A of the immediate jeopardy on [DATE] at 4:46 PM. The immediate jeopardy was removed on [DATE], however, the deficient practice continues at a scope/severity level D as the facility continues to implement its action plan. Findings include: The facility's Cardiopulmonary Resuscitation (CPR) policy, dated [DATE], indicates: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding CPR .If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advance directives, or b. In the absence of advance directives or a Do Not Resuscitate order, and c. If the resident does not show obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition). On [DATE], Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm (cancer) of the prostate with metastasis (secondary cancer) to bone, atrial fibrillation (an irregular and often rapid heart rate), obstructive sleep apnea (when throat muscles intermittently relax and block the airway during sleep), and history of transient ischemic attacks (commonly known as a mini-strokes). R1's Minimum Data Set (MDS) assessment, dated [DATE], contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R1 had little cognitive impairment. R1's medical record indicated R1 was responsible for R1's healthcare decisions. R1 passed away at the facility on [DATE]. On [DATE], Surveyor reviewed R1's POAHC document, dated [DATE], which indicated, I want to be resuscitated, with R1's initials in a corresponding box on the document. R1's medical record indicated R1 received Hospice services. R1's progress notes indicated R1 was undecided whether R1 wanted a Do Not Resuscitate order. R1's physician orders did not contain a code status order. R1's care plan did not mention R1's code status or wish to be resuscitated. R1's progress notes contained the following: ~A progress note, dated [DATE] at 9:59 AM and written by Licensed Practical Nurse (LPN)-C, indicated: .The current status is (R1) found by this LPN at 6:45 AM on floor between bed and window lying on abdomen. (R1's) head was turned slightly to the left. Oxygen cannula was shifted out of (R1's) nose. (R1) was cold and motionless. Assisted by (LPN-D) and repositioned (R1) on (R1's) back to assess. No breathing, pulse or blood pressure. Skin was cold and body with obvious rigidity. Face was dusky, skin cold, eyes fixed and no pupil reaction, mouth was relaxed. Seen by (Registered Nurse (RN)-E) for assessment. (LPN-D) called (Director of Nursing (DON)-B) .(Hospice Company) called and spoke with (RN). RN to call (Hospice RN (HRN)-F) and Coroner. (On-call Hospice staff) requested nursing home call family. (DON-B) here and saw (R1). (DON-B) assisted with transfer back onto the bed. (DON-B) called (R1's sibling). (R1's sibling) will not come to nursing home. (HRN-F) here at 9:20 AM and assisted with paperwork for (Funeral Home). Order written to release R1's body. (Funeral Home) here at 9:30 AM . On [DATE] at 9:31 AM, Surveyor interviewed LPN-C who indicated a resident's code status is in their medical record and in a binder at the nurses' station. Surveyor and LPN-C reviewed a binder titled DNR Book. The front section of the binder contained documentation for each resident on the unit who expressed DNR wishes. The back section of the binder contained documentation for each resident on the unit who expressed Full Code (resuscitation) wishes. When asked about R1's code status, LPN-C indicated R1 received Hospice services and stated, I believe (R1) wanted to be resuscitated. (R1) had not come to grips with making that decision. (DON-B) told me (R1) was on the fence. LPN-C verified LPN-C found R1 on the morning of [DATE]. LPN-C indicated when LPN-C entered R1's room sometime between 6:30 AM and 6:45 AM, R1 was not in R1's bed so LPN-C checked the bathroom. LPN-C indicated R1 was not in the bathroom, so LPN-C looked again and saw R1's feet on the floor between the bed and the window. LPN-C indicated R1 was lying on the floor on R1's abdomen, R1's head was turned, and R1's right cheek was on the floor. LPN-C indicated R1 felt cool to the touch. LPN-C stated, No way I could render aid in the position (R1) was in. LPN-C indicated LPN-C instructed staff to get another nurse. LPN-C indicated LPN-D entered the room and assisted LPN-C with repositioning R1 onto R1's back. LPN-C indicated R1's extremities were flaccid (hanging loosely or limply). LPN-C indicated LPN-C listened for R1's heartbeat, felt for a pulse and checked for breathing, but found none. LPN-C indicated staff asked RN-E to come to the unit. LPN-C indicated RN-E also listened to R1's heart and found no heartbeat. LPN-C stated, No mistaking this (person) was very, very, very gone. LPN-C indicated there was no blood on the floor, but there was saliva on floor where R1's mouth was. LPN-C indicated R1's facial color was cyanotic (bluish skin color due to decreased amounts of oxygen) and discolored. LPN-C stated when DON-B arrived, (DON-B) agreed with me that (R1) was very expired. LPN-C indicated DON-B took over as LPN-C needed to administer medications to other residents. On [DATE] at 10:16 AM, Surveyor interviewed Social Service Director (SSD)-G who indicated SSD-G tries to determine a resident's code status upon admission. SSD-G indicated SSD-G speaks with residents about the meaning of Full Code and DNR and asks specific questions to ensure understanding. SSD-G indicated some residents choose to wait and don't want to decide right away. SSD-G stated SSD-G informs residents who are undecided that staff are required to consider them Full Code status. When asked about R1's code status, SSD-G indicated R1 was undecided. SSD-G indicated SSD-G talked with R1 several times and each time R1 indicated R1 wanted to discuss the issue with R1's family before deciding. On [DATE] at 11:06 AM, Surveyor interviewed HRN-F via phone who indicated HRN-F was the primary Hospice nurse assigned to R1. HRN-F indicated R1 was a Full Code status. HRN-F indicated HRN-F arrived at the facility at 8:47 AM on [DATE] and stated, When I got there, the funeral home was already there. (R1) was on their cot ready to leave. HRN-F indicated Hospice medical records indicated the Hospice Triage RN received a call from the facility at 6:45 AM and was told R1 was found expired in room at 6:30 AM. When asked about the expectations for a resident with a Full Code status, HRN-F stated, Generally they (facility staff) would initiate CPR and call EMTs (Emergency Medical Technicians). HRN-F indicated Hospice staff had numerous conversations with R1 regarding code status and stated, (R1) didn't want to talk about it. HRN-F stated, It was strange having the funeral home there. HRN-F indicated usually the facility waits for Hospice staff to arrive before calling the funeral home. HNR-F indicated Hospice medical records indicated the Hospice Triage RN called the Coroner and notified the facility at 7:30 AM that the Coroner would not be taking the case. On [DATE] at 11:28 AM, Surveyor interviewed DON-B who indicated DON-B received a call from staff on DON-B's way to work that R1 passed away. Upon arrival at the facility, DON-B was informed staff called Hospice, but had not yet called R1's family. DON-B stated, We were waiting on funeral home notification and Hospice to return the call. DON-B indicated a short time later, the facility received a call from Hospice who indicated Hospice was sending a staff, the Coroner was going to meet R1 at the funeral home instead of the facility, and it was okay for the facility to call family and move R1 from the floor into bed. DON-B indicated DON-B called R1's family and asked staff to help DON-B move R1 into bed. DON-B indicated DON-B and staff moved R1 into bed at approximately 8:20 AM or 8:30 AM. When asked if R1 was a Full Code status, DON-B stated, As far as I could tell yes. When asked the expectation for a Full Code status resident found PNB, DON-B stated, If no obvious sign of rigidity, then start CPR. When asked why CPR was not started in R1's case, DON-B stated, I am only going by what the nurses told me. (R1) was pulseless, dusky in face, eyes fixed with obvious rigidity. Two LPNs and an RN assessed (R1). When asked what R1's extremities were like when R1 was moved into bed, DON-B indicated DON-B observed mottling (a bluish-red, lace-like pattern under the skin caused by deoxygenated blood pools that can occur prior to death), no bruising, no pooling meaning no dependent lividity, and R1's extremities were rigid. On [DATE] at 1:21 PM, Surveyor interviewed LPN-D via phone. LPN-D indicated LPN-D assisted LPN-C with rolling R1 onto R1's back on the floor. LPN-D indicated R1's face was blue and R1's fingers were blue and ashen. LPN-D indicated LPN-C stated to LPN-D, I think (R1's) gone. LPN-D indicated LPN-D called DON-B while LPN-C called Hospice. LPN-D indicated LPN-D then returned to LPN-D's assigned unit to administer medications to other residents. When asked what R1's body was like when LPN-D assisted LPN-C with rolling R1 over, LPN-D stated, I was only in room for like two minutes. (R1's) arms weren't stiff, but (R1's) torso was stiff. When asked if the facility provided code status education since R1's death, LPN-D stated, (R1) was DNR Hospice. When informed by Surveyor that R1 was a Full Code status, LPN-D stated, I didn't know. On [DATE] at 1:37 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-H via phone who verified CNA-H worked the night shift on R1's unit on [DATE] into [DATE]. CNA-H indicated CNA-H spoke with R1 on midnight rounds when R1 refused to wear R1's CPAP (continuous positive airway pressure) machine (a common treatment for obstructive sleep apnea). CNA-H also checked R1 on 2:00 AM rounds and stated R1 was asleep with the head of the bed elevated. CNA-H indicated the last time CNA-H saw R1 was at 4:45 AM and R1 was asleep with the head of the bed elevated. When asked about R1's code status, CNA-H stated, I know (R1) was on Hospice, so I don't think (R1) was a code (Full Code). On [DATE] at 2:38 PM, Surveyor interviewed DON-B who, when asked to define rigidity stated, Limbs are stiff, like rigor mortis. Surveyor discussed the above interview with DON-B in which LPN-C indicated R1's arms were flaccid, and LPN-D indicated R1's arms weren't stiff. When Surveyor asked DON-B the expectation regarding CPR given the knowledge that R1's arms were not stiff when R1 was found, DON-B stated, They should have looked at (R1's) code status. If wasn't one, (R1) would have been a Full Code. When asked if flaccid arms are considered rigor mortis, DON-B stated, Not by my definition, but I can only go by what they told me. When asked what DON-B would have done if DON-B found a resident PNB with flaccid arms, DON-B indicated DON-B would check the resident's code status and stated, By policy, (R1) would have been a Full Code. On [DATE], Surveyor reviewed the facility's resident list that indicated 25 of 52 residents had a Full Code order, 27 of 52 residents had a DNR order, and 1 resident was undecided. On [DATE] at 8:30 AM, Surveyor interviewed RN-E via phone who indicated at approximately 6:45 AM on [DATE], RN-E responded to R1's unit. RN-E indicated when RN-E entered R1's unit, LPN-C was at the nursing station. LPN-C indicated LPN-C called Hospice and told RN-E that R1 passed away. RN-E entered R1's room and observed R1 on R1's back on the floor between the bed and the window. RN-E indicated R1 was cold to the touch, mottling, and ashen in color. RN-E listened for a heartbeat and heard none. RN-E indicated RN-E did not try to move R1's extremities. RN-E indicated LPN-C picked up R1's right hand and R1's wrist was limp. When asked about R1's code status, RN-E stated, I'm not sure, I didn't look at that. Surveyor informed RN-E that R1 was considered a Full Code. RN-E indicated RN-E did not observe any dependent lividity in R1 and stated, Everything was grey. When asked what RN-E would have done if RN-E found a resident PNB with flaccid arms, RN-E indicated RN-E would start CPR. RN-E indicated RN-E did not ask LPN-C about R1's code status. The failure to ensure code status was determined which led to the failure to perform CPR when a resident was found PNB created a reasonable likelihood for serious harm which created a finding of Immediate Jeopardy. The facility removed the jeopardy on [DATE] when it completed the following: 1. Audited residents' medical records to ensure they contained a code status form and physician order. 2. Educated staff on following code status and to ensure medical records contain a code status upon admission. 3. Initiated interviews with nurses on various shifts involving case studies and what if scenarios to validate understanding and expectations during a code situation. 4. Initiated code drills. 5. Reviewed their CPR policy.

Based on staff interview and record review, the facility did not ensure care and treatment in accordance with professional standards of practice was provided for 1 Resident (R) (R1) of 9 sampled residents. R1 experienced a change in condition, including altered mental status, on the [DATE] AM shift. The facility did not complete an appropriate assessment or notify a physician. EMS (Emergency Medical Services) was notified at 8:50 PM when R1 was found unresponsive. R1 was transferred to the hospital and passed away on [DATE]. The facility's failure to complete an appropriate assessment and timely notify a physician for a resident who experienced a change in condition created a finding of immediate jeopardy that began on [DATE]. The State Agency (SA) notified Nursing Home Administrator (NHA)-A of the immediate jeopardy on [DATE] at 5:14 PM. The immediate jeopardy was removed on [DATE], however, the deficient practice continues at a severity/scope level D as the facility continues to implement its action plan. Findings include: The facility's Change in Condition of the Resident policy, with a review date of [DATE], indicates: A facility should immediately inform the resident; consult with the resident's physician .when .a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); or a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) .When a resident presents with a possible change of condition .1. Assess the resident's need for immediate care .2. Assess/evaluate the resident. This assessment/evaluation could include, but is not limited to, the following: a. Vital signs, oxygen saturation, blood glucose level .e. Personality, behavioral and/or cognitive changes. F. Alteration in level of consciousness, ability to respond .k. Gait, posture, or balance change .3. Notify resident's physician .a. Immediate notification: Immediate notification for any symptom, sign or apparent discomfort that is: i. Acute or sudden in onset, and: ii. A marked change (i.e., more severe) in relation to usual symptoms and signs .Do not fax for issues requiring immediate notification . According to https://www.ncbi.nlm.nih.gov/books/NBK430939/, patients progressing to septic shock will experience signs and symptoms of severe sepsis with hypotension. With the progression of septic shock into the uncompensated stage, hypotension ensues, and patients may present with cool extremities, delayed capillary refill (more than three seconds), and thready pulses, also known as cold shock. After that, with continued tissue hypoperfusion, shock may be irreversible, progressive rapidly into multiorgan dysfunction syndrome and death. On [DATE], Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including paraplegia (impairment in motor or sensory function of the lower extremities), chronic kidney disease and chronic pain syndrome. R1's Minimum Data Set (MDS) assessment, dated [DATE], contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R1 had little to no cognitive impairment. R1's medical record indicated R1 was responsible for R1's healthcare decisions. R1's medical record contained a Do Not Resuscitate (DNR) order which complied with the wishes expressed in R1's Power of Attorney for Healthcare (POAHC) document, dated [DATE]. R1 was transferred to an emergency room (ER) on [DATE] and did not return to the facility. R1 passed away at the hospital on [DATE]. R1's medical record contained the following information: A Nurse Practitioner (NP) note, dated [DATE], indicated: .(R1) denies pain, shortness of breath, chest pain, nausea/vomiting, constipation. (R1) reports pain is well managed with current regimen. (R1) reports smoking ,d+[DATE] pack of cigarettes per day, has no interest in quitting. Nursing denies any concerns . A care conference summary, dated [DATE], indicated: (R1) did not have any nursing concerns or questions regarding medications or treatments .(R1) had no questions or concerns regarding (R1's) care plan .SSD (Social Services Director) reviewed (R1's) code status with (R1) . A nursing note, dated [DATE] at 1:16 PM, indicated: (R1) was sleepy at lunch time and writer had to wake (R1) up for medication administration. (R1) was mildly difficult to wake. (R1) ate only a bite or two of lunch. After lunch, (R1) was found slouching to the right of (R1's) wheelchair sleeping hard. Staff had to shake (R1) moderately to awake. (R1) was cold and clammy. Blood sugar-138. (R1) insistent (R1) was ok. (R1) admits 'its been a few' days when asked when (R1) last had a bowel movement. (R1) did not want to lie down for a suppository. Writer advised (R1) should lie down for a suppository. (R1) said (R1) wanted to wait until later. Charting shows (R1) has not had a bowel movement since [DATE] AM. DON (Director of Nursing) notified. Surveyor reviewed the facility's Medication Administration Audit Report for medications administered to R1 on [DATE]. The report indicated Licensed Practical Nurse (LPN)-D administered R1's medication at 11:19 AM. A nursing note, dated [DATE] at 1:46 PM, indicated: Writer went to advise (R1) that (R1) hadn't had a bowel movement in 8 days and found (R1) slumped to (R1's) right and hard to wake. (R1) agreed to lay down and have a suppository administered. (R1) continues to be diaphoretic (excessive sweating for no apparent reason, often described as cold and clammy). R1's Medication Administration Record (MAR) indicated LPN-D administered a bisacodyl suppository 10 mg (milligrams) rectally at 1:49 PM on [DATE] with effective results. A nursing note, dated [DATE] at 8:00 PM, indicated: (R1) observed to be unresponsive. Not responsive at this time. Blood pressure-,d+[DATE]; Pulse-103; Temperature-97.3; Respiratory rate-3 to 4, periods of apnea (not breathing) lasting ,d+[DATE] seconds. Oxygen saturation level is between 55 and 75% (normal oxygen saturation is above 90%) on 5 liters of oxygen. (Physician's Assistant) updated and gave order to send to ER for evaluation and treatment. (R1) sent to ER. DON updated. Surveyor reviewed a Run Report from the ambulance service, dated [DATE], that indicated: .The unit was notified at 8:50 PM, responded at 8:52 PM, arrived at the scene at 8:58 PM, left the scene at 9:32 PM, arrived at the hospital at 9:36 PM, and completed the call at 9:58 PM .When we arrived, we were told (R1) was a DNR and earlier in the day (R1) expressed that (R1) did not want CPR (cardiopulmonary resuscitation) if (R1's) heart stops. (R1) also expressed that (R1) was ready to die and wanted to be left alone. The staff noticed how relaxed (R1) seemed after that and said they felt (R1) knew the end was coming. At noon, they laid (R1) down in bed and went to check on (R1) around 5:00 PM and found (R1) sleeping. They checked on (R1) around 9:00 PM and found (R1) unconscious. They informed the doctor .and the doctor ordered (R1) be transported to the hospital. The staff told us that (R1) is still unconscious and is agonal breathing. We found (R1) supine (laying flat on back) on the bed .(R1's) respiratory rate was about 10 breaths per minute and (R1) was cool to the touch .We attempted a sternal rub which was unsuccessful. We took an initial set of vitals .Blood pressure-,d+[DATE]; Heart rate-94 beats per minute; Respiratory rate-10 breaths per minute; Oxygen saturation level-90%; Blood sugar-113 . An Emergency Medicine note, dated [DATE] at 10:14 PM, indicated: .Presentation consistent with altered mental status and respiratory compromise .Diagnoses .Altered Mental Status .Acute Kidney Injury .Severe Sepsis (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever) . On [DATE], Surveyor reviewed a hospital Discharge Summary, dated [DATE], that indicated: .(R1's) admission findings were consistent with acute respiratory failure with hypoxia (lower than normal level of oxygen in the blood) and hypercapnia (higher than normal level of carbon dioxide in the blood. (R1) never regained consciousness during (R1's) stay. Blood cultures remained negative. (R1) was adamantly DNR/DNI (Do Not Intubate) so treatment options were limited. We were unable to correct the acidosis (a condition in which acids build up in the body) with basic oxygen support .(R1's) multi-organ failure (renal, hepatic and cardiac) failed to respond to therapies .Throughout the last 24 hours, (R1) was progressively more agonal (relating to, or associated with the act of dying) and slowed with breathing. (R1) did not demonstrate tachypnea (rapid shallow breathing), restlessness or other cues of pain or air hunger .Actual time of death is 7:16 AM .Likely cause of death: sepsis with multi-organ failure due to pneumonia . On [DATE] at 10:16 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-C who indicated CNA-C remembered R1 well and worked the AM shift on [DATE]. CNA-C indicated R1 required staff assistance with personal cares and was alert, able to express R1's needs, and cooperative with cares. CNA-C indicated when CNA-C delivered a lunch tray to R1 on [DATE], R1 was incoherent. CNA-C stated, It took a bit, but (R1) woke up. CNA-C reported R1's change in mental status to the nurse. On [DATE] at 12:04 PM, Surveyor interviewed LPN-D who verified LPN-D worked the AM shift on [DATE]. LPN-D indicated when LPN-D administered R1's medication prior to lunch, R1 was sleeping in R1's wheelchair and was mildly difficult to wake up which was unusual for (R1). When LPN-D asked nursing staff if R1 ate lunch, staff said (R1) only ate a bite or two. LPN-D checked on R1 after lunch and found R1 sleeping and slumped to the right side in R1's wheelchair which was not normal for R1 who usually had good posture. LPN-D had to wake (R1) again and stated, (R1) was cold and clammy, like a cold sweat. LPN-D checked R1's blood sugar and R1 insisted R1 was okay. LPN-D indicated R1 refused to lay down in bed and LPN-D reported the above information to DON-B. LPN-D did not recall if LPN-D checked R1's vital signs and verified vital signs for that timeframe were not documented in R1's medical record. When asked what type of assessment should be completed when a resident is found with altered mental status, LPN-D indicated staff should obtain a full set of vital signs. LPN-D also indicated LPN-D should have called R1's physician. On [DATE] at 4:09 PM, Surveyor interviewed CNA-G who started work at 2:00 PM on the [DATE] PM shift. CNA-G indicated CNA-G remembered R1 well and stated, The day before, (R1) was fine. CNA-G indicated R1 was in bed when CNA-G entered R1's room at 2:15 PM on [DATE]. When asked if R1 woke up, CNA-G stated, No, (R1) had end of life breathing going on. CNA-G went to the nurses' station and asked, What's going on with (R1)? CNA-G indicated the PM shift nurse checked R1's vital signs, but CNA-G was unable to remember further details and stated, I was crying. On [DATE] at 11:29 AM, Surveyor interviewed CNA-H via phone. CNA-H verified CNA-H worked the [DATE] PM shift and remembered R1. CNA-H indicated staff were unable to wake R1 all shift and stated, When we checked and changed (R1), (R1) turned blue. CNA-H could not recall when R1's apnea started and indicated R1 was gurgling like when the tongue gets caught in the back of the throat and had abnormal breathing most of the shift. CNA-H stated, Apparently (R1) was fine in the morning. Later on in the day before our shift, they laid (R1) down because (R1) was all sweaty and not (R1's) self. Usually, (R1) stayed up all day until we put (R1) to bed. On [DATE] at 1:33 PM, Surveyor interviewed DON-B who indicated DON-B remembered telling staff to notify a physician on [DATE] after DON-B was notified of R1's symptoms. When asked if DON-B told the AM or PM shift nurse to notify a physician, DON-B stated, I don't remember which one. DON-B reviewed R1's nursing notes and verified LPN-D should have taken R1's vital signs and notified a physician regarding R1's altered mental status and change in condition. DON-B indicated staff education was completed following the incident. Surveyor reviewed the facility's Training Log/Sign In Sheet, dated [DATE], which contained the following objectives: Medication/Insulin Administration, Hand Hygiene, Dressing Changes, and MD notification. The document contained nine nurses' signatures with dates from [DATE] through [DATE]. The document did not contain LPN-D's signature. On [DATE] at 1:46 PM, Surveyor interviewed DON-B who verified the Training Log/Sign In Sheet did not contain LPN-D's signature. On [DATE] at 3:21 PM, Surveyor interviewed Medical Director (MD)-E and NP-F together via phone. MD-E indicated MD-E expected an evaluation of R1's condition to include a complete set of vital signs at a minimum. MD-E and NP-F verified LPN-D should have notified R1's provider (NP-F or the provider on-call) of R1's altered mental status and change in condition. When asked what would have been ordered if MD-E or NP-F were notified, MD-E indicated the orders would have been dependent on R1's vital signs and stated, Vitals would have guided my decisions. The failure to complete an appropriate assessment and notify a physician timely for a resident who experienced a change in condition led to serious harm for R1 which created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE] when it completed the following: 1. Completed an audit to determine if other residents were experiencing a change of condition. 2. Reviewed the Change of Condition policy. 3. Completed education with licensed nurses. 4. Implemented ongoing change of condition audits including completion of assessment/data gathering and appropriate MD notification.

Based on interviews and record reviews, the facility did not ensure 1 of 3 residents reviewed for Pressure Injuries (R1) received care consistent with current standards of practice in the prevention, assessment and treatment of [REDACTED]. R1 was admitted without any skin impairments. He was then hospitalized and a pressure injury was discovered in the Emergency Department (ED). Following the hospitalization , there was only one comprehensive nursing assessment of the pressure injury until he was seen by a wound doctor and the wound required debridement. Following the debridement, again, there were no comprehensive nursing assessments of the wound to ensure staff were monitoring for progress or deterioration. This is evidenced by: According to the National Pressure Injury Advisory Panel (NPIAP), Revised 2019, Pressure Injury assessments should include, but are not limited to the following: 1. Assess the pressure injury initially and re-assess it at least weekly. A two-week period is recommended for evaluating progress toward healing. However, weekly assessments provide an opportunity for the health professional to assess the ulcer more regularly, detect complications as early as possible, and adjust the treatment plan accordingly. 2. With each dressing change .assess and accurately document physical characteristics such as location, category/stage, size, tissue type(s), wound bed and periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, necrotic tissue, odor, presence/absence of granulation tissue, and [MEDICATION NAME]. Resident (R) 1 was admitted to the facility on [DATE] following hospitalization for generalized weakness and functional decline discovered at the assisted living facility he was then residing at. Medical [DIAGNOSES REDACTED]. The Minimum Data Set Assessment (MDSA) completed for R1's admission was dated 10/13/20 and indicated that R1 required extensive assistance with bed mobility, transfers, bathing, dressing, personal hygiene and toileting. R1 was non-ambulatory and an indwelling Foley catheter was in place. R1 was actively being treated for [REDACTED]. It was also identified on this assessment that R1 was at risk for the development of pressure injuries. The interventions listed on this assessment were a pressure reduction cushion for the chair and a pressure reduction mattress for the bed. Of note, a repositioning program was not marked as being implemented. The Care Area Assessment (CAA) completed for the MDSA identified R1 as . having need for assist with bed mobility and being totally incontinent of bowel putting him at an increased risk for developing pressure sores. The CAA further indicates that R1 needs a special mattress or seat cushion to reduce or relieve pressure. The Comprehensive Care Plan, dated 10/9/20 identified the following problem: The resident has actual impairment to skin integrity r/t (related to) pressure ulcer to right heel. Approaches included: - 10/9/20- Keep skin clean and dry - 10/20/20 - Pressure reduction bed - 10/20/20 - Pressure reduction chair Note: Given the risk R1 had on admission, the specialized chair and mattress should have been implemented then. This is nearly two weeks later. The initial skin assessment completed by the facility was dated 10/7/20 and indicated 1+ [MEDICAL CONDITION] to bilateral lower extremities, but no open areas. Note: Pitting [MEDICAL CONDITION] is when a swollen part of your body has a dimple (or pit) after you press it for a few seconds. 1+ indicates that when the area is depressed with the finger, it leaves an indentation but the dimple disappears rapidly. It is considered mild [MEDICAL CONDITION]. The facility completed a Braden Skin Assessment also on 10/8/20. According to this assessment, R1 scored 17. A score of 15-18 indicates the individual is at risk for the development of a pressure injury. The areas of concern that created this risk for R1 included: - Chair-fast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. - Ability to change and control body position - Slightly Limited: Makes frequent though slight changes in body or extremity position independently. - Friction and Shearing - Potential Problem: Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. Surveyor then reviewed all potential assessments in which staff could have documented skin condition or wounds from 10/7/20 - 10/23/20. These included the Interdisciplinary Progress Notes (IDTPN), Daily Skilled Observations, Daily General Follow Up Observations, Head To Toe Assessments, Skin Observation Tools, Post Event Observations and PUSH (Pressure Ulcer Scale for Healing) Tools. There were no entries indicating R1 had any pressure injuries. On 10/23/20, R1 developed a fever of an unknown cause. The IDTPN's indicate that at 2:00 PM, the facility called the ED to give a report regarding the resident. The ED then indicates in their notes that the first set of vital signs were taken in the ED at 2:31 PM (Hospital Timeline page 25 of 38); at 5:13 PM (page 31 of 38), the ED staff discovered a 4 cm (centimeter) blistered weeping lesion to right heel with mild [DIAGNOSES REDACTED] to the wound edges. The wound was cleansed and dressed and according to the ED documentation, the pressure boot from the ECF (Extended Care Facility) was replaced. On 10/23/20 at 1:20 PM, prior to the ED visit, Dynamic Mobile Imaging conducted an X-ray of R1's heel. However, there are no IDTPN's regarding the reasoning for the X-ray. There is no entry in the IDTPN's that the X-ray was done. R1 returned to the facility that evening with [DIAGNOSES REDACTED]. There were no comprehensive skin assessments recorded to indicate nursing staff were evaluating the right heel ulcer or the condition of the right leg [MEDICAL CONDITION] after this hospitalization . There are notes indicating R1 has these issues, but no thorough assessment of either. From his return on 10/23/20 - 11/3/20, there was no comprehensive nursing assessment completed of R1's right heel. Surveyor reviewed all potential areas as listed above, in which staff could have completed this assessment, and none were found. On 10/31/20, R1 developed a blister on his coccyx with bilateral excoriation that measured 1 inch x 1 inch. comfort border foam applied . The nurse noted multiple excoriated areas on the buttocks and coccyx area approximately 1/2 inch x 1/2 inch and 1/4 inch x 1/4 inch. The nurse applied 20% zinc oxide cream to the area. On 11/2/20, an air mattress was implemented. There was no comprehensive assessment located for this wound. It healed on 11/17/20. On 11/4/20, the facility did complete an assessment. It was a PUSH Tool and it indicated the right heel measured 1.5 cm length x 1.4 cm width with no depth. The area was described as .Upon initial inspection of 10/30/20, right heel entirely blacken (sic). Today post intervention, Dark pink and only quarter to nickel sized area. Off loaded heel. Surrounding area pink and noted improvement . This is the first assessment documented. The PUSH Tool indicates one was completed on 10/30/20, however, it could not be located to review. The Surveyor then reviewed all potential areas of which staff could document skin including (Interdisciplinary Progress Notes (IDTPN), Daily Skilled Observations, Daily General Follow Up Observations, Head To Toe Assessments, Skin Observation Tools, Post Event Observations and PUSH Tools.) There were no assessments completed following this last PUSH Tool assessment. There is no indication the heel was a problem until R1 was seen by the wound doctor (MD-C) on 11/22/20, and he ordered [MEDICATION NAME] to the heel every other day while he was awaiting lab results. On 11/28/20, MD-C debrided the wound. According to MD-C progress notes, the heel measurements prior to debridement were 5.1 cm length x 8.6 cm width. It had purulent (pus) drainage and was foul smelling with a boggy eschar. Note: Boggy Eschar is dead tissue and needs to be removed in order for healing to take place. Following debridement, R1's right heel wound measured 5.4 cm length x 9 cm width x 1.0 cm deep. MD-C ordered a new treatment of [REDACTED]. On 12/9/20, MD-C again completed wound care on R1 and changed the treatment to a combination of Dakins solution and Acetic Acid (vinegar). Following the debridement and up until R1 was discharged from the facility to an assisted living facility (12/14/20), there were no assessments located of the right heel or the [MEDICAL CONDITION] of the right leg. On 1/25/21 and again on 1/29/20, the Surveyor telephoned Family Member (FM)- E, who is R1's daughter and activated Power of Attorney (POA) as of 11/28/20. FM-E stated the facility did not notify her of R1's wound. She realized at the time it developed, she was not activated POA but, I guess I still would expect to be told if dad was declining. I know he was considered his own decision-maker, but his dementia was progressing and his physical state was declining. I was waiting for a second doctor to sign the paperwork, but with Covid-19, no doctors were going into the facility . FM-E further stated that on the evening of 10/23/20, the ED nurse called her and informed her that R1 had an infected pressure sore to the right heel as well as [MEDICAL CONDITION] to the foot. FM-E was concerned that she was not informed of this by the facility. She stated about one month later, .dad saw a wound doctor and he had to cut away quite a bit of tissue. He told me the wound was the size of a small fist . On 1/26/20 at 10:20 AM, the Surveyor interviewed MD-C regarding R1's right heel wound. MD-C stated that when he first saw R1 on 11/22/20 the right heel was a classic DTI (Deep Tissue Injury) that started as a blister. When MD-C saw it, the wound was necrotic and needed to be debrided, as it would not heal until the dead tissue was removed. MD-C stated that he needed to remove a lot of tissue. When asked how a DTI develops, MD-C stated It appears when the heels are not off-loaded. You need to off-load the area to allow for circulation to occur, otherwise, you cut off the blood flow to the area and an injury occurs. MD-C further stated, often staff will check the skin and see that it is clear, no open areas, but do not take into consideration that discoloration is the beginning of a DTI, indicating that pressure is being applied to the area, interrupting the circulatory process. MD-C indicated R1 had many precipitating factors that increased the likelihood for wounds to develop, including severely impaired circulation and [MEDICAL CONDITION]. On this same date at 11:20 AM, the Surveyor interviewed Certified Nursing Assistant (CNA) D and asked what she would report to the nurse that she would observe with the residents she cares for. CNA-D stated that she reports anything new that she observes, such as unusual behaviors, increased sleepiness, temperature or any new skin breakdown. She stated she reports right away so the nurse can assess the resident. At 12:25 PM, Surveyor interviewed the Director of Nursing (DON) regarding R1. The DON stated R1 had precipitating factors, including Failure to Thrive. R1 had no breakdown when admitted to the facility 10/7/20. There was no wound nurse on staff and the floor nurses are responsible to conduct weekly skin assessments. The DON stated these assessments are completed on a PUSH Tool. The DON stated that staff were off-loading R1's heels but that he never remained in the positions staff placed him in. R1 would move himself to his preferred bed position which was knees bent up, slightly left side-lying and his face to his right. Note: There is very little documentation to indicate this. On 1/28/20 at 10:08 AM, the Surveyor interviewed the DON and asked what the expectations of staff are regarding skin assessments, and explained that only one PUSH Tool was located. The DON stated skin assessments were to be done weekly, using the PUSH Tool, measure and describe the wound. Nurses were to update the physician with any worsening and obtain new orders if the wound does not improve in two weeks. The DON stated she noticed the nurses were documenting See TAR (Treatment Administration Records), instead of documenting the condition of R1's wound. The TAR only shows that the treatment was completed. It does not allow for details of the wound appearance. They need to do the actual assessment. When asked to describe the [MEDICAL CONDITION] of R1's right foot, the DON stated It was red, warm and painful. Rashy area on his foot, ankle and just up the right leg about three inches. The right heel was a DTI. The DON stated she has identified issues with the nurses completing the assessments and the facility will be initiating a PIP (Performance Improvement Plan). The Surveyor requested any new information the facility may have on 1/28/21 and as of 2//1/21, has not received any information from the facility to indicate the right heel pressure injury was assessed weekly by nursing staff. Of concern is the facility identified R1 as being at risk for the development of pressure injuries on admission. Aggressive interventions were not put into place and the resident then developed a DTI to his heel. Following this development, no aggressive interventions were put into place until he developed another wound on his coccyx 11/2/20, at which time an air mattress was initiated. There is only one assessment located of the DTI, and even after debridement, no assessments were located.

Based on staff interviews and record reviews the facility did not notify the physician of significant changes in condition and the possible need to alter treatment for 1 of 7 sampled residents (R2). R2 had significant declines in his food and fluid intake, severe weight loss, and an increase in restlessness. There is no evidence the physician was consulted for these issues. By the time R2 was hosptalized on [DATE], he was severely dehydrated, had severe protein calorie malnutrition and acute on [MEDICAL CONDITION] with acute kidney injury grade 5. This is evidenced by: On 03/09/20 Surveyor received the following policy and procedure entitled from the DON (Director of Nursing). It includes the following policy statement: Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) Policy Interpretation and Implementation indicates the following: 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: .d. A significant change in the resident's physical/emotional/mental condition. e. A need to alter the resident's medical treatment significantly; f. A need to transfer the resident to a hospital/treatment center; . R2 was admitted to the facility on [DATE] following a left [MEDICAL CONDITION] and repair. R2 had [DIAGNOSES REDACTED]. R2 was his own legal decision maker. R2 chose to be full code. R2's admission weight was noted to be at 170 pounds. By 02/06/20, R2's weight had dropped to 158.6 pounds. There was no evidence the physician was consulted about R2's weight loss. Further review of R2's medical record reveals that R2's foley catheter was removed on 02/08/20 in an attempt to discontinue the catheter. On 02/09/20, R2 was sent to emergency room due to agitation. The [DIAGNOSES REDACTED]. R2 was put on [MEDICATION NAME] for the retention and [MEDICATION NAME] (antibiotic) and the recommendation to increase oral hydration. The catheter needed to be inserted due to [MEDICAL CONDITION]. R2 came back to the nursing home. Review of the Chemistry results completed at that time included the following: BUN was 33.0 (high) range (8.0-24.0), Creatinine 2.57 (high) range (0.55-1.30). These labs are indicative of dehydration and decline in kidney function. These were a decline in baseline labs from his 01/03/20 labs prior to admission. The BUN was 22 (normal) and the Creatinine was 2.09. Review of R2's meal intake records from 02/11/20 through 02/24/20 reveals that R2 refused 17 of the 39 meals offered. In addition, the record reveals that R2 ate only 0-25% of 5 meals during that time. Review of R2's fluid intake records from 02/11/20 through 02/24/20 reveals that R2's daily intake ranged from a high of 1020 cc's (cubic centimeters) on 02/12/20, to no intakes on 02/16/20 and 02/20/20. On 02/14/20, 02/15/20, 02/19/20 notes indicate that R2 only consumed 240 cc's of fluid. On 02/22/20, R2 only consumed 100 cc's of fluid. Review of R2's interdisciplinary progress notes reveal the following entries: 02/24/20 at 1:25 am nursing note: Resident exhibiting terminal restlessness. Interventions included repositioning and toileting. Offered fluids, however not accepting. Significant cognitive impairment. Foley cath patent and draining 60 cc amber colored urine via gravity bag. Mouth care performed. Medical intervention following with administration of md prescribed [MEDICATION NAME] with noted effective relief. Currently resting quietly, eyes closed. No further restlessness exhibited. Signed RN I (Agency Registered Nurse). No vitals were noted. The physician was not contacted due to the terminal restlessness and no fluid intake. R2 was full code and not on comfort measures or hospice. On 03/09/20 at 3:45 p.m., Surveyor spoke with MD H (Medical Doctor). MD H said R2 was not on comfort measures at the time of the 02/24/20 note and that he should have been contacted related to this change. MD H said the terminology terminal restlessness suggests that R2 was on comfort measures only and he was not. On 03/10/20 at 8:50 a.m., Surveyors spoke via phone to RN I. RN I said that she had never worked with R2 before 02/24/20. RN I said she recalls R2 was very thin, very restless and that R2 wasn't eating or drinking anything. Surveyor read RN I her progress note from 02/24/20. RN I said she should not have used the term of terminal restlessness as this is not in her scope of practice. RN I was told R2 was full code, not on comfort measures. RN I said that she should have checked R2's vitals and should have called the doctor. Surveyor reviewed of R2's interdisciplinary progress notes/vitals record reveal no nurses notes or vitals for the day shift of 02/24/20. On 03/09/20 at 12:45 p.m., Surveyor spoke with the DON B (Director of Nursing). DON B said that R2 was full code at the time he went to the hospital on [DATE]. DON B said the physician should be notified of any change in condition, for instance weight loss, decline in ability to do activities of daily living, decrease in swallowing, not eating or drinking. DON B was asked why there was no note or any vitals on the 02/24/20 day shift. DON B said she thought the day shift nurse was going to update the doctor as she had told them to do that. On 03/09/20 at 1:15 p.m., Surveyor reviewed the nursing schedule for the unit on which R2 was residing on 02/24/20. The schedule reveals that RN F (Registered Nurse) was assigned to the day shift on 02/24/20. Surveyor spoke with RN F and asked RN F if she had any information for R2 on 02/24/20. RN F said she didn't know of any information related to R2's status on that day shift. Surveyor reviewed R2's interdisciplinary progress notes which included, 02/24/2020 at 17:36 (5:36 p.m.). Type communication with physician. MD notified of resident refusal to eat or drink the last 10 days. Urine from foley cath is brown. 100 cc out in 8 hours. Eyes sunken, > (greater than) 3 seconds tenting of skin. Refusing to allow VS (vital signs) or take medications. New orders to send to ER (emergency room ) for eval of UTI (urinary tract infection). Signed RN E (Registered Nurse). On 03/09/20 at 9:53 a.m., Surveyor spoke with RN E via phone. RN E said R2 had resided on the unit that she usually worked and then had moved to a different unit. RN E said R2 had come into the facility following a [MEDICAL CONDITION] and repair of the fracture. RN E said R2 had a catheter for [MEDICAL CONDITION] when he came to the facility, chose to be full code, did not talk very much and did not have any visitors. RN E said when R2 first came in he would drink a lot of water and that getting R2 to eat was more of a problem. RN E said she knew that R2 had lost some weight after he was at the facility and the physician knew about the weight loss. RN E said she was assigned to work the evening shift of 02/24/20 on the unit to which R2 had been transferred . RN E said she had gotten report from the day shift nurse RN F who had said R2 wasn't eating or drinking and that he was very agitated. RN E said when she saw R2 she could tell he had had a significant change in condition from the time she had last seen R2. RN E said that R2's eyes were sunken, was very thin (rib cage sticking out hollow,) urine was brown in the catheter and she was told that R2 was not eating or drinking. RN E said she called the physician and R2 was sent to the emergency room and was admitted to the hospital in the critical care unit. Review of R2's medical record reveals that R2 was hospitalized from [DATE] to 03/05/20. Discharge [DIAGNOSES REDACTED]. Should note that in the past, patient's Creatinine has been approximately 1.44, currently 5.89 . R2's admission weight at the hospital was noted to be 134 pounds. R2 is currently at the facility on hospice comfort care and has a Court Appointed Guardian of his Person.

Based on observation, staff interviews, and record reviews the facility did not ensure that 2 of 7 sampled residents maintain acceptable parameters of their nutritional and hydration status to maintain their health. (R1 and R2). Since his admission to the facility on [DATE], R2 had significant declines in his food, fluid intake and weight without reassessment of his nutritional needs and/or interventions to prevent weight loss. R2 was hosptalized on [DATE] with a severe weight loss of 21.1%, severe dehydration, protein calorie malnutrition and acute on [MEDICAL CONDITION] with acute kidney injury grade 5. R1 had a decline in his appetite and a significant weight loss without reassessment and re-exploration of his nutritional needs and modalities for intervention. There is no evidence the facility staff reevaluated his diet and reviewed his hydration needs and food preferences in a timely manner. The facility has no evidence of reevaluating R1's likes and dislikes, introducing increased nutritious snacks, or attempting to make his meals as close to his usual pattern and preferences as at home. The facility immediately added a supplement rather than offering real food first as is the standard of practice. This is evidenced by: Surveyor received a copy of the facility policy and procedure titled Resident/Patient Heights and Weights, The purpose of this policy is to provide consistency in the method heights and weights are obtained and recorded and to provide guidelines for the frequency of monitoring heights and weights. It is also to provide guidelines for notification and documentation of significant weight changes. The Procedure includes the following: .2. Upon day of admission, the nursing department staff will weigh resident on the appropriate scale .weekly thereafter for 4 weeks and then monthly unless otherwise ordered by the physician or recommended by the Dietitian . 5. Weekly or daily weights are recommended if any of the following are present: a. Sudden, unplanned weight loss. b. Significant unplanned weight loss in 30 days. c. Decreased meal intake for a period >48 hours. d. Gradual, unplanned weight loss over multiple months. e. Unstable [MEDICAL CONDITION] ([MEDICAL CONDITION] or significant [MEDICAL CONDITION]. f. Suspicion of fluid deficit 7. Any weight change of 5 lbs. (pounds) or greater within 30 days will be retaken within 24 hrs. (hours) for verification. Once an accurate weight is verified, the inaccurate weight should be struck out with the appropriate explanation . Example 1 R2 was admitted to the facility on [DATE] following a left [MEDICAL CONDITION] and repair. R2 had [DIAGNOSES REDACTED]. R2 was his own legal decision maker. R2 chose to be full code. R2's admission weight at the nursing home was noted to be at 170 pounds. By 02/06/20, R2's weight had dropped to 158.6 pounds. This is a 6.7% severe weight loss in 1 month. When hosptalized on [DATE] his weight was noted to be 134 pounds. This is a total loss of 36 pounds or 21.1% R2's signed physician order [REDACTED]. R2's care plan includes a problem dated 01/13/20 of The resident has nutritional problem or potential nutritional problem, Fx left femur, dementia,[MEDICAL CONDITION](fracture hypertension). The goals stated, Will accept assistance with meals as needed, Will continue to feed self and will drink fluid offered. Initiated 01/09/20. Interventions included, Diet Texture Regular. Diet Type Regular. Eating Eats in own room, Eating set up, Fluids regular thin, Hydration Screener (weekly) Provide nutritional supplement with med pass: 60 cc plus 2 Bid/Meds, Provide serve diet as ordered. Monitor intake and record every meal. RD to evaluate and make diet change recommendations prn (as needed). record weight. See tray card for specific food preferences. R2's Nutritional assessment dated [DATE] states, Nutritional Assessment/Screening Summary: Resident is a 79 y/o (year old) male with diagnosis (sic) including: s/p (status [REDACTED]. Diet order is Regular with regular texture and thin liquids. Meal intakes average 50-100%. Estimated needs are 1927-2159 kcals/day; 62-77 g protein/day. No concerns noted with chewing or swallowing. Continue with plan of care. Will continue to monitor. Signed RD G (Registered Dietician). R2's Nutritional assessment dated [DATE] indicates that R2's weight on 01/06/20 was 170 pounds. R2's usual body weight was noted to be 170 pounds. No [MEDICAL CONDITION] was present. Estimated fluid needs were noted to be 1927-2313 ml/day (milliliters). Average fluid intake was noted to be 1200-1500 cc (cubic centimeters). R2 was noted to be independent in eating assistance. The nutritional assessment identified R2 was not getting the minimum assessed amount of fluids. There were no new interventions added to ensure proper fluid intake. A physician's orders [REDACTED]. On 02/06/20, R2's weight had dropped to 158.6 pounds. The facility's charting system sent an automated weight warning to DM C (Dietary Manager). On 03/05/20 at 12:45 p.m., Surveyor spoke with DM C. DM C said that when R2 had the weight loss from 170 to 158.6 pounds noted on 02/06/2020, she had repeatedly asked for a reweigh. DM C said that she could not get the nursing staff to reweigh R2. On 03/09/20 at 10:27 a.m., Surveyor spoke with RD G (Registered Dietician). RD G said the facility policy is to get weekly weights for 4 weeks upon admission. RD G said they will get a reweigh of weight with a 5 pound change up or down. RD G said R2 had a 11.4 pound weight loss between 01/06/20 and 02/06/20 and they were requesting a reweigh. RD G said they had started plus 2 med pass supplement twice a day on 02/04/20. RD G said she had sent emails to DM C and the DON requesting the reweigh for R2. RD G said they did not get the reweigh. RD G provided Surveyor with R2's weights which included 01/06/20 of 170 pounds and 02/06/20 of 158.6 pounds noted a month later. No reweighs were obtained. RD G provided surveyor with emails requesting a reweigh for R2 sent to DM C (02/11/20) and DON (02/17/20 and 02/26/20). DM C's progress note in R2's medical record states, 02/20/2020 weight change note. Note text: Weight warning: Value: 158.6. Vital Dated 02/06/2020 at 10:42 a.m MDS: -5.0% change over 30 day(s) (6.7%, 11.4). -3.0% change from last weight (6.7%, 11.4). -3.0% change over 30 days (6.7%, 11.4) have asked many times for a re weight on him, Will continue to monitor him, care plan reviewed and updated. Signed DM C. On 03/09/20 at 12:45 p.m., Surveyor spoke with DON B. DON B said DM C will ask for reweighs if she sees any discrepancy in weights. DON B said she had been asked by both DM C and RD G for a reweigh for R2 because of the decline in R2's weight from 170 pounds on 01/06/20 down to 158.6 pounds on 02/06/20. DON B said she had asked the nursing staff repeatedly to reweigh R2, and they never did. DON B said R2 was admitted downstairs and eventually moved upstairs. DON B said that over time, R2 was eating and drinking less and then wouldn't get out of bed. DON B said R2 had a catheter for [MEDICAL CONDITION] and it was removed for a short period of time and had to be put back in due to retention. R2 then developed a urinary tract infection and was placed on an antibiotic. DON B said when a resident is treated for [REDACTED]. DON B said the nurses have to follow the intakes to determine if the resident is eating and drinking enough based on their food and fluid intake needs. The medical record reveals R2 was sent to the emergency roiagnom on [DATE] for agitation. He was diagnosed with [REDACTED]. R2 was put on [MEDICATION NAME] for the retention and [MEDICATION NAME] (antibiotic) and the recommendation to increase oral hydration. R2 came back to the nursing home. Review of the Chemistry results completed at that time included the following: BUN was 33.0 (high) range (8.0-24.0), Creatinine 2.57 (high) range (0.55-1.30) and Glucose 133 (high) 70-100. These labs are indicative of dehydration and decline in kidney function. These were a decline in baseline labs from his 01/03/20 labs prior to admission. The BUN was 22 (normal), Glucose 110 (high) and the Creatinine was 2.09. Surveyor review of R2's medical record reveals a Hydration Risk Eval and assessment dated [DATE]. The finding indicate that risk factors were present. Section B Hydration assessment does not mention the elevated BUN, Creatinine and Glucose. The summary indicated to encourage fluid intake. There is no indication the facility implemented any interventions to increase R2's fluid intakes. Surveyor review of R2's medical record reveals a physician progress notes [REDACTED]. R2's meal intake records from 02/11/20 through 02/24/20 indicates R2 refused 17 of the 39 meals offered and had 5 meals where intake was 0-25%. Fluid intake records for 14 days from 02/11/20 through 02/24/20 reveals that R2's highest fluid intake for 24 hours was 1020 cc's. All other intakes were below this amount including 240 cc's on 3 days, 100 cc's 1 day, and no fluids for 2 days. R2 was not meeting his recommended fluid needs of 1927-2313 cc's per day or even his average fluid intake of 1200-1500 cc's per day. On 03/05/20 at 1:45 p.m., Surveyor spoke with CNA D (Certified Nursing Assistant). CNA D said they record all meal intakes and fluid intakes for all residents in Point Click Care (charting system). CNA D said R2 was not eating or drinking very well and he would refuse to allow them to feed him. A nursing progress note dated 02/20/20 states, Dr. (MD H) updated that resident has had a significant weight change in the past month. No new orders. Another note on 02/20/2020 indicates the physician had decreased R2's Tylenol and [MEDICATION NAME] doses at night and R2 is completed with the antibiotic for a urinary tract infection. The notes do not mention that the physician was informed of the decrease in food and fluid intakes. Review of R2's interdisciplinary progress notes reveal the following entries: 02/24/2020 at 01:25 am nursing note: Resident exhibiting terminal restlessness. Interventions included repositioning and toileting. Offered fluids, however not accepting. Significant cognitive impairment. Foley cath patent and draining 60 cc amber colored urine via gravity bag. Mouth care performed. Medical intervention following with administration of md prescribed [MEDICATION NAME] with noted effective relief. Currently resting quietly, eyes closed. No further restlessness exhibited. Signed RN I (Agency Registered Nurse). On 03/10/20 at 8:50 a.m., Surveyors spoke via phone to RN I. RN I said she had never worked with R2 before 02/24/20. RN I recalled R2 was very thin, very restless, and was told R2 wasn't eating or drinking anything. R2's interdisciplinary progress notes includes, 02/24/2020 at 17:36 (5:36 p.m.). Type communication with physician. MD notified of resident refusal to eat or drink the last 10 days. Urine from foley cath (catheter) is brown. 100 cc out in 8 hours. Eyes sunken, > 3 (greater than) seconds tenting of skin. Refusing to allow VS (vital signs) or take medications. New orders to send to ER (emergency room ) for eval of UTI (urinary tract infection). Signed RN E. On 03/09/20 at 9:53 a.m., Surveyor spoke with RN E via phone. RN E said R2 had come to the facility following a [MEDICAL CONDITION] and resided on the unit she usually worked and then moved to a different unit. RN E said R2 had a catheter for [MEDICAL CONDITION] when he came to the facility. RN E said that R2 did not talk very much and did not have any visitors. RN E said when R2 was first admitted , he would drink a lot of water and that getting R2 to eat was more of a problem. RN E said she knew that R2 had lost some weight after he was at the facility and the physician knew about the weight loss. RN E said that R2 was full code. RN E said she was assigned to work the unit where R2 resided on the evening shift on 02/24/20. RN E said she had gotten report from the day shift nurse, RN F who had said R2 wasn't eating or drinking and that he was very agitated. RN E said when she saw R2 she could tell he had had a significant change in condition from the time she last saw him. RN E said R2's eyes were sunken, was very thin (rib cage sticking out hollow), urine was brown in the catheter and she was told R2 was not eating or drinking. RN E said she called the physician and they sent R2 into the emergency roiagnom on [DATE] and R2 was admitted to the critical care unit at the hospital. R2 was hospitalized from [DATE] to 03/05/20. Discharge [DIAGNOSES REDACTED]. Should note that in the past, patient's Creatinine has been approximately 1.44, currently 5.89 (elevated creatinine levels is indicative of kidney impairment) . R2's admission weight at the hospital was noted to be 134 pounds. R2's weight loss since admission (01/06/20) was a total of 36 pounds, or 21.1% weight loss. From 01/06/20 through 02/24/20, there were no new interventions to address R2's declining food and fluid intakes or to increase fluids when R2 was started on an antibiotic for a urinary tract infection. Review of R2's medical record and interview with staff reveals that R2 came back from the hospital on [DATE] with hospice services. Example 2: R1 was admitted to the facility in December 2019 for what was initially a short term respite stay, which was then extended to a long term stay. R1's [DIAGNOSES REDACTED]. Review of his most recent MDS (Minimum Data Set) assessment, shortly after his admission, finds he was able to express himself but had severe impairment in his attention, orientation, ability to recall new information, and both long and short term memory impairment. He had no issues with his moods however he did have disruptive verbal behaviors directed at others. He needed supervision when getting about with his walker and at times the extensive assistance of a staff member to get dressed, use the toilet, and take care of his personal hygiene. He was independent in his ability to eat and drink with the staff just setting him up. The CAAs (Care Area Assessment) indicated that R1 had a BMI (Body Mass Index) that was too low. R1 passed away on 2/23/20 from [MEDICAL CONDITION] and heart failure. R1's plan of care states he has a nutritional problem or the potential for one due to his dementia and reflux. Included in his goals for his care is that he will continue to eat by himself, have no GI (gastrointestinal) complaints, will drink what is offered him and will eat over 75% for 2 of his 3 meals. There is a target date of 12/18/19 however his care plan was not revised or updated since mid-December. Interventions for his care includes he has a regular diet and eats independently in the dining room with staff setting him up. Staff are to record how much he eats and drinks, record on a weekly basis how his hydration is, get his weight daily, report GI complaints to the nurse, and the RD (Registered Dietician) is to evaluate this and make changes to his diet as needed. Review of his physician orders [REDACTED]. ~ 2/22/20 Plus 2 120 cc (cubic centimeters) twice a day with med pass on 1/28/20 and then increased on 2/22/20 to 3 times a day at the family's request. ~ [MEDICATION NAME] 40 mg (milligram) tablet, a diuretic since his admission. ~ [MEDICATION NAME] 25 mg tablet, also a diuretic since his admission. ~ [MEDICATION NAME] DHA (docosahexaenoic) 200 mg Capsule, a multivitamin with fish oil since his admission. The facility has evidence of just one Hydration Risk Eval and assessment dated [DATE] that indicates R1 is at risk for dehydration. The facility's assessment indicates he is at risk for dehydration and indicates staff will schedule additional screens weekly or daily however none were done. This is especially imperative as R1 takes 2 diuretics every day for his [MEDICAL CONDITION]. According to the New Dinning Practice Standards published by the Pioneer Network in August of 2011 and endorsed by numerous dietary, geriatric health, long-term care professionals and the medical directors' association, the concept of real food first is the standard of geriatric care. Of note is that the facility has only 2 documented weights for his entire stay: ~ 12/4/19 - 168# (pounds) ~ 1/22/20 - 156# This is a 12 pound or 7.14% weight loss in 7 weeks. R1's mean average intake from December 2019 through the first 10 days of February 2020 calculated to approximately 51% to 75%. From 2/11/20 to 2/22/20 he ate 51% to 75% only 5 meals, 26% to 50% 3 times, 0 to 25% 11 times and refused his meal entirely 13 times for a average of approximately 0 to 25%. Despite the decline in R1's intakes, there were no change in approaches to increase R1's intake. There was no increase in monitoring his weight, no evidence that his food preferences were reevaluated, that any lab work was discussed with his physician, any review of how his increasing anxiety was interfering with his intakes and exploring ways to increase his calories. The only change being the family's request for an increase in his supplement on 2/22/20. Review of the interdisciplinary notes found only 3 narrative notes by RD G and DM C: The first initial note by RD-G on 12/6/19 reviewed his diagnoses, his calorie and protein needs, and that he is eating 50% to 75%. The next note was made by DM-C on 1/28/20 in which she notes a warning that he had a weight loss of 7.6% and 12.8# to 156# in a month, his intakes were down to 25% to 75%. Plus 2 120 ccs was added 3 times a day with his meds. The order was just for the supplement 2 times a day. There is no notation about getting additional weights, reviewing his food preferences, and/or how and when he would like his food prepared. The only intervention was the introduction of his supplement. The next note is RD-G on 1/31/20 that again noted the weight loss, that a supplement was added, his average intakes, and the fact that he had no [MEDICAL CONDITION]. RD-G stated the plan of care was to be continued. There were no notations by the nursing staff about how his eating, nutrition, and/or hydration with the exception of a brief mention in some head to toe assessments that ended on 12/16/19. On 3/9/20 at 8:58 a.m. Surveyor interviewed RD-G. RD-G stated the facility's usual first course of action when a resident is losing weight and not eating is to add the supplement Plus 2 to be given when residents are getting their medications. The RD stated, I like to do the Plus 2 first at the med pass because there is usually good documentation that it's being given and that way it does not get in the way of the meals. She reiterated the facility's policies however did not know why the weights were not obtained per the policy. RD-G stated she would talk to DM-C or DON-B if weights were missing however she has 6 facilities she covers and did not recall if that had been done for R1 in particular. RD stated she relies on DM-C for day to day assessments of the residents. On 3/10/20 at 2:30 p.m. Surveyor interviewed DM-C. DM-C stated she will request from nursing on a sticky note any missing weights she needs and did not know why R1's weight was only checked once since his admission.

Based on observations, interviews, and record reviews, the facility did not provide care consistent with professional standards of practice, to prevent pressure injuries nor did the facility ensure that resident's with pressure injuries received necessary treatment and services to promote healing, prevent infection, and prevent new injuries from developing for 6 (R4, R9, R10, R12, R14 and R20) of 12 residents reviewed for pressure injuries. R14 was admitted with a Stage 4 Sacrum/Coccyx pressure injury, with bone visible, and a [DIAGNOSES REDACTED]. On 4/9/17, R14 was positioned predominately on her back for 3 hours and 15 minutes. Observation the following day found the wound had declined. In addition, R14 was to be repositioned side to side and was to be tilted to reduce pressure to the trochanters (hips). R14 developed a pressure injury to the left trochanter. The prescribed dressing was not available, so staff had to use a dressing that was too large for R14. The dressing was noted to wrinkle due to the size and caused additional injury to the pressure injury site. This example is being cited at the level of actual harm. R12 was admitted to the facility without pressure ulcers to the left heel. R12 developed an avoidable stage II pressure ulcer. Additionally, wound care was not performed according to the standards of practice for R12. R4 has a Stage 3 pressure injury to her coccyx and is to be repositioned every 1 to 2 hours. R4 was not repositioned for over 4 hours on 2 seperate occassions. In addition, the licensed nurse applied a dressing to the wound be with a gloved finger and not an applicator per acepted standards of practice. R10 was admitted to the facility with a history of pressure injuries and required extensive assistance of staff for movement. The facility did not develop interventions to prevent the development of pressure ulcers. R10 later developed a pressure injury (blood blister) on his right medial heel on 02/24/17. On 04/09/17 a pressure injury was observed to still be present on the heel in addition to a small open area above the pressure injury. It was later in the day on 04/09/17, that the facility first implemented bilateral boots for R10 to wear when in bed. R9 is high risk for developing Pressure Injuries. Observations of not being repositioned for 4 hours 15 minutes. R20 was at high risk for pressure injury developement. Staff did not offer or assist with repositioning for over 4 hours. This is evidenced by: Example 1: R14 was admitted on [DATE], and has [DIAGNOSES REDACTED]. R14 was admitted with a Wound Vac to the coccyx area. The Minimum Data Set (MDS) assessment, dated 3/22/17, indicated R14 requires total assistance of 2 staff for transfers, extensive assistance of 2 staff for bed mobility, is incontinent of bowel, has 2 pressure injuries (1 Stage 4 and 1 Stage 2), and is receiving antibiotics since admission. R14's Care Plan, dated 12/14/16, states, .has actual impairment to skin integrity r/t (related to) stage 4 pressure ulcer: Unstageable L (left) trochanter (1/20/17): Interventions include: Reposition resident every 90 mins (minutes); side to side only, 12/20/16. Treatment in place for Pressure ulcer left trochanter, see TAR (Treatment record), 1/20/17. Resident sees wound clinic weekly on Mondays, 1/20/17. Position with pillows on Trochanters, 2/1/17. Tx (treatment) in place for coccyx ulcer, see TAR, 2/21/17. CNA (Certified Nurse Aide) care card also indicates: Up For Lunch Only. Once done with meal will need to lay back down. 1/23/17, Wound Clinic Note added, when repositioning side to side - tilt patient to offload coccyx and minimize pressure to trochanters, use pillows as needed for support along with the other interventions . This is not added to the Care plan or the CNA care card. On 4/11/17 at 7:55 a.m., Surveyor observed CNA-V in R14's room. CNA-V stated the night shift does R14's a.m. cares and she is only repositioning her. Surveyor noted R14 was on her back with her hips slightly to the right. CNA-V directed R14 to turn on her left side. R14 stated, Oh my butt! CNA-V stated R14 is assist of one for bed mobility. CNA-V asked R14 to move over more on her left side. A pillow was placed behind R14's back. R14 was lying directly on her left hip with no pillows used to minimize pressure to the left hip. The MDS indicated R14 requires extensive assist of 2 staff for bed mobility, however the care plan does not reference this need. 2 assist would be needed to ensure appropriate pressure relief is met during repositioning. On 4/10/17 at 11:20 a.m., Surveyor spoke to CNA-T and CNA-W who stated staff cannot reposition or toilet residents every 2 hours because there is no time. Most of the residents are 2 assist. The facility has 1 Licensed Nurse and 2 CNAs on Cedar Ridge Wing (2 halls) where R14 resides. Review of R14's facility and wound clinic weekly wound care documentation indicates the following: ~12/16/16, Sacrum measures: 3.0 cm x 2.4 cm x 1.6 cm. Stage 4 pressure injury: Full-thickness skin and tissue loss. Area was recently debrided in the hospital prior admission. R14 was admitted with a Wound Vac that is to be changed three times a week. Two times at the facility and one time by the wound care clinic. R14 receiving antibiotics for [DIAGNOSES REDACTED]. ~1/3/17, Wound Care Clinic (WCC) notes: measures 5.2 x 3.5 x 2.0, Stage 4, Serosanguinous red, brown large drainage. No tendon, joint or bone are visible. There is no nursing documentation from 1/16/17 until 1/21/17 when the night nurse documented the wound vac was not attached upon entering room; re-applied and in working condition. ~1/20/17, R14 developed a Stage 2 to the left trochanter. 2.1 x 2.5 x 0.1 Stage 2 Pressure Injury. Tissue type identifies slough tissue present (yellow, tan, white, stringy). With slough in the wound, it would not be possible to stage as the base of the wound could not be visualized. The only changes made to R14's care plan on this date were: ~Treatment in place for Pressure ulcer left trochanter, see TAR (Treatment record), 1/20/17. ~Resident sees wound clinic weekly on Mondays, 1/20/17. No changes related to pressure relief, or repositioning were made on this date despite the development of an unstageable pressure injury. ~1/23/17, WCC notes added: when repositioning side to side - tilt patient to offload coccyx and minimize pressure to trochanters, use pillows as needed for support along with the other interventions of Strict Bedrest, no pressure to coccyx and reposition every 1-2 hours side to side only. ~1/30/17, WCC changed the left trochanter treatment: *Cleanse with normal saline, Vaseline to periwound. Purachol Collagen to Ulcer and apply [MEDICATION NAME] with gentle border or may use, change every 3 days. ~2/7/16, Sacral wound debrided. [DIAGNOSES REDACTED]. Continue treatment ~2/15/17, Sacrum measures 7.4 x 6.0 x 1.7. Stage 4 pressure injury. Granulation present. ~2/27/17, WCC notes: Sacrum measures: 6.4 x 5.2 x 2.0. Exposed structures: Fascia: yes, Fat: yes, Muscle:yes. Tendon: no, Joint: no and bone:no. *High Risk for Nutrition. [MEDICATION NAME] is 5. (normal is 20-40). Encourage ensure three times a day. Complex/Palliative Management was generated. ~3/6/17, left trochanter measures 2.1 x 2.3 x 0.1, serosanguinous drainage documented. ~3/13/17, WCC notes indicate: Precautions: Contact-MRSA. Sacrum measures: 6.0 x 5.8 x 1.3. No tendon, joint or bone visualized. Physician orders [REDACTED]. The facility measures the sacrum: 6.4 x 5.0 x 1.7 Stage 4, Granulation. Infection suspected. Placed on contact precautions. ~3/13/17, WCC measured left trochanter: 2.0 x 2.5 x 0.1. On 3/14/17, R14 moved to the 2nd floor. Review of the documentation found contact precautions were not continued on Cedar Ridge until 4/10/17, when surveyor inquired about [MEDICAL CONDITION]. In addition, no specialty mattress was available until the next day. ~Nurse note dated 3/15/17 indicated a pink blanchable skin on right hip bone. Anticipate this will resolve when air mattress is applied today. ~3/17/17, nurses note: WCC updated by nursing that Purachol product is not available for left hip dressing, will order through our pharmacy. WCC stated to restart this part of Rx (prescription) when it is available. ~3/20/17, left trochanter measures 2.7 x 2.5 x 0.1 worsening ~3/21/17, *treatment changed to every day instead of every three days. A note written to the WCC, need Vaseline and Purachol. No signature or date. ~3/21/17, WCC measurement sacrum: 6.0 x 5.8 x 1.3. No bone exposure. *Tx change to Twice a day and as needed from daily dressing change. On 3/28/17, new air mattress applied. ~4/3/17, WCC notes: coccyx measures 6.5 x 6.0 x 1.5.* Bone is now present, which is a decline. The treatment changed: Discontinue Dakins wet to dry dressing. Sacrum ulcer: Vaseline to periwound. Apply [MEDICATION NAME] dressing over exposed bone, Normal saline wet to dry dressing, pack gently into undermined area, cover with dry gauze. ABD pad and secure with tape. Change twice daily and as needed. ~4/3/17, WCC notes: left trochanter measured: 2.3 x 2.3 x 0.1. Category/Stage 2, Purulent drainage; yellow, brown, green in color. Necrotic tissue 67-100%. Periwound is Friable. Treatment: *Left Hip Ulcer: Cleanse with normal saline, vaseline to periwound, Purachol collagen to ulcer and apply [MEDICATION NAME] with gently border or equivalent dressing. Change daily and as needed. ~4/5/17, left trochanter measures 2.8 x 2.4 x 0. Unstageable due to 100% slough. On 4/9/17 the Survey Team completed a continuous observation of R14 from 6:45 a.m. - 10:00 a.m. At 6:45 a.m., R14 was observed lying in bed positioned predominantly on her back with a slight left side position. At 9:08 a.m., CNA-A (Certified Nursing Assistant) entered R14's room and elevated the head of her bed. There was no repositioning done at that time. At 10:00 a.m., 3 hours and 15 minutes later, CNA-A and CNA-B entered R14's room to reposition her onto her far left side. Surveyor asked the staff about R14's care needs. CNA-A stated R14 was to be repositioned every 1-1 1/2 hours as she has sores. R14's care plan indicates she is be repositioned every 90 minutes. On 4/10/17 at 5:10 p.m., the Surveyor interviewed the Director of Nursing (DON) regarding the repositioning schedule for R14. The DON stated that R14 was to be repositioned every 90 minutes at a minimum because of her bad wounds. Upon the repositioning, the Surveyor observed a large dressing over R14's coccyx and a 4 x 4 inch dressing over R14's left hip. On 4/9/17 at 2:58 p.m., Surveyor observed the wound treatment for [REDACTED]. LPN-F indicated that she had pre-medicated R14 in preparation for the treatment. R14 was very thin. LPN-F conducted the treatment to R14's coccyx area first. When LPN-F removed the old dressing, the drainage was observed by Surveyor to be brownish-bloody and it saturated the dressing. The wound itself was a deep crater approximately 10 cm in size (about the size of a baseball), with what appeared to be slight purplish bruising on the outer circumference of the wound. It was not formally measured during this observation. The coccyx bone was slightly visible as there was a very thin covering of granulation tissue over the bone. RN-G stated the wound is slowly improving, as the bone had been much more visible. RN-G proceeded to conduct the dressing change and treatment to R14's left hip. Upon removing the dressing, the drainage was noted by the Surveyor to be brownish/pink in color approximately the size of a quarter coin on the old dressing. There were linear markings on the residents skin with the removal of the dressing. When asked about the cause of these markings, RN-G stated that R14 was Just skin and bone and is supposed to have a 2 x 2 inch Gentle Border dressing in place because of her malnourishment. The NHA (Nursing Home Administrator) will not order these special dressings for (R14), so it wrinkles in the corners because she is so thin. The wound itself was approximately 2.0 cm in diameter located directly over R14's left hip bone. It contained a reddish purple area surrounding the wound that measured approximately 0.5 cm. Next to this discolored area and moving inward, there was approximately 1.5 cm of yellowish/white slough. In the center of the slough there was an approximately 0.5 cm diameter area of a brownish discoloring. The treatment was conducted appropriately, with the exception of the incorrectly sized dressing. Surveyor observed the new dressing wrinkle at the corners as the old dressing had. On 4/9/17, nurses note indicated the day shift dressing change was not completed until shift change. Notified the PM nurse that it was late. On 4/10/17 at 1:55 p.m., Surveyor interviewed RN-D regarding R14 facility acquired left hip pressure injury. RN-D stated that she believed the CNA's were being hesitant, careful when repositioning R14 because of the wound vac bridge was partially on her left, also R14 was nutritionally compromised along with an infection. R14 has multiple factors along with Adult Failure to Thrive. On 4/10/17 at 4:20 p.m., the Surveyor observed RN-D conduct the treatment to R14's coccyx and left hip. There was noticeable decline in the coccyx wound by the Surveyor at this time. RN-D also stated the wound has declined. The old dressing contained copious amounts of purulent (pus) drainage and was odorous. This was not present on the previous observation. The drainage on the old dressing was yellowish to green in color with slight specks of dark pink (bloody) areas. The bone remained slightly visible through a very thin covering of new granulation tissue. RN-D stated she last saw the wound on 4/5/17 and now the area of bone visibility is double in size. She further stated originally, the depth of the wound was 2.0 cm but now is 1.5 cm, indicating that the wound is filling in. On 4/17/17 at 12:05 p.m., RN-D entered the Conference room with the current DON and the DON in training. RN-D stated she misspoke regarding R14's wound being worse. She stated the wound actually has improved. The Surveyor then asked her what purulent drainage symbolizes in regard to wounds. RN-D stated that it indicates infection. The Surveyor then explained that the purulent drainage and odor was not present the previous day when the treatment was observed, and thus, indicates decline. Example 2: The admission Braden dated 11/1/16 assessed R12 to be At Risk for pressure ulcer development. The plan of care dated 11/1/16 indicated R12 had the following interventions in place to maintain skin integrity and prevent pressure ulcers: encourage good nutrition and hydration, roho cushion, and use a draw sheet or lifting device to move resident. The Admission MDS dated [DATE] assessed R12 to require extensive assistance with bed mobility and transfers. R12 was also assessed to be at risk for pressure ulcer development with no current pressure ulcers. The MDS indicated R12 had the following Diagnoses: [REDACTED]. The CAA (Care Area Assessment) Worksheet for Pressure Ulcer dated 11/11/16 indicated the following care plan interventions were in place for R12: staff assists with repositioning and toileting every 2 hours and as needed. Pressure reduction mattress and chair pad are in place .Staff monitors skin every shift with cares and reports any changes . The electronic progress notes dated 11/12/16 stated a 2 x 2 fluid filled blister was noted to the left heel. The progress note dated 11/13/16 indicated R12 was discharged to the hospital for an unrelated reason and returned to the facility on [DATE]. The plan of care was updated on 11/12/16 to include the intervention to free float the heels. An undated Skin Review was conducted for the period of 12/29/16 - 1/11/17 at which time it was noted R12's left heel had progressed to an unstageable ulcer with [MEDICAL CONDITION] (Methicillan Resistant Staphylococcus Aureus) infection. [MEDICATION NAME] 500 mg (Milligrams) three times daily was prescribed on 1/4/17 with the antibiotic course to be completed on 1/18/17. R12 was admitted with a risk of development of pressure ulcers. No interventions were implemented to protect the heels after admission and the development of a stage II pressure ulcer occurred, at which time the facility implemented free floating the heels. The ulcer became infected [MEDICAL CONDITION]. On 4/9/17 at 12:55 p.m., Surveyor interviewed RN-O who confirmed the only intervention to protect R12's feet on admission was repositioning the resident every 2 hours. On 4/9/17 at 10:30 a.m., Surveyor observed RN-I provide wound care to a stage IV pressure injury located on R12's buttocks. RN-I removed the old dressing from the pressure ulcer, which had a notable tunnel present. RN-I cleansed the wound and used two separate pieces of gauze to dress the wound. One piece of gauze was inserted into the tunnel, with approximately 1-2 cm (centimeters) of the gauze left over and exposed in the bed of the wound. A second piece of gauze was placed in the wound bed. At 11:10 Surveyor interviewed RN-I who stated the tunnel was approximately 1/2 inch deep and she used two separate pieces of gauze; one to fill the tunnel and one to fill the wound bed. RN-I was not aware that she needed to use one continuous piece of gauze to pack a tunneling wound. Example 3: The MDS dated [DATE] assessed R4 to require total assistance with transfers and extensive assistance with bed mobility. R4 is at risk for pressure ulcer development with a current stage III pressure injury. R4 has impaired range of motion to the bilateral lower extremities. The plan of care dated 12/9/16 indicated R4 had a stage III pressure ulcer to the coccyx. The electronic progress note dated 1/19/17 stated R4 returned from the wound clinic with interventions to include repositioning the resident every 1-2 hours and strict bed rest. On 4/9/17 at 7:49 a.m., Surveyor interviewed CNA-H who stated the staff were in R4's room at approximately 5 a.m. at which time the resident was repositioned and cares were completed. CNA-H stated the resident is not repositioned as often as the resident should be repositioned, because there are only 2 CNAs on the unit and they don't have time to do so. At 9:30 a.m., Surveyor observed the staff reposition R4. R4 was not repositioned for approximately 4 1/2 hours (5:00 a.m. - 9:30 a.m.). On 4/9/17, a continuous observation began at 9:30 a.m. R4 was not repositioned until 1:51 p.m., 4 hours and 21 minutes later. On 4/9/17 at 9:21 a.m., RN-O completed wound care to R4's stage III coccyx pressure ulcer. After cleansing the wound bed, RN-O applied collagen hydrogel to her gloved finger tip and applied the ointment to R4's wound bed. On 4/10/17 at 10:25 a.m., Surveyor interviewed DON-HH (Director of Nursing) who confirmed applying the collagen hydrogel to the wound bed via a gloved finger is not the standard of practice. Example 4: R10 was readmitted to the facility on [DATE] after observation at the hospital with a Stage 2 pressure injury on his coccyx and an ulcer on his lower left shin and [MEDICAL CONDITION] to his lower extremities. Those ulcers healed. R10's admission MDS (Minimum Data Set Assessment) dated 01/26/17 reveals R10 is dependent on 2 staff for bed mobility, uses a wheelchair for mobility, extensive assist with transfers of 2 staff and at risk of developing pressure ulcers and is on hospice care. A corresponding CAA dated 01/26/17, shows that section M (skin conditions) was triggered. Immobility and chronic or end stage renal, liver or [MEDICAL CONDITION]. Despite the known risk for pressure injury developement and decreased mobility, there is no evidence the facility implemented any measures to protect R10's heels upon admission 1/19/17. Review of R10's current care plan page 6 shows a focus area with an initiation date of 01/19/17 as follows: The resident has actual impairment to skin integrity. Interventions include: Float heels on pillows at night Date initiated: 03/01/17 . On 02/24/17, R10 developed a blood blister the size of a 50 cent piece on his right medial heel. Surveyor review of R10's physician's orders [REDACTED]. Review of R10's nurse's progress notes indicates the following note dated 04/05/17: Resident's previous DTI (deep tissue injury) on R medial heel is resolved today . On 04/09/17 at 6:50 a.m., Surveyor observed R1 sitting on his bed wearing socks with his feet/heels directly on the floor. At 7:35 a.m., CNA-A (Certified Nursing Assistant) was observed in R10's room asking R10 what clothes he would like to wear for the day. R10 was still seated on his bed with only socks on his feet and his feet directly on the floor. CNA-A assisted R10 with morning cares. The DON assisted with transferring R10 with a mechanical lift to his recliner chair in R1's room. Once R10 was seated in his recliner Surveyor asked CNA-A and the DON to see R10's feet. When R1's black socks were taken off Surveyor observed a collapsed blister the size of a 50 cent piece on R1's right medial heel. No dressing or skin prep was observed on R10's heel. CNA-A indicated that the blister had been acquired recently. At 8:15 a.m., LPN-F (Licensed Practical Nurse) indicated that the treatment to R10's right heel blister was skin prep. On 4/9/17 at 8:25 a.m., the Surveyor observed LPN-F conduct a treatment to R10's right inner heel. The wound was an absorbed blister the size of a quarter. Directly above this reabsorbed blister area was a dime-sized calloused area. Between the callous and the blister there was an open slit that measured approximately 1.0 cm (centimeter) in size. The Surveyor asked R10 how long he has had the wound. R10 responded Oh about 5-6 months. The area did not have a dressing in place and R10's legs were very [MEDICAL CONDITION], the right foot containing approximately 3+ [MEDICAL CONDITION]. The DON stated during this dressing that the open slit was new. At 8:25 a.m., the Surveyor interviewed LPN-F, who stated that R10 has had the wound for a long time, but that it was not open on the previous day. At 9:40 a.m., Surveyor observed CNA-A walking down the hallway to R10's room with a pair of Soft Blue Boots in her hand. Surveyor spoke with CNA-A after she delivered the blue boots to R10's room. CNA-A said that R10 never had the blue boots since he had been on that unit. On 04/10/17 at 8:45 a.m., Surveyor spoke with the DON. The DON said that R10 got the right medial heel blister (deep tissue injury) around 02/26/17. Surveyor asked the DON what the cause of the blister was. The DON said that she believes it was from R10's feet rubbing together when he was lying on his side. The DON indicated that the blue boots were first implemented on 04/09/17. Example 5: R9 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] indicates R9 is totally dependent on staff for transfers and is nonambulatory. R9's Care Plan, dated 5/28/16 states, .limited physical mobility r/t (related to) weakness. Interventions: Bed Mobility-Assist -One (May use Assist of Two if resident is displaying behaviors) .Transfer-Assist-Two .Full-Body-Lift .Turned and repositioned every 90 minutes. Date initiated: 6/15/16.incontinent of bowel and bladder .Goal: Skin will be intact .Interventions: Check and Change every 1 hour and as needed . The most recent Braden Score completed for R9 was 14, dated 3/24/17. This indicates a moderate risk for the development of a pressure injury. On 4/10/17 a continuous observation began at 7:05 a.m.: ~ At 7:05 a.m., R9 was noted to be seated in his Broda chair outside the Cedar Ridge Dining Room/Nursing Station. ~ At 7:50 a.m., R9 was taken inside the dining room and placed at his table in preparation for the morning meal. ~ At 9:05 a.m., R9 was taken out of the dining room and placed near the nursing desk. ~ At 11:20 a.m., R9 was taken to his room. ~At 11:20 a.m., Surveyor observed CNA-T and CNA-W transferring R9 from Mechanical Lift to bed. R9 was checked for incontinence. R9 was dry in the front and back. CNA-T and CNA-W transferred him back into his Broda chair using the Mechanical lift. This was the first time in 4 hours and 15 minutes R9 was repositioned. Surveyor spoke to CNA-T and CNA-W. CNA-T and CNA-W stated this was the first time since R9 has been up that he was repositioned. Staff stated they would not be able to do it now, but there was a float CNA to help today. We don't usually get a float person. Normally he would be repositioned and checked after lunch. The staff indicated at this time of day, they have to get everyone to the dining room, pass trays and help those who need to eat. There is no time to reposition and toilet residents every 2 hours. Most of the residents are 2 assist. The facility has 1 Licensed Nurse and 2 CNAs on Cedar Ridge Wing (2 halls). On 4/10/17 at 5:10 p.m., Surveyor asked the DON about R9's repositioning schedule. The DON stated that R9 should be repositioned every 90 minutes. Example 6: R20 has medical [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] indicates R20 requires extensive assistance of 2 for transfers. The most recent Braden Score was 12, dated 3/28/17. This indicates a high risk for the development of pressure injuries. On 4/10/17 a continuous observation began at 7:05 a.m.: ~ At 7:05 a.m., R20 was noted to be seated in her wheelchair outside the Cedar Ridge Dining Room/Nursing Station. ~ At 7:40 a.m., R20 was taken inside the dining room and placed at her table in preparation for the morning meal. ~ At 8:30 a.m., R20 was taken out of the dining room and placed near the nursing desk. ~ At 10:40 a.m., the Hospice nurse approached R20 and propelled the resident to her room. Surveyor followed. The Hospice nurse sat on a stationary chair beside R20 and began to converse with her and took vital signs of R20. On 4/10/17 at 11:40 a.m., Surveyor observed CNA-T and CNA-W transfer R20 from the wheelchair to the bed using a mechanical lift. R20 has an urinary catheter. CNA-T proceeded to do frontal peri care. This was the first time in 4 hours and 35 minutes R20 was repositioned. Surveyor observed peri area and buttock area. R20's buttocks were red with linear lines with no open areas. CNA-T and CNA-W transferred R20 back into her chair. Both CNAs stated that R20 will not stay in bed. CNA-T and CNA-W stated that they have a lot of people who can't be left alone in the bathrooms because they are a fall risk. They stated that 1 CNA is with them which leaves only 1 CNA on the floor. Both stated that they never get to lay down or reposition residents like they should. On 4/10/17 at 5:10 p.m., Surveyor asked the DON about R20's repositioning needs. The DON stated that R20 should be repositioned as needed but should not be over two hours. On 4/11/17 at 10:25 a.m., Surveyor asked CNA-T about R20's repositioning schedule. CNA-T was on duty during the continuous observation on 4/10/17. After being informed of the extended observation without offers for repositioning, CNA-T stated, There is just no time. It's really hard to decide who should I do next, who has to wait. I am busy all day. Something gets missed.

Based on observation, record review and interview, the facility did not ensure care and treatment of [REDACTED]. This was found for 1 of 8 sampled residents reviewed with pressure ulcers. Resident #7 has an unstageable pressure ulcer that did not have a dressing on for at least three hours. The treatment being used was not suitable for an unstageable wound covered with slough (fibrous necrotic tissue). The facility is treating the wound with two skin protectants rather than a [MEDICATION NAME] agent to remove the necrotic/dead tissue. In addition, the facility has mistakenly assessed the wounds as stage III wounds when they are in fact unstageable. This classification of the wounds is critical in choosing the appropriate treatment. This is evidenced by: Resident #7 has been a resident of the facility since May 2015 with four hospital admissions for health changes. Resident #7's [DIAGNOSES REDACTED]. He is on [MEDICAL TREATMENT] and has diabetes. Review of the most recent Minimum Data Set (MDS) assessments dated 9/29/15 and 9/16/15, finds that he needs the physical assistance of one staff member to position himself in bed and the assistance of two staff members to transfer in and out of bed. Review of the plan of care finds that on 9/10/15 a focus area was implemented that he had an open slit over his coccyx, a stage II on his left buttocks, and a deep tissue injury (DTI) on his right buttocks after he had returned from one of his hospitalization s. Review of the facility's wound documentation finds the wounds were found upon readmission to the facility on [DATE]. The weekly documentation by the Assistant Director of Nursing (ADON) indicates: ~9/11/15. Resident #7 came from the hospital with two stage III wounds. Wound #1. The assessment found a slit over his coccyx that is 0.7 cm (centimeters) by 0.2 cm, stage III, and 100% covered in yellow slough. Wound #2. An area that is 1.0 cm by 0.2 cm stage III and also covered with slough. This area was also over his coccyx. The staging of the ulcers is incorrect as the ADON could not see the wound beds and it should be staged as unstageable. The treatment was to put on a protectant called Sensi-care. The goal of treatment should be to remove the slough in order to allow new tissue granulation. The skin protectant would not accomplish that. ~9/23/15. Resident #7 has four wounds now after another readmission from the hospital. Wound #1. Is a new stage II on his left buttock 0.3 cm x 0.2 cm. Wound #2. Is the same size over his coccyx and is covered with slough. Wound #3. There is a new stage III to his coccyx that is 0.3 cm x 0.3 cm. Wound #4. There is a new stage II to his right buttock 1.2 cm by 1.1 cm. The resident has a low loss air mattress and a [MEDICATION NAME] dressing is being used. ~9/30/15. Resident #7 has same four wounds. Wound #1. Has doubled in length and width. The ADON indicated a slight increase in size. Wound #2. Has decreased in length, but is still being incorrectly staged due to the slough. Wound #3. Has increased in length by 0.1 cm and is still incorrectly staged. Wound #4. Has decreased in length but increased in width and is incorrectly staged. According to the physician orders, the treatment was changed to two skin protectants and a foam covering dressing that is to be changed on Monday, Wednesday and Friday. ~10/7/15. Resident #7 has four wounds. Wound #1. The stage II wound has again increased in size to 2.0 cm by 1.5 cm, tripling in size and has deteriorated with a yellow thin slough. It is identified as an unstageable wound. Wound #2. The wound is the same size but is incorrectly staged. Wound #3. The wound is the same size but is also incorrectly staged. Wound #4. The wound is the same size but is also incorrectly staged. Wounds #2, #3, and #4 are still covered 100% with yellow slough and the treatment is still protectants and not a [MEDICATION NAME] agent. On 10/12/15 at 10:30 a.m., Surveyor # observed RN-J (Registered Nurse) do the treatment to Resident #7's ulcers. The skin on Resident #7's buttocks and coccyx was discolored with very dark pigmentation with five distinct white areas of scar tissue. Two of the scar tissue areas were open wounds (later found to be wounds #2 and #3) with a pink wound bed. Over the coccyx there was what appeared to be a 4 cm wide wound with a stringy slough covering (later found to be two separate wounds, #1 and #4) as there is a 0.1 cm line of skin separating this wound. RN-J cleansed the buttocks and coccyx area with normal saline and then sprayed the skin barrier film, [MEDICATION NAME], over the entire area and applied another skin protectant, Selan Plus, over the open areas and the wound covered with slough. RN-J then applied a foam dressing over the wounds. RN-J did not measure the wounds. The dressing was a [MEDICATION NAME]. [MEDICATION NAME] dressing is used to cushion and protect a wound. RN-J stated she had never seen the wound or had done the treatment before. Surveyor # reviewed the manufacturer's information of the two products: ~[MEDICATION NAME] - A sting-free, alcohol-free liquid barrier film that dries quickly to form a breathable, transparent coating on the skin, designed to protect intact or damaged skin from urine, feces, other body fluids, tape trauma, and friction. ~Selan Plus - For treatment and prevention of diaper rash and other rashes due to moisture, stage one pressure ulcers . The active ingredient is zinc oxide, a skin protectant. Neither of these products would remove the slough covering the wound. The removal of slough is needed to see the wound bed and to see the depth of the wound in order to determine the best treatment. RN-J told Surveyor # that before the treatment was done she had asked CNA-A and CNA-B (Certified Nursing Assistants) to lay Resident #7 in bed in order to change the dressing. RN-J stated the CNAs had told her the dressing had been off when they helped Resident #7 get dressed before breakfast. Of note is that Surveyor # observed Resident #7 up in his wheelchair since 7:30 a.m. Resident #7 sat for at last three hours without a dressing on the pressure ulcers. On 10/12/15 at 10:45 a.m., Surveyor # interviewed CNA-A. CNA-A stated the dressing was not on when Resident #7's cares were done that morning. She stated she had not informed the nurse and thought maybe CNA-B had. At 11:07 a.m. Surveyor # interviewed CNA-B. CNA-B stated she had not even known what the treatment for [REDACTED]. On 10/14/15 at 9:10 a.m., Surveyor # observed the ADON complete the treatment of [REDACTED]. The ADON is wound care certified. The ADON told the surveyor that the wound was originally a stage III but it was now covered with slough so it would be classified as an unstageable wound. The ADON completed the treatment as RN-J had done with the exception of spraying the [MEDICATION NAME] only on the surrounding skin and not over the unstageable wound. The ADON measured the wounds and found: ~Wound #1: L (length) 1.8 cm by W (width) 1.5 cm, completely covered in slough. This is a 0.2 cm decrease in length. ~Wound #2: L - 0.5 cm by W - 0.1 cm, with pink healing tissue. The wound is decreasing in size. ~Wound #3: L - 0.2 cm by W - 0.2 cm, with pink healing tissue. The wound is now twice the width it was the week prior. ~Wound #4: L - 2.2 cm by W 2.0 cm, completely covered with slough. This wound is now more than twice the length it was and 0.2 cm larger in width. The identification of the numbers of the wounds were confirmed by the ADON. The ADON was asked by Surveyor # if she thought the treatment was appropriate for an unstageable wound. The ADON indicated it was not, as the wound needed something to be debride it. The ADON stated she completed the treatment as it was ordered as that was her only choice and would call the resident's physician today to get the treatment changed after she did some research. Of note is that wounds #1 and #4 had deteriorated to unstageable ulcers on 10/7/15, the week prior, as assessed by the ADON and she had not changed the treatment then. The stage II wound on the buttocks, wound #2, has gotten smaller in the last week as the treatment of [REDACTED]. The stage II wound on the buttocks, wound #3, has gotten larger. The original stage III wounds, #1 and #4, have since worsened to unstageable wounds. There was very slight improvement for wound #1, from a length of 2.0 cm to 1.8 cm. However, wound #4 has more than doubled in length from 1.0 cm to 2.2 cm in length and 1.8 cm to 2.0 cm in width.

Based on observation, interview, and record review, the facility did not ensure that 2 of 7 sampled residents reviewed with bladder incontinence, received the necessary care and treatment to maintain and/or restore bladder function. Resident #6 and Resident #15 both had a decline in bladder function. The facility did not complete a comprehensive bladder assessment when the decline was identified. This would be necessary in order to determine causative factors of the decline to determine new strategies to improve both Resident #6's and Resident #15's continence status. This is evidenced by: Example #1: Resident #6 was admitted to the facility in April 2014. Resident #6's admission MDS (Minimum Data Set) was dated 4/29/14. The MDS indicated: ~Speech was clear, was understood and understands others; ~Had a BIMS (Brief Interview for Mental Status) of 15 indicating Resident #6 was cognitively intact; ~Required the assistance of 1 staff person for all aspects of care except; and ~Was occasionally incontinent of bladder. Surveyor # completed a review of Resident #6's most current MDS dated [DATE]. The MDS was noted as a significant change in condition MDS. The MDS indicated Resident #6 was now frequently incontinent of bladder. Resident #6's CAA (Care Area Assessment) for continence was dated 7/21/14. The CAA indicated Resident #6 had functional incontinence, had a decline in bladder function, and was frequently incontinent of urine. The CAA indicated staff were to assist Resident #6 to the bathroom every 2 hours. Resident #6 did not have a specific continence care plan. Noted within the problem identified as "...ADL (Activities of Daily Living) self-performance deficit..." dated 4/23/14, the care plan directed staff to assist Resident #6 to the bathroom every 2 hours. There were no updates to the care plan following identification of the decline in bladder status. Surveyor # requested Resident #6's admission comprehensive bladder assessment, as well as a comprehensive bladder assessment completed during the time frame of Resident #6's decline in bladder function. Surveyor # received a bladder assessment dated [DATE]. The assessment directed the user to check multiple areas of data regarding bladder function specific to Resident #6. The assessment indicated Resident #6 had functional incontinence. There was no evidence of a physical assessment. The assessment did not include a critical analysis of the data obtained. This would be necessary in order to determine and implement an individualized bladder program designed to maintain and/or improve Resident #6's continence status. Surveyor # received no bladder assessment during the time frame the facility identified Resident #6's decline in bladder function. A comprehensive bladder assessment would be critical in order to determine causative factors for Resident #6's decline and implement new strategies specific to Resident #6's needs to improve Resident #6's continence status. Surveyor # received a bladder assessment dated [DATE]. This was however received after the start of survey and after Surveyor # 's request for a bladder assessment. On 9/16/14 at 4:00 p.m., Surveyor # observed CNA-Q (Certified Nursing Assistant) assist Resident #6 to the bathroom. CNA-Q indicated to Surveyor # that Resident #6's continence status had deteriorated and Resident #6 was now "pretty much incontinent." CNA-Q assisted Resident #6 onto the toilet and changed Resident #6's brief. The brief was noted to be soiled. CNA-Q also indicated to Surveyor # that Resident #6 was a "heavy wetter." On 9/17/14 at 10:50 a.m., Surveyor # spoke with the DON (Director of Nursing). The DON indicated she was aware the facility had weaknesses in their Continence Management Program. Example #2: Resident #15 had current diagnoses, including but not limited to, dementia. Resident #15's most current MDS (Minimum Data Set) was dated 8/30/14 and indicated Resident #15 had both long and short-term memory problems, required extensive assistance of 1 to 2 staff persons for all aspects of care, did not walk, and was always incontinent of urine. Surveyor # completed a review of Resident #15's MDSs, dated 5/30/14 and 3/3/14. Both MDSs indicated Resident #15 was frequently incontinent of urine. Resident #15 had a decline in bladder function from being frequently incontinent to always incontinent. Resident #15's continence care plan was dated 3/26/14. The care plan directed staff to check and change Resident #15 every 2 hours. Surveyor # requested Resident #15's most current bladder assessment. Surveyor # received an assessment dated [DATE]. The assessment directed the user to check multiple areas of data regarding bladder function specific to Resident #15. The assessment indicated Resident #15 had overflow incontinence. The assessment did not include a physical assessment. The assessment did not include a critical analysis of the data obtained. This would be necessary in order to determine and implement an individualized bladder program designed to maintain and/or improve Resident #15's continence status. The assessment indicated Resident #15 had overflow incontinence. Overflow incontinence is characterized by leakage of small amounts of urine due to a full bladder. Overflow incontinence requires staff to monitor and manage Resident #15's bladder function in order to prevent complications from an over-distended bladder. There were no interventions on Resident #15's plan of care which directed staff to monitor or how to manage Resident #15's overflow incontinence. On 9/16/14 at 3:35 p.m., Surveyor # observed CNA-Q and CNA-R assist Resident #15 to the bathroom via a sit-to-stand lift. Once seated on the toilet, CNA-Q removed Resident #15's adult brief. CNA-Q indicated the brief was dry. Surveyor # noted Resident #15 voided while on the toilet. This was also noted by CNA-Q. CNA-Q obtained an adult brief as well as a large pad. CNA-Q placed the large pad inside of the brief. CNA-Q and CNA-R assisted Resident #15 to stand in the lift and assisted Resident #15 in pulling up Resident #15's brief and pants. Surveyor # asked why a large pad and adult brief were used for Resident #15. CNA-Q indicated it was because Resident #15 was a "heavy wetter." On 9/17/14 at 10:50 a.m., Surveyor # spoke with the DON (Director of Nursing). The DON indicated she was aware the facility had weaknesses in their Continence Management Program.

Based on observation, interview, and record review, the facility did not ensure that 4 of 7 sampled residents reviewed for psychoactive medications, had medications administered based on a comprehensive assessment to determine necessity and had a gradual dose reduction attempted in the presence of adverse reactions and/or adequate indication for use. Resident #6's admission orders [REDACTED]. Since admission, Resident #6 was placed on [MEDICATION NAME] (an antianxiety medication), [MEDICATION NAME] (a antidepressant medication), [MEDICATION NAME] sleep medication) for facility defined behaviors of stomach pain, shortness of breath, and sleep disturbance. None of the facility identified target behaviors are considered behavioral. All of the medications ordered have significant side effects. Prior to initiating these medications, there was no comprehensive assessment completed by the facility to determine the cause or what triggered the behavior. There was no care plan developed that included non-pharmacological measures to decrease and/or eliminate the behaviors. When Resident #6 began to show indicators of potential adverse reactions to these medications, including a decline in overall functioning, there was no comprehensive assessment completed by the facility. There was no consideration that medications were causing Resident #6's decline. There was no reduction of these medications. Instead, the facility increased Resident #6's [MEDICATION NAME] and [MEDICATION NAME]. Resident #6 subsequently had a significant decline in overall functioning and was placed on hospice. Resident #3 has been on [MEDICATION NAME] 25 mg for paranoid/anxiety/suspicious of others for 18 months ([DATE]) with only one gradual dose reduction on [DATE] when the [MEDICATION NAME] was decreased to 12.5 mg. Review of the behavior monitoring documentation since last survey of [DATE] through [DATE], indicated 3 documented events of being suspicious of others. After several requests, the facility did not submit any behavior monitoring documentation from [DATE] until [DATE]. The facility did not have interventions or quantitative/qualitative goals to determine if the medication was justified as a necessary medication. The pharmacist consultant did not identify the need for a gradual drug reduction. Resident #4 has been given a nightly antianxiety medication for [MEDICAL CONDITION] since October of 2013 without any assessment as to the quality and quantity of her sleep, any non-pharmacological interventions, no attempt at a gradual dose reduction, and no recognition by the pharmacist of this missing information. Resident #12's physician orders [REDACTED]. Resident #12's care plan did not contain measurable goals for evaluating the ongoing need for the medication. The facility did not have a system in place to monitor the effectiveness of the medication. This is evidenced by: Example #1: According to the "Nursing 2013 Drug Handbook," [MEDICATION NAME] is a medication given to prevent nausea and vomiting. Adverse reactions to the medication included: anxiety, drowsiness, restlessness, confusion, depression, hallucinations, [MEDICAL CONDITION] (inability to sleep), bowel disorders including diarrhea and nausea, and incontinence. According to the "Nursing 2013 Drug Handbook," [MEDICATION NAME] is a medication given for anxiety. Adverse reactions to the medication included: drowsiness, sedation, amnesia, [MEDICAL CONDITION], agitation, weakness, unsteadiness, disorientation, depression, nausea, and a change in appetite. Overdose signs and symptoms included drowsiness, confusion, lethargy, and ataxia (lack of muscle control during voluntary movements). According to the "Nursing 2013 Drug Handbook,"[MEDICATION NAME] a medication given for short-term treatment of [REDACTED]. According to the "Nursing 2013 Drug Handbook," [MEDICATION NAME] is an antidepressant. Adverse reactions included: ataxia, anxiety, [MEDICAL CONDITION], restlessness, drowsiness, weakness, hallucinations, delusion, disorientation, nausea, vomiting, anorexia, stomach pain, and diarrhea. the "Nursing 2013 Drug Handbook" also indicated, "...Alert (which was noted in red lettering)[MEDICATION NAME] one of the most sedating...antidepressants...Elderly patients may have an increased sensitivity...If signs or symptoms of [MEDICAL CONDITION] occur or increase, expect prescriber to reduce dosage..." Resident #6 was admitted to the facility in [DATE]. Admitting [DIAGNOSES REDACTED]. diabetes, [MEDICAL CONDITION] ulcer disease, and recent hospitalization for a [DIAGNOSES REDACTED] ulcer, [MEDICAL CONDITION] (blood clot) in the left lower extremity and PE (pulmonary emboli or blood clot in the lung). Resident #6's admission MDS (Minimum Data Set) was dated [DATE]. The MDS indicated Resident #6: ~ Speech was clear, was understood and understands others; ~ Had a BIMS (Brief Interview for Mental Status) of 15 indicating Resident #6 was cognitively intact; ~ Had no symptoms of [MEDICAL CONDITION]; ~ Had 1 mood indicator of feeling tired; ~ Had no behaviors; ~ Required the assistance of 1 staff person for all aspects of care except; ~ Ate independently; ~ Was steady at all times moving on and off the toilet and surface to surface transfers; ~ Was occasionally incontinent of bladder; ~ Weighed 116 pounds; and ~ Expected to be discharged back to the community. Resident #6's admission CAA (Care Area Summary) did not trigger behavior. Surveyor # completed a review of Resident #6's most current MDS dated [DATE]. The MDS was noted as a significant change in condition MDS. The MDS indicated Resident #6: ~ Had a BIMS score of 15; ~ Had mood indicators of feeling down, trouble sleeping, and feeling tired; ~ Required the assistance of 1 staff person for all aspects of care; ~ Weighed 118 pounds; ~ Was frequently incontinent of bladder; ~ Could not maintain balance without staff support; and ~ Had fallen. According to Resident #6's clinical record, staff, and Surveyor # observations at the time of survey, Resident #6 had also had a significant cognitive decline and had multiple falls. The MDS, dated [DATE], did not trigger behavior. The CAA for "ADL (Activities of Daily Living)/Rehabilitation Potential" dated [DATE] indicated, "...has had a significant change in condition due to the fact that she was admitted to hospice on [DATE]..." The CAA for Mood state, dated [DATE], indicated "...Resident has a [DIAGNOSES REDACTED]. Also on prn med for inability to sleep...stated she gets worrying about things...occasionally have complaints about medical issues and then will dwell on them...intermittent periods of anxiety...does better if staff provide attention..." Resident #6's care plan did not contain a specific behavior problem. The following approaches were scattered throughout the care plan: ~ [DATE], "...Monitor/Document/Report...adverse effects of Sedative/Hypnotic therapy: day time drowsiness, confusion, loss of appetite in the morning, increased risk of falls...Evaluate other factors potentially causing [MEDICAL CONDITION] to modify and control these external factors before initiating hypnotic therapy...report changes in usual routine, sleep patterns...report...loss of appetite, refusal to eat and weight loss..." ~ [DATE], "...Administer anti-anxiety medications as ordered...Monitor for side effects and effectiveness...Monitor for safety...is taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia...Monitor/document/report...any adverse reactions...Drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression...impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset...impulsive behavior, hallucinations..." ~ [DATE]. "...Staff will assist with diversional activities..." While the care plan directed staff to monitor for side effects of medications, there was no indication this had been done. None of the above approaches included non-pharmacological approaches based on Resident #6's specific needs. Surveyor # completed a review of Resident #6's physician orders [REDACTED]. ~ [DATE], on admission [MEDICATION NAME] 5 mg (milligram) four times a day was ordered. ~ [DATE],[MEDICATION NAME] mg was ordered as needed for [MEDICAL CONDITION]. ~ [DATE], [MEDICATION NAME] 0.25 mg was ordered once a day as needed for anxiety. On [DATE], the dose was increased to three times a day as needed. ~ [DATE], [MEDICATION NAME] 5 mg was ordered as needed for stomach pain and [MEDICAL CONDITION]. On [DATE], the dose was increased to once a day scheduled and once a day as needed. Surveyor # completed a review of Resident #6's MARs (Medication Administration Records) since admission and noted the following medications administered and number of times administered. ~ From admission to [DATE], Resident #6 received [MEDICATION NAME] as ordered. On [DATE], hospice recommended the medication be tapered off. Ambien ~ [DATE] - [DATE], 23 doses. ~ [DATE] - [DATE], 24 doses. ~ [DATE] - [DATE], 20 doses. ~ [DATE] - [DATE], 9 doses. [MEDICATION NAME] ~ [DATE] - [DATE], 10 doses. ~ [DATE] - [DATE], 9 doses. ~ [DATE] - [DATE], 20 doses. ~ [DATE] - [DATE], 17 doses. [MEDICATION NAME] ~ [DATE] - [DATE], 2 doses. ~ [DATE] - [DATE], 14 doses. ~ [DATE] - [DATE], 30 doses. ~ [DATE] - [DATE], 22 doses. Prior to initiating Ambien, [MEDICATION NAME], and [MEDICATION NAME], there was no indication the facility completed a comprehensive assessment to clinically analyze what the behavioral symptom actually was that required treatment, what the root cause of the symptom was, and identify what non-pharmacological interventions could be put into place to alleviate the symptom. There was no indication prior to Resident #6 receiving Ambien, [MEDICATION NAME], or [MEDICATION NAME] that non-pharmacological approaches based on Resident #6's specific needs, were attempted. Surveyor # completed a review of Resident #6's behavior tracking from [DATE] through [DATE]. The behavior tracking indicated staff were to monitor behavior symptoms of stomach pain, shortness of breath, and inability to sleep. Surveyor # noted the following: ~ From [DATE] to [DATE] there were no behaviors observed. ~ From [DATE] to [DATE] staff identified "wandering" 11 times. Stomach pain, shortness of breath, and [MEDICAL CONDITION] are not considered behavioral symptoms. Pain and shortness of breath are symptoms of a disease process. [MEDICAL CONDITION] is a diagnosis. Wandering in and of itself is not a behavioral symptom. There was no indication the facility had a process in place to quantify behaviors. On [DATE], Resident #6 was admitted to hospice. Surveyor # completed a review of hospice progress notes and noted the following: ~ [DATE], "...wishes to be DNR (do not resuscitate)...Terminal Diagnosis: [REDACTED]. ~ [DATE], "...pain...occasional...per staff, patient had episodes of diarrhea...Wt (Weight) 117 lbs (pounds)...Ambulation Distance: ,[DATE] ft (feet)...Orientation: Self...Place...verbal...Anxiety: mild...Sleep pattern: ,[DATE]/day (12 to 14 hours per day)...Unable to identify day or week or weekend events...increased forgetfulness...Staff report increase of anxious episodes and forgetfulness..." According to the hospice notes, the facility identified Resident #6 was having diarrhea, had increasing episodes of anxiety, was more forgetful, and was sleeping for extended periods of time. These symptoms were all possible side effects from the medications Resident #6 was receiving. There was no comprehensive assessment completed. Hospice progress notes continue: ~ [DATE], "...pain...occasional...confused/disoriented...Sleep pattern: ,[DATE]/day per staff...patient seemed very disoriented/confused at visit...Staff reports significant cognitive decline past 2 wks (weeks)...increase hours slept. Is more sleepy...increase confusion/disorientation over past 2 wks...Patient sleeping in bed. Aroused easily to voice...very confused and disoriented...Unable to carry on conversation unable to process what writer saying..." In addition to the symptoms as noted above, Resident #6 was now showing a significant decline in cognition. There was no comprehensive assessment completed to determine the potential cause of Resident #6's decline. Hospice progress notes continue: ~ [DATE], "...denies pain...decrease distance able to walk...Anxiety: 0 (none) observed...Responsiveness: verbal/delayed...Affect: lethargic/flat...Sleep pattern: 14 - 16 /day per staff - sleeps all day...but only ,[DATE] hours at a time...Patient increasingly confused and lethargic over past 2 wks...found sitting on floor in hall...Patient c/o (complains of) increased tired slept throughout assessment...decreased ability/distance ambulate...Requires more cues to eat...verbalized fatigue and proceeded to sleep through 95% of assessment..." ~ [DATE], "...Pain...occasionally...States 'not very hungry,' Per staff eating less...patient fell [DATE]...increase of sleeping to 16 - 18 hours/day per staff...may be d/t (due to) urinary infection...eating less for 3 of 3 meals...increase hours of sleep...fall...Require assist...to transfer/amb (ambulate). Only required SBA (stand by assist)...hospice admit...speech is non-sensical at times...Writer made visit d/t staff reports of increased confusion and unwitnessed fall..." ~ [DATE], "...Pain...occasionally...Now weighs 109.4# (pounds). Was 117.8# on [DATE]...fall x 2 (two times)...Unable to support weight with transfers. Independent in ADLs (Activities of Daily Living) [DATE]...Confusion...improved since ATB (antibiotic) started..." In addition to the symptoms as noted above, Resident #6 now had fallen several times, and had a weight loss. Despite all of the symptoms as described indicative of potential medication side effects, there was no indication a comprehensive assessment was completed by the facility. Hospice progress notes continue: ~ [DATE], "...weight...now 109...Patient unable to remain awake at visit. Continues to sleep 16 - 18 hours/day...increased confusion and disorientation...request for med (medication) review..." Despite the continued and progressive decline in Resident #6's overall functioning, this was the first time medications were addressed as potential causative factors for Resident #6's significant decline since the medications were started. Additionally, the request for a medication review was done at the request of hospice. On [DATE] at 11:15 a.m., 1:15 p.m., 2:00 p.m., and 2:15 p.m., Surveyor # noted Resident #6 sleeping on a love seat in the day room area next to the nursing station. On [DATE] at 7:15 a.m., Surveyor # noted Resident #6 sleeping on the love seat in the day room area next to the nursing station. On [DATE] at 8:35 a.m., 11:05 a.m., and 12:00 p.m., Surveyor # noted Resident #6 sleeping in bed. On [DATE] at 2:20 p.m., Surveyor # noted Resident #6 sleeping on the love seat near the nursing station. On [DATE] at 11:15 a.m. during the initial tour of the facility, CNA-P (Certified Nursing Assistant) indicated to Surveyor # that Resident #6 was prone to falls, was very confused, "didn't know one minute to the next," and had declined since admission. On [DATE] at 12:10 p.m., Surveyor # spoke with RN-T (Registered Nurse). RN-T indicated she worked full time on the unit where Resident #6 resided. Surveyor # asked RN-T the facility's practice for behavior monitoring. RN-T stated the nurses initiate target behavior monitoring based on the reason a medication was ordered. RN-T stated the nurses chart all behaviors based on what they see and what the CNAs tell them. On [DATE] at 3:55 p.m., Surveyor # spoke with CNA-Q about Resident #6. CNA-Q stated Resident #6 was very "with it," liked to walk, and liked to be around other people when first admitted . CNA-Q stated Resident #6 had "gone down hill quickly" in the last couple of months. On [DATE] at 4:35 p.m., Surveyor # spoke with LPN-S (Licensed Practical Nurse). Surveyor # asked LPN-S her thought of why Resident #6 had such a dramatic decline in functioning. LPN-S stated she did not know why. LPN-S stated Resident #6 was alert, oriented, and could carry on a conversation when first admitted . LPN-S indicated she thought Resident #6 was on [MEDICATION NAME] for stomach pain. LPN-S stated she was not sure if Resident #6 was on [MEDICATION NAME] for sleep or for anxiety. LPN-N indicated Resident #6 was [MEDICATION NAME] sleep. On [DATE] at 8:35 a.m., Surveyor # spoke with RN-T about Resident #6. RN-T stated Resident #6 had a progressive decline and has gotten "worse and worse" since admission. RN-T stated she was not sure why. On [DATE] at 10:30 a.m., Surveyor # spoke with RN-T again. RN-T stated Resident #6's behavior was "restlessness." RN-T also stated Resident #6 used to have a lot of health complaints including Resident #6's stomach hurting. RN-T stated she has however, not heard Resident #6 complain of stomach pain in the recent past. RN-T stated Resident #6 was on [MEDICATION NAME] and [MEDICATION NAME] for restlessness [MEDICATION NAME]. RN-T stated Resident #6 sometimes gets "really sleepy from [MEDICATION NAME]." RN-T stated she didn't feel she had seen much improvement in Resident #6's restlessness from the increased dosage of [MEDICATION NAME]. RN-T stated Resident #6's restlessness had gotten worse and Resident #6 was "up and down" more. RN-T stated Resident #6 used to be able to do many more things independently. RN-T also indicated when Resident #6 was admitted , it was for short term care. Surveyor # asked RN-T why Resident #6's medications had not been addressed in relation to Resident #6's decline in function with either the pharmacist or physician. RN-T stated she was not sure. RN-T indicated she had requested hospice look at resident's medications. On [DATE] at 10:50 a.m., Surveyor # spoke with the DON (Director of Nursing). The DON indicated the facility had identified issues within their Behavior Management Program and use of psychoactive medications. The DON indicated the facility had created an action plan to address the issues. Surveyor # requested information regarding the facility recognizing and addressing Resident #6's medications in relation to Resident #6's decline. On [DATE] at 3:15 p.m., the DON approached Surveyor # and indicated the facility had not completed a medication review, nor clinical review of Resident #6's medications. The DON indicated the first review was completed by hospice. Example #2: Resident #3 has [DIAGNOSES REDACTED]. The MDS assessment, dated [DATE], indicated Resident #3 is mildly depressed, has no behaviors, receives an antipsychotic and an antidepressant medication, and has no delusions or hallucinations. Review of physician orders [REDACTED]. The first and only gradual dose reduction was on [DATE], when the physician lowered the dose to 12.5 mg. In the first 12 months after initiating an antipsychotic medication, the facility must attempt a gradual dose reduction in 2 separate quarters. There was no evidence that this was attempted. Review of the CAAs (Care Area Assessments), dated [DATE], for [MEDICAL CONDITION] Drug Use was not completed. Under the care plan consideration to describe the impact of this problem/need on the resident and rationale for care plan decision states, "Continue monitoring resident psychiatric drugs use and effectiveness of the drugs on res (resident) anxiety and depressions." Review of the behavior monitoring sheets from [DATE] to [DATE], indicate only 3 episodes over a years time of being suspicious of others: [DATE] at 1:41 p.m., [DATE] at 12:00 p.m., and [DATE] at 4:45 p.m. There was no justification for the [MEDICATION NAME] medication. There was no rationale why Resident #3 was receiving a Black Box Warning Drug without any documented behaviors for the need of the medication. Review of the care plan date initiated: [DATE], revision on [DATE]. "Focus: The resident uses antidepressants & antipsychotic medication r/t (related to) depression & anxiety." Interventions include: Administer Antidepressant & Antipsychotic medications as ordered by physician. Monitor/document side effects and effectiveness every shift." initiated [DATE]. Revision on: [DATE]. "...Target Behaviors: feeling blue, tearful, loss of appetite, paranoid, suspicious of others. Offer conversation, talk about grandkids, provide snacks, encourage activity participation." There was no specific intervention for the [MEDICATION NAME] and no quantitative or qualitative goals to determine if the [MEDICATION NAME] is needed, or should be increased or decreased. During the time of survey, Surveyor # observed Resident #3 throughout the day with no behaviors of being suspicious of others or paranoid. Resident #3 was alert, oriented to name, and could make her needs be known. On [DATE] at 11:19 a.m., Surveyor # spoke with CNA-D who cares for Resident #3. CNA-D stated Resident #3 is a very nice lady. She has her good days and some days she is so tired and sleeps all day. CNA-D said Resident #3 does talk about her kids in school and has no real behaviors. Surveyor # spoke with the Assistant Director of Nurses who stated the facility/interdisciplinary team is working on a behavior management team and maybe should have the meeting more than quarterly. Example #3: Resident #4 has been a resident of the facility since [DATE]. Her [DIAGNOSES REDACTED]. Her latest Minimum Data Set (MDS) assessment, dated [DATE], indicated she receives an antianxiety on a daily basis, has significant cognitive impairments and memory deficits (her Brief Interview for Mental Status(BIMS) score was ,[DATE]), and is able to transfer herself to and from her wheelchair independently. Resident #4's physician orders [REDACTED]. The order asks staff to update the physician in 1 week as to how the resident is sleeping. Review of the nursing notes regarding sleep found: ~[DATE] "Sleep Hygiene Assessment. Unable to assess, has no documented responses to question of whether she feels rested in the AM. Will have asked the next 7 mornings." ~[DATE] "Sleep Hygiene Assess: Feels rested 5 of 7 days. Sleep changes do not interrupt usual activities. Is on [MEDICATION NAME] .25 mg daily at 8:00 p.m. There are no environmental factors, and no signs or symptoms present. Non-medicated approaches are unknown, but the summary is that Resident #4 is well rested." This is the last notation in the nursing notes related to any type of sleep assessment. There is no monitoring of the effectiveness of the medication in terms of the quantity and quality of her sleep on the medication. There is no documentation of Resident #4's sleep goals in terms of how much she would like to sleep. There is no evidence of exploration of non-pharmacological approaches to enhance her sleep. There is no interview with her as to her life long sleep patterns, if the environment affects her sleep, if pain or worries keep her awake, and any trouble staying awake during the day. In addition, the pharmacist's monthly reviews since her admission has no identification of this missing information. Example #4: Resident #12 was admitted on [DATE] with a [DIAGNOSES REDACTED]. According to Resident #12's sleep assessment completed on [DATE], Resident #12: ~ Does not feel rested 5 of 7 days; ~ Has a history of sleep disorder; ~ Has anxiety; ~ Has frequent awakenings; ~ Gets up and dressed between 1:00 a.m. and 3:00 a.m. by request; and ~ Has Non-Medication Approaches that include: provide snacks, individualized toileting, reposition for comfort, and offer reassurance. According to Resident #12's sleep assessment completed on [DATE], Resident #12: ~ Feels rested 5 of 7 days; ~ Sleep changes do not interrupt his usual activities; ~ Has a history of sleep disorder; ~ Has impaired physical function; ~ Has multiple medication used; ~ Has anxiety; and ~ Has Non-Medication Approaches that include: usual bedtime, back rub, and provide snacks. Resident #12's care plan includes a focus of uses antidepressant medication related to [MEDICAL CONDITION] with complaint of inability to sleep. Interventions include: Administer medications...Monitor /document side effects and effectiveness..., staff to offer conversation, allow to make simple decisions, offer gentle reminders, offer activity, involve family, assist him with using the phone. The care plan does not have a measurable goal related to quality and quantity of sleep. The care plan does not include non-medication approaches identified in Resident #12's sleep assessments such as: provide snacks, individualized toileting, position for comfort, usual bedtime and back rub. Resident #12's Medication Administration Record [REDACTED] [DATE] time. [DATE] times. [DATE] time. [DATE] times. [DATE] tmes. [DATE] times. February 2014, 17 times. [DATE] times. [DATE] times. [DATE] times. [DATE] times. Resident #12 expired [DATE]. Although Resident #12's MAR indicated [REDACTED]. On [DATE] at 12:10 p.m., Surveyor # spoke with the Director of Nursing (DON) regarding Resident #12's use of [MEDICATION NAME] for sleep, his care plan and the facility's process for monitoring the effect of the medication. The DON indicated the care plan did not include a measurable goal related to sleep and lacked interventions. The DON also indicated there was no system in place to evaluate the effectiveness of the medication. The DON expressed she would check Resident #12's medical record for other means of monitoring the effectiveness of the medication. No additional information was received.

Based on observation, interviews and record, the facility failed to provide care to prevent further pressure ulcers from developing for 1 resident (Resident #6) of 11 sampled residents reviewed for pressure ulcers. Resident #6 has a history of pressure ulcers. Resident #6 had 2 healed Stage 2 pressure ulcers and had a current Stage 3 pressure ulcer. The facility did not implement approaches to prevent the redevelopment of the pressure ulcers or to promote the healing of the Stage 3. On 8/27/13, staff identified that a previously healed pressure ulcer had reopened. In addition, the Wound Clinic had ordered [MEDICATION NAME] cream to be applied around Resident #6's Stage 3 dressing two times a day. The order was not transcribed onto the MAR (Medication Administration Record), TAR (Treatment Administration Record) or care plan. There was no evidence that the treatment was being provided. This is evidenced by: Resident #6 has [DIAGNOSES REDACTED]. The most current MDS (Minimum Data Set) Assessment, dated 6/20/13, indicated Resident #6: ~Has a BIMS score of 12 indicating a moderate cognitive impairment; ~Requires extensive assistance of 2 staff for bed mobility and transfers; ~Does not walk; and, ~Has 1 Stage 2 pressure ulcer, 1 Stage 3 pressure ulcer and 2 suspected DTI (deep tissue injury) due from MASD (moisture associated skin damage). Resident #6 was being followed by the wound clinic for treatment of [REDACTED].#1 on the coccyx measures (Length x Width x Depth in centimeters) 1.5 x 0.4 x 0.4 and was a Stage 3. Wound #2 coccyx was healed. Resident #6's nurse's note dated 8/2/13 states, "Stage 3 pressure ulcer to coccyx was .3cm (sic) in length, .3 cm > (greater) in width and .2 cm < (less) in depth this week than last...Two stage 2 pressure ulcers between rectum and coccyx are healed...Toileting and repositioning q (every) 2 hours. Low air loss mattress on bed. Side to side lying when in bed. Roho cushion in w/c. float heels off bed. Bilateral heel lift boots when in bed. HOB 30 degrees when in bed..." Resident #6's care plan dated 4/27/13 includes a problem of "Skin Integrity" updated on 8/6/13 to include, "Healed Stage 2...above rectum. Healed Stage 2 open area next to slit. Stage 3...coccyx." Approaches include assess and measure the area weekly, roho cushion, wound clinic evaluation and treatment. There were no changes in the care plan to prevent the redevelopment of the 2 previously opened areas between the rectum and the coccyx. Resident #6's undated CNA (Certified Nursing Assistant) Communication Sheet included approaches of "Maintain hydration, specialty mattress low air loss, keep off coccyx, and roho cushion." 8/6/13 nurse's note states, "Stage 3 coccyx, length/cm: 1.5 same as 2 weeks ago, Width/cm: .6 was .8 cm last week, depth/cm: .3 same as last week...Wound not healing to coccyx. Measurements approx (approximately) the same the last couple of weeks...Continue current plan of care." There were no changes made to Resident #6's care plan to promote the healing of the Stage 3. Wound Clinic note dated 8/13/13, states Wound #1, measures 1.5 x 0.4 x 0.3, and was a Stage 3. Resident #6's treatment to the wound was changed. The Wound Clinic also wrote, "...Only up for meals. Turn patient every hour or more as needed to avoid pressure to coccyx. Prop patient with a pillow behind her back to assure that she stays on her side." The facility continued to assess and document Resident #6's Stage 3 pressure ulcer on the coccyx. The wound showed little progress towards healing. There were no changes to Resident #6's care plan. The plan after each assessment stated for staff to "continue current care plan." On 8/27/13, nurse's notes document the coccyx wound (Wound #1) measures 1.4 x 0.5 x 0.5 (increased in size) and is a Stage 3. The note also states, "Stage 2. Coccyx, reopen distal to wound #1. Length/cm: 1 (1.0), width/cm: 0.3, depth/cm: 0.1...Continue current plan of care, wound clinic manages wound care..." There were no updates to Resident #6's care plan to address lack of healing of the Stage 3 or the redevelopment of the Stage 2. On 8/27/13, Resident #6 was seen at the wound care clinic. The updated orders included, "Apply [MEDICATION NAME] cream around dressing twice daily, including inferior gluteal area..." The August TAR includes, "Lotion with [MEDICATION NAME] around dressing..." dated 8/28/13. It does not include frequency of two times per day. The treatment was not signed as being completed on 8/28/13 through 8/31/13. On 8/29/13, Resident #6 was put on "Comfort Care." The physician's orders [REDACTED]. D/C all meds except [MEDICATION NAME] and [MEDICATION NAME]" The orders did not include to discontinue treatments of the pressure ulcers. The September TAR did not include the order for [MEDICATION NAME] two times a day around the pressure ulcer dressing. On 9/5/13 at 9:12 a.m., Surveyor # observed the facility WCN (Wound Care Nurse) changing dressings and measuring Resident #6 pressure ulcers. The WCN did not apply [MEDICATION NAME] Cream around the dressing, including the inferior gluteal area as ordered. This order was not on the MAR indicated [REDACTED]. Wound #1 has declined to 1.5 x 1.0 x 0.7 (wider and deeper), Wound #2 measures 1.0 x 0.7 x 0.1 (wider and deeper). Surveyor # also observed an abrasion dot on left inner buttock; a 3.0 x 0.4 superficial open area on right inner buttock; a 3.0 x 8.0 red area that is blanchable; and, a 9.0 x 5.0 cm purple color bruise seen on the right buttock area. On 9/5/13 at 9:48 a.m., Surveyor # asked the WCN how the CNAs know how often to reposition Resident #6 as there is no direction in their communication sheet. The WCN stated that it is the standard to reposition residents every 2 hours unless otherwise directed. On 9/5/13, Surveyor # spoke with the NHA and the WCN regarding Resident #6. The NHA stated Resident #6 was placed on comfort care on 8/29/13 and on that same date, the Wound Care Clinic visits were also discontinued. The NHA stated the nurse decided that since the Wound Care Clinic was discontinued, so were the treatments that they had previously ordered.

Based on observation, interview, and record review, the facility failed to provide care to prevent the development of pressure ulcers, promote the healing of pressure ulcers and/or prevent the development of infection resulting in the development of an avoidable Stage 4 pressure ulcer with systemic infection for 1 resident (Resident #4) of 9 sampled residents reviewed for pressure ulcers. In addition to the resident in immediate jeopardy, the facility failed to prevent the development of and promote the healing of pressure ulcers resulting in harm that is not immediate jeopardy to an additional 2 of 9 sampled residents (Residents #5 and #6). Resident #4 was admitted to the facility with newly diagnosed [MEDICAL CONDITION]. On admission to the facility, Resident #4's skin was intact. On admission, Resident #4 had a pressure relieving standard mattress and a pressure relieving cushion in the wheelchair. On 4/5/13, Resident #4 was identified as having IAD (Incontinent Associated [MEDICAL CONDITION]). From 4/5/13 through 5/4/13, Resident #4's skin condition significantly deteriorated, including the development of a suspected DTI (Deep Tissue Injury) on the left sacrum. During this period of time, there were inaccurate skin risk assessments, no evidence of a daily assessment of Resident #4's wounds, no timely documentation including staging and wound characteristics, and no new or timely interventions added to Resident #4's care plan consistent with Resident #4's needs. Resident #4's physician and PA (Physician Assistant) were in the facility every day Monday through Friday. Despite this, staff did not request either the physician or PA to visualize Resident #4's pressure ulcer. The physician indicated he was unaware of the significant deterioration of Resident #4's pressure ulcer. On 4/24/13, Resident #4's pressure ulcer was showing signs and symptoms of an infection. A wound culture obtained indicated Resident #4's pressure ulcer was infected [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus), [MEDICATION NAME] faecalis and pseudomonas. Resident #4 was subsequently started on both oral and topical antibiotics. On 5/1/13, Resident #4 began showing symptoms of infection including fever and chills. On 5/4/13, Resident #4 was admitted to the hospital and diagnosed with [REDACTED]. The pressure ulcer was subsequently surgically debrided to a stage IV with tunneling and visible bone. The facility did not: ~ Assess Resident #4's skin risk assessment accurately; ~ Implement timely interventions to Resident #4's plan of care; ~ Implement interventions based on Resident #4's specific needs; ~ Identify Resident #4 as having a pressure ulcer; ~ Update Resident #4's care plan with new interventions to direct staff on how to manage the pressure ulcer; and ~ Assess Resident #4's pressure ulcer according to current standards of practice including timely documentation, staging, characteristics of both the wound and peri-wound. The immediate jeopardy began on 4/15/13, the date the deep tissue injury developed on Resident #4's left sacrum. The NHA (Nursing Home Administrator) was notified of the immediate jeopardy at 11:30 a.m. on 7/12/13. The immediate jeopardy was removed on 7/13/13 but noncompliance remains at the lower scope and severity of G (actual harm that is not immediate jeopardy/isolated) as evidenced by the following examples and by the fact that the facility must fully implement their corrective plan. Resident #5 was readmitted to the facility at risk for the development of pressure ulcers. On 4/4/13, a stage II was identified on Resident #5's coccyx. A nutritional supplement was added, however, no other interventions were implemented to promote the healing of the existing pressure ulcer or to prevent the development of additional pressure ulcers. The coccyx ulcer increased in size and worsened to a stage III with no new interventions. On 5/31/13, Resident #5 developed a new stage II to the left buttock. On 7/10/13, Resident #5 developed a new stage II to the right buttock. No new interventions were developed following these changes in condition. A continuous observation revealed Resident #5 sat for 3 hours and 40 minutes without offloading of the buttocks and coccyx. Resident #6 had pressure ulcers to the coccyx and gluteal cleft, which reopened on 10/15/12 as stage II and deteriorated to stage III before healing in May 2013. The facility did not implement any new preventative interventions after the pressure ulcer was healed. Resident #6 has an order for [REDACTED]. On 6/4/13, the stage II redeveloped and deteriorated to 2 stage III pressure ulcers as of 7/9/13. This is evidenced by: Professional standards of practice for the prevention and treatment of [REDACTED]. In the EPUAP/NPUAP (European Pressure Ulcer Advisory Panel/National Pressure Ulcer Advisory Panel) "Clinical Practice Guidelines for Prevention and treatment of [REDACTED]. Continue to turn and reposition the individual regardless of the support surface in use. Establish turning frequency based on the characteristics of the support surface and the individual's response." According to the EPUAP and NPUAP, "Pressure Ulcer Prevention Quick Reference Guide," a pressure ulcer is an area of localized injury over a bony prominence which results from pressure and/or sheering. The EPUAP and NPUAP indicate to monitor a pressure ulcer daily and assess any pressure ulcer at least weekly identifying the stage, location, wound characteristic, including the wound bed and periwound and any exudate. Example #1: Resident #4 was admitted to the facility on [DATE] after being hospitalized for [REDACTED]. Resident #4's historical [DIAGNOSES REDACTED]. Resident #4's admission MDS (Minimum Data Set), dated 4/3/13, indicated Resident #4: ~Had a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment; ~Required extensive to total assistance of 1-2 staff persons for bed mobility transfers, and toileting; ~Did not walk; ~Was occasionally incontinent of bladder and always incontinent of bowel; ~Weighed 340 pounds; ~Was at risk for the development of pressure ulcers; ~Had no pressure ulcers and no other ulcers, wounds, or skin problems; and, ~Had a pressure-reducing device for the bed. Resident #4's CAAs (Care Area Assessment) summary, dated 4/9/13, did not contain a specific skin CAA. The pain, incontinence, and ADL (Activities of Daily Living) CAAs, all dated 4/9/13, indicated Resident #4 had progressive weakness of the lower extremities, inability to use legs, frequent bowel and bladder incontinence, and a rash to the back and buttocks. All CAAs indicated a care plan would be developed. Resident #4's skin care plan, dated 4/5/13, had the following approaches: ~ 3/28/13, "...Assist with positioning q (every) 2 hours and PRN (as needed)...CNA (Certified Nursing Assistant) Skin Inspection: weekly..." Surveyor # requested Resident #4's admission CNA care plan. On 7/12/13 at 8:00 a.m., Surveyor # received an untitled form from the DON. The DON indicated their computer system would not allow them to print past CNA care plans, but this document listed all the items that would have been on Resident #4's admission CNA Care Plan. Surveyor # completed a review of the form received by the DON. The skin care approaches included those as noted above. The form also included an intervention dated 3/28/13, which directed staff to use the Ergo slide (plastic-type sheet) for positioning. Surveyor # completed a review of Resident #4's skin risk assessments. The risk assessments dated 3/28/13, 4/4/13, 4/10/13, 4/17/13, and 4/25/13, all indicated Resident #4 either had no or slightly limited sensory perception. Surveyor # questioned the accuracy of the skin risk assessments due to Resident #4's lower extremity paralysis. Resident #4's nurse's notes included an entry on 3/28/13 which stated, "...Skin...Groin pink...R (right) buttock cheek small scratch...no pressure ulcers..." The next nurse's note to reference skin integrity was on 4/5/13, "...has new IAD (Incontinence Associated [MEDICAL CONDITION]) to bilateral buttock R>L (right greater than left)...Reposition every 1 hr (hour)...Control incontinence side-to-side while in bed, up for therapy only..." On 4/5/13, Resident #4's care plan was updated to include up for therapy only. However, repositioning every hour and side-to-side turning while in bed was not added to Resident #4's care plan. Review of the list of items included on the CNA care plan found that side-to-side turning, repositioning every hour, and up only for therapy was not added to Resident #4's CNA care plan. There were no further nursing notes regarding Resident #5's skin until 4/15/13 which stated, "...Suspected Deep Tissue Injury...Location Left buttocks, mid...Length/CM (Length per centimeter) 1.9, Width/CM: 1 (1.0), Depth/CM: closed...Wound perimeter: Attached, IAD present Wound Bed: dark purple in color...Necrosis present...Eschar...Firmly adherent...Pain: No resident unable to feel due to spinal stenosis...Incont (Incontinent) Associated [MEDICAL CONDITION]: Yes...left buttocks...Length/CM: 11 (11.0) Width/CM: 7 (7.0), Depth/CM: 0.1...beefy red moist...Unstageable DTI mid left buttocks. Surround tissue is denuded skin due to IAD...refer to wound clinic if needed...Resident can't feel the urge to void. Is incont (incontinent) of bowel and bladder. Needs staff assist with repositioning and toileting q (every) 2 hours...no sensation to buttocks and legs due to spinal stenosis and hx (history) of lumbar laminectomy...check, change and reposition every 2 hours ...Assess for s/s (signs and symptoms) of infection, side to side lying when in bed, sling out of W/C (wheelchair) when up, up for therapy only. Float heels off bed...Requested a low air loss mattress for bed. Panacea cushion in W/C..." The above entry indicated Resident #4 should be checked and changed related to incontinence and repositioned every 2 hours. This intervention was previously implemented and found to be unsuccessful in preventing development of a pressure ulcer. A previous recommendation indicated repositioning should be completed hourly. On 4/16/13, Resident #4's care plan was updated to include "...Speciality Mattress - low air loss..." A nursing note, dated 4/18/13, indicated a low air loss mattress was implemented. This was 13 days after Resident #4 developed skin problems. Resident #4's care plan was updated on 4/18/13 to include "...HOB (head of bed) elevated < (less than) 30 degrees, Keep heels off bed..." However, repositioning every hour and side-to-side turning while in bed was again not added to Resident #4's care plan. The list of CNA care plan items indicated the CNA care plan was again not updated to include the approaches of side-to-side turning, repositioning every hour, and up only for therapy. There were no further nursing notes regarding Resident #4's pressure ulcer until 4/24/13 which stated, "...Suspected Deep Tissue Injury...Left buttocks, - mid...Length/CM: 1.4, Width/CM: 1 (1.0)...not open...[DIAGNOSES REDACTED] present...Incont Associated [MEDICAL CONDITION] buttocks...Length/Cm: 10.2, Width/CM: 4 (4.0), Depth/CM: .1 (0.1)...Moist, Beefy red, mixed with slough...Drainage: Large...sero sang (sero-sanguineous) mixed with sero purulent...IAD to left buttocks was worse this week...Wound culture obtained...DTI now yellow in color...roho cushion on order..." An entry on 4/26/13 stated, "...Skin Committee Meeting Note...IAD to left buttock had s/s of infection this week. Outer layer of skin was off, area was non-healing. Black covering to left upper buttock was off and area was yellow slough in color. Wound culture obtained...Results [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus), [MEDICATION NAME] faecalis & (and) psuedamonas (sic)..." Resident #4 was started on topical and oral antibiotics. The condition of Resident #4's pressure ulcer had further deteriorated. There were no new interventions put into place. Nurse's note on 4/30/13 stated, "...Suspected Deep Tissue Injury - No - turned out to be an infection...Left buttock, inner...healing has divided into two...distinct areas. #1 upper Length/CM: 6 (6.0), Width/CM: 2.5, Depth/CM: .2 (0.2)...slough...#2 lower...Length/CM: 3.4, Width/CM: 2 (2.0), Depth/CM: .1...Healing IAD left inner buttocks [MEDICAL CONDITION] infection..." There were no further nursing notes describing Resident #4's pressure ulcer even though it is now open and unstageable due to the presence of slough (non-viable tissue). Resident #4's care plan was updated on 4/30/13 to include a Roho cushion in the wheelchair. This was 25 days after the facility identified Resident #4's skin problems/pressure ulcers. Nursing notes continue:~ 5/1/13, "...Shaking: yes...Nausea: Yes...Abdominal Pain: All over general abdominal...Dark urine...Temperature: 100.6..." ~ 5/2/13, "...Diaphoretic: Yes...Pressure Sore...Yes...left buttocks pressure ulcer/MRSA...nausea...Temperature...99.3..." ~ 5/3/13, "...Temperature...101.1...stated he has had flank pain all week..." On 5/4/13, Resident #4 was admitted to the hospital. The admission "History and Physical" dated 5/4/13 indicated, "...chills, fever, as well as sweats...admits to having nausea...Skin: Examination shows a stage 3 gluteal ulcer on the left side. There is no other rash except as described over his gluteal area...Assessment...infected sacral decubitus ulcer. Rule out underlying osteo[DIAGNOSES REDACTED]..." Surveyor # completed a review of hospital wound notes and noted the following: ~ 5/4/13, "...Initial assessment date: 5/4/13...L (left) buttock... Granulation...Y (yes)... Slough...Y... Exudate: Purulent Amount: Moderate to heavy Surrounding skin...Intact:Y [MEDICAL CONDITION]: Y [DIAGNOSES REDACTED]: Y Induration: Y Maceration: Y... Etiology: Pressure Wound classification: Infected wound..." ~ 5/5/13, "...Length cm 15.0...Width cm 8.0...L buttock..." Resident #4 was started on IV (intravenous) antibiotics to treat the infection in the pressure ulcer. On 5/8/13, Resident #4 was transferred to another hospital. According to a "Discharge Summary" dated 6/5/13, the transfer was necessary for treatment of [REDACTED]. The "Discharge Summary" also indicated on 5/13/13, Resident #4's pressure ulcer was surgically debrided. The "Discharge Summary" indicated, "...debridement to include subcutaneous tissue of 180 square cm x (by) 6 (6.0) cm deep..." Resident #4 was hospitalized for [REDACTED]. Resident #4's care plan for skin integrity, dated 6/5/13, included the following approaches: ~Treatment as ordered wound VAC dressing change M-W-F (Monday, Wednesday, Friday). ~Speciality Mattress - low air loss. ~CNA Skin Inspection weekly. ~Float heels. There is no direction for repositioning in the wheelchair or bed, no direction for a wheelchair cushion, and no indication if time sitting up should be limited to alleviate pressure to the buttocks. On 7/10/13 at 11:25 a.m., Surveyor # observed LPN-K (Licensed Practical Nurse) and LPN-I complete a dressing change on Resident #4's pressure ulcer. Surveyor # observed a left sacral wound which visually measured approximately 6.0 cm in diameter and approximately 4.0 cm to 5.0 cm deep at the deepest point. Bone was visualized at the deepest point. The walls of the ulcer were beefy red with small amounts of scattered yellow slough. At the 12:00 o'clock position, there was tunneling according to LPN-I at 6.0 cm. At the 6:00 o'clock position, there was also tunneling according to LPN-I at 2.0 cm. (Tunneling is ongoing tissue damage under the skin that extends from the visible wound.) At the 3:00 o'clock position, there was an area measuring approximately 1 cm of light purple skin. The wound was surrounded by excoriation. LPN-I indicated the area of excoriation was a yeast infection currently being treated with anti-fungal medications. On 7/10/13 at 9:45 a.m., Surveyor # spoke with LPN-K. LPN-K worked on the unit where Resident #4 resided. LPN-K indicated the facility had a wound nurse. LPN-K indicated the wound nurse did all the weekly wound rounds including documentation of wounds. LPN-K indicated the nurses working the floor did not do any measurements unless a new wound was brought to their attention. LPN-K stated the floor nurses were responsible to document the new wound and then notify the wound nurse. LPN-K stated from that point, the wound nurse would follow any wound. On 7/10/13 at 9:46 a.m., Surveyor # spoke with Resident #4. Resident #4 indicated he was unsure of when the pressure ulcer on his sacrum started. Resident #4 stated the area got worse and worse. Resident #4 indicated since returning from the hospital, he has been bed bound. Resident #4 indicated his usual routine prior to going to the hospital was for staff to assist him into his wheelchair before therapy. Resident #4 indicated his therapy was at 10:00 every day. Resident #4 indicated he would be up in his wheelchair through lunch, after which he returned to the therapy department to work on his own. Resident #4 indicated he did this to work on his strength to expedite his discharge back home. Resident #4 indicated typically prior to supper he would lay down and remain in bed for the remainder of the evening. On 7/10/13 at 11:05 a.m., Surveyor # spoke with CNA-J. CNA-J indicated she worked on the unit where Resident #4 resided. CNA-J stated she worked 5 days a week but worked a short shift. CNA-J indicated shortly after admission, Resident #4 developed a small area on his buttocks which was not open and appeared as a bruise. CNA-J stated she felt the area was caused by him "sitting too much." CNA-J stated the area "kept getting bigger." CNA-J indicated she went on vacation and when she came back the area was "much worse." CNA-J indicated the area looked like a bruised area and the area got "bigger." CNA-J stated the area didn't look like it was caused by urine as it didn't look like a urine or stool burn. CNA-J stated she felt it was from sitting too long. CNA-J stated she told Resident #4 the condition of his skin, but he would refuse to lay down. CNA-J stated she did inform the floor nurse of his refusals. CNA-J stated Resident #4 was "young and had his own mind." CNA-J indicated she felt Resident #4 didn't realize the condition of his skin as he could not feel anything below his waist. On 7/10/13 at 1:05 p.m., Surveyor # spoke with LPN-K. LPN-K indicated she worked full time on the unit where Resident #4 resided. LPN-K indicated the area on Resident #4's buttock appeared as a dark spot. LPN-K indicated blisters then developed which broke open. LPN-K stated the wound nurse was following Resident #4. LPN-K stated the area "progressively got worse and worse." LPN-K stated Resident #4 would sit up for extended periods of time and refuse to lay down. There was no evidence of refusals in the nurse's notes. On 7/10/13 at 2:32 p.m., Surveyor # spoke with CNA-M. CNA-M indicated she always worked the unit where Resident #4 resides. CNA-M indicated Resident #4's left sacrum started as a "purple area that got bigger." CNA-M indicated she didn't recall the area ever looking rash-like (characteristic of IAD). CNA-M indicated Resident #4 would typically ask to be laid down before supper and then remain in bed for the rest of the evening. CNA-M stated Resident #4 many times didn't get up for dinner. CNA-M also stated Resident #4 never refused to turn or reposition. On 7/10/13 at 2:37 p.m., Surveyor # spoke with CNA-N. CNA-N indicated she always worked the unit where Resident #4 resides. CNA-N indicated she recalled Resident #4's left sacral area as a "purple area that got bigger." CNA-N stated the area didn't look rash-like, but looked more purple in color. CNA-N indicated Resident #4 had never refused any cares. On 7/10/13 at 3:30 p.m., Surveyor # spoke with PTA-Q (Physical Therapy Assistant). PTA-Q indicated she worked with Resident #4 every day since admission up to the point of his last hospitalization on [DATE]. PTA-Q indicated during this time she was not aware Resident #4 had a pressure ulcer. PTA-Q stated she did change Resident #4's wheelchair cushion at the direction of the wound nurse but could not recall when. On 7/11/13 at 7:10 a.m., Surveyor # spoke with PT-R (Physical Therapist). PT-R indicated she worked with Resident #4 since admission. PT-R stated Resident #4 was flaccid from his waist down and was in therapy for sitting balance and transfer training. PT-R stated she didn't recall ever hearing Resident #4 had a pressure area on the left sacrum. On 7/11/13 at 7:25 a.m., Surveyor # spoke again with LPN-K about Resident #4. LPN-K stated Resident #4 was typically up every day by 10:00 a.m. and after that refused to lay down. Surveyor # asked LPN-K what her response was to Resident #4's refusal. LPN-K indicated she tried to re-educate Resident #4. Surveyor # asked why Resident #4's refusals to lay down was not noted in the nursing notes nor care plan. LPN-K stated she assumed the wound nurse was documenting this. On 7/10/13 at 11:45 p.m., Surveyor # again spoke with Resident #4. Surveyor # asked Resident #4 if he had ever refused any cares including laying down. Resident #4 indicated he was a "pretty agreeable guy." Resident #4 also stated he did not refuse to lay down and would "do what needs to be done to get out of here." On 8:50 a.m., Surveyor # spoke with COTA-S (Certified Occupational Therapy Assistant). COTA-S indicated she worked with Resident #4 every day from admission on 3/28/13 though 5/4/13 when he was hospitalized . COTA-S stated she was not aware Resident #4 had a pressure ulcer during that time. COTA-S stated therapies were not involved in the facility's wound management program and pressure reducing modalities were dictated by the wound nurse. COTA-S stated if she was aware a resident had a pressure ulcer and was refusing to off-load the area, she would instruct them on changing their position and getting off the area of concern. COTA-S stated Resident #4 was a paraplegic, however had good upper body strength. COTA-S stated Resident #4 had the ability to do wheelchair pushups where he could raise his buttocks off of the wheelchair. COTA-S stated Resident #4 was very motivated and wanted to get home. On 7/11/13 at 11:30 a.m., Surveyor # spoke with CNA-U. CNA-U indicated she worked full time and usually worked the unit where Resident #4 resided. CNA-U indicated Resident #4's skin was "good" when he first came in to the facility. CNA-U stated Resident #4 developed 3 blisters which broke open and got worse. CNA-U stated Resident #4's skin then looked like "raw meat" with redness in the center with "purple" around the redness. CNA-U indicated Resident #4 was up at least 3 to 4 hours on her shift. CNA-U indicated she was never given any specific directives via the nurse or CNA care plan on how to manage Resident #4's pressure ulcer. CNA-U also stated Resident #4 never refused to lay down. CNA-U indicated she told the nurse working the floor as well as the wound nurse, that Resident #4's pressure ulcer was getting worse. CNA-U also stated she felt there was not enough done fast enough and Resident #4's pressure ulcer "should not have happened." On 7/12/13 at 8:40 a.m., Surveyor # spoke with the DON (Director of Nursing) and RN-X (Registered Nurse). RN-X indicated she was the wound nurse. Surveyor # asked RN-X about the facility's Wound Management Program. RN-X stated on admission, Resident #4's skin was assessed and a skin risk assessment was completed by the floor nurses. RN-X stated she reviews the skin risk assessments as well as any other co-morbidities putting residents at risk for the development of pressure ulcers, and implements the interventions. RN-X indicated the floor nurses also implement care planned approaches based on resident need. RN-X indicated the facility's standard of care for a resident at high risk for the development of pressure ulcers was to implement a good mattress and cushion, to turn side-to-side when in bed, and to be up for meals and therapies only. RN-X stated she would also involve dietary and ensure vitamins and/or minerals had been ordered. RN-X indicated the facility used a standard pressure-relieving mattress for all residents. RN-X stated if needed the facility also had 13 low air-loss mattresses. RN-X also stated they had a variety of pressure redistribution mattresses which could be used. RN-X indicated any new pressure ulcers would be initially assessed by the nurse on the floor. RN-X indicated the documentation completed should include the stage, measurements, condition of the wound bed and peri wound, and percentage of slough and/or eschar. RN-X indicated she or another nurse would then complete wound rounds weekly and complete the documentation. RN-X indicated the wound nurse's role was to assess and document weekly any open wounds, pressure ulcers, or surgical incisions. RN-X stated all other skin issues were managed by the floor nurses. RN-X also stated if a wound deteriorated, she would still continue to see that resident on a weekly basis. Surveyor # asked RN-X how the facility monitors on a daily basis the status of pressure ulcers. RN-X stated there was no formal process for monitoring daily. RN-X indicated it was an informal process whereby if a nurse noted issues during their dressing change, they would inform her. RN-X stated if a wound worsened, the nursing staff would have either MD-T (Medical Doctor) or PA-AA (Physician Assistant) look at it as one of them was in the building every day Monday through Friday. RN-X also indicated if a wound deteriorated they would get the wound clinic involved. RN-X stated the first time she observed Resident #4's pressure ulcer was on 4/15/13. RN-X indicated she had not looked at Resident #4's skin prior to this as there were no open areas, thus the nurses on the floor were managing Resident #4's skin. RN-X stated when she observed Resident #4's skin on 4/15/13, she identified a DTI. RN-X indicated the next week when she look at Resident #4's skin she felt it appeared as an area of [MEDICAL CONDITION]. RN-X indicated she requested a wound culture. RN-X indicated PA-AA had observed Resident #4's skin and ordered a referral to the wound clinic. RN-X indicated once Resident #4's infection was treated with antibiotics it improved. (Review of Resident #4's medical record found no evidence that PA-AA saw Resident #4 and/or ordered a referral to the wound care clinic.) RN-X indicated she felt Resident #4's skin condition was related to [MEDICAL CONDITION] rather than pressure. RN-X however, indicated she felt it occurred because Resident #4 sat up for extended periods of time while in therapy and during meals. RN-X also stated Resident #4 wanted to spend time outside and was not the "most compliant" in laying down. Surveyor # asked RN-X what other interventions the facility had discussed and/or tried taking into consideration Resident #4's specific needs. RN-X indicated she spoke to Resident #4 and attempted to re-educate him. (Surveyor # completed a review of all of Resident #4's nursing notes and care plan from 3/28/13 to 5/4/13. Neither the nursing notes nor the care plan identified Resident #4 as refusing to lay down or refusing cares.) On 7/12/13 at 11:25 a.m., Surveyor # spoke again with RN-X. Surveyor # asked RN-X why some areas of Resident #4's skin risk assessment indicated inaccurate information (documented no limitations in sensory perception even though he is paralyzed from the waist down). RN-X indicated she did not know. Surveyor # also asked RN-X how they were managing Resident #4's incontinence. RN-X indicated Resident #4 was able to use the urinal independently and that he wore a brief. RN-X indicated she had never considered a Foley catheter to assist in the management of Resident #4's pressure ulcer. On 7/11/13 at 10:25 a.m., Surveyor # spoke with MD-T (Medical Doctor). MD-T indicated he was the physician following Resident #4 in the facility. Surveyor # asked MD-T if he had ever visualized Resident #4's pressure sore. MD-T indicated he had not. Surveyor # asked MD-T if he was aware of the significant deterioration of Resident #4's sacral ulcer. MD-T indicated he was not. MD-T indicated Resident #4 had extreme mobility problems related to his spinal cord issues. MD-T stated he would not however expect a pressure ulcer to develop. MD-T stated he should have been informed of the significance of Resident #4's pressure ulcer. On 7/15/13 at 12:00 p.m., Surveyor # spoke with PA-AA. PA-AA indicated she saw Resident #4 only once on 4/29/13. PA-AA indicated at that time she did not observe Resident #4's pressure ulcer nor did she order a consult with the wound clinic. On 7/12/13 at 11:55 a.m., Surveyor # spoke with the DON. Surveyor # asked the DON about the facility's failure to keep MD-T and/or PA-AA well informed of the significant deterioration of Resident #4's pressure ulcer. The DON indicated MD-T and/or PA-AA should have been informed. The immediate jeopardy that began on 4/15/13 was removed on 7/13/13 by which time: 1. All residents identified had their skin condition re-assessed by the DON/Certified Wound Care Nurse/Designee. 2. Care plans were updated as needed to reflect the re-assessment findings. 3. Dietitian reviewed all residents identified in the cite to determine need for nutrition interventions. 4. All other residents identified as being at risk for pressure ulcers on the most recently completed MDS were re-assessed and care plans updated as needed. 5. All nursing staff were re-educated, prior to working their next scheduled shift to identify any skin condition, report to professional nurse for thorough assessment, full documentation and care plan updates as needed to reflect resident's current condition. The noncompliance continues at the lower scope and severity level of G (actual harm that is not immediate jeopardy/isolated) as the facility needs to fully implement its correction plan for all residents and as evidenced by the following examples. Example #2: Resident #5 has [DIAGNOSES REDACTED]. The most current MDS, dated [DATE], indicated Resident #5: ~Has a BIMS score of 12 indicating a moderate cognitive impairment; ~Requires extensive assistance of 2 staff persons for bed mobility, transfers, bathing, dressing, and toileting, ~Does not walk; ~Is frequently incontinent of bladder and occasionally incontinent of bowel; ~Is at risk for the development of pressure ulcers; and, ~Has 1 Stage 2 pressure ulcer. Resident #5's CAAs for skin was dated 4/12/13. It indicated Resident #5 was readmitted to the facility from the hospital with a Stage 2 pressure ulcer on the coccyx measuring 0.3 cm by 0.1 cm. The CAA also indicated Resident #5 had a decline in overall functioning. The CAA indicated a care plan would be developed. Resident #5's skin care plan was da

The F314 is being recited at this survey. Details of the deficiency are found in survey event ID VGG711.

Based on interview and record review, the facility did not ensure that staff provided supervision to prevent inappropriate contact and to remain free from abuse by another resident for 1 of 9 sampled residents. Resident #1 has a history of Hypersexuality and a history of inappropriate comments and gestures to female staff. On 9/16/12 he was observed by RN-A (Registered Nurse) to be sitting on a couch holding the hand of a confused female, Resident #2. RN-A did not provide supervision of Resident #1 even though she felt it was inappropriate. A short time later CNA-B (Certified Nursing Assistant) observed Resident #1 sitting next to Resident #2, with both hands on Resident #2's breasts "fondling" them. This is evidenced by: Resident #1 is [AGE] years old and was admitted to the facility in 2007. Resident #1's most current MDS (Minimum Data Set Assessment) dated 8/23/12, indicated: ~Has a BIMS (Brief Interview for Mental Status) score of 7 out of 15 indicating severe impairment; ~Has displayed verbal behavioral symptoms 1 to 3 days a week; ~Is independent with ambulation and transfers; ~Uses a walker. Resident #1's current plan of care in regards to "inappropriate sexual comments and actions" is included in a Thought process problem. The goal is that along with directing his own routine and going on outings with family and friends, he "will display no inappropriate behaviors for 3 months." The approaches staff are to do to ensure this are: ~5/30/12 Nurses -- Note changes and notify MD as needed. ~7/18/12 Nurses -- Meds as ordered: prozac. ~7/25/12 Nurses -- Assess behaviors each shift. ~4/28/07 Nurse Aide -- Offer conversation. ~4/28/07 Nurse Aide -- Praise resident. ~5/30/12 Nurse Aide -- Speak slowly/clearly. ~4/28/07 SocServ -- 1:1/enc. conversation/support. ~4/28/07 SocServ -- Involve family. ~7/21/08 SocServ -- Assess as needed. ~7/21/08 SocServ -- Make referrals. ~10/29/09 SocServ -- 1:1 sessions prn to discourage inappropriate behavior. ~7/25/12 SocServ -- Review behaviors monthly. ~7/25/12 SocServ -- PHQ-9, (Patent Heath Questionnaire, it is a 9 question assessment to explore possible depression). ~7/25/12 SocServ -- PHQ-9, 1 month after start of med (medication). ~2/28/12 All Staff -- Reorient as needed. Surveyor # reviewed a facility self report. The report states that on 9/16/12, "Resident #1 touched Resident #2's breast outside her shirt." The report indicates CNA-B saw Resident #1 "fondling" Resident #2 while she was sitting on the couch watching the birds. CNA-B told him to stop, he couldn't do that, and that he needed to find something else to do. Resident #1 walked away and CNA-B asked Resident #2 if she was OK, and Resident #2 just smiled. CNA-B then went to tell LPN-C (Licensed Practical Nurse) and RN-A. RN-A and CNA-B walked Resident #2 back to her unit. Included in the report was an interview of Resident #1 on the day after the incident by the NHA (Nursing Home Administrator). The interview is as follows: ~"When I interviewed Resident #1 regarding this incident and asked him why he touched Resident #2's breast, he said, 'We were watching the birds and I told her she had nice ones and she said do you want to feel 'em and I said I don't care.' I asked Resident #1 if he knew Resident #2 was married and he said, 'Oh, she's married?' I told him yes. I explained to him that Resident #2 would not be able to consent to such activity even if asked. He said, 'Oh, I didn't know that. I don't want no trouble.'" The NHA's report also states that right after the incident, she gave staff direction to contact the doctors and significant others of both residents. Resident #1 was placed in 15-minute checks. Resident #2 was reassessed. In addition, the police were notified as well as the county social services organization. Surveyor # reviewed the nursing notes and physician orders [REDACTED]. According to the record, Resident #1 has been receiving Paxil for "inappropriate sexual behavior" since 6/16/09. Paxil is an antidepressant used to treat depression as well as obsessive compulsive disorder. One of the side effects of Paxil is a decreased sex drive. The Paxil was discontinued on 3/22/12 as the resident presented with little to no inappropriate sexual behavior or loud disruptive behaviors. Review of the behavior monitoring documentation found the following after the medication was discontinued: ~3/30/12 He had one inappropriate comment. ~4/1/12 He had an episode of being very loud and making inappropriate comments towards a female staff member. ~4/3/12 He made inappropriate comments. ~4/5/12 He was very loud. ~4/26/12 He had an inappropriate sexual comment. ~5/4/12 He grabbed a housekeeper and would not release. (There is no further information.) ~5/5/12 He was "overly excited," excitable during supper by singing and laughing at other residents. ~7/6/12 SW-G (Social Worker) was updated on Resident #1 being loud and disruptive, refusing to put on pants, and not being redirectable. ~7/16/12 He tried to kiss an aide in the elevator. On 7/16/12, Prozac was ordered at 10 mg (milligrams) every day. Prozac is an antidepressant used to treat depression, obsessive compulsive disorder among others. One of the side effects of Prozac is decreased sex drive. On 7/27/12, Resident #1's behavior tracking recorded by the Behavior Committee states he has had 3 additional behaviors documented since the medication was restarted. On 8/29/12, the committee notes state he has 3 documented behaviors since the last review. The inappropriate sexual contact with Resident #2 occurred on 9/16/12. On 9/27/12, the committee notes state he has 5 charted behaviors since the last review and that his Prozac was increased to 20 mg everyday on 9/17/12. On 10/17/12 the committee notes state he had 2 documented behaviors of loud outbursts. Following the 9/16/12 incident, the following approaches were added: ~ 9/17/2012 Nurses -- Targeted behavior: loud outbursts, sexually inappropriate comments or touching of staff or residents. ~ 9/16/2012 Nurse Aide -- 15-minute checks. ~ 9/17/2012 Nurse Aide -- Offer alone time for sexual needs. ~ 9/17/2012 Nurse Aide -- Report behaviors: loud outbursts, sexually inappropriate comments or touching of staff or residents. On 11/19/12 at approximately 9:30 a.m., Surveyor # interviewed the NHA. The NHA reiterated the above and indicated the MD (Medical Doctor) reinstated the medication, Prozac, which had been used in the past and discontinued as Resident #1 did not have any sexual behaviors. The NHA stated she did not interview any other staff or residents to determine if this had happened in the past, as the persons interviewed were the only persons involved in the incident. On 11/19/12 at 10:12 a.m., Surveyor # interviewed CNA-B. CNA-B reiterated her statement with added details. CNA-B stated Resident #1 was sitting next to Resident #2 and had both hands on her chest. She told Resident #1 to stop, he did, and she told him to leave. CNA-B stated she waited until he was walking away and then went to tell LPN-C. She stated the nurse was right at the nurses' station and she could see Resident #2 on the couch. CNA-B stated that while Resident #1 was not in her line of sight, he was found sitting on a chair steps away from the couch. On 11/19/12 at 10:20 a.m., Surveyor # interviewed RN-A. RN-A readily told the surveyor that she had seen Resident #1 sitting next to Resident #2 on the couch and holding her hand prior to the incident. RN-A stated she was walking past to go on a break. She stated she told Resident #1 that Resident #2 was married and Resident #1 stated he did not know that. RN-A stated she felt the contact was "not appropriate" and "he had no business holding her hand." RN-A stated she did not "feel comfortable." She stated she was aware of his targeted sexual behaviors and Resident #2 could not give consent. RN-A stated when she left the floor, Resident #1 was in the process of leaving the couch and she thought it was then over. She stated she was surprised to find out after her break what Resident #1 had done. RN-A was asked if she had reported this to the NHA or volunteered this information when interviewed. RN-A stated, "I may have. It might be in my charting." Resident #1's BIMS score of 7 indicates severe cognitive impairment. It is questionable if a verbal reminder would be effective. In addition, Resident #1 indicted he was unaware of Resident #2's marital status when the NHA spoke with him even though RN-A had informed him of the same. On 11/19/12 at 12:15 p.m., Surveyor # interviewed LPN-C. LPN-C stated she recalled CNA-B coming to her and telling her that she saw Resident #1 "massaging her front." LPN-C stated she talked to Resident #1. She stated Resident #1 is very alert and oriented but gave her a strange response. LPN-C stated she had heard that prior to the incident Resident #1 had been seen sitting too close to Resident #2. LPN-C stated Resident #1's hypersexuality has been towards the staff. She stated the CNAs knew the smart thing for dealing with Resident #1 was to maintain a safe distance and keep things strictly business. She stated the CNAs had to protect themselves and be cognizant of where they were positioned when assisting him with his personal cares and applying ace wraps and lotion to his legs. Staff were to admonish him while not being rude. LPN-C stated she did not recall any changes to his plan of care after the incident, as Resident #1 didn't leave his room after the incident and when told it was inappropriate, he was nice and didn't object. LPN-C stated, "We looked in on him." Surveyor # also interviewed direct care staff working on Resident #1's unit on 11/19/12 and noted the following: At 10:55 a.m., Surveyor # interviewed RN-D. RN-D was working on Resident #1's unit that day. RN-D stated she works the unit about once a week. RN-D stated she was aware of the targeted behaviors for Resident #1's sexual advances towards the aides as he tries to hug and kiss them. She stated she was not made aware of the instance in which Resident #1 had fondled Resident #2. When asked how she would handle it if she saw two resident holding hands, RN-D stated if the residents were able to consent to the contact she would allow it. If one of the residents were not able to consent, then she would redirect them and report it to the NHA. At 11:15 a.m., the surveyor interviewed CNA-E. CNA-E is a full time employee on Resident #1's unit. CNA-E stated Resident #1 is total care for his perineal cleansing. She stated he can be loud and noisy and has made sexual advances to the CNAs but not to her. CNA-E also stated she was not told about the incident between Resident #1 and Resident #2. When asked what she would do if she saw Resident #1 holding the hand of a female resident, CNA-E stated she would redirect him to somewhere else as she would be "leery with him" because of his "advances." At 1:00 p.m., the surveyor interviewed CNA-F. CNA-F works on Resident #1's unit every other weekend and when she picks up a shift. CNA-F stated she "was never told" of the incident with Resident #2. CNA-F stated that staff are to redirect him if being rude and get him off the subject when he starts talking in a sexual nature. At 2:10 p.m., Surveyor # interviewed the NHA and asked about her knowledge of RN-A's observations of Resident #1 holding Resident #2's hand on 9/16/12. The NHA stated she was not made aware of the earlier observation by RN-A.

Based on observations, record review, and interviews, the facility did not ensure that 1 of 16 sampled residents received the necessary care and services to maintain the highest practicable physical function. Resident #12 was hosptalized on [DATE] due to bowel obstruction, dehydration,[MEDICAL CONDITION], and a urinary tract infection. Resident #12 returned to the facility on [DATE]. The facility did not conduct a comprehensive assessment to identify risk factors that would lead to the bowel obstructions, dehydration, and infections. The facility did not develop a care plan to monitor for these conditions. Resident #12 was again hosptalized on [DATE] with another bowel obstruction and urinary tract infection. Resident #12 also has had pruritis (chronic itching) since 12/2011. The documentation did not reflect current conditions. The facility had physician orders [REDACTED]. The facility was not following these orders. Resident #12 was observed with scratches on the left side of her body starting at the waist and extending down to the top of the thigh with the entire left buttock covered with scratches. Resident #12 was observed with long, jagged, dirty fingernails as well. This is evidenced by: Resident #12 was admitted to the facility on [DATE] due to late affects of a stroke including right-sided paralysis, difficulty swallowing, difficulty speaking. Other [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident #12: ~Is sometimes able to make self understood and understand others; ~Has short and long term memory impairments; ~Has severely impaired daily decision making skills; ~Required extensive assist for eating, hygiene, and dressing; ~Required extensive assist of 2 or more staff for toilet use and bed mobility; ~Always incontinent; and, ~No current toilet plan. The annual MDS assessment dated [DATE], indicated the following changes for Resident #12: ~Only long term memory impairments; ~Moderately impaired daily decision making skills; and, ~Required total assistance of 2 or more staff for toilet use. SKIN PROBLEM During the initial tour which began on 06/04/12 at 11:00 a.m. and conducted by Surveyor # , CNA-R (Certified Nursing Assistant) stated Resident #12 had scratches on her buttocks from her nails. CNA-R stated staff applied cream to Resident #12's buttock. CNA-R stated Resident #12 was incontinent. On 06/04/12 at 11:10 a.m., Surveyor # interviewed RN-S (Registered Nurse) regarding Resident #12's care needs. RN-S stated Resident #12 was dependent on staff for all cares because of a stroke that left her with right sided paralysis. RN-S stated Resident #12 had multiple scratches on her left buttock which was currently being treated with [MEDICATION NAME], Sarna lotion, and [MEDICATION NAME] lotion. The physician and PA (Physician Assistant) progress notes indicated chronic skin rashes that were first noted 02/28/12. Treatments were changed several times before Resident #12 was seen by the dermatologist. On 03/27/12, Resident #12 was seen by a dermatologist because of long standing urticaria. The physician ordered [MEDICATION NAME] ([MEDICATION NAME] to treat urticaria) 10 mgs (milligrams) daily as needed for itching; wash with Dove sensitive bar soap followed by [MEDICATION NAME] daily; Sarna lotion as needed for itching; and [MEDICATION NAME] 0.1% ointment twice daily to hands until clear and thighs as needed for itching. Review of Resident #12's care plan titled "Skin Integrity" dated 05/30/12 and last reviewed on 06/04/12, noted symptoms of "healed self inflicted open areas left buttocks" and "itchy skin." The goal was no skin breakdown for three months. The approaches were "[MEDICATION NAME]" and "No perfumed lotions, hypo-[MEDICATION NAME] only." The care plan did not include the physician orders [REDACTED]. Review of the MAR (Medication Administration Record) noted Resident #12 received [MEDICATION NAME] on the following dates: 04/12/12, 04/24/12, and 04/29/12. On 05/29/12, the physician ordered [MEDICATION NAME] 10 mgs to be given daily. Resident #12 has received [MEDICATION NAME] daily since 05/30/12. ~The March 2012 TAR (Treatment Administration Record) noted [MEDICATION NAME] twice daily, Sarna lotion twice daily for 14 days, and [MEDICATION NAME] ointment twice daily for 7 days. ~The April TAR noted [MEDICATION NAME] twice daily, [MEDICATION NAME] ointment twice daily, and Sarna given on 19 days of the month. ~The May 2012 TAR noted [MEDICATION NAME] at least daily, and Sarna lotion applied 11 days. ~The June 2012 TAR noted Sarna lotion applied once and no [MEDICATION NAME]. The order for Dove or Tone bar soap was transcribed onto the TAR as of 03/13/12; however, there was no documentation of the delivery of this order through 06/07/12. The order for the use of [REDACTED]. On 06/05/12 at 9:30 a.m., Surveyor # observed CNA-P and CNA-R transfer Resident #12 from the wheelchair into bed. Resident #12 had been incontinent of urine. CNA-R provided incontinent care for Resident #12 using a disposable cloth. CNA-R took the disposable cloth and wiped the right side then the left side of the groin. CNA-R used the same cloth to wipe down the center between the labia. CNA-R went back and forth once using the same cloth. Neither CNA-R nor CNA-P applied barrier cream following incontinence care. Neither CNA-R nor CNA-P requested the licensed nurse to apply the Sarna lotion. Surveyor # noted Resident #12's left buttock to be almost completely covered with scratches. Surveyor # also noted scratches as far up as Resident #12's waist and as low as the upper thigh on the left side. These scratches were in multiple stages of healing. During perineal care, Resident #12 used her left hand to reach back to scratch her buttock; however CNA-P instructed Resident #12 not to scratch. Surveyor # observed Resident #12 to have long, jagged, dirty fingernails. CNA-R and CNA-P completed perineal care for Resident #12 and settled her in bed. On 06/06/12 minutes before the 12:18 p.m. observation, Surveyor # interviewed CNA-T regarding Resident #12's care needs. CNA-T stated the night shift provided morning hygiene for Resident #12. The Surveyor noted a white rectangular shaped bar of soap in the wash basin. The Surveyor asked CNA-T if the soap was used to wash Resident #12 and CNA-T stated yes. The Surveyor noted the bar of soap to be approximately 1/3 used with a heavy flower fragrance. On 06/06/12 at 12:18 p.m., Surveyor # observed CNA-U and CNA-T transfer Resident #12 from the wheelchair into bed. Resident #12 had been incontinent of urine. CNA-T provided incontinence care using a disposable cloth. Resident #12 again reached back with her left hand on 2 separate occasions to scratch her buttock and CNA-T instructed her not to scratch. Surveyor # observed Resident #12's left buttock to be almost completely covered with scratches. The Surveyor also noted scratches up to the waist and down to the upper thigh of Resident #12. Following perineal care, the scratches on the buttock were observed to be more red. CNA-T left Resident #12's room and RN-S entered. CNA-U assisted Resident #12 to a side lying position, while RN-S applied Sarna lotion to the left buttock. CNA-U positioned Resident #12 onto her right side using pillows to support the back and float the heels. At 12:46 p.m., Surveyor # showed RN-S the bar of soap in Resident #12's wash basin and asked what kind of soap was used to wash Resident #12. RN-S retrieved a bar of soap from the supply closet with the same shape, color, and fragrance as was in Resident #12's wash basin. The bar of soap was labeled "Dial." RN-S stated the Dial soap was used for Resident #12. The Surveyor asked where was the Dove soap for Resident #12 and RN-S stated she was unsure, but would look into that. On 06/07/12 at 10:00 a.m., Surveyor # interviewed the DON (Director of Nurses) regarding Resident #12's care needs. The DON stated CNA staff conduct a weekly skin inspection and document findings in the electronic medical record. The DON stated Resident #12 was first noted to have scratches on the buttock area on 12/26/11. The Surveyor requested copies of the CNAs' skin inspection notes. Review of the weekly skin inspection notes revealed Resident #12 had self inflicted scratches that were treated with [MEDICATION NAME] cream on 12/26/11. On 02/27/12 Resident #12 had a rash on her back. On 06/04/12 Resident #12 had an open sore on her right shoulder due to scratching. There was no mention of the multiple scratches on Resident #12's left buttock, waist, or thigh. These scratches were observed by Surveyor # on 06/05/12. HYDRATION On 06/07/12 Surveyor # requested and reviewed the facility policy titled "Hydration Assessment." The "Purpose" of the policy was "To identify residents at risk for dehydration and assess residents for signs and symptoms of dehydration." The "Procedure" read "Complete a monthly assessment on all resident if not exhibiting symptoms. Complete...weekly if any of the following listed below: D. Complete daily hydration assessment for seven (7) days on resident admitted or readmitted with a [DIAGNOSES REDACTED]." "Method of Procedure...G. Update the C.N.A. worksheet and the nursing care plan as needed. H. Dietary is to review hydration assessments weekly." This Surveyor reviewed Resident #12's dehydration and ADL (Activities of Daily Living) CAAs (Care Area Assessments) that were triggered during the annual MDS assessment and completed on 09/02/11. The dehydration CAA read "Resident is drinking <240 cc at 1 out of 16 meals. Resident is not able to always communicate...Resident's hydration, weight and intakes are monitored weekly." The dehydration CAA did not identify other risk factors of dehydration for Resident #12, such as deficits in communication, unmet thirst needs, being dependent on staff for all fluids, impaired swallowing, history of urinary tract infections, history of bowel obstructions, and mechanically altered diet with regular liquids. The ADL CAA read "Is able to use the left hand to drink out of a double handled cup." The ADL CAA did not identify risk factors of dehydration, did not include the bowel obstructions or urinary tract infections for Resident #12. On 06/04/12 at 11:10 a.m., Surveyor # interviewed RN-S regarding Resident #12's care needs. RN-S stated Resident #12 received a high calorie supplement called Plus 2 with all meals. RN-S stated Resident #12 could drink independently once positioned properly in her wheelchair. Review of Resident #12's care plan titled "Self Care" dated 09/22/10 and last reviewed on 05/30/12, noted required extensive assist with eating. Review of Resident #12's care plan titled "Nutrition" dated 09/29/10 and last reviewed on 05/25/12, noted a [DIAGNOSES REDACTED]. The goal was will show no signs of dehydration for three months. The approaches were to "Provide supplement w/med (with medication) pass 240 cc +2 TID (three times per day)" and "Hydration assessment monthly." Review of the kitchen tray card for Resident #12 revealed a puree diet with yogurt for breakfast and lunch, juice for all meals, soup for lunch, and fortified cereal for breakfast. Resident #12 required a lipped plate and cups with handles. Observations were made of Resident #12 by Surveyor # during the following dates/times: ~06/05/12 at 8:01 a.m. was served a puree meal, 240 mls of supplement, no juice; ~06/05/12 at 11:46 a.m. was served a puree meal, 240 mls of supplement, no soup or juice; ~06/06/12 at 11:54 a.m. was served a puree meal, 240 mls of supplement, no soup or juice; ~06/07/12 at 8:05 a.m. was served a puree meal, 240 mls of supplement, no juice; ~06/07/12 at 11:50 a.m. was served a puree meal, 240 mls of supplement, no soup or juice. On 06/07/12 at 8:15 a.m., Surveyor # interviewed the DM (Dietary Manager) regarding Resident #12's fluid needs. The DM stated Resident #12 was to be served juice at all meals, shakes three times per day, and 240 mls (milliliters) of her high calorie supplement at all meals as well. The DM stated these fluids would provide Resident #12 with 1420 mls per day in addition to fluids during medication pass and water at her bedside. During the observation that occurred on 06/05/12 at 9:30 a.m. when CNA-P and CNA-R provided incontinence care and bed positioning for Resident #12, neither CNA-R nor CNA-P offered Resident #12 any fluids. Resident #12 had 2 cups with handles on her bedside table. One cup was empty and the other cup had a measured amount. Using a pen, Surveyor # measured the level of water in the cup, then measured the mark on the pen. The cup was filled with 1 and 3/4 inches of water. At 4:00 p.m., Surveyor # noted there was no change in the water level of Resident #12's cup. The nutrition assessment completed by the DM on 08/24/11 for Resident #12, indicated fluid needs based on 25 mls per kilogram were 1706 mls per day. The assessment indicated Resident #12's intakes were adequate to meet fluid needs. Based on Resident #12's current weight of 67.7 kilograms multiplied by 25-30 mls per kilogram, Resident #12's fluids needs would be between 1693-2031 mls per day. There was no evidence that Resident #12 received the required fluids needed. Surveyor # had 5 observations where Resident #12 was served only 240 mls per meal which would total 720 mls per day. Based on the DM's fluid calculations of 1706 mls per day, Resident #12 was served 986 mls less than her required fluid needs. The facility completed weekly hydration assessments for Resident #12 beginning in May 2011. The hydration assessments identified Resident #12 needed staff assistance for her fluid intakes as well as using bowel medications for constipation. The hydration assessments determined Resident #12 showed no signs of dehydration. Resident #12 was sent to the emergency room per family request on 12/26/11. The hospital laboratory data showed an elevated BUN of 62.7 (normal 7-17), elevated creatinine of 1.81 (normal 0.7-1.2), elevated sodium of 146 (normal 134-144) which resulted in a [DIAGNOSES REDACTED]. Resident #12 was also found to have a partial distal large bowel obstruction. The hydration assessment completed for Resident #12 on 01/03/12 upon her return to the facility, noted abnormal laboratory values of an elevated BUN/creatinine ratio greater than 23 and an elevated sodium value greater than 145. The hospital discharge summary indicated dehydration and kidney failure. There were no changes made to Resident #12's hydration care plan despite her increased risk for dehydration. On 06/07/12 at 8:15 a.m., Surveyor # interviewed the DM (Dietary Manager) regarding the nutrition care plan for Resident #12. The DM stated she reviewed the care plans at least quarterly during the MDS (Minimum Data Set) assessment schedule. The DM stated she missed the changes to the nutrition care plan. The DM stated she did not develop a care plan for dehydration but did include a goal of no signs of dehydration under the nutrition care plan. At 12:00 p.m., the DM approached Surveyor # and stated after review of Resident #12's medical record, she was unable to locate additional information regarding dehydration, bowel obstructions, and urinary tract infections. The DM stated Resident #12 would be monitored for dehydration in the future and the kitchen staff would be providing Resident #12 with fluids as per her meal card instructions. BOWEL OBSTRUCTION Review of Resident #12's care plan titled "Bowel and Bladder" dated 09/22/10 and last reviewed on 05/30/12, noted a [DIAGNOSES REDACTED]. The approaches were "Meds (Medications) as ordered: [MEDICATION NAME]. Supp (Suppository) as ordered. Meds as ordered: MOM (Milk of Magnesia). Report hard stools. Offer extra fluids." The care plan did not include the risk for reoccurring bowel obstructions including dehydration or urinary tract infections. The care plan did not mention anything regarding Resident #12's bowel obstruction history. Resident #12 was examined by the primary physician on 12/26/11 at 6:55 a.m. The progress note indicated "...gradual abdominal distention...Last BM (bowel movement) was 2 days ago c (with) normal stools... Abdomen was distended; nontender c bowel sounds...Constipation & abd (abdominal) distention...Give fleets enema today." Resident #12 was sent to the emergency room per family request on 12/26/11. The hospital laboratory data showed an elevated BUN of 62.7 (normal 7-17), elevated creatinine of 1.81 (normal 0.7-1.2), elevated sodium of 146 (normal 134-144) which resulted in a [DIAGNOSES REDACTED]. The hospital also took an abdominal xray which showed "partial distal large bowel obstruction." Resident #12 was readmitted back to the nursing home on 01/03/12 with orders to administer Senna S (laxative) twice daily and continue with [MEDICATION NAME] (stool softener). On 01/05/12 the primary physician also ordered [MEDICATION NAME] (bulk laxative) daily. Review of the care plan found no new interventions to address Resident #12's history of a bowel obstruction. On 06/07/12 at 8:15 a.m., Surveyor # interviewed the DM (Dietary Manager) regarding the nutrition care plan for Resident #12. The DM stated she did not develop a care plan for the bowel obstructions or frequent urinary tract infections that Resident #12 has experienced in the past 6 months. On 01/11/12, Resident #12 was noted to have diarrhea and her abdomen was slightly rounded and hyperactive bowel sounds. Bowel medications were held and the physician was consulted. On 01/13/12, Resident #12 had abnormal bowel sounds with a hard and distended abdomen and loose watery stools. The PA (Physician Assistant) was consulted and ordered a fleets enema. The PA was updated at 2:38 p.m. and stated, "Ss long as resident is passing stool and appetite has increased and distention has decreased, continue only to monitor at this time." Diarrhea/watery stools and distended abdomen can be signs of a bowel obstruction. On 01/14/12 at 6:50 a.m., the nurse's notes read "Bowel sounds present in all quadrants. No loose stools during noc (night) V/S (vital signs) stable. Resident's abdomen slightly distended, soft and round Non tender..." On 01/14/12 at 2:22 p.m., the nurse's notes read "...PA was notified of abdominal distention, and abnormal bowel sounds...send the resident to the ER (emergency room )..." Review of the hospital history and physical note for Resident #12 dated 01/14/12 read partial small bowel obstruction and dilated colon and urinary tract infection. Resident #12 was returned to the nursing home 01/18/12 with no changes to her bowel medications. Upon return to the nursing home, the primary physician ordered a [MEDICATION NAME] suppository daily for constipation. Surveyor # reviewed the comprehensive care plan for Resident #12 and was unable to locate a care plan to address Resident #12's dehydration condition, urinary tract infections, or the bowel obstructions. Surveyor # requested any care plan information that would address these conditions and approaches to prevent reoccurrences. There was no additional information provided as of 06/08/12. On 06/07/12 at 9:45 a.m., Surveyor # interviewed RN-W regarding the development and updating of care plans. RN-W stated she completes the MDS and CAAs (Care Area Assessments) and then develops or updates the care plan. RN-W stated she reviews the medical record as part of her assessment and updates the care plan based on information gathered. RN-W stated any dehydration concerns should be under the nutrition care plan. RN-W stated the bowel obstruction problem should be under the bowel and bladder care plan. RN-W stated the urinary tract infections should be under the physical care plan. On 06/07/12 at 10:00 a.m., Surveyor # interviewed the DON (Director of Nurses) regarding the development and updating of care plans. The DON stated all nurses who accept and transcribe a physician order [REDACTED]. The DON stated Resident #12's medical conditions of dehydration, urinary tract infections, and bowel obstructions should be included on the comprehensive care plan.

Based on observation, interview, and record review, the facility did not ensure that 6 of 9 sampled residents received the necessary care and treatment to prevent the development of dehydration and bowel obstructions. Resident #10, #12, #16, #27, and #29 either had historical [DIAGNOSES REDACTED]. None of the residents had a systematic comprehensive hydration assessment completed including intake and output to determine individualized interventions to ensure sufficient fluid intake to prevent dehydration. Additionally, while the facility had completed dehydration assessments, none of the assessments were comprehensive to include each resident's current risk factors and clinical condition, which could lead to dehydration. Residents #12, and #30 also had historical [DIAGNOSES REDACTED]. This is evidenced by: The "Evidenced-Based Practice Guideline Hydration Management" indicates triggers for dehydration would include: a decline in functioning, problems with hand dexterity, the use of diuretics, swallowing problems, comprehension and communication problems, inadequate food and fluid intake, infection, fever, weight loss, diarrhea, vomiting, dizziness, and a current [DIAGNOSES REDACTED]. The guideline also indicates that, "...The hydration management intervention is an individualized daily plan to promote adequate hydration based on risk factor identification that is derived from a comprehensive assessment..." The guideline indicates that the assessment would include: ~Basic physiological measures which would include vital signs including orthostatic blood pressure, weight, height, calculation of body mass index, and an assessment of mucous membranes; ~Current hydration status which would include intake and output and urine color; ~Cognition, and mood; ~Current functional status; ~Medical history which would include current medical condition and historical [DIAGNOSES REDACTED]. ~Current medications including the use of diuretics. The guideline also indicated, "...Any resident who develops a fever, vomiting, diarrhea, or a non-febrile infection should be closely monitored by implementing intake and output records and provisions of additional fluids..." Example #1: Resident #10 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. The current Minimum Data Set (MDS), dated [DATE], indicated Resident #10: ~Had both long and short-term memory problems; ~Required limited assistance to eat; and, ~Had had a recent urinary tract infection [MEDICAL CONDITION]. Resident #10's nutrition care plan, dated [DATE], indicated Resident #10 had a history of [REDACTED]. The bowel and bladder care plan, dated [DATE], directed staff to offer fluids with interactions. Surveyor # completed a review of Resident #10's nursing notes and noted the following: ~[DATE], "...UTI symptoms...Last 24 hours..UA(urinalysis)...positive...increased aggression...anxiety...Temperature: Tympanic 98.8...intermittent agitation..." Resident #10 was treated with an antibiotic. Surveyor # completed a review of Resident #10's most current hydration assessment dated [DATE]. The hydration assessment indicated there were no significant findings. The hydration assessment however, did not include that Resident #10 had a history of [REDACTED]. All of these concerns increase a person's risk for dehydration. The only changes made to Resident #10's care plan was to complete weekly hydration assessments instead of monthly. On [DATE], Surveyor # requested intake and output records for Resident #10. No records were received. There was no evidence that intake and output (I&O) had been started to ensure Resident #10 was receiving sufficient fluids to prevent dehydration. Example #2: Resident #12 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. According to Resident #12's record, she was also hospitalized for [REDACTED]. The current MDS, dated [DATE], indicated Resident #12: ~Had severely impaired cognition; ~Had mood indicators of a poor appetite; ~Required extensive to total assist of 1 to 2 staff persons for eating; ~Was always incontinent of both bowel and bladder; and, ~Had coughing and choking during meals. Resident #12's bowel and bladder care plan, dated [DATE], directed staff to listen to bowel sounds every shift, monitor for hard stools and diarrhea, offer fluids with interactions, and offer extra fluids. The bowel and bladder care plan also indicated Resident #12 had a history of [REDACTED]. Resident #12's nutrition care plan, dated [DATE], directed staff to complete a hydration assessment monthly and to weigh weekly. The nutrition care plan also indicated Resident #12 had a history of [REDACTED]. Resident #12's most current hydration assessment was dated [DATE]. The hydration assessment indicated no significant findings for dehydration. The hydration assessment did not include that Resident #12 had a history of [REDACTED]. These triggers would put Resident #12 at high risk for again becoming dehydrated. There was no individualized plan for managing Resident #12's fluid status as it related to her high risk for dehydration. Resident #12 also had 2 bowel obstructions, which date back to [DATE] and [DATE]. On [DATE], Surveyor # requested and received Resident #12's most current GI assessment. Surveyor # received a nursing note dated [DATE] which was titled, "...Gastrointestinal Note..." It indicated Resident #12 had "gastrointestinal problems." Surveyor # spoke with the Director of Nursing (DON) regarding a more recent GI assessment. The DON indicated the assessment dated [DATE] was the most current. To date, there was no evidence of a systematic comprehensive GI assessment since the nursing note dated [DATE]. On [DATE] at 1:10 p.m., Surveyor # observed CNA-P (Certified Nursing Assistant) and CNA-R assist Resident #12 into bed and then provide cares. Surveyor # noted a sippy cup filled to the top with water on Resident #12's bedside stand. At no point prior to CNA-P and CNA-R exiting Resident #12's room did they offer Resident #12 anything to drink. Example #3: Surveyor # completed a review of Resident #16's clinical record and noted the following. Resident #16 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated Resident #16: ~Had a severe cognitive impairment; ~Had mood indicators of feeling down; ~Ate independently with set-up; and, ~Had a recent Urinary Tract Infection [MEDICAL CONDITION]. Resident #16's bowel and bladder care plan, dated [DATE], directed staff to offer extra fluids. Resident #16's nutrition care plan indicated Resident #16 had a history of [REDACTED]. It directed staff to encourage fluids with every interaction. Resident #16's most current dehydration assessment was dated [DATE]. It identified Resident #16 as having symptoms of dehydration. Surveyor # completed a review of Resident #16's nursing notes and noted the following: ~[DATE], "...Nutrition Risk...Eats < (less than) 75% 3 Consecutive: Yes... Infection: yes, recently treated for [REDACTED]. ~[DATE], "...Dietary Note: Annual Review... Total Fluid Requirement: 1950cc (cubic centimeters)...Fluid Intake..XXX,[DATE]cc daily from meals alone... Constipation: yes... Depression: Yes... UTI Past 30 Days: Yes...Intake adequate to meet estimated needs. At risk for dehydration..." The facility had identified that Resident #16 was at risk for dehydration based on a recent infection, diagnoses, and a fluid intake that was 950 cc's less than what Resident #16 required. Despite this, there were no changes made to Resident #16's plan of care to manage her fluid status and provide for additional fluids. On [DATE] at 2:00 p.m., Surveyor # spoke with the Director of Nursing (DON) and requested intake and output (I&O) for Resident #16. The DON indicated formal I&O had not been done. The DON stated they utilized the Certified Nursing Assistant (CNA) documentation of food and fluid intakes to look at resident's fluid intake. Surveyor # completed a review of the facility's policy for documenting fluid intake. The policy titled "Nutritional Risk Tracking," directed staff, via a computer program, to document fluid intake in specific ranges rather than actual amounts of fluid consumed. This practice makes it impossible to determine actual fluid intake. Nursing notes continue: ~[DATE], "...Resident is eating <75% at 7 of 9 meals. Resident's weigh is stable and she is averaging ,[DATE]% at meals...is now finished with antibiotic, anticipate her intakes to be > (greater than) 75% at most meals in the next week or 2..." ~[DATE], "When checked on next rounds between 0500 (5:00 a.m.) and 05:30 (5:30 a.m.) she was unresponsive, lethargic...Resident is eating <75% at 7 of 9 meals. Resident's weight is stable at this time will continue with her current plan of care..." Surveyor # completed a review of Resident #16's weights and noted the following: [DATE] - 125.8 pounds [DATE] - 121.8 pounds. This is a 4-pound weight loss in 14 days. Nursing notes continue: ~[DATE], "...Resident refused fluids at the past 3 meals, will encourage fluids with every interaction...Several meds (medications) dc'd (discontinued) due to change of condition of being lethargic and unresponsive...Dx (diagnosis) of UTI. Put on PO (oral) ATB (antibiotic)...new intervention to encourage fluids with every interaction and daily hydration assessments..." There was no hydration assessment completed until [DATE] at which point, Resident #16 had indicators of dehydration. Nursing notes continue: ~[DATE], "...refusing to eat or drink anything this shift..." Resident #16 has had a significant decline in condition. Despite this, the only new intervention added to her plan of care was to encourage fluids with every interaction and daily hydration assessments. No I&O was initiated. There were no individualized approaches added to Resident #16's plan of care in attempts to improve intake. Additionally, there was no evidence of vital signs being obtained since [DATE]. On [DATE], Resident #16 was placed on comfort measures. Example #4: Resident #27 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current MDS, dated [DATE], indicated Resident #27: ~Was cognitively intact; ~Required extensive assistance to eat; ~Weighed 236 pounds; and, ~Was on a mechanically altered diet. Resident #27's Care Area Assessment (CAA) summary, dated [DATE], indicated Resident #27 triggered dehydration and fluid maintenance. The dehydration CAA indicated, "...triggered for dehydration CAA due to having s/s (signs and symptoms) of constipation. Resident went 5 days with no BM (bowel movement) on admission...offered extra fluids...is drinking < (less than) 240cc (cubic centimeters) at 3 of 17 meals...weigh, intake, and hydration are monitored weekly." The CAA indicated Resident #27 was at very high risk for developing dehydration. The only care plan intervention was to offer extra fluids. Resident #27's nutrition care plan, dated [DATE], directed staff to complete a weekly hydration assessment, weigh weekly, and encourage fluids with every interaction. Surveyor # completed a review of Resident #27's dietary assessment dated [DATE]. This indicated Resident #27 had a weight of 236 pounds, required 3218 cc's (cubic centimeters) of fluid every day, was on a pureed diet with honey thickened liquids, had an elevated serum osmolality indicating possible dehydration, and had constipation. The assessment indicated, "...no special nutritional approaches are necessary for the resident..." Under the heading "Summary of Findings" it indicated, "...Intake adequate to meet estimated needs. At risk for dehydration...Weekly weight. Weekly hydration assessment..." Surveyor # completed a review of Resident #27's hydration assessment dated [DATE]. The assessment indicated Resident #27 had no findings for dehydration. The care plan intervention was to assist Resident #27 with fluids and to monitor weekly. Surveyor # completed a review of Resident #27's nursing notes and noted the following: ~[DATE], "...Blood Pressure: ,[DATE]...Weight: 236 (pounds)..." ~[DATE], "...Thickened liquids...puree diet...Problems with eating and swallowing..." ~[DATE], "...Requires setup help only from staff for eating..." ~[DATE], "...Infections: admitted with Thrush treated with [MEDICATION NAME]" ~[DATE], "...open area where toenail fell off..." On [DATE], the facility completed another dehydration assessment. This assessment indicated Resident #27 had no findings for dehydration. Resident #27 was admitted after having a stoke. Resident #27 had been identified as requiring an altered diet including thickened liquids, had problems with swallowing, had thrush an oral fungal infection, and had developed an open area. These are all significant risk factors for the development of dehydration. There were no changes made to Resident #27's plan of care to ensure that Resident #27 was receiving sufficient fluids. Nursing notes continue: ~[DATE], "...kelfex qid (four time a day) for suspected infection of right of second toe..." ~[DATE], "...Weight: 224.7 (pounds)..." ~[DATE], "...redness, necrotic nail bed right foot 2nd (second) toe...Drainage: Scant...yellow..." On [DATE], the facility completed another dehydration assessment. The assessment indicated Resident #27 had no findings for dehydration. Resident #27 now had an infection, and had lost 11.3 pounds in 13 days. These are significant indicators for possible dehydration. There were no changes made to Resident #27's plan of care to ensure Resident #27 was receiving sufficient fluids. According to "Dehydration And Fluid Maintenance In the Long-Term Setting," which states, "...The presence of multiple signs and symptoms may provide a more urgent or specific indication that the patient has a fluid or electrolyte imbalance. Recent rapid weight loss is often an important clue because it may reflect progressive depletion of fluid volume..." Nursing notes continue: ~ [DATE], "...PA (physician assistant) reviewed blood sugars this am (morning) and new orders received due to [MEDICAL CONDITION] (high blood sugar)..." On [DATE], the facility completed another dehydration assessment. This assessment again indicated Resident #27 had no findings for dehydration. Resident #27 did have multiple significant indicators of dehydration. Resident #27 now was also having problems with high blood sugars, which in and of itself, creates fluid and electrolyte imbalances. These indicators were not captured on Resident #27's dehydration assessment. There were no changes made to Resident #27's plan of care to ensure that he was receiving sufficient fluids. Nursing notes continue: ~[DATE], "...Blood Pressure: ,[DATE]...Dr (physician)...notified of deceased appetite..." ~[DATE], "...Noted poor intake/wt (weight) loss..." ~[DATE], "...Has had a weight loss of 5% or more in the last 30 days...Right foot 2nd toe remains red/swollen...Nail bed is necrotic...Weight: 212.4 (pounds)..." Resident #27 was noted to be hypertensive with a blood pressure of ,[DATE], and had now lost 23.6 pounds in less than 30 days. There were no changes made to Resident #27's care plan. Surveyor # completed a review of Resident #27's bowel record for [DATE] and noted the following: ~From [DATE] through [DATE], Resident #27 did not have a bowel movement. On [DATE], Resident #27 was noted to have 1 moderate stool. ~From [DATE] through [DATE], Resident #27 did not have a bowel movement. On [DATE], Resident #27 was noted to have 1 large stool. ~From [DATE] through [DATE], Resident #27 did not have a bowel movement. On [DATE], Resident #27 was noted have 1 moderate stool. From [DATE] through [DATE], (21 days), Resident #27 had 6 bowel movements. This would indicate constipation. According to "Dehydration And Fluid Maintenance In the Long-Term Setting," constipation also suggests a hydration problem. The facility's practice is to document fluid intake via a computer program, which documents fluid intake within ranges instead of the actual amount of fluid intake. The ranges are as follows: ~less than 240 cc (cubic centimeters) ~240 - 299 cc ~300 - 359 cc ~360 - 419 cc ~420 - 480 cc ~greater than 480 cc. Surveyor # completed a review of Resident #27's fluid intake for [DATE] utilizing the highest amount of fluid documented in each range. Fluid intake ranged from 539 cc's to 1379 cc's in a 24-hour period. Resident #27 did not meet his required fluid needs of 3218 cc's on any day in July. Example #5: Resident #29 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. In [DATE], Resident #29 was hospitalized . The Discharge Summary, dated [DATE], indicated Resident #29 had been hospitalized for [REDACTED]. The Discharge Summary directed staff to ensure Resident #29 consumed at least 1800 cc's (cubic centimeters) of fluid but not to exceed 2000 cc's of fluid every day. On [DATE], Resident #29 was again hospitalized . Resident #29 returned to the facility on [DATE]. The Discharge Summary, dated [DATE], indicated Resident #29 had been hospitalized for [REDACTED]. Resident #29's most current OBRA Minimum Data Set (MDS), dated [DATE], indicated Resident #29: ~Cognition was moderately impaired; ~Had mood indicators of feeling down or depressed and tired; ~Required extensive to total assistance of 1 to 2 staff persons for bathing, dressing, bed mobility, transfers, and toileting; ~Required supervision and set up to eat; and, ~Did not walk. Resident #29's most current Care Area Assessment (CAA) summary was dated [DATE]. Dehydration and fluid maintenance were not triggered. The Care Area Assessment (CAA) summary for falls was dated [DATE]. It indicated, "..XXX[DATE] was admitted to the hospital due to weakness, unable to amb (ambulate) at home & (and) freq (frequent) falls. Labs showed dehydration. Received IV (intravenous) hydration..." Resident #29's care plan for bowel and bladder was dated [DATE]. It directed staff to offer Resident #29 extra fluids. Resident #29's care plan for nutrition indicated Resident #29 had a history of [REDACTED]. Surveyor # completed a review of Resident #29's dehydration assessments dated [DATE] and [DATE]. Both assessments indicated no findings for dehydration. Surveyor # completed a review of Resident #29's most current comprehensive dietary assessment dated [DATE]. This indicated Resident #29 required 3282 cc's of fluid every day. The assessment also indicated Resident #29 had adequate intake but was at risk for dehydration related to a recent [DIAGNOSES REDACTED]. This assessment was based on Resident #29's clinical condition upon admission. Since that time, Resident #29 had been hospitalized twice for acute conditions. There were no further comprehensive dietary assessments received. Surveyor # completed a review of Resident #29's weight and noted the following: ~[DATE], "...Weight: 220.5..." ~[DATE], "...Weight: 220.0..." ~[DATE], "...Weight 208.5..." This reflects a 12-pound weight loss in 14 days. According to Resident #29's medical record, on [DATE], Resident #29 developed a stage 2 pressure ulcer. By [DATE], the pressure ulcer was noted to be a stage 3 pressure ulcer. On [DATE], Surveyor # requested intake and output records as they related to Resident #29's hospital discharge orders from [DATE]. On [DATE] at 2:00 p.m., Surveyor # spoke with the Director of Nursing (DON). The DON indicated Resident #29 had not been on intake and output. The DON stated she was unsure of the circumstances surrounding the order. No further information was received. The facility's practice is to document fluid intake via a computer program, which documents fluid intake within ranges instead of the actual amount of fluid intake. The ranges are as follows: ~less than 240 cc (cubic centimeters) ~ 240 - 299 cc ~300 - 359 cc ~360 - 419 cc ~420 - 480 cc ~greater than 480 cc. Surveyor # completed a review of Resident #29's fluid intake from [DATE] through [DATE], utilizing the highest amount of fluid documented in each range. Fluid intake ranged from 240 cc's to 1440 cc's in a 24-hour period with the average fluid intake being 763 cc's per day. Resident #29 did not meet her fluid needs of 3282 cc's per day as noted by the dietary assessment nor by the physician, as ordered on [DATE], on any day. Neither of the hydration assessments dated [DATE] or [DATE] captured Resident #29's weight loss, pressure ulcer, infection, decreased fluid intake, or changes in her clinical condition since admission. There were no changes made to Resident #29's plan of care to ensure Resident #29 was receiving sufficient fluids to prevent dehydration. Example #6: Resident #30 was admitted to the facility on [DATE] from the hospital. Admitting [DIAGNOSES REDACTED]. Resident #30 also had a history of [REDACTED]. The MDS dated [DATE], indicated Resident #30: ~Had no cognitive or memory problems; ~Was always continent of bowels; and, ~Was not on a bowel toileting program. Resident #30's Care Area Assessment (CAA) summary, dated [DATE], does not address Resident #30's bowel obstruction. Resident #30's bowel and bladder care plan, dated [DATE], indicated a history of a volvulus. There were no approaches on the care plan however to direct staff on how to assess and/or identify a bowel obstruction. Surveyor # completed a review of Resident #30's nursing notes from [DATE] through [DATE]. The nursing notes did not contain a systematic bowel assessment. On [DATE], Surveyor # requested evidence of a comprehensive bowel assessment for Resident #30. No information was received. On [DATE] at 1:45 p.m., Surveyor # spoke with RN-Z (Registered Nurse) about the facility's practice of placing residents on intake and output (I&O). RN-Z indicated there was no set policy for I&O. RN-Z stated I&O was based on each individual resident and their condition. RN-Z indicated if she had a concern of someone who was not getting enough fluids, she would initiate I&O. RN-Z indicated she would consider I&O for anyone with an infection or low fluid intake. RN-Z stated the DM (Dietary Manager) also monitored residents' intake and weights. RN-Z stated if the DM had any concerns regarding a resident's fluid intake she would inform nursing. Surveyor # also asked RN-Z what the care planned approach meant by offering fluids with every interaction. RN-Z stated anytime that anything was done for a resident, fluids should be offered. On [DATE] at 2:00 p.m., Surveyor # spoke with the DON and DM. The DM indicated she was the person who monitored residents for dehydration. She indicated any resident with symptoms of dehydration would be put on I&O. The DM indicated at risk residents were identified via a clinical evaluation as well as the documentation of fluid intake completed by the CNAs (Certified Nursing Assistants). The DON indicated the DM managed residents' hydration status with nursing's input. Surveyor # asked the DM when she completed a comprehensive assessment for residents. The DM indicated it was done according to the MDS schedule, that being upon admission, annually, and with a significant change.

Based on observations, staff interviews and record reviews, the facility did not provide the necessary treatment and services to promote the healing and prevent infection for 1 of 14 sampled residents reviewed for pressure ulcers. Resident #3 has a stage III pressure ulcer on her coccyx that was acquired at the facility. Observations during the survey revealed that facility staff were not repositioning Resident #3 on a regular basis, did not do a proper dressing change treatment of [REDACTED].#3 when she sat in her wheelchair. This is evidenced by: Surveyor # 's review of Resident #3's medical record revealed Resident #3 was admitted to the nursing home on 11/30/11, following a [MEDICAL CONDITION] (stroke). This resulted in [MEDICAL CONDITION] and [MEDICAL CONDITION] affecting Resident #3's left side. Resident #3 has a flaccid left side. Resident #3 also has [DIAGNOSES REDACTED]. Resident #3 uses a mechanical lift for transfers, which is operated by staff. Review of Resident #3's most recent Minimum Data Set Assessment ((MDS) dated [DATE], reveals the following: ~Extensive assistance for bed mobility; ~Total dependence of staff for transfers; ~Upper and lower extremity impairment on one side; ~No rejection of care; ~Frequently incontinent of urine and always incontinent of bowel; and, ~1 stage III pressure ulcer. Review of the Braden Scale for Pressure Ulcer Assessment Risk completed on Resident #3 on 06/03/12, revealed a score of 12 (score of 10-12 indicates high risk). Review of Resident #3's most recent care plan and CNA communication sheet (Certified Nursing Assistant) received from the facility on 06/05/12, includes the following approaches: ~Up for meals only; ~Full body lift; ~Toilet check and change q 2 hours; and, ~Lotion skin with cares. On 06/04/12, the wound clinic recommendations were as follows for Home Ulcer Care: "Cleanse with skin cleanser, apply [MEDICATION NAME] (over collagen), Collagen, change every 3 days (and as needed). Reposition off coccyx to reduce pressure." Review of Resident #3's wound notes dated 06/01/12, indicates the following: Pressure Ulcer: Stage 3. Location: Coccyx. Size: Length/CM (centimeters): .5, width/CM: 4, Depth/CM: .2. Wound perimeter: maceration present. Wound bed: beefy red. Tissue condition: granulation present. The plan was noted to be as follows: Toilet and reposition every 2 hours....maintain correct w/c (wheelchair) positioning, control incontinence. Surveyor # observed staff get Resident #3 out of bed on 06/04/12 at 3:05 p.m. Resident #3 was lifted from the bed with a mechanical lift using a sling. Resident #3 was placed in her wheelchair and the canvas sling was left underneath her. On 06/05/12 beginning at 6:45 a.m., Surveyor # conducted a continuous observation of Resident #3 and noted the following: ~6:45 a.m., Resident #3 was observed dressed and sitting up in her wheelchair in her room. A heavy canvas sling was observed underneath Resident #3. ~7:05 a.m., Resident #3 was observed still sitting in her wheelchair in her room, sleeping. ~7:50 a.m., Resident #3 was assisted by staff to the dining room for breakfast. Resident #3 was observed assisted with breakfast, and remained in the dining room in her wheelchair. ~9:05 a.m., she was assisted back to her room in her wheelchair. Resident #3 was left sitting in her wheelchair in her room. ~9:40 a.m. a staff person entered her room and told Resident #3 that they would be laying her down shortly. ~9:46 a.m., staff assisted Resident #3 from her wheelchair to her bed. Staff took off Resident #3's incontinence brief/pad which was wet and staff reported to Surveyor # that they were cleansing her. A new brief/pad was put on. No offer of toileting was given to Resident #3. Resident #3 was up for 3 hours sitting in her wheelchair directly on her coccyx with no repositioning. When repositioned at 9:45 a.m., no toileting was offered and Resident #3 had a wet incontinence brief/pad. On 06/05/12 at 2:00 p.m., Surveyor # spoke with CNA-E (Certified Nursing Assistant). CNA-E said Resident #3 has open areas on her bottom and that Resident #3 goes to the Wound Clinic for these. CNA-E said Resident #3 can only be up for short periods at a time, usually just up for meals. CNA-E said they check and change Resident #3 at least every 2 hours and when positioned in bed, they position Resident #3 side to side. CNA-E said they do not take Resident #3 into the bathroom for toileting. On 06/06/12 at 8:20 a.m., Surveyor # spoke with RN-F (Registered Nurse). RN-F said Resident #3 is at high risk for pressure ulcers. RN-F said Resident #3 had a blister on her left buttocks on 12/27/11; and, a stage II pressure ulcer on her coccyx on 01/11/12, which is now a stage III. RN-F was asked why Resident #3 developed the pressure ulcer on her coccyx. RN-F indicated it was due to incontinence and immobility. RN-F said the current care plan for Resident #3 is to reposition and check and change Resident #3 every 2 hours, reposition side to side in bed, and check the settings on the air mattress. RN-F said Resident #3 had a Joerns Pressure reduction mattress on her bed until she got a low loss air mattress on 02/16/12. On 6/5/12 at 10:18 a.m., Surveyor # observed a dressing change being conducted by LPN-B (Licensed Practical Nurse) for Resident #3. LPN-B washed her hands and donned a pair of gloves. She then removed the soiled dressing from Resident #3's coccyx area, which was a [MEDICATION NAME] and a Collagen within the wound itself. According the LPN-B, the area above the coccyx which measured approximately .5 centimeters in diameter was a healing Stage 3 pressure ulcer. Below the wound was a new area of opening. LPN-B stated, "...it was not identified prior to today. This is a new area of breakdown." The new area measured approximately .25 centimeters in diameter. LPN-B did not remove the soiled gloves and wash or sanitize her hands, nor did she cleanse the wound of potential pathogens. She then placed a new 1-inch squared piece of Collagen into the wound and covered the area with a new [MEDICATION NAME] dressing. According to the Wound Clinic orders dated 6/4/12, staff are to cleanse the wound with skin cleanser then apply a [MEDICATION NAME] dressing over the Collagen. They are to change the dressing every three days and as needed.

Based on observation, interview, and record review, the facility did not ensure that 1 of 3 residents sampled for pressure ulcers received the necessary care and treatment to promote healing and prevent new pressure ulcers from developing. Resident #29 had a history of [REDACTED]. The only notation of the pressure ulcer was on Resident #29's physician orders. There were no changes made to Resident #29's plan of care to direct staff on how to care for Resident #29's pressure ulcer. From 7/2/12 to 7/8/12, there was no documentation in Resident #29's clinical record regarding the status of Resident #29's pressure ulcer. There were no changes made to Resident #29's plan of care. On 7/8/12, Resident #29's pressure ulcer had deteriorated and was noted as a stage 3 pressure ulcer. It was not until 7/9/12, that the facility implemented changes to Resident #29's plan of care. This is evidenced by: Resident #29 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. According to Resident #29's admission Minimum Data Set ((MDS) dated [DATE], Resident #29 entered the facility without a pressure ulcer. The most current MDS, dated [DATE], indicated Resident #29: ~Had moderately impaired cognition; ~Required extensive to total assistance of 1 to 2 staff persons for bathing, dressing, bed mobility, transfers, and toileting; ~Was frequently incontinent of bladder; ~Did not walk; ~Had a pressure reduction mattress, and had pressure ulcer care; and, ~Had a stage 3 pressure ulcer. The MDS did not identify Resident #29 as having a pressure reduction device in her wheelchair. Resident #29's most current Care Area Assessment (CAA) summary for pressure ulcers was dated 3/19/12. The CAA indicated, "...No pressure ulcers...requires staff assistance to move sufficiently to relieve pressure...confined to a bed or chair most of the time. Requires pressure reducing mattress or seat cushion...Incontinence - freq (frequently) of [MEDICAL CONDITION] (stroke)...Recent decline...Functional limitation in range of motion due to left sided [MEDICAL CONDITION] (weakness)...Will develop Care Plan..." Resident #29's skin care plan was dated 3/7/12. On 8/2/12, a revised care plan was printed with additional information added to the care plan which indicated Resident #29 had a stage 3 pressure ulcer. The approaches were noted as follows: ~3/7/12, "...Float Heel..." ~3/12/12, "...side to side lying when in bed..." ~7/9/12, "...Pressure relieving device...for chair - Roho - check inflation q (every) shift..." ~7/12/12, "...Check mattress control setting, q shift..." ~7/20/12, "...Pressure relieving device...for bed..." ~7/27/12, "...Treatment as ordered to coccyx..." Surveyor # completed a review of Resident #29's physician orders [REDACTED]. According to the National Pressure Ulcer Advisory Panel, a Stage 2 ulcer is defined as, "Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough...This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. Nurse's noted indicate: ~7/7/12, "...New Open Area: None..." Surveyor # completed a review of Resident #29's skin risk assessment titled "Braden Scale," dated 7/7/12. Resident #29 scored a "16," which, according to this scale indicates Resident #29 is "at risk" for pressure ulcer development. The accuracy of the skin risk assessment is in question as Resident #29 already had an existing pressure ulcer. Nurse's notes continue: ~7/8/12, "...Pressure Ulcer: Stage 3...coccyx...Length/CM (per centimeter) 4 (4.0), Width/CM: 2 (2.0), Depth/CM: 0.2..." ~7/10/12, "...Location: Left buttocks, upper, Right buttocks, upper...Length/CM: 4, Width/CM: 2, Depth/CM: .2 (0.2)...Check, change and Reposition every 2 hours. Enc (encourage) side to side lying when in bed...Treatment changed to dodder...Added zinc sulfate to vitamin regime...Cushion in W/C (wheelchair) changed from honeycomb to roho..." ~7/12/12, "...Now has low air loss mattress on bed...up for meals only as tolerated..." All the changes made to Resident #29's plan of care were after the stage 2 coccyx ulcer deteriorated to a stage 3 pressure ulcer. On 7/15/12, Resident #29 had a change in condition and was subsequently admitted to the hospital. Resident #29 returned to the facility on [DATE]. The facility completed another skin risk assessment on 7/15/12. The skin risk assessment identified Resident #29 as being at high risk for the development of a pressure ulcer. This is after the development of Resident #29's stage 3 pressure ulcer. Nursing notes continue: ~7/20/12, "...gluteal cleft length/CM: 4.4, Width/CM: 2, Depth/CM: .1 (0.1)...Wound Bed...50% slough..." According to the National Pressure Advisory Panel, any pressure area where the wound bed is covered with slough is considered an unstagable pressure ulcer. Nursing notes continue: ~7/27/12, "...Late entry for 7/25/12...gluteal cleft...Length/CM: 3.9, Width/CM: 1.7, Depth/CM: .1...Wound Bed...Slough 75%...healing..." Resident #29's pressure ulcer was covered with 75% slough. This would make it impossible to determine the stage of the pressure ulcer as the wound base was not visible. To indicate that the pressure ulcer was healing would be inaccurate. On 7/28/12, Resident #29 was unable to void. A Foley catheter was subsequently placed. Nursing notes continue: ~8/2/12, "...Pressure Ulcer: Stage 3...coccyx...Length/CM: 3, Width/CM: .9 (0.9), Depth/CM: .1 On 8/8/12 at 10:20 a.m., Surveyor # observed RN-Z and RN-F complete a dressing change for Resident #29's pressure ulcer. Surveyor # observed a stage 3 pressure ulcer on Resident #29's coccyx area. The pressure ulcer was measured by RN-F as length: 1.5 cm width: 1.0 cm and depth: 0.2 cm (the wound was wider and deeper than the previous measurement on 8/2/12). Surveyor # noted that the wound base was pink, clean, and without slough. There was also approximately 0.5 CM to 1.0 CM of maceration surrounding the wound. RN-F indicated she was the certified wound nurse. RN-F stated the facility had previously classified Resident #29's pressure ulcer as Incontinent Associated [MEDICAL CONDITION] (IAD). RN-F stated when Resident #29 was hosptalized on [DATE], Resident #29 returned to the facility with orders to go to the wound clinic. RN-F stated the wound clinic identified the wound as a stage 3 pressure ulcer. According to the article, " Beyond ' diaper rash ' : Incontinence Associated [MEDICAL CONDITION] Does it Have You Seeing Red? " published in Nursing 2008, " The condition of IAD (Incontinence Associated [MEDICAL CONDITION]) occurs as a result of exposure to urine or fecal matter. Therefore IAD injuries will not be confined to an area over a bony prominence...The injured area will have more irregular, diffuse margins in the locations exposed to the output. Another difference between IAD and PrUs (Pressure Ulcers) is that IAD will not cause a full-thickness skin injury (unless complicated by infection). " Because the original ulcer was confined to an area over a bony prominence and had regular margins (described as a "slit") the area was incorrectly defined as IAD. RN-F also stated she was initially unaware of Resident #29's pressure ulcer which was noted on 7/2/12. RN-F also stated she felt Resident #29 developed the pressure ulcer related to moisture from incontinence and of Resident #29's size. RN-F indicated she felt the facility had treated the pressure ulcer appropriately and also felt it would heal. On 8/8/12 at 9:25 a.m., Surveyor # spoke with the DON. The DON indicated any new pressure ulcer should be put on the care plan to ensure appropriate treatment.

Based on interviews and record reviews, the facility did not maintain 1 of 1 sampled resident's highest practicable physical well-being. Resident #1 was admitted following a 20 day hospitalization . Upon admission, the facility did not identify Resident #1's risk factors for dehydration, did not develop a care plan to prevent Resident #1 from developing fluid volume deficits, and did not act on Resident #1's low fluid intakes. 6 days after admission to the facility, Resident #1 was hospitalized for [REDACTED]. This is evidenced by: On 09/27/11 the facility provided a copy of the policy titled "Hydration Assessment." The purpose of the policy was "to identify residents at risk for dehydration and assess resident for s/s (signs and symptoms) of dehydration." The procedure read "Complete monthly as a pertinent note if not exhibiting symptoms. Complete per symptom pursuit if acute symptoms, or weekly if any of the following present:...C. Fluid intake < 1000cc/24hrs..." Resident #1 was admitted to the facility on [DATE] with the following, but not all inclusive, Diagnoses: [REDACTED]. The Whipple procedure consists of the removal of the gallbladder, common bile duct, part of the duodenum (part of the small intestine), and the head of the pancreas. Review of the discharge summary from the hospital stay of 08/08/11 through 08/30/11 noted, "On the fifth postoperative day, he was started on sips of clear liquids, which initially he tolerated. But, over the course of the hospitalization , he had the usual poor [MEDICAL CONDITION] emptying that most Whipple patients have, and he would vomit approximately once a day." Surveyor # reviewed Resident #1's hospital progress notes and noted the following: *08/25/11, physician discontinued TPN (total [MEDICATION NAME] nutrition) and started a soft diet; *08/29/11, hospital RD (Registered Dietician) wrote calorie count noted 510 calories and 32 gms (grams) of protein; *08/29/11, physician wrote calorie count of 500 not nearly enough, encourage fluids; *08/30/11, RD wrote calorie count of 940 calories and 38 gms protein. Hospital lab data revealed: *08/29/11 BUN (blood urea nitrogen) was 24.3. Normal values are 8.4 - 25.7; *08/29/11 creatinine was 1.32. Normal values are 0.72 - 1.5; *08/29/11 sodium was 141. Normal values are 136 - 145. Review of the hospital BP (blood pressure) and pulse for Resident #1 from 08/28/11 through 08/30/11, the systolic blood pressure ranged from 117-148. The diastolic blood pressure ranged from 60-91. Resident #1's pulse ranged from 79-98 beats per minute. Review of the hospital MAR (Medication Administration Record) from 08/23/11 through 08/30/11 noted Resident #1 received medication for nausea on 5 out of the 8 days including the day of discharge. The MDS (Minimum Data Set) assessment completed on 09/12/11 noted that Resident #1: *Was able to make self understood and understand others; *Short and long term memory was adequate; *Was independent with decision making; *Was independent with eating; *Had frequent pain complaints; *Weighed 187# and was 67" tall; *Received a therapeutic diet; *Had no problems chewing or swallowing; and, *Had no weight loss identified. Review of the comprehensive care plan for Resident #1 did not identify any risk for dehydration or fluid volume deficit. Resident #1 had a care plan with problems of "discharge," "altered thought process," "skin integrity," and "nutrition." The nutrition care plan was dated 09/06/11 and noted Resident #1's strengths as "Eats well, Feeds self, Verbalizes preferences." The care plan noted a goal of "Will have no nausea, Will have no GI (gastrointestinal) complaints, Three months." The approaches were medications as ordered, diet as ordered, hydration assessment monthly, diabetic condiments, eats in dining room, and weekly weights on Monday. Review of the facility's MAR indicated [REDACTED]. Review of the nurse's notes for Resident #1 dated 09/02/11 and 09/05/11 noted Resident #1 had an emesis of undigested food. There was no notification of the primary physician. Review of Resident #1's initial dietary note on 09/06/11 by the DM (Dietary Manager) noted the following: *usual body weight was 180#; *total daily calorie requirement was 1991 calories; *total daily fluid requirement was 2552 mls (milliliters); *no infection (Inaccurate: Resident #1 was actively being treated for [REDACTED]. *weight was 187# (Inaccurate: Resident #1's weight was documented as being 171 to 169#); *no surgery (Inaccurate: Resident #1 had a Whipple procedure on 08/08/11); *no weight loss (Inaccurate: According to the documented weights, Resident #1 had a 9# or 5% weight loss in less than 30 days); *no pressure ulcers or stasis ulcers (Inaccurate: Resident #1's skin assessment indicated a red coccyx, surgical incision, and 2 drains); *fluid intake less than 1000 mls per day; *no constipation (Inaccurate: Resident #1 had a [DIAGNOSES REDACTED]. *summary of findings were "Intake adequate to meet estimated needs. Not at risk for dehydration." Plan was "Weekly weights, Monthly hydration assessment..." In the assessment, the Dietary Manager identified that Resident #1 was consuming less than half of his required fluids on a daily basis. Review of Resident #1's medical record found no Registered Dietitian assessment of Resident #1's nutrition or hydration status or needs. Review of the intake documentation for Resident #1 as receiving the following amounts of fluid: *08/31/11 total of 570 mls; *09/01/11 total of 600 mls; *09/02/11 total of 360 mls; *09/03/11 total of 1080 mls; *09/04/11 total of 900 mls; *09/05/11 total of 840 mls. Resident #1's intakes were not sufficient to meet his assessed needs. Review of the nutrition at risk assessment completed for Resident #1 on 09/02/11 by RN-A (Registered Nurse) noted no nutritional problems. Information contained in the assessment included meal consumption, weight loss, pressure ulcers, and other skin problems. On 09/06/11, Resident #1 had a previously scheduled follow-up appointment with the PMD (Primary Medical Doctor). Review of the PMD notes dated 09/06/11, revealed a BP of 78/48 and a pulse of 101. "Dehydrated aprox (approximately) 20% fluid vol (volume). PT (patient) FOUND TO BE HYPOTENSIVE...LOSS OF SKIN TURGOR. ESTIMATED VOL (volume) CONTRACTION 20-30%. WILL ADMIT ACUTELY FOR REHYDRATION..." Clinic weight was noted as 166#s. "Mouth: Dry and tacky. EXTREMITIES: total loss of skin turgor. Follow up ADMIT FOR SEVERE DEHYDRATION." Review of the hospital records for Resident #1's hospital stay of 09/06/11 through 09/14/11 noted: *09/06/11 physician orders [REDACTED]." The admission orders Admit-dehydration (20%). IV (intravenous) D5NS-20 KCl/L 200 cc/hr x 2 liters then 125 cc/hr." *09/06/11 BUN was 29.6 high; *09/06/11 creatinine was 1.70 high; *09/06/11 sodium was 137 normal; *09/11/11 BUN was 7.2 low; *09/11/11 creatinine was 1.15 normal; *09/11/11 sodium was 135 low Review of the physician progress notes [REDACTED]. Review of the blood pressure for Resident #1's hospital stay beginning 09/06/11 noted: *at 4:40 p.m. 95/56; *at 8:40 p.m. 107/54; *at 11:55 p.m. 118/62. Review of the hospital graphic data for Resident #1 noted: *the total 24 hr IV intake for 09/06/11 through 09/07/11 was 3056 mls; *the total 24 hr IV intake for 09/07/11 through 09/08/11 was 2824 mls. On 09/27/11 at 10:25 a.m., Surveyor # interviewed the facility's Medical Director. The Medical Director reviewed Resident #1's medical record prior to the interview. Surveyor # asked how long it would take for Resident #1 to be volume depleted and the Medical Director stated "within a few days." Surveyor # asked what standards of medicine should the facility have done for Resident #1 and the Medical Director stated monitor intakes and outputs, review medications for possible nausea side effects, and report any vomiting to the physician. The Medical Director stated Resident #1 had "a lot of pathology." On 09/27/11 at 11:10 a.m., Surveyor # interviewed the DM regarding Resident #1. The DM stated she was unaware that Resident #1 had thrush. The DM stated Resident #1 had a recorded weight of 171# on 08/31/11 and 09/01/11 and a recorded weight of 169# on 09/02/11. The Surveyor discussed the inaccurate information that was noted in the DM's assessment which the DM confirmed was done on 09/06/11. On 09/27/11 at 1:00 p.m., Surveyor # interviewed the DON (Director of Nurses). The DON confirmed to Surveyor # that Resident #1 did not have a hydration assessment completed upon admission. The DON stated that since Resident #1's PMD (Primary Medical Doctor) voiced concern to the facility regarding Resident #1's rehydration hospitalization , the facility had changed its practice to include hydration assessment to be completed on all new admissions. On 09/27/11 at 1:45 p.m., Surveyor # interviewed the PMD regarding Resident #1. Surveyor # asked the PMD what medical standards should the facility have done for Resident #1. The PMD stated Resident #1 was not eating or drinking and the facility, "Should have called me and I would have come to see him at the nursing home." The PMD stated he would have expected the nursing staff to inform him of any emesis or poor intakes. The PMD stated he did not receive any information regarding Resident #1's status until the first post operative office visit. The PMD stated Resident #1 had lost weight, had sunken eyes, had no skin turgor, had low BP, and had abnormal laboratory data. On 09/27/11 at 3:20 p.m., Surveyor # interviewed LPN-B (Licensed Practical Nurse). LPN-B stated she cared for Resident #1 over the week-end of 09/03/11. LPN-B stated Resident #1 was able to eat and drink independently. LPN-B stated that Resident #1 "never looked good" and he looked "tired." LPN-B stated she made an effort to ensure that Resident #1 ate or drank a bedtime snack because of his diabetes. LPN-B stated she did not consider the emesis a change in status because Resident#1 had multiple emesis while in the hospital and thus did not notify the physician. LPN-B stated that some residents need staff to monitor strict intakes and outputs, but most residents receive ranges of intakes only. On 09/27/11 at 4:25 p.m., Surveyor # interviewed the NHA (Nursing Home Administrator) regarding Resident #1. The NHA stated that the PMD had contacted the facility to report his dissatisfaction with Resident #1's care received while at the facility for only 6 days. The NHA stated she had completed an investigation and telephoned the PMD with her findings. The NHA stated there were no physical findings of any fluid volume deficits and that Resident #1 was progressing in therapy. The NHA stated that the facility had implemented changes that included hydration assessments upon admission as a result of the PMD's complaints.

Based on observation, record review and interviews, the facility did not ensure that 1 of 1 sampled residents reviewed for pressure ulcers received appropriate care and services to prevent the ulcers from reoccurring. Resident #13 was admitted to the facility with a Stage 2 which progressed to a Stage 3 pressure ulcer on her coccyx. The area was healed 5 months later. Since that time, the same area has reopened 3 more times. After each recurrence, the facility did not implement new pressure ulcer prevention interventions. When the area reopened the second time, staff did not document the size, characteristics, location and changes to the ulcer on at least a weekly basis. This is evidenced by: Resident #13 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. An entry in Resident #13's nurse's notes dated 2/23/10 states, "...Pressure ulcers present: Stag. (Stage) 2. # (number of ulcers): 1. Location: Coccyx. Size: Length/cm (length in centimeters): 3.5. Width/cm: 0.6 ..." Resident #1 's Braden Scale assessment completed on 2/23/10 indicates a score of 15. According to the facility's scoring system, 15-18 means a person is "At risk" for pressure ulcer development. The assessment identifies Resident #13's risks to include, "...unable to move self in bed...." Initially, on 2/23/10, the area was assessed as a Stage 2 pressure area and covered with a [MEDICATION NAME] dressing. A [MEDICATION NAME] dressing is designed to be an absorbent, waterproof, adhesive covering of a wound. Resident #13's care plan includes a problem of skin integrity dated 3/3/10. Approaches at the time of development included, "Pressure reduction/bed. Keep heels off bed. Reposition q (every 2-3 hours). CNA skin inspection weekly. Pressure reduction/chair cushion ...." Within 3 weeks time, 3/14/10, the area became larger in size and depth. It became deeper, from a superficial 1 mm (millimeters) in depth to 3 mm in depth. This being a change from a Stage 2 pressure ulcer to a Stage 3. There were no changes made to Resident #13's care plan until 4/1/10. On 4/1/10 an approach of "Roho cushion (air filled) in w/c (wheelchair) ... " was added to the care plan. A Roho cushion is designed to conform to the user's body and self adjusts with movement to increase blood flow. There is no documentation of the size or characteristics of the pressure ulcer the weeks of 4/4/10 and 4/11/10. On 7/9/10, the facility ' s skin committee documented, " ...Remains noncompliant at times with laying down ... " There is no evidence that the facility made changes to Resident #13's care plan to address the noncompliance. According to documentation in the nurse's notes, the Stage 2 pressure ulcer to Resident #13's coccyx resolved on 7/16/10. Review of Resident #13's care plan found that no changes were made/no new interventions were implemented to address prevention of new pressure ulcers. A Braden Scale assessment completed on 8/20/10, identified that Resident #13 continued to be "At Risk" for pressure ulcer development with a score of 15. An entry in Resident #13's nurse's notes dated 10/22/10 states, "Incontinence Associated [MEDICAL CONDITION] (IAD). Location: Coccyx. Length/cm: 3cm, Width/cm: .2cm, Depth/cm: .2 ...." There is no indication that Resident #13 has open/reddened areas anywhere else and that the area is confined to an area over a bony prominence. According to the article, "Beyond Diaper Rash: Incontinence Associated [MEDICAL CONDITION] Does it Have You Seeing Red?" Junkin and Lerner-Selekof state, "...IAD injuries will not be confined to an area over a bony prominence. The injured area will have more irregular, diffuse margins in the locations exposed to the output. Another difference between IAD and PrUs (pressure ulcers) is that IAD will not cause a full-thickness skin injury (unless complicated by infection)." There is no further documentation related to the pressure ulcer over Resident #13's coccyx. Even though previous interventions were found to be ineffective, there were no changes made to Resident #13's care plan to prevent the development of pressure ulcers. A Braden Scale assessment completed on 2/10/11 indicates that Resident #13 is at Moderate Risk for development of a pressure ulcer. An entry in the nurse's notes on 3/4/11 states, "Pressure ulcer: no ...slit coccyx. Length/cm: 9cm, Width/cm: .2, Depth/cm: .1...Plan: Reposition every 2 hours. Lie down after meals ...Continue current plan of care ...." A 3/11/11 Skin Condition note states, "...Resident has reopened an area to her coccyx, ...Will continue current treatment.... " The next note dated 3/24/11 states, " ...Coccyx area remains healed x2 weeks ... " Previous care planned interventions were unsuccessful in preventing the pressure ulcer from redeveloping. However, no new interventions were implemented. A Braden Scale assessment completed on 5/3/11 indicates Resident #13 is at risk for development of pressure ulcers. On 5/10/11 at 9:55 a.m., Surveyor # observed CNA-B and CNA-M perform morning cares and perineal cleansing for Resident #13. Observed during the cares was that Resident #13's coccyx, which was previously healed, had reopened on this date. On 5/10/11 at 10:11 a.m., LPN-C measured the area as 0.8 cm long, 0.4 cm wide, and 0.3 cm deep. The wound bed was bright red. The LPN called the physician and got an order to treat the area at the recommendation of RN-A, as she had completed a recent course in wound care. As of 5/11/11, the treatment had changed but again there are no changes in preventative strategies. There are no updates to Resident #13's care plan. On 5/11/11 at 8:14 a.m., Surveyor # interviewed CNA-B about times in which staff help Resident #13 position off of her bottom. CNA-B (Certified Nursing Assistant) is a consistent caregiver of the resident. CNA-B stated that Resident #13 doesn't like to lay on her side and will often refuse to do so because her hips hurt. Resident #13 will refuse to lay down if it interferes with Bingo or church. On 5/11/11 at 8:19 a.m., Surveyor # interviewed LPN-C (Licensed Practical Nurse). LPN-C is a consistent nurse for the resident. LPN-C stated the pressure relief measures for Resident #13 were her mattress, the Roho cushion, and repositioning. LPN-C also stated that Resident #13 will often not allow staff to reposition her as she prefers to lay on her back and doesn't tolerate being on her sides. Resident #13's refusals to reposition or to lay down were not addressed on the care plan. On 5/11/11 at 9:44 a.m., Surveyor # spoke with the DON. The DON confirmed that no new preventative interventions were implemented for Resident #13.