Every finding on record at Wonder City Rehabilitation and Nursing Center

Based on observation, resident and staff interviews, clinical record review, and facility document review, the facility failed to store hazardous chemicals in a manner to minimize accidents and hazards on two of two units, which had the potential to affect residents on both units. The deficient practice resulted in the identification if immediate jeopardy (IJ) and substandard quality of care. Following the verification and removal of IJ, the scope and severity was lowered to level two, pattern. The findings included:The facility staff failed to ensure that hazardous chemicals were stored in a manner to prevent resident access where the liklihood of exposure and/or accidental ingestion was present, which would likely result in severe injury, harm, or even death. On 05/04/2026 at 12:57 PM, during a tour of the facility, outside of the activity room and therapy gym, in an area with direct access by residents, four (4) unsecured and unlocked janitor carts were observed on unit 2. Two of the carts had faulty locks where the lock mechanism could be freely pulled up and down to engage and disengage the locking mechanism, without requiring a key. The other two carts had the key in the lock, where anyone could use the key to open the cabiner and access the chemicals contained within. Each of the carts contained multiple chemicals, which included foam cleaner, Clorox urine cleaner, Clorox cleaner with bleach, disinfectant spray, and neutral floor cleaner, that were unsecured and accessible to residents. One of the janitor carts had an unlabeled yellowish green colored liquid that was observed in a miniature transparent water bottle, identified as neutral floor cleaner by the Environmental Services (EVS) Director.On 05/05/26 at 5:00 PM during additional observations within the facility, the housekeeping storage room was observed unlocked with a and the door was ajar and the lock was not engaged. Upon entering the room, six (6) unsecured janitor carts were observed. Four (4) of six (6) of the janitor carts were unlocked. Each of the four carts had an accessible compartment that contained multiple chemicals that were unsecured and accessible to residents. The cleaning items included foam cleaner, Clorox urine cleaner, Clorox cleaner with bleach, disinfectant spray, neutral floor cleaner.On 05/05/2026 at 5:05 PM, a housekeeper, Other Staff #3 was asked if the house keeping storage room should be locked and they said the room should be locked at all times. When asked if the housekeeping carts should be locked, they stated the carts are supposed to be locked.Material Safety Data Sheets provided by the facility revealed that one of the chemicals in the house keeping cart, a cleaning solution that contained bleach, had a classification that This product is considered hazardous by the 2012 OSHA [Occupational Safety and Health Administration] Hazard Communication Standard (29 CFR 1910.1200). It also stated, if ingested, call a poison control center or doctor.Staff were interviewed about the risks of residents having access to unsecure chemicals on 05/05/2026 at 6:30 PM. The Unit Manager Second Floor stated the risks could be chemical exposure, dementia residents getting ahold of them, chemical poisoning, possible death.At 6:34 PM, the MDS Coordinator # 2 stated the risks could be They can get burned, they can ingest it, they can spill it and slip, death.At 6:35 PM, the MDS Coordinator #1 stated the risks could be Depends if it's a dementia resident, may try to swallow it. They may use it as a weapon. Depends on cognition and motive, if someone may be aggressive.At 6:37 PM, the Social Worker stated the risks could be Well they could try to take them back to their room, maybe cleaning something on their own without gloves and injure their hands. They may ingest them in they are cognitively impaired and don't know they should not be consumed. If they spilled it, it could cause a slip.At 6:39 PM, Certified Nursing Assistant (CNA) # 10 stated the risks could be Umm they can get sick! They can stop breathing. Have an allergic reaction. They could die. They could get someone else sick. Person who left the chemicals could lose their license or get fired.At 6:6:42 PM, Licensed Practical Nurse (LPN) # 7 stated the risks could be They could drink them, put them in the wrong places if they aren't in a secure place. They should be locked away. Should be in a cleaning cart that is locked and requires a key or code. Can't just leave a bottle of bleach out. Potential for people with dementia, Alzheimer's drinking them.At 6:45 PM, Licensed Practical Nurse (LPN) # 8 stated the risks could be If we have residents who wander or they are not alert and oriented, residents with infections that are confused. They could think it's a drink and it could cause poisoning. If they touch it they may be allergic to it. It might be some materials there that aren't part of the data sheet where we would look for treatment of chemicals.The survey team identified that the facility was in IJ, the Administrator was notified and provided a copy of the IJ template on 05/05/2026 at 6:29 PM.On 05/05/2026 at 6:54 PM, the Administrator submitted an IJ Removal Plan with a completion date of 05/06/26 at 8:00 AM. The plan read as follows.F689 Accidents and Hazards Removal Plan Plan Corrective Action for those residents found to be affected by the deficient practice:The facility immediately removed the chemicals that were found on [NAME] housekeeping storage room and a doorknob with a lock was placed on the housekeeping storage room that locked to ensure the chemicals are secure and inaccessible to the residents. All housekeeping carts were locked and secure.Corrective Actions taken for residents with potential to be affected by deficient practice:All residents have the potential to be affected. The facility did a search of janitor closets to ensure chemicals were secure and inaccessible. The doors to the janitor supply room and the housekeeping office were checked to ensure they were locked and no chemicals were accessible. The shower rooms, common areas, dining rooms, kitchen and service hallways and residents rooms were inspected to ensure no chemicals were unsecured and accessible to residents. Findings were corrected immediatelySystemic Changes put into place to ensure the deficient practice does not recur: The Interdisciplinary Team (Administrator, Director of Nursing, Assistant Director of Nursing, Director of Social Work, Dietary Manager, Business Office Manager, Director of Housekeeping and Laundry, Human Resources, Rehab Director and Unit Managers) will be educated by the Regional Director of Operations on the proper storage of chemicals to ensure that they are stored in a manner that prevents resident access. The Facility Staff will be educated by the Director of Nursing or designee will educate staff on the proper storage of chemicals to ensure that they are stored in a manner that prevents resident access. No employee will be allowed to work until educated.Completion of removal plan at 8:00 am on 5/6/26. On 05/06/2026 at 9:40 AM, interviews were conducted with staff from various departments to include, Director of Maintenance, Rehab Director, Physical Therapy Assistant, Housekeeping Aide, Laundry Aide, Cook, Social Services Director and Social Services Assistant, Human Resources Director, Director of Nursing, Infection Preventionist, Staff Development Coordinator, MDS Nurse, EVS Director, two Unit Managers, Admissions Director, three Nurses, Assistant Director of Nursing, four certified nursing assistants who confirmed they had received education on the proper storage of chemicals to ensure that they are stored in a manner that prevents resident access and were able to articulate if they observed a potentially hazardous chemical what they would to secure and notify appropriate supervisors. Staffing sheets were reviewed to verify staff had received the training in addition to the interviews.On 05/06/2026 at 9:40 AM, the survey team conducted rounds to verify the community's IJ removal plan. During observation of resident rooms at 9:50 AM the observations revealed dermal wound cleanser in Resident # 18's room, spray disinfectant in the bathroom of Resident # 19's room, air freshener aerosol spray in Resident # 11's room, air freshener aerosol spray in Resident # 15's room, Dakins (diluted, antiseptic bleach solution, used to cleanse skin and wounds) wound cleanser solution and extra strength fabric spray in Resident # 20's room, disinfectant spray and rubbing alcohol in Resident # 21's room at 10:11 AM.On 05/06/2026 at 10:20 AM, the Administrator and Regional Director of Clinical Services #2 were notified that the facility's continued failure to ensure all potentially hazardous chemicals were secured and inaccessible to residents. As a result, the likelihood for serious injury, serious impairment, serious harm or death remained present, and the immediate jeopardy removal plan could not be validated. On 05/06/2026 at 10:52 AM, the Administrator submitted a revised IJ Removal Plan with a completion date of 05/06/26 at 2:00 PM. The plan read as follows. F689 Accidents and Hazards Removal Plan Plan Corrective Action for those residents found to be affected by the deficient practice:The facility immediately removed the chemicals that were found on [NAME] housekeeping storage room and a doorknob with a lock was placed on the housekeeping storage room that locked to ensure the chemicals are secure and inaccessible to the residents. All housekeeping carts were locked and secure.Corrective Actions taken for residents with potential to be affected by deficient practice:All residents have the potential to be affected. The facility did a search of janitor closets to ensure chemicals were secure and inaccessible. The doors to the janitor supply room and the housekeeping office were checked to ensure they were locked and no chemicals were accessible. The shower rooms, common areas, dining rooms, kitchen and service hallways and residents rooms were inspected to ensure no chemicals were unsecured and accessible to residents. Findings were corrected immediatelySystemic Changes put into place to ensure the deficient practice does not recur: The Interdisciplinary Team (Administrator, Director of Nursing, Assistant Director of Nursing, Director of Social Work, Dietary Manager, Business Office Manager, Director of Housekeeping and Laundry, Human Resources, Rehab Director and Unit Managers) will be educated by the Regional Director of Operations on the proper storage of chemicals to ensure that they are stored in a manner that prevents resident access. The Facility Staff will be educated by the Director of Nursing or designee will educate staff on the proper storage of chemicals to ensure that they are stored in a manner that prevents resident access. No employee will be allowed to work until educated.Completion of removal plan at 2:00 pm on 5/6/26On 05/06/2026, the facility's policy for the storage of chemicals was requested. The policy states, [Housekeeping] Carts need to be remain locked at all times and no chemicals stored within easy reach. The policy also states, Janitor closets should be identified on the outside of the door and are to remained locked at all times.On 05/06/2026 beginning at 2:15 PM, a second review of resident rooms and activity room was conducted, with verification that all chemicals were secure.On 05/06/26 at 2:50 PM, additional interviews were conducted with various departments 3 LPNs, 4 certified nursing assistants, Director of Maintenance, Social Services Assistant, 2 Housekeeping aides, Dietary aide, Physical Therapy Aide and 2 Unit Managers. All staff interviewed were able to articulate re-training conducted and what type of items could be potentially dangerous if left unsecure in a resident room or common area.The survey team concluded verification of the IJ removal plan on 05/06/2026 and determined that IJ had been removed. Following the removal of IJ, the scope and severity was lowered to a level 2, pattern.

Based on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare and serve food in accordance with professional standards for food service safety in the main kitchen, which had the potential to affect residents on two of two units. The findings included:The facility staff failed to maintain the main kitchen in a clean and sanitary manner which had the potential to affect residents on two of two units as all food is stored, prepared and served from the main kitchen.On 5/6/26 at 2:45 PM, a tour was conducted of the facility's kitchen, the surveyor was accompanied by the dietary manager. The tour revealed the kitchen and food storage areas were not maintained in a clean and sanitary manner. There were multiple dead bugs noted in the food service area (underneath the three-compartment sink), outside of the walk-in freezer and in the dry storage area.Throughout all areas of the kitchen were food crumbs, debris and a build-up of grime. The food preparation area was not clean and sanitary. Throughout the kitchen and food storage areas were significant damage to the walls, base boards and tile missing, walls pulling away leaving gaps and a disregard for repair and upkeep of the kitchen area. Following the observations/tour of the kitchen, an interview was conducted with the dietary manager. When asked about the kitchen and the identified areas of concern discussed during the tour, the dietary manager reported that the kitchen needed a lot of attention. The dietary manager was asked about the cleaning schedule of the kitchen. The dietary manager reported they have a cleaning schedule and provided the surveyor with two separate logs. One log was titled, Cooks daily cleaning assignments which identified various equipment to include, grill, steam table, steamer, tilt skillet, convection oven, fryer, prep wall, spice cart, all prep tables, and slicer. The second was titled, Monthly Cleaning Assignments. The monthly cleaning assignment noted, Clean plate/tray/mug dollies, walk in freezer, walk-in [cooler], sweep/mop dish room, clean all baseboards, ceiling vents, slicer table/above shelf and below, clean convection ovens, clean conventional. When asked if there was any daily cleaning schedules other than what had been provided, the dietary manager reported while there wasn't a form they do mop the floor daily. On 5/7/26 at 1 PM, an interview was conducted with the facility administrator. When asked if he visits the kitchen, the administrator reported he visits the kitchen a couple of times a week I make rounds. When asked if he had identified any concerns, he reported, no. When asked what he looks for when making rounds in the kitchen, the administrator said, I look at the temperature logs, ensure everything is stored correctly, that's mainly what I am going in there for, checking out the tray line and temperatures. When asked if he had any observations regarding the cleanliness of the kitchen, the administrator said, it is usually pretty clean when I go.According to the Food Code, U.S. Public Health Service 2017 published by the U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, it read in part, .This shared responsibility extends to ensuring that consumer expectations are met and that food is unadulterated, prepared in a clean environment, and honestly presented. Section 2-102.11 read in part, Based on the risks inherent to the food operation, during inspections and upon request the person in charge shall demonstrate to the regulatory authority knowledge of foodborne disease prevention, application of the hazards analysis and critical control point principles, and the requirements of this Code. The person in charge shall demonstrate this knowledge by: . (8) Describing the relationship between the prevention of foodborne illness and the management and control of the following: . d) Maintaining the food establishment in a clean condition and in good repair. Section 3-305.111 of the Food Code, titled, Food Storage read, (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (1) In a clean, dry location. Section 4-602.13 read, Nonfood-Contact Surfaces. Nonfood contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.No additional information was provided.

Based on staff interview and record review, the facility failed provide a full-time, qualified social services worker meeting requirement of S483.70(p). Specifically, the facility employed an individual with a Bachelor of Science degree as the facility social worker; and the facility was unable to provide credible evidence demonstrating the individual had completed at least one year of supervised social work experience under the supervision of a qualified bachelor's degree-level social worker. This deficient practice had the potential to affect residents requiring psychosocial assessment, discharge planning, behavioral support services, and coordination of resident rights and social service needs. The findings included: Personnel file review for SW (Social Worker) 1, identified by the Administrator as the facility's social worker, revealed documentation of a Bachelor of Science degree. The personnel file lacked evidence of:A bachelor's degree in social work.Documentation demonstrating one year of supervised social work experience under the supervision of a qualified social worker.During an interview on 5/7/26, at 2:55pm, the Administrator stated SW#1 had a degree in human services with a major in criminal justice. When asked if SW # 1 degree and training met the required qualifications, the Administrator stated yes, she has been in other buildings. The Administrator did not have additional documentation supporting supervised social work training or experience for SW #1.On 5/7/26 at 3:30pm the Administrator presented a document titled SWDP (Social Workers Department) New Hire Orientation Training dated 3/6 with seven attendees as well as four documents titled Central Weekly SWDCP Meeting dated 3/23/26, 4/13/26 and 4/27/26. Provided documents, did not reveal supervised training. On 5/7/26 at: 4:00p.m., Administrator, Director of Nursing and Regional Nurse were informed of this concern. No additional information was provided prior to exit.

Based on observation, resident and staff interview, clinical record review, and facility document review, the facility failed to provide food and drink that is palatable, attractive, and at a safe and appetizing temperature affecting residents on two of two units.The findings include:On 05/05/2026 at 9:10 AM, Resident #4 was interviewed and asked about meals at the facility. She said the food is terrible and not good, she also said it is sometimes cold, especially breakfast.On 05/05/2026 at 4:53 PM an interview with the Administrator was conducted and he was asked about why residents are being served meals in Styrofoam, he said it is because the dishwasher is broken. When asked how long the dishwasher had been broken, a definitive timeframe could not be provided, just that it had been months.Resident council meeting minutes from April 2026 reveal that in response to concerns about meal temperatures, the Dietary Manager's written response states, Due to equipment out of service (dishmachine) we are using Styrofoam which makes it a little difficult to keep food hot as it loose temp. due to not being able to use hot plates/pellets. Late trays/carts are sometimes unavoidable due to preparation equipment not in service which mean it takes longer to prepare everything at once.Facility documentation review of resident council minutes revealed concerns with the preparation and appearance of meals during the January resident council meeting. Concern with the temperature of meals was recorded in resident council meetings in February, March, and April. No additional information was provided.

Based on observation, resident and staff interview, facility document review, and resident record review, the facility failed to provide sufficient nurse staffing to meet the needs of residents on two of two units.The findings included:The facility staff failed to ensure that adequate staffing was maintained to meet the needs of residents when nursing staff walked out on 4/6/26, due to chronic staffing issues, which resulted in Resident #1, Reisdent #2, and Resident #5 not receiving medications timely. On 05/04/2026 at 1:35 PM, Unit Manager second Floor was interviewed about an incident of staff walking out of the building. She stated that this was one incident I believe and it was in March or April on dayshift. She also stated, it was normal to be working with two or three CNAs all the time, she also said when all the CNA's walked out that day, there was an 'all hands-on deck and two of the three CNAs returned. She added that this incident prompted the use of agency and identified the CNAs on shift that day. On 05/04/2026, at 1:45 Unit Manager First Floor was interviewed related to staffing. She stated they had been staff challenged some days, stating there was usually two CNA's, maybe three, and four on a good day. On the day (04/06/2026) that the staff walked out, she stated there were three CNAs for the entire. She stated that administrative staff assisted the residents when the staff walked out. On 05/04/2026 at 2:09 PM, CNA #1 was interviewed. She was one of the CNAs that walked out of the facility on 04/06/2026. She has been a CNA at the facility for 37 years. Certified Nursing Assistant #3, another one of the CNAs that walked out on 04/06/2026, was also interviewed at the same time. She has been an employee at the facility for 24 years. The CNA's stated that they were tired of only having two CNAs for 60 residents. They stated the weekends were the worst times with staffing. Certified nursing assistant #1 stated that she had worked short all weekend and then to come in on Monday, 04/06/2026, and only have three CNAs really frustrated her. They stated they left a little after 8:00 AM and came back by a little after 9:00 AM and administrative staff were helping residents. The CNAs stated staffing has been better since they walked out. On 05/04/2026 at 2:25 PM, the Scheduler/Staffing Coordinator was interviewed about staffing patterns and challenges. She stated whenever there were staffing challenges, she let the Administrator know. When she was asked what staffing should be, she stated she believes the PPD is budgeted for 3.27. When asked how many CNA should be on each shift, she stated 12 CNAs on dayshift, 10 CNAs on evening shift, and eight CNAs on night shift. She stated during the time of being staff challenged with CNAs she went to the Administrator and agency was requested and corporate said no to agency. The Scheduler/Staffing Coordinator was asked about the time between January and April 2026, she stated that 70% of the time they were short staffed with two to three CNAs per unit per shift and during this time they were using agency for nurses. She stated they had daily staffing meetings with Human Resources, the Scheduler/Staffing Coordinator, and the Administrator. On 05/04/2026 at 2:44 PM, the Director of Nursing was interviewed. When asked about what staffing patterns had been like and if nursing had been short staffed. She stated at times there were three CNA's on one unit and there could be two on one unit because of callouts. The Director of Nursing was asked if they had ever considered using agency because of being very short staffed. She stated she asked for agency and the Regional Director of Operations would not approve it. The Director of Nursing advised that daily staff meetings were happening, which included Human Resources, the Administrator, the Scheduler/Staffing Coordinator, and the Director of Nursing. On 05/04/2026 at 3:00 PM, MDS Coordinator #2 was interviewed. When asked about staffing, she stated that it was not unusual to have two or three CNA's on a unit since she started. She stated she started as a unit manager and became an MDS coordinator in March. She stated during her time as a unit manager, she asked for agency or other help with staffing for a while, she notified the Administrator. She said the Administrator said he would talk to corporate. She was asked if she saw an increase in acquired wounds. She said she did see an increase in acquired wounds and that it could've been attributed to staffing. On 05/05/2026, the survey team requested documentation/meeting minutes related to staffing meeting since 01/01/2026. On 05/05/2026 at 3:45, the survey team was provided with a Weekly Retention Focus Meeting Agenda, dated Tuesday February 24, 2026, at 3:00 PM. A facility census provided to the survey team on 05/07/2026 for 04/06/2025 revealed that occupancy for the day the CNA's walked out was 123 of 131 (93.9%). On 05/07/2026, medication administration records for 04/06/2026 were provided to the survey team. Records revealed that Resident #2 was scheduled to receive Insulin Lispro (1 unit Dial) Subcutaneous Solution Pen-injector 100 Unit/ML at 7:30 AM and did not receive the medication until 9:55 AM. On 04/06/2026, Resident #1 was scheduled to receive Ferrous Sulfate Tablet 325(65 Fe) MG at 8:00 AM and eight medications at 9:00, Two medications were administered at 10:26 AM and the other eight were administered at 10:28 AM. On 04/06/2026, Resident #5 was scheduled to receive Metoprolol Tartrate Tablet 25 MG and one other medication at 8:00 Am and Lipitor Oral Tablet 80 MG and five other medications at 9:00 AM, six of the medications were administered at 12:53 PM and the other two were administered at 12:55 PM. No additional information was provided.

Based on observation, resident and staff interview and facility document review, the facility failed to provide sufficient dietary support personnel resulting in meals being served late to residents on two of two units.The findings include:On 05/04/2026, during the facility's entrance conference, the facility provided the survey team with a document of mealtimes. The document read as follows:Resident Mealtimes: Breakfast Hours 7:30am, Lunch Hours: 11:45am 2nd & 1st floor, Dining Room - 1:00pm. Dinner Hours: 4:45pm 2nd & 1st floor, Dining Room - 6:00pm. Snack Times - 10am, 2pm, 8pmOn 05/05/2026 at 9:00 AM a tour of unit one was conducted to observe breakfast, breakfast had not been served on the unit.On 05/05/2026 at 9:05 AM. Resident #3 asked me where breakfast was. Nurse #2 , the nurse assigned to Resident #3 said it should be coming soon.On 05/05/2026 at 9:23 AM, The Administrator was asked about breakfast and whether it was a normal occurrence for breakfast to be this late. He stated, Trays should have come around eight-ish.On 05/05/2026 at 9:23 AM the first tray cart came to unit one.On 05/05/2026 at 9:37 AM, Resident #3 called me in her room again to ask about breakfast because she still had not received her food.On 05/05/2026 at 9:41 AM, the second tray cart came to unit one.On 05/05/2026 at 9:42 AM, Nurse #2, assigned to this hall was asked why breakfast had not arrived as it was nearly 10:00 AM. She said that there was only the Dietary Manager and one other person in the kitchen because of callouts.On 05/05/2026 at 9:45 AM, Resident #10 and #15 asked the administrator where breakfast was and he stated it should be coming now.On 05/05/2026 at 9:47 Resident #3 asked again when food is coming.On 05/05/2026 at 9:48 AM, the Regional Director of Clinical Services #2 was rounding on the hall and checked on Resident #16. Resident #16 stated they were hungry and the Regional Director of Clinical Services #2 offered a snack.On 05/05/2026 at 9:51 AM, Resident #3 again asked when food is coming.On 05/05/2026 at 9:55 AM, the third meal tray cart came to unit one.On 05/05/2026 at 10:00 AM, Resident #3 called out again, Where's my food and an aide brought her tray in.On 05/05/2026 at 1:40 PM, the Registered Dietitian was asked why breakfast did not come out until 10:00 AM. She said she believed it was because there were two callouts in the kitchen and there was only two staff to prepare the meals. On 05/05/2026 at 3:02 PM, the Dietary Manager was interviewed about why breakfast did not come out on unit one until 10:00 AM. She said it was because it was only her and the cook in the kitchen that morning. The Dietary Manager was asked what time dinner was served on Monday. She stated It was between 4:45 PM and 5:15 PM, indicating that it was nearly 17 hours between the meals.Resident council meeting minutes from January 2026 reveal that in response to concerns about late meal times, the Dietary Manager's written response states, late meal times could be caused by staff shortages which results in slower meal preparation and try assembly. Complex meals or limited equipment cause prep to take longer than planned.No additional information was provided.

Based on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to maintain essential equipment in a functional manner in the main kitchen, which affected residents on two of two units.The findings included:On 5/4/26, during observations of the meals, it was noted that all residents were being served on Styrofoam/disposable containers with disposable cups and utensils. On 5/5/26 at 9:10 AM, Resident #4 was interviewed and asked about meals at the facility. She said the food is terrible and not good, she also said it is sometimes cold, especially breakfast.On 5/5/26 at 4:53 PM, an interview was conducted with the facility administrator. When asked about residents being served with disposable tableware, the administrator reported the dishwasher was broken. Review of the resident council meeting minutes revealed that during the April 2026 meeting a grievance form was completed and according to the investigative initiatives it noted, 2. Due to equipment out of service (dish machine) we are using Styrofoam which makes it a little difficulty to keep food hot as it loose temperature [sic]. Similar concerns about the food being cold were reported in February and March resident council meetings.On 5/6/26 at 2:45 PM, a tour was conducted of the facility's kitchen with the dietary manager. The tour revealed that the dish room had plastic sheeting hanging from the ceiling to block the room off from the remainder of the kitchen area, the area did not contain a dish machine. In the back storage area of the kitchen, the dietary manager identified two large pieces of equipment that were still packaged and encased in a wooden shipping crate as the two dish machines that had been delivered. The dietary manager went on to explain that the facility has been using disposable dishes for several months due to the dishwasher having to be replaced. The dietary manager reported a dish washer went down the beginning of March, it stopped getting the dishes clean. She reported the service technician came and noted the machine would not reach temperature and indicated the machine needed to be replaced. He then ordered a replacement machine.The dietary manager reported that when the dish machine was delivered, the service technician returned to install it and said it was the wrong machine, so he then ordered another dish machine. The old machine was then removed by the service technician and the dietary manager said, we had to replace tile in the dish room, it was broken and cracked. The dietary manager went on to report that they determined the floor in the dish room also needed to be replaced. The maintenance department reported the floor was completed on Sunday, 5/3/26, but it needed time to cure so they had to postpone the scheduled install of the new dish machine for 5/4/26. The dietary manager reported the new install date is scheduled for 5/19/26.On 5/6/26 at 3 PM, an interview was conducted with the facility's maintenance director. The maintenance director reported that the facility could not use their two-compartment sink, it was turned off last week, so the only means to wash dishes or cooking pans and utensils was the three-compartment sink. The maintenance director reported that the contracted company they lease kitchen equipment from came and did an inspection and determined the floor needed to be replaced before the new machine could be installed. The maintenance director reported that he and his staff did the work and completed the floor on Friday, 5/1/26. On 5/6/26 at 3:27 PM, an interview was conducted with the service technician from the lease company. The service technician explained that they had to postpone installation of the new dishwasher on several occasions, due to the wrong machine, the floor repairs, etc. He went on to explain that they also had to replace the chemical dispensers for the three-compartment sink since the chemicals were no longer available for the dispensers in use. When asked when the dish machine went down and quit working, the service technician referenced from documents and reported in January or February he determined the machine needed to be replaced and in February or March it went out of service. The technician said, they have been on paper for some time. After looking at service records, he reported that on February 5, 2026, the vacuum breaker was leaking very badly, and it could not be repaired so he decided the machine needed to be replaced. On 5/7/26, the facility administrator provided evidence of text messages with the service technician dating back to mid-February where they were awaiting the signature of the lease to order the new dish machine. There were also messages indicating an install date of March 26, 2026, which wasn't completed. Then on May 3, notice that the floor needed three days to dry and the installation had to be postponed again.On 5/7/26 at 1 PM, an interview was conducted with the facility administrator. When asked to explain the timeline of events involving the dish machine, the administrator reported, It was old, had some issues. They would send tech to fix it; they would fix it. In February it completely stopped working, we reached out to [company the dish machine was leased from redacted], they figured out what to do and said it was best to get a new machine. February 13, they sent over a lease, on February 19 it was signed. March 2, 2026, I reached back out and they didn't have any update on the status of the new machine. Sometime in March we received the new machine, they said it was the wrong unit and removed the existing machine. Fast forward a few weeks and we received what they said was the correct machine. Ends up they said the first machine was correct and we didn't need the second one, there was a gap in all this with getting another machine ordered, etc. They gave an install date of this Monday [5/4/26] but they had to reschedule to May 19 because the floor needed to dry.On 5/7/26 at 4:10 PM, another interview was conducted with the facility's maintenance director. When asked for details about how the repairs to the floor in the kitchen dish room came about and what had to be done, the maintenance director said, we had to rebuild the floor back up and replace some pipes, clean up in the area- had some fruit flies, had to wait for it to dry. The maintenance director reported the repairs took about a week and a half. When asked what the delay in getting the floor in the kitchen repaired was, the maintenance director said, We had to finish room [ROOM NUMBER] so we could fill the building up. We had to rebuild the room; they hadn't had it up [available for occupancy] for several years. We redid the floors, put new closets in, new lights, a new p-tac unit [personal heating/air unit], new beds, painted and everything. We had to finish that before we could start on the kitchen floor.On 5/7/26, during an end-of-day meeting, the above concerns and the details of the facility being without a functioning dishwasher for several months, which has resulted in the use of disposable dishes, was discussed. In addition, the use of disposable dishes has been identified as the reason for ongoing resident complaints about cold and unpalatable food. No additional information was provided.

Based on observation, staff interview, and facility documentation review, the facility staff failed to maintain an effective pest control program affecting the main kitchen, which had the potential to affect residents on two of two units, as all food for the facility is stored and prepared in the main kitchen. The findings included:On 5/6/26 at 2:45 PM, a tour was conducted of the facility's kitchen, the surveyor was accompanied by the dietary manager. The tour revealed a dead bug that appeared to be a cockroach underneath the three-compartment sink where a staff member was actively washing meal service pans/dishes. When the dietary aide was asked about pest control, he reported it is better than it used to be and they rarely see pests.As the observations in the kitchen and food storage areas continued, another dead bug, which appeared to be a dead cockroach, was noted in the dry storage room floor. Along the outer wall/doorway of the walk-in freezer was another dead bug. Dietary staff were actively cleaning the door in the hallways where the walk-in freezer was located. There was visible damage to the walls, baseboards missing, cracks and large crevices that appeared to be long-standing were identified throughout the kitchen and food storage areas. Further review revealed that under the three-compartment sink was a large access gap around a drainage pipe that could allow pests entry into the kitchen. At the back door of the kitchen, was a gap between the doors where pests could enter.Following the observations/tour of the kitchen, an interview was conducted with the dietary manager. When asked about pests in the kitchen and the needed repairs to the wall, the dietary manager reported that the kitchen needed a lot of attention. An interview was conducted with the cook, who reported that he feels the pest problem has improved.On 5/6/26-5/7/26, a review of the pest control records revealed that a contracted pest control company had been making routine visits to the facility. In their monthly reports it was noted that the areas identified/observed by the surveyor had been identified in the pest control company's routine reports dating back to January 2025. Many of the items were identified in the report as having a high priority level noting they . allowing pest access. Please repair to prevent pest entry.On 5/7/26 at 4:10 PM, during an interview with the facility's maintenance director, he was asked about pest control within the facility. The maintenance director reported that usually they come one to two times a month, I meet them, give them the pest control book kept at the nursing station and go through what the nurses have written. They go to the location and take care of it. I ask them to call me when they leave, sometimes they leave a report, or I ask them to send it. When asked what the maintenance director does with the reports, he said, I just stick them in the book, I didn't look through the last few reported. I just learned about it in the last three months and how big pest control is here, that's when I took it seriously.On 5/7/26 at 1 PM, an interview was conducted with the facility administrator. When asked if he visits the kitchen, the administrator reported he visits the kitchen a couple of times a week I make rounds. When asked if he had identified any concerns, he reported, no. When asked what he looks for when making rounds in the kitchen, the administrator said, I look at the temperature logs, ensure everything is stored correctly, that's mainly what I am going in there for, checking out the tray line and temperatures. When asked if he had any concerns with pests in the kitchen, the administrator said no.During the above interview with the administrator, he was asked about their pest control contracted company and if he reviewed their reports. The administrator said, sometimes, they go to [the maintenance director's name redacted]. It is his responsibility to make sure they provide services when they come out, we call if we have urgent issues. When asked if he was aware they made recommendation in their report, the administrator said, I was not aware they had recommendations. The pest control reports were reviewed with the administrator, and it was noted that identified issues from over a year ago had yet to be corrected and there was evidence of active pest activity within the kitchen during the survey. Review of the facility's policy titled, Pest Control with an effective date of 5/1/2022 was conducted. The policy read in part, The center environment will be inspected monthly and treated for pests by a corporate-approved contractor.No additional information was provided.

Based on observation, interview and record review, the facility staff failed to have credible evidence of a hospice plan of care, services provided by hospice and documentation of hospice provider visits for (1) one resident in a survey sample of (13) thirteen residents receiving hospice care (Resident #5).Findings included: Resident #5 was admitted to the facility on [DATE] with diagnosis including but not limited congestive heart failure, pulmonary embolism (blood clot), hypertension, chronic obstructive pulmonary disease, anxiety, and myocardial infarction (heart attack). Resident #5 was admitted to hospice services on 12/18/25. Resident #5's most recent MDS (Minimum Data Set) Assessment with an ARD (Assessment Reference Date) of 3/24/26 coded the resident in C0500 BIMS (Brief Interview of Mental Status) Summary as a 15 out of 15 indicating resident was cognitively intact and Section K1. the resident was coded as Yes for receiving hospice services.On 5/7/26 during clinical record review for Resident #5, an order read as admitted to [name redacted] hospice services with admitting diagnosis: Congestive Heart Failure. No 911, Do not transport, continue scheduled/ and (PRN) as needed medications, No vital signs (monitoring of blood pressure, heart rate, respirations or temperature), labs, or weights. Further review of the clinical record did not reveal any visit notes or visit documentation from hospice provider nurses, aides, social services, or clergy and no hospice plan of care or hospice agreement was found. Progress notes written by the facility's attending physician, nurse practitioners and nurses did show that Resident #5 was receiving hospices services for congestive heart failure, that she had orders for medications to manage pain and anxiety as needed, and that hospice providers were being notified of changes in condition such as fall events and nausea by the facility staff. No evidence of documentation or visit notes from the hospice provider. Resident #5 has been receiving comfort care services from [name redated] hospice services since 12/18/25.A review of Resident #5's care plan revealed a care plan focus titled, HOSPICE: The resident is receiving hospice services and is not expected to improve in condition for diagnosis of: CHF (congestive heart failure), NO vital signs, labs, or weights. admitted to (name redacted) Hospice with admitting diagnosis: Congestive Heart Failure. Attending Physician- [name and telephone number redacted] Created on 12/19/2025 and Revised 04/24/2026. The care plan included interventions: admitted to [name redacted] Hospice with admitting diagnosis: congestive heart failure. Do not call 911, do not transport to hospital, continue scheduled medications and medications as needed (PRN), No vitals, labs, or weights, refer to hospice provider as needed, see hospice plan of care.Unable to locate a plan of care developed by Hospice provider.On 5/7/26 at 1:25 PM, during a visit with Resident #5 she confirmed she had been receiving hospice services for a few months due to her diagnosis of heart failure.On 5/7/26 at 2:00 PM during a meeting with the Administrator, (DON) Director of Nursing Services, and Regional Director of Clinical Services, the DON was asked where hospice visit notes and hospice plan of care documentation and agreement could be found for Resident #5. According to the DON, all hospice documentation and paperwork is kept in a designated purple binder located at the nurse's station.On 5/7/26 at 6:00PM, the Administrator was asked if they had presented all the documents requested and he stated Yes, we have given you everything you have requested except we are waiting for a fax from the hospice provider for [name redacted] Resident #5. When asked what they were waiting for from hospice, the DON entered the room and said they were waiting for the hospice provider to fax over the hospice visit notes and other hospice related paperwork as they were unable to locate the purple hospice binder for Resident #5. She stated that they had had a change in Unit Managers and were not able to locate the purple binder for Resident #5 and the documents had not been scanned into the electronic medical record. When asked what her expectation of documentation of visits and the plan of care from the hospice provider was, she said, They should be in the resident's chart or a designated binder.A request for the facility's policy on hospice services policy was requested, none was provided.No further information was provided.

Based on observation and resident interview, the facility failed to maintain a clean, comfortable and homelike environment for one of two units.The findings include:On 05/04/2026 at 12:15 PM an initial tour of Unit One was conducted and the following was observed. The walls on the A side of room [ROOM NUMBER] were scuffed up and discolored, the tiles in the bathroom had cracks in them which appeared a dark color and the sill around the toilet was stained. In room [ROOM NUMBER] the B side bed had the finish peeling from the footboard. room [ROOM NUMBER] had black footprints across the floor of the entire room. room [ROOM NUMBER] had a heavy amount of dirt on the floor including a plastic plasticware wrapper.On 05/05/2026 at 9:08 AM during a tour of Unit One, room [ROOM NUMBER] was observed with a heavy amount of dirt and debris on the floor to include toilet paper, napkins, and a plastic lid and straw.On 05/05/2026 at 2:50 PM, resident # 10 was met in the hallway and began talking about the cleanliness of the floors. The resident stated, These floors are filthy. They are all scratched up and there's dirt all over them. The resident stated they did not want their feet to touch the ground, that's how dirty the floor is. Observation of room [ROOM NUMBER] revealed a disheveled room that included an unmade bed with food crumbs all over it, heal boots, balled up napkins, a plastic lid, and other dirt on the floor, a quarter full urinal and food item trash on the overbed table. The B side had a patched wall that had a large hole in the drywall by the window. The sink vanity had the finish coming off it, balled up used napkins on it, and the back splash on the left side had come off, revealing damaged drywall. The bathroom tiles were discolored, had large, discolored cracks between them, and the sill around the toilet was dark and discolored.On 05/06/2025 at 2:32 PM, room [ROOM NUMBER] was observed with dirt and egg on the floor and the wall by the door was scraped and discolored including patching that did not match the wall paint color.On 05/06/2026 at 2:42 PM, room [ROOM NUMBER]'s bathroom had floor tiles that were cracked and discolored and the sill around the toilet was dark and discolored. No additional information was provided.

Based on observation and clinical record review, the facility failed to implement the comprehensive person-centered care plan for (4) four of (13) thirteen residents in the survey sample. (Resident #8, #6, #2 and #3).Findings included:1. For Resident #8, the facility staff failed to implement the comprehensive care plan interventions for enhanced barrier precautions and to honor the resident's food preferences. Resident #8 was originally admitted to the facility 11/25/25 and re-admitted after a hospitalization from 4/26/26 to 5/1/26 for a GI bleed (gastro-intestinal, bleeding in the stomach). Other diagnoses included but are not limited to diabetes mellitus type 2, (GERD) gastroesophageal reflux disease, anemia, atrial fibrillation (irregular heart rate), hypertension, asthma, hemiparesis and hemiplegia following a cerebral infarction (reduced strength in extremities following a stroke), and memory deficit following stroke. Resident #8's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date 3/3/26 coded the resident as completing the BIMS (Brief Interview for Mental Status) 15 out of 15. This indicates the resident is cognitively intact for daily decision making. On 5/5/26 at 9:00 AM, Resident #8 was visited as she was finishing her breakfast. Resident #8 expressed displeasure that kitchen staff failed to ensure that her meal preferences were honored. Resident #8 said, Look here, just look here, my oatmeal is smothered in butter, I can't eat this, it messes with my reflux, and I don't eat sausage or bread because it goes against my body. A review of Resident #8's meal ticket revealed: oatmeal, hard-boiled egg, hot cereal, egg patty (alternate-bread, alternate-breakfast meat); Dislikes: Bread, sausage, grits, potatoes, orange juice, scrambled eggs, fried eggs. Resident #8's meal tray revealed hard-boiled eggs, toast, sausage patty, oatmeal with butter. Resident #8 stated she was happy with her hard-boiled eggs but not with the oatmeal smothered in butter and the toast and sausage. On 5/5/26, approximately 12:15 PM, Resident #8 visited during the midday meal where she received meal tray with sliced ham, broccoli and tomato soup, magic cup, lemonade. Meal ticket revealed: Alternate entrée, broccoli, brownie, apple juice and magic cup. As Resident #8 was eating her lunch, a staff member came in with a bowl of chicken noodle soup and removed the tomato soup. Meal ticket showed Dislikes: Bread, potatoes, tomato sauce, fried foods, mayonnaise, orange juice. On 5/5/26 at 2:20 PM during a meeting with the RD (Registered Dietician), Resident #8's food preferences and care plan were discussed. According to the RD, the residents' preferences should be honored, and the staff has been trying to honor her preferences, but it has been a challenge as they change frequently. The RD revealed that a care plan meeting had been conducted with the resident, her granddaughter, dietary, nursing and social services on the morning of 5/4/26 that included discussion of her food preferences, and her meal ticket was being updated as her preferences changed. On 5/6/26, a review of Resident #8's care plan read in part is at nutritional risk related to diagnosis of cerebral infarction (stroke with reduced strength and function of the arms and legs), asthma, adult failure to thrive, type 2 diabetes mellitus, GERD (gastroesophageal reflux disease, a burning sensation in the chest, also referred to as heartburn), hypertension and history of gastric bypass (weight-loss surgery). Receives a therapeutic diet for diabetes management. Double protein entrees ordered as resident refuse high-calorie dairy-based nutritional supplements. Snacks in room and resident consumption of food brought in by family. Amino acid protein supplements started to encourage healing of pressure injury. Created on: 12/01/2025 Revised on: 05/05/2026. Care plan focus included an intervention of Honor diet-compliant food preferences as made known by resident Created on: 12/01/2025 Revision on: 12/01/2025. The review of Resident #8's care plan also revealed a care plan focus The resident has a chronic wound or pressure ulcer to the sacrum. The resident has a risk for worsening wound(s) or the development of additional wounds related to pressure, sacrum. Created on: 05/04/2026. Revised on: 05/05/2026 with an intervention for Enhanced barrier precautions Created on: 05/04/2026. Resident #8 was visited with room rounds on 5/4/26 at 12:55 PM, meal visits 5/5/26 at 9:00 AM and 12:30 PM, and on 5/7/26 at 9:15 AM and no evidence of signage for Enhanced Barrier Precautions or a bin for personal protective equipment. According to Unit 2 Manager, any resident with an open wound or indwelling devices would have enhanced barrier precautions implemented including placing a sign on or near the door frame and a bin for personal protective equipment such as gloves and gowns to wear when providing direct care. 2. For Resident #6, the facility staff failed to implement the comprehensive care plan for the intervention to administer oxygen as ordered. Resident #6 was admitted to the facility 4/1/25 with diagnoses to include but not limited to chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, diabetes mellitus type 2, chronic kidney disease stage 3, convulsions, hypertensive heart disease, and heart failure. Resident #6's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) 3/30/26 coded the resident in Section C. Cognitive Patterns for a BIMS (Brief Interview Mental Status) of 09 out of 15 indicating resident has moderate cognitive impairments with memory, attention and orientation. Section 0. Special Treatments C1 was coded yes for use of oxygen. On 5/4/26 at 12:20 PM, during initial rounds Resident #6 was observed in her bed with the head of the bed elevated and the oxygen concentrator set on 6 liters per minute via nasal cannula. On 5/4/26 at 12:30 PM, Unit 2 Nurse Manager confirmed the oxygen concentrator was set at 6 liters, which exceeded the ordered 4 liters per minute. When asked what the danger of exceeding the oxygen flow rate she stated, it could be toxic to the resident. A review of Resident #6's physician orders revealed an order for oxygen continuous at 4 liters per minute via nasal cannula. A review of Resident #6's care plan revealed a care plan focus: Respiratory: the resident is at risk for respiratory complications secondary to chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia Created on: 12/17/2024 Revision on: 05/05/2026 with intervention to administer oxygen as ordered Created on: 12/17/2024. On 5/7/26 at 2:06 PM during a meeting with the Administrator, DON (Director of Nursing), Regional Director of Clinical Services and Regional Director of Operations, they were made aware of the findings of facility staff not following the care plan for Resident #8 and Resident #6. A request for the facility's policy on care planning was requested, none was provided. According to the Center for Medicare and Medicaid Resident Assessment Manual October 2023, Version 3.0, Chapter 4: Care Area Assessment (CAA) Process and Care Planning, Chapter 4, page 8, As required at 42 CFR 483.21(b), the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. No further information was provided. 3. For Resident #2, the facility staff failed to implement fall interventions for bilateral fall mats. Resident #2 was originally admitted to the facility 01/20/2026. Diagnoses include but are not limited to diabetes mellitus type 2, muscle wasting and atrophy, muscle weakness, moderate protein calorie malnutrition, difficulty in walking, myocardial infarction type 2, history of falling, essential hypertension, benign prostatic hyperplasia, anemia, urinary tract infection, and Parkinson's Disease without dyskinesia. Resident #2's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date 01/26/2026 coded the resident as completing the BIMS (Brief Interview for Mental Status) 08 out of 15. This indicates the resident is moderately cognitively impaired for daily decision making. Observation on 5/4/2026 at 12:17 PM, 5/5/2026 at 9:05 AM, and 5/5/2026 at 12:50 PM, revealed that a fall mat was only on the right side of Resident #2's bed. A review of Resident #2's care plan revealed a care plan intervention bilateral floor matts. On 5/6/2026 at 12:35 PM the Unit Manager for First Floor was interviewed about a care plan intervention of bilateral fall mats for Resident # 2. She confirmed that fall mats should be on both sides of the beds. She also stated that the housekeeper took them last week and did not bring them back. 4. For Resident #3, the facility staff failed to implement the care plan intervention for bilateral fall mats. Resident #3 was originally admitted to the facility 02/10/2026. Diagnoses include but are not limited to anxiety disorder, adult failure to thrive, hypotension, fracture of unspecified part of neck of right femur, moderate protein calorie malnutrition, essential hypertension, acute respiratory failure with hypoxia, and insomnia. Resident #3's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date 03/31/2026 coded the resident as completing the BIMS (Brief Interview for Mental Status) 14 out of 15. This indicates the resident is cognitively intact for daily decision making. Observation on 5/4/2026 at 12:17 PM, 5/5/2026 at 9:05 AM, and 5/5/2026 at 12:50 PM, revealed that a fall mat was only on the right side of Resident #3's bed. A review of Resident #3's care plan revealed a care plan intervention bilateral fall matts. On 5/6/2026 at 12:35 PM the Unit Manager for First Floor was interviewed about a care plan intervention of bilateral fall mats for Resident # 3. She confirmed that fall mats should be on both sides of the beds. She also stated that the housekeeper took them last week and did not bring them back. No further information was provided.

Based on staff interviews and clinical record review, the facility staff failed to revise and update the residents' person-centered care plan for (2) two of (13) thirteen residents in the sample (Resident #5 and Resident #2). Findings included:1.Resident #5 was admitted to the facility on [DATE] with diagnosis including but not limited congestive heart failure, pulmonary embolism (blood clot), hypertension, chronic obstructive pulmonary disease, anxiety, and myocardial infarction (heart attack). Resident #5's most recent MDS (Minimum Data Set) Assessment with an ARD (Assessment Reference Date) of 3/24/26 coded the resident in C0500. BIMS (Brief Interview of Mental Status) Summary Score as a 15 out of 15 indicating resident was cognitively intact and Section GG0130 - Functional Abilities coded her as 06 indicating independent. On 5/7/26 a review of Resident #5's care plan revealed: Care plan focus The resident prefers to smoke (cigarettes, cigar, pipes, electronic delivery systems (electronic cigarettes/e-cigs, vape pen, etc.) Created on: 12/26/2025, with a revision on 05/05/2026 that included conflicting interventions: 1) May smoke independently - Created on: 01/06/2026, Revised on: 01/31/2026 and 2) Supervise with smoking - Created on: 01/13/2026, Revised on: 05/05/2026. Care plan focus Respiratory infection: the resident has developed an infection secondary to pneumonia Created on: 12/17/2025. Resident #5 does not currently have a respiratory infection. Care plan focus Respiratory: the resident is at risk for respiratory complications secondary to asthma, COPD (chronic obstructive pulmonary disease) Created on: 12/17/2025 with an intervention to obtain vitals as needed Created on: 12/17/2025. A review of Resident #5's physician orders revealed an order - No vitals, labs, or weights dated 12/18/25 per hospice provider. An order CPAP/BiPAP Oxygen tubing change weekly every night shift every Sun, dated 04/20/2026 is not reflected on Resident #5's care plan. No order for CPAP, an order only for tubing change of the CPAP. Resident #5 states she makes her roommate's bed because she likes to help her friend; this was confirmed by the roommate Resident #8 and Resident #8's granddaughter and the Unit 2 Nurse Manager as Resident #5's preference to help her friend. Resident #5's care plan does not reflect her desire to make her roommates bed. Care plan does not reveal any care plan focus or intervention that Resident #5 wishes to make her roommate's bed. On 5/7/26 at 2:06 PM during a meeting with the Administrator, (DON) Director of Nursing Services, Regional Director of Clinical Services and Regional Director of Operations, Resident #5's care plan focus on smoking, respiratory infection and order for CPAP (continuous positive airway pressure, a treatment for obstructive sleep apnea), nasal cannula hanging on her rollator, and having intervention to obtain vital signs when order reveals no vital signs was reviewed. According to the DON, Resident #5 does not currently have a respiratory infection, and the care plan should be updated to reflect her preference to store her nasal cannula on her rollator handle and to make her roommates bed, and resident now requiring supervision with smoking and should not have intervention for obtaining vital signs (measuring blood pressure, heart rate, respirations and temperature) and she was not sure if Resident #5 was using a CPAP. The facility's policy for updating care plans was requested. No policy was provided. According to the Center for Medicare and Medicaid Resident Assessment Manual October 2023, Version 3.0, Chapter 4: Care Area Assessment (CAA) Process and Care Planning, Chapter 4, page 8, As required at 42 CFR 483.21(b), the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. Chapter 4, page 12. 6) The resident's care plan must be reviewed after each assessment, as required by 483.20, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. No further information was provided. 2. Resident #2 was originally admitted to the facility 01/20/2026. Diagnoses include but are not limited to diabetes mellitus type 2, muscle wasting and atrophy, muscle weakness, moderate protein calorie malnutrition, difficulty in walking, myocardial infarction type 2, history of falling, essential hypertension, benign prostatic hyperplasia, anemia, urinary tract infection, and Parkinson's Disease without dyskinesia. Resident #2's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date 01/26/2026 coded the resident as completing the BIMS (Brief Interview for Mental Status) 08 out of 15. This indicates the resident is moderately cognitively impaired for daily decision making. On 05/06/2026 during a review of Resident #2's clinical record, it was documented in a 72-hour post fall note dated 01/26/2026 1:28 AM that close monitoring was the intervention in place. On 05/06/20206, A review of Resident #2's care plan revealed the care plan had identified Resident # 2 at risk of falls. A care plan focus the resident is at risk for falls related to recent hospitalization, history of falls, Parkinson created on: 01/20/2026, with a revision on 0 1/21/2026. Medical record review revealed resident #2 had falls on 01/20/2026, 01/21/2026. 01/24/2026, and 02/20/2026. The care plan interventions revisions following these falls are as follows bilateral floor matts created on: 01/21/2026, therapy assessment of w/c cushion created on: 01/22/2026, encourage staff to provide chair activities created on: 01/26/2026, scoop mattress created on: 02/17/2026, and offering prefer clothing created on: 02/23/2026. The care plan was not revised after a fall to include intervention of close monitoring. On 5/6/2026 at 12:35 PM the Unit Manager for First Floor was interviewed and confirmed that the care plan should have been revised to include the intervention close monitoring.

Based on staff interviews, clinical record review and facility document review, the facility staff failed to follow physician orders for administration of insulin with specific parameters for (1) one of (13) thirteen residents in the survey sample (Resident #8).Findings included:Resident #8 was originally admitted to the facility 11/25/25 and re-admitted after a hospitalization from 4/26/26 to 5/1/26 for a GI bleed (gastro-intestinal, bleeding in the stomach). Other diagnoses included but are not limited to diabetes mellitus type 2, (GERD) gastroesophageal reflux disease, anemia, atrial fibrillation (irregular heart rate), hypertension, asthma, hemiparesis and hemiplegia following a cerebral infarction (reduced strength in extremities following a stroke), and memory deficit following stroke.Resident #8's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date 3/3/26 coded the resident as completing the BIMS (Brief Interview for Mental Status) 15 out of 15. This indicates the resident is cognitively intact for daily decision making. Section I. Active Diagnosis coded I2900 Diabetes Mellitus. Section N0350.A coded insulin injections and Section N. Medications coded N0415 for High-Risk Drug Class for insulin.A review of Resident #8's clinical record revealed:4/6/26 Nurse Practitioner progress notes revealed: Provider interviewed staff and reviewed chart to assess resident status type 2 diabetes mellitus with hyperglycemia. Blood glucose 212 mg/dL today, with recent glucose variability ranging from 173-216 mg/dL over the past 4 days. Hemoglobin A1c (lab test measuring blood sugar levels over several months) improved to 5.7% on 03/25/2026 from 6.0% in December 2025, approaching the lower end of target range. Active medication management decision made today: adding hold parameter to Lantus (1) insulin regimen (hold for blood glucose less than 200 mg/dL) to prevent hypoglycemia given the improved A1c and risk of hypoglycemia with continued full-dose insulin in the setting of improved glycemic control. This represents a clinical decision balancing tight glycemic control against hypoglycemia prevention, particularly given the recent glucose variability and hold threshold of 200 mg/dL. Continue Lantus 12 units subcutaneously at 6 PM with new hold parameter. Continue continuous glucose monitoring. The patient continues to be noncompliant with diabetic diet. Nursing to monitor for hypoglycemia with the new hold parameter and document continuous glucose monitoring trends and alerts.4/6/26 order Insulin Glargine 300 unit/ml inject 12 units subcutaneously in the evening for diabetes mellitus to HOLD for BS (blood glucose) less than 200mg/dl was transcribed to the MAR (Medication Administration Record).The MAR revealed blood sugar results 4/6/26 BS=184, 4/8/26 BS=197, 4/10/26 BS=189, 4/13/26 BS=158, 4/17/26 BS=165 with nurse documenting insulin was administered outside the physician's order to hold insulin if blood sugar less than 2200mg/dl.4/16/26 Attending Physician progress note read in part: Resident (#8) was seen for physician recertification visit. No acute changes from baseline today. Blood glucose is 196 mg/dL. A hold parameter was added 4/6/26 to her Lantus insulin regimen to hold the dose for blood glucose less than 200 mg/dL. Type 2 diabetes mellitus with hyperglycemia. Stable on current insulin regimen. Continue insulin glargine 12 units with hold parameters. Continue continuous glucose monitoring. The resident remains non-compliant with diabetic diet; continue dietary counseling.4/16/26 Nurse Practitioner progress notes read in part - Monthly medication review completed, taking medications as prescribed; adherence reinforced, no side effects reported, medication list reviewed and reconciled, continue current regimen, blood glucose 192 mg/dL today, blood glucose has ranged from 118 to 216 mg/dL over the past week, with a notable spike to 353 mg/dL on 03/28/2026.4/17/26 Nurse Practitioner progress notes read in part - Assessment: Type 2 diabetes mellitus with diabetic polyneuropathy. Continue insulin glargine 12 units subcutaneously at 6 PM with parameter to hold for blood glucose less than 200 mg/dL and continuous glucose monitoring with sensor.4/18/26 an order was changed on the Medication Administration Record to read: Insulin Glargine Solostar Subcutaneous Solution Pen-Injector 300 unit/ml, inject 12 unit subcutaneously in the evening for Diabetes Mellitus, If the blood sugar is less than 60 or greater than 400 call the provider.Review of the MAR (Medication Administration Record) and blood sugar readings from 4/18/26 through 4/25/26 did not reveal any blood sugars less than 60 or greater than 400.4/20/26 Nurse Practitioner progress note reads in part: Assessment of Type 2 diabetes mellitus with diabetic polyneuropathy. Continue insulin glargine 12 units subcutaneously at 6 PM with parameter to hold for blood glucose less than 200 mg/dL and continue continuous glucose monitoring with sensor.The MAR did not contain the instructions to HOLD if blood sugar is less than 200 mg/dl from 4/18/26 through 4/26/26. No blood sugar readings were recorded less than 200 mg/dl.On 4/26/26, Resident #8 blood sugars were 324 mg/dl at 7:53 AM and 314 mg/dl at 10:38 AM. Due to a change in condition and family request, Resident #8 was transferred to the local hospital. Resident #8 presented to the hospital with acute onset of bloody diarrhea and was admitted on [DATE] at 8:05 PM with diagnosis of acute drop in hemoglobin - blood loss anemia, bloody diarrhea and abdominal pain and sepsis secondary to proctitis.On 5/5/26 at 1:15 PM, an interview and review of Resident #8's April 2026 Medication Administration Record was conducted with the DON (Director of Nursing) and Regional Director of Nursing on their expectation of nurses documenting insulin was administered when the physician orders contained specific parameters to hold the insulin if blood sugar was less than 200 mg/dl. According to the DON, the nurses are to read the entire order and follow the physician orders or notify provider for additional instructions. When asked if the provider reviews the MARs, she did not know for sure but would expect them to review the MAR if they were documenting medications reconciled and taking medications as prescribed.A review of the facility policy titled, General Guidelines for Medication Administration Policy #8.2 effective date 9/2018, revised 8/2020. Page 113. Procedures: II. Administration. 2. Medications are administered in accordance with written orders of the prescriber. ReferenceLantus is a long-acting (basal) insulin used to treat high blood sugar and is designed to work steadily for 24 hours without a pronounced peak, providing a consistent, low level of insulin to control blood sugar between meals and overnight. Sanofi, Manufacturer of Lantus/Glargine insulin. https://www.lantus.com.

Based on staff interview, facility document review, and review of nursing schedules, the facility failed to ensure the services of a registered nurse were provided for at least 8 consecutive hours a day, 7 days a week, as required by S483.35(b), for a facility census of 123 residents.This deficient practice had the potential to affect all residents residing in the facility requiring ongoing nursing assessment, clinical oversight, care planning, change in condition evaluation, medication management, and supervision of licensed nursing staff.The findings included: Review of the facility nursing schedules, staffing records, and daily assignment sheets revealed the facility failed to schedule or provide coverage by a registered nurse (RN) for at least 8 consecutive hours on the following dates:4/4/26 and 4/5/26: No RN scheduled or documented as working during the required 8 consecutive-hour period and posted staffing records lacked evidence of RN presence for the required duration.Further review of payroll records and staffing documentation failed to demonstrate an RN was present and providing services during the identified periods.During an interview on 4/7/26 at 3:45pm, the Director of Nursing acknowledged the facility did not have RN coverage for the identified dates and stated the facility was experiencing staffing challenges.The facility's failure to ensure RN services were provided for at least 8 consecutive hours per day in a 24 hour period constitutes noncompliance with 483.35 (b).The Director of Nursing confirmed no supplemental staffing documentation or alternate RN coverage records were available.

Based on observation, staff interviews, clinical record review and facility document review, the facility staff failed to deliver the prescribed oxygen flow rate according to the physician's order for (1) one of (13) thirteen residents in the survey sample (Resident #6)Findings include:Resident #6 was admitted to the facility 4/1/25 with diagnoses to include but not limited to chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, diabetes mellitus type 2, chronic kidney disease stage 3, convulsions, hypertensive heart disease, and heart failure. Resident #6's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) 3/30/26 coded the resident in Section C. Cognitive Patterns for a BIMS (Brief Interview Mental Status) of 09 out of 15 indicating resident has moderate cognitive impairments with memory, attention and orientation. Section 0. Special Treatments C1 was coded yes for use of oxygen.On 5/4/26 at 12:20 PM, during initial rounds Resident #6 was observed in her bed with the head of the bed elevated and the oxygen concentrator set on 6 liters per minute via nasal cannula. On 5/4/26 at 12:30 PM, Unit 2 Nurse Manager confirmed the oxygen concentrator was set at 6 liters, which exceeded the ordered 4 liters per minute and she adjusted the flow rate. When asked what the danger of exceeding the oxygen flow rate she stated, it could be toxic to the resident. A review of the clinical record revealed nurse practitioner progress notes dated 5/4/26 and 5/5/26 reading in part continue supplemental oxygen at 2 liters per minute via nasal cannula. A review of Resident #6's physician orders revealed an order for oxygen continuous at 4 liters per minute via nasal cannula. A review of Resident #6's care plan revealed a care plan focus: Respiratory: the resident is at risk for respiratory complications secondary to chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia Created on: 12/17/2024 Revision on: 05/05/2026 with intervention to administer oxygen as ordered Created on: 12/17/2024.On 5/7/26 at 2:06 PM during a meeting with the Administrator, DON (Director of Nursing), Regional Director of Clinical Services and Regional Director of Operations, these findings were shared. The DON was asked what outcome of oxygen flowrate exceeding the physician's order be. According to the DON, the gas exchange of multiple concerns may occur and that could be dangerous to residents. When asked what she expected nurses to do to monitor oxygen flow rate she responded, they are to check the oxygen flow rate each shift, when in and out of the room, when providing meds, and all throughout the day. A review of the facility's policy titled, Respiratory Care & Oxygen Equipment, Poly #1901, effective date 1/19/24, reads in part, Procedure, 1b. Follow physician's order for flow rate and/or oxygen concentration. 4. For continuous oxygen therapy, verify and document in the medical record each shift and as needed. No further information was provided.

Based on interview, record review, and policy review, the facility failed to implement its abuse prevention policies by ensuring staff identified in an allegation of sexual abuse were prohibited from resident contact pending completion of the investigation for 1 of 3 sampled residents reviewed for abuse allegations (Resident #9).The findings include:Review of the facility policy titled Abuse Prevention and Investigation, dated 1/29/24, revealed the facility would immediately implement interventions to protect residents from further potential abuse during investigations, including removal of alleged perpetrators from resident contact pending investigative findings.Review of the facility investigation revealed Resident #9 alleged on 12/16/25 that two identified housekeeping employees attempted revealed themselves and made sexual comments towards her. Documentation showed the allegation was reported to administration on 12/16/25. Review of statements from resident and staff all have time of incident redacted or blank.The facility failed to implement interim protective measures after the alleged incident was reported during the initial investigation. Staffing schedules and assignment sheets showed Employee # worked 8.16 hours and Employee # worked 10.04 hours on 12/16/25 after the allegation had been made to the administration. Clinical with records reveal resident was noted after the investigative report guarded and worried about her safety.Review of the incident summary failed to reveal documented rationale supporting continued resident access by the identified employees, evidence of increased supervision, resident separation measures, or other interventions implemented to protect residents pending completion of the investigation.Interview with the Administrator on 5/7/26 at 3:30pm advised both identified employees were permitted to continue working the full shift during the initial investigation. The Administrator stated, We did not suspend them initially because we were still trying to determine whether the allegation was credible.The facility's failure to implement protective interventions and restrict alleged perpetrators from resident contact during an active sexual abuse investigation placed residents at risk for ongoing abuse, intimidation, retaliation, and psychosocial harm.

Based on interview, record review, and policy review, the facility failed to thoroughly investigate and prevent further potential abuse by ensuring protective measures were implemented after an allegation of sexual abuse was reported for 1 of 3 sampled residents reviewed for abuse investigations (Resident # 9).The findings include: Review of the facility policy titled Abuse Prevention and Investigation, dated 1/29/24, revealed the facility would immediately implement interventions to protect residents from further potential abuse during investigations, including removal of alleged perpetrators from resident contact pending investigative findings.Review of the facility investigation revealed Resident #9 alleged on 12/16/25 that two identified housekeeping employees attempted revealed themselves and made sexual comments towards her. Documentation showed the allegation was reported to administration on 12/16/25. Review of statements from resident and staff all have time of incident redacted or blank.The facility failed to implement interim protective measures after the alleged incident was reported during the initial investigation. Staffing schedules and assignment sheets showed Employee # worked 8.16 hours and Employee # worked 10.04 hours on 12/16/25 after the allegation had been made to the administration. Clinical with records reveal resident was noted after the investigative report guarded and worried about her safety.Review of the incident summary failed to reveal documented rationale supporting continued resident access by the identified employees, evidence of increased supervision, resident separation measures, or other interventions implemented to protect residents pending completion of the investigation.Interview with the Administrator on 5/7/26 at 3:30pm advised both identified employees were permitted to continue working the full shift during the initial investigation. The Administrator stated, We did not suspend them initially because we were still trying to determine whether the allegation was credible.The facility's failure to implement protective interventions and restrict alleged perpetrators from resident contact during an active sexual abuse investigation placed residents at risk for ongoing abuse, intimidation, retaliation, and psychosocial harm.

Based on staff interview, facility document review, and clinical record review, the facility failed to notify a provider of two falls for one (1) of seventeen (17) residents, Resident #2.The findings include:Resident #2 was originally admitted to the facility 01/20/2026 with diagnoses to include but are not limited to diabetes mellitus type 2, muscle wasting and atrophy, muscle weakness, moderate protein calorie malnutrition, difficulty in walking, myocardial infarction type 2, history of falling, essential hypertension, benign prostatic hyperplasia, anemia, urinary tract infection, and Parkinson's Disease without dyskinesia.Resident #2's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date 01/26/2026 coded the resident as completing the BIMS (Brief Interview for Mental Status) 08 out of 15. This indicates the resident is moderately cognitively impaired for daily decision making.On 05/06/2026 during a review of Resident #2's clinical record, there was no evidence that the facility notified the doctor/provider of falls that occurred on 01/21/2026 and 02/20/2026.On 05/06/2026 at 12:35 PM the Unit Manager for the First Floor was interviewed regarding the falls. Related to the fall on 01/21/2026, the unit manager stated that she did not see a progress note about the fall in the clinical record. She also stated that she did not see documentation in the progress notes or risk management about the provider or responsible party being notified. The Unit Manager was also asked about the fall on 2/20/2026 and she could not provide evidence that the provider was notified of the fall.The Executive Director, Director of Nursing, Regional Director of Operations, and Regional Director of Clinical Services were made aware of the concern on 5/7/26 at 2:06 PM. No additional information was provided.

Based on observation, resident interview, and clinical record review, the facility failed to ensure a resident was treated with respect and dignity for one (1) of seventeen (17) residents, Resident #3.The findings include:For Resident #3 the facility staff failed to maintain the resident's dignity during a meal as evidenced by standing over the resident to feed the resident and failed to remove facial hair that the female resident indicated she did not wantResident #3 was originally admitted to the facility 02/10/2026. Diagnoses include but are not limited to anxiety disorder, adult failure to thrive, hypotension, fracture of unspecified part of neck of right femur, moderate protein calorie malnutrition, essential hypertension, acute respiratory failure with hypoxia, and insomnia.Resident #3's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date 03/31/2026 coded the resident as completing the BIMS (Brief Interview for Mental Status) 14 out of 15. Indicating the resident was cognitively intact for daily decision making.Review of Resident #3's Physician orders revealed, she was on a Regular diet, dysphagia pureed texture, thin liquids consistency which was started on 04/12/2026 at 1:21 PM. In review of Resident #3's care plan, there was a focus that included the statement, Receives an altered diet with thickened liquids and requires feeding from staff. An intervention stated Encourage optimized PO [intake by mouth] and assist with feeding as needed.On 05/05/2026 at 9:58 AM the Executive Director brought Resident # 3's tray to her room. The nurse stated not to take the tray in because she's a feeder.On 05/05/2026 at 10:00 AM, a CNA brought Resident #3's tray into her and began setting her up for breakfast. The CNA remained standing above the resident and began feeding the resident. The CNA continued standing through the feeding of Resident #3.On 05/05/2026 at 9:05 AM, Resident #3 was noted to have facial hair around her mouth and covering her chin. In an interview on 05/07/2026 at 12:05 PM with Resident #3, she was told that she had facial hair around her mouth and on her chin and asked if she wanted the facial hair. She said no, I don't.The Executive Director, Director of Nursing, Regional Director of Operations, and Regional Director of Clinical Services were made aware of the concerns on 5/7/26 at 2:06 PM.No additional information was provided.

Based on interview, record review, and policy review, the facility failed to implement its abuse prevention policies by ensuring staff identified in an allegation of sexual abuse were prohibited from resident contact pending completion of the investigation for 1 of 3 sampled residents reviewed for abuse allegations (Resident #9).The findings include: Review of the facility policy titled Responding to Abuse/Neglect/Misappropriation/Crime, dated 1/29/24, revealed the facility would immediately protect residents from further potential abuse, including removal of alleged perpetrators pending the outcome of the investigation.Review of an incident summary dated 12/16/25 revealed Resident #9 alleged on 12/16/25 that two identified housekeeping employees attempted revealed themselves and made sexual comments towards her . Documentation showed the allegation was reported to facility administration on 12/16/25. Review of statements from resident and staff all have time of incident redacted or blank.Further review of staffing schedules, payroll records, and assignment sheets revealed identified employees continued to work full shifts on 12/16/25 after the allegation was reported. Interview with the Administrator on 5/7/26 at 3:30pm advised both employees were permitted to continue working the full shift during the initial investigation. The Administrator stated, We did not suspend them initially because we were still trying to determine whether the allegation was credible.The facility's failure to implement protective interventions and restrict alleged perpetrators from resident contact during an active sexual abuse investigation placed residents at risk for ongoing abuse, intimidation, retaliation, and psychosocial harm.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free from accident hazards for one Resident (#223) in a survey sample of 32 Residents. Immediate Jeopardy (IJ) was identified on 11/2/23 at 12:10 PM, at which time the facility Administrator and Director of Nursing were made aware. Following verification of the removal of immediacy the facility abated IJ on 11/3/23 at 4:15 PM. The scope and severity were lowered to a level 2, pattern. The findings included: For Resident # 223 the facility staff failed ensure the mattress was secured to the bed so that it did not slide off the bed frame. On the morning of 10/30/23 Resident #223 was observed resting in bed with the mattress sliding off the side of the bed frame, the mattress was hanging over the edge about 3-4 inches. Upon closer inspection of the bed frame, it was discovered that there were no mattress retainers on the bed frame. The bed had no type of bed rails or other positioning device attached. On 10/31/23 at 1:00 PM Resident #223 was observed in bed resting with eyes closed; the side of the mattress was slightly hanging over the frame about 2-3 inches. On 10/31/23 at approximately 1:00 PM on an interview was conducted with RN C (registered nurse-C) who was asked about the overlap, and she stated that this does pose a problem if the Resident were to sit on the edge of the bed they could possibly slide to the floor since the mattress was not on the bed frame properly. On 11/1/23 a review of the clinical record revealed that Resident #223 had no orders and was not care planned for side rails. On 11/1/23 at 2:00 PM observation was made of Resident #223 in bed resting with eyes closed and 1/2 side rails were present on bed. On 11/1/23 at 2:37 PM an interview was conducted with the maintenance director who stated that he was called by the Administrator to put siderails on Resident #223's bed. When asked why he stated, They don't tell me why, all I know is they have to do an assessment and then whatever the reason the Resident needs a siderail they contact me, and I put the rail on and do an entrapment assessment. When asked if this bed had mattress guards to keep the mattress from sliding off the bed he stated, No, the bed is too old, it's a discontinued model. On 11/1/23 at 3:00 PM an interview was conducted with the Administrator who stated that he spoke with someone from the company that manufactured the bed and was told that the bed was too old and there were no mattress stops and that they could use a bed rail to secure the mattress to the bed. When asked if he was saying that the bed rail was being used to secure the mattress to the bed, he stated that it was. On 11/1/23 at 3:15 PM a policy for Bed Rails was requested and the surveyors were told there is no policy at the facility specific to bed rail use. A device policy was submitted to the survey team. A review of the facility policy read: Policy Name: Medical Equipment Policy: Nursing will follow manufacturer's recommended guidelines on all medical equipment and clinical devices. The manufacturer emailed the surveyors a copy of a document called Entrapment Risk Mitigation excerpts are as follows: The specifics for these best practice guidelines were developed from a review of the incident responses received and pertain to dimensional and clinical criteria. The risk of entrapment increases with large gaps or openings in the bed system that could entrap a patient's neck, head, or chest. Gaps can be caused by mattresses that are not the correct recommended size, loose side rails, or design elements such as wide spaces between the openings in the rails. Since the development of the Bed entrapment guidelines CMS has created F-Tags 700 and 909 pertaining to the use of bedrails and regular inspection of the bed system. These updates have utilized the guidance set forth by the HBSW but added that when a rail is in use on a bed, this must be specified to that patient and documented accordingly. This means that for each admission documentation is required for bed rail use and bed systems should be checked frequently for entrapment compliance. On 11/2/23 at 9:04 AM a phone call was placed to the manufacturer of the bed and when asked if this bed (Model 330 B) had mattress stops or guides to keep the mattress from sliding off the frame, the employee stated this is an old bedframe and it did not have built in mattress guides or stops at the time the bed was manufactured. The product support specialist for the manufacturer stated that Mattress stops are available for sale as an accessory for the bed. When asked if the manufacturer would recommend using side rails to stop the mattress from sliding, he stated It is the position of our company that side rails are used only for the needs of the Residents. The Resident must be evaluated, and it must be documented that they need the rails for positioning and as an assistive device. There are regulations that vary from state to state about using siderails as positioning devices, but they are NOT recommended to be used to secure a mattress in place to a bed. For securing the mattress our company has mattress stops available for purchase. Immediate Jeopardy (IJ) was identified on 11/2/23 at 12:10 PM, at which time the facility Administrator and Director of Nursing were made aware. On 11/2/23 at 4:15 PM, the facility submitted an accepted IJ removal plan which read as follows: 11/2/23 - Resident # 223's bed has been replaced with a bed which has a secured mattress. An audit of all facility beds will be conducted to identify any unsecured mattresses. The unsecured mattresses will be corrected to prevent accident hazard. An audit of all bed side rails will be completed to determine the need for the bed side rail and if the resident is at risk of entrapment. Bed side rails determined to be unnecessary will be removed from the bed. All facility staff will be educated on identification of safety hazards related to unsecured mattresses and side rails. All nurses will be educated by Nursing Administration on completion of a bed side rail assessment prior to initiation of bed side rails to ensure the bed side rail is appropriate that risks and benefits have been explained to the resident and/ or responsible party and plan to reduce the use of bed side rail is documented. All staff on duty will be educated on the above and those coming on duty will be educated on the above prior to being permitted to work. Completion date: 11/3/23 12 noon. The survey team verified that education was conducted and the measures stated in the plan were implemented by the facility staff. Immediate Jeopardy was abated on 11/3/23 at 4:15 PM. On 11/3/23 during the end of day meeting, the Administrator was made aware of the concerns; no further information was provided.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide care consistent with standards of practice to promote the healing of and prevent infection of pressure ulcers for one Resident (Resident #214) in a survey sample of four Residents reviewed for pressure ulcers, resulting in harm for Resident #214. Immediate Jeopardy (IJ) was identified on 10/31/23 at 3:10 PM, at which time the facility Administrator and Director of Nursing were made aware. Following verification of the removal of immediacy the facility abated the IJ on 11/3/23 at 3:15 PM. The scope and severity was lowered to a level 3, isolated. The findings included: For Resident #214, the facility staff failed to conduct timely and accurate skin assessments, which included failure to identify wounds, and signs of wound infection; and failed to provide treatment to wounds in accordance with physician orders, resulting in wound deterioration, which constituted harm. On 10/30/23, Resident #214's clinical record was reviewed and revealed the following: a. The most recent note by the wound care specialist dated 10/11/2023, indicated the resident had a stage III wound (1) to her left medial heel, the wound was noted as being stable with 100% granulation tissue. The note also indicated Resident #214 had an unstageable pressure wound (2) to her left lateral ankle. This wound was noted as stable with Exudate amount: Moderate, Exudate Description: Serosanguineous. b. The treatment orders in the wound care specialist's note to the left medial heel and the left lateral ankle read as follows: cleanse with wound cleanser, silver alginate, bordered foam, rolled gauze, every other day. c. Review of the active physician orders and treatment administration record revealed the wound care specialist's orders were not carried out and the orders/treatment being applied were based on orders dated 9/15/22, which read, clean with NS/WC [normal saline/wound cleanser], apply silvercel cover with dry dressing daily. d. Resident #214 had a skin observation tool, dated 10/27/2023, performed by a facility RN. The RN failed to identify either of the wounds to the left lateral heel or left lateral foot. e. Resident #214 was ordered to receive 21 days of IV [intravenous] antibiotic starting 10/3/23, for a right foot post operative wound infection, which was ordered by the infectious disease doctor. The note from the Infectious Disease doctor noted Resident #214 had a history of multiple drug resistant A. Baumannii [Acinetobacter baumannii- an organism that can cause infections in the blood, urinary tract, and lunch, or in wounds in other parts of the body] infection. The Resident missed 5 consecutive doses. On 10/30/2023 at 2:55 p.m., Surveyor C and D made observations of the wounds with LPN B (licensed practical nurse-B) and RN B(registered nurse-B). Upon observation of the right and left foot wounds, it was noted the dressing in place was brownish yellow in color from drainage. There was no date to indicate when the dressings were last changed. RN B and LPN B were asked to describe what was being seen. Both acknowledged the bandage was saturated and brown in color, and it did not appear the dressings had been changed the day prior as ordered. Upon removal of the dressing, there was a significant foul odor. There was brown, yellowish, and green tinted exudate noted in a wound that was on the plantar of the foot across the metatarsal joint region, and the exudate was copious. LPN B and RN B confirmed the odor and exudate. The wound bed was not able to be visualized. Following the observations of Resident #214's wound on 10/30/2023, and acknowledgement of signs of infection confirmed by 2 facility staff, the following was noted: On 10/31/23, the clinical chart of Resident #214 was reviewed again and revealed no evidence that the facility staff had notified the physician of the observed changes in the wounds and signs of infection as evidenced by malodor and copious exudate that had been observed the day prior. The facility policy titled; General Wound Care/Dressing Changes was reviewed. This policy read, A licensed nurse will provide wound care/dressing change(s) as ordered by physician. Procedure: 1. Notify the physician and obtain orders for treatment(s) and dressing changes . 3. Provide treatments as ordered. 4. Remove and reapply dressings as ordered and/or indicated . 9. Document in progress notes any unusual findings and follow-up interventions including notification of physician/responsible party. The facility's Regional Director of Clinical Services identified [NAME] as their nursing standard of practice. According to the [NAME] Manual of Nursing Practice, Eighth Edition, chapter 32, on page 1090 stated the following: Osteomyelitis is a severe pyogenic infection of the bone and surrounding tissues that requires immediate treatment . Management: . 2. Chronic: develops with inadequate or ineffective course of antibiotics or delayed treatment . Complications: 1. Nonhealing wound, 2. Sepsis, 3. Immobility, 4. Amputation . The [NAME] manual of Nursing Practice also stated, in Chapter 2: Standards of Care, Ethical and Legal Issues on page 18, Common Legal Claims for Departure from Standards of Care: Failure to monitor or observe a patient's clinical status adequately, Failure to monitor or observe a change in a patient's clinical status, failure to communicate or document a significant change in a patient's condition to the appropriate professional . Failure to implement a physician/NP [nurse practitioner]/PA [physician assistant] order properly or in a timely fashion, Failure to administer medications properly and in a timely fashion, or to report and administer omitted doses appropriately . failure to prevent infection . Immediately Jeopardy was identified on 10/31/23 at 3:10 PM, at which time the facility Administrator and Director of Nursing were made aware. On 11/1/23 at 1:15 PM, the facility submitted an accepted IJ removal plan, which read as follows: A skin assessment will be conducted on all current residents to include accurate documentation of wounds and identification of signs/symptoms of wound infection. The physician will be notified of any new wounds, changes in the wound status, and/or signs/symptoms of infection. Resident #214's physician was notified of the changes in the wounds and signs/symptoms of infection on 10/31/23. Education will be provided by Nursing Administration to all licensed nurses concerning care and services for provision of appropriate care of residents with wounds to include timely assessment of wounds, timely identification of wounds, identification, and response to signs/symptoms of infection, and physician notification of changes to wounds. Education will be provided to CNAs (certified nursing assistants) on reporting any changes noted in skin through verbal report to the nurse. The nurses will be educated on identification of new wounds and reporting the new wounds to the wound practitioner and Resident physician. The nurses will be educated on signs/symptoms of wound infection to include odor, increased drainage, change in wound color of wound bed, warmth to the surrounding area. The nurses will be educated on notifying the physician of changes to wounds. Nurses will be educated on initialing and dating of dressings prior to placing a dressing on the resident. The wound practitioner will assess residents with wounds on a weekly basis. All nurses and CNAs on duty will be educated on the above and all nurses and CNAs coming on duty will be educated on the above prior to being permitted to work. Completion date 10:00 am on 11/2/23. On 11/2/23 at 10:40 AM, the facility administration submitted to the survey team credible evidence of the IJ immediacy removal plan. Included in the documents was evidence of skin assessments completed on all Residents and the staff education. On 11/2/23, the survey team selected a sample of Residents to observe their skin to identify any skin impairments and verify that any impairments and/or signs of infection had been appropriately identified and communicated to the doctor. During this verification the air mattress for Resident #214 was inadvertently deflated when the head of the bed was elevated and the Resident had to be changed to another mattress, so the observation had to be suspended. When Resident #225 was going to be observed, the Director of Nursing noted that the low-pressure light was on, and her air mattress was not functioning properly, and this observation had to be suspended as well. On 11/3/23, the survey team returned to the facility to verify the abatement of IJ. Upon review, it was noted that for several Residents, which included Resident #214, the skin assessment was inaccurate and didn't identify all skin impairments. Also, there were 4 staff that had worked the night shift from 11/2-11/3, that had no evidence of having received training and 2 current staff working that had no evidence of having received training as noted in the facility's IJ removal plan. On 11/3/23 at 12:28 PM, the facility Administrator, Director of Nursing (DON) and Regional Director of Clinical Services were made aware that the survey team had not been able to verify the abatement of IJ for the above noted reasons. On 11/3/23 at 12:34 PM, the DON provided the survey team with a progress note written 11/3/23 at 11:49 AM, from Resident #214's attending physician. The note read, I was notified by the charge nurse that patient missed the doses of iv antibiotics. Since patient has chronic persistent wounds but clinically had no fever, I ordered blood work and wound culture and advised the wound care NP to assess the wound again before giving her another round of antibiotics and exposing her unnecessarily to antibiotics and increasing the risk of resistant and c. diff [sic]. There was no indication that the missed doses of IV antibiotics were discussed with the infectious disease doctor who ordered the IV antibiotics and there was no evidence in the clinical chart of wound cultures being obtained/conducted as per this note. Following the inability to abate IJ on 11/2/23-11/3/23, the provider submitted a revised IJ removal plan with the only change being the date and time they would complete the plan: the revision indicated it would be complete on 11/3/23 at 2 PM. On 11/3/23, in the afternoon the survey team attempted again to verify the facility staff had implemented their approved IJ immediacy removal plan. Staff interviews were conducted with facility staff from the nursing department to ensure they had received training. A revised skin assessment for Resident #214 was submitted to the survey team. The survey team obtained a Resident census listing and cross checked to ensure that all Residents had a skin assessment and a sample of 10% of the Residents had skin observations conducted by the survey team. The survey team confirmed Immediate Jeopardy was abated on 11/3/23 at 3:15 PM. References: https://www.cms.gov/files/document/pocket-guidepressure-ulcers-and-injuries-stages-and-definitions.pdf (1) Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue. (2) Unstageable-Pressure ulcer known but not stageable due to coverage of wound bed by slough and/or eschar.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure Residents received adequate supervision and assistance prevent accidents for 1 Residents (#331) in a survey sample of 61 Residents. Resident #331 who was supposed to be on one-to-one (1:1), went out a second story window and sustained injuries. Immediate Jeopardy was called for Resident #331 on 7/13/23 at 9:10 am. The Immediate Jeopardy began on 6/17/23 and was removed on 7/14/23 at 12:40 PM. The findings included: For Resident #331, the facility staff failed to continuously supervise Resident #331 and as a result, Resident #331 had time to go to her room, shut the door, remove a drawer from her closet, break the window in her room, go out the window, and was found on the ground below her second-floor window and sustained a thoracic fracture and intra-cranial bleed. Resident #331 was admitted to the facility on [DATE] with diagnoses that included but were not limited to, Non-Traumatic Intracranial Hemorrhage, Unspecified, Psychological Condition (Unspecified Psychosis) Personal History of Traumatic Brain Injury, Unspecified Protein-Calorie Malnutrition, Restlessness and Agitation. A review of the discharge summary dated 6/15/23 from the hospital revealed the following excerpts: Was evaluated by psychiatry patient lacks capacity to make her own decisions her friends are her medical POA. Patient has advanced directives for DNR no PEG or artificial means of nutrition. Continue meds for psychosis increase Seroquel to 50 mg [milligrams] bid [twice a day] add prn [as needed] Zyprexa continue prn Xanax Continue Depakote added by Neurology for seizure prophylaxis and mood stabilization. Family would prefer patient at VA facility and will transition to hospice -no further need for sitter at bedside - continue other supportive care. On 7/13/23 a review of the clinical record revealed that the following psychotropic medications were ordered at the facility: Depakote 500 mg twice per day Seroquel 50 mg twice per day Haldol 1 mg 3 times per day (began on 6/16/23 at 9:00 PM) Valium 2mg every 12 hours prn Review of the Medication Administration Record (MAR) showed the Zyprexa and Xanax were not started. On 7/14/23 at approximately 11:55 AM, an interview was conducted with the DON who stated that the nurse did make a transcription error and did not have all the medications put into the system that were ordered from the hospital. Resident #331 arrived on 6/15/23 at 5:35 PM and according to the MAR, received her 9 PM dose of Seroquel and Depakote. The following are excerpts from Resident #331's progress notes: 6-16-23 at 7:47 AM - Note Text: Multiple behavior issues during the night. Wandering halls and intrusive wandering into other resident rooms. Also, trying to rummage into other resident's belongings. Exit seeking x1 this shift-has wander guard in place & functional. Disrobed completely & was wandering naked x2. Also urinated out in the hallway x1-leaned against linen cart & voided on floor. Numerous attempts to orient to facility & room without success. Also walked up to desk & laid down on floor x2. Also took sheet/blanket, put on floor, and laid down in hallway. Resident currently wandering halls at this time. 6-16-23 at 11:59 AM Nurse Practitioner Note- Alert, standing in room naked going through another resident's closet, very manic and only able to tell me her name spoke to nurse manager and other staff outside of her door she has been this way since admission and unable to be left alone, requiring 1:1 very close supervision combative, verbally and physically staff currently waiting on police and EMS to transport her back to hospital in hopes to get a TDO [Temporary Detainment Order] because she is unsafe to not only herself but the staff and other resident's needs to be a locked facility 6-16-23 at 5:57 PM - Type of Behavior: Resident was naked in roommates' bed, unable to redirect, she became combative with CNA staff and caused a skin tear to her left arm during combative episode. She wanted to get out of room while naked she began to bang on glass window. She was redirected to other areas of the room and the banging stopped. Non-pharmacological intervention: Writer sat 1:1 at residents' door during psychotic episode to ensure residents safety Effect: Effective till EMS, 911 arrived and they took her to ER for eval PRN Medication: Outcome: NP assessed resident in room during episode, N.O. [new order] for Haldol 1mg sublingual TID x 3days. However, Resident #331 she was not admitted on a TDO and was returned to the facility. The following are notes included in the discharge summary from the hospital dated 6-16-23. 6/16/23 at 5:15 PM - She was put on meds for psychosis including Seroquel and prn Zyprexa and prn Xanax. She was discharged in [sic] a skilled nursing facility; she was sent to the facility due to increased agitation and hit a staff member. However, chair [sic] also reports that patient was standing naked being [sic] her head against the window at the facility. Patient was not given any prn medications by staff at facility. Our case manager discussed with the case manager at the facility. It seems like they (the facility) did not reach out to the doctor to get any other additional medications to help out with anxiety or agitated behaviors and they can help adjust them. The following progress note was entered into the facility clinical records about the events that took place when she returned from the hospital on the evening 6/16/23 through the morning of 6-17-23: 6/17/23 at 9:30 AM - Description of the fall/V/S/injuries if any: Resident came back from hospital at 2300, was assigned a staff all night to watch her. Resident was restless off and on but later started sleeping early this morning at 0500. At 7:15 resident was seen pacing the hallway with her staff, she was agitated and combative, she stated that we won't let her do what she wants, and she said to get ready to call 911, I'm getting out of here. However, I kept following her around, she walked to another hall going into resident rooms exit seeking, banging on doors and windows. Resident stated she will deal with me if I don't get out of her way. Attempted to administer PRN Haldol but she wouldn't take it. Resident ran inside her room and shut the room door up. After 3 mins a call came in from downstairs stating resident was at the backyard. Rushed inside the room, searched for resident could not find her, noted her glass window was broken into pieces, looked downward through the broken window saw her kneeling with both knees while bowing down her head. Rushed downstairs go assess her while I called 911 on the phone. They stated someone already called. On arrival of 911 resident was assessed and collar placed on her neck and was transported to [hospital name redacted] Hospital. What interventions were in place at the time of the fall? 911 was called, resident assessed. On 7/14/23, an interview was conducted with RN B who worked the evening of 6-16-23 (3-11) and the overnight shift (11-7). When asked to describe the events of the evening and night shift she stated that it was Just like I put in my notes. She stated that Resident #311 was put on 1:1 supervision from evening shift until morning. She stated that the night shift CNA left at 7 AM and that the Resident was restless on and off all night but fell asleep at around 5 AM. She stated she cannot speak for the day shift CNA, however she knew for sure the night shift CNA stayed with her every step she took. RN B stated in the morning after the night shift CNA left, she (RN B) was trying to report off to the oncoming shift and there were a lot of people around, so she (RN B) did not notice if the assigned day shift CNA was following Resident #311. RN B stated she was trying to give report and in about 2-3 minutes she received a call that Resident #331 had broken the window and, Fallen down from her second-floor window to grass below her window. RN B stated she then ran down while calling 911. She stated the Resident was alive and breathing but mumbling about some people chasing her. She stated she tried to keep the Resident calm and still until the EMS arrived. According to a facility synopsis, Resident #331 sustained a thoracic fracture and intra-cranial bleed from the fall. 7/12/23 at 4:23 PM, an interview was conducted via telephone with the CNA D who worked the overnight shift (11 -7 on 6/16/23-6/17/23). CNA D stated that she stayed with the Resident all evening and night until 7 AM. She stated that the Resident was agitated and that she (CNA D) reported off to the day shift CNA that she needed close monitoring. She stated that she left and got on the elevator and the day shift CNA was sitting near the nurse's station watching the Resident from about 20 feet. Several unsuccessful attempts were made during survey to contact CNA B during survey. CNA B is the agency CNA assigned to 1:1 with Resident #311 during the day shift on 6/17/23. A review of the as worked schedules for 6-15-23 through 6-17-23 revealed no 1:1 specifically identified on the schedule or assignment sheet. Resident # 311 was in room [ROOM NUMBER] and was assigned to the CNA covering that hall however there was no staff listed as dedicated 1:1 with Resident #311. The facility was notified of Immediate Jeopardy on 7/13/2023 @10:30am. The facility presented the following removal plan. As of 7/13/23 the facility has reviewed residents with diagnoses of impaired cognition, mental disorder, depression, bipolar disorder, anxiety disorder, and behavior requiring interventions. There are currently no residents requiring one to one supervision. Education will be provided by Nursing Administrations to all staff concerning care and services to provide appropriate care of residents with impaired cognition, mental disorders, depression, bipolar disorder, anxiety disorder, and behaviors requiring intervention. Behaviors requiring one to supervision include but are not limited to agitated pacing, agitated pacing toward any type of exit, knocking or kicking at doors or windows, physical aggression towards self or others, or objects. Behavior management includes but is not limited to notifying the practitioner of the behaviors, provision of one-to-one supervision, provision of calm, quiet environment, notification of the Director of Nursing and Administrator, and initiation of emergency management by calling 911 if indicated. One -to-one supervision is defined as staying within direct line of vision of the resident. All staff will be educated that an alternatives staff member will provide relief to ensure continuity of one-to-one supervision. All staff will be educated that if the resident becomes more agitated, staff will initiate emergency management by calling 911. All staff on duty have been educated and all staff coming on duty will be educated prior to the next shift. Completion date 7/14/23 at 10 AM. The survey team verified the IJ removal plan as evidenced by the following: On 7/14/23, at 10 AM, the survey team reviewed the facility's submitted credible evidence that all Residents with diagnosis to include, but not limited to, impaired cognition, mental disorders, depression, bipolar disorder, anxiety disorder, and behaviors requiring intervention, had been reviewed to identify if behaviors warranted one-on-one supervision. There were no Residents identified to need one on one services by the facility staff. The survey team observed all residents and none were observed to have behaviors requiring intervention. The survey team reviewed the staff education provided to facility staff with regards to Residents with behaviors and how to handle one on one supervision. Staff interviews were conducted of across all departments to verify the education was provided and the staff understood one-on-one supervision and how to respond when Residents displayed behaviors that could warrant initiation of one-on-one supervision. The Immediate Jeopardy was removed on 7/14/23 at 12:40 PM.

Based on observation, interview, record review, and facility menu review, the facility failed to coordinate services and provide meals and snacks for one of two sampled residents (Resident (R) 7) reviewed for dialysis and received dialysis treatments at an outside dialysis center. Findings include: Review of R7's Admission Record, located under the Profile tab in the resident's electronic medical record (EMR) revealed R7 was admitted to the facility with diagnoses which included end stage renal disease (ESRD), prediabetes, and dependent on renal dialysis. Review of R7's Physician Orders, located under the Orders tab in the resident's EMR, revealed current orders for R7 to receive hemodialysis on Monday, Wednesday, and Friday at 6:30 AM and to receive a renal diet. Review of R7's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/06/23, located in the resident's EMR, specified the resident received dialysis. The resident had a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicated the resident was cognitively intact. Review of R7's current care plan, located in the EMR under the care plan tab, revealed a Focus area initiated on 12/14/22, that specified, Increased risk for complications secondary to requiring dialysis secondary to ESRD. The care plan's goal specified [No] complications secondary to requiring dialysis thru review period. Care plan approaches included, Therapeutic diet as ordered and Pack lunch or snacks to be sent with the resident to dialysis as needed. Review of the facility's planned breakfast menu for 07/10/23 revealed a resident ordered to receive a renal diet was planned to be served the following: four ounces of apple juice, four ounces of hot cereal, two ounces of scrambled eggs, one slice of toasted white bread and four ounces of skim milk. During an interview on 07/09/23 at 2:40 PM, R7 stated she was transported from the facility to her dialysis treatments every Monday, Wednesday, and Friday. R7 explained that on the days she received dialysis treatments, she left the facility between 6:15 AM to 6:30 AM. R7 stated prior to leaving the facility for dialysis she was not always served a breakfast meal. The resident stated when she was provided something to eat prior to going to dialysis it was usually something she did not like to eat, so she did not eat it. R7 stated when she returned to the facility at around 11:30 AM to 12:00 PM after her dialysis treatment she was hungry because she did not eat any breakfast. An additional interview with R7 on 07/10/23 at 6:07 AM revealed she was leaving her room to go for her dialysis treatment and had not received her breakfast meal. Observation on 07/10/23 at 6:17 AM revealed R7 was seated in her wheelchair near the nurse's station when a nurse offered her a Styrofoam container. R7 was observed to look inside the container and stated that she could not eat any of the food and left the container at the nurse's station. Interview with R7 on 07/10/23 at 6:18 AM revealed the items in the Styrofoam container were all too sweet and would run her sugar up, so she could not eat any of it. Observation of the contents of the Styrofoam container revealed it contained a carton of whole milk, raisin bran cereal, yogurt, fruit punch, apple sauce, and a banana. Observation on 07/10/23 at 6:22 AM revealed a nurse provided R7 with her dialysis bag. R7 was observed to look through the bag and take out a bottle of water and hand the bag back to the nurse. R7 stated that she did not like anything in the bag except the water, because the other food and beverage in the bag were too sweet. Observation on 07/10/23 at 6:30 AM, revealed R7 exited the facility and was assisted onto the transport van by the van driver for transport to her dialysis treatment. R7 had the bottle of water from her dialysis bag but did not take any food with her to the dialysis center. Observation on 07/10/23 at 6:37 AM, of the remaining contents of R7's dialysis bag, with the Dietary Manager (DM) present, revealed it contained a peanut butter and jelly sandwich, 2 fig bars, apple sauce and cranberry juice. During an interview on 07/10/23 at 6:40 AM, the Dietary Manager (DM) stated a resident's dialysis bag contained food and beverages the resident was to take with them to their dialysis treatments. The DM was informed that R7 only took the bottle of water from her dialysis bag to her dialysis treatment this morning because the other food and beverage were too sweet. The DM stated that she discussed food preferences with residents, but not necessarily what foods and beverages they preferred to receive in their dialysis bags. During an interview on 07/11/23 at 2:15 PM, the DM stated prior to R7 leaving the facility for her early morning dialysis treatment on Monday, Wednesday, and Friday she should be served a breakfast meal as planned on the facility menu. The DM confirmed there were mornings when R7 was not served a breakfast meal before she left the facility for her dialysis treatment. The DM explained the kitchen opened at 5:30 AM and the dietary staff were to prepare R7 a breakfast meal as specified on the facility menu. But there were mornings when the nurse aides did not come to the kitchen to pick up R7's breakfast meal until after R7 had left the facility for her 6:30 AM dialysis treatment.

Based on observation, staff interview, clinical record review, and facility documentation the facility staff failed to provide appropriate treatment to prevent a urinary tract infection for 1 Resident (Resident #21) in a survey sample of 61 Residents resulting in harm. The findings include: For Resident #21, the resident developed a urinary tract infection. This is harm. On 07/09/23 at 01:55 PM, during an interview with Resident #21, the Resident said the facility staff replaced her Foley catheter (a flexible tube that passes through the urethra and into the bladder to drain urine) few days ago, but something is not right, it hurts, and urine comes from around it. Resident #21 reported that she has told the nurses on several occasions and They said they were going to come look at it but haven't come back yet. Resident #21 reported that her gown had been saturated with urine that morning from the leakage. On 7/9/23 at approximately 2 PM, an interview was conducted with LPN G. LPN G confirmed that Resident #21's gown had been wet with urine that morning. LPN G said that there was urine in the catheter drainage bag, and she had advised the Resident and staff to let her know if they noted any further leakage. On 7/9/23, during the end of day meeting, the facility Administrator and Director of Nursing were made aware that Resident #21 was reporting pain at her urinary catheter and leakage. On 7/10/23 at 8:44 AM, an interview was conducted with Resident #21. Resident #21 reported the following when asked about her catheter, They changed it last night. On 7/11/23 at 10:58 AM, Surveyor D made an observation of Resident #21's sacral wound, with RN C, the treatment nurse. During this observation, it was noted that a towel was between Resident #21's legs. When asked, Resident #21 reported that the catheter was still leaking. On 7/11/23 at approximately 11:09 AM, an interview was conducted with Resident #21. Resident #21 reported that the catheter isn't hurting like it was, but it feels like it is pulling. Resident #21 went on to report, they got some urine out of the bag to send to the lab, but they haven't told me the results yet. Resident #21 reported she has had the catheter for a long time. They claim it was because I was staying wet and it was interfering with my bottom [wound on her sacrum], I've got the catheter in and I'm still wet. On 7/11/23 at approximately 11:15 AM, Surveyors C and D talked with LPN G, who was assigned to care for Resident #21. LPN G confirmed that the Resident's gown had been saturated with urine that morning and they were waiting on the results from the urine sample. On 7/10/23 and 7/11/23, a clinical record review was conducted. Review of Resident #21's diagnosis revealed a diagnosis of neuromuscular dysfunction of bladder, but no physician notes made mention of this diagnosis and no urology notes could be found. This review revealed that preliminary results of the urine sample were available. The results had been reported to the facility at on 7/10/23 at 7:39 PM. The results were indicative of the urinary tract infection as noted by, having turbid clarity, specific gravity of 1.006, 500 Leuk Esterase, 2+ nitrite, 3+ blood, 3+ urine bacteria, WBC [white blood count] of 21-50, and amorphous crystals present. On 7/11/23, in the afternoon, interviews were conducted with LPN D, LPN E and LPN G. When asked about the process for labs, all of them indicated the labs are reported/loaded directly into the clinical record of each Resident and the providers [doctor and/or nurse practitioner] looks at them and will put in any orders they have. Each of the nurses interviewed indicated they do not monitor to see when results come back and notify the provider, it is the providers responsibility to check for results, except in the instance of the lab result being critical, in which case the lab will call the facility and the facility nurse will then call the provider. During the above interview with LPN G, Surveyor C asked the nurse to see if Resident #21 had any labs. LPN G accessed the clinical chart and noted, She has a urine culture to be reviewed, the doctor will review it. She is growing something; it usually takes 3 days for the culture and sensitivity to come back. On 7/11/23 at 1:22 PM, an interview was conducted with Employee D, one of the doctors at the facility and the attending physician of Resident #21. The doctor was asked about the process for lab results. The doctor said, The nurse will call us if the result is positive. The doctor was asked about why Resident #21 had a urinary catheter and he said it was for wound healing. On 7/11/23, during the end of day meeting, the facility Administrator and Director of nursing were made aware that the urine lab report for Resident #21 had been received on the evening of 7/10/23, and no action had been taken despite the Resident continuing to report pain and discomfort. The urine report/result was noted to be in a status of to be reviewed. During the end of day meeting on 7/11/23, the director of nursing explained that having a urinary catheter must be handled with care because Residents are at an increased risk of infection. The facility staff were also asked to provide any supporting documentation with regards to the diagnosis of neuromuscular dysfunction of bladder when this diagnosis was made and by whom. On the morning of 7/12/23, the facility staff reported that Resident #21 had been started on an antibiotic and the Foley catheter had been removed. They also stated that Resident #21 had the Foley due to a sacral pressure wound and the diagnosis of neuromuscular dysfunction of bladder had been entered into her diagnosis listing in error. On 7/12/23, the urine culture report noted, >100,000 CFU/ML Lactose fermenting gram negative rods, result: Escherichia coli (E-Coli). (E-Coli is a bacteria that can cause diarrhea, urinary tract infections, respiratory illness and pneumonia, and other illnesses.) On 7/13/23 during the end of day meeting, the DON and Administrator were made aware of the above findings and no further information was provided.

Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to provide care and services to prevent the development and worsening of pressure ulcers for 2 Residents (Resident #18 and #21), resulting in harm for both Residents, in a survey sample of 61 Residents. The findings included: 1. For Resident #18, a Resident who was in a persistent vegetative state, the facility staff failed to implement preventative measures to prevent the development of a pressure sore. Resident #18 developed a pressure sore that was found at an advanced stage of stage III, this constituted harm. On 7/13/23, during a clinical record review the following was noted: A physician order dated 3/9/23, read, PREVALON boots to bilateral feet as tolerated - remove during ADL care and skin checks- directions: every shift. A nursing note dated 07/10/23 said Resident #18 had a pressure ulcer that was found on her left foot at an advanced stage. Review of the care plan revealed that Resident #18 was identified as being at risk for wound development and indicated her wounds were healed. Some of the interventions included: Bilateral Prevalon Boots at all times-remove for care and skin checks each shift. The record review revealed no evidence of skin checks being performed each shift. On 7/13/23, Surveyor C was accompanied by one of the Clinical Nurse Consultants/Employee O. Employee O stated she had looked at the wound on Resident #18's left third toe and that it was a Stage III wound. Surveyor C observed the wound, and this observation revealed a full thickness tissue loss with no bone or muscle visible. However, full observation was difficult due to Resident #18's impaired mobility and the location of the wound. Resident #18 was observed with the wound open to air, foot being floated by a pillow. Employee O stated that it was open to air because they are coming to assess it and change the treatment, it was keeping it too moist. On 7/13/23 at 6:20 PM, the survey team met with the attending physician of Resident #18, Employee N. The physician was asked about Resident #18's order for the prevalon boots, remove during ADL care and skin checks, every shift. The doctor acknowledged that his expectation was that staff would be looking at the Resident's skin condition at a minimum of daily and the Prevalon boots would have to be removed to make such observations. The doctor also stated that he would expect wounds to be identified prior to being an advance stage and said, That's the standard practice but if they have agency staff, they may not look at things. On 7/13/23, during an end of day meeting, the facility Administrator and Director of Nursing were asked to provide any evidence of skin checks being performed each shift. No documentation was submitted to the survey team prior to conclusion of the survey. On 7/14/23 at approximately 10:45 AM, Resident #18 was observed in bed with her feet on the bed, not being floated and Prevalon boots not on. On 7/14/23 at 11:03 AM, CNA E accompanied Surveyor C to the room of Resident #18. CNA E confirmed that Resident #18 is total care and non-verbal. CNA E also confirmed that Resident #18 doesn't refuse care as she isn't able to engage with staff. During observations Resident #18 was observed with her feet resting on the bed, not being floated and Prevalon boots not on. When CNA E was questioned, CNA E found 1 Prevalon boot in the room but was unable to find the second one. CNA E said, she had been off the day prior (7/13/23) but had Resident #18 on 7/12/23 and had not applied the Prevalon boots that day either, as she was not aware of them and had not seen them in the room on Wednesday, 7/12/23. An additional clinical record review performed on 7/14/23, revealed the wound care specialist had come on the evening of 7/13/23, to assess Resident #18's newly identified wound. The note dated 7/13/23 indicated the following: left foot third toe, Etiology: Pressure, Stage/Severity: Stage 3, Acquired in House: Yes, Date Wound Acquired: 07/07/2023, Wound Status: New . % Slough: 50-74% slough .% Granulation: 25-49% granulation . Exposed Tissue: Subcutaneous . The facility policy titled; Skin Assessments was reviewed. This policy read, . 4. Care plan specific interventions will be developed based on skin risk assessment outcomes and individual patient needs. On 7/14/23, during an end of day meeting, the facility Administrator and Director of Nursing were made aware of the above findings. No further information was provided. 2. For Resident #21, who had a pressure ulcer, the facility staff failed to provide interventions and treatment to prevent the worsening of a pressure ulcer. This is harm. On 7/9/23 at 1:55 PM, during an interview with Resident #21. The Resident reported having a sacral pressure ulcer that hurts. Resident #21 reported, It was just starting when I came here, it has gone out of proportions now, I can tell when it is getting well, it doesn't hurt me so bad but then in a day or two it goes back the other way. The Resident reports they put cream on it daily but here it is 2 o'clock and no one done nothing to it yet. I would get up every day, but I can't get them to put me back to bed when I get to hurting, they will say you have to wait, they have to get someone to come do it. On 7/10/23, a clinical record review was conducted. This review revealed the treatment had not been performed on 7/9/23, as ordered. On 7/11/23 at 10:10 AM, an interview was conducted with RN C, the treatment nurse. RN C was asked about Resident #21's sacral pressure ulcer and pain. RN C said, lately it has redness around it, so I have been putting cream on the peri-wound. She has a stage III; I use lidocaine gel because I know it hurts her. On 7/11/23 at 10:58 AM, RN C conducted the treatment and dressing of Resident #21's sacral pressure ulcer. Surveyor D observed this and noted there was no dressing on the sacral pressure ulcer when the treatment nurse rolled the Resident to her side. RN C confirmed the findings. Following the treatment, on 7/11/23 at approximately 11:09 AM, an interview was conducted with Resident #21. Resident #21 reported that her pain was a 5, on a 1-10 pain scale. Resident #21 went on to say, The pain pill only helps my legs. My bottom really hurts so bag, sometimes I just cry and cry. It gets better then slacks up and goes right on back. Resident #21 reported having pain medication at 6 AM. It looks like they just don't . [resident hesitated and didn't finish statement] you have to tell them. It is so many different people coming in everyday, it is never the same people. On 7/11/23, during an end of day meeting, the facility Administrator and Director of Nursing were made aware of the above findings. No further information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure Residents receive care and services in accordance with professional standards and the comprehensive care plan and Resident choices for 1 Resident (#123) in a survey sample of 61 Residents. The findings included: For Resident # 123, the facility staff failed to ensure the Resident was provided transportation to her follow up surgeon appointments, causing her to miss 2 appointments. On 7/12/23 at approximately 2:00 PM an interview was conducted with Resident #123 who complained that she missed 2 of her last 3 appointments due to transportation issues. She stated she was supposed to go at the end of May, but it got rescheduled to June 8th and she made it to that one. She stated she then had a follow up June 22nd and it got rescheduled to June 28th, because transportation did not arrive and the one on June the 28th got rescheduled because of transportation too. When asked how she is transported she stated that she is supposed to go in a wheelchair. A review of the clinical record revealed that this was in fact true Resident #123 did miss two of the last 3 appointments. On 7/13/23 at approximately 4:00 PM an interview was conducted with the Social Worker who stated that she does not arrange transportation that Employee P is responsible for that. On 7/13/23 at 4:10 PM an interview was conducted with Employee P who stated that she is the person who arranges transportation for appointments. When asked what she does if the transportation does not show up, she stated that she will call the company and see if there is a reason for the delay if they are not coming then she will call the doctor's office and reschedule the appointment. She stated there is not much else I can do other than reschedule. On 7/13/23 at 5:00 PM an interview was conducted with the DON who stated that it is ultimately the facility's responsibility to get the resident to their doctor appointments timely. On 7/13/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure freedom from accidents and hazards for 2 Residents (#'s 9 & 4) in a survey sample of 13 Residents. Immediate Jeopardy was found to start on 07/20/2022, called on 7/21/22 at 4:02 PM, and removed on 7/22/22 at 5:10 PM. The findings included: 1. For Resident #9 the facility staff failed to ensure the Resident was provided a safe smoking environment and supervised by staff for safety while smoking. On 7/20/22 at approximately 3:00 PM Surveyors B, C, and D were walking to their respective vehicles and it was observed 2 Residents sitting in wheelchairs in the parking lot area, smoking by the dumpsters. Surveyor C interviewed Resident #9 who had obvious speech impairment and right sided deficits. Resident #9 was asked his name and he stated it with difficulty. When asked if he was a Resident at the facility he nodded. When asked if staff knew he was outside he nodded. When asked if he was new at the facility he pointed to his mouth with his left hand and said Speech. When asked if he had difficulty with speech he nodded yes. When asked if had previously had a stroke he nodded yes again. On 7/20/22 at approximately 3:10 PM an interview was conducted with the Administrator and the DON informing them of the 2 residents outside smoking. The Administrator acknowledged that the facility was a Non-Smoking facility. The DON stated that they do not conduct safe smoking assessments because they are non-smoking facility. She stated the non-smoking status of the facility is in the Resident's Admission Contract signed by the Resident and / or Representative on admission. On the morning of 7/21/22, a record review as conducted on Resident #9. The record review revealed that Resident #9 was admitted to the facility 2/12/22 with diagnoses that include status post cerebral infarction (stroke) with right sided deficits, [CONDITION(S)], [CONDITION(S)], dysphasia, and [CONDITION(S)]. This Resident's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/5/22 coded Resident #9 as having a BIMS (Brief Interview of Mental Status) score of 0 out of 15 indicating severe cognitive impairment. Section G of the MDS coded the Resident as requiring limited assistance with physical assist of 1 staff for all aspects of ADL care with the exception of eating, which he requires set up only. This Resident was not his own Responsible Party. On 7/21/22 at 10:15 AM an interview was conducted with the ADON who stated that PCC (Point Click Care - Electronic Health Record program) has a section to be filled out on the Admission Screen for Residents who are smokers or former smokers. When asked how the nurse would know if the Resident was a smoker or former smoker the ADON responded, You would ask the Resident or family member and you would look in the discharge summary from the hospital or the history and physical. A review of the clinical record revealed the following excerpt from the admission progress note: 2/12/22 3:56 PM -Respiratory: Nail beds are normal. Lips/mucous membranes appear pink. No respiratory symptoms noted. No oxygen orders are present. No [CONDITION(S)] present. Unable to determine smoking history. Excerpts of his hospital discharge summary dated 2/12/22 are as follows: He does follow simple commands. He is not able to provide any info. I spoke with the administrator of [Assisted Living facility name redacted] who reports he's been there for [AGE] years. States at baseline he has limited verbal interaction and often signs for communication. Patient was a smoker as recent as 9 months ago. A review of the clinical record revealed the following progress note by the DON: 7/20/2022 4:57 PM - Note Text - : Resident was noted by visitors smoking outside in parking area. Resident was educated that we are a no smoking facility and was offered a nicotine patch instead. MD was notified and new order for Nicotine Patch 14 mg x 14 days and then 7 mg x 14 days was given. On 7/21/22 at approximately 9:55 AM a Safe Smoking Evaluation and a BIMS evaluation for Resident #9 were submitted to the surveyors. The Safe Smoking Evaluation indicated that Resident #9 was An independent smoker. Capable and independent, requires no supervision to smoke. This document was signed by the DON. An interview was conducted with the DON at that time and she stated that she did the smoking evaluation herself on 7/20/22. The BIMS document also signed by the DON scored the Resident as having a BIMS of 10 / 15 indicating moderate cognitive impairment. The progress note written by the DON read: 7/20/22 at 4:42 PM -Safe Smoking Evaluation - Safe smoking evaluation completed on [Resident #9 name redacted]. Short-term memory appears intact. Some difficulties noted with long-term memory. Able to make consistent and reasonable decisions. [Resident #9 name redacted] is able to effectively communicate and/or make needs known. Vision is adequate; able to see without difficulty. [Resident #9 name redacted] has no physical limitations noted related to safe smoking techniques. Able to maintain balance while sitting/standing. During observation, safe smoking techniques were observed including holding and lighting a cigarette as well as proper disposal. Remained alert while smoking. No evidence of burn injuries or holes noted on clothing or wheelchair. Interview showed an understanding of designated smoking times and areas. [Resident #9] verbalized understanding that smoking accessories would be secured by the center staff when not in use. Understands safety risks associated with smoking. Based on evaluation, {Resident #9] is an independent smoker requiring no supervision to smoke. On 7/21/22 at 1:55 PM Resident #9 was observed propelling self out of door and headed toward the dumpster area. On 7/21/22 at approximately 2:06 PM Surveyors B and C observed Employee C and LPN E perform a Safe Smoking Evaluation on Resident #9. When Employee C asked Resident #9 where he gets the cigarettes he gestured with his left hand to his leg. Employee C asked him if he got them from another Resident who is a known smoker and wears a bandage to his leg he nodded. He then said Check, month when asked if he pays the other Resident for cigarettes when he gets his check every month, he nodded his head yes. Excerpts are as follows: 1. Cognitive Function a. Short term memory is ok able to recall events after 5 minutes? Yes b. Long term memory is Ok recall of long past events ? No c. Able to make decisions regarding the tasks of daily life e.g. decisions are consistent and reasonable. Yes 3. Physical Function a. Patient is free from physical limitations interfering with the ability to perform safe smoking techniques, e.g. able to grasp and handle cigarettes , lighter or matches without assistance? NO b. Patient is able to maintain balance while sitting or standing? Yes. 4. Observations a. Patient demonstrates safe smoking techniques: holding cigarette, lighting cigarettes (NO), extinguishing matches, (NO) lighter and cigarette after use and disposal of ashes. No 5. Interview a. Patient understands that smoking may only take place at designated times and in designated smoking areas? NO\ c. Patient is able to communicate safety risks associated with smoking? NO 6. Determination b. At risk smoker Requires staff, family member or friend for physical support or supervision to smoke. 2. For Resident #4, the facility staff failed to ensure the Resident was provided a safe smoking environment and supervised by staff for safety while smoking. Resident #4 was a current resident of the facility diagnoses that include but are not limited to: altered mental status, unspecified; muscle weakness (generalized); and unsteadiness on feet. On 07/21/22 at approximately 10:15 a.m., Resident #4 was observed smoking outside of the facility near the dumpster without direct 1:1 supervision. That is, there was no staff standing within a hands reach of Resident #4. About 20 feet beyond the rear of the dumpster where Resident #4 was observed smoking there were facility staff observed smoking in the shade of the trees. There were approximately four facility staff sitting on milk crates smoking, but were not interacting with Resident #4. 07/22/22 at approximately 11:00 a.m., Resident #4 was observed outside on a bench. The resident appeared to be having a conversation with himself. There were no staff present. On 7/22/22 at approximately 2:00 p.m., interviewed the Assistant Director of Nursing (ADON). The ADON stated that smoking assessment were completed for resident who had a history of smoking prior to entering the facility. 07/22/22 at approximately 3:00 p.m., an electronic health record (EHR) review was conducted: On 6/30/22 at 1:35 p.m., a safe smoking evaluation was conducted with a determination that Resident #4 was an at risk smoker. Which means that Resident #4 requires staff, family, or friend for physical support or supervision to smoke. A Nurse's progress note on 7/21/22 at 10:25 a.m., showed that Resident #4 was noted outside of the building smoking by the dumpster in the parking lot. The care plan was reviewed and there was not care plan with regard to smoking. Immediate Jeopardy was found to start on 07/20/2022 and was called at 4:02 PM on 7/21/22. The facility presented the following removal plan. 1. The corrective action for the alleged deficient practice will be accomplished by: Resident #9 and Resident #4 had skin assessments performed and no injuries were noted due to smoking. Residents #9 and #4 had updated smoking assessments completed. Any residents smoking outside of the facility will be monitored by facility staff to ensure safety of smoking occurs regardless of completed smoking assessment. The identified supervise smokers that are deemed at risk will be supervised by the facility staff while in the designated smoking area by the activity staff or designee. Smoking aprons will be provided for residents deemed unsafe to smoke. Facility administrator met with residents who identified to smoke and educated on facility policy related to smoking which includes implementation of monitor and safekeeping of smoking paraphernalia by the staff. Safekeeping of smoking paraphernalia include cigarettes lighters labeled and secured in a locked filing cabinet at the receptionist desk and the smoking aprons are individually separated with name labeled on bag for identification located at the receptionist desk. The receptionist, Administrator, DON, first floor nursing station will have keys to unlock the filing cabinet to retrieve smoking paraphernalia, cigarettes and lighters and replacing after smoking. The designated smoking times will be at 8 AM through 8 PM and the designated smoking area is the courtyard. The residents and staff were informed on 7/22/22 of the current designated times of 8 AM through 8 PM and then in two weeks on 8/4/22 the designated times will be 9:30 AM, 2 PM, 4 PM and 6 PM. Residents were informed of the designated smoking times on 7/21/22 by the administrator. The designated smoking area is in the courtyard with shaded roof area, posted signage to indicate that it is a designated smoking area with a fire extinguisher available and a receptacle/bin for extinguishing and discarding cigarettes. Staff education initiated on 7/21/22 administrator or designee and ongoing until completed and will not be allowed to work until education was received. A list of residents that smoke is located on the nursing units and at the reception desk to know who smokes independently or require supervision with a smoking apron and designated smoking area and times. 2. Residents with the potential to be affected by the alleged deficient practice: All residents who smoke have the potential to be affected by this alleged deficient practice. The facility interdisciplinary team will conduct resident smoking safety assessments on 7/21/22 assessing the residents for safe smoking criteria. All residents assessed for smoking will have smoking materials removed from the person by 7/21/22 and stored by the facility. Facility administrator will conduct individual meetings with the residents and/or responsible parties that smoke and review the facility smoking policy and consequences for noncompliance. All residents in the facility assessed on 7/22/22 if they smoke or need smoking cessation intervention Such as [MEDICATION(S)] patch or nicotine gum per position order and any resident that is not in the facility will be assessed when he returns to the facility. If it if identified wish to smoke a smoking evaluation and BIMS will be conducted and smoking policy and agreement will be reviewed with the resident signature to indicate it was reviewed and understood and the care plan will be updated and resident informed if he's independent or supervision required with smoking apron designated smoking area and times. Systemic changes: I. The interdisciplinary team (Administrator, Director of Nursing, Assistant Director of Nursing, Director of Social Work, Activities Director, Dietary Manager, Business Office Manager, Director of Maintenance, Environmental Services Manager, Human Resources and Unit Managers) will be educated by the regional Director of nursing on smoking policy, resident smoking practices, supervision with smoking and resident noncompliance with smoking policy. Starting 7/22/22 no staff will return to work unless they've completed the mandatory education on facility smoking policy, safe smoking and supervision, and noncompliance with smoking policy. A resident smoking evaluation assessment completed by licensed nurses to determine independent or at risk that require supervision while smoking. The facility staff will monitor and provide supervision while the identified supervised smoker is smoking in the designated smoking area and at times with a smoking apron on. The residents that are noncompliant with smoking will be monitored and redirected to the smoking area and reported to the administrator the administrator will discuss with the resident and re-educate them on smoking policies in agreement II. The facility will monitor Resident for change in condition, if a resident is observed by a smoking monitor with unsafe smoking practices the resident will be stopped from smoking and have a new assessment completed to determine ability The administrator made the medical Director aware of the immediate jeopardy abatement plan via telephone on 7/21/22 at 5:55 PM The removal plan was accepted on 7/22/22 at 2:12 PM. The survey team verified the following items listed in the removal plan: The Surveyors reviewed skin assessments for the known smokers. The Survey Team requested a list of all of the known smokers and whether or not they were deemed safe to smoke. The Surveyors reviewed the updated smoking assessments for all of the Residents who smoke. The Surveyors observed locked filing cabinet where smoking materials are stored. The Surveyors verified who holds access to smoking materials (DON and Unit Managers). The Surveyors observed courtyard with shaded roof area where Residents smoke. The Surveyors observed fire extinguisher in smoking area and the bin used to extinguish and discard cigarettes. The Surveyors interviewed staff for education content of smoking in-service, to include how they will know who is a smoker, how they will know who needs an apron and supervision, how they will know and to whom they will report a change in condition or ability of Resident to smoke safely. The Surveyors reviewed the care plans of Residents that are smokers. The Survey Team reviewed the in-service education sheets for staff signatures. The Surveyors reviewed the updated Smoking Agreements that Residents and or RP's signed, outlining the location, and times, as well as the fact that staff will secure smoking materials for the Residents. Immediate Jeopardy was removed on 7/22/22 at 5:10 PM. On 7/25/22 during the end of day meeting the Administrator was again made aware of the concerns and no further information was provided.

Based on observation, clinical record review, staff interview, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide infection control measures in accordance with the Center for Medicare and Medicaid Services (CMS) and The Centers for Disease Control and Prevention (CDC) recommendations, to prevent the spread of COVID-19, for 4 Residents (Resident #28, #29, #30, and #31) in a survey sample of 32 Residents. Immediate Jeopardy was identified on [DATE] at 5:00 PM but it started on [DATE]. After verification, Immediate Jeopardy was removed on [DATE] at 12:00 PM. The findings included: The facility staff failed to provide infection control measures to prevent the spread of COVID-19 by allowing COVID positive staff, RN B and CNA C, to work prior to meeting the CDC Return to Work (RTW) criteria and allowed them to provide direct resident care to Residents #28, #29, #30 and #31, who were all previously negative for COVID-19. On [DATE] at approximately 11:30 AM, an interview was conducted with the Facility Administrator regarding the facility's staffing during the COVID-19 pandemic. The Facility Administrator stated that to date there has never been a need to implement the Facility's Emergency Staffing Plan and the facility has always been able to meet the need of our residents. The Facility Administrator stated, I have only recently needed to use agency nurses for some weekend shifts, the last weekend in January (2021), I have had no problem getting agency nurses. A staff infection surveillance log was requested and received from the Facility Administrator. On [DATE], the staff infection surveillance log was reviewed and revealed RN B tested Positive for COVID-19 on [DATE] with symptoms of cough and new onset malaise and Return to Work Date as [DATE]. This data was verified by RN B's COVID lab results and time card. The log also revealed CNA C tested Positive for COVID-19 on [DATE] with no symptoms and Return to Work Date as No Leave. CNA C's COVID lab results were verified and the time card revealed CNA C returning to work on [DATE]. On [DATE], the clinical records for Resident #28, #29, #30, and #31 were reviewed and revealed the following: 1. Resident #28, who was COVID negative per facility test performed on [DATE], received direct resident care per Activities of Daily Living (ADL) documentation on [DATE] and [DATE] by CNA C who was COVID positive per facility test performed on [DATE] and allowed to remain on duty without meeting the Return to Work (RTW) criteria recommended by the CDC. Resident #28 tested Positive for COVID-19 on [DATE]. On [DATE], Resident #28 was found unresponsive in his room, CPR was initiated at the facility, and subsequently expired at the Emergency Department on [DATE]. 2. Resident #31, who was COVID negative, received direct resident care per ADL documentation on [DATE] by CNA C who was COVID positive per facility test performed on [DATE] and allowed to remain on duty without meeting the RTW criteria recommended by the CDC. 3. Resident #29, who was COVID negative, received direct resident care per Medication Administration Record [REDACTED]. 4. Resident #30, who was COVID negative, received direct resident care per MAR indicated [REDACTED]. On [DATE] at approximately 2:55 PM, a group interview was conducted with the Facility Administrator, Director of Nursing (DON), and Infection Preventionist (IP). The Facility Administrator confirmed that the facility follows CDC guidance for COVID infection control. The Facility Administrator, DON, and IP were asked if they had knowledge of COVID positive staff members working without a quarantine as recommended by the CDC and the Facility Administrator deferred answering to the DON who responded, I know there was an RN who had requested to come back to work, I thought she was asymptomatic and the IP stated, she (RN B) wanted to come back to work. The Facility Administrator was asked if she would expect to see a COVID positive staff member, who had not quarantined, document direct care activities, such as ADL's or MAR, on COVID negative residents and all three (Administrator, DON, and IP), responded, No. On [DATE] at approximately 11:20 PM, a telephone interview was conducted with RN B, who confirmed she tested positive for COVID on [DATE] and reported symptoms of headache, fatigue, and loss of taste. RN B stated, (name redacted, Infection Preventionist) tested me on the 22nd, I was positive and she told me to stay home for 2 days until my symptoms got better and to call back. RN B stated, I called back on the 24th and I was asked to come in to work the COVID unit, I don't remember who I spoke to but I felt ok to work. RN B was asked about her resident assignment when she returned on ,[DATE] and stated, I worked on 2nd floor South, all the residents were positive, however I had part of the East Hall and I don't recall the residents there or what their (COVID) status was. RN B was asked if she may have taken care of a COVID negative resident when she returned on ,[DATE] and she stated, Yes, it is possible. On [DATE] at approximately 12:10 AM, a telephone interview was conducted with CNA C, who confirmed she tested positive for COVID on [DATE] and had no symptoms. CNA C stated, I work the night shift and I needed to know whether or not I could come back to work, I felt fine to work, I called and spoke to (Employee H, Staff Coordinator) who told me that I didn't need to stay home since I felt fine to work. CNA C was asked about her resident assignment when she returned on ,[DATE] and stated, I was assigned to 1st floor South and all the residents were (COVID) positive but I did have residents on (1st floor) East and they were mostly all (COVID) negative, I didn't know if I was doing the right thing, I just do as the bosses told me, I hope I didn't do anything wrong. On [DATE] at approximately 10:40 AM, an interview was conducted with the Staffing Coordinator (Employee H) who stated, It is my job to find coverage when there are callouts, (name redacted, DON) and (name redacted IP) lets me know about the staff members who test (COVID) positive and how many days they will be out before returning. Employee H stated, I have been told that if they (positive staff members) are asymptomatic and want to work then I can schedule them for the COVID unit, I put their names on the daily staffing list and give it to the different nursing units, the charge nurses make the actual assignments for their unit but I am not sure if they know who the positive staff members are, I am not sure about quarantines, that is not my decision. On [DATE] at approximately 3:55 PM, an interview was conducted with the Facility Administrator and DON with regard to staffing decisions to allow COVID positive staff members to return to work prior to completing a 10 day quarantine as recommended by the CDC. The Facility Administrator stated, It has always been my understanding that, after testing positive for COVID, employees would be advised to stay home for 10 days of quarantine irregardless of whether or not they were symptomatic. We (the facility) had some staffing challenges during our (COVID) outbreak in December and at that time, (name redacted, Infection Preventionist) came up with this variation and advised me that COVID positive staff could return to work with COVID positive residents as long as they (positive staff member) were asymptomatic, I trusted (name redacted, IP) that she knew what she was talking about. I should have checked into this further for myself. The DON stated, I am the one who made these staffing decisions because that's just where we were in December, you don't understand, as COVID began increasing around the second week in December, all the staff were very afraid, we were dealing with callouts and no shows, we had to improvise and that's how it happened with (name redacted, CNA C), she (CNA C) became (COVID) positive on [DATE]th, right after returning from taking some time off, it was getting close to Christmas, she didn't have symptoms and she really wanted to work, I approved for her (CNA C) to work on [DATE]th, for a South assignment because all of the residents were COVID positive but at 11 PM there was a third CNA who was a 'no show' and assigned to East Hall so the shift charge nurse had to cover East Hall and moved (name redacted, CNA C) over to pick up residents on that hall too, the charge nurse was unaware of (CNA C) COVID positive status, that's how (name redacted, CNA C) had picked up (assigned COVID) negative residents. On [DATE] at approximately 9:15 AM, an interview was conducted with the Infection Preventionist (IP) with regard to staffing decisions to allow COVID positive staff members to return to work prior to completing a 10 day quarantine as recommended by the CDC. The IP stated, I do follow CDC guidelines, both asymptomatic and symptomatic (COVID positive) staff members are removed from work for 10 days. They are encouraged to call if they need extended time and I recommend that they get checked out by their doctor. We had a COVID outbreak in the facility around [DATE]th and cases continued to increase, staffing challenges also increased. The IP stated, The Administrator and Director of Nursing made all the staffing decisions including when staff can return to work. I do not have that authority. My role related to staffing is to share with them (Administrator and DON) what the latest CDC guidance is and I told them that asymptomatic (COVID positive) staff could work with COVID positive residents only, however my first recommendation was to utilize agency staffing as we were not using any agency staff at the time or anytime in December for that matter, the facility did not use any agency staff until just recently, around the last weekend in January. Review of the facility's COVID Infection Control Policy titled, COVID-19 ([MEDICAL CONDITION]) Prevention and Monitoring, revised [DATE], read, Return to Work Criteria for HCP (Healthcare Personnel) with [DIAGNOSES REDACTED]-CoV-2 (COVID-19) Infection. Symptom-based strategy for determining when HCP can return to work. HCP with mild to moderate illness who are not severely immunocompromised: At least 10 days have passed since symptoms first appeared and at least 24 hours have passed since last fever without the use of fever-reducing medications and symptoms (e.g., cough, shortness of breath) have improved. Note: HCP who are not severely immunocompromised and were asymptomatic throughout their infection may return to work when at least 10 days have passed since the date of their first positive [MEDICAL CONDITION] diagnostic test. CDC guidelines that were in effect in [DATE] read, Return to Work Criteria for HCP with [DIAGNOSES REDACTED]-CoV-2 Infection. Symptom-based strategy for determining when HCP can return to work. HCP with mild to moderate illness who are not severely immunocompromised: At least 10 days have passed since symptoms first appeared and at least 24 hours have passed since last fever without the use of fever-reducing medications and symptoms (e.g., cough, shortness of breath) have improved. Note: HCP who are not severely immunocompromised and were asymptomatic throughout their infection may return to work when at least 10 days have passed since the date of their first positive [MEDICAL CONDITION] diagnostic test. On [DATE] at 5:00 PM, Immediate Jeopardy (IJ) was identified and the facility was notified. On [DATE] at approximately 5:30 PM, the Facility Administrator submitted an IJ removal plan, which the Survey Team accepted. The removal plan stated: 1. All Staff will be educated prior to working next shift regarding Covid-19 Positive Return to Work Policy according to the current CDC guidance. 2. All staff have been tested for COVID-19 within past 48 hours or prior to working next shift. 3. Any staff member that tests positive for COVID-19 will be sent home for at least 10 days. 4. Currently no COVID positive staff have been identified during the audit and none are working. Date of Compliance: February 25, 2021 1. The Survey team verified that all staff that are currently COVID-19 positive have been removed from the schedule. 2. The survey team verified that no staff currently working are COVID positive. Records were reviewed for all staff currently working on [DATE] to include that they were tested for COVID-19 on [DATE], [DATE] or prior to working their scheduled shift today. No staff were identified to test positive. 3. The survey team verified that all staff currently working were educated on the current CDC guidance of a minimum of a 10 day quarantine period if they test positive for COVID-19, regardless if symptomatic or not. 4. The team verified that any staff that tested positive for COVID-19 within the past 10 days have not worked since their positive test. Therefore, no current Residents require isolation for direct exposure to a COVID positive staff. 5. The survey team conducted staff interviews across all departments of the staff currently working to ensure they were able to state the current return to work guidance from CDC if they do test positive for COVID-19. The Survey Team verified IJ was removed on [DATE] at 12:00 PM. No further information was provided. COMPLAINT RELATED DEFICIENCY

Based on, staff interview, facility documentation review, and clinical record review, the facility staff failed to follow infection control practices to control and prevent infections, COVID-19, for 2 Residents (Resident #6 & #7) in a survey sample of 9 Residents, which resulted in harm for Resident #6. 1. The facility staff failed to properly isolate Resident #7, who displayed symptoms of COVID-19, which resulted in harm of Resident #6. The findings included: Resident #7 was admitted to the facility on [DATE], with a readmission date of [DATE]. Resident #7 discharged from the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #7's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of [DATE] was coded as an admission assessment. Resident #7 had a BIMS (brief interview for mental status) score of 0, out of 15. This indicated she had severe cognitive impairment. Resident #7 was also coded on this assessment as having been totally dependent upon staff for all ADL's (activities of daily living) such as bathing, dressing, toileting and personal hygiene. Review of the closed clinical record for Resident #7 revealed that on [DATE], Resident #7 was identified as having had a change in condition. The change in condition evaluation dated [DATE], read acute onset of 3 or more episodes of loose stools. The physician was contacted and an order for [REDACTED]. Review of the facility provided testing log, Resident #7 had last been tested for COVID-19 on [DATE], and tested negative. Resident #7's physician orders dated [DATE], read maintain droplet precautions every shift keep resident room door closed at all times. if semi-private room keep curtain pulled between beds. every shift for COVID 19 presumptive or positive. On [DATE], Resident #7 was moved into a semi-private room with Resident #6. Resident #6 was under observation due to having a hospitalization and being readmitted to the facility on [DATE]. Resident #6 was negative for COVID-19 due to being tested on [DATE] and again on [DATE], with both test being negative. Further review of the closed clinical record for Resident #7 revealed another change in condition evaluation that was conducted [DATE]. This evaluation noted, Resident noted to fill (sic) warm and V/S (vital signs) was taken. Resident noted to have a temp 100.5 oral. This same evaluation indicated that on [DATE] at 14:38 Resident #7's temperature was 101.8. The physician was again notified of the change in condition and orders given were STAT CxR, U/A C+S, CBC and CMP D/T temp elevation. Tylenol 325mg give 2 tabs via peg Q4rs PRN (urgent chest x-ray, urinalysis with culture and sensitivity, complete blood count lab, complete metabolic panel lab due to temperature elevation and Tylenol 325 mg, give 2 tablets by peg tube (feeding tube) every 4 hours as needed). None of these orders included a COVID-19 test, despite Resident #7 now having displayed 2 different COVID-19 symptoms. The chest x-ray obtained on [DATE] revealed Resident #7 had pneumonia. Resident #7 was being treated with antibiotics for the pneumonia but on [DATE] Resident #7 had a fever of 100.0 and on [DATE] her temperature was 101.1, despite the antibiotics. The facility staff then performed a COVID-19 test which was positive. Resident #6 was next tested for COVID-19 on [DATE], and tested positive. This constitutes harm for Resident #6, as the facility staff cohorted her with a Resident (Resident #7) with known COVID-19 symptoms. On [DATE], Resident #6 was seen by a physician who noted, now is presenting with multiple [MEDICAL CONDITION] in BLE (bilateral lower extremities), with right thigh abscess and left lower leg wound, she has a very high risk of developing a septic arthritis if the right knee intra articular injection is done. Today, also the patient tested positive for COVID-19 and has been changed to a new room in the COVID wing for isolation, she will continue her PT/OT (physical therapy and occupational therapy) treatment and will be monitor (sic) for symptoms of COVID-19. On [DATE] a nursing note for Resident #6 read, writer spoke with (name redacted) (RP) (responsible party) regarding residents current condition and her stat (urgent) labs, CBC (complete blood count) and CMP (complete metabolic panel). Writer made RP aware that resident has been retaining fluids and was seen by NP (nurse practitioner) (name redacted) regarding her possible fluid retention. She was also made aware that the possibility of rehopsitalization was discussed by NP. Another nursing note dated [DATE] at 22:24 read, Resident was sent to (hospital name redacted) per family's request due to [MEDICAL CONDITION] because our facility could not meet her medical needs . Resident got admitted . Resident #6's family reported to the Office of Licensure and Certification that Resident #6 expired while at the hospital from COVID-19 complications. On [DATE] during an end of day meeting, the facility staff to include the facility Administrator and Director of Nursing indicated Resident #6 had not returned to the facility but they were unaware that she had expired. On [DATE] at 10:05 AM, an interview was conducted with the facility Administrator (Employee A). Employee A stated, They (Resident #6 & #7) did go into the room together on [DATE]. (Resident #6 name redacted) was on droplet precautions for a 14 day observation. (Resident #7 name redacted) started on contact precautions on ,[DATE] as a precautionary measure due to having an elevated temperature and chest x-ray showed pneumonia. I spoke to the nurse practitioner and she stated because we put her on contact precautions and her chest x-ray showed pneumonia her plan of care wouldn't have changed so she didn't feel the need to test for COVID. She was started on [MEDICATION NAME] and her temperature went down but when it spiked again she decided to test her, she was previously negative. The administrator also stated that COVID positive rooms were available but that the facility was saving them for hospital discharges that were COVID positive. On [DATE] at 1:03 PM, an interview was held with the facility Infection Preventionist (Employee C). Employee C was asked if the facility typically isolates a person for pneumonia and puts them on precautions, Employee C said no. When Employee C was asked when they test someone for COVID-19, she said, if they have symptoms. Employee C and Employee A were asked what the symptoms of COVID-19 are, and they said, its a lot, fever, respiratory problems, GI (gastro-intestinal) headache, loss of taste and smell, abdominal cramping, decreased O2 sats, vomiting and diarrhea. On [DATE] at 2:29 PM, the facility Administrator was made aware of the concerns regarding Resident #7 being symptomatic for COVID-19 and being placed in the room with a COVID negative Resident (Resident #6). The facility Administrator was asked why Resident #7 had orders for droplet precautions written on ,[DATE] for COVID 19 presumptive or positive. The facility Administrator stated, we moved her into (Resident #6's name redacted) room and put her on precautions because (Resident #6 name redacted) was on precautions for observation, we were trying to protect her. Review of the facility policy titled COVID-19 ([MEDICAL CONDITION]) Prevention and Monitoring read, Droplet precautions will be implemented for residents with suspected or confirmed [MEDICAL CONDITION]. Residents with suspected [MEDICAL CONDITION] will be placed in a private room (if available) or area and monitored according to CDC guidelines. CDC (Center for Disease Control) provided the following guidance to nursing homes: Have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, implement use of Transmission-Based Precautions, prioritize for testing, transfer to COVID-19 unit if positive). -Residents in the facility who develop symptoms consistent with COVID-19 could be moved to a single room pending results of [DIAGNOSES REDACTED]-CoV-2 testing. They should not be placed in a room with a new admission nor should they be moved to the COVID-19 care unit unless they are confirmed to have COVID-19 by testing. While awaiting results of testing, HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html Further recommendations from CDC stated: Resident with new-onset suspected or confirmed COVID-19: Ensure the resident is isolated and cared for using all recommended COVID-19 PPE. Place the resident in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing. -Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit). -If cohorting symptomatic residents, care should be taken to ensure infection prevention and control interventions are in place to decrease the risk of cross-transmission. Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html On [DATE] during an end of day meeting held, the facility Administrator was made aware of the findings and concerns noted above. No further information was received.

Based on observation, staff interview, facility documentation review and clinical record review, the facility staff failed for 2 residents (Resident #9 and #22) of 24 residents in the survey sample to ensure residents were free from significant weight loss, resulting in harm for Resident #9. Resident #9 experienced an 11.2% weight loss in 180 days and developed an unstageable pressure wound to the sacrum. 1. For Resident #9, the facility failed to provide adequate calories, protein, vitamin and minerals resulting in harm (significant weight loss of 11.2% in 180 days and development of an unstageable pressure area to the sacrum). The Wound Care Specialist documented that poor wound healing was caused by nutritional compromise. 2. For Resident #22, the facility staff failed to develop or implement nutritional strategies after the development of a significant weight loss. The Findings Included: Resident #9, a [AGE] year old, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #9's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an assessment reference date (ARD) of 4/27/16. She was coded with moderate cognitive impairment. She was not coded to have weight loss. Resident #9 received 100% of her nutrition through a feeding tube. She was observed during the initial tour of the facility on 6/1/16. Her tube feeding, Glucerna 1.5, was running at 35 cc (cubic centimeters) per hour. On 3/9/16, an SBAR (concern note) was documented in Resident #9's clinical record. The note read Change in condition related to -10.0% change over 180 days. This change in condition started on 3/7/16. Noted to have issues with [MEDICAL CONDITION] or weight loss. SKIN: Noted to have the following skin conditions present: Excoriation of sacrum. A list of Resident #9's weights for the past year were requested. Weights (in pounds): 6/10/15- 197.2 7/6/15- 195.4 8/10/15- 192.5 9/8/15- 195.6 10/9/15- 190.8 11/16/15- 184.8 12/7/15- 182.5 1/8/16- 181.3 2/5/16- 179.6 3/7/16- 173.6 4/11/16- 179.6 5/6/16- 181.4 Between the six month time frame of 9/8/15 (195.6) and 3/7/16 (173.6), Resident #9 lost 22 pounds. This loss equaled an 11.2% weight loss in six months, a significant weight loss. On 6/8/16 at 11:15 a.m., the Registered Dietitian (RD) was interviewed. The RD stated that she was supposed to complete resident nutrition evaluations when the resident was first admitted to the facility and then annually. She was asked to provide the most current nutrition evaluation for Resident #9. An evaluation dated 4/1/15 was provided. The RD was asked if a nutrition evaluation had been completed in 2016, as the annual would have been due in April 2016. She stated that the 2015 evaluation was the most recent annual evaluation. When asked why she had not completed the annual evaluation in April 2016, the RD stated the facility had not told her that it needed to be completed. When asked who at the facility notified her to complete annual nutrition evaluations, the RD stated that the MDS (Minimum Data Set) staff made a list for her. The Nutrition Monitoring & Evaluation Form dated 4/1/15 was reviewed. Caloric and protein needs were not calculated on this most recent annual evaluation. The initial Nutrition Assessment completed on 7/7/14 calculated estimated caloric, protein, and fluid needs. The needs were calculated using a height of 62 inches and a weight of 196.5 pounds. Resident #9's daily needs were calculated as follows: Energy: 1932 calories Protein: 89 grams Fluid: 2670 cc Quarterly assessments were documented on the Nutrition Monitoring & Evaluation Form. Tube feeding orders were documented as follows: - 7/8/15: Glucerna 1.5 @ 40 cc/ hour (1440 calories, 78 gram protein, 1968 cc fluid) Goal for no significant weight change achieved this review. Weight stable. Tolerating tube feeding - 10/7/15: Glucerna 1.5 @ 30 cc/ hour (1080 calories, 57 grams of protein) Goal for no significant weight change achieved despite change in tube feeding order. Blood sugar remains under good control. Will continue to monitor. Current tube feeding does not meet estimated energy needs. In the margin of the form, the RD wrote: Change in tube feeding rate noted. No doctor note relating to change. Between the month of July 2015 and October 2015, Resident #9 lost 5 pounds. It is unclear when and why the tube feeding was decreased from 40 cc per hour to 30 cc per hour. The change from 40 cc to 30 cc per hour equals a decrease of 360 calories per day. The following nutrition notes were documented in the progress notes: 1/13/16- Weight is stable, but above IBW (ideal body weight). BMI (body mass index) remains much above critical range. Good tolerance to current TF (tube feed) schedule Glucerna 1.5 at 30 cc per hour. A flush of 200 cc water every 4 hours provided. Recent A1c (measurement of quarterly blood sugar level via blood sample) at 6.0, indicating good blood sugar control. Current tube feed does not appear to meet estimated needs, but with stable nutritional status, is meeting needs. Will continue current regime, no new recommendations. 3/9/16- Slow weight loss noted this review, now triggering significant x 180 days. Weight loss is desired as weight remains above ideal body weight, BMI is above critical range. Tolerating TF at 30 cc per hour. Current regime does not meet estimated needs, but nutritional status has been stable in the past. Area of pressure noted, showing slow improvement. Vitamins and minerals are provided. Will suggest an increase in TF to 35 cc per hour, Glucerna 1.5, to provide 1260 calories. This remains below estimated needs. Will monitor for change. While the 3/9/16 nutrition progress note read Area of pressure noted, showing slow improvement, the Wound Care Specialist documented on3/7/16 (2 days prior) that Resident #9's sacral wound was not healing due to nutritional compromise. The wound care note read: 3/7/16- Wound Care Specialist notes, Sacral wound: Wound progress: deteriorated, Findings that indicate deterioration: Nutritional Compromise. Measurements: 3 x 2.4 x 0.1 cm. (centimeters) Assessment & Plan read Deteriorated due to nutritional compromise: Optimize nutrition. On 3/28/16, a second Wound Care Specialist note read Wound progress: deteriorated, Findings that indicate deterioration: Nutritional Compromise. Measurements: 1 x 0.8 x 0.1 cm. Assessment & Plan read Deteriorated due to nutritional compromise: Optimize nutrition. The 3/9/16 nutrition progress note written by the RD also read, Vitamins and minerals are provided. According to the physician orders, the multivitamin, zinc and vitamin C had been started the day prior on 3/8/16. Resident #9 had been receiving only iron supplementation (10/30/15) and vitamin D supplementation (1/4/16). Product information for Glucerna 1.5 was accessed from the Abbott Nutrition website on 6/15/16 at 2:09 p.m. <http://static.abbottnutrition.com/cms-prod/abbottnutrition.com/img/Glucerna-1.5-Cal.pdf> Per the Glucerna 1.5 product information 1500 cal provide at least 100% of the DV (daily value) for 24 key vitamins and minerals. During the time of the sacral wound development and significant weight loss, Resident #9 was receiving 1080 calories. If 1500 calories provided 100% of the daily vitamin and mineral need, it is calculated that Resident #9 was only receiving about 72% of her daily need of vitamin and minerals (except for iron and vitamin D) through tube feeding prior to 3/8/16. Resident #9's vitamin and mineral needs were not being met through the tube feeding at the time of the wound development. She was not started on a multivitamin until 3/8/16. At the time of the wound development, while on Glucerna 1.5 @ 30 cc per hour, Resident #9 was provided 57 grams of protein. Using a weight of 179.6 pounds or 81.6 kilograms (weight in kilograms= pounds/2.2) measured in February 2016, Resident #9's protein need was calculated to be at least 81.6 grams per day at the time the sacral wound developed (when using 1.0 gram per kilogram as used by RD in initial nutrition assessment). When multiplied by an injury factor of 1.2 grams per kilogram of body weight for wound healing (as used by facility RD), Resident #9's protein need is calculated as 97.9 grams of protein per day for wound healing. According to the above calculations, Resident #9's protein need was not being met through the tube feeding at the time of the wound development. 81.6 grams (need) - 57 gram (actual)= 24.6 grams per day deficient. Using a weight of 179.6 pounds or 81.6 kilograms measured in February 2016 and 21.5 calories per kilogram (as used by RD in initial nutrition assessment), Resident #9's calorie need during the month of February 2016 is calculated as 1754 calories per day. According to the above calculations, Resident #9's caloric need was not being met through the tube feeding at the time of the wound development. 1754 calories (need) - 1080 (actual)= 674 calories per day deficient In summary, during February 2016, the month that Resident #9 developed the sacral wound and triggered for significant weight loss, she lost five pounds. Per day, she received 674 calories less and 24.6 grams of protein less than her estimated needs. The following nutrition information from the American Academy of Family Physician's document titled Pressure Ulcers: Prevention, Evaluation, and Management was accessed on 6/8/16 at 2:55 p.m. at www.aafp.org/afp/2008/1115/p1186.html#sec-4 <http://www.aafp.org/afp/2008/1115/p1186.html> The section titled Nutrition Evaluation read If oral dietary intake is inadequate or impractical, enteral or [MEDICATION NAME] feeding should be considered, if compatible with the patient's wishes, to achieve positive nitrogen balance (approximately 30 to 35 calories per kg per day and 1.25 to 1.5 g of protein per kg per day). Table 3: Markers for Identifying Protein-Calorie Malnutrition in Patients with Pressure Ulcers Unintentional weight loss of 5 percent or more in the previous 30 days or of 10 percent or more in the previous 180 days Weight less than 80 percent of ideal Serum [MEDICATION NAME] level less than 3.5 g per dL (35 g per L)* (grams/liter) [MEDICATION NAME] level less than 15 mg per dL (150 mg per L)* Transferrin level less than 200 mg per dL (2 g per L) Total lymphocyte count less than 1,500 per mm3 (1.50 × 109 per L) *dehydration can falsely elevate Nitrogen balance is the state of the body in regard to the rate of protein intake and protein utilization. A negative nitrogen balance occurs when more protein is used by the body than is taken in. A positive nitrogen balance implies a net gain of protein in the body. Negative nitrogen balance can be caused by such factors as malnutrition, debilitating diseases, blood loss. Accessed on 6/16/16 at 9:30 a.m. at <<http://medical-dictionary.thefreedictionary.com/nitrogen+balance>> [MEDICATION NAME] is a protein made by the liver. A serum [MEDICATION NAME] test measures the amount of this protein in the clear liquid portion of the blood. This test can help determine if a patient has liver disease, kidney disease, or if the body is not absorbing enough protein. Accessed at <https://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm on 6/15/16 at 3:09 p.m. Two [MEDICATION NAME] levels were provided for Resident #9: 2/14/16- 4.3 grams per deciliter, (reference range: 3.0-4.5) 4/7/16- 3.4 gram per deciliter While Resident #9's [MEDICATION NAME] level appeared in the normal range on 2/14/16, it is important to note that on the same date, Resident #9 was provided IV fluids for hydration. An order dated 2/14/16 read 1/2 NS (normal saline) @ 70 milliliter per hour x 1 liter and increase peg tube flushes to 250 mililiter per hour every 4 hours. As noted above, dehydration can falsely elevate serum [MEDICATION NAME]. The 2/14/16 [MEDICATION NAME] level is most likely inaccurate (elevated). Resident #9 had a weight loss of 10% in 180 days and she also had a serum [MEDICATION NAME] level less than 3.5 grams per deciliter. These are two markers of Protein-Calorie Malnutrition in patients with pressure ulcers according to Table 3 above. The facility physician did not have knowledge that Resident #9 was losing weight. He documented the following note in Physician Progressive Notes on 3/8/16. The note read 1) Wt loss? Doubt as patient is on a tube feeding monitor weight closely 3) Pressure Ulcer add MVI (multivitamin) B supplement. On 6/8/16 at 11:15 a.m., the RD was asked why she was providing Resident #9 with a tube feeding that did not meet nutritional needs. She stated that the resident was obese and weight loss was desired. When asked if the resident's physician wanted the resident to lose weight, the RD stated yes. It was reviewed with the RD that there was no documentation in the clinical record documenting that the physician desired a weight loss for the resident. She was asked to provide documentation of the physician desired weight loss. No documentation was provided. The RD was informed that the Wound Care Specialist felt that Resident #9's wound was not healing due to nutritional compromise. The RD stated that she disagreed. In addition to developing the sacral wound in February 2016, Resident #9 was diagnosed with [REDACTED]. On 2/2/16 an SBAR (concern form) was documented. It read resident noted to have elevated temp. Resident #9 continued with the following elevated temperatures: 2/13/16- 102.7 2/13/16- 100.7 2/14/16- 100.7 2/14/16- 101.7 2/15/16- 100.0 2/18/16- low grade temp 2/21/16- 100.8 She was treated with additional antibiotics, completing antibiotic therapy on 2/24/16. The following information regarding an increased need for protein during periods of infection is from the document The Requirements of Protein & Amino Acid During Acute & Chronic Infections. Infectious episodes result in hypermetabolism and a negative nitrogen balance. The extent of the negative nitrogen balance varies with the type of infection and its duration; however, it is reasonable to suggest that the loss of body protein could be minimized by the provision of dietary nitrogen accessed on 6/16/16 at 9:45 a.m. at www.ncbi.nlm.nih.gov/pubmed/ 927 <http://www.ncbi.nlm.nih.gov/pubmed/ 927> During the 6/8/16, 11:15 a.m. interview with the RD, she was asked if she used an increased injury factor to determine protein needs for someone with an infection or wound. She stated she liked to use 1.2 grams of protein per kilogram body weight when assessing protein needs for wound healing. She also stated that she would work together with the doctor to determine protein needs. She did not say whether she provided increased protein during periods of infection. There is no evidence that the RD consulted either the primary physician or wound care physician in determining Resident #9's protein needs. While the RD did increase Resident #9's tube feeding on 3/9/16, she did not calculate a protein need to address wound healing and infection. Her note for 3/9/16 does not document the estimated need for protein or the amount of protein provided in Glucerna 1.5 @ 35 cc per hour. Resident #9's care plan was reviewed. A focus area Nutritional Status as evidenced by potential weight loss/gain related to enteral/[MEDICATION NAME] nutrition, Swallowing difficulty was initiated on 3/11/16. Interventions included: Administer vitamin/ mineral supplements as ordered, discuss weight loss desires with physician and make recommendations for supplements, enteral nutrition per physician orders. On 6/8/16 at 11:15 a.m., the RD was asked how often she updated the nutrition care plan. She stated that she did not update care plans. The facility policy titled Skin Integrity Program: Identification and Prevention was reviewed. The section titled Identify New or Existing Wounds read 4.3 Notify the dietician for nutritional interventions. There is no evidence that the facility RD was not notified or consulted regarding the identification of Resident #9's sacral wound. The RD did document that Resident #9 had a wound when completing the assessment regarding the significant weight loss (3 weeks after the wound development). On 6/8/16 at 4:20 p.m., Resident #9's significant weight loss was discussed with the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON). They were notified that the deficiency was being considered as a harm level deficiency. At this time, the facility staff were asked if weekly weights were supposed to be performed once a resident had been identified with significant weight loss. The DON stated it depended on what the RD recommended. The ADON stated that weekly weights should be done for 4 weeks. They were informed that weekly weights were not done for Resident #9 after her significant weight loss was identified. At this time, the DON stated that wounds were discussed in the weekly risk (We Care) meeting. She stated that the RD was present at the meetings. She stated that the RD should assess nutritional status after hearing about the wounds discussed in the meeting. The DON was notified that the RD did not assess Resident #9's nutritional needs after identification of the wound. The DON was notified that the RD completed an assessment for significant weight loss and mentioned the wound in her note. This note was completed three weeks after the wound was identified and did not address protein needs. The facility was asked to provide any information related to the significant weight loss and wound development. In summary: It was documented by the RD that nutritional needs were not being met by the tube feeding rate being provided. Specifically, caloric needs, protein needs, and vitamin/ mineral needs were not being met. It was documented by the physician that he was unaware that Resident #9 had weight loss. It was documented by the wound care physician that Resident #9 was at nutritional compromise for wound healing. As a result of inadequate nutrition, Resident #9 experienced significant weight loss and the development of an unstageable sacral ulcer. 2. For Resident #22, the facility staff failed to develop or implement nutritional strategies after the development of a significant weight loss. Resident #22, a female, was admitted to the facility 8/17/15 and discharged to an assisted living facility on 10/14/15. Her [DIAGNOSES REDACTED]. Resident #22's most recent MDS (minimum data set) with an ARD (assessment reference date) of 8/24/15 was coded as an admission assessment. Resident #22 was coded as having short and long term memory deficits and required total assistance with making daily life decisions. She was coded as requiring extensive to total assistance with her activities of daily living, with the exception of eating. For eating she was coded as needing limited assistance. Resident #22's weight was coded as being 172 pounds. Review of Resident #22's clinical record revealed upon admission she weighed 171.5 pounds and was 63 inches tall. Over the weeks of her stay at the facility, the following weights were noted: 8/17/15 171.5 pounds 8/26/15 153.8 pounds 156.8 pounds reweighed 9/2/15 153 pounds 9/8/15 148 pounds 9/16/15 142.2 pounds 9/23/15 145.8 pounds 9/28/15 145.6 pounds 10/9/15 147.4 pounds Review of Resident #22's discharge records from the hospital revealed her weight on 8/14/15 was 80.1 kg (kilogram) or 176.22 pounds. Review of Resident #22's clinical record revealed the significant weight loss was not identified nor were any strategies developed to prevent any further weight loss. EMP. F, the registered dietitian, stated 6/8/16 at 11:20 a.m., upon admission, Resident #22 should have had her weight obtain weekly for four weeks. Also the dietary tech, Other I enters all pertinent information into the facility's computerized system. EMP. F stated she completes an initial assessment and when informed, will reassess Residents for weight loss. EMP F stated that significant weight loss is flagged in the computer and the Resident is then discussed during We Care meetings held weekly. EMP. E stated the Resident should also have been reassessed at 14 days, 30 days, and 60 days after admission. During the time of Resident #22's admission, EMP. F stated the reassessment would have been completed on a paper or hard chart form. Review of Resident #22's clinical record revealed she had her initial Nutrition Assessment completed on 8/19/15. EMP. F entered that the goal should be for Resident #22 to have no significant weight change by the next review. Her diet was changed to a regular diet, however Resident #22 was on 1800 cc (cubic centimeter) fluid restriction due to [MEDICAL CONDITION] ( a low sodium level). No evidence was present to indicate that after Resident #22 experienced a 17.7 pound weight loss on 8/26/15 that the significant weight loss was identified. While Resident #22's weight was repeated on 8/26/15, no information was evident that the weight loss had been referred to any staff. By 9/16/15, Resident #22 had lost 29.3 pounds with a weight of 142.2 pounds. EMP. F entered a dietary note that included, Spoke with resident on this day, r/t (related to) recent weight loss. Resident with dx (diagnosis) of dementia. Will need cueing with meals. States weight loss is ok Blood sugar well controlled. Restricted diet provided. With weight changes and progression of disease, will suggest D/C restricted diet, change to regular regime. When interviewed, EMP. F stated she would only be aware of any Resident weight changes if someone told me. EMP. F stated it would be up to either the dietary tech or one of the nurses to inform her of any significant weight loss. When asked about changing Resident #22's diet to regular on 9/16/15 EMP F stated she felt there was more information in the clinical record. Review of Resident #22's clinical record revealed her diet had been changed from a diabetic (low concentrated sweet) diet to a regular diet on 8/19/15, shortly after Resident #22's admission to the facility. Review of the notes from the We Care minutes 9/16/15 revealed Resident #22 was discussed at the meeting, however the only recommendation was for her diet to be changed to a regular diet (that had been changed shortly after admission). Other I, the dietary tech, stated 6//6/16 at 3:14 p.m., she only was responsible for entering data into the computerized system. Other I stated it was the registered dietitian's responsibility to develop or recommend strategies for weight loss. Other I stated if she happened to notice a significant weight loss, she would notify the dietitian. Resident #22's physician only entered a note regarding her weight loss 8/26/15 when her weight was noted to be 153.8 pounds. The progress note written that day indicated, not sure about wt (weight). No other entries were evident from the physician that he had been informed regarding the significant weight loss Resident #22 experienced. Review of her comprehensive care plan revealed the only care plan developed to address nutritional concerns was developed on 8/28/15, Risk for alteration in nutrition r/t (related to) tolerance of therapeutic diet, pain, impaired cognition. Included in the Interventions was Honor food preferences; Notify physician and responsible party of significant weight changes; Weights as ordered. No other information was evident that indicated Resident #22 had been identified as having experienced a significant weight loss or that the staff had developed any nutritional strategies to prevent further weight loss. EMP. F stated even if a Resident had significant weight loss, she, as the facility registered dietitian was not involved in the formulation or revision of care plans. Guidance was provided at emedicine.medscape.com: Nutritional screening has become a primary tool to identify at-risk patients and should be performed when the patient is admitted to a rehabilitation unit. While a standard nutritional screening tool has not been established, there are several tools available that can be incorporated easily into routine clinical practice. It is often necessary at a minimum to do a mini-nutritional assessment of the patient at the point of admission into a rehabilitation unit, since poor nutritional status could lead to greater debility and an inability to fully participate in intensive in-patient rehabilitation therapies. The administrator, DON (director of nursing) and ADON (assistant DON) were informed of the failure of the staff to identify Resident #22 experienced a significant weight loss and failure to develop and implement nutritional strategies to prevent further weight loss, 6/8/16 at 4:08 p.m.

Based on observation, staff interview and clinical record review, the facility staff failed for three residents, (Resident #4, #9 and #5) in a survey sample of 24 residents, to prevent, assess, identify and treat three avoidable pressure ulcers resulting in harm for all three residents. 1. For Resident #4, the facility failed to identify an unstageable pressure ulcer to the left heel. On 2/5/16, the wound was first identified by the Wound Care Specialist as 100% eschar, unstageable, measuring 3.4 x 4 x not measurable centimeter. Discoloration to the heels was noted in November 2015. Interventions were not put into place to prevent the deterioration of the heel until 1/5/16 (off loading of the heels) and 1/26/16 (specialty mattress). 2. For Resident #9, the facility failed to identify an unstageable pressure ulcer to the sacrum. On 2/22/16, the wound was first identified by the Wound Care Specialist as unstageable, 70% yellow necrotic, 30% granulation tissue, measuring 3.4 x 1.8 x 0.1 centimeter. On 2/15/16, the facility first documented a skin condition present between the buttocks, the area they consider the origin of the wound. Interventions were not put into place to prevent the deterioration of the area until 2/20/16 (wedge for turning & positioning) and 2/23/16 (specialty mattress). 3. For Resident #5, the facility failed to identify a pressure wound until it had reached an unable to stage pressure wound. On 4/25/16, a new area measured 1.7 cm (centimeters) by 2.0 cm with no depth. Area was 100% slough. And the facility staff failed to follow wound care recommendations by the wound clinic physician. Resident #5 was observed in the gerichair on her back from 8:30 AM to 12:00 PM; this was a continual observation. There was no observation of the resident being repositioned. Wound care recommendations included limit sitting for 30 minutes. The findings included: Resident #4, a [AGE] year old, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #4's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an assessment reference date (ARD) of 4/20/16. She was coded with a Brief Interview of Mental Status score of 1 indicating severe cognitive impairment and required extensive assistance with her activities of daily living. An annual MDS with an ARD 10/13/15 (prior to the development of the heel wound) did not code Resident #4 to have any open skin areas. Resident #4 was coded as a 4/3 (total dependence with two person assistance) for both bed mobility and transfers. During the initial tour of the facility on 6/1/16, the survey team was notified that Resident #4 had an acquired stage IV pressure wound to the left heel. Resident #4 was included in the survey sample. The form Braden Scale for Predicting Pressure Sore Risk was completed 1/14/16. Resident #4 was assessed to have a score of 14 indicating Moderate Risk. In section 4, Mobility- ability to change and control body position, Resident #4 was assessed as Completely Immobile: Does not make even slight changes in body or extremity position without assistance. On 6/3/16 at 10:50 a.m., two surveyors observed Resident #4's heel wound in the presence of the wound care nurse and Unit Manager. The left heel dressing was not affixed to the heel when the sock was removed. The dressing was very moist and was hanging off the heel. The wound measured approximately 4 centimeters in diameter with 100% granulation of wound bed. The outer area surrounding the lower part of the wound had eschar. Two areas of discoloration (black), appearing as a deep tissue area, surrounded the wound. After the heel wound observation, the wound care nurse pulled the sock up over the open, raw wound. The wound did not have a dressing. The resident started to cry. The issue of pain assessment will be addressed in deficiency F309. According to the wound care nurse, the CNA would complete the form titled Skin and Body Alert Form when a shower or bed bath was provided. They were to use the form to document any skin issues observed during care. The form read Use any time a new area is found to document communication and initial interventions. All areas identified by the CNA were then supposed to be evaluated by a nurse. Resident #4's Skin and Body Alert Forms were reviewed. There were no forms provided prior to January 2016. Resident #4's skin issues were documented as follows: 1/6/16- both heels 1/9/16- area right heel 1/16/16- right heel 2/10/16- dark areas on heels 2/13/16- open right heel 2/17/16- dark area on heels, left heel open 2/20/16- dark area on ankles The licensed nurses performed the weekly skin checks. They documented their findings on the Body Audit form. Resident #4's Body Audit forms were reviewed. Most of Resident #4's weekly skin checks were completed by Licensed Practical Nurse C (LPN C). The area to Resident #4's left heel was documented as follows: 11/23/15- dark area both heels- completed by LPN C 12/7/15- dark area both heels (calloused)- completed by LPN C 12/14/15- dark calloused areas both heels- not signed 12/21/15- dark calloused areas both heels 12/28/15- dark calloused areas both heels- completed by LPN C 1/4/16- dark calloused areas both heels- completed by LPN C 1/11/16- both heels 1/18/16- dark calloused heels- completed by LPN C 1/25/16- dark calloused heels- completed by LPN C 2/1/16- skin check not completed 2/8/16- calloused areas both heels- completed by LPN C 2/15/16- calloused areas heels- completed by LPN C On 2/5/16, the Wound Care Specialist evaluated Resident #4's heel. A Wound Care Specialist Initial Evaluation was completed. The evaluation read: present with an unstageable (due to necrosis) of the left heel of at least 1 days duration. Wound size = 3.4 x 4 x not measurable centimeter (cm). 100% black necrotic tissue. Peripheral vascular: no [MEDICAL CONDITION] of the left or right extremity, pedal pulse of left and right: posterior tibial detected by portable doppler. Continue skin prep every shift and as needed, float heels while in bed, off- load wound, reposition. While the Wound Care Specialist documented the left heel wound as 100% eschar on 2/5/16, LPN C continued to document the area to the left heel as a callous on her 2/8/16 and 2/15/16 weekly skin checks. On 6/6/16 at 4:00 p.m., LPN C was interviewed about Resident #4's heel. LPN C was asked to describe what the area to the left heel looked like. She described the area as a calloused, crusty area, darker brown than the normal skin tone. In addition, she stated that the area was flush with the skin, felt thick like dried skin and felt tough. When asked if Resident #4 could lift her leg, LPN C stated no. LPN C stated that Resident #4 was able to move her leg back and forth. When asked how Resident #4 could have developed a callous, LPN C stated she was not sure. The Body Audit documentation was reviewed with LPN C. It was explained to LPN C that on 2/5/16, the Wound Care Specialist documented an unstageable pressure wound (due to necrosis) of the left heel, 100% black necrotic tissue. It was reviewed with LPN C that her weekly skin check for 2/8/16 and 2/15/16 documented the area to the left heel as a calloused area. LPN C was asked how she continued to assess the area to the left heel as a callous when it had been a documented wound with 100% eschar for at least 10 days. LPN C stated that no one told her the area was a pressure wound. LPN C was asked to describe the process for wound identification at the facility. She stated that the Skin and Body Alert form was completed by the CNAs during a shower or bed bath. Skin areas of concern were to be noted on the form. LPN C stated that the nurses completed the Body Audit form weekly. On 6/6/16 at 1:45 p.m., the Wound Care Specialist was interviewed. The Wound Care Specialist began work at the facility in the fall of 2015. He agreed that the facility had an issue with wounds and stated that wound treatments were not always done as recommended. When asked to define a callous, he stated it was a build up of skin. He stated it would be thickened and caused by rubbing. When asked how someone who did not move their legs could develop a callous on the heel, the Wound Care Specialist stated he was unsure how that would happen without movement. Wound tracking documentation for the left heel was reviewed. The wound was documented as follows: 1/4/16- Non-Pressure Skin Condition Record was initiated for the left heal. Date first observed is blank. The area is described as intact discoloration measuring 3.5 x 6 x 0 centimeters (cm). The sections titled Exudate, Wound Bed, Surrounding Skin, Pain, Progress, Treatment, Speciality Interventions, Nutritional Interventions and progress Notes were not completed. The Nurse's Signature section was blank. The assessment appeared to be incomplete. 1/13/16- Non-Pressure Skin Condition Record 3.5 x 6 x 0 cm, intact, no exudate, wound bed= dark pink/ red tissue, surrounding skin= discoloration/ darkened area, prevalon boots in place 1/18/16- Non-Pressure Skin Condition Record 3.5 x 6 x 0 cm, characteristics= intact and partial thickness, wound bed= normal for skin, surrounding skin= normal for skin, interventions= speciality bed, bilateral boots, wedge cushion 1/25/16- Non-Pressure Skin Condition Record 3.5 x 6 x 0 cm, characteristics= intact, wound bed= normal for skin, surrounding skin= normal for skin, interventions= speciality bed, bilateral boots, wedge cushion, supplements, continue with skin prep 1/27/16- Non-Pressure Skin Condition Record 3.5 x 6 x 0 cm, intact, no exudate, Wound Bed= Eschar, Surrounding skin= dry, Progress= not changed, continue skin prep (***NOTE- facility documented eschar present and also noted the progress of the wound unchanged.) 2/5/16- Wound Care Specialist Initial Evaluation, present with an unstageable (due to necrosis) of the left heel of at least 1 days duration. Wound size = 3.4 x 4 x not measurable cm. 100% black necrotic tissue. Peripheral vascular: no [MEDICAL CONDITION] of the left or right extremity, pedal pulse of left and right: posterior tibial detected by portable doppler. Continue skin prep every shift and as needed, float heels while in bed, off- load wound, reposition. 2/5/16- Pressure Ulcer Record initiated. Unstageable, measurements= 3.4 x 4 x 0 cm As of the time of the survey, the wound was unhealed. Staff continued to assess the wound weekly. The most recent assessment was conducted on 6/6/16. The wound was documented as follows: wound not staged, Measurements= 1.9 x 2.6 x 0.2 cm, 100% hypergranulation tissue. On 6/2/16 at 2:10 p.m., the wound care nurse was asked at what stage a pressure wound should be identified. She stated stage I. The wound care nurse was also asked if skin issues to the heel should be tracked on a nonpressure skin form. The wound care nurse stated no. The wound care nurse explained that she started in her position in March 2016. She stated that there was no one in the role of wound care nurse for about a month prior to her start. The wound care nurse stated that weekly skin checks should be completed on shower days. If a skin issue is identified, a SBAR (concern form) should be completed and treatment should be initiated. The floor nurse was responsible for initiating the pressure or nonpressure form. The forms were added to the treatment book. The wound care nurse stated that she reviewed the treatment book daily. Resident #4's Care Plan was reviewed. A care plan focus addressed risk for alteration in skin integrity, initiated 5/12/15. Interventions dated 5/12/15 included diet and supplements per physician order, assist to reposition, pressure distributing device to bed and chair, speciality matress. Interventions dated 5/9/16 included: Consume fluids, labs as ordered, provide preventative skin care, suspend/ float heels as able. Another care plan focus initiated on 1/5/16 addressed actual alteration in skin related to left heel Interventions dated 1/5/16 included: obtain labs, provide diet and supplement per order, specialty mattress, suspend heels, use pillows/ positioning devices as needed. an order for [REDACTED]. an order for [REDACTED]. The facility did not provide an answer. No order for prevalon boots was located in the record or provided by the facility. The use of prevalon boots or heel floats was not documented on the Treatment Administration Record for January, February or March 2016. The facility policy Skin Integrity Program: Identification and Prevention was reviewed. The policy read Residents with risk factors for pressure injury development or any actual impairment in skin integrity will be identified, and a risk based interdisciplinary plan of care will be implemented. The section titled Identify New or Existing Wounds read Upon identification of a new pressure injury or lower extremity wound; or when admitting a patient with a pressure injury or lower extremity wound: 4.1. The nurse will evaluate the area, notify the supervisor, practitioner, and patient or patient's representative. The section Plan and Implement Care read The resident's skin will be observed daily during personal care, direct caregivers must promptly report any alteration in skin integrity to the nurse. The resident's skin will also be thoroughly observed by the nurse weekly, and findings documented. The following definitions regarding pressure injuries and staging were accessed from the National Pressure Ulcer Advisory Panel website on 5/31/16 at 1:25 p.m. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ Pressure Injury: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. 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. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on an ischemic limb or the heel(s) should not be removed. At the end of day meeting on 6/2/16, the Administrator and Director of Nursing were notified that the issue with the heal was being considered as a harm level deficiency. They were asked to provide all wound related information. The Administrator and Director of Nursing were given additional opportunities to submit wound related information at the end of day meeting on 6/6/16 and 6/8/16. 2. For Resident #9, the facility failed to identify an unstageable pressure wound to the sacrum. On 2/22/16, the wound was first identified by the Wound Care Specialist as unstageable, 70% yellow necrotic, 30% granulation tissue, measuring 3.4 x 1.8 x 0.1 centimeter. On 2/15/16, the facility first documented a skin condition present between the buttocks, the area they consider the origin of the wound. Interventions were not put into place to prevent the deterioration of the area until 2/20/16 (wedge for turning & positioning) and 2/23/16 (specialty mattress). Resident #9, a [AGE] year old, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #9's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an assessment reference date (ARD) of 4/27/16. She was coded with moderate cognitive impairment. She was coded as 4/2 (total dependence, one person assist) for bed mobility and 4/3 (total dependence, two person assist) for transfers. She was not coded to have any skin issues. Resident #9 also had an annual MDS with an ARD of 2/24/16. She was coded with moderate cognitive impairment. She was coded as 4/2 (total dependence, one person assist) for bed mobility and 4/3 (total dependence, two person assist) for transfers. She was coded to have one unstageable pressure wound. The form Braden Scale for Predicting Pressure Sore Risk was completed 2/3/16. Resident #9 was assessed to have a score of 11 indicating High Risk. In section 4, Mobility- ability to change and control body position, Resident #4 was assessed as Completely Immobile: Does not make even slight changes in body or extremity position without assistance. On 6/3/16 at 1:35 p.m., Resident #9's sacrum was observed in the presence of Certified Nursing Assistant I (CNA I). Old scar tissue was observed at the sacral area. No open areas were observed. During a review of Resident #9's clinical record, it was identified that the resident had a facility acquired pressure wound to the sacrum. The area healed on 4/18/16. Skin issues were documented in the clinical record as follows: On 2/15/16, a SBAR (concern note) was write regarding the buttocks. The note read Change in condition noted related to Shredding between buttock. SKIN: Noted to have the following skin conditions present: Between buttocks. The Interventions read Zinc oxide mixed with [MEDICATION NAME] cream. The following telephone orders regarding the zinc treatment were written: - 2/15/16 8:15 a.m. Mix Zinc Oxide with [MEDICATION NAME] (housestock); apply mixture to excoriation between buttock until healed q (every) shift. - 2/15/16 3:00 p.m. Order clarification: Zinc Oxide 2% ointment apply to excoriated/ shearing area between buttock. - 2/20/16 3:00 p.m. Order clarification: zinc oxide 20 % oint mixed with dermaseptin (housestock) to bet. (between) buttock area; cleanse with NS (normal saline); Apply mixture & dry dsg (dressing) until healed Q (every) day. 1) Zinc oxide 20 % mixed mixed with dermaseptin to Rt. (right) ischium area cleanse with normal saline; apply mixture & dry dressing Q (every) day/ PRN (as needed) until healed. On 2/22/16, the Wound Care Specialist evaluated Resident #9 at the request of the facility doctor. The Wound Care Specialist notes were reviewed. The chief complaint read patient has rash. Incontinence Associated [MEDICAL CONDITION] was documented. The treatment read Zinc paste to bilateral buttocks bid (two times per day) and prn (as needed). During the 2/22/16 evaluation, in addition to assessing the rash on the buttocks, the Wound Care Specialist identified an unstageable pressure wound on the sacrum. Under Assessment & Plan the evaluation notes read Unstageable (due to necrosis) of the sacrum- initial evaluation. The wound was assessed as unstageable necrosis greater than 1 day duration, etiology: pressure, 70% yellow necrotic, 30% granulation tissue, exudate: light serosanguinous, measurements: 3.4 x 1.8 x 0.1 cm. Treatment: santyl- once daily, dry protective dressing- once daily. Recommendation: Limit sitting to 30 minutes, off-load wound, reposition per facility policy. A skin note, written by the Assistant Director of Nursing (ADON) on 2/22/16, was the first time a skin impairment to the sacral area is documented in the progress notes. The note read 2/22/16, Skin Note: Res was seen by wound doctor ____ today for the UTS (unable to stage) area to sacrum res has light serosanguineous to the area 70% yellow necrosis and 30% granulation. On 2/25/16, the facility doctor documented a visit with Resident #9 on the Physician Progressive Notes. The note read sacral ulcer stage II. This note was completed three days after the Wound Care Specialist documented the sacral ulcer as unstageable. The floor nurses performed the weekly skin checks. They documented their findings on the Body Audit form. Resident #9's Body Audit forms were reviewed. 2/10/16- clear 2/17/16- shearing with treatment, area between buttocks indicated on form 2/24/16- open area: sacral, wound with treatment indicated the area between buttocks and area with treatment indicated the back of upper right leg. Certified Nursing Assistants (CNAs) would complete the form titled Skin and Body Alert Form when a shower or bed bath was provided. They were to use the form to document any skin issues observed during care. The form read Use any time a new area is found to document communication and initial interventions. All areas identified by the CNA were then supposed to be evaluated by a nurse. There was no CNA report of any skin concerns for Resident #9 during the month of February 2016. During the month, it was documented on the Activities of Daily Living flow sheet that Resident #9 received a bed bath at least daily. The following Pressure Ulcer Records were available in Resident #9's clinical record: 1. Right Buttock, date of origin: 2/15/16. Assessment date: 2/19/16. The area is not staged. Measurements: 1 x 0.5 x 0. Wound bed= pink, Surrounding tissue= reddened, Exudate= none, treatment in progress. Signed by Licensed Practical Nurse F (LPN F). 2. Right Buttock, date of origin- blank. Assessment date: 2/19/16. The area is not staged. Measurements: 0.5 x 0.5 x 0. Wound bed= pink, Surrounding tissue= reddened, Exudate= none, treatment in progress. Signed by LPN F. 3. Between Buttocks, date of origin- 2/11/16. Facility acquired. Assessment date: 2/19/16. The area is documented as Unstageable. Measurements: 3 x 2 x 0.5. Wound bed= pink, dark pink/reddened tissue, Surrounding tissue= reddened, Exudate= serosanguineous, treatment in progress. (NOTE: This form was originally photo copied for surveyors on 6/6/16. The facility provided an explanation of the wound development on 6/8/16, to include copies of wound tracking. This same form (originally copied 6/6/16) was provided on 6/8/16 and had been altered from the original. The date of origin had been changed to 2/15/16 and the word error was written in next to where unstageable was documented.) Signed by LPN F. 4. Sacrum, date of origin- 2/19/16. Assessment date: 3/7/16. The area is documented as stage III. Small amount of serosanguinous exudate. Wound bed= dark pink/reddened tissue, Surrounding tissue= normal for skin. 100% granulation. On 6/8/16 at approximately 9:45 a.m., the Director of Nursing (DON) was notified that the pressure ulcer record Between Buttocks had been altered from the original copy. She was asked to have which ever staff who had changed the document to come speak to the survey team. On 6/8/16 at 10:00 a.m., the Corporate Nurse arrived to speak with the survey team. She stated that she had changed the document in attempts to make the wound documentation make sense. She stated that the four pressure ulcer records (noted above) were all the same wound, the sacral wound. It was reviewed with the Corporate Nurse that three of the four pressure ulcer tracking forms identified different locations for the wound. The Corporate Nurse stated that a new pressure ulcer form was started every month and that staff changed the name of the area. The Corporate Nurse stated that the sacral wound was first identified on 2/15/16, as documented in the SBAR. It was reviewed with the Corporate Nurse that the SBAR documented an area between the buttocks, not the sacrum. It was reviewed with the Corporate Nurse that the survey team continued to have difficulty understanding the wound tracking. The Corporate Nurse responded This is a hot mess. According to his assessment on 2/22/16, the Wound Care Specialist documented that Resident #9 had two separate skin issues, an unstageable sacral wound and incontinence associated [MEDICAL CONDITION] on the buttocks. Resident #9's care plan was reviewed. A Focus area was created on 3/18/15 regarding risk for alteration in skin integrity. Interventions dated 3/18/15 read barrier cream to perianal/ buttocks as needed, diet and supplements per physician order, observe skin condition with care daily, provide preventative skin care routinely. Intervention dated 4/28/16 read use pillows/ positioning devises as needed. The facility provided an order dated 2/20/16 for a wedge: use wedge for turning & positioning q (every) shift. In addition, the facility provided an invoice for a specialty mattress. Resident #9 was first charged for the specialty mattress on 2/23/16. Both interventions were put into place five days after the facility states they identified the skin issue as documented in the SBAR dated 2/15/16. The facility policy Skin Integrity Program: Identification and Prevention was reviewed. The policy read Residents with risk factors for pressure injury development or any actual impairment in skin integrity will be identified, and a risk based interdisciplinary plan of care will be implemented. The section titled Identify New or Existing Wounds read Upon identification of a new pressure injury or lower extremity wound; or when admitting a patient with a pressure injury or lower extremity wound: 4.1. The nurse will evaluate the area, notify the supervisor, practitioner, and patient or patient's representative. The section Plan and Implement Care read The resident's skin will be observed daily during personal care, direct caregivers must promptly report any alteration in skin integrity to the nurse. The resident's skin will also be thoroughly observed by the nurse weekly, and findings documented. The following definitions regarding pressure injuries and staging were accessed from the National Pressure Ulcer Advisory Panel website on 5/31/16 at 1:25 p.m. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ Pressure Injury: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. 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. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on an ischemic limb or the heel(s) should not be removed. At the end of day meeting on 6/2/16, the Administrator and Director of Nursing were notified that the issue with the sacral wound was being considered as a harm level deficiency. They were asked to provide all wound related information. The Administrator and Director of Nursing were given additional opportunities to submit wound related information at the end of day meeting on 6/6/16 and 6/8/16. 3. For Resident #5, the facility failed to identify a pressure wound until it had reached an unable to stage pressure wound. On 4/25/16, a new pressure area was identified ( left superior ischium pressure wound) and measured 1.7 cm (centimeters) by 2.0 cm with no depth. The area was 100% slough. And the facility staff failed to follow wound care recommendations by the wound clinic physician. Resident #5 was observed in the gerichair on her back from 8:30 AM to 12:00 PM; this was a continual observation. There was no observation of the resident being repositioned. Wound care recommendations included limit sitting for 30 minutes . Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 3/3/16. She was coded with a Brief Interview of Mental Status score of 0 out of a possible 15 indicating severe cognitive impairment. She required total assistance of one staff member for bed mobility and transferring. The resident was incontinent of bowel and bladder. The resident did not have recent weight loss. The resident was not coded with any pressure sores. On 6/2/16 at 8:30 AM, Resident #5 was observed up in her gerichair. A geri chair is a reclining lounge type chair. On 6/2/16 at 10:00 AM, through continuous observation, Resident #5 remained in the hallway in gerichair, yelling out, on back in the gerichair. On 6/2/16 at 10:30 AM, Resident #5 was taken back to her room, remained in gerichair, on her back. On 6/2/16 at 11:35 AM, through continuous observation, Resident #5 remained in her room in her gerichair, remained on her back. On 6/2/16 at 12:00 PM, the resident remains in the gerichair on her back. On the hallway where the resident resided, there was a strong, persistent urine odor. On 6/2/16 at 1:10 PM, the resident was lying in bed on the right side, facing the door. A CNA (certified nursing assistant) F was in the room. CNA (F) stated, I put her back to bed 5 minutes ago. The resident had received incontinence care at this time. CNA (F) went on to state that her usual routine was to get the resident up in the morning and put her back to bed after lunch. A housekeeper was observed spraying disinfectant in the hallway. Resident #5 had been up in the gerichair for approximately 4.5 hours. Review of the resident's History and physical dated 12/7/15 (hospitalized for [REDACTED]. Review of the wound tracking notes from the wound clinic, Resident #5 had healed stage 4 on the left ischium (the back lower portion of the hip bone) and an abscess of the left medial ischium had healed as of 1/11/16. All the wounds had been healed on 1/11/16. On 4/18/16 (according to the skin and body alert form done by nursing) the form showed an open area (not measured) on the left ischium. No other information was available. On 4/18/16 wound clinic notes documented a stage 3 pressure wound of the left ischium measuring 0.9 cm by 0.1 cm with 20 % necrosis. This was the re-opening of the left lower ischium. Further review of the wound tracking from the wound clinic revealed the resident had acquired a new, unable to stage left superior ischium pressure wound with 100% necrosis, on 4/25/16. The area measured 1.7 cm (centimeters) by 2.0 cm, depth not measurable. This was documented on the wound clinic notes for 4/25/16. Recommendations included: Limit sitting to 30 minutes, offload wound, reposition per facility protocol. On 5/23/16, according to the wound clinic notes, the left superior ischial wound had healed. http://www.merriam-webster.com/dictionary/ischium the dorsal and posterior of the three principal bones composing either half of the pelvis www.NPUAP.com <http://www.NPUAP.com> defined an unstageable pressure

Based on observation, staff interview, facility documentation review, complaint investigation and clinical record review the facility staff failed to maintain the highest practicable well-being for two residents (#6 and #22) resulting in harm for Residents #6. 1. For Resident #6, the facility staff failed to provide medical consultation for an arterial foot wound until it developed into a broken skin wound, resulting in harm. 2. For Resident #22, the facility staff failed to administer Ancef, an antibiotic, per physician's orders [REDACTED].>The findings included: 1. For Resident #6, the facility staff failed to provide medical consultation for an arterial foot wound until it developed into a broken skin wound, resulting in harm. Resident #6, a [AGE] year old female, was admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident #6 was the victim of a motor vehicle accident in 3/2014 resulting in a skull fracture and subdural hematoma. Her hands and feet were contracted and she was nonverbal. Resident #6's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/9/16 was coded as an annual assessment. She was totally dependent on one person for her activities of daily living and was always incontinent of bowel and bladder. Resident #6 had a peg (percutaneous endogastric-feeding tube inserted through the skin and into the stomach) tube for nutrition, and a [MEDICAL CONDITION] (tube placed into the throat through the neck) to facilitate breathing. Resident #6 was observed on 6/2/2016 at 11:00 AM in a reclining wheelchair in her room. CNA Certified Nursing Assistant) C had just finished dressing the Resident. Resident #6's toes were contracted at the first joint and an open wound on the knuckle of the right great toe was seen. CNA C stated that she was unsure when or how this wound developed. On 6/2/2016 at 1:20 PM Resident #6 was again observed with LPN D and the right toe wound was more closely examined. The wound was over the bony prominence of the first knuckle of the right great toe and measured 1.8 cm (centimeters) x 2.1 cm. The depth was not measureable. The wound bed contained moderate sero-sanguinous tissue with 100% granulation tissue. It was treated with calcium alginate and covered with a dry dressing daily. LPN D did not know the origin of the wound or how long the condition existed. The clinical record was then examined and revealed the following progress notes relating to the right foot wound: 2/7/2016 (First entry for this wound)- Right great toe has open area 2/7/2016- Reddened area to right great toe. 2/9/2016-(by Nursing Management)- Noted to have reddened area to right great toe . 2/11/2016- Open area to right great toe appears to be getting progressively better. 5/9/2016- Change in condition-culture of right great toe. Since this started it has gotten worse. 5/13/2016- [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staph Aureus) right great toe. Contact precautions started. 5/18/2016- Right great tow (sic) measure 0.6 cm x 1.5 cm x 0.1 cm granular with small amount of drainage. 5/22/2016- Resident on ATB (antibiotic) [MEDICAL CONDITION] in right great toe. No adverse reactions noted. 5/23/2016- Resident on ABT [MEDICAL CONDITION] in right great toe, no adverse reactions noted, remains on contact precautions. Facility skin condition records were examined and they showed no mention of the right great toe wound. Activities of Daily Living (ADL) records were examined and there was no mention of the right great toe wound. physician progress notes [REDACTED]. One note (6/1/2016) stated open area over right toe. No granulation tissue. Daily dressing wet to dry. Initial admission assessment on 4/14/2014 did not indicate the presence of any skin problems. Readmission assessment of 2/5/2016 also showed no skin problems. On 6/2/2016 at 4:00 PM an interview was conducted with Employee B, Director of Nursing who was asked to comment on this wound. She stated that We should have looked more closely at this wound before now. On 6/6/2016 at 11:00 AM, Other A, Wound Care Physician examined Resident #6 and an interview was conducted with him. He stated that he felt that the wound was a result of poor arterial blood flow to the foot. He recommended a vascular surgery consult, bilateral arterial Doppler studies, and bilateral ABI (Ankle Brachial Index). These tests will confirm the diagnosis. He stated that the clinical record was difficult to follow, and sometimes contradictory, and that the facility should have called him at the very early stages of the development of this wound. He recommended the application of foam to the wound until tests were completed. On 6/6/2016 at 3:10 PM an interview was again conducted with Employee B, Director of Nursing in the presence of the survey team. Regarding the Wound Care Physician, she stated that I asked him to see the Resident because you were looking at her (Resident #6). On 6/6/2016 at 5:30 PM the Survey Team asked Employee B, Director of Nursing to describe the facility wound care process. She stated that nurses do skin checks two times per week. She was further asked how Resident #6's wound escaped the assessment and why the wound care physician was not summoned in the early days of the wound development. She stated that It is difficult for me to see what happened. We must have missed it. Resident #6's Care Plan was examined and it contained no mention of the toe wound. Facility Skin Integrity Program: Identification and Prevention stated: Identify New or Existing Wounds 4. Upon identification of a new pressure injury or lower extremity wound or when admitting a patient with a pressure injury or lower extremity wound: 4.1 The nurse will evaluate the area, notify the supervisor, practitioner, and patient or patient's representative. 5. A comprehensive, interdisciplinary resident care plan will be developed and implemented based on identified risks and individual needs to avoid skin breakdowns and treat impaired skin integrity and existing ulcers. 6. The resident's skin will be observed daily during personal care; direct caregivers must promptly report any alterations in skin integrity to the nurse. Administration was informed of the harm findings on 6/8/2016 at 6:00 PM and no other information was provided. THIS IS A COMPLAINT DEFICIENCY 2. For Resident # 22, the facility staff failed to administer Ancef, an antibiotic, per physician's order [REDACTED].>Resident #22, a female, was admitted to the facility 8/17/15 and discharged to an assisted living facility on 10/14/15. Her [DIAGNOSES REDACTED]. Resident #22's most recent MDS (minimum data set) with an ARD (assessment reference date) of 8/24/15 was coded as an admission assessment. Resident #22 was coded as having short and long term memory deficits and required total assistance with making daily life decisions. She was coded as requiring extensive to total assistance with her activities of daily living, with the exception of eating. For eating she was coded as needing limited assistance. Resident #22's weight was coded as being 172 pounds. Review of Resident #22's clinical record revealed she was diagnosed as having an infected left great toe on 9/24/15. Her physician ordered for a culture to be done of the toe and started Resident #22 on two different antibiotics, [MEDICATION NAME] 350 mg (milligram) daily [MEDICATION NAME] gram every 8 hours. Both antibiotics were to be administered IV (intravenously). Accompanying entries were noted on the MAR (medication administration record), with nurses initials indicating the medications were administered. Calculation of the doses administered [MEDICATION NAME] Resident #22 was administered 33 doses of Ancef, from 6 a.m. on 9/25/15 through 10 p.m. on 10/5/15. Calculation of the number of doses that should have been administered by physician's orders [REDACTED]. When interviewed, the DON (director of nursing) stated 6/8/16 at 4:08 p.m., she had counted the doses and Resident #22 did receive three doses too many. Additionally, the DON stated the staff should administer medications per physician's orders [REDACTED].>Guidance was provided at www.drugs.com for administration of Ancef, Follow all directions on your prescription label. Do not use this medicine in larger or smaller amounts or for longer than recommended. The administrator, DON, and ADON (assistant DON) were informed of the failure of the staff to [MEDICATION NAME] physician's orders [REDACTED].

Based on observation, resident interview, staff interview, facility document review, clinical record review, and in the course of complaint investigation, the facility staff failed to transfer one of 3 residents (Resident #1) in a safe manner to prevent injury. Resident #1 was transferred on a mechanical bath lift in an unsafe manner resulting in a fall. Resident #1 sustained a hip fracture which required surgery. The findings included: Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 09/15/2012 coded Resident #1 with the ability to understand others and to be understood. In addition, the Minimum Data Set coded Resident #1 as independent in terms of transfer. Resident #1 was coded as requiring supervision in terms of bathing. Nurses Notes for Resident #1 dated 11/14/2012 documented, "Resident in shower room with CNA (certified nurse aid) & student. Resident being transferred via mechanical shower lift/chair into bath tub with 2 persons present. Shower lift hung on side of bathtub & overturned onto shower floor; Resident hit L (left) hip onto shower floor & L elbow with small superficial scrape; Upon assessment, no bruising/swelling to L hip/leg; Resident c/o (complaint) moderate/severe pain upon movement; Medicated w/ Tylenol 650 mg (milligram) x 1; not effective for pain upon movement; (Physician) paged x 2, no return call; (Medical Director) paged, awaiting return call; Resident alert/verbal. (X-Ray company) into x-ray L hip; awaiting results." Nurses Notes for Resident #1 dated 11/14/2012 documented, "MD (physician) return call aware of x-ray report. N.O (new order) send to (Hospital emergency room ). 911 called. Report called to (ER nurse) at (Hospital ER). EMS (emergency medical service) into P/U (pick up). Church member took resident's purse to follow res (resident) to ER, transported via stretcher." Incident/Accident Report for Resident #1 dated 11/14/2012 documented, "Tub lift malfunctioned, tipped over. Resident landed on left arm & hip. Abrasion & bruise to left medial arm, left leg appears shorter than Rt (right) while lying down. Stat (urgent) x-ray ordered. Fall Investigation Worksheet for Resident #1 dated 11/14/2012 documented, "Resident's Description of Fall: Sitting in shower lift, lift tipped over. Recommendations to prevent further falls: None at this time." Hospital ER Report for Resident #1 dated 11/14/2012 documented, "Chief Complaint: Pain in the left hip. History of Present Illness: The patient is a [AGE] year-old Caucasian female who is a resident of (Facility). The patient was in the shower room and during the transfer, the patient fell and developed pain in the left hip. X-ray was taken and showed left femoral neck fracture. The patient was sent to the ER and then was admitted to the hospital." Hospital Record for Resident #1 dated 11/14/2012 documented, "Physical Examination: Examination of the lower extremities showed external rotation, deformity, and some shortening of the left lower extremity, and mild swelling around the left hip area. Any movements of the lower extremity were painful and were not attempted." Hospital Record for Resident #1 dated 11/14/2012 documented, "Recommendations: I had a detailed discussion with the patient about her underlying diagnosis, natural history, and treatment options. The patient was recommended surgical treatment as definitive treatment of [REDACTED]. The risks and benefits of the surgery were discussed with the patient. She wished to proceed with surgical treatment." Hospital Record for Resident #1 dated 11/14/2012 documented, "treatment plan: [REDACTED]. We will get orthopedic surgeon for surgery. The patient appears to be medically stable for surgery." Facility Reported Incident (FRI) for Resident #1 dated 11/15/2012 documented, "Describe incident, including location, and action taken: Resident being lifted to bathtub via mechanical bath bed, to be placed into tub; battery pack got stuck on tip of bathtub while resident was being lifted into bath tub. The lift overturned with resident strapped in. Resident fell on to shower floor onto L (left) side, sustaining L hip fx (fracture) & superficial scratches to upper left arm. Employee action initiated or taken: Stat (urgent) X-ray obtained; revealed fx of L hip. Resident sent to (Hospital) for evaluation." FRI for Resident #1 dated 11/19/2012 documented, "The (maker of the mechanical bath lift) Bath Trolley was inspected by our maintenance department immediately following incident. Two of the four wheels used for maneuvering the device have locks on them, neither of which was locked during transfer of (Resident #1). It is not certain that the locking of these wheels would have prevented this incident of happening, due to the lift overturning on the side in which the wheels do not have locks. This lift, along with an identical lift on another unit have been locked and tagged out by our maintenance director and removed from the premises." Interdisciplinary Plan of Care for Resident #1 dated 11/22/2012 included but not limited to "Problem: 11/22/12 Res (resident) readmitted after L hip fx (fracture) from fall. Interventions: Encourage res to call for assist with transfers & ambulation. Transfer/ambulate resident with assistance & walker. Encourage res not to bend L leg or abduct L leg." The User Manual for the mechanical bath lift documented, "Bathing the resident: Apply brakes on all castors. Warning: To avoid falling, ensure that the resident is positioned in accordance with these instructions for use." The User Manual for the mechanical bath lift documented, "Caregiver Obligations- Action/Check: Disinfect-everyday. Check/clean castors-every week. Visually check all exposed parts-every week. Visually check mechanical attachments-every week. Check hand control and cable-every week. Check battery charger and battery-every week. Visually check the safety belts-every week. Check the side support holder-every week. Perform a functionality test-every week. Warning: To avoid malfunction resulting in injury, make sure to conduct regular inspections and follow the recommended maintenance schedule. In some cases due to heavy use of the product and exposure to aggressive environment more frequent inspections should be carried out." The User Manual for the mechanical bath lift documented, "Qualified Personnel-Action/Check: Inspect castors. Check emergency Hi/Low function-every year. Check function of emergency stop-every year. Check battery and battery charger-every year. Perform full feature functionality test-every year. Check mechanical attachments-every year. Check that the latest updates have been implemented-every year. Check the safety stop function-every year. Perform a safe working load test-every year. Warning: To avoid injury and/or unsafe product, the maintenance activities must be carried out at the correct frequency by qualified personnel using correct tools, parts and knowledge of procedure. Qualified personnel must have documented training in the maintenance of this device." The User Manual for the mechanical bath lift documented, "Caregiver Obligations: Every week-visually check all exposed parts, especially where personal contact is made by either the resident or caregiver. Make sure no cracks or sharp edges have developed that could cause the resident or user injury or that has become unhygienic. Replace damaged parts." The User Manual for the mechanical bath lift documented, "Caregiver Obligations: Check that the castors are properly fixed and are rolling and swiveling freely. Clean with water." The User Manual for the mechanical bath lift documented, "Yearly: (maker of the lift) has to be serviced according to the Preventive Maintenance Schedule (Qualified Personnel Action/Check)." On 12/05/2012 at 2:10 p.m., surveyor went to an offsite storage, where the mechanical bath lift was located. Surveyor noticed one of the brakes was broken. An interview was conducted with Maintenance Director. He stated one of the brakes was broken when he picked up the mechanical bath lift on 11/15/2012. On 12/05/2012 at 2:50 p.m., an interview was conducted with Certified Nurse Aid-A (CNA-A). CNA-A stated she only locked one wheel when using the mechanical bath lift to transfer Resident #1 on 11/14/2012. CNA-A stated the battery pack got stuck under the tub, and it tipped over. "I only lock one wheel, and the thing kept rolling, (Resident #1) fell and landed on her hip." According to CNA-A, Resident #1 was about 43 inches off the floor. CNA-A stated she did not receive any formal training on how to operate the mechanical bath lift. "Another CNA just show me how to use it." On 12/05/2012 at 3:00 p.m., an interview was conducted with Licensed Practical Nurse-B (LPN-B). LPN-B stated the mechanical bath lift "tipped over", and Resident #1 landed on her hip. LPN-B assessed Resident #1 after the fall, and complained of left hip pain. On 12/05/2012 at 3:05 p.m., an interview was conducted with Resident #1. Resident #1 stated "The lift kept rolling, it was not locked, and I fell and broke my hip." On 12/05/2012 at 3:30 p.m., an interview was conducted with CNA-B. CNA-B stated if both brakes on the bath lift were not lock properly, "it will tip over". On 12/05/2012 at 3:36 p.m., an interview was conducted with CNA-C. CNA-C stated "both brakes need to be locked". According to CNA-C, the bath lift would "tip over" if not lock properly. "It will roll if you only lock one." On 12/05/2012 at 4:22 p.m., an interview was conducted with Maintenance Director. Maintenance Director stated no one checks the mechanical bath lift, unless there's a work order. "And there's no work order." On 12/05/2012 at 5:08 p.m., an interview was conducted with Registered Nurse-A (RN-A), Unit Manager. RN-A stated plan of correction was not done for the 11/14/2012 incident. "Both bath lifts were removed." On 12/06/2012 at 12:30 p.m., an interview was conducted with Interim Director of Nursing (IDON). IDON stated there's no tub bath at this time. "We contacted the manufacturer." On 12/06/2012 at 1:00 p.m., an interview was conducted with CNA-D. CNA-D stated she did not receive any formal training on how to operate the mechanical bath lift. "A CNA just show me." On 12/06/2012 at 2:35 p.m., an interview was conducted with CNA-E. CNA-E stated the mechanical bath lift had been broken for a long time, at least 6-9 months. According to CNA-E, she reported to the previous Maintenance Director. "He told me it's too much trouble to get it fix." CNA-E stated the previous Administrator,the previous DON, and the IDON were informed of the broken brake on the bath lift as well. "You have to get underneath to lock it, since it's broke." CNA-E also stated, "(Maintenance Director) said we did not write a work order, so it won't be fixed." On 12/07/2012 at 12:08 p.m., an interview was conducted with IDON. IDON stated Yearly Preventive Maintenance on the bath lift was not done, and weekly checks were not performed. On 12/07/2012 at 12:35 p.m., an interview was conducted with CNA-D. CNA-D stated the mechanical bath lift had been broken for quite some time, at least 6-9 months. According to CNA-D, she reported to the previous Maintenance Director. "It never got fixed." "We work with what we got." CNA-D also stated the bath lift would "tilt" if not lock. CNA-D stated "You can lock it if you get underneath it." On 12/07/2012 at 12:45 p.m., an interview was conducted with CNA-C. CNA-C stated the mechanical bath lift had been broken for months, and management knew about it. According to CNA-C, the bath lift would "tip over" if both locks were not locked. On 12/07/2012 at 4:26 p.m., an interview was conducted with IDON. IDON was unable to provide a complete list of employees who attended the training for "use of mechanical bath lift". List provided showed 2 employees (certified nurse aid) attended. Complaint Deficiency

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure two Residents (Residents' #4 and #16) were free from unnecessary medications. 1. For Resident #4, [MEDICATION NAME] was administered without physician ordered monitoring resulting, when hospitalized for [REDACTED]. 2. For Resident #16, [MEDICATION NAME] was administered without physician ordered heart rates being obtained. The findings included: 1. For Resident #4, [MEDICATION NAME] was administered without physician ordered monitoring (PT/INR) resulting, when hospitalized for [REDACTED]. Resident #4, a [AGE] year old female, was admitted to the facility initially 8/4/11 and readmitted after a hospitalization [DATE]. Her [DIAGNOSES REDACTED]. Resident #4's most recent MDS (Minimum Data Set) with an ARD (assessment reference date) of 4/16/12 was coded as a quarterly assessment. Resident #4 was coded as being alert, oriented and able to make her own daily life decisions. She was also coded as having no memory deficits. Resident #4 was coded as having a Stage III pressure ulcer. Resident #4 had been admitted to the hospital on [DATE] due to a [DIAGNOSES REDACTED]. While hospitalized for [REDACTED]. Resident #4's PT/INR prior to discharge from the hospital was 2.4. Upon returning to the facility 5/4/12, included within the hospital discharge orders was an order, "[MEDICATION NAME] Sodium (Trade Name: [MEDICATION NAME]) 5 MG (milligrams) daily. Additionally an order was evident on the hospital discharge orders with a hand written star by it, "PT/INR ON MONDAY INR TARGET IS 2-3." A PT/INR as defined at www.surgery.com is: PT: "This test is done to evaluate the blood for its ability to clot. INR: "The INR is used to make sure the results from a PT test is the same at one lab as it is at another lab. In the 1980's the World Health Organization determined that patients may be at risk because the results of a PT test would vary from one lab to another, based upon the way the test was done. The "normal" range for one lab would be different than a "normal" value from another lab, creating problems for patients who were being treated in several locations. In order to standardize the results between labs, the INR was created. The INR result should be the same, regardless of the location where the tests are performed." [MEDICATION NAME] (generic for [MEDICATION NAME]), according to www.nlm.nih.gov, is: "[MEDICATION NAME] is used to prevent blood clots from forming or growing larger in your blood and blood vessels. It is prescribed for people with certain types of irregular heartbeat, people with prosthetic (replacement or mechanical) heart valves, and people who have suffered a [MEDICAL CONDITION]. [MEDICATION NAME] is also used to treat or prevent venous [MEDICAL CONDITION] (swelling and blood clot in a vein) and [MEDICAL CONDITION] embolism (a blood clot in the lung). [MEDICATION NAME] is in a class of medications called anticoagulants ('blood thinners'). It works by decreasing the clotting ability of the blood. Your doctor will probably start you on a low dose of [MEDICATION NAME] and gradually increase or decrease your dose based on the results of your blood tests. Make sure you understand any new dosing instructions from your doctor." Review of a FRI submitted to the SA revealed after being readmitted on [DATE], a nurse at the facility notified the physician of Resident #4's hospital discharge orders and while continuing the [MEDICATION NAME] 5 mg daily, a physician's orders [REDACTED]. As the nurse involved was no longer at the facility, no interview with her could confirm. When interviewed, the administrator stated on 6/5/12 at 4:37 p.m., during the facility's investigation, the nurse involved was interviewed and gave a statement that she had contacted Resident #4's physician and informed him of Resident #4's return to the facility. At that time the physician stated he wanted all of the hospital discharge orders to be continued at the facility, including the PT/INR to be obtained the following Monday (Resident #4 returned to the facility on [DATE], a Friday). The administrator stated the nurse failed to add the need for the PT/INR on the order sheet and no blood work to monitor Resident #4's clotting times was obtained. Documentation revealed Resident #4 had been administered [MEDICATION NAME] 5 mg daily from 5/4 through 5/19/12. Review of Resident #4's care plan for the time in question included a problem of "Resident at risk for internal bleeding r/t (related to) anticoagulant therapy." The goal was for Resident #4, "will have no episodes of internal bleeding AEB (as evidenced by) no black, tarry stools, increased fatigue, frank blood in stools, hematuria, new or increased bruising of skin, waxy pallor, GI upset with c/o (complaint of) burning or pain, emesis with the appearance of coffee grounds thru next review." The interventions were to include: "Administer [MEDICATION NAME] as ordered. See MAR for times and amount. Monitor VS (vital signs) if active bleeding is suspected. Observe for signs/sx of bleeding. Report any abnormal findings to MD Obtain and report labs as ordered Observe for possible interactions with [MEDICATION NAME], Bactrim, [MEDICATION NAME], [MEDICATION NAME], Cipro, [MEDICATION NAME], and [MEDICATION NAME] if resident is placed an these medications. Notify MD if interaction occurs." On 5/20/12 Resident #4 reportedly had episodes of bright red rectal bleeding and was transported back to the hospital. No nurses' notes were available within the clinical record to review regarding Resident #4's development of rectal bleeding. When hospitalized , the admitting notes included: "who presents with multiple episodes of passing bright red clots per rectum. Initially, her hemoglobin was found to be very low at 4. She was [MEDICAL CONDITION]. I was notified that the patient has [MEDICAL CONDITION] with rapid ventricular rate. I have request the ER physician to get at least an INR and finally the results were available with a PT over 200. They could not even calculate the INR." www.aafp.com provides guidance that a hemoglobin of less that 12 g/dl (grams per deciliter) is considered to be [MEDICAL CONDITION]. The ER physician included in his history and physical for Resident #4 the following: "The patient is a [AGE] year old female who was sent over from a nursing home with bright red blood per rectum. She was found to be severely anemic in the emergency room . She is being admitted for evaluation of [MEDICAL CONDITION]. The patient is on [MEDICATION NAME] for a recent [DIAGNOSES REDACTED]. IMPRESSION: 1. Lower [MEDICAL CONDITION] 2. [MEDICAL CONDITION] secondary to #1 3. [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] 4. [MEDICAL CONDITION] most likely due to [MEDICAL CONDITION] and [MEDICAL CONDITION]. 6. History of coagula secondary to [MEDICATION NAME] PLAN: 1. Patient being resuscitated with volume including packed red blood cells and plasma." Resident #4 received 5 units of packed red blood cells and 5 units of fresh frozen plasma during the hospitalization . After Resident #4 stabilized, she was transferred back to the facility on [DATE]. <http://www.inchem.org>, read : "[MEDICATION NAME] acts by blocking liver [MEDICATION NAME] production and by causing vascular injury at the capillary level (Baselt & Cravey, 1994). Symptoms of poisoning usually occur after repeated ingestions of [MEDICATION NAME]. The degree of haemorrhage depends on individual response, pre-existing liver disease and current drug treatment. After a variable period of time (between 1 and 7 days), external bleeding and internal haemorrhage may occur from any site. Signs may include epistaxis, gingival bleeding (and in other miscellaneous mucocutaneous sites), petechial rash, ecchymoses, large haematomas (including intra-articular), haematuria and melaena. [MEDICATION NAME] time (PT) monitoring is essential. For the first 5 to 6 days it should be done at least daily, and repeated even if results were normal upon admission. [MEDICATION NAME] time may initially be normal, even in a severe poisoning because vitamin K-dependent clotting factors have a long half-life and are still circulating several hours after [MEDICATION NAME] starts its effect." When interviewed, the administrator stated 6/6/12 at 11:10 a.m. that while the nurse had failed to include the order for the PT/INR on the admission orders simply a clerical" error. She further stated the failure to obtain the tests for clotting time had nothing to do with the [MEDICAL CONDITION] that Resident #4 experienced on 5/20/12. The administrator, DON, and ADON were advised on 6/6/12 at 11:10 am of the failure of the staff to obtain a PT/INR that Resident #4's physician wanted to be obtained. Resident #4 subsequently developed a [MEDICAL CONDITION]. COMPLAINT DEFICIENCY 2. For Resident #16, [MEDICATION NAME] was administered without physician ordered heart rates being obtained. Resident #16, a [AGE] year old female, was initially admitted to the facility 7/29/10 and readmitted after a hospitalization [DATE]. Her [DIAGNOSES REDACTED]. Resident #16's most recent MDS with an ARD of 3/19/12 was coded as a quarterly assessment. Resident #16 was coded as having no memory deficits and was able to make her own daily life decisions. She was coded as requiring total assistance with her activities of daily living. Resident #16 was observed 6/5/12 at 2:58 p.m. She was lying on her back in bed with her eyes closed. Resident #16 was receiving oxygen at 2 L/M (liters per minute) via nasal cannula. A nasal cannula is a plastic tube that delivers oxygen directly into the nostrils. Review of Resident #16's clinical record revealed a signed physician's orders [REDACTED].<100 (systolic blood pressure less than 100) OR HR<60 (heart rate less than 60)." A corresponding entry was noted on the MAR (medication administration record) for June, 2012 with guidance to administer the [MEDICATION NAME] at 9 a.m. and 5 p.m. Documentation revealed Resident #16 had been administered [MEDICATION NAME] 12.5 mg twice daily since 6/1/12. A thorough review of the clinical record revealed no documentation that Resident #16's heart rate had been obtained on 6/1 at 9 a.m. or 5 p.m., 6/2 at 5 p.m., or 6/3 at 5 p.m. When interviewed, the DON stated 6/6/12 at 9:50 a.m., the blood pressures and pulses were to be documented on the "VITAL SIGNS AND WEIGHT RECORD." While blood pressures were obtained at least twice daily no heart rates were obtained for the days and times in question. The Administrator, DON, and ADON were advised of the failure of the staff to monitor Resident #16's heart rate prior to the administration of [MEDICATION NAME] per physician's orders [REDACTED].