Every finding on record at Woodside Lutheran Home

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 1 resident (R) (R61) of 1 sampled resident.R61 had an indwelling urinary catheter. Enhanced barrier precautions (EBP) were not implemented for R61. In addition, staff provided high-contact resident care without donning the appropriate personal protective equipment (PPE).Findings include:The facility's Enhanced Barrier Precautions policy, dated 2/3/25, indicates: This policy is implemented for the prevention of transmission of multidrug-resistant organisms (MDROs) .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of MDROs that employs targeted gown and glove use during high-contact resident cares .When using EBP, staff should wear a clean gown and gloves while performing high-contact resident care activities such as: transfers, personal hygiene care, wound care, showering, changing linens, assisting with toileting, and device care. Device care is defined as central line care, urinary catheter, feeding tubes, and tracheostomy cares .From 9/22/25 to 9/24/25, Surveyor reviewed R61's medical record. R61 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and benign prostatic hyperplasia (BPH) with lower urinary obstructive and reflex uropathy. A Minimum Data Set (MDS) assessment, dated 6/24/25, indicated R61 was dependent on staff for transfers, hygiene, dressing, and mobility. The assessment had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R61 had moderate cognitive impairment. R61 was R61's own decision maker. On 9/23/25 at 11:19 AM, Surveyor observed Certified Nursing Assistant (CNA)-C empty R61's catheter leg bag. CNA-C washed hands, applied gloves, and cleansed R61's catheter port with an alcohol wipe. CNA-C emptied the contents of the bag into a urinal and again cleansed the port. CNA-C then emptied the urinal, removed gloves, and washed hands. CNA-C did not wear a gown during catheter care in accordance with the facility's EBP policy. Following the observation, Surveyor observed an EPB sign outside R61's room with CNA-C who verified CNA-C should have worn a gown during catheter care.On 9/23/25 at 12:26 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated CNA-C should have worn a gown during catheter care for R61. DON-B verified catheter care is considered high-contact resident care and confirmed the facility's EBP policy indicates staff should wear a gown during high-contact cares.

Based on observation, staff interview, and record review, the facility did not ensure medications for 11 Residents (R) (R33, R404, R28, R21, R6, R76, R47, R65, R44, R15 and 26) of 11 residents in 4 of 8 medication carts and 3 of 5 treatment carts were stored, labeled, and/or dated appropriately. In addition, the facility did not ensure alcohol wipes, sterile syringes, and other medical supplies that were stored in 3 of 5 medication rooms were discarded after they expired Medication carts, treatment carts, and medication rooms contained opened, undated, unlabeled, and/or expired stock medication, treatment supplies, and prescribed medication for R33, R404, R28, R21, R6, R76, R47, R65, R44, R15, and R26. Findings include: The facility's Medication Storage policy, with a revision date of January 2018, indicates: .H) Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal .Expiration dating (beyond use dating): .C) Certain medications or package types, such as intravenous (IV) solutions, multiple dose injectable vials, ophthalmics, .blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency .; D) When the original seal of the manufacturer's container or vial is initially broken, the container or vial will be dated: 1. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating; F) No expired medication will be administered to a resident; G) All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining .; I) Nursing staff should consult with the dispensing pharmacist for any questions related to medication expiration dates . The facility's Medication Administration policy, with a revision date of 1/19/22, indicates: .4) Administration of any prescription medications will meet the following requirements: .b. For storage and stability of bulk medications and insulin products, nursing is to refer to the pharmacy provided storage and stability recommendations. Nursing is to compare the manufacturer's expiration date to the pharmacy label expiration date and use whichever date comes first. Nursing will label and/or date each medication as appropriate .;10) Medication Cart: .c. All eye drops, insulin, etc., must be dated when opened. Most of these medications expire 28 days after opening. Mutli-dose vials must be dated when opened . On 7/29/24 at 8:36 AM, Surveyor observed Licensed Practical Nurse (LPN)-I administer medication for R33 and noted the following: ~ An Albuterol Nebulizer 0.083% vial from an open foil package that did not contain an open date. LPN-I verified there was no open date and indicated there should have been an open date on the package. On 7/29/24 at 8:58 AM, Surveyor observed LPN-I administer medication for R404 and noted the following medication was open and did not contain an open date on the package or the inhaler: ~ Trelegy Ellipta 200 mcg (micrograms)/62.5 mcg/25 mcg inhaler. The package indicated the medication expired 42 days after opening. On 7/30/24 at 9:23 AM, Surveyor observed the medication storage room and treatment cart on the P.R. unit with Registered Nurse (RN)-G and noted the following: ~ Four packages of two 9 x 10.5 inch Medline Readyprep 2% chlorhexidine gluconate disposable cloths with an expiration date of December 2023. ~ Fifty nine packets of [NAME] lubricating jelly (144 packs per box) Lot: CHBJ04-05 with an expiration date of 4/28/23 mixed with packets with an expiration date of 8/8/25. ~ One package of Medline Therahoney sheet HD, honey impregnated wound dressing 2 x 2 square, Lot: W0197886 with an expiration date of 7/2022. ~ Two packages of Medline Maxorb II alginate wound dressing 4 x 4 square; Lot (10): 83620118779 with an expiration date of 11/1/23. On 7/30/24 at 10:42 AM, Surveyor verified the above items with RN-G who confirmed the items were expired and should have been discarded. On 7/30/24 at 10:44 AM, Surveyor verified the above items with Nurse Manager (NM)-H who confirmed the above items were expired and should have been discarded. On 7/30/24 at 11:32 AM, Surveyor observed medication carts on the H.B. unit with LPN-F and noted the following: ~ An open and undated Flonase Sensimist suspension 27.5 mcg nasal spray for R28. ~ An open Humulin Kwik Pen 70/30 for R21 with no open date on the pen or storage bag. ~ An open and undated bottle of Geri Care extra strength acetaminophen 500 mg. ~ An open bottle of Artificial Tears ophthalmic solution for R6 dated of 5/16/24. Per facility's policy, the medication expired 30 days after opening. ~ An open bottle of Artificial Tears ophthalmic solution for R76 dated of 5/16/24. Per the facility's policy, the medication expired 30 days after opening. ~ An open and undated Albuterol AER HFA 90 mcg inhaler for R47. ~ A vial of Lantus Injection 100/ml insulin for R65 with an expiration date of 7/27/24. The insulin expired 28 days after opening. In addition, Surveyor observed an open and undated 0.25 ounce tube of 10% Zilactin B Gel for R65. ~ An open and undated Fluticasone Propionate 50 mcg nasal spray and an open and undated QVAR Redihaler AER 80 mcg inhaler for R44. On 7/30/24 at 12:30 PM, Surveyor observed the H.B. unit medication room and treatment cart and noted the following: ~ One box of [NAME] 3 cc (cubic centimeter) sterile syringes Lot-CJCA06-06 with an expiration of 5/31/26 stored with 7 syringes Lot-CKD112-04 with an expiration date of 11/4/24 and 2 syringes Lot-CKDG06-03 with an expiration date of 5/3/22. ~ An open and undated 16 ounce bottle of Biotene dry mouth oral rinse. ~ An open, unlabeled, and undated 1.5 ounce tube of Medihoney #31515. On 7/30/24 at 12:50 PM, Surveyor interviewed LPN-F regarding observations on the H.B. unit. LPN-F stated syringes with different expiration dates should not be stored in the same box and staff should confirm the expiration date prior to use. LPN-F verified the syringes had different expiration dates and verified two of the syringes were expired and should not be used. LPN-F also verified the tube of Medihoney was not in a package and was not labeled with a name or open/expiration date. LPN-F also verified the bottle of Biotene did not contain an open date. On 7/30/24 at 1:25 PM, Surveyor interviewed NM-C regarding Surveyor's observations. NM-C stated syringes with different expiration dates should not be stored together and expired items should be discarded. NM-C also stated open medications, treatments, and other medical supplies should be labeled with the resident's name and/or open date. Rehab Units: On 7/30/24 at 9:21 AM, Surveyor observed the medication storage room on the Rehab Unit and noted an open and undated bottle of 3% hydrogen peroxide. On 7/30/24 at 9:28 AM, Surveyor observed the medication cart on Rehab Unit 1 and noted the following: ~ An open, unlabeled, and undated Fluticasone/Salmeterol AER 230-21 inhaler for R15. ~ An open and undated Fluticasone SPR 50 mcg nasal spray for R26. ~ An open Lidocaine 1% injectable vial with the cap taped on and an open date of 7/23/24. ~ An unlabeled and undated tube of what appeared to be glucose tabs. ~ An open and undated bottle of Pro-Stat AWC. The bottle indicated the shelf life was 3 months after opening. ~ An open, unlabeled, and undated tube of Bengay. ~ An open and unlabeled tube of Intensive Skin Therapy. ~ An open and unlabeled tube of Biofreeze with a pharmacy label that was torn off. ~ Two tubes of [NAME] Hydrogel Amorphous wound dressing with an expiration date of 6/2024. ~ One box of [NAME] alcohol prep pads with an expiration date of 9/2023. On 7/30/24 at 10:13 AM, Surveyor interviewed RN-D who confirmed the unlabeled and expired items. On 7/30/24 at 10:15 AM, Surveyor observed the medication storage area on Rehab Unit 2 and noted the following: ~ Three tubes of [NAME] Hydrogel Amorphous wound dressing with expiration dates of 6/2024, 7/2023, and 9/2022. ~ A tube of Medline Skintegrity Hydrogel with an expiration date of 4/2022. ~ An open and undated bottle of [NAME] PVP prep solution USP 10% povidone iodine. On 7/30/24 at 10:30 AM, Surveyor interviewed RN-E who confirmed the expiration dates of the items and verified the bottle of iodine did not contain an open date. On 7/30/24 at 1:35 PM, Surveyor interviewed NM-C who verified expired medications should be discarded. NM-C also verified inhalers and nasal sprays should contain open dates and residents' names per the facility's policy.

Based on observation, interview and record review, the facility failed to ensure accurate administration of pharmaceuticals for 1 Resident (R) (R4) of 3 residents reviewed for accurate medication administration. Potassium Chloride 10 meq ER (Extended Release) (used to treat and prevent low blood potassium) was ordered by physician to be administered to R4. Registered Nurse (RN)-C attempted to crush Extended-Release medications and Surveyor intervened. Findings include: The National Library of Medicine, in a 1/2022 web based publication, indicated the following about Potassium Chloride 10 meq ER: Swallow tablets whole without crushing, chewing or sucking. The facility policy titled Medication Administration with revised date 1/19/22, stated: Medications that cannot be crushed: Extended release. On 11/3/22 at 8:45 AM, Surveyor observed RN-C begin to prep R4's medications. During the process RN-C verbalized that R4 has difficulty with swallowing and will crush medications. On 11/3/22 at 8:53 AM, Surveyor observed RN-C begin to place R4's Potassium Chloride 10 meq ER tab in bag used to crush medications. At this time Surveyor intervened and asked RN-C if all R4's medication should be crushed. RN-C stated, I think so. RN-C reviewed R4's medical record and stated no, the Potassium Extended-Release should not be crushed. RN-C Verified no Extended-Release medications should be crushed. On 11/3/22 at 11:02 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding if Extended-Release medications should be crushed. NHA-A verified Extended-Release medication should not be crushed.

Based on staff interviews and record review, the facility did not ensure a Resident (R) with an unwitnessed fall had neurological checks completed to screen for subdural hematoma (blood collection on surface of the brain) for 5 (R8, R56, R354, R36, and R6) of 6 residents reviewed for falls. The facility did not implement their policy to consistently complete neurological checks and/or vital signs after R8 had unwitnessed falls on 5/8/22, 6/20/22, 7/19/22, and 7/20/22. The facility did not implement their policy to consistently complete neurological checks after R56 had an unwitnessed fall on 6/2/22 that resulted in an ankle fracture. The facility did not implement their policy to consistently complete neurological checks after R354 had an unwitnessed fall on 12/29/21, 1/5/22, and 2/5/22. The facility did not implement their policy to consistently complete neurological checks after R36 had an unwitnessed fall on 4/22/22, 4/24/22, 4/30/22, and 7/2/22. The facility did not implement their policy to consistently complete neurological checks after R6 had an unwitnessed fall while transferring self from R6's wheelchair to the bed on 5/5/22. Findings include: The facility policy titled Fall Prevention Program, with a revised date of 10/24/16, states: Neuro checks and vital signs will be initiated post fall if the fall was unwitnessed, or head injury occurred. The timeframe for these is: at time of incident, 30 minutes post incident, 1 hour x 6, Q (every) shift x 8. Staff may utilize neurologic vitals flow sheet post fall as a recording tool on the nursing drive. 1. R8 was admitted to the facility on [DATE] with diagnoses that included: Encounter for orthopedic aftercare; Type 2 Diabetes with diabetic kidney complication; congestive heart failure; early onset Alzheimer's disease; dementia without behavioral disturbance; osteoarthritis; chronic pain; [CONDITION(S)] (swelling in the arm or leg); obesity; psychophysiologic [CONDITION(S)] (inability to sleep); anxiety disorder; depression; acquired absence of right leg above knee; [CONDITION(S)] disorder; muscle weakness; need for assistance with personal care. R8 did not have an activated Power of Attorney (POA) at the time of this review. On the Minimum Data Set (MDS) (a comprehensive assessment completed on each resident at regular intervals or upon a significant change of condition) dated 7/27/22, R8 had a Brief Interview of Mental Status (BIMS) (a brief verbal test that indicates the level of one's cognition) of 14/15 (indication resident is cognitively intact), though R8's records show R8's cognition and level of alertness did vary greatly. Between 8/1/22 and 8/3/22, Surveyor reviewed R8's medical records and noted R8 had 4 unwitnessed falls and neuro checks and/or vitals were not implemented per policy. R8's medical record showed falls on: ~5/8/22 - unwitnessed fall, R8 found sitting upright on floor facing bed with reddened area to left eyebrow. R8 indicated R8 may have hit head. Neurological checks and vitals were initiated at 9:45 AM and 10:15 AM, then R8 was sent to the hospital for evaluation. R8 returned from the hospital on 5/9/22 and Neurological checks were not re-started. 6 Neurological checks and 6 out of 16 vital signs were missed post fall. ~6/20/22 - R8 had an unwitnessed fall in which the CNA found R8 sitting next to the bed on the floor. R8 denied hitting head. Neurological checks were not initiated and 10 out of 16 vital signs were missed post fall. ~7/19/22 - R8 had an unwitnessed fall in which CNA entered R8's room and found R8 laying on right side in front of recliner. R8 denied hitting R8's head. At the time of the fall neurological checks were completed, but the facility was unable to provide any further post fall neurological checks. 7 out of 16 post fall vitals were missed as well. ~7/20/22 - R8 had an unwitnessed fall in which R8 was found on the floor in front of recliner. R8 indicated R8 was having a dream R8 was riding a horse and fell off and woke up on the floor. The fall record does not indicate if R8 had hit head. Vital signs were completed per facility policy, though R8's medical record showed only an initial neurological check at the time of the fall was completed and nothing further. On 8/3/22, Surveyor interviewed Licensed Practical Nurse (LPN-D) who indicated that neuro checks and vitals were completed if there was an unwitnessed fall or a witnessed fall in which a resident hits head. LPN-D also indicated that if a resident was cognitively intact and had an unwitnessed fall and the resident indicated they did not hit their head, neuro checks would not be completed. On 8/3/22 at 1:25 PM, Surveyor interviewed DON-B who confirmed that neuro checks should have been continued for R8 upon return from hospital for the fall on 5/8 since R8 did indicate R8 hit head. DON-B also indicated that staff were not doing neuro checks if resident's cognition was intact and if resident indicated they did not hit their head. DON-B also indicated that if the resident indicated they did not hit head, vitals were only done 1 time per shift which is why their were sections crossed out on the vitals sheet. DON-B confirmed staff should have completed neuro checks and vital signs per policy for the above falls for R8 and further education to staff would be provided. 2. R56 was admitted to the facility on [DATE] with diagnoses that included: diabetes mellitus; dementia; [CONDITION(S)] (can cause leg pain when walking); and congestive heart failure. R56 had a BIMS score of 12/15 on the most recent MDS of 7/29/22. R56 did not have an activated power of attorney. Between 8/1/22 and 8/3/22, Surveyor reviewed R56's medical record and noted that R56 had an unwitnessed fall on 6/2/22 in which R56 was found lying flat on R56's back in the bathroom doorway. R56 had been ambulating with walker per usual and indicated ankle had twisted and R56 fell to the floor. R56 denied hitting R56's head. neuro checks were not initiated post fall and 7 out of 16 vital signs were missed post fall. On 8/3/22, Surveyor interviewed LPN-D who indicated that neuro checks and vitals were completed if there is an unwitnessed fall or a witnessed fall in which a resident hits head. LPN-D also indicated that if a resident was cognitively intact and had an unwitnessed fall and the resident indicated they did not hit their head, neuro checks would not be completed. On 8/3/22 at 1:25 PM, Surveyor interviewed DON-B who indicated that staff were not doing neuro checks if resident's cognition was intact and if resident indicated they did not hit their head. DON-B also indicated that if the resident indicated they did not hit head, vitals were only done 1 time per shift which is why their were sections crossed out on the vitals sheet. DON-B confirmed staff should have completed neuro checks and vital signs per policy for the above fall for R56 and further education to staff would be provided. 3. From 8/1/22 through 8/3/22, the Surveyor reviewed R354's medical record which documented R354 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses that included: non-displaced intertrochanteric fracture of right femur, repeated falls, history of falling, muscle weakness, [CONDITION(S)] disease, covid-19, cognitive communications deficit, dysphagia, [CONDITION(S)], [CONDITION(S)] due to known physiological condition, [CONDITION(S)] disorder, extrapyramidal and movement disorder. R354 Power of Attorney for Healthcare (POAHC) was activated on 1/10/22. R354 had a BIMS, dated 1/10/22, of 8/15 which indicated R354 had mild cognitive impairment. R354 had an extensive history of falls, including unwitnessed falls on 12/29/21, 1/5/22 and 2/5/22. On 12/29/21 R354 was found on floor in R354's room. The Surveyor noted neuro checks as well as vital signs were initiated but the documentation showed blanks where neuro checks and vital signs were not consistently completed. On 1/5/22 R354 was found on knees in room. The surveyor noted vital signs were initiated but the documentation showed blanks where vital signs were not consistently competed. The surveyor did not observe documentation of neuro checks completed for the fall on 1/5/22. On 2/5/22 R354 was found sitting on floor next to recliner. The Surveyor did not observe documentation of neuro checks or vital signs completed for fall on 2/5/22. On 8/2/22 at 4:25 PM, the Surveyor interviewed DON-B regarding neuro checks being completed after an unwitnessed fall. DON-B verified they expected staff to complete neuro checks per policy. The Surveyor specifically asked about neuro checks and unwitnessed falls. DON-B verified neuro checks should be completed for all unwitnessed falls. DON-B verified R354's neuro checks were not completed at all on 1/5/22 and 2/5/22 and not consistently completed for fall on 1/29/22. 3. R36 was admitted on [DATE] with diagnoses including severe protein-calorie malnutrition, [CONDITION(S)] Disease, unspecified dementia without behavioral disturbance, fracture of right and left femur, and repeated falls. R36's MDS dated [DATE] included a BIMS score of 6 meaning severely impaired cognition. Between 8/1/22 and 8/3/22, Surveyor reviewed R36's medical record and noted that R36 had unwitnessed falls on 4/22/22, 4/24/22, 4/30/22, and 7/2/22. On 4/22/22 four vital were missed post fall. On 4/24/22 two neuro checks and four vitals were missed post fall. On 4/30/22 two neuro checks and two vitals were missed post fall. On 7/2/22 one neuro check and one vital signs were missed post fall. 5. From 8/1/22 through 8/3/22, the Surveyor reviewed R6's medical record which documented R6 had a BIMS score of 15 out of 15 indicating R6 was cognitively intact. R6 had diagnoses to include repeated falls, unsteadiness on feet, and muscle weakness. R6 had an extensive history of falls, including an unwitnessed fall on 5/5/22 when R6 was found on the floor by staff. R6 told the staff R6 was attempting to transfer self from R6's wheelchair to the bed when the fall occurred. Nurses notes indicated nurse initiated facility fall protocol with VS (vital signs) and neuro checks. The Surveyor noted neuro checks as well as vital signs were initiated but the documentation showed blanks where neuro checks and vital signs were not consistently completed. On 8/3/22 at 11:32 AM, the Surveyor interviewed DON (Director of Nursing)-B regarding incomplete neurological checks for R6. DON-B verified the neuro checks for R6 were not consistently completed. DON-B indicated DON-B had previously completed audits on residents who had unwitnessed falls and noted neuro checks and vital signs were not getting completed consistently. DON-B further added education was provided previously to the nursing staff (nurses and CNAs (Certified Nursing Assistants) regarding completion of neuro checks and vital signs. DON-B indicated there would be additional education provided to staff following this survey.

Based on record review and staff interview, the facility did not notify a physician of resident change of condition for 1 resident (R) (R354) of 1 reviewed for physician notification. R354's weight changed by seventeen lbs (pounds) from 12/31/22 to 2/7/22. R354's physician was not notified of R354's weight changes. Findings include: The National Library of Medicine, in a web-based article published 2022 regarding [MEDICATION(S)], indicated: A boxed warning suggests the cautious use of [MEDICATION(S)] as it is a potent diuretic, which can predispose to excessive loss of water and electrolytes, resulting in dehydration with electrolyte depletion .Careful monitoring of the patient's clinical condition, daily weight, fluids intake, urine output, electrolytes, i.e., potassium and magnesium, kidney function monitoring with serum creatinine and serum blood urea nitrogen level is vital to monitor the response of [MEDICATION(S)] . On 8/1/22 through 8/3/22, Surveyor reviewed R354's medical record. R354 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R354 was discharged on [DATE] to an assisted living facility. R354's Minimum Data Set (MDS) assessment dated [DATE] stated R354's Brief Interview for Mental Status (BIMS) score was 8 out of 15, which indicated R354 had moderate cognitive impairment. R354's medical record indicated R354 was responsible for R354's own medical decisions until 1/10/22. On 1/10/22, R354's Power of Attorney for Health Care (POAHC) was activated. R354's MDS assessment, dated 1/5/22, indicated R354 was not on a physician-prescribed weight loss regimen. R354's medical record contained the following physician orders: ~Daily weights every am shift, dated 12/29/21. ~[MEDICATION(S)] Tablet 20 MG. Give 1 tablet by mouth one time a day every other day for [CONDITION(S)] (held on 1/25/22), dated 1/4/22. R354's medical record indicated the following weights for R354: ~12/31/21 weight 205.8 lbs ~1/10/22 weight 202.1 lbs ~1/25/22 weight 202.6 lbs ~1/27/22 weight 191.6 lbs ~1/28/22 weight 191.8 lbs ~1/29/22 weight 184.8 lbs ~1/30/22 weight 187 lbs ~1/31/22 weight 185 lbs ~2/1/22 weight 178 lbs ~2/2/22 weight 188.6 lbs ~2/3/22 weight 190 lbs ~2/4/22 weight 188.6 lbs ~2/5/22 weight 189 lbs ~2/6/22 weight 188.2 lbs ~2/7/22 weight 188 lbs R354's medical record did not contain evidence of physician notification of R354's unintended weight loss. On 8/3/22 at 10:14 AM, Surveyor interviewed Registered Dietician (RD)-E regarding R354. RD-E reported that they routinely will do a weight review on everyone on Wednesdays. RD-E verbalized that they used R354's weight on 1/25/22 for the review on 1/26/22 and at that time did not have any concerns with R354's weight. RD-E indicated for the weight review performed on 2/2/22, R354 triggered for weight loss. RD-E described that they go through the list of residents who triggered for weight loss and will triage the list. RD-E discussed when R354's medical record was reviewed and there was already an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Due to illness, RD-E was unable to follow up until 2/7/22. Since resident was discharging 2/7/22, RD-E did not notify physician of 17 lb weight loss. On 8/3/22 at 11:04 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R354's weight loss. DON-B verified they would expect staff to update a physician and complete an assessment to determine cause of the significant weight loss. On 8/3/22 at 1:18 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding R354's weight loss and if a physician was notified. NHA-A verified no documentation was found in the medical record that the physician was updated regarding R354's weight loss.

Based on staff interview and record review, the facility did not ensure a Resident (R) with a planned discharge had a discharge summary including a recapitulation (recap) of stay for 1 (R354) of 2 sampled closed records. The facility did not create a recap of R354's stay when R354 was discharged to an Assisted Living Facility (ALF). Findings include: On 8/2/22, Surveyor reviewed R354's medical record which documented R354 resided at the facility from 12/29/21 through 2/7/22. R354's record contained order for discharge to (named) ALF, prescriptions to be sent to (named) pharmacy, and (named) therapy services to treat after discharge. Surveyor noted R354's last progress note entry on 2/7/22 addressed a fall R354 had on 2/5/22. No progress note was entered indicating R354 left the facility. R354 did not have a discharge assessment completed in Electronic Health Record (EHR). R354's Minimum Data Set (MDS) discharge assessment, dated 2/7/22, verified R354 discharged to the community. On 8/2/22 at 2:40 PM, Surveyor interviewed Director of Nursing (DON)-B regarding R354. DON-B explained R354 started out in skilled (rehabilitation therapy/short term stay) then remained in building in the Long Term Care (LTC) section. DON-B reviewed R354's medical record and verified R354 did not have a discharge assessment completed in the EHR. The discharge assessment form had an area to enter a recap of stay. DON-B explained the facility's practice was to fill out the EHR discharge assessment form when planned discharges happened. The responsibility for completion typically was handled by the care transitions coordinator for skilled discharges. DON-B verbalized that the facility didn't have many discharges from LTC so no facility staff was designated to complete the discharge assessment. DON-B indicated that for long term care residents, generally the Primary Care Provider (PCP) completed a final recap of stay. DON-B confirmed R354's PCP did not complete a recap for R354. DON-B denied the existence of a system to check if PCP completed recaps for residents discharged from LTC.

Based on staff interviews and record review, the facility did not ensure identification of individualized depression symptoms, monitoring of identified symptoms, and non-pharmacological responses were care planned for individualized depression symptoms for a Resident (R) diagnosed with depression and treated with anti-depressant medication(s) for 2 (R8 and R82) of 5 residents reviewed for medications. Findings include: Psychology Today (https://www.psychologytoday.com/us/basics/depression/signs-depression) documents Mood dysregulation revealed by unrelenting sadness may be the sign most associated with depression, but the disorder can be reflected in impaired functioning in almost every system of the body, from sexual desire to pain perception . Because depression is complex and affects so many systems of the body, it has many manifestations, and which ones are most prominent can vary from person to person. 1. From 8/2/22 through 8/3/22, Surveyor reviewed R8's medical record which documented R8 had a diagnosis of depression and was prescribed two anti-depressant medications, buproprion and [MEDICATION(S)], taken daily. R8 did not have an activated Power of Attorney (POA) for health care and was responsible for R8's own medical decision making. R8's most recent Minimum Data Set (MDS) assessment, dated 7/27/22, documented R8's Brief Interview for Mental Status (BIMS) score was 15 out of 15 (cognition intact). R8's Patient Health Questionnaire-9 (PHQ-9) (brief depression assessment) score was 9 out of 27 (mild depression). Details of R8's PHQ-9 assessment revealed depression affected R8's speed of movement, sleep patterns, interest or pleasure in doing things, overall feelings, and feelings about self. Surveyor noted R8's care plan did not identify R8's target behaviors or non-pharmacological interventions for R8's depression. Facility behavior monitoring was not individualized but instead included generalized behavior monitoring for frequent crying, repeated movement, yelling/screaming, kicking/hitting, pushing, grabbing, pinching/scratching/spitting, biting, wandering, abusive language, threatening behavior, sexually inappropriate behavior/comments, and rejection of care. R8 was documented as not having behaviors in any of the listed categories. On 8/3/22 at 2:20 PM, Surveyor interviewed Registered Nurse (RN)-C, who verified being a nursing manager, regarding R8's depression care plan. RN-C verified no target behaviors or non-pharmacological interventions were documented. RN-C indicated R8's depression was stable. RN-C explained that when residents are admitted with anti-depressants, the symptoms are usually not being exhibited so target behaviors are frequently unknown until Gradual Dose Reduction (GDR) trials fail. RN-C claimed nurses would know if a depression related symptom began because of overall monitoring during interactions. Surveyor questioned why target behaviors and interventions were identified for residents with anxiety but not depression. RN-C indicated anxiety is more likely to be treated with a PRN (as needed) medication and target behaviors identification assisted staff with ensuring medication was administered appropriately when needed. RN-C confirmed R8 was not interviewed to determine target behaviors that led to the use of medication or which non-pharmacological interventions were useful to respond to R8's symptoms. RN-C indicated RN-C talked with R8 on date of Surveyor interview (8/3/22) about depression and R8 told RN-C R8 was depressed because of being in nursing home. Surveyor noted R8 was admitted with anti-depressant medications and no changes in dose happened since admission. 2. From 8/2/22 through 8/3/22, Surveyor reviewed R82's medical record which documented R82 had a diagnosis of depression and was prescribed [MEDICATION(S)] (anti-depressant) taken daily. R82 had an activated POA for health care and a diagnosis of dementia. R8's most recent MDS assessment, dated 7/5/22, documented R82's BIMS score was 8 out of 15 (moderately impaired cognition). R8's PHQ-9 score was 4 out of 27 (minimal depression). Details of R82's PHQ-9 assessment revealed depression affected R82's sleep, overall feelings, and R82 frequently felt R82 may be better off dead or thought of hurting R82's self. Surveyor noted R82's care plan did not identify R82's target behaviors. One none non-pharmacological intervention was to offer R82 opportunities to socialize and share thoughts and feelings. Facility behavior monitoring was not individualized but instead included generalized behavior monitoring for frequent crying, repeated movement, yelling/screaming, kicking/hitting, pushing, grabbing, pinching/scratching/spitting, biting, wandering, abusive language, threatening behavior, sexually inappropriate behavior/comments, and rejection of care. R82 was documented as rejecting care one time in 30 days reviewed. On 8/3/22 at 2:04 PM, Surveyor interviewed RN-C regarding R82's depression care plan. RN-C verified no target behaviors were documented. RN-C indicated R82's depression was stable but R82 sometimes cried or made statements of wanting to go home. RN-C verbalized that R82's symptoms usually resolved quickly and staff knew to comfort and redirect R82. RN-C explained that when residents are admitted with anti-depressants, the symptoms are usually not being exhibited so target behaviors are frequently unknown until GDR trials fail. RN-C claimed nurses would know if a depression related symptom began because of overall monitoring during interactions. Surveyor questioned why target behaviors and interventions were identified for residents with anxiety but not depression. RN-C indicated anxiety is more likely to be treated with a PRN medication and target behaviors identification assisted staff with ensuring medication was administered appropriately when needed. RN-C confirmed R82 and R82's POA were not interviewed to determine target behaviors that led to the use of medication or which non-pharmacological interventions were useful to respond to R82's symptoms. RN-C verified most behaviors listed on monitoring, such as kicking and biting, were not R82's symptoms of depression. RN-C revealed R82's one rejection of care was most likely not a symptom of R82's depression.

Based on record review and staff interview, the facility did not promptly consult with a physician after 1 Resident (R) (R1) of 1 resident reviewed choked on medication and was administered the [MEDICATION(S)] Maneuver and after a chest x-ray revealed bilateral upper lobe infiltrates. On the 10/24/21 AM shift, RN (Registered Nurse)-C performed the [MEDICATION(S)] maneuver after R1 choked on medication. RN-C did not notify a physician, R1's POA (power of attorney) (FM (Family Member)-H) or on-coming staff that the [MEDICATION(S)] maneuver was performed. R1 complained of rib pain and developed a wet cough on the 10/24/21 PM shift. A chest X-ray showed infiltrates (white spots that indicate an infection) in R1's lungs. Staff did not promptly consult with a physician or notify FM-H of the X-ray findings until R1 developed signs and symptoms of severe [CONDITION(S)] (an absence of enough oxygen in the tissues to sustain bodily functions) and required emergency medical services on the 10/25/21 PM shift. R1 was admitted to the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 passed away on 11/02/21. The facility's failure to promptly consult with a physician after the [MEDICATION(S)] maneuver was performed on 10/24/21 and after an x-ray revealed bilateral upper lobe infiltrates created a finding of immediate jeopardy that began on 10/24/21. NHA (Nursing Home Administrator)-A was notified of the immediate jeopardy on 1/12/22 at 1:53 PM. The immediate jeopardy was removed on 1/13/22; however, the deficient practice continues at a scope/severity level D (Potential for More than Minimal Harm/Isolated) as the facility continues to implement its action plan. Findings include: The facility's Choking/[MEDICATION(S)] Maneuver policy, dated 1/18/20, stated: Scope/Intent: To provide emergency care to all residents who are choking on a food/foreign object, until the object is expelled, the resident becomes unconscious or Emergency Medical Services (911) arrive. Procedure: 3. Stand behind the victim. 4. Wrap your hands around the victim as if to give a hug. 5. Make a fist with your right hand and place it just above the victim's belly button. 6. Grab your fist with your left hand and thrust inwards and upwards forcefully. If object is dislodged, monitor the patient for adverse side effects of maneuver. The policy did not instruct staff to notify the physician, the resident's representative or on-coming staff. The Surveyor reviewed R1's medical record. R1 was admitted to the facility for short-term rehab following hospitalization for an exacerbation of CHF, increased weakness and shortness of breath. R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Admission MDS (Minimum Data Set), dated 10/19/21, indicated R1 was not cognitively impaired, ate independently following set-up assistance and required minimal assistance for transfers, dressing and toileting. R1's plan of care indicated R1 was admitted for short-term rehab with a goal to return home or transition to an ALF (assisted living facility). R1's plan of care indicated R1 was at risk for impaired respiratory status and contained an intervention to monitor/document/report PRN (as needed) any signs and symptoms of respiratory infection such as increased difficulty breathing, increased coughing and wheezing. R1's medical record indicated R1 was monitored for a decreasing hemoglobin (a protein in red blood cells that carries oxygen throughout the body) level and a suspected upper GI (gastrointestinal) bleed. R1's TAR (treatment administration record) contained an order, dated 10/21/21, to monitor for signs and symptoms of bleeding every shift. R1 had an order, dated 10/12/21, for oxygen at 1-3 liters per nasal cannula continuously to keep oxygen saturation level greater than or equal to 90%. A late entry progress note, dated 10/24/21 at 8:15 AM, but written on 10/25/21 by DON (Director of Nursing)-B, stated, Late entry for (RN-C): (R1) was taking [MEDICATION(S)] (an antacid used to treat ulcers) and started choking on medication. Nurse had to administer [MEDICATION(S)] maneuver x 2 fast compressions and (R1) spit out med .Will monitor for other respiratory (signs and symptoms). RN-C did not promptly consult with a physician regarding this choking episode and the need to administer the [MEDICATION(S)] maneuver. A progress note, written by RN-D on 10/24/21 at 4:20 PM, stated R1's family asked about R1's rib pain due to a choking episode that morning. The note stated, per (R1) (RN-C) hugged/squeezed (R1) at that time, writer was unaware that happened physically .(FM-H) in room and did ask for an X-ray. A progress note, written by RN-E on 10/24/21 at 5:09 PM, stated MD-M was notified and a chest X-ray was ordered. An after-hours page documentation written by MD-M stated R1 complained of bilateral (affecting both sides) rib pain with no other change in condition. The note indicated a chest X-ray would be obtained and stated, (Nursing Home) to call if abnormal. An X-ray report, dated 10/24/21, stated R1 had bilateral upper lobe infiltrates, right greater than the left associated with small-volume bilateral pleural effusion (fluid surrounding the lungs) (that) may be due to pneumonia or pulmonary [CONDITION(S)]. The heart is enlarged with mild pulmonary venous congestion from CHF. The report stated R1 had cardiomegaly (an enlarged heart) with mild CHF and bilateral pneumonia (affecting both lungs) or pulmonary [CONDITION(S)] with pleural effusion . Clinical correlation and a follow up examination were recommended. The report also indicated the left ribs were not fractured. A progress note, dated 10/24/21 at 11:56 PM, stated Chest X-ray results received. No gross fracture of ribs on left side. Call placed to (FM-H) and updated per (FM-H's) request. Copy of results put in (MD-G's) binder. The nurse did not promptly consult with the physician regarding bilateral upper lobe infiltrates even though the physician had asked to call if abnormal. An occupational therapy note, dated 10/25/21 at 2:54 PM, stated, .At OT arrival, appears pale, and very fatigued. Therapist took baseline vitals. The note stated R1's oxygen saturation was 61% on two liters of oxygen via a finger monitor and 76% on three liters of oxygen via an earlobe monitor. On 1/12/22 at 8:20 AM, the Surveyor interviewed OTR (Occupational Therapist)-I via telephone. OTR-I stated OTR-I entered R1's room on 10/25/21 for a treatment session at approximately 2:54 PM; however, R1 looked fatigued and zoned out and wasn't very responsive. OTR-I noted R1's oxygen saturation (with a finger monitor) was in the low (60th percentile). OTR-I increased R1's oxygen level from two to three liters and rechecked R1's level with an ear monitor. OTR-I noted R1's oxygen saturation level was still severely low and notified a nurse who applied a breathing mask. A change of condition note, dated 10/25/21 at 2:43 PM, stated, Therapy in room and came to nurses station to report (oxygen saturation) on 2.5 liters (of oxygen) was 61 (percent) .(R1) denies any (shortness of breath) or pain, lungs congested, no noted cough while in room, writer continued to turn up (oxygen) therapy per nasal cannula and had (R1) try to (cough and deep breathe) .put on non rebreather mask at 10 (liters) and was only at 80% (oxygen saturation). (MD-O) and (APNP (Advanced Practice Nurse Prescriber)-Q) in house .order received to send to ER (emergency room ). A progress note, dated 10/25/21 at 3:10 PM stated 911 was called as R1's oxygen saturation was at 71%. R1's hospital paperwork, dated 10/25/21, stated R1 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital course stated R1 was admitted due to increased oxygen requirements following a witnessed episode of aspiration on 10/24/21. While in the facility, R1 required more and more oxygen and was brought to the ER. The paperwork also stated, After admission to the ICU (intensive care unit), (R1) experienced a confluence of serious medical conditions the most urgent of which was declining respiratory status in the setting of aspiration pneumonia, likely pulmonary [CONDITION(S)] (a condition caused by excess fluid in the lungs) and ongoing upper GI bleed .To further complicate matters, (R1) began to experience acute kidney injury from diuresis (increased urination due to the administration of a diuretic medication) to improve respiratory status . R1 was transferred to hospice services for end-of-life care on 10/30/21 and passed away on 11/02/21. On 1/11/22 at 11:40 AM, the Surveyor interviewed DON-B regarding R1. When asked the procedure for notification following the [MEDICATION(S)] maneuver, DON-B stated physician and POA notification should have occurred following the incident. On 1/11/22 at 1:10 PM, the Surveyor interviewed APNP-P regarding R1. APNP-P could not answer whether APNP-P would have initiated orders or sent R1 to the ER if APNP-P was notified about R1's choking episode immediately after the incident occurred. APNP-P stated if a physician wasn't notified between the time the incident occurred (approximately 8:15 AM) and 5:00 PM, it seemed like a bit of a gap. On 1/11/22 at 4:23 PM, the Surveyor interviewed MD-G regarding R1. MD-G stated MD-G would generally want notification if the [MEDICATION(S)] maneuver was performed. MD-G stated MD-G would have wanted to know if R1 was hypoxic and if there was a change in condition that the facility couldn't manage or that warranted further attention. MD-G stated MD-G would have ordered an assessment, including lung sounds and vital signs. MD-G stated if R1 didn't have acute symptoms, notification the following morning was potentially acceptable. MD-G stated information contained in the provider binder was signed off as soon as residents were seen or the information was processed. The Surveyor noted R1's X-ray result, which was placed in the binder on the previous night shift, was signed by APNP-Q on 10/25/21 and stated, Sent out to ER. (Oxygen saturation) at 61%. The signature did not contain a time. On 1/11/22 at 2:20 PM, the Surveyor interviewed FM-H via telephone. FM-H verified FM-H was not notified R1 choked on a pill and was given the [MEDICATION(S)] maneuver prior to FM-H's arrival at the facility on 10/24/21. FM-H stated R1 told FM-H that R1's nightgown had blood on it from when the nurse squeezed R1 and R1 threw up. FM-H verified R1's nightgown contained a quarter-sized spot of bright red blood. FM-H stated R1 complained of rib pain and had a wet cough. FM-H questioned RN-D about R1's statements; however, RN-D stated RN-D was not informed RN-C performed the [MEDICATION(S)] maneuver and could not find documentation in R1's medical record. FM-H verified an X-ray was performed and stated a nurse called FM-H at approximately 11:45 PM and said everything was good. FM-H stated FM-H was not aware anything was wrong until the next day when a family member stopped to visit R1 and they were loading (R1) in a rescue squad. On 1/12/22 at 9:08 AM, the Surveyor interviewed RN-F who worked the 10/25/21 AM shift on R1's unit. RN-F was told by RN-E that R1 stated RN-C squeezed R1; however, RN-F was not informed that R1 choked. RN-F did not see documentation of the [MEDICATION(S)] maneuver in R1's medical record. RN-F stated RN-F did not believe R1's MD was updated on the morning of 10/25/21 as staff were still attempting to contact RN-C to find out details of the incident. RN-F was not aware an X-ray was taken and was not told to monitor R1. As of this writing, RN-C did not return multiple voice mails left by the Surveyor. In addition, the Surveyor attempted to reach MD-O multiple times; however, the Surveyor was unable to leave a message as MD-O's voicemail was full. The Surveyor was also unable to reach APNP-Q and was told APNP-Q recently retired. According to the article, Should You Visit the Doctor after the [MEDICATION(S)] Maneuver, The simple answer is yes you should visit the doctor after choking . Choking may seem like a quick happenstance, an emergency that's over as abruptly as it started, but its effects can be surprisingly long-[MEDICATION(S)]. After a serious choking emergency where successful first aid has been delivered, most victims probably would prefer to relax or even finish their meal than head off to the doctor's office. But that's exactly what they should do, particularly after someone has performed the [MEDICATION(S)] maneuver on them. Let's take a look at some of the [MEDICATION(S)] effects that can occur after a person chokes: Aspiration Pneumonia Food that has been chewed and swallowed is in the early stages of breaking down, separating into smaller bits that can be digested. Food is by far the most common cause of choking, and when first aid is successfully delivered, it's not uncommon for some of that food to remain in the person's airway. You may feel like you've dislodged the bite of steak or other food completely, but small particles might still remain in your airway. These tiny bits can then migrate into the lungs in a process called aspiration. You may not feel this occur, and it can lead to serious respiratory conditions such as pneumonia, an infection that can be life-threatening to some people. Doctors can perform a variety of diagnostic tests, from listening with a stethoscope to imaging procedures, that can ensure your airway and lungs are clear. Injuries to the Airway When you choke on a bite of food or another object, trapping it your airway, that object can cause damage to the delicate lining of your airway itself. Once you've dislodged the object, you will feel your breathing hugely improved, but your airway may begin to swell over time from the damage left behind. Doctors can monitor your breathing, provide medications to help reduce inflammation and administer oxygen if necessary as you recover. Internal Injuries One of the more serious complications that can follow a choking incident is damage to the ribs or internal organs as a result of the [MEDICATION(S)] maneuver. Also known as abdominal thrusts, this first-aid treatment has been the standard protocol for choking victims for decades. Although it's often effective, it can leave victims with bruising, cracked ribs or even internal bleeding and organ damage. Signs of these injuries may not be clear immediately, and they can be serious. Doctors can perform scans to determine whether any internal damage has occurred. https://www.dechoker.com/blogs/news/should-you-visit-the-doctor-after-the-[MEDICATION(S)]-maneuver The failure to promptly consult with a physician to ensure medical awareness and medical intervention if needed created a reasonable likelihood of serious harm occurring and, thus created a find of immediate jeopardy. The facility removed the jeopardy on 1/13/22 when it completed the following: 1. Educated staff on the facility's policy and procedure for Change of Condition and Notification of Physician/Family. 2. Educated staff on the facility's policy and procedure for Choking/[MEDICATION(S)] Maneuver, including protocols for communicating to physician and family of status change. 3. Added notification of physician protocol to the facility's policy for Choking/[MEDICATION(S)] Maneuver.

Based on record review and staff interview, the facility did not provide the necessary care and services according to professional standards of practice to maintain the highest practicable physical well being when a change in condition occurred for 1 Resident (R) (R1) of 1 resident reviewed. On the 10/24/21 AM shift, RN (Registered Nurse)-C performed the [MEDICATION(S)] maneuver after R1 choked on medication. RN-C did not notify a physician, R1's POA (power of attorney) (FM (Family Member)-H) or on-coming staff that the [MEDICATION(S)] maneuver was performed. Therefore, assessment and monitoring procedures were not initiated to detect and monitor for signs and symptoms of aspiration pneumonia and internal injury to ensure timely treatment if needed. R1 complained of rib pain and developed a wet cough on the 10/24/21 PM shift. A chest X-ray showed infiltrates (white spots that indicate infection) in R1's lungs. Staff did not notify a physician or FM-H of the X-ray findings until R1 developed signs and symptoms of severe [CONDITION(S)] and required emergency medical services on the 10/25/21 PM shift. R1 was admitted to the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 passed away on 11/02/21. The facility's failure to implement monitoring and assessment procedures after the [MEDICATION(S)] maneuver was performed on 10/24/21 created a finding of immediate jeopardy that began on 10/24/21. NHA (Nursing Home Administrator)-A was notified of the immediate jeopardy on 01/12/22 at 1:53 PM. The immediate jeopardy was removed on 1/13/22; however, the deficient practice continues at a scope/severity level D (Potential for More than Minimal Harm/Isolated) as the facility continues to implement its action plan. Findings include: The facility's Choking/[MEDICATION(S)] Maneuver policy, dated 1/18/20, states: Scope/Intent: To provide emergency care to all residents who are choking on a food/foreign object, until the object is expelled, the resident becomes unconscious or Emergency Medical Services (911) arrive. Procedure: 3. Stand behind the victim. 4. Wrap your hands around the victim as if to give a hug. 5. Make a fist with your right hand and place it just above the victim's belly button. 6. Grab your fist with your left hand and thrust inwards and upwards forcefully. If object is dislodged, monitor the patient for adverse side effects of maneuver. The policy did not instruct staff to monitor for adverse side effects of choking and administration of the [MEDICATION(S)] maneuver, including aspiration pneumonia. According to N6 Wisconsin Nurse Practice Act, An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.'s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. The Surveyor reviewed R1's medical record. R1 was admitted to the facility for short-term rehab following hospitalization for an exacerbation of CHF, increased weakness and shortness of breath. R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Admission MDS (Minimum Data Set), dated 10/19/21, indicated R1 was not cognitively impaired, ate independently following set-up assistance and required minimal assistance for transfers, dressing and toileting. R1's plan of care indicated R1 was admitted for short-term rehab with a goal to return home or transition to an ALF (assisted living facility). R1's plan of care indicated R1 was at risk for impaired respiratory status and contained an intervention to monitor/document/report PRN (as needed) any signs and symptoms of respiratory infection such as increased difficulty breathing, increased coughing and wheezing. R1's medical record indicated R1 was monitored for a decreasing hemoglobin (a protein in red blood cells that carries oxygen throughout the body) level and a suspected upper GI bleed. R1's TAR (treatment administration record) contained an order, dated 10/21/21, to monitor for signs and symptoms of bleeding every shift. R1 had an order, dated 10/12/21, for oxygen at 1-3 liters per nasal cannula continuously to keep oxygen saturation level greater than or equal to 90%. R1 also had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's medical record indicated R1's pulse and oxygen saturation level (97%) were documented on the 10/24/21 AM shift. No vital signs were documented on the 10/24/21 PM shift. On the 10/24/21 NOC (night) shift, a full set of vital signs were taken and within normal limits. On the 10/25/21 AM shift, R1's pulse and oxygen saturation level (95%) were documented. R1's medical record did not contain documentation to indicate R1's lung sounds were assessed aside from the 10/24/21 NOC shift or that R1 was monitored for internal injuries or aspiration pneumonia following administration of the [MEDICATION(S)] maneuver. A care conference note, dated 10/18/21, indicated R1 needed two more weeks of PT (physical therapy) and OT (occupational therapy). The note also stated R1 would start weaning off oxygen on 10/19/21 in preparation for discharge. Progress notes, dated 10/22/21, indicated R1 received a blood transfusion at a local hospital and returned to the facility the same day. A late entry progress note, dated 10/24/21 at 8:15 AM, but written on 10/25/21 by DON (Director of Nursing)-B, stated, Late entry for (RN-C): (R1) was taking [MEDICATION(S)] (an antacid used to treat ulcers) and started choking on medication. Nurse had to administer [MEDICATION(S)] maneuver x 2 fast compressions and (R1) spit out med .Will monitor for other respiratory (signs and symptoms). Contrary to N6 Wisconsin Nurse Practice Act, RN C did not document what had occurred, did not begin routine monitoring and assessment of R1's condition, and did not inform the oncoming shift that the [MEDICATION(S)] maneuver had been done so that monitoring and assessment could continue. A progress note, dated 10/24/21 at 3:46 PM, indicated MD (Medical Doctor)-G was notified of R1's recent hemoglobin level. R1 was scheduled for a blood transfusion the following day. MD-G ordered a recheck of R1's hemoglobin following the transfusion. There is no indication that MD-G was informed that the [MEDICATION(S)] maneuver had been done earlier in the day. A progress note, written by RN-D on 10/24/21 at 4:20 PM, stated R1's family asked about R1's rib pain due to a choking episode on the AM shift. The note stated, Per (R1) (RN-C) hugged/squeezed (R1) at that time, writer was unaware what happened physically .(FM-H) in room and did ask for an X-ray. A progress note, dated 10/24/21 at 5:09 PM, stated MD-M was notified of R1's rib pain and a chest X-ray was ordered. An after-hours page documentation by MD-M stated R1 complained of bilateral (affecting both sides) rib pain with no other change in condition. The note indicated a chest X-ray would be obtained and stated, (Nursing Home) to call if abnormal. A skilled care note, dated 10/24/21 at 11:44 PM, indicated R1's vital signs, including oxygen saturation level, were within normal limits, R1's lungs were clear, no cough was noted, R1 denied pain and there were no signs of a swallowing disorder. The note did not mention the choking incident. An X-ray report, dated 10/24/21, stated R1 had bilateral upper lobe infiltrates, right greater than the left associated with small-volume bilateral pleural effusion (fluid surrounding the lungs) may be due to pneumonia or pulmonary [CONDITION(S)]. The heart is enlarged with mild pulmonary venous congestion from CHF. The report stated R1 had cardiomegaly (an enlarged heart) with mild CHF and bilateral pneumonia (affecting both lungs) or pulmonary [CONDITION(S)] with pleural effusion . Clinical correlation and a follow up examination were recommended. The report also indicated the left ribs were not fractured. A progress note, written by RN-E on 10/24/21 at 11:56 PM, stated Chest X-ray results received. No gross fracture of ribs on left side. Call placed to (FM-H) and updated per (FM-H's) request. Copy of results put in (MD-G's) binder. There is no documentation that the physician was promptly informed of the bilateral infiltrates in the lungs. (Cross reference F580.) An occupational therapy note, dated 10/25/21 at 2:54 PM stated, Per RN, (patient) recently (diagnosed ) with pneumonia .At OT arrival, appears pale, and very fatigued. Therapist took baseline vitals. The note stated R1's oxygen saturation was 61% on two liters of oxygen via a finger monitor and 76% on three liters of oxygen via an earlobe monitor. The note stated, Withheld rest of therapy session as (patient) is too medically unstable this date. On 1/12/22 at 8:20 AM, the Surveyor interviewed OTR (Occupational Therapist)-I via telephone. OTR-I stated OTR-I entered R1's room on 10/25/21 for a treatment session at approximately 2:54 PM; however, R1 looked fatigued and zoned out and wasn't very responsive. OTR-I took R1's vital signs and noted R1's oxygen saturation (with a finger monitor) was in the low (60th percentile). OTR-I increased R1's oxygen from two to three liters and rechecked R1's level with an ear monitor. OTR-I noted R1's oxygen saturation was still severely low. OTR-I notified a nurse who applied a breathing mask. OTR-I stated OTR-I exited the room and did not provide therapy because R1 didn't look right. A change of condition note, dated 10/25/21 at 2:43 PM, stated, Therapy in room and came to nurses station to report (oxygen saturation) on 2.5 liters (of oxygen) was 61 (percent) .(R1) denies any (shortness of breath) or pain, lungs congested, no noted cough while in room, writer continued to turn up (oxygen) therapy per nasal cannula and had (R1) try to (cough and deep breathe) .put on non rebreather mask at 10 (liters) and was only at 80% (oxygen saturation). (MD-O) and (APNP (Advanced Practice Nurse Prescriber)-Q) in house .order received to send to ER (emergency room ). A progress note, dated 10/25/21 at 3:10 PM stated 911 was called as R1's oxygen saturation was at 71%. A physical therapy note, dated 10/25/21 at 3:22 PM, stated, (Patient) reports being sore 'from being squished' .Instructed (patient) on abdominal breathing hand out/exercise due to low (oxygen saturation level) initially 88% with two liters of (oxygen) . The note stated R1 did not ambulate during the session due to medical complexities and a low oxygen saturation level. The note also indicated R1's recliner was adjusted to a more upright level per R1's statement that it was easier to breathe in that position. On 1/12/22 at 8:53 AM, the Surveyor interviewed PTA (Physical Therapy Assistant)-J via telephone. PTA-J did not recall details of R1's therapy session on 10/25/21. PTA-J also verified the therapy session could have occurred earlier in the day, despite the fact the note was documented at 3:22 PM (which was after 911 was called). PTA-J also could not recall if PTA-J notified R1's nurse on 10/25/21 when R1's oxygen saturation level was below 90%. R1's hospital paperwork, dated 10/25/21, stated R1 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital course stated R1 was admitted due to increased oxygen requirements following a witnessed episode of aspiration on 10/24/21. While in the facility, R1 required more and more oxygen and was brought to the ER. The paperwork also stated, After admission to the ICU (intensive care unit), (R1) experienced a confluence of serious medical conditions the most urgent of which was declining respiratory status in the setting of aspiration pneumonia, likely pulmonary [CONDITION(S)] (a condition caused by excess fluid in the lungs) and ongoing upper GI bleed .To further complicate matters, (R1) began to experience acute kidney injury from diuresis (increased urination due to the administration of a diuretic medication) to improve respiratory status . R1 was transferred to hospice services for end-of-life care on 10/30/21 and passed away on 11/02/21. On 1/11/22 at 11:40 AM, the Surveyor interviewed DON-B regarding R1 and the progress note DON-B wrote on 10/25/21. DON-B stated RN-C was a part-time employee who worked every other weekend. DON-B stated DON-B was made aware of the choking incident on Monday morning (10/25/21) when DON-B arrived at work. DON-B called RN-C to get a better understanding of what occurred and documented the occurrence in R1's medical record. When asked the procedure for assessment and monitoring following administration of the [MEDICATION(S)] maneuver, DON-B stated staff should have done an assessment and initiated on-going monitoring for aspiration pneumonia. On 1/11/22 at 11:55 AM, the Surveyor interviewed UM (Unit Manager)-L regarding R1. UM-L verified R1 had issues with [CONDITION(S)] (an absence of enough oxygen in the tissues to sustain bodily functions) and required a recent blood transfusion. UM-L verified R1 choked on medication on 10/24/21 and was administered the [MEDICATION(S)] maneuver. UM-L verified RN-D (the PM shift nurse on 10/24/21) was not aware the [MEDICATION(S)] maneuver was performed on the AM shift. On 1/11/22 at 1:10 PM, the Surveyor interviewed APNP-P regarding R1. APNP-P could not answer whether APNP-P would've initiated orders or sent R1 to the ER if APNP-P was notified about R1's choking episode immediately after the incident occurred. APNP-P stated if a physician wasn't notified between the time the incident occurred (approximately 8:15 AM) and 5:00 PM, it seemed like a bit of a gap. On 1/11/22 at 2:20 PM, the Surveyor interviewed FM-H via telephone. FM-H verified FM-H was not notified R1 choked on a pill and was given the [MEDICATION(S)] maneuver prior to FM-H's arrival at the facility on 10/24/21. FM-H stated R1 told FM-H that R1's nightgown had blood on it from when the nurse squeezed R1 and R1 threw up. FM-H verified R1's nightgown contained a quarter-sized spot of bright red blood. FM-H stated R1 demonstrated that the nurse did a bear hug. FM-H stated R1 complained of rib pain and had a wet cough. FM-H stated RN-D entered the room a short time later to administer R1's medication. FM-H questioned RN-D about R1's statements; however, RN-D stated RN-D was not informed RN-C performed the [MEDICATION(S)] maneuver and could not find documentation in R1's medical record. FM-H verified an X-ray was performed and stated a nurse called FM-H at approximately 11:45 PM and said everything was good. FM-H stated FM-H was not aware anything was wrong until the next day when a family member stopped to visit R1 and they were loading (R1) in a rescue squad. On 1/11/22 at 2:45 PM, the Surveyor interviewed RN-D regarding R1. RN-D verified RN-D worked the PM shift on 10/24/21. RN-D stated RN-D was told in report that R1 choked on a pill so we should starting crushing pills and putting them in applesauce. RN-D was not aware RN-C performed the [MEDICATION(S)] maneuver until RN-D was informed by R1 and FM-H. RN-D stated RN-D monitored R1 for a sore throat and and watched for aspiration pneumonia, but couldn't recall if the monitoring was documented or if R1's vital signs were taken. RN-D stated RN-D was unsure of the facility's policy and procedure regarding the [MEDICATION(S)] maneuver. On 1/11/22 at 4:23 PM, the Surveyor interviewed MD-G regarding R1. MD-G stated MD-G would generally want notification if the [MEDICATION(S)] maneuver was performed. MD-G stated MD-G would have wanted to know if R1 was hypoxic and if there was a change in condition that the facility couldn't manage or that warranted further attention. MD-G stated MD-G would have ordered an assessment, including lung sounds and vital signs. MD-G stated if R1 didn't have acute symptoms, notification the following morning was potentially acceptable. MD-G stated information contained in the provider binder was signed off as soon as residents were seen or the information was processed. The Surveyor noted R1's X-ray result, which was placed in the binder on the 10/24/21 NOC shift, was signed by APNP-Q on 10/25/21 and stated, Sent out to ER. (Oxygen saturation) at 61%. The signature did not contain a time. On 1/11/22 at 11:17 PM, the Surveyor interviewed RN-E via telephone. RN-E could not recall much about the incident; however, RN-E remembered being surprised that nothing was charted from (the) day shift. When asked if R1 complained of pain or had a wet cough, RN-E stated, If something was wrong, I would've called the doctor. RN-E did not recall whether or not RN-E called FM-H regarding R1's X-ray. On 1/12/22 at 9:08 AM, the Surveyor interviewed RN-F who worked the 10/25/21 AM shift on R1's unit. RN-F stated RN-E reported R1 stated RN-C squeezed R1; however, RN-F was not informed that R1 had choked. RN-F stated R1 was alert and oriented with intermittent confusion; however, RN-F could trust what (R1) said. RN-F did not see documentation of the [MEDICATION(S)] maneuver in R1's medical record; however, RN-N (who also worked the AM shift on 10/24/21) informed RN-F that RN-C performed the [MEDICATION(S)] maneuver. RN-F stated R1 did not complain of pain except when RN-F asked R1 about the incident. RN-F was not aware an X-ray was taken and was not told to monitor R1. As of this writing, RN-C did not return multiple voicemails left by the Surveyor. RN-N also did not return a voice mail left by the Surveyor. In addition, the Surveyor attempted to reach MD-O multiple times; however, the Surveyor was unable to leave a message as MD-O's voicemail was full. The Surveyor was also unable to reach APNP-Q and was told APNP-Q recently retired. The article, Death from Aspiration Pneumonia, notes that Aspiration occurs when foreign material is inhaled into the airway. Causes of death include .irritation or infection of the respiratory tract due to inhaled material, or aspiration pneumonia .Outcomes with aspiration pneumonia can vary greatly depending on many factors, including the severity and extent of the pneumonia, the type of bacteria involved and the timeliness of treatment. Individuals who are in poor physical condition at the onset of symptoms will obviously not fare as well as those who are healthier. (Emphasis added.) https://hrstonline.com/hrst-u-2/article-library/aspiration-pneumonia/ The failure to properly assess and monitor a resident who received the [MEDICATION(S)] maneuver created a reasonable likelihood for serious harm to occur, thus creating a finding of immediate jeopardy. The facility removed the jeopardy on 1/13/22 when it completed the following: 1. Educated staff on the facility's policy and procedure for Change of Condition. 2. Educated staff on the facility's policy and procedure for Choking/[MEDICATION(S)] Maneuver, including protocols for necessary documentation after an adverse event. 3. Changed shift report protocols for verbal and written nurse-to-nurse report and added a protocol for aspiration risk nursing assessment orders to be completed after any adverse choking/aspiration event.

Based on observation, record review, and staff interview, the facility did not ensure each resident received care consistent with professional standards of practice to prevent PIs (pressure injuries) from developing for 1 Resident (R) (R2) of 3 sampled residents reviewed for PIs. R2 was at risk for the development of PIs. R2 was observed in the recliner without a pressure redistribution cushion on the seated surface of the recliner. Findings include: The facility policy and procedure for skin breakdown/pressure injury prevention and treatment with a revision date of February 2020, indicated the facility initiates a preventative skin/pressure injury program for all residents upon admission. This program decreases the risk of developing pressure injuries unless the individual's clinical condition demonstrates that pressure injuries are unavoidable. Interventions included a ROHO cushion to be used in the wheelchair based on the needs/risk factors of the resident. 1. On 1/11/22, the Surveyor reviewed R2's medical record. The medical record indicated R2 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's five (5) day admission MDS (Minimum Data Set) assessment, dated 12/22/21, indicated R2's cognition was 15 out of 15. R2's cognition was not impaired. R2 required extensive assistance from two plus staff for bed mobility and required extensive assistance from two plus staff for transfer. R2 did not ambulate. R2 did not have a PI, was at risk for the development of PIs, had a pressure reducing device for bed and chair, and repositioning program. R2's current Braden skin risk assessment dated [DATE] documented R2's score as 17, which indicated R2 was at risk for the development of PIs because R2's skin was occasionally moist, R2's mobility was very limited with R2 able to make occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. R2 was chairfast with the ability to walk severely limited or non-existent. R2 cannot bear own weight and/or must be assisted into chair or wheelchair. R2's nutrition was probably inadequate, and friction/shear was a potential problem R2's current plan of care, not dated, indicated R2 had an actual (unavoidable) unstageable pressure injury to sacrum related to immobility, right sided weakness, previous stroke with [CONDITION(S)], history of [CONDITION(S)] (urinary tract infection), weakness, difficulty walking, malnutrition, and cognitive deficits. Interventions included to ensure ROHO cushion is being used in recliner and wheelchair when sitting. Additionally, R2 needs reminding/assistance to turn/reposition at least every two hours, more often as needed or requested. Re-educate risk/benefits when non-compliant. R2's current CNA (Certified Nursing Assistant) Bedside Kardex Report with a print date of 1/11/22, indicated staff were to ensure a ROHO cushion was being used in R2's recliner and wheelchair when sitting. Additionally, R2's CNA Kardex indicated, R2 was dependent on one staff assist for bed mobility, was non-ambulatory, and transferred with an EZ stand lift. On 1/11/22 at 2:33 PM, the Surveyor interviewed R2 after R2's wound care was completed. R2's ROHO cushion was on the seated surface of the wheelchair. R2 verified R2 was sitting in the recliner prior to the wound care and did not have a ROHO cushion on the seated surface of the recliner. On 1/11/22 at 2:55 PM, the Surveyor observed CNA-K transfer R2 from the bed to the recliner. CNA-K stated R2 will be transferred back to the recliner because R2 does not want to stay in bed. CNA-K verified CNA-K started work at 2:00 PM and R2 was sitting in the recliner when R2 got to work. CNA-K transferred R2 from the bed to the recliner. The seated surface of the recliner did not have a ROHO cushion. The Surveyor asked CNA-K if R2 should have a ROHO cushion on the seated surface of the recliner. CNA-K stated if I'm being honest, (R2) didn't have one (ROHO cushion) under (R2) when I put (R2) to bed for the wound care. CNA-K then picked up the ROHO cushion from the seated surface of R2's wheelchair, lifted R2 off the seated surface of the recliner, and placed the ROHO cushion on the seated surface of the recliner for R2 to sit on. On 1/11/22 at 3:03 PM, the Surveyor interviewed CNA-K after CNA-K had the Bedside Kardex Report printed to review. CNA-K verified R2's plan of care indicated R2 should have the ROHO cushion on the seated surface of the recliner and wheelchair when R2 is in the recliner or wheelchair. CNA-K then stated CNA-K did what the last CNAs did when placing R2 on the recliner without a ROHO cushion on the seated surface of the recliner. CNA-K confirmed CNA-K should look at the plan of care per self to make sure the correct interventions are in place for each resident. On 1/11/22 at 3:06 PM, the Surveyor interviewed R2. R2 stated R2's bottom felt better with the ROHO cushion on the seated surface of the recliner.

Based on staff interviews and record review, the facility did not ensure a Resident (R) saw a physician at least every 60 days for 1 (R3) of 4 sampled residents reviewed for physician visits. The facility did not ensure R3's Medical Doctor (MD) or Non-Physician Practitioner (NPP) visited R3 since 10/20/2021 (90 days before investigation). Findings include: On 1/18/22, Surveyor reviewed R3's medical record which documented R3's most recent MD visit was 10/20/21 by MD-S. On 1/18/22, Surveyor interviewed Health Information Assistant (HIA)-R regarding R3's MD visits. HIA-R reviewed R3's medical record with Surveyor and verified 10/20/21 was the most recent MD visit in R3's medical record. HIA-R reviewed electronic database information documenting physician visit dates and confirmed MD-S most recently visited R3 on 10/20/21. HIA-R explained that some NPP visited residents between MD visits and HIA-R searched electronic database without success in locating a NPP visit for R3. On 1/18/22, Director of Nursing (DON)-B followed-up with Surveyor regarding R3's physician visits. DON-B explained DON-B communicated with an Advanced Practice Nurse Practitioner (APNP) who visits residents as a NPP at facility. DON-B confirmed that based on communication with APNP, R3 did not have a physician visit since 10/20/21. DON-B indicated HIA-R sent a request to MD-S for R3's physician visit in December 2021 but MD-S did not respond. DON-B identified MD-S's preference to not utilize NPP coverage in general and indicated the facility would implement a back-up plan going forward to ensure R3's 60 day visits occurred timely.

Based on record review and staff interview, the facility did not provide pharmacy services to ensure the accurate administration of medication for 1 Resident (R) (R1) of 1 resident. R1 choked while swallowing [MEDICATION(S)] (an antacid used to treat ulcers) on the 10/24/21 AM shift and was administered the [MEDICATION(S)] maneuver (a first aid procedure in which abdominal thrusts are used to treat upper airway obstruction by a foreign object). Following the incident, R1's medical record indicated the rest of R1's AM medications were crushed. In addition, the PM shift nurse was instructed to crush R1's medication. R1's medical record contained a pharmacy review sheet, dated 10/12/21, that stated R1 was prescribed one or more medications that could not be crushed. The sheet instructed staff to consult with the pharmacy prior to crushing medication. Staff did not obtain a physician order or consult with the pharmacy prior to crushing and administering R1's medication. Findings include: The facility's Medication Administration policy, dated 3/09/16, states: Policy: To pass medication with respect for safety, accuracy and privacy for the residents .To be conscientious when passing medications, documenting appropriately and following the directions of the physician. Scope/Intent: This policy pertains to any licensed staff member responsible for administering prescription medications. Procedure: 3. Transcribing Physician Medication Orders to the eMAR (electronic Medication Administration Record): c. Residents who are required or request an altered medication route administration (example: crushed with applesauce or thickened liquids) must be clearly identified on Care profile. Staff must follow pharmacy recommendations regarding the crushing of specific meds. i. Crushing medications Medications that cannot be crushed: *Slow release *Control release *Extended release *Enteric coated *Sustained release The Surveyor reviewed R1's medical record. R1 was admitted to the facility for short-term rehab following hospitalization for an exacerbation of CHF ([CONDITION(S)]) (a chronic condition in which the heart doesn't pump blood as well as it should), increased weakness and shortness of breath. R1 had diagnoses to include [CONDITION(S)] (chronic obstructive pulmonary disease) (a group of lung diseases that block airflow and make it difficult to breathe), [CONDITION(S)] (an irregular, often rapid heart rate that commonly causes poor blood flow) and chronic kidney disease. R1's medical record indicated R1 was monitored for a decreasing hemoglobin (a protein in red blood cells that carries oxygen throughout the body) level and a suspected upper GI (gastrointestinal) bleed. R1's Admission MDS (Minimum Data Set), dated 10/19/21, indicated R1 was not cognitively impaired and ate independently following set-up assistance. R1 was prescribed a no-added salt, regular texture diet with thin liquids. R1's medical record indicated R1's medications were to be given whole in applesauce one at a time. An Initial Medication Regimen Review sheet, dated 10/12/21 and contained in R1's medical record, stated R1 received one or more medications that should not be crushed. The sheet instructed staff to consult with the pharmacy with any crush order. The Surveyor reviewed R1's physician orders and noted R1 received the following medications: Aspirin 81 mg (milligrams) delayed release once daily for coronary artery disease, [MEDICATION(S)] sulfate 325 mg delayed release three times daily for [CONDITION(S)] (a condition in which the blood has a lower than normal number of red blood cells or hemoglobin or a lowered ability of the blood to carry oxygen) and [MEDICATION(S)] 40 mg delayed release twice daily for GERD (gastroesophageal reflux disease). A late entry progress note, dated 10/24/21 at 8:15 AM, but written on 10/25/21 by DON (Director of Nursing)-B, stated, Late entry for (RN (Registered Nurse)-C): (R1) was taking [MEDICATION(S)] and started choking on medication. Nurse had to administer [MEDICATION(S)] maneuver x 2 fast compressions and (R1) spit out med . The note indicated the rest of R1's AM medications were crushed as R1 was hesitant to take whole medications following the incident. The note further stated, Passed on in report to crush medications . A progress note, written by RN-D on 10/24/21 at 4:20 PM, stated, During first med pass family in room asking about (R1's) left thoracic rib pain (related to) was chocking (sic) on a med this AM and per (R1) (RN-C) hugged/squeezed (R1) at that time . The note stated RN-D was unaware the [MEDICATION(S)] maneuver was performed, but confirmed RN-D was notified R1 choked on a pill and was told in report to crush and administer R1's medications in applesauce. On 1/11/22 at 11:40 AM, the Surveyor interviewed DON-B regarding R1 and the progress note written on 10/25/21. DON-B stated RN-C was a part-time employee who worked every other weekend. DON-B stated DON-B was made aware of the choking incident on Monday morning (10/25/21) when DON-B arrived at work. DON-B called RN-C to get a better understanding of what occurred and documented the occurrence in R1's medical record. On 1/11/22 at 2:20 PM, the Surveyor interviewed FM (Family Member)-H (R1's power of attorney) via telephone. FM-H verified FM-H was not notified R1 choked on a pill and was given the [MEDICATION(S)] maneuver prior to FM-H's arrival at the facility on the 10/24/21 PM shift. FM-H stated FM-H noted R1 had a wet cough and was told by R1 that R1 threw up when a nurse squeezed her earlier in the day. Shortly after, RN-D entered R1's room to administer medication. FM-H stated R1's medications were crushed in applesauce; however, prior to that day, R1's medications were not crushed. FM-H questioned RN-D about the medication and was told there was a little scare on the AM shift when R1 had a coughing spell due to difficulty swallowing a medication. FM-H stated RN-D was not informed RN-C performed the [MEDICATION(S)] maneuver and could not find documentation in R1's medical record. On 1/11/22 at 2:45 PM, the Surveyor interviewed RN-D regarding R1. RN-D stated RN-D was told in report on 10/24/21 that R1 choked on a pill so we should starting crushing pills and putting them in applesauce. RN-D verified RN-D was not aware RN-C performed the [MEDICATION(S)] maneuver until RN-D was informed by R1 and FM-H. RN-D was unsure if an order was obtained to crush R1's medication. On 1/11/22 at 11:17 PM, the Surveyor interviewed RN-E via telephone. RN-E worked the 10/24/21 NOC (night) shift and could not recall much about R1's choking incident; however, RN-E remembered being surprised that nothing was charted from (the) day shift. When asked if RN-E was instructed to crush R1's medication, RN-E could not recall. On 1/11/22 at 3:35 PM, the Surveyor interviewed NHA (Nursing Home Administrator)-A regarding R1. NHA-A verified RN-C did not consult with the pharmacy to obtain an order to crush R1's medication. As of this writing, RN-C did not return multiple voice mails left by the Surveyor.

Based on Resident (R) interview, staff interview, and record review, the facility did not ensure requested code status was accurately and consistently documented in medical records for 1 (R50) of 26 sampled residents. The facility maintained inconsistent code status documentation in R50's Electronic Health Record (EHR) which documented R50 as both Do Not Resuscitate (DNR) (do not perform CPR (Cardiopulmonary Resuscitation)) and full code (perform CPR). The facility was made aware of R50's desired code status change [DATE] but did not update R50's EHR until [DATE]. Findings include: The facility policy titled Advance Care Planning/Code Status, with an original effective date of [DATE], outlines that the facility admission assessment includes completion of a code status form, documenting the resident's decision to resuscitate or do not resuscitate. If the resident chooses DNR status, the Department of Health Services/State of Wisconsin DNR order form (Form F- ) will be completed by facility staff with the resident. The facility policy also instructs licensed nursing staff that if resident's condition is quickly declining we (facility staff) should refer to advanced care planning directive form in chart. From [DATE] through [DATE], Surveyor reviewed R50's EHR which documented R50 as DNR per EHR profile banner and physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The advanced care planning documentation in R50's EHR, dated [DATE], indicated R50 requested full code status. On [DATE] at 11:46 AM, Surveyor reviewed R50's paper medical chart. Surveyor could not locate a signed State of Wisconsin DNR order form. Surveyor noted that the advanced care planning documentation in R50's paper health record was dated [DATE] and indicated R50 requested full code status. On [DATE] at 12:52 PM, Surveyor interviewed Registered Nurse (RN)-D, regarding code status. RN-D indicated that resident's code status can be found in the EHR but should be verified with the documentation in the paper health record. On [DATE] at 1:20 PM, Surveyor interviewed Director of Nursing (DON)-B related to R50's code status. DON-B verified with Surveyor that staff should refer to the resident's paper health record to determine code status. DON-B and Surveyor reviewed R50's paper health record. DON-B confirmed that the advanced care planning documentation in R50's record was dated [DATE] and indicated R50 was a full code. DON-B also located a DNR bracelet in the paper record. DON-B indicated that DON-B would verify R50's code status. DON-B later provided Surveyor with a faxed order sheet to R50's physician. The faxed sheet, dated [DATE], contained a physician signature and documented R50 desires code status DNR. DON-B could not locate for Surveyor any documentation signed by R50 to indicate change to DNR status. On [DATE] at 8:43 AM, Surveyor interviewed R50 regarding advance directives. R50 indicated that R50 would want all measures put into place in order to be revived. R50 indicated the preference for full code status. Surveyor reviewed R50's EHR and noted that the profile banner reflected that R50 was DNR status. A nursing progress note from [DATE] at 6:52 PM noted that facility staff had discussed advance directives with R50, and R50 had signed updated documentation for full code status. On [DATE] at 9:07 AM, Surveyor noted R50's code status in the EHR updated to reflect full code status and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 1:53 PM, Nursing Home Administrator (NHA)-A was made aware of the inconsistent code status documentation. NHA-A indicated that R50's DNR orders were put in on [DATE], but staff had missed securing a signed DNR form from R50.

Based on observation, interview and record review, the facility did not ensure the accurate preparation of pharmaceutical medication for administration for 1 of 5 sampled Residents (R) (R76). R76 was prescribed [MEDICATION(S)] (anti-[CONDITION(S)] medication) liquid in a suspension form via J tube (tube surgically inserted into a portion of the small intestine to receive food and or medications). The bottle of [MEDICATION(S)] suspension was not shaken during preparation to ensure proper dosing for administration. Findings: R76 was admitted to facility on 06/18/2021. Per review on 07/20/2021 of R76's medical record, R76's provider ordered R76 to receive [MEDICATION(S)] liquid suspension via J tube. R76's MDS (Minimum Data Set) (part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) coded R76's BIMS (Brief Interview for Mental Status) score as 15 (cognitively intact). On 07/20/2021 at 9:17 AM, Surveyor observed LPN (Licensed Practical Nurse)-C prepare medication for administration into R76's J-tube. LPN-C took a bottle labeled [MEDICATION(S)] suspension from the med cart. LPN-C poured the liquid [MEDICATION(S)] into a med cup and then drew the contents up into a syringe. LPN-C did not shake the [MEDICATION(S)] suspension. Prior to administration of the medication, Surveyor asked LPN-C if LPN-C had shaken the bottle. LPN-C replied, No, I didn't. Surveyor pointed out that as the medication was in suspension form, it was necessary to shake the medication to ensure proper dosing. LPN-C was not aware that a suspension medication had to be shaken. The label on the bottle of [MEDICATION(S)] suspension stated to shake well. On 07/21/2021 at 8:17 AM, Surveyor asked Registered Nurse (RN)-D how a bottle of liquid suspension medication would be prepared for administration. RN-D replied that the bottle would be swished around. 07/21/2021 8:20 AM, Surveyor interviewed RNM (Registered Nurse Manager) RNM-E. Surveyor asked RNM-E what the expectation was for nursing staff when administering a liquid suspension. RNM-E responded, That you would shake it.

Based on interview, observation and record review, the facility did not ensure the provision of care consistent with professional standards of practice to prevent pressure injuries (PIs) for one of three sampled residents (R) (R308). R308 had an order entered into the electronic medical record to monitor a small reddened, sheared area on the right buttock on 01/31/2020, the day after R308's admission. The facility failed to evaluate R308's extensive risks for PI development, failed to assess and monitor a noted wound, and evaluate the origin of complaints of pain in R308's right buttock area. R308 developed an unstageable wound on the buttocks. The facility also failed to implement additional preventative interventions following the discovery of a PI to R308's left heel to prevent pressure wounds elsewhere on the body, or follow facility Skin Care Protocol. R308 did not receive treatment and services to the extent possible in the prevention of PIs and suffered pain and discomfort due to the PIs. Findings: Facility's policy titled, Skin Care Assessment, revised May 26, 2010, stated, Woodside Lutheran Home incorporates a preventative program for all residents with or without pressure areas. This program decreases the risk of developing pressure ulcers unless the individual's clinical condition demonstrates that pressure ulcers are unavoidable. Woodside Lutheran Home also ensure that any resident having pressure areas or other interruptions in skin integrity receives necessary treatment and services to promote healing, prevent infection, and prevent development of new pressure ulcers. R308 was admitted to facility on 01/30/2020 following surgical repair of a left [MEDICAL CONDITION] sustained from a fall at home. R308 admitted to facility with [DIAGNOSES REDACTED]. R308 was coded as an extensive assist for Activities of Daily Living (ADLs) including bed mobility, transfers, locomotion on the unit, toileting, dressing and personal hygiene, per R308's Minimum Data Sets (MDS) (part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes), dated 02/04/2020 and 02/14/2020. R308's Brief Interview for Mental Status (BIMS) scores were 15/15 (cognitively intact) per R308's MDS's dated 02/04/2020 and 02/14/2020. R308's Braden Scale for Predicting Pressure Injury Risk assessments indicated R308 was at risk for the development of pressure sores. R308's Braden Scale for Predicting Pressure Injury Risk assessment dated [DATE] score was 17 (at risk) and R308's Braden Scale for Predicting Pressure Injury Risk assessment dated [DATE] score was 16 (at risk). R308's Baseline Care Plan, dated 01/30/2020, indicated a, small area to R (right) buttock. R308's Baseline Care Plan at readmission on 02/07/2020 indicated R308 had a, Surgical incision. R308 had a left hip surgical incision from the surgical repair of the [MEDICAL CONDITION]. R308's order dated 01/31/2020 to: monitor small reddened, sheared area to R (right) buttock every day and evening shift, was signed off as completed by numerous facility RN staff. On 02/19/2020 at 2:45 PM, Surveyor interviewed RN-L. RN-L reported not seeing the right buttock wound and reported signing the order to monitor the right buttock sheared area. RN-L reported checking the right buttock area by having R308, Lean forward in the chair, and pulling R308's pants waistband out and looking down stating, I guess I didn't look down far enough. On 02/19/2020 at 3:03 PM, Surveyor interviewed RN-M. RN-M reported changing R308's dressing on the right buttock on 02/11/2020 during the AM shift after a CNA, had come to get me. The CNA had toileted R308 and the dressing on the right butt had come off. RN-M stated, This is the only day I had (R308) as a patient. RN-M stated about the wound, To me, it looked slightly open. I think when the [MEDICATION NAME] came off it pulled some skin with it. It looked like the top layer of skin came off. The old dressing was crumpled up. RN-M reported R308 complained of pain when the dressing was replaced. On 02/19/2020 at 3:20 PM, RN-M returned to speak with Surveyor and reported the following: Medical Doctor (MD)-N was here the morning of 2/11/2020 to see R308. RN-M reporting telling MD-N about changing R308's dressing to the right buttocks because the old dressing had come off. RN-M reported telling MD-N that R308's wound was, a shearing with a slight open area in the center where the skin had peeled off. RN-M reported MD-N was aware of R308's heel wound also and requested to talk with a wound care nurse. RN-M reported calling RN-O (who no longer works at the facility) and let RN-O know that MD-N wanted to talk with RN-O about R308's skin treatments. RN-M stated not remaining for the discussion but, made the assumption that MD-N and RN-O would discuss R308's buttock wound. RN-M was unable to locate any documentation by MD-N of R308's buttock wound in MD-N's progress notes from MD-N's evaluation of R308 on 02/11/2020. MD-N's notes of the same date reflected knowledge of R308's heel wound, however, there was no mention of a buttock wound. On 02/19/2020 at 2:12 PM, Surveyor interviewed CNA-R. CNA-R reported that this past Monday morning, (02/17/2020), RN-G, Put a new dressing on because the old dressing was saturated. CNA-R reported that when R308 first came into the facility (01/30/2020), There was a little red spot. I noticed a couple of days after (R308) came back from the hospital (02/07/2020), it was bigger and open. Surveyor asked if a nurse was alerted to the open wound and CNA indicated RN-G was notified. CNA-R stated, I had (R308) a week or two after (R308) came back from the hospital. It (buttocks wound) was not like it is now before (R308) went out to the hospital because I toileted (R308). It's (buttocks wound) much bigger now. CNA-R reported assisting RN-G with changing R308's buttock dressing the past Monday, and a couple of other times within the last two weeks. On 02/17/2020 at 10:25 AM, Surveyor observed R308 in R308's room sitting in a wheelchair. R308 was wearing a blue heel protecting boot on the left foot. Surveyor asked R308 about the blue boot. R308 indicated having a sore on left foot. R308 indicated having a wound on backside, butt too, and reported the wound on the buttocks area caused pain. On 02/18/2020 at 11:08 AM, Surveyor met with R308. R308 indicated having pain to the right butt area stating, Oh, it was sore. They changed a dressing on it and it isn't as sore now. On 02/19/2020 at 10:24 AM, R308 indicated to Surveyor having pain stating, The right side was hurting on my butt. It was hurting this morning. I asked for Tylenol. It was about four o-clock this morning. R308's Medication Administration Record [REDACTED]. On 02/19/2020 at 10:34 AM, Surveyor observed RN-E perform a dressing change to R308's right buttocks area. RN-E removed a [MEDICATION NAME] dressing on R308's right buttock to reveal a wound that contained 100% slough (necrotic or dead tissue) in the wound bed, preventing the visualization of the tissue under the slough in the wound bed. RN-E stated, It (wound) didn't look like that the last time I saw it. RN-E stated, I will have to update the doctor on how it's looking. On 02/19/2020 at 10:55 AM, RN-E entered the following progress note regarding R308's right buttock wound: Assessed shearing/ulcer to right buttock; measurements obtained at 7.0cm (centimeters) x 4.9cm, wound bed appearing with 100% slough/ slightly macerated to center, periwound pink with dried skin at edges, no s/s infection to surrounding skin. Pt (patient) reports site as tender to touch/ pressure. Using air overlay mattress pad as protective measure. On 02/19/20 at 3:29 PM, Surveyor interviewed RN-D, who is wound care certified. RN-D stated, I just assessed the (buttocks) wound. It measured 5cm in length by 4cm in width. It is an unstageable pressure ulcer. RN-D described R308's wound bed as having: 100% slough with induration (dermal thickening) from seven to three o-clock. RN-D reported R308 had pain with the treatment. RN-D reported requesting new orders from the doctor. Wound Nurse Documentation by RN-D, dated 02/19/2020 at 3:35 PM, was as follows: Location: Right Ischial Tuberosity, Type of Wound: (In House or admitted with): In House - Unstageable, Size: (LxWxD): 5 cm x 4 cm (unable to determine depth due to slough), Undermining or Tunneling?: NA, [MEDICATION NAME]? Amount?: Fresh [MEDICATION NAME] tissue is noted on the edges of the wound going inward. Granulation? Amount?: 0%, Necrotic Tissue? Amount?: 100% adhered slough, Wound Edges:: Wound edges are attached all the way around. Peri Wound: [MEDICAL CONDITION] or Induration?: Peri wound is intact, normal skin color further out from wound edges but does have some redness noted over indurated area from 7 - 3 o'clock that measures 0.5 cm out from wound edge and does blanch. No [MEDICAL CONDITION] noted. Drainage Type, Amount, Odor?: Copious amount of drainage noted to old dressing when removed that was yellowish in color. No odor noted to wound or dressing. Pain? Requiring follow up? Intervention?: Patient stated that pain was present with palpation of wound/peri wound and sometimes when sitting. Interventions: Mosaic Roho cushion. Requesting alternating pressure mattress. Encourage/offer & assist with laying down throughout the day to off load area to R buttock. Assist with frequent repositioning to assist with off loading. Other/ Education: Writer had extensive talk with patient about the need to off load this area. Patient stated that (patient) has always laid on (patient's) right side while in bed even at home prior to left hip surgery. Writer explained that the pressure to the area from laying on that side only can deteriorate the wound. Writer explained that staff could assist with repositioning off of the right side while in bed utilizing a pillow and patient stated that (patient) does not want that. Patient stated to writer and nurse manager that this area will be fine without her repositioning off the area and that (patient) does not want to be positioned on left side even if staff assist and a pillow is used. Nurse manager and writer continued to attempt the patient to understand the necessity of the off loading but was unsuccessful at this time. Interventions will be updated on care plan for staff to attempt with patient. Dietary and Therapy updated. Treatment Change Suggestions: Writer sent message to (Redacted), PAC via Bellin Epic to give full assessment and education that was completed. Also, requested orders for cleansing with NS (normal saline), skin prep peri wound, apply moistened [MEDICATION NAME] blue cut to size of wound to wound bed and cover with a large foam dressing. Change every other day and PRN (as needed). On 02/19/2020 at 10:50 AM, Surveyor interviewed RN-D, the facility's wound care certified nurse, regarding R308's right buttock area wound. RN-D stated, I wasn't aware of a wound there; only of the wound on the heel. Maybe the other wound nurse looked at it, but her last day of employment was yesterday. I'll check into that. A few minutes later RN-D approached Surveyor and stated, It (wound on buttocks) was there on admission, indicating an order went in on 1/31/20 to monitor the sheared area on R308's right buttock. RN-D stated, It was a nursing order. Because it was documented as a shearing, I don't look at that. The wound care nurses just look at pressure wounds. Surveyor asked RN-D if there was an order to apply and change a dressing to the buttocks wound and RN-D replied, I'm not sure. I will look at it and attempt to get it all healed up. Surveyor reviewed R308's medical record and noted an order to, monitor small reddened, sheared area to R (right) buttock every day and evening shift. This order was entered by RN-P on 01/30/2020 at 5:35 PM. R308 verbalized to Surveyor that the right buttock wound caused pain and required [MEDICATION NAME] to help with the pain. Record review indicated R308 was administered [MEDICATION NAME] for pain fifteen times from 02/08/2020 through 02/19/2020. Record review indicated R308's pain ratings were as follows: 8, 7, 3, 5, 5, 4, 7, 6, 2, 4, 5, 3, 3, 8 and 6, in order of request from 02/08/2020 to 02/19/2020, based on a 1-10 pain scale. R308 was administered [MEDICATION NAME] (narcotic [MEDICATION NAME]) eleven times during the same dates of 02/08/2020 through 02/19/2020. R308's MDS, dated [DATE], coded R308 as having no pressure injuries and coded R308 as having pressure relieving devices for R308's chair and bed. RN-D indicated it was standard to place a mattress overlay on the bed for facility residents. RN-D indicated requesting an order for [REDACTED]. Assist with frequent repositioning to assist with off loading. R308 developed a pressure injury to the left heel after admission. Staff put additional interventions in place after discovery of the heel wound to assist in healing, including a pressure reducing boot to be worn on the left foot and off-loading of the feet when in bed. No additional interventions were put into place to prevent the development of other pressure injuries. R308 complained of pain in the right buttock area; however, there was no indication a Registered Nurse assessed the area to determine the cause of pain. At some point during R308's stay at facility, nursing staff began using a [MEDICATION NAME] dressing to R308's right buttock however, there was no order to use a [MEDICATION NAME] or any other type of dressing for R308. CNA-R reported seeing a small red area to R308's right buttock after R308's 01/30/2020 admission and reported the right buttock wound as much bigger now. CNA-R reported alerting a registered nurse and assisting this registered nurse with a dressing change the past Monday, and two to three other times over the last couple of weeks however, there were no noted assessments of the buttock wound, no referrals made to facility's wound certified nurse, no notification to the provider and no additional interventions implemented to prevent worsening of the wound. R308 was at increased risk of lower extremity pressure wounds because of R308's limited mobility. R308 also developed a stage two pressure injury (partial-thickness skin loss into but no deeper than the dermis on the left heel. This includes intact or ruptured blisters) as documented in R308's progress notes on 02/10/2020. The left heel wound was originally classified as a deep tissue injury (DTI) (an injury to a patients underlying tissue below the skins surface that results from prolonged pressure) pressure wound when discovered on 02/09/2020 and reclassified to a stage two pressure wound on 02/10/2020. Upon admission to facility on 01/30/2020, R308 was assessed to be at risk for pressure wound development. Staff initiated a pressure reducing mattress overlay and chair cushion. R308 was coded as an extensive assist for ADL's per the MDS dated [DATE], requiring extensive assistance with transfers, mobility, toileting and dressing. It was not until after R308 developed a pressure wound to the left heel that staff initiated a heel protecting boot and off-loading of the heels in bed. R308 was limited in the ability to shift the body and make substantial position changes especially on the left leg and foot due to R308's recent surgical repair of the left [MEDICAL CONDITION].

Based on observation, record review, staff and resident interview, the facility did not establish and maintain an infection control program designed to help prevent the development and transmission of disease and infection in the following areas: The facility did not ensure their infection prevention and control surveillance program included the time of symptom-onset for residents experiencing illness as a means to accurately identify an outbreak. This had the potential to affect all residents in the facility. The facility did not include 1 Dietary Aide (DA) (DA-T) who had respiratory illness (RI) symptoms on the RI tracking log and did not determine the time this employee's symptoms resolved so as to ensure DA-T did not return to the facility while contagious. This had the potential to affect all residents residing on Mulberry Meadows Unit. The facility did not follow through with infection control precautions for 1 Resident (R) (R62) (who was diagnosed with [REDACTED]. The facility did not ensure staff performed proper hand hygiene for 2 Residents (R) (R88 and R53) of 13 residents observed during the provision of cares. Findings Include: 1. Wisconsin (WI) Department of Health Services (DHS) Division of Public Health (DPH) Memo BCD 2017-04 dated 10/09/2017 states a respiratory disease outbreak in long term care facilities (LTCF) is defined as three or more residents and/or staff from the same unit with illness onsets within 72 hours of each other who have: * Pneumonia, or * Acute respiratory illness (ARI), or * Laboratory-confirmed [MEDICAL CONDITION] or bacterial infection (including influenza) DPH defines ARI as illness characterized by any two of the following: * Fever (fever is defined as 2 degrees above the resident's established baseline) * Cough (new or worsening, productive or nonproductive) * Rhinorrhea (runny nose) or nasal congestion * Sore throat * Myalgia (muscle aches) greater than the resident's norm WI DHS DPM Publication of December 2017 titled Recommendation For Prevention and Control of Acute Gastroenteritis (AGE) Outbreaks in Wisconsin LTCFs advises, Each facility should have a surveillance mechanism in place that will monitor for GI (gastrointestinal) illness as well as other illnesses in residents throughout the facility to rapidly identify when a unit, wing or floor has an increase in illness. Staff illness and call-ins should be monitored. When staff call in, it is important to understand what symptoms the ill staff member is experiencing (GI, respiratory, sore throat) to monitor for increase in certain disease syndromes. Regardless of where the staff member likely acquired their infection, they should remain off of work until asymptomatic (without symptoms) for 48 hours to prevent spread of illness within the facility. Early recognition of outbreaks and immediate implement of aggressive infection prevention and control measures is crucial to interrupting disease transmission and stopping outbreaks quickly. On 02/17/2020 at 11:35 AM, Surveyor interviewed facility-designated Infection Preventionist Registered Nurse, (RN) (RN-D) regarding surveillance of infection. RN-D reported not tracking symptoms of illness stating, I have tried and it is impossible to do. RN-D reported the facility does not keep line lists (a list which identifies resident and staff symptoms of illness, the onset date and time symptoms started, their location within the facility and the date which symptoms resolved). RN-D reported attending the facility's weekday morning meeting and writing down notes related to resident symptoms as a means of knowing who has what symptoms. RN-D reported reviewing symptoms which developed over the weekend on Monday. On evenings and weekends, Unit RNs (URN) would contact the on-call Nurse with resident symptoms of illness on evenings and weekends. The on-call RN would then determine if there was a potential outbreak. On 02/18/2020, the facility provided Surveyor with documents labeled Line List which revealed the following: November 2019 RI line list included 3 residents who had 2 or more ARI symptoms, resided on the same unit (Hollyberry Heights) and with potential to be within 72 hours of onset of illness from each other (hour/minute of onset of symptoms not recorded): 1. A resident with cough, fever, sore throat - symptom onset date was blank on the line list. Surveyor reviewed the electronic medical record (EMR) which revealed documentation dated 11/15/2019 related to sore throat and documentation dated 11/16/2019 related to cough. 2. A resident with cough and stuffy/runny nose - symptom onset date of 11/16/2019. 3. A resident with cough and stuffy/runny nose - symptom onset date of 11/18/2019. December 2019 RI line list included 2 residents with 2 or more ARI symptoms who resided on the same unit (Rehab 1) with potential to be within 72 hours of onset of illness of each other(hour/minute of onset of symptoms not recorded): 1. A resident with cough and fever - symptom onset date of 12/17/2019. 2. A resident with cough and stuff/runny nose - symptom onset date of 12/20/2019. A staff RI line list for December 2019 was not provided. December 2019 GI line list for staff revealed Dietary Aide (DA-T) had GI symptom of nausea. Additional notes written on this entry included DA-T also had a runny nose and cough. (Which would constitute 2 ARI symptoms). Onset of symptoms was 12/19/2019. The GI Line List indicated DA-T returned to work on 12/20/2019. On 02/19/2020 at 9:00 AM, Surveyor interviewed RN-D who confirmed November 2019 line list for RI did not include a date of onset for 1 of the 3 residents who potentially met criteria for an outbreak. RN-D reviewed the EMR and confirmed 11/15/2019 onset of first symptom and 11/16/2019 as onset of second symptom for this resident. Upon review of the line list, RN-D confirmed 3 residents had ARI symptoms between 11/15/2019 and 11/18/2019; RN-D reported that they did not quarantine residents/units nor was the PHN notified. RN-D then reviewed the EMR and noted that the time the RN charted the first resident's symptoms on 11/15/2019 was at 3:41 pm and the time the RN charted the third resident's symptoms on 11/18/2019 was 6 pm - an over 74 hour time span between documentation. RN-D confirmed the actual time of onset of symptoms was not recorded in the documentation. RN-D acknowledged the time of charting may not be the actual time the symptoms started but that this was the only way RN-D had to track time of onset. RN-D indicated that in the future investigation of symptom start times would occur. RN-D reviewed the EMR for documentation times for the two residents identified on the December RI line list, noting the time of documentation between 12/17/2019 and 12/19/2019 was less than 72 hours. RN-D confirmed DA-T's ARI symptoms of 12/19/2019 were not recorded on a RI line list. RN-D indicated it was not taken into account how dietary staff illness would be calculated for an outbreak. RN-D adds it may depend if they were assigned to work in a dining room vs the kitchen. RN-D confirmed DA-T, unfortunately returned to work 12/20/2019. RN-D stated facility policy is that staff should not return to work until 24 hours after symptoms resolve. RN-D stated a phone conversation occurred with DA-T on 12/20/2019 and DA-T reported feeling significantly better; however, RN-D did not have knowledge of time of DA-T's last symptom. On 02/19/2020 at 9:30 AM, RN-D reported review of the schedule with regards to duties DA-T performed on 12/20/2019 included DA-T going to the kitchen to retrieve a cart full of supper meal trays for residents, bringing the cart from the kitchen to Mulberry Meadows Unit and then delivering the trays to the residents. 3. On 2/18/2020, the Surveyor was speaking to R62 in the room where R62 resided with another resident (R32), during an initial interview. The Surveyor observed R62 was coughing frequently during the interview. R62 stated R62 had been diagnosed previously with pneumonia and had been taking an antibiotic and was placed on isolation. R62 stated R62 was concerned about R32 (the roommate) because now R32 had a cough. R62 stated R62 was told to wear a mask when R62 left the room but R62 was never instructed to wear a mask while in the room near R32 and they were never told to keep the privacy curtain pulled while R62 was ill. R62 further stated there were even nurses coming in and out of our room not wearing masks. R62 stated R62 did tell nursing staff that R32 had a cough and that R62 was concerned R32 was also becoming ill. R32 stated staff had not done any assessment of R32 to determine if R32 was ill. The Surveyor verified R32's medical record did not show any nursing assessment was completed on R32 until the Surveyor brought the concern to the attention of staff. On 2/18/2020 at 11:22 AM, the Surveyor interviewed DON-B who stated per policy, the privacy curtain should be pulled, or the resident should have been wearing a mask in the room. 2. Facility provided policy titled Hand Hygiene dated 11/16/18 stated, Clean your hands: . If hands will be moving from a contaminated-body site to a clean-body site . After glove removal . On 2/17/20 at 11:45 AM, Surveyor observed CNA (Certified Nursing Assistant)-W put on a hair net and assisted with meal service from the steam table in the dining room. At 11:51 AM, CNA-W placed a food plate on a tray, took CNA-W's hair net off and, without performing hand hygiene, accepted a bowl of peaches and placed it on the food tray. CNA-W took the tray from dining area to an area used to further prepare food trays. CNA-W poured fluids into glasses, covered those glasses with plastic covers and took the prepared food tray to R88's room. CNA-W placed the tray on R88's over-bed table and moved the table closer to R88. CNA-W performed hand hygiene before removing the cover from R88's food plate. On 2/17/20 at 11:55 AM, Surveyor interviewed CNA-W who indicated, when asked, that CNA-W should have performed hand hygiene after removal of hair net and before touching items being prepared for resident use. On 2/18/20 at 9:10 AM, Surveyor observed RN-M apply medicated cream to R53's right facial cheek. During the provision of this care, R53 requested lotion be applied to R53's nose. RN-M removed RN-M's gloves and, without performing hand hygiene, donned new gloves and applied lotion to R53's nose. RN-M then removed gloves and performed hand hygiene. On 2/18/20 at 9:43 AM, Surveyor interviewed RN-M who indicated RN-M should have performed hand hygiene between gloves changes. On 2/19/20 at 10:37 AM, Surveyor interviewed DON-B who verified CNA-W should have performed hand hygiene after removal of hair net and before touching items being prepared for resident use. DON-B verified RN-M should have performed hand hygiene between glove changes.

Based on staff interview and record review, the facility did not ensure a significant change MDS (Minimum Data Set) assessment was completed for 1 Resident (R) (R86) of 28 sampled residents. R86's shearing injury (shearing wounds occur when forces moving in opposite directions are applied to tissues in the body) worsened and R86 experienced significant weight loss at the facility. The facility did not complete a significant change MDS when R86 met the significant change MDS criteria. Findings include: On 2/19/20 the Surveyor reviewed R86's medical record which included documentation that R86's [DIAGNOSES REDACTED]. A nutrition/dietary note dated 1/29/20 documented the following for R86: Weight on 7/26/19 118.6 (16.6 lb weight loss in 6 months.) Weight on 12/27/19 110 lbs. Weight on 1/25/20 102 lbs (8 lb weight loss in 1 month.) The Surveyor calculated the 8 lb weight loss to be a decrease in R86's weight of 7.27% in 1 month and a 14% decrease in R86's weight in 6 months. R86's most recent quarterly MDS with an assessment reference date of 1/28/20 documented R86's current weight was 102 lbs and that R86 had weight loss. R86 was not on a prescribed weight loss regimen. The Long Term Care Facility Resident Assessment Instrument 3.0 Users Manual Version 1.16 dated October 2018, includes the following in Section K: -Code 2, yes, not on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was not planned and prescribed by a physician. A nutrition/dietary note dated 1/23/2020 documented: Wound note: Resident with stage 2 pressure injury to coccyx which worsened from shearing injury. (Note: a stage 2 pressure injury is an injury to the skin and underlying tissue. At stage 2, the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin.) A skin/wound entry dated 1/29/20 documented: type of wound: in house stage 2 The Long Term Care Facility Resident Assessment Instrument 3.0 Users Manual Version 1.16 dated October 2018, includes the following: A SCSA (significant change in status assessment) is appropriate if there are either two or more areas of decline or two or more areas of improvement. Some examples of areas of decline are: ~ Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days.) ~- Emergence of a new pressure ulcer at Stage 2 or higher, a new unstageable pressure ulcer/injury, a new deep tissue injury or worsening in pressure ulcer status. On 2/19/20 at 1:54 PM, the Surveyor interviewed MDS (Minimum Data Set) Coordinator-C who verified due to the decline in two areas, R86 should have had a significant change MDS completed.

Based on interview, observation and record review, the facility did not ensure the development of an individualized and comprehensive plan of care for two of twenty-eight sampled Residents (R) (R50, R250). The facility failed to develop an individualized and comprehensive plan of care to address R50's on-going respiratory monitoring and needs. R250 was assessed as having nocturnal preferences (up all night, sleep during day) and had no individualized plan of care to address R250's nocturnal preferences. Findings: 1. R50 was admitted to facility on 12/31/2019 with [DIAGNOSES REDACTED]. R50 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) per R50's Minimum Data Set (MDS) (part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) dated 02/05/2020. On 02/18/2020, Surveyor observed R50 in bed resting. Surveyor noted R50 had oxygen delivery devices, a nebulizer machine (a nebulizer turns liquid medicine into a very fine mist that a person can inhale through a face mask or mouthpiece) and a [MEDICAL CONDITION] (continuous positive airway pressure machine) in the room. R50 indicated using the [MEDICAL CONDITION] machine at nighttime for a [DIAGNOSES REDACTED]. R50 indicated being hospitalized recently while at the facility for, respiratory problems. Surveyor reviewed R50's medical record and noted a Health Status Note dated 01/23/2020 at 10:32 PM that read: Pt (patient) c/o (complains of) SOB (shortness of breath), audible wheezes with crackles and wheezes present on auscultation Rt (right) mid-upper lobes (of lung),O2 sat 88% RA (room air),temp 99.3 F, BP (blood pressure) 118/64, HR (heart rate) 92 RR (respiratory rate) 32. [MEDICATION NAME] (a respiratory medication) neb (nebulizer) per prn (as needed) order. Humidified O2 (oxygen) at 2L(liters) per NC (nasal cannula) placed for increase in sats (saturation level) to 94%. MD (medical doctor) paged with orders received for AM CXR (chest xray) AP/LAT (front to back and lateral views) & CBC (complete blood count). Pt stable, states neb effective for SOB, insp (inspiratory) wheezes remain RUL (right upper lobe (of lung)), prod (productive) cough of sm (small) amount thin,clear secretions. Report to noc (night) RN (registered nurse). Surveyor noted another entry in R50's medical record dated 01/24/2020 4:34 AM that read: Change of Condition (SBAR) (Situation, Background, Assessment, Recommendation) Situation: Pt started having SOB on pm shift, O2 applied, labs ordered for tomorrow and a chest x-ray. Pt continued to be sob throughout the night, requested nebs frequently. Nebs administered with no relief. Background: [MEDICAL CONDITIONS], UTI (urinary tract infection). Assessment (RN)/Appearance (LPN): Bilateral wheezing noted to lungs with fine crackles to bilateral bases. Pt is alert and oriented x3 but daughter reports confusion per baseline. She states (R50) was weak and unable to perform well in therapy today. Reccomendations(sic): Send to ER (emergency room ) for eval. R50 was readmitted to facility after hospital stay as noted by medical record entry dated 01/30/2020 5:59 AM that read: Pt. readmitted from hospital stay for influenza A and metabolic alkalosis. Pt. is alert, oriented x 4. Uses call light appropriately. Lungs are clear, denies SOB. [MEDICAL CONDITION] on for sleep. O2 sat 91% RA. States not coughing much and states cough is NP (non-productive). BS (bowel sounds) active x 4. Has trace [MEDICAL CONDITION] (swelling) LEs (lower extremities). Denies pain. On 02/18/2020 at 3:00 PM, Surveyor requested R50's respiratory plan of care from Director of Nursing (DON)-B. On 02/18/2020 at 3:55 PM, Surveyor received Activities of daily living (ADL) self-care deficit and Falls care plans from DON-B and NHA-A. Surveyor asked if these were R50's care plans for respiratory care and NHA-A indicated they were. The ADL and Falls care plans did not address R50's respiratory [DIAGNOSES REDACTED]. R50 had no individualized and comprehensive plan of care for R50's significant respiratory problems. R50 developed acute respiratory symptoms on 01/23/2020 and was hosptalized on [DATE] for continued respiratory symptoms. R50 readmitted to facility on 01/30/2020 from the hospital with a [DIAGNOSES REDACTED]. 2. R250 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. enough of certain crucial hormones), [MEDICAL CONDITION] (swelling caused due to excess fluid accumulation in the body tissues), Major [MEDICAL CONDITION] (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life), and Anxiety (an emotion characterized by feelings of tension, worried thoughts and physical changes like increased blood pressure) Disorder. On 2/17/20 at 10:03 AM, Surveyor interviewed R250 who stated, I am nocturnal. It does bug me that they want me to sleep at night and be awake during day. On 2/18/20 at 1:32 PM, Surveyor reviewed R250's medical record which contained a Social Services Social History & assessment dated [DATE] which stated, (R250) makes it known that (R250) is 'nocturnal.' (R250) has been up frequently during the day as well . Included in R250's medical record was a Sleep assessment dated [DATE] that indicated R250's usual bedtime to be 5:30 AM and usual rise time as 3:00 PM. The Sleep Assessment further stated, (R250) Is a life-long night person: sleeps during day hours, up all night every night. R250's care plan did not address R250's nocturnal preferences other than the following: ~(R250) has requested a meal tray to be ready to be heated at night should (R250) want it. This will be in the dining area fridge. Please do not throw out until around breakfast time. ~(R250) has repeatedly complained that NOC (night) shift CNAs (Certified Nursing Assistants) and nurses are not letting (R250) eat, and has said (R250)'s gone days without meals. Staff has been instructed to prepare and save a dinner tray in the resident fridge, and to document night time eating and sleeping habits, including refusals. On 2/19/20 at 10:19 AM, Surveyor interviewed NHA (Nursing Home Administrator)-A who indicated being unaware of R250's nocturnal needs. Surveyor discussed the above findings with NHA-A. NHA-A verified R250's nocturnal preferences should have been on R250's care plan.

Based on record review and staff interviews, the facility did not ensure treatment and care in accordance with professional standards of practice, as related to Hospice Services, for 1 Resident (R) (R88) of 4 residents reviewed for Hospice Services. R88 expressed a desire to receive physical therapy to gain strength to return home before R88 would pass away. Facility did not follow-up with Hospice communication to assist R88 in achieving that goal. Facility did not designate a member of the facility's interdisciplinary team in the facility's policy who was responsible for working with Hospice representatives to coordinate care for residents receiving Hospice Services. Findings include: Facility provided policy titled Hospice dated 11/1/18 stated, . 4. Once admitted on to Hospice, facility staff work in conjunction with Hospice agency, the Provider and resident or resident representative to create a personalized plan of care to ensure al resident's wishes and comforts are being met . 6. Facility Nursing staff will work with resident/patient's attending Physician, as well as the Hospice agency to ensure communication and understanding on all fronts regarding treatments and resident clinical conditions. 7. Facility IDT (interdisciplinary team) team will monitor quality and follow up with any concerns regarding care, communication or overall quality with these partnerships to Hospice agency to ensure continuous quality improvement. On 2/17/20 at 9:39 AM, Surveyor interviewed R88 who stated, Since I have been here, I have not had therapy yet. R88 verified R88 was receiving Hospice services and stated, I want to get strong enough to go home before I die. On 2/17/20 at 3:06 PM, Surveyor reviewed R88's medical record which indicated R88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R88's medical record contained a Hospice care plan for R88. R88's medical record did not contain visit notes from Hospice staff. R88's medical record contained a progress note dated 2/10/20 which stated, Social Services Note Text: Awaiting a return call from (hospice staff name) at (hospice company name). Left a message for (hospice staff name) to meet with (R88) and (R88's family member) regarding (R88)'s new desire to have Therapy services to get stronger and get home. Left message for (hospice social worker) to see if (hospice social worker) is able to check into the possibility of (R88) being able to have some therapy covered. R88's medical record further contained a progress note dated 2/12/20 which stated, Social Services Note Text: Received call from nurse (hospice staff name) at (hospice company name). (Hospice staff) will be contacting the MD (phyician) to get orders for PT (physical therapy). (Hospice staff) will then get them faxed to (facility unit name). Surveyor was not able to locate physician order [REDACTED]. On 2/18/20 at 2:48 PM, Surveyor interviewed LPN (Licensed Practical Nurse)-U who stated, when asked about R88's therapy order, We are still waiting on that. LPN-U indicated LPN-U would follow-up to locate R88's therapy order. On 2/19/20 at 9:52 AM, Surveyor reviewed R88's medical record which included a physician's orders [REDACTED]. On 2/19/20 at 10:16 AM, Surveyor interviewed NHA (Nursing Home Administrator)-A who verified facility policy did not designate a member of the IDT responsible for communication between the facility and Hospice agencies but did indicate that the facility's Social Worker would likely be that person. On 2/19/20 at 10:38 AM, Surveyor interviewed DON (Director of Nursing)-B. Surveyor discussed with DON-B R88's request for therapy, the progress notes listed above and the physician order [REDACTED]. On 2/19/20 at 12:41 PM, Surveyor interviewed LPN (Licensed Practical Nurse)-V regarding communication processes with Hospice. LPN-V indicated when Hospice staff are done with a visit, they verbally report to facility staff any concerns. LPN-V stated, They have their own charting. We don't have access to that. They are kind of in their own world. LPN-V was unsure of how frequently Hospice staff visit. On 2/19/20 at 12:51 PM, Surveyor interviewed NHA-A who indicated care plan updates were faxed from hospice agencies to the facility as they are made. NHA-A stated, Hospice should be sending progress notes. We don't have access to their electronic medical record.

Based on interview and record review, the facility did not ensure adequate pain assessment was provided to 1 Resident (R) (R25) of 28 sampled residents. R25 consistently rated R25's pain at 7 or higher from a scale of 0-10 (7 indicates unmanageable pain per facility pain scale guidelines). R25 indicated R25's pain was causing increased depressed mood. The facility did not re-evaluate R25's pain management regime. Findings include: Facility provided policy titled Pain Assessment/Management, revision date listed as 1/16/19, stated, Resident will be assessed for pain according to the following guidelines: . 3. Documentation on continued pain not relieved with current prescriptions. 4. Pain Scale will be utilized when any pain medication given to assess the level of pain, and thereafter for the effectiveness . Documentation of effectiveness of PRN (as needed) medication given for pain shall be addressed. Each time a PRN pain medication is administered the following scale is to be utilized before and after: Pain Scale for Responsive Resident- 0-10 pain scale with description of severity. Included within the policy was a picture which indicated the following scale: 10 = Unable to Move 9 = Severe 8 = Intense 7 = Unmanageable 6 = Distressing 5 = Distracting 4 = Moderate 3 = Uncomfortable 2 = Mild 1 = Minimal 0 = No Pain Further stated in the policy was, 1 . Monitor effectiveness of pain regime and document. 2. Notify attending physician if medication is not effective for relief of pain. R25 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. depressed mood and long-term loss of pleasure or interest in life), Panic Disorder (an anxiety disorder characterized by reoccurring unexpected panic attacks), [MEDICAL CONDITION] (a chronic disorder that causes unprovoked, recurrent [MEDICAL CONDITION]), and Cognitive Social or Emotional Deficit (increased difficulty in coping with the social and emotional demands) following Unspecified [MEDICAL CONDITION] Disease (Cerebral Infarction/Stroke). R25's medical record contained MDS (Minimum Data Set) assessment dated [DATE] which stated R25's BIMS (Brief Interview for Mental Status) score was 13 of 15, indicating little to no cognitive impairment. On 2/17/20 at 10:19 AM, Surveyor interviewed R25. Surveyor introduced self to R25 and, without Surveyor asking about any topic, R25 immediately stated, I am having a lot of pain. I am not satisfied with what I get. I want to try something different. On 2/18/20, Surveyor reviewed R25's medical record which contained the following care plan: Focus: (R25) has chronic pain r/t (related to) altered mobility and neuro (neurological) pain [MEDICAL CONDITION](after cardiovascular accident). (R25) also has a hx (history) of headaches. Goal: (R25) will express feeling of comfort or of pain relief. Decreased pain indicators and will require less pain medication. Interventions: o Assess need for scheduled [MEDICATION NAME]. o Assess physical symptoms. Anticipate pain and treat. o Encourage fluids. Report pain indicators. o Follow pain management protocol. o Investigate other causes of pain. o Monitor/document for side effects of opioid pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. o Position for comfort. Encourage adequate rest. o (R25) enjoys receiving massages with [MEDICATION NAME] lotion for non pharmacological pain management. Offer (R25) massages with [MEDICATION NAME] lotion as desired. R25's medical record further contained physician orders [REDACTED].>~[MEDICATION NAME] (opioid pain medication) Tablet Extended Release 15 MG (milligrams) Give 15 mg by mouth two times a day for pain management ~[MEDICATION NAME] Solution 100 MG/5ML (milliliters) Give 0.5 ml by mouth every 1 hour as needed for SOB (shortness of breath)/pain ~Biofreeze Gel (a topical [MEDICATION NAME]) 4 % (percent) Apply to R (right) ankle topically (on the skin) as needed for soreness BID (twice daily) ~[MEDICATION NAME] (anti-[MEDICAL CONDITION] pain medication) Tablet 200 MG Give 2 tablet by mouth every 6 hours as needed for pain give with food ~[MEDICATION NAME] (generic name for Tylenol; mild pain medication which also treats fever) Tablet 325 MG Give 1 tablet by mouth every 4 hours as needed for mild pain or fever ~[MEDICATION NAME] Tablet 325 MG Give 2 tablets by mouth every 4 hours as needed for pain or fever On 2/18/20, Surveyor reviewed R25's MARs (Medication Administration Records) for the months of January 2020 and February 2020. Each entry documented for R25's routine doses of [MEDICATION NAME] Extended Release given twice daily included the number R25 provided to facility staff when asked to rate R25's pain on 0-10 scale. In January 2020, of the 62 documented responses, 33 times R25 rated pain at 7. In February, of the 35 documented responses, 15 times R25 rated pain at 7 and 4 times R25 rated pain at 8. In accordance with the above facility policy, 7 means R25's pain was unmanageable and 8 means R25's pain was intense. R25 also received as needed medications in addition to R25's routine [MEDICATION NAME] doses. In January 2020, R25 received doses of [MEDICATION NAME] solution 74 times. Of those 74 times, 62 times were given for expressed pain levels of 7. Once dose was given for expressed pain level of 10 (pain so severe resident was, Unable to Move per facility pain indicator guidelines). In February 2020, from 2/1/20 to 2/18/20 (form was printed on 2/18/10 at 3:55 PM), R25 received doses of [MEDICATION NAME] solution 39 times. Of those 39 times, 29 times were given for expressed pain levels of 7. Three times doses were given for expressed pain levels of 8. In January 2020, R25 was provided with two doses of Biofreeze. No expressed pain level was documented with these doses. No doses of Biofreeze were provided to R25 between 2/1/20 and 2/18/20. No doses of [MEDICATION NAME] were provided to R25 from 1/1/20 to 2/18/20. In January 2020, R25 was given two doses of [MEDICATION NAME], each for expressed pain levels of 7. Between 2/1/20 and 2/18/20, R25 was given four doses of [MEDICATION NAME], once for expressed pain level of 7 and three times for expressed pain level of 8. None of the as needed doses indicated an expressed pain level in response to the medication provided. On 2/19/20 at 10:49 AM, Surveyor interviewed DON (Director of Nursing)-B. When questioned how often facility expected resident pain management regimes to be reviewed for effectiveness, DON-B stated, My hope is every few weeks. Surveyor discussed R25's responses of expressed pain as documented on MARs and R25's statement of not being satisfied with current pain management. DON-B indicated that if nurses were aware R25 was rating pain at high levels on a consistent basis, R25's physician should have been updated. Surveyor asked DON-B to provide documentation that R25's physician was updated regarding R25's pain management. Facility did not provide documentation to Surveyor that R25's physician had been updated prior to 2/19/20. On 2/19/20 at 1:51 PM, Surveyor interviewed R25. When questioned about how R25's pain was affecting R25, R25 stated, It's hard to explain. It's difficult in many different ways. My muscles are in pain most of the time. I have a difficult time dealing with the pain. My mouth, my head. It's difficult dealing with the pain. When questioned if R25 was not able to do certain things because of R25's pain, R25 stated, It's difficult for me to explain the way I feel and what it causes. When asked, R25 indicated it was difficult for R25 to feed self due to the pain in R25's arms and stated, I don't know if I could feed myself easier if the pain was controlled. When questioned if pain was affecting R25's mood, R25 stated, It's making me more depressed.

Based on record review and staff interviews, the facility did not ensure that 3 of 15 sampled residents (resident #1, resident #10 and resident #13) were free from significant medication errors. Resident #1 was administered medications belonging to resident #14. The medications included [MEDICATION NAME] (used to treat high blood pressure) 50 mg (milligrams), [MEDICATION NAME] 20 mg/Hydrochlorathiazide 12.5 mg (used to treat high blood pressure), and ASA (Aspirin) 81 mg were administered to resident #1 in error, resulting in severe [MEDICAL CONDITION] (low blood pressure), [MEDICAL CONDITION] (slow heart rate) and acute [MEDICAL CONDITION] for the resident. Resident #1 was sent to the hospital emergency room as a result of the medication error. Resident #1 expired in the hospital three days after admission. This significant medication error resulted in a finding of immediate jeopardy that began on [DATE]. The facility was notified of the immediate jeopardy on [DATE]. The immediate jeopardy was removed on [DATE], however, the deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan, and as evidenced by: Resident #10 was administered a medication that belonged to another resident who resided at the facility. The resident was administered 20 mg of [MEDICATION NAME] (used to treat high cholesterol and triglyceride levels) in error. Resident #13 was administered a medication that belonged to resident #15. The resident was administered one gram of [MEDICATION NAME] (an antibiotic used to treat infections) intravenously (within vein) in error. Findings include: The Facility's policy and procedure last revised on [DATE], entitled, Medication Administration, indicated: 12. Safety a. Identify the resident by looking at the photo in the MAR or verifying name and DOB (Date of Birth) .13. b. The nurse must observe the six (6) rights of medication pass: · the right resident; · the right time/day; · the right route; · the right medication; · the right dosage; · documentation. c. The nurse must verify the medication card label with the eMAR three (3) times. Compare the pharmacy label, dosage and all directions with the MAR; On [DATE], surveyor # reviewed the medical record for resident #1. The undated facesheet contained within the electronic medical record indicated resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 also had a status [REDACTED]. Upon admission to the facility, the resident's medication regimen included the antihypertensive beta blocker, [MEDICATION NAME] ER (Extended Release) 25 mg by mouth daily at HS (hour of sleep/ bedtime.) On [DATE], the resident's physician ordered [MEDICATION NAME] to be lowered to 12.5 mg at HS related to the resident's low blood pressures. Resident #1's eMAR (electronic Medication Administration Record) dated [DATE], revealed staff administered [MEDICATION NAME], ER 12.5 mg at HS (approximately 8 p.m.). The resident's blood pressure at that time was documented at ,[DATE]. Upon review of resident #1's eMAR, surveyor # noted there was no profile photo of resident #1, but in its place, was documented resident refused (photo). Additionally, an eMAR order for resident #1, dated, [DATE], indicated, Crush meds, give in applesauce. On [DATE] a significant medication error occurred when RN-A gave resident #1 the medications intended for resident #14. The facility presented their investigation summary of the [DATE] medication error that resident #1 had received which documented, The following medication was administered to the wrong patient: [MEDICATION NAME] 25 mg (two tablets - 50 mg), [MEDICATION NAME]-[MEDICATION NAME] 20 mg-12.5 mg tablet, ASA 81 mg tablet. At 9:14 and 9:15 (RN-A) administered the above medications intended for (resident #14) in room (5xx) to (resident #1) in room (5nn). At 9:45 RN-C went into (resident #1's) room to give morning medications, crushed and in applesauce. (The resident) did not seem any different than usual self. (RN-C) was kneeling next to (resident #1) with the morning meds .RN-A came into the room at approximately 9:55 and told RN-C she had to ask a question .RN-A told RN-C that she had already given resident #1 the medications for the morning .RN-A determined she had administered resident #14's morning medications to resident #1 RN-C returned to the resident's room to take vital signs and do a thorough assessment .(resident #1) feeling light headed .BP ,[DATE], AP (Apical Pulse)-45, R (Respirations)-12 .By 10:10 called PCP (Personal Care Provider) .(resident #1) sent to ER (emergency room ) for eval (evaluate) and treat .(RN-A) stated she was ok to continue her shift .After a root-cause analysis was completed on [DATE], it was determined that RN-A failed to identify (resident #1) prior to administering medications through asking the (resident's) name or birthdate or comparing the (resident's) photo in the eMAR to the (resident) .(RN-A) was terminated from employment for gross misconduct on [DATE] after it was determined by facility leadership that it was not a facility process that caused the error but RN-A's failure to follow the rights of medication administration that put the resident at harm. On [DATE] at 8:55 a.m., surveyor # interviewed RN-C regarding resident #1. RN-C verified on [DATE] at about 9:45 a.m., she was about to administer medications to resident #1, crushed in applesauce. I had already given the supplement, but not the medications, yet. RN-A came into the room saying she had already given resident #1 morning medications. We left the room, went to the medication carts and pulled up the residents (on the eMAR). I told her it was the wrong meds. RN-C indicated resident #1 was then assessed, vital signs were obtained, the resident reported feeling dizzy, but was alert and oriented. The resident's physician was notified and because the doses differed significantly, it was ordered to send the resident to ER via EMS (Emergency Medical Services) .911 was called .By the time resident #1 left, (the resident) was a wet noodle and could not hold a conversation. Surveyor interviewed RN-C regarding workload and nurse assignments. It was verified that RN-A was not assigned to care for resident #1 that day, but had resident #14 on her assignment sheet. RN-C further stated usually, the daily assignments were prepared by either RN/UM-B or RN-C. RN-C indicated daily assignments could change based on acuity like IVs (intravenous) and dressing changes. It was not unusual to care for a resident one day and based on acuity, a single resident could be re-assigned to another nurse. On [DATE] at 10:30 a.m., surveyor # interviewed RN-A regarding resident #1. RN-A verified she administered resident #14's medications to resident #1. RN-A indicated both residents had the same first name and both resident's last name began with the same letter. RN-A verified to surveyor # she did not follow the 5 rights of medication administration and did not verify the resident by asking his name or birthdate before administering the medications. RN-A verified she did not check the resident's photo from the eMAR and was also not aware that a photo of resident #1 was not in the eMAR. RN-A verified resident #1 was not assigned to her that day, but resident #14 was assigned to her. It was verified that RN-A had previously worked with both residents before and felt she knew them. RN-A verified the daily assignments could change based on acuity, such as the number of IVs (intravenous medications) or dressing changes, but that she had just returned from being off for four days and this was a new assignment. On [DATE] surveyor # reviewed hospital records from resident #1's admitted d [DATE] through [DATE]. ER admission data indicated at 11:04 a.m., (resident #1) presented to the ER alert and oriented with heart rate of 42 and blood pressure of ,[DATE] presented to ER after receiving a different patient's medications .hypotensive. ICU (Intensive Care Unit) Progress note dated [DATE], documented: (Resident #1) .presents to the ER from SNF (Skilled Nursing Facility) where (resident #1) apparently was given another patient's medication ([MEDICATION NAME] 50 mg and [MEDICATION NAME] 20 mg) in addition to own meds. In the ER apparently they did not have a blood pressure, (resident #1) was given fluids, [MEDICATION NAME] and started on [MEDICATION NAME] and [MEDICATION NAME] drip with improvement in the heart rate and BP (Blood Pressure) .Upon presentation to the ICU (resident #1) is awake and responsive, denies chest pain or SOB (Shortness of Breath) .Overnight developed acute [MEDICAL CONDITION] with creatinine increased to 2.6, anuria (absence of urine) and [MEDICAL CONDITION] (excessive sodium in the blood). ICU Progress note dated [DATE] at 12:01 p.m., documented: Awake, but not interacting much, just moaning .Family opted for comfort measures .transitioned off all drips and medications . Hospital nursing progress note dated [DATE] at 11:15 a.m., documented: (resident #1) is completely unresponsive. POA .has refused further work-up including vitals or active treatment .Will continue with comfort measures. Hospital progress note dated [DATE] at 6:40 p.m., documented Dr. notified that (resident #1) passed at 16:35 (4:35 p.m.) .is a coroners case. On [DATE] at 12:00 p.m., surveyor # interviewed ME (Medical Examiner)-F, from the Brown County Coroners office. ME-F indicated resident #1's admitting hospital referred the case to the coroners office. ME-F indicated resident #1 likely died from acute [MEDICAL CONDITION], but the exact cause was pending. ME-F confirmed an autopsy was performed and toxicology results would take 60 to 90 days to return. ME-F indicated it was not known if the [MEDICAL CONDITION] was from the resident's usual dose of medications or the subsequent medication error. On [DATE] at 8:20 a.m., surveyor # interviewed FM-E, the son of resident #1. FM-E stated the resident was in the facility for rehab after a stroke and was on target for discharge back to senior living apartment on [DATE]. FM-E verified he was notified by the facility on [DATE] that there was a mix-up in medications given to resident #1. The facility indicated the physician was called and the resident was going to ER to get checked out. When FM-E arrived at the hospital, Four people were trying to get a heart rate and blood pressure on (resident #1), one of the people in the room had a 'code blue' jacket. FM-E further indicated resident #1 was receiving [MEDICATION NAME] (to keep blood pressure up) and could not be weaned off that medication all day and night while in ICU. Resident #1 continued to decline and after a discussion with the physician, FM-E stated it was the [MEDICATION NAME] keeping resident #1 alive. The [MEDICATION NAME] was discontinued and comfort measures were initiated on [DATE]. FM-E confirmed resident #1 expired on [DATE]. On [DATE] at 9:20 a.m., surveyor # interviewed RN/UM-B regarding resident #1. RN/UM-B verified resident #1 had impaired renal function, but was preparing for discharge home on [DATE]. RN/UM-B verified RN-A did not follow the 5 rights of medication administration and had no rational explanation for the error .she was not side tracked, only had 12 residents that day, it was just poor nursing practice. On [DATE] at 10:30 a.m., surveyor # interviewed RPH (Registered Pharmacist)-N regarding the difference between [MEDICATION NAME] (which was ordered for resident #1) and [MEDICATION NAME] (which was erroneously given to resident #1). RPH-N indicated the [MEDICATION NAME] form of this antihypertensive is an extended release product and usually dosed once daily. Additionally, RPH-N indicated this form of the medication ([MEDICATION NAME]) should not be crushed or chewed and that crushing an extended release tablet, allows too much of the medication to be released into the system at one time. RPH-N stated the [MEDICATION NAME] form of [MEDICATION NAME] is intended for two or three times a day dosing, and is released more rapidly in the body, allowing for faster action. RPH-N verified adverse consequences with overdosing of [MEDICATION NAME] included stomach upset, dizziness and [MEDICAL CONDITION] (low blood pressure). The USFDA (United States Food and Drug Administration) in a web-based article last revised ,[DATE], indicated the following: [MEDICATION NAME] is a beta selective adrenoreceptor blocking agent (beta blocker) for oral administration .available as an extended release tablet has been formulated to provide a controlled and predictable release of [MEDICATION NAME] for once daily administration .comprised of multiple unit system .multitude of controlled release pellets .delivers [MEDICATION NAME] continuously over dosage interval .Acute toxicity: severe [MEDICAL CONDITION], sinus [MEDICAL CONDITIONS]-ventricular block, heart failure, cardiogenic shock, [MEDICAL CONDITION], [MEDICATION NAME], coma, nausea, vomiting .do not chew or crush. [MEDICATION NAME], the manufacturer of [MEDICATION NAME] indicated in a web based publication dated ,[DATE]: In man, the absorption of [MEDICATION NAME] is rapid and complete .usual dosage is 100 mg daily given in two divided doses .Acute toxicity; several cases have been reported, some leading to death. On [DATE] at 1:50 p.m., surveyor # interviewed RN-Q who verified he had administered [MEDICATION NAME] 12.5 mg on [DATE], crushed in applesauce as the ,[DATE] MAR included an order that all medications are to be crushed. There was no reason not to crush the medication. On [DATE] at 8:40 a.m., surveyor # interviewed DON (Director of Nursing)-D regarding resident #1. DON-D verified she was notified of the medication error by RN/UM (Registered Nurse Unit Manager)-B. We talked to both nurses, RN-A gave the wrong dose, it only happened one time .RN-C was about to administer resident #1's morning meds, but was stopped because RN-A had already given them. RN-A no longer works here. We started an immediate investigation and talked to staff development about HCA (Health Care Academy). HCA is a computerized video training system; this one was about medication administration. I had them start the training in January because of another error, but after this, I had them move up the completion date from [DATE] to [DATE]. Information provided to surveyor # regarding education of staff included the following: ~ a list of 46 Department of Nursing staff registered and eligible to complete the HCAMedication Administration course. The list included the course status, (completed or not attempted) and the status completion date. ~ a summary of the HCA Course Description: Medication Administration is a great addition to any medication related education program. In this lesson learners will discuss the impact of medication errors and identify common pharmacokinetic changes in the elderly that affect medication administration. The adverse reactions, special guidelines and precautions associated with medications in the elderly will be discussed .The 6 rights of medication administration are discussed. ~ of the 46 Nursing staff names listed, 13 staff members completed the training from [DATE] through [DATE]. After the significant medication error that occurred on [DATE], 10 additional staff members completed the training. ~ 23 total staff had not yet completed the Medication Administration Training. On [DATE] at 12:55 p.m., surveyor # interviewed RN-A regarding training. RN-A verified she did not watch the video training regarding medication errors, but understood it needed to be completed by [DATE]. On [DATE] at 1:00 p.m., surveyor # interviewed RN-G regarding training. RN-G verified she did not watch the video training in the last three months or received education regarding medication administration in the previous two weeks. On [DATE] at 1:04 p.m., surveyor # interviewed RN-H regarding training. RN-H verified to surveyor # she did not watch the medication training video but understood it needed to be completed by [DATE]. On [DATE] at 1:06 p.m., RN-I verified to surveyor # she received emails, texts and face to face reminders to complete the medication training video by [DATE]. RN-I confirmed completion of the training, but was not aware of why the training was mandated. On [DATE] at 1:10 p.m., surveyor # interviewed RN-J regarding training. RN-J verified to surveyor # she did not complete the medication training. RN-J indicated this was expected as part of the annual training and was not aware of any incident prompting the mandate. On [DATE] at 1:15 p.m., RN-K verified to surveyor # she had completed the training and heard a rumor that some bigger med error had happened. RN-K verified she was aware the training was mandated to be completed by [DATE]. On [DATE] at 3:00 p.m., during the final exit with the facility, ED (Executive Director)-L indicated the facility did not have a sense of urgency regarding the re-education of all nursing staff. ED-L indicated the med-error incident was isolated and because the nurse who was involved had been terminated, the plan already in place was adequate. The facility's failure to prevent a significant medication error for resident #1 created a situation of Immediate Jeopardy. Resident #1 had significant cardiac history and [MEDICAL CONDITION] as well as additional co-morbidities, placing him at risk for [MEDICAL CONDITION]. Resident #1 had a recent onset of dysphagia related to a stroke and as a result was consuming thickened liquids and crushed medications. Resident #1 current physician's orders [REDACTED]. Additionally, 12 hours later, the resident received [MEDICATION NAME] 50 mg and [MEDICATION NAME] 20 mg/Hydrochlorathiazide 12.5 mg intended for another resident. Resident #1 developed severe [MEDICAL CONDITIONS] and acute [MEDICAL CONDITION] resulting in death. Following the significant medication error, the facility did not ensure that similar medication errors did not re-occur by educating all staff promptly. The facility removed the Immediate Jeopardy on [DATE] when it completed the following: ~ Medication Administration Policy & Procedure was reviewed and revised to separate residents with same name from same med cart or room location to fullest extent possible. ~ All charts (resident records) audited to verify that resident pictures for identification purposes are in place. Residents who have refused to have their pictures taken for this purpose will be revisited every 30 days on short term care unit and quarterly on the long term care unit. If no photo is present, policy directs nurse to verify resident name and date of birth prior to administering medication. ~ Facility shall implement an identification wristband for residents admitted to the short term care unit. ~ Identification of other residents having potential to be affected by the deficiency. The other resident whose medications were administered to the wrong individual was immediately reviewed and it was verified that the medications were administered to him within proper time frame and protocols. ~ Implemented measures to ensure that the deficiency does not reoccur ~ The nurse who committed the medication error was terminated from employment. ~ All nursing staff are receiving specific in-service education related to avoiding Medication Administration Errors prior to working any further shifts to ensure proper protocols are being reinforced to all licensed staff. ~ A separate medication administration education session to be scheduled by Pharmacy provider to further reinforce proper adherence to medication administration policies and procedures. ~ Facility will audit five (5) medication passes per week including all shifts for six (6) weeks to ensure that nursing staff are following established procedures when administering medications. ~ Facility monitoring of performance to ensure continued compliance. ~ Facility will continue to monitor and track/trend medication errors. Each medication error which occurs will result in individual staff education. Staff education to be provided on ongoing basis related to medication administration including one to one, group training, on-line training and utilization of outside sources such as Pharmacy provider. Annual skills fair will include medication administration. New employee orientation also to include medication administration education. ~ Pharmacy will provides routine medication cart and medication room reviews. ~ Medication administration errors and trends are monitored in the Quality Assurance program to ensure proper medication protocols are followed on a consistent basis. The deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as evidenced by: 2. Resident #10's face sheet contained within the medical record and dated [DATE], indicated resident #10 was admitted to the facility for rehab following a [MEDICAL CONDITION]. Additionally, the face sheet indicated the resident had a [DIAGNOSES REDACTED]. Resident #10's 30 day MDS (minimum data set) assessment dated [DATE], documented the resident's cognition was intact. On [DATE], surveyor # reviewed medication errors that had occurred in the facility. On [DATE] at 1:46 a.m., RN-P documented the wrong medication was prepared/dispensed for resident #10 on [DATE]. [MEDICATION NAME] 20 mg was dispensed to resident #10, rather than the ordered atorvastatin 80 mg. On [DATE] at bedtime, RN-P administered 20 mg of [MEDICATION NAME] to resident #10 that belonged to another resident who resided at the facility. No reaction to receiving the wrong medication was observed by RN-P. The physician was contacted regarding the medication error and no treatment was determined to be needed. On [DATE] at 7:47 p.m., RN-B documented RN-P discussed the medication error with RN-B on [DATE], where the [MEDICATION NAME] from one resident was given to another resident. RN-P acknowledges the need to identify resident prior to medication administration as part of the rights of medication administration. 3. Resident #13's face sheet contained within the medical record and dated [DATE], indicated resident #13 was admitted to the facility for IV (intravenous) antibiotic therapy for osteo[DIAGNOSES REDACTED] of the right hand. Resident #13's 14 day MDS assessment dated [DATE], documented the resident's cognition was intact, the resident had received an antibiotic and received IV medication. On [DATE], surveyor # reviewed medication errors that had occurred in the facility. On [DATE] at 2:33 p.m., RN-B documented [MEDICATION NAME] 1 gram was administered to the wrong resident. The IV antibiotic ([MEDICATION NAME] 1 gram) belonging to resident #15 was administered to resident #13 on [DATE] at 7:16 p.m. by RN-P. The error was discovered by RN-K the morning of [DATE], when RN-K went to administer the ordered dose of [MEDICATION NAME] 600 mg IV. RN-P failed to validate right resident and right dose of [MEDICATION NAME] prior to administering the IV medication to resident #13. RN-P was removed from the schedule and will not be permitted to work the last three scheduled shifts (had resigned and last scheduled shift was [DATE]). RN-P will be informed of medication error and disciplinary action. On [DATE] at 11:27 a.m., surveyor # interviewed RN-B regarding the above medication administration errors related to resident #10 and resident #13. RN-B verified RN-P had completed training on the six rights of medication administration on [DATE]. RN-B confirmed 1:1 education was provided to RN-P after resident #10 was administered 20 mg of [MEDICATION NAME] that belonged to another resident who resided at the facility. RN-B then stated the medication error on [DATE] was isolated. Did not educate all (nurses) after error. Educated RN that made the error (RN-P). After (RN-A) made mistake (on [DATE]) all (nurses) were educated on medication administration. Didn't do any good (education) because (RN-P) had another error of the same type on [DATE] with (resident #13). RN-P would have made error whether educated or not, poor practices. Documentation indicated RN-P was educated on the six rights of medication administration on [DATE] and again on [DATE] with 1:1 education. On [DATE] during a 90 day evaluation medication errors were discussed again as well as the need to follow the six rights of medication administration to prevent further medication errors. Not system error, employee error. If had to go back and do it again to provide education right away, (after [DATE] medication error) would not. Poor performance .not be punitive to all.

Based on record review, observations, and staff interviews the facility did not ensure that the resident environment remained as free of accident hazards as possible for 1 of 13 independently mobile cognitively impaired residents who resided on the unit. Resident #1 resided on a secured memory care unit for cognitively impaired residents. The facility did not ensure adequate supervision to prevent accidents for resident #1 while the steam table on the secured unit was on and hot. On 5/12/12, resident #1 touched the steam table while it was hot and unattended, which resulted in a second degree burn to resident #1's left thumb. Additionally, the secured unit contained a coffee and hot chocolate machine which was accessible to residents. Although the facility was aware resident #1 would at times obtain the hot liquids from the machines independently, the facility did not assess the safety of this process for resident #1. Findings include: On 6/19/12 surveyor # completed a record review for resident #1. According to the facility admissions face sheet, dated 3/12/12, contained within the medical record, resident #1 was admitted to the facility on [DATE]. The diseases index report, dated 2/6/12, documented resident #1 had [DIAGNOSES REDACTED]. The facility completed a quarterly MDS (minimum data set) assessment with a reference date of 4/6/12. The MDS documented resident #1 had moderately impaired cognition, wandering occurred daily, and required supervision with locomotion on the unit. The CAA (care area assessment) for psychosocial well-being dated 8/8/11 documented resident #1 has a [DIAGNOSES REDACTED]. The CAA for cognitive loss/dementia dated 8/8/11 documented resident #1 had short and long term memory loss and impaired decision making skills related to dementia. The plan of care dated 8/16/11 documented: "I need reminders and some direction at times because I am forgetful". The interventions included: -offer choices throughout day related to his clothing, meals, activities, etc. -explain cares before doing them, if he is confused, take the time to explain, be patient and ensure he understands, and encourage to call for assistance. The nurses' progress notes documented the following: 3/27/12 at 12:15 p.m., "...MD (Medical Doctor) made area that res. (resident) has been witnessed by staff to retrieve ice cream cups on his own from refrigerator + pour self hot cocoa. Staff attempts to distract + redirect...". 3/28/12 at 11:45 a.m., "...MD aware that res. retrieves his own ice cream for the refrigerator in kitchen + hot cocoa from machine...". 3/28/12 at 9:00 p.m., "...redirects when res. obtains ice cream + hot chocolate on his own...". 3/30/12 at 5:45 a.m., "...Was informed by CNA (Certified Nursing Assistant) resident had made attempts to help himself to ice-cream from freezer + self serve hot cocoa from machine...". 5/12/12 at 3:00 p.m., "Visitor in dining area heard pt. (patient) say "Ouch" + then observed him lifting cover off steam table trays + reported incident to CNA who brought pt. to writer. Dark pink area noted on (L) (Left) thumb, bet. (between) knuckle et. (and) joint. Res. verbalized pain. Area wrapped in cool moist washcloth...". The Resident Incident/Injury report dated 5/12/12 at 1500 (3:00 p.m.) documented resident #1 sustained a burn to the left thumb when exposed to steam when resident #1 lifted the cover off the unattended steam table. The action plan (to prevent reoccurrence) was to secure the steam table so residents cannot access it. The nurse manager conclusion dated 5/15/12 documented, steam table to be monitored when dietary staff turns it on to heat up. Dietary will look for barrier or thermal blanket to keep others from not touching areas. The nurse's progress notes documented the following: 5/13/12 at 12:01 a.m., "(left) thumb has a fluid filled blister measuring approx. (approximately) 2 X 2.4 cm (centimeters)...". 5/14/12 at 1:00 p.m., "(left) thumb fluid filled blister 3 X 3 cm (lt. (light) yellow in color)...". The blister was noted to be resolved per documentation in the nurse's progress notes on 5/27/12 at 10:30 a.m. 6/2/12 at 4:30 p.m., "...Staff reports res. has been taking ice cream from freezer and helping himself to hot cocoa...". 6/12/12 at 5:00 p.m., "...Staff reports seeing Res. helping himself to Hot Chocolate this afternoon. Will redirect res. away from Hot Choc. (chocolate) machine...". 6/13/12 at 2:10 p.m., "...Res. able to independently obtain his own hot cocoa. Staff attempts to intervene & offer sugar-free cocoa when he is seen getting his own-successful only at times...". On 6/19/12 at 7:15 a.m. surveyor # observed the memory care unit. The unit contained a kitchenette area within the dining area on the unit. The counter within the kitchen area contained a 3 well steam table. The steam table was on and hot, but was covered with a moveable thermal blanket. The thermal blanket covered the surface of the steam table, but was not secured and could be easily moved. The kitchenette/dining room contained a coffee and hot chocolate machine which were on and accessible to residents. There was a screen in place secured to the ceiling in front of the machines. The screen was in the up position; therefore the machines remained visible and accessible. During an interview with RN (Registered Nurse)-A on 6/19/12 at 7:20 a.m. verified to surveyor # resident #1 touched the steam table when it was on an hot which resulted in a burn to the resident's left thumb. RN-A stated following the incident, the area was barricaded to prevent resident access until a thermal blanket could be obtained to cover the steam table once hot. RN-A indicated the thermal blanket had been secured on one side by a Velcro strip to secure the blanket to the counter. On 6/19/12 at 7:35 a.m. surveyor # interviewed DA (Dietary Aide)-B. DA-B indicated after the incident with resident #1 a thermal blanket was placed over the steam table. DA-B stated the last time he worked the blanket had a Velcro strip on one side to secure the blanket to the counter. DA-B verified the Velcro strip was not adhered to the counter at the time of the above noted observation and interview, and verified the mat was moveable. On 6/19/12 at 7:39 a.m. RN-A informed surveyor # she had contacted maintenance, as the Velcro strip was not in place, making the mat easily moveable. RN-A indicated maintenance would be coming to the unit to secure the mat. On 6/19/12 at 8:00 a.m. surveyor # observed a maintenance staff person securing the front edge of the heat resistant blanket to the counter utilizing snaps adhered to the counter and the blanket. On 6/19/12 at 9:15 a.m. surveyor # observed resident #1 propelling about the unit independently utilizing a wheelchair. An interview was attempted with resident #1, but unable to answer detailed questions related to cognitive impairments. On 6/19/12 at 9:37 a.m. surveyor # obtained coffee, hot water, and hot chocolate from the accessible machines within the memory care unit. The screen remained in the up position. The coffee temperature was 144.8 degrees Fahrenheit, the decaffeinated coffee was 144 degrees Fahrenheit, the hot water was 141 degrees , and the hot chocolate was 148.6 degrees Fahrenheit. No staff were in the area at the time of the observation, and resident #1 remained propelling about the unit independently. On 6/19/12 at 9:45 a.m. surveyor # interviewed DA-D. DA-D stated it was the facility process for the dietary staff to turn on the steam table approximately one hour before the meal is served. DA-D indicated dietary staff did not supervise the steam tables when on, and verified there was no barrier to prevent resident access to the steam table prior to the incident with resident #1. DA-D stated following the incident with resident #1 being burned, the facility implemented the use of a thermal blanket over the steam table when on. DA-D indicated one side of the blanket had been secured to the counter with Velcro, but as of today (6/19/12) one side was now secured with snaps. DA-D verified the other three sides of the blanket could be easily lifted. DA-D indicated she felt as if the blanket should be secured on all sides to further prevent access to the hot steam table. DA-D was not aware of any supervision plan or barriers in place prior to the incident with resident #1. DA-D confirmed dietary staff would turn on the steam table, then exit the unit until the food was placed in the steam table, which was approximately an hour after turning on the steam table. DA-D verified the coffee and hot chocolate machines are always in the on position and accessible to residents. DA-D indicated there was a screen in front of the machines which could be pulled down, but verified it was not at the time of this interview. On 6/19/12 at 9:55 a.m. surveyor # interviewed CNA (Certified Nursing Assistant)-E. CNA-E stated resident #1 does propel about the unit in the wheelchair independently. CNA-E verified resident #1 is cognitively impaired . CNA-E stated resident #1 does help himself to items in the kitchen area (i.e. ice cream, hot chocolate). CNA-E indicated resident #1 is a very curious person. CNA-E stated staff attempt to assist resident #1 when he is helping himself to hot chocolate from the machine located in the dining area. CNA-E indicated after the incident with resident #1 being burned on the steam table, the facility implemented the use of a thermal blanket over the steam table. CNA-E stated the blanket had only been secured on one side, and a person could easily lift up one of the unsecured sides and be exposed to the hot surface. On 6/19/12 at 10:35 a.m. surveyor # interviewed CNA-F. CNA-F verified resident #1 has safety deficits, and is independently mobile in a wheelchair throughout the unit. CNA-F verified prior to the incident with resident #1 being burned on the steam table the process would be for dietary staff to turn on the steam table prior to the meal, then exit the unit until the meal was to be served. CNA-F stated there was no direct supervision plan of the hot steam table, but rather nursing staff would "keep an eye" on the area. CNA-F verified although general supervision was attempted, there were times in which no staff were directly in the area due to meeting the needs of other residents on the unit. CNA-F verified after the incident, the facility placed furniture around the area of the steam table to prevent resident access until the facility obtained a thermal blanket to cover the steam table. CNA-F confirmed after the implementation of the thermal blanket the furniture around the area was removed. CNA-F verified the thermal blanket was secured only on one side, and the other three sides could be easily lifted exposing the hot surface underneath. CNA-F verified the hot chocolate and coffee machines are accessible to residents throughout the day, and verified resident #1 does help himself to the hot chocolate at times. CNA-F stated when staff see resident #1 obtaining hot chocolate from the machine, they do try to assist, but verified there had been no direct plan in place regarding the safety of this practice for resident #1. On 6/19/12 at 10:40 a.m. surveyor # observed maintenance staff securing the other three sides of the thermal blanket covering the steam table to the counter utilizing snaps. On 6/19/12 at 10:45 a.m. surveyor # interviewed UM (Unit Manager)-G. UM-G verified prior to the incident in which resident #1 was burned by the steam table, the process had been for dietary staff to turn on the steam table approximately an hour before the meal. Dietary staff would then leave the unit, and the hot steam table, without any barrier, and the steam table would be under general supervision of nursing staff. UM-G verified there was no specific supervision plan of the hot steam table. UM-G stated the facility had been utilizing the steam tables in that manner and had not anticipated a problem with regard to resident safety. UM-G verified following the incident, the facility barricaded the area with furniture to prevent resident access to the hot steam table until a thermal blanket could be obtained. UM-G indicated after the thermal blanket was obtained and placed on the steam table, the furniture barricading the area was removed. UM-G indicated initially the thermal blanket was secured on one side with Velcro to the countertop, but as of today (6/19/12) was being secured with snaps on all sides. UM-G verified the hot chocolate and coffee machines on the unit remain in the on position at all times. UM-G verified resident #1 does help himself to hot chocolate at times. UM-G stated the screen in front of the machines is pulled down at night. On 6/19/12 at 10:55 a.m. surveyor # interviewed MP (maintenance person)-C. MP-C stated the facility attempted to utilize Velcro to secure one side of the thermal blanket to the counter, but the Velcro was not holding well. MP-C stated the thermal blanket was now secured on all sides with snaps. On 6/19/12 at 11:13 a.m. surveyor # completed a telephone interview with CNA-H. CNA-H verified she was working the memory care unit on the evening in which resident #1 obtained the burn (5/12/12). CNA-H stated she did not witness the event, as she was not in the area at the time of the occurrence. CNA-H stated dietary staff would turn on the steam table approximately an hour before the meal, then exit the unit. CNA-H verified there was no barrier or direct supervision plan in place to prevent resident access to the hot surface. CNA-H stated there is not always nursing staff in the area, as staff are assisting residents with cares. CNA-H was unsure if anyone was monitoring the area. CNA-H verified following the incident, the facility placed barriers around the hot steam table to prevent resident access to the area and obtained a thermal blanket to cover the hot surface. CNA-H verified resident #1 did wander about the unit prior to and following the incident. CNA-H verified resident #1 is independently mobile in the wheelchair. On 6/19/12 at 11:22 a.m. surveyor # completed a telephone interview with CNA-I. CNA-I verified she was assigned to the memory care unit on 5/12/12 for the evening shift. CNA-I stated she did not witness resident #1 being burned, but had been informed following the event. CNA-I indicated resident #1's usual routine was to propel independently about the unit in the wheelchair, including around the kitchenette area. CNA-I was not aware of any supervision plan in place regarding the steam table when turned on prior to the incident. CNA-I confirmed there was no barrier or system in place to prevent resident access to the area when the table was on and hot. CNA-I verified following the event, furniture was placed around the steam table to prevent resident access to the area. CNA-I confirmed the facility obtained a thermal blanket to place over the surface when hot, and the furniture to block access to the area was removed. CNA-I verified the blanket had been secured on one side with Velcro, but the other three sides remained unsecured. CNA-I indicated she felt the blanket should be secured on all sides to prevent access to the hot surface. On 6/19/12 at 11:45 a.m. UM-G provided surveyor # with the facility incident report dated 5/12/12 (as noted above). UM-G confirmed it had been normal practice for dietary staff to turn on the steam table, then leave the area unsupervised. UM-G there had been no policy/procedure in place with regard to safety of the steam table when in use prior to the incident. At 12:06 p.m. on 6/19/12, UM-G informed surveyor # the facility placed the barricades (of tables) to prevent access to the area immediately following the incident, and discontinued the use of such furniture following the implementation of the thermal blanket on 6/7/12. UM-G confirmed the blanket was secured on the front side with Velcro when initiated. On 6/19/12 at 12:52 p.m. surveyor # interviewed LPN (Licensed Practical Nurse)-J. LPN-J verified she was assigned to the memory care unit in 5/12/12. LPN-J stated she had been informed resident #1 lifted the cover of the steam table and sustained a burn the the left thumb. LPN-J indicated she provided first aide to resident #1, then looked at the steam table. LPN-J verified the steam table was on and unattended by staff. LPN-J verified the table was accessible to residents. LPN-J indicated she lifted the cover of the steam table, and steam escaped. LPN-J stated she immediately placed tables around the area to prevent resident access to the area, then called the dietary department. LPN-J stated she was informed it was the normal process for dietary staff to turn on the steam tables approximately an hour before the meal, then exit the unit until the meal was to be served. LPN-J indicated she was not aware the steam table was turned on and unattended. LPN-J verified she was not in the area of the steam table at the time the incident occurred. LPN-J indicated staff were alerted to the incident by a visitor, and no staff had witnessed the event. LPN-J verified the CNA's were not in the area either as they were assisting other residents. LPN-J indicated leaving a steam table on and unattended on a unit in which cognitively impaired residents reside was a safety hazard. LPN-J indicated she works for a staffing agency and had only worked at the facility one other time; therefore she was unaware of the facility practice. On 6/19/12 at 1:45 p.m. surveyor # completed a telephone interview with CNA-K. CNA-K confirmed she was assigned to resident #1's unit on the evening of the incident (5/12/12). CNA-K verified she was not in the area at the time of the incident. CNA-K was not aware of a supervision plan in place regarding the steam table when on prior to the incident. On 6/19/12 at 2:20 p.m. surveyor # completed a telephone interview with DA-L. DA-L was unsure of the date of the incident with resident #1, but indicated she did remember a nurse calling dietary and "complaining the table was too hot". DA-L verified it was the facility practice to turn on the steam table approximately an hour before the meal was served, then leave the unit, and return when the meal was to be served. DA-L was not aware of any precautions in place regarding the steam table, including no system of notification of nursing staff that the table was turned on. DA-L stated the dial on the steam table ranges from 1-10 and would be turned on to 7 or 8, and when staff would return to place the food in the table and serve the water in the table would be boiling. During a telephone interview with surveyor # on 6/19/12 at 3:45 p.m., DA-Q verified she was working on 5/12/12. DA-Q believed she was probably the staff who turned on the steam table on resident #1's unit to heat up for the supper meal. DA-Q verified the facility practice of turning on the steam table approximately one hour before the meal and leaving the unit. DA-Q indicated she did not report to anyone on the unit that the steam tables were turned on prior to her exiting the unit. DA-Q could not recall if any staff were present in the area. During a telephone interview with surveyor # on 6/20/12 at 9:58 a.m. HSK (housekeeper)-T verified she was assigned to the memory care unit on the evening of 5/12/12. HSK-T verified she was not in the general area of the steam table when resident #1 sustained a burn. HSK-T indicated she was not aware of the incident until the following day. On 6/19/12 at 2:45 p.m. surveyor # interviewed DD (Director of Dietary)-M and ADD (Assistant Director of Dietary)-N. DD-M verified the process of dietary staff turning the steam tables on approximately an hour before the meal, then dietary staff would return to the kitchen until meal service would begin on the unit. DD-M stated she would have expected nursing staff to supervise the area when the steam tables were on until dietary staff returned to serve the meal. DD-M verified the facility had general meetings regarding the use of the steam table on the unit for all meals, but no specific plan regarding supervision had been established. DD-M indicated the unit manager and CNA's were informed of the time the steam tables would be turned on, but no direction that dietary staff would need to report to anyone when the steam tables were in use to ensure staff were supervising the area. Furthermore, DD-M and ADD-N were not aware of any direct supervision plan implemented other than general supervision by staff on the unit. DD-M and ADD-N verified following the incident with resident #1, the area by the steam table was secured with furniture to prevent access. DD-M verified on 6/7/12 a thermal blanket was placed over the steam table and secured only on one side with Velcro, and the barricades removed. ADD-N indicted on 6/13/12 or 6/14/12 a maintenance request was initiated to place some type of grommet system to secure the thermal blanket as it was evident the Velcro was not staying in place. DD-M and ADD-N verified the mat was secured on all sides with snaps on 6/19/12. On 6/19/12 at 2: 55 p.m. surveyor # interviewed MP-O. MP-O indicated within a couple of days of implementation of the thermal blanket secured on one side with Velcro, staff informed him the Velcro was not staying in place. MP-O indicated staff had been removing the entire blanket from the counter with each use, instead of flipping the blanket over the front of the counter as he had envisioned. MP-O indicated he instructed staff to leave the Velcro adhered and just flip the blanket over the front of the counter. MP-O stated after a couple of days after this instruction to staff, again he was informed the Velcro was not staying in place. At that time MP-O identified the steam was causing the Velcro to not adhere well, and it was evident another approach needed to be implemented. MP-O stated the facility had snaps which were to be secured into the counter and the thermal blanket. MP-O verified the snaps were placed on 6/19/12. MP-O indicated he was not sure of the exact date in which he identified the Velcro was not effective but indicated it was within the first few days of use. MP-O verified the facility had the supplies (snaps) for the thermal blanket prior to 6/19/12, but due to time constraints was not completed until today. On 6/19/12 at 3:10 p.m. surveyor # interviewed NHA (Nursing Home Administrator)-P. NHA-P stated the facility had been utilizing the steam table on the memory care unit for the breakfast meal for approximately 2 years, and verified the steam table had not been secured or directly supervised while on during that time period. NHA-P indicated the facility expanded the use of the steam table to the lunch and supper meals as well around the end of April 2012. NHA-P verified there had been no direct supervision plan of device to prevent access prior to the incident involving resident #1. NHA-P stated during the implementation process the area was monitored, and no identified safety risk had been identified. NHA-P stated she felt there were enough staff in the general area during the times the steam tables were turned on to provide general supervision to the area. NHA-P verified after the incident with resident #1, the area was barricaded to prevent resident access, and a thermal blanket was obtained NHA-P verified after the thermal blanket was obtained the furniture barricading the area was removed. On 6/20/12 DD-M provided surveyor # the following information: DD-M indicated on 3/27/12 the facility began serving lunch on the unit utilizing the steam table, and on 4/30/12 the facility began utilizing the steam table on the unit for the supper meal as well. On 6/19/12 at 5:52 p.m. UM-G verified to surveyor # the facility does not measure the temperature of the actual steam tables, but does monitor the holding temperatures of the food being stored within the table. UM-G provided surveyor # a copy of the temperatures recorded for the food in the steam tables on the memory unit. The temperatures recorded for the supper meal on 5/12/12 were recorded as follows: Meat: 150 (degrees) Potato: 140 Vegetable: 175 Puree: Meat: 180 Puree: Potato: 160 Puree: Vegetable: 180 On 6/19/12 at 5:55 p.m. surveyor # interviewed LPN-R. LPN-R verified resident #1 has cognitive impairments, and is independently mobile about the unit in a wheelchair. LPN-R stated resident #1 is always exploring and rummaging through items on the unit, needing redirection. LPN-R indicated although staff redirect resident #1 when he obtaining his own ice cream, hot chocolate, resident #1 does not remember. LPN-R verified there had not been a supervision plan in place regarding the hot steam table prior to the incident with resident #1 sustaining a burn. LPN-R in general staff are in the area, but there were times in which the area was not directly supervised. LPN-R verified resident #1 helps himself to hot chocolate from the machine located in the dining area. LPN-R stated staff redirect when they see resident #1 obtaining the hot liquid independently, but resident #1 does not remember to ask for assistance. LPN-R indicated the screen in front of the machines is pulled down at night, but open during other waking times. LPN-R indicated she was not aware if resident #1 was assessed to be safe to obtain his own hot chocolate from the machine, and was not aware of any specific plan other than redirection. On 6/19/12 at 6:12 p.m. surveyor # observed the hot chocolate and coffee machines to be accessible to residents (the screen was not down). The temperatures measured: hot chocolate=143.2 degrees Fahrenheit, coffee=134.9, hot water=140.5, and decaffeinated coffee=141.2. At 6:16 p.m. surveyor # interviewed DA-L. DA-L verified the screen in front of the machine is pulled down at night, but otherwise is accessible to residents. DA-L verified resident #1 does try to help himself, and when observed, staff will assist. On 6/20/12 at 7:40 a.m. and 12:02 p.m. UM-G verified to surveyor # resident #1 does assist himself to hot chocolate from the machine. UM-G verified no assessment for the safety of this practice for resident #1 had been completed. UM-G verified resident #1's care plan did not address any safety concerns or interventions for this practice. On 6/20/12 at 8:02 a.m. surveyor # interviewed CNA-S. CNA-S verified resident #1 does obtain hot chocolate from the machine independently at times. CNA-S indicated staff assist when observed as they do not want resident #1 to get burned. CNA-S stated the liquid temperature from the machine is very hot and has the potential to cause a burn. CNA-S verified she was unsure if resident #1 was deemed safe to use the machine independently, and was not aware of a specific supervision plan in place. On 6/20/12 at 9:45 a.m. DD-M verified to surveyor # the facility did not have a written policy and procedure for the use of the unit steam tables or the hot chocolate /coffee machines. DD-M indicated dietary staff do test the temperatures of the coffee/hot chocolate on a weekly basis. Surveyor # reviewed the temperature logs. The logs documented the coffee and hot chocolate temperatures from 12/14/12-6/12/12 ranged from 134 to 156 degrees Fahrenheit. During an interview with surveyor # on 6/20/12 at 7:30 a.m. UM-G verified the memory care unit was home to a total of 24 residents, 13 of which were independently mobile either with or without assistive devices. UM-G verified all residents who resided on the unit had cognitive impairments.

Based on observation, staff interview and record review, the facility did not ensure that 2 (residents #5 and #4) of 5 residents reviewed for pressure ulcers in a total sample of 24 residents received the necessary care and treatment to prevent the development of pressure ulcers, promote healing and prevent infection. Resident #5 was admitted with no pressure ulcers and was identified by the facility as being at low risk for the development of pressure ulcers. Eight days after being admitted , resident #5 developed a stage II (partial thickness skin loss) sacral pressure ulcer, which subsequently deteriorated and became unstageable, necrotic with tunneling and infected. Resident #5 had to be admitted to the hospital for four days to receive intravenous antibiotics and surgical debridement of the ulcer revealing a stage IV (full thickness skin loss with exposed tendons, muscles or bones) pressure ulcer. Although some interventions were in place, the facility did not consistently evaluate or revise interventions when they identified deteriorating characteristics of resident #5's pressure ulcer. The failure of the facility to implement alternate interventions when resident #5's pressure ulcer showed marked signs of further deterioration created a situation of immediate jeopardy beginning on 5/11/11. The Nursing Home Administrator was formally notified of the immediate jeopardy on 6/28/11 at 11:00 a.m. Immediate jeopardy was determined to have been removed on 6/30/11, but not corrected. The deficiency continues at a scope/severity level of D (potential for harm that is not immediate jeopardy/isolated) related to resident #4 and that resident's potential for development of pressure ulcers. Resident #4 was identified to be at risk for the development of pressure ulcers. The facility did not consistently provide the resident with appropriate preventative measures. Findings include: 1. The face sheet, dated 6/16/11 and contained within the medical record, indicated resident #5 was initially admitted to the facility on [DATE] following a four-day hospitalization for treatment of [REDACTED]. The hospital transfer summary, dated 4/19/11, indicated the resident had multiple [DIAGNOSES REDACTED]. The facility's admission nursing assessment, dated 4/19/11, indicated resident #5 was alert; oriented to person, place and time but with unclear speech; was pleasant, cooperative, incontinent of bowel and bladder, dependent for bed mobility and hygiene requiring one-person assist; and was dependent for transfers, dressing and toileting requiring a two-person assist. The admission skin check, dated 4/19/11, indicated resident #5 had no pressure ulcers and no discoloration or abnormalities to the sacral area. The initial Braden Scale assessment, which is used for predicting pressure ulcer risk, was completed on 4/19/11 and resulted in a score of 15 (low risk). The initial skin integrity care plan developed on 4/19/11 for resident #5 directed staff to: *Turn and reposition before and after meals, with rounds (every two hours) and as needed, *Complete weekly body checks, *Assess and document skin status, *Handle skin gently, avoid friction and shearing, *Moisturize skin daily and as needed, *Keep skin clean and dry, *Keep heels up off of bed. The initial nursing assistant daily plan of care, initiated on 4/19/11, indicated the facility also implemented a pressure reducing ROHO cushion in resident #5's wheel chair and a pressure reduction mattress to the resident's bed. On 4/21/11 a weekly skin check was completed for resident #5 and indicated no skin breakdown. The skin check, dated 4/28/11, indicated resident #5 had developed an open area to the sacrum. The wound assessment, dated 4/28/11, indicated the open area was assessed to be superficial and a stage II pressure ulcer. The wound bed, edges and surrounding tissue were described as pink, and the pressure ulcer measured .9 x .7 cm (centimeters) in length and width. The resident had no pain. Resident #5's family, physician and the facility dietitian were updated related to the pressure ulcer. The facility implemented the following additional interventions to resident #5's skin integrity care plan: *Have resident lay down between meals and therapy, and *Apply a [MEDICATION NAME] dressing to open area, change every three days and as needed. On 6/27/11 at 10:50 a.m. surveyor # interviewed CNA (Certified Nursing Assistant)-G regarding resident #5. CNA-G indicated from the time resident #5 was first admitted to the facility until the resident was put on bed rest on 4/28/11, it was the resident's routine to get up in the wheel chair for meals and therapies and lie down in bed the rest of the time. On 6/28/11 at 8:47 a.m. surveyor # interviewed RNUM (Registered Nurse/Unit Manager)-A regarding resident #5. The RN indicated she verified with other nursing staff, who were familiar with resident #5's daily routine since admission, that the resident was up in the wheel chair for meals and therapies and would take breaks and lie down in between. On 6/28/11 at 9:00 a.m. surveyor # interviewed RN-M regarding resident #5. RN-M verified when resident #5 was admitted to the facility, it was the resident's daily routine to be up in the wheel chair for meals and therapies and lie down the rest of the time. Per the above interviews, the care plan intervention put in place after resident #5 developed a stage II pressure ulcer was not a change to the resident's current routine. On 5/5/11 a weekly skin check was completed and indicated a stage II pressure ulcer continued to resident #5's sacral area. The pressure ulcer assessment completed on 5/5/11 for resident #5 indicated the ulcer continued at a stage II but increased in size significantly, measuring 3 x 3 cm in length and width and .5 cm in depth. The ulcer was assessed to have a pale-to-pink wound bed with slough and uneven pink surrounding tissue/edges. The resident had no pain. The "Plan of Care Updated" section of the assessment form was left blank. Dietary was updated. No changes were made to resident #5's care plan and no new changes in treatment were implemented. The pressure ulcer assessment completed on 5/6/11 indicated resident #5's pressure ulcer further deteriorated and became unstageable (full thickness ulcer that has slough, necrosis or scab covering the wound bed; and depth is unable to be determined), measuring 3 x 3 cm in length and width and .1 cm in depth, scant yellow exudate, wound bed covered in slough with uneven surrounding tissue/edges and surrounding skin was pinkish. The resident had no pain. The facility updated the physician and received new treatment orders. The care plan was updated to include: *Resident to be up for meals and therapy only (which was no change from the previous care plan), *Side-to-side repositioning in bed, and *Air mattress to bed. On 5/9/11 the facility implemented an alteration in skin integrity care plan to replace the initial care plan. That care plan included the following changes: *Reposition resident every one to two hours, *Remind resident to shift weight in wheel chair, *Dietary - one egg daily, good source of vitamin C daily and large meat portions, and *Assess need for or administer house supplement if resident has less than 50% intake. Although resident #5 developed a pressure ulcer on 4/28/11, the facility did not complete an analysis tool to determine the cause or contributing factors of resident #5's sacral pressure ulcer until after the ulcer deteriorated and was unstageable. On 5/9/11 the facility completed an analysis tool, which alleged the pressure ulcer developed from a deep tissue injury that could have been acquired at the resident's gynecology appointment on 4/26/11. The facility's analysis indicated when the facility questioned the family member who accompanied the resident to the appointment, the family member stated the resident bounced on the exam table to move into position. The "Release of Responsibility for Leave of Absence" sign out sheet indicated on 4/26/11 resident #5 was out of the facility from 1:30 p.m. until 4:30 p.m. with family. The "Report of Consultation" form, dated 4/26/11, indicated resident #5 saw the gynecologist that day. The form gave no indication of any difficulty with transferring or positioning the resident during the appointment. On 6/27/11 at 3:00 p.m. surveyor # spoke with RN-N from resident #5's gynecologist's office. RN-N consulted with resident #5's physician and verified to surveyor # that resident #5 was examined at that office on 4/26/11. RN-N indicated the transfer for resident #5 was gentle, the resident was not left on the padded table for very long and there was nothing documented indicating there could have been any injury to the resident during the appointment. On 6/27/11 and 6/28/11 surveyor # made several attempts to contact resident #5's family member, who was at the gynecologist appointment with the resident on 4/26/11, but was unsuccessful. The facility's policy and procedure titled "Skin Care Interventions", revised 4/30/09, indicated deep tissue injuries...appear as a deep maroon or purple blood-filled blister caused from pressure or shearing and may appear boggy, cool, warm, firm or mushy. The facility did not have any documentation indicating the above characteristics to resident #5's sacral area after the gynecologist appointment and before the stage II pressure ulcer was noted. Additionally, the facility's assessments of resident #5's sacral pressure ulcer were not consistent with the above characteristics of a deep tissue injury. The 5/11/11 wound assessment indicated resident #5's pressure ulcer measured 2.8 x 2.9 cm in length and width (smaller) and .3 cm in depth (deeper). The assessment indicated the wound had scant exudate, slough in the wound bed, and the surrounding skin was pink/red; but the ulcer deteriorated and had a foul odor. The resident had no pain. The assessment indicated the care plan was not updated, and the nurse practitioner would be coming that week to assess the ulcer. The progress notes indicated resident #5 was assessed by the nurse practitioner on 5/11/11. The facility received orders from the nurse practitioner to continue the same treatment, have the dietitian review the resident and refer the resident to the wound clinic. Although resident #5 was assessed by the nurse practitioner, as the wound continued to deteriorate, the facility did not evaluate the current interventions for effectiveness, did not revise them to prevent further deterioration, and did not implement new changes in treatment. On 5/12/11 the weekly skin check for resident #5 indicated, "Ulcer to coccyx." On 5/12/11 and 5/13/11 the facility provided an inservice to licensed staff on pressure ulcer prevention and identification. One piece of the education defined a deep tissue injury as "...purple or maroon area of discolored, intact skin or blood filled blister." The education also directed, "Any deterioration of the area must be immediately reported to the nurse manager and physician and the treatment re-evaluated." On 6/27/11 at 7:05 a.m. RNUM-A verified to surveyor # the 5/12/11 and 5/13/11 inservice was not in response to any pressure ulcer issue at the facility, but as a refresher for staff. The pressure ulcer assessment completed on 5/18/11 indicated resident #5's pressure ulcer continued to deteriorate, measuring 2.9 x 3.0 cm in length and width (larger) and 1.2 cm in depth (deeper). The wound was unstageable, had scant exudate, foul odor, slough to the wound bed, surrounding skin was pink/red, and the edges were uneven. Resident #5 continued with no pain. All prior assessments revealed there had been no tunneling, but this assessment indicated "unable to tell" where tunneling would have been documented. Even though resident #5's pressure ulcer again continued to deteriorate, the facility made no changes to the resident's plan of care or in treatment, only commenting on the assessment form, "Has appointment at wound clinic on 5/24/11." A weekly skin check, completed on 5/19/11, noted the pressure ulcer continued to be unstageable. The nurses' notes dated 5/19/11 in resident #5's medical record indicated, "Wound continues to decline; slough starting to lift off. Pressure reduction measures in place. Wound Clinic appointment on 5/24/11." No interventions to resident #5's care plan were evaluated or revised, and no changes in treatment were implemented. Nurses' notes on 5/20/11 noted the slough was darker in color and thready, the ulcer began tunneling enough to fit the cotton tip of a Q-tip, and the foul odor persisted. Although the wound was again assessed to be deteriorating, no changes to the plan of care or in the treatment of [REDACTED]. On 5/21/11 the nurses' notes indicated the pressure ulcer continued with a foul odor, slough and necrotic tissue with tunneling. Again, no changes to the plan of care or in the treatment of [REDACTED]. On 5/23/11 the nurses' notes indicated resident #5's pressure ulcer continued with a foul odor, slough, necrotic tissue and tunneling. On 5/23/11 the facility obtained an order via fax from resident #5's physician to begin [MEDICATION NAME], a nutritional supplement to promote wound healing. On 5/24/11 resident #5 went to the wound clinic for treatment of [REDACTED].#5 presented with chills and felt achy. Resident #5 was referred to the hospital from the wound clinic. The hospital infectious disease consultation, dated 5/25/11, indicated resident #5 was admitted to the hospital on [DATE] after being referred from the wound clinic for surgical debridement and intravenous antibiotics. The report indicated the resident's temperature was ranging from 99.1 degrees to 101.1 degrees, and the resident's white blood cell count was elevated (indicative of infection). The exam of the sacral ulcer read "... there is a deep, possible stage 4, ulcer, necrotic base with hard induration around the surrounding area and [DIAGNOSES REDACTED]. There is a very strong odor to it." The consultation also noted the sacral ulcer would require intravenous antibiotics and surgical debridement. The hospital transfer summary, dated 5/28/11, indicated resident #5's sacral pressure ulcer was cultured and showed Escherichia Coli (bacteria normally found in the intestines), [MEDICATION NAME] (bacteria normally found in the intestines) and Dipthroids (bacteria that is considered normal flora). Resident #5 required surgical debridement of the necrotic stage IV sacral pressure ulcer and intravenous antibiotic treatment for [REDACTED]. On 6/28/11 at 9:02 a.m. surveyor # interviewed RN-M regarding changes to the plan of care for resident #5 related to the pressure ulcer. RN-M indicated any changes in care interventions would be in the resident's care plan, which was where direct care staff would look to find out how to care for a resident. RN-M indicated, "If during a pressure ulcer assessment, a change for the worse is noted, the physician will be notified. If there's no new orders, then there's not much you can do." When surveyor # asked if staff could still revise interventions, even though the physician had no new orders, RN-M stated, "Oh yeah, there are always many, zillions of interventions you can try. It just depends on the situation." The failure of the facility to aggressively pursue alternative interventions when resident #5's pressure ulcer began to show signs of further deterioration, such a foul odor on 5/11/11, created a situation of immediate jeopardy starting on 5/11/11. The immediate jeopardy was removed on 6/30/11 when the facility initiated mandatory training for all nursing staff related to pressure ulcer prevention and treatment. The training addressed assessment including information related to the Braden Scale, skin and pain assessment, risk factors and CNA responsibilities; preventive interventions including appropriate surfaces and cushions, turning/repositioning, minimizing of friction/shear, pressure reduction devices, managing urinary/fecal incontinence, managing infection and nursing care plans/CNA plans of care; and monitoring/evaluation including changes in skin, appropriate skin barriers/interventions, wound team, daily/weekly skin inspections, nutrition and hydration, labs, risk/benefit education, weekly wound assessment by wound team, thorough documentation and physician notification/consultation. The deficiency continues at a scope/severity level of D (potential for harm that is not immediate jeopardy/isolated) related to resident #4 and that resident's potential for development of pressure ulcers. 2. The disease index report, dated 6/9/10 and contained within the medical record, indicated resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change MDS (Minimum Data Set), dated 5/19/11, revealed resident #4 had no pressure ulcers at that time and was at risk for the development of pressure ulcers. Interventions in place for resident #4 listed on the MDS included pressure reducing device for bed and chair. On 5/10/11 resident #4 was admitted to a Hospice program. On 6/9/11 a Hospice nurse's note indicated resident #4 had a "reddened spot" on the buttocks. On 6/18/11 a facility nurse's note indicated the facility had "...notified hospice of 2 dark bruised areas on coccyx, CNA noted no cushion in chair, hospice will order cushion." Additional facility nurses' notes from 6/18/11 indicated "...weekly skin check - stage II (pressure ulcer)." A Hospice nurse's note, dated 6/20/11, indicated the development of an open area on resident #4's buttocks. A Roho cushion, gel pad or other cushion device was not ordered for resident #4 until 6/18/11 when the bruised area on resident #4's coccyx advanced to a stage II pressure ulcer. Nurses' notes on 6/18/11 indicated, "Hospice getting (Roho cushion)." On 6/22/11 surveyor # requested and received the skin integrity written plan of care for resident #4 from RNUM-A. Interventions included on the plan of care directed staff to apply a Roho cushion in resident #4's wheel chair, conduct weekly skin checks and report to the nurse if any skin tears, bruising or redness were observed. The plan of care further directed staff to not place resident #4 in the lounge area after meals and ensure proper sitting position in the Broda chair. On 6/23/11 at 8:15 a.m. RNUM-A presented surveyor # with an updated plan of care for resident #4. The updated care plan no longer included use of the Roho cushion, and added "...side to side repositioning frequently every one to two hours while in bed, Meplex dressing to bilateral buttocks near coccyx, and lay down between meals unless family here to visit." On 6/24/11 at 7:35 a.m. surveyor # interviewed RNUM-A regarding the use of a Roho cushion for resident #4. RNUM-A indicated resident #4 had a previous order and used a Roho cushion, which was discontinued on 5/22/11. According to RNUM-A, use of a Roho cushion in a Broda chair was unnecessary, as the Broda chair had pressure reducing properties. RNUM-A did indicate Hospice was slated to bring a Roho cushion, but it still had not arrived as of 6/24/11. On 6/24/11 RNUM-A obtained a cushion from the facility's own stock to provide pressure relief for resident #4. Additionally, when asked, RNUM-A indicated it would be preferred that resident #4 be up in the chair no longer than one hour at a time. On 6/23/11 at 8:04 a.m. surveyor # observed CNA-J transfer resident #4 to a Broda chair with no additional cushion. Surveyor # made a continuous observation from that time until 10:00 a.m. During the observation, resident #4 was given breakfast in the dining room. At 9:30 a.m. the resident was moved to the lounge area, where she remained until moved by CNA-J back to her room at 10:00 a.m. At no time during the observation was resident #4 repositioned in the chair. On 6/24/11 at 8:00 a.m. surveyor # observed resident #4. The resident was laying in bed in a side-lying position with the right leg resting on top of the left leg. The resident's bony prominences of the knees and ankles were touching, and both heels were observed to be in direct contact with the mattress. On 6/24/11 at 12:25 p.m. surveyor # observed CNA-K transfer resident #4 to the Broda chair, which had a Roho cushion. Resident #4 remained in the Broda chair through the noon meal. At 1:40 p.m. CNA-K stated to the surveyor resident #4 would not be laid down, as the resident had an appointment at the beauty shop. At 2:05 p.m. and 2:45 p.m. surveyor # observed resident #4 in the beauty shop, sitting in a wheel chair. On 6/27/11 at 8:00 a.m. surveyor # observed resident #4 in the lounge. The resident was sitting in the Broda chair, dressed and waiting for breakfast. Resident #4 was wheeled to the dining area; and after breakfast, at 9:05 a.m., resident #4 was wheeled back to the lounge, in front of the television. At 9:45 a.m. surveyor # observed resident #4 being transferred from the Broda chair to bed. CNA-L positioned resident #4 in bed, placing the resident's feet and heels directly on a pillow. On 6/27/11 at 10:00 a.m. surveyor # interviewed CNA-L regarding the above observation of positioning for resident #4. CNA-L confirmed the heels of resident #4 were resting on the pillow to prevent pressure ulcers.

Based on staff, physician and family interviews and record review, the facility did not ensure sufficient fluid intake to prevent dehydration for 1 (resident #1) of 14 sampled residents. Resident #1 had a decline in her ability to eat and drink independently following a fall on 9/21/10 with fractures. The facility did not calculate fluid needs for resident #1 based on her body weight after the resident experienced a decline in her ability to eat and drink independently. The facility did not monitor their intake records to ensure adequate intake for resident #1 and did not communicate between Nursing and Dietary Departments to prevent further decline in hydration. The facility did not recognize the need to monitor resident #1's condition until after the family brought forth the concern of her decreased intake on 9/29/10. At that point the facility began recording I&O (intake and output) between meals. The facility did not calculate the daily totals of those records or of fluid intake records between 9/23/10 and 9/29/10. The facility did not use the I&O records to adjust resident #1's care plan to meet her intake needs. The facility did not inform the physician, on 9/30/10 during his exam of resident #1, of the extent of the decrease in fluid intake from 9/23/10 to 9/30/10. The facility did not inform resident #1's physician of her further decrease in intake and altered mental status from 9/30/10 to 10/3/10. On 10/3/10 resident #1 was hospitalized with severe dehydration. The facility's actions created a situation of Immediate Jeopardy to resident #1's health and welfare that began on 9/23/10. On 10/21/10 the facility was formally notified that an Immediate Jeopardy situation existed. The Immediate Jeopardy situation was determined to be removed but not corrected on 10/21/10. The deficiency continues at a scope/severity level E (potential for harm that is not Immediate Jeopardy/pattern) for residents #4, #5, #6, #7, #8, #9, #10 and #11 until the facility is able to evaluate and implement procedures within the facility that will ensure residents at risk for dehydration are appropriately assessed and adequate interventions are implemented. Findings include: The face sheet, contained within the medical record and dated 10/22/09, indicated resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's DPOAHC (Durable Power of Attorney for Health Care) was activated on 3/15/10 making FM (Family Member)-C resident #1's DPOAHC. Resident #1's MDSs (Minimum Data Sets) dated 7/1/10 and 9/12/10 indicated the resident had modified independence, some short-term memory loss and needed only supervision at meal times. The annual MDS dated [DATE] had a triggered RAP (Resident Assessment Protocol) for dehydration due to resident #1 being on [MEDICATION NAME]/HCTZ 37.5/25 once daily for hypertension, which is a diuretic. The RAP indicated no signs or symptoms of dehydration, no weight loss (resident #1 weighed 139.8 pounds) and mucous membranes moist. Nurses' notes on 9/21/10 indicated resident #1 sustained a fall in her room while transferring with a CNA (Certified Nursing Assistant). The hospital emergency room report dated 9/21/10 showed resident #1 sustained a small nasal fracture with two lacerations to her nose; a fractured right proximal humerus, treated with an immobilizer; a 1 cm (centimeter) facial laceration; a 3 cm inner upper lip laceration requiring three sutures and a large hematoma over her left eye. Resident #1 returned to the facility the evening of the fall. During an interview with surveyor # on 10/19/10 at 3:10 p.m. CNA-G and CNA-H said after resident #1's fall on 9/21/10, the resident did not eat or drink well. The CNAs felt resident #1 took in minimal fluids after the fall. CNA-H indicated that, before the fall, resident #1 was independent in eating and drinking. After the fall, the resident was dependent on staff to eat and drink. CNA-H said resident #1 had difficulty taking liquids even from a straw and would decline at times when offered. CNA-H said that, after the fall, staff logged resident #1's intake at meals and fluids like they did on all residents. CNA-H said resident #1 would hesitate to answer before the fall; but after the fall, was lethargic, had trouble making her needs known and would stare into space. Prior to the 9/21/10 fall, resident #1's care plan indicated she was independent in feeding herself but required some supervision. After the 9/21/10 fall, resident #1 was seen by Occupational Therapy for an evaluation on 9/27/10. That evaluation indicated resident #1 had been independent in feeding herself and in wheel chair mobility prior to the 9/21/10 fall. The evaluation showed that, after the 9/21/10 fall, resident #1 had a decreased level of function, needed to be transferred with a Hoyer lift and was dependent for feeding and hygiene needs. On 9/28/10 an Occupational Therapy note indicated resident #1 had poor neck strength, required neck support and needed a built up handled spoon and swivel spoon to improve her feeding ability. On 9/21/10 a note was made on resident #1's nutritional assessment, which indicated "Trial puree texture." There was no evidence of any further nutritional assessment of resident #1's need for monitoring or assistance to eat despite her injuries from her fall, which impaired her ability to feed herself. The facility did not complete an assessment as to what resident #1's hydration needs were when the resident became dependent for her intake and more at risk for dehydration. In an interview with surveyor # on 10/19/10 at 3:05 p.m., RN (Registered Nurse)-F, who worked on resident #1's wing, said that if a resident was on a hydration program, they would receive fluids with med pass; and the nurse aides would provide extra fluids with snacks throughout the shift. RN-F indicated she was not aware of a fluid needs assessment completed on resident #1 to alert staff to individual resident fluid needs. There was nothing specific to resident #1 that she was aware of. On 10/19/10 at 3:10 p.m. surveyors # and # interviewed DM (Dietary Manager)-I, ADM (Assistant Dietary Manager)-J, RN-A and RN-B regarding fluid needs and intake for residents. DM-I indicated the facility coordinated fluid intake with meals. She indicated they would use the fluid assessment to determine if residents needed more monitoring. DM-I said the facility did not routinely identify the fluid needs for each resident. If a resident scored a 3 or above on the fluid assessment sheet, they would not put the resident on a hydration risk program. Resident #1's fluid assessment dated [DATE], when she was independent, indicated she scored a 6. There was no further fluid assessment completed by the facility after resident #1's fall on 9/21/10. In an interview with surveyor # on 10/19/10 at 4:12 p.m. RN-B, who worked the unit where resident #1 resided, verified resident #1 had no change to her plan of care regarding hydration to address the resident's decreased ability to eat and drink independently. Nurses' notes and daily intake for meals/fluids for resident #1 were as follows: 9/23/10 - 330 cc's (cubic centimeters) - emesis of pureed food. Ate 100% lunch. 9/24/10 - 470 cc's - Didn't cooperate with fluids offered. Refused lunch. Dr. dc'd [MEDICATION NAME]. Thought it caused nausea and vomiting. 9/25/10 - 360 cc's 9/26/10 - 180 cc's 9/27/10 - 390 cc's - Having hard time keeping head up. Ordered high back wheel chair. Refused dinner. Temp - 99.4. 9/28/10 - 270 cc's - Eats with staff assistance. 9/29/10 - 580 cc's - Care plan conference. Family questioning fluid intake now that resident can't eat independently. Dietary reported taking fluids well. (It should be noted there was no documentation to support that.) Started charting intake on the p.m. shift per family's request. O.T. (Occupational Therapy) requested a curved spoon at meals. The facility did not take measures to monitor resident #1's fluid intake until resident #1's family brought a concern for her decreased intake to their attention. Resident #1's care plan was changed on 9/28/10 to note the resident needed extensive assistance and was to use a swivel spoon at all meals. On 9/29/10 the care plan had a new approach added to chart every shift the amount of fluid given to resident #1 between meals. The care plan was updated on 9/30/10 to reflect resident #1's pureed diet, which had been trialed since her 9/21/10 fall due to stitches in her mouth, and that resident #1 needed assistance to eat and drink. A nurse assessment dated [DATE] and completed by RN-A showed resident #1 had no weight loss, fluids encouraged, voids every shift per CNAs, no signs and symptoms of dehydration and mucous membranes moist. In an interview with surveyors # and # on 10/19/10 at approximately 3:20 p.m. RN-A verified the meal/fluid intake from 9/23/10 to 9/30/10 looked inadequate. She verified she did not know what resident #1's intake should be based on body weight. There was no evidence of the facility taking orthostatic blood pressures or assessing to meet resident #1's hydration needs. RN-A indicated a hydration program was started on 9/29/10 after family questioned resident #1's intake. Per RN-A the tracking method for fluid intake the facility had was the daily meal/fluid intake sheets, which were completed on every resident. RN-A indicated those intake records were for meals. The RN indicated an additional sheet of intake for fluid between meals was started for resident #1 on 9/29/10 and would be started on anyone who scored less than 3 on the fluid assessment. Per interview with surveyor # on 10/19/10 at 3:20 p.m., DM-I, ADM-J, RN-A and RN-B did not know who was to monitor the daily intake sheets to determine if a resident was having a problem with hydration. The facility did not have a system to monitor fluid intake between meals to determine if residents were receiving proper hydration. Although the facility indicated resident #1 was started on a hydration program, there was no evidence the intake was being monitored and adjusted to meet her needs. On 10/19/10 at approximately 3:15 p.m. surveyors # and # interviewed ADM-J and DM-I regarding resident #1. ADM-J indicated she completed the dietary progress note on 9/30/10 for resident #1. That note indicated that, prior to her fall, resident #1 had average food intake of 90% and drank on average 950 cc's with three meals. ADM-J simply re-dated the fluid assessment on 9/30/10 but made no changes to it and did not complete a new assessment. There was no mention of what resident #1's intake was after the fall and no mention of what her fluid intake needed to be. DM-I and ADM-J confirmed the Dietary Department had not been notified of any decline in resident #1's intake. DM-I and ADM-J indicated they were not aware of a hydration program being started. Nurses' notes and meal/fluid intake records showed resident #1 to be deficient in fluid intake from 9/23/10 to 9/30/10. The facility did not notify the physician of the low intakes during his visit with resident #1 on 9/30/10. The facility's policy and procedure for Change of Condition-Notification dated March 6, 2009 indicated any signs or symptoms suggestive of an acute illness would be reported to the resident's physician by the charge nurse as soon as possible after they were identified. Any substantial change in physical condition, functional status, or new physical sign, which did not require immediate notification, should be discussed with the attending physician on rounds. On 9/30/10 resident #1 was seen by her physician, MD (Medical Doctor)-E, at 8:10 a.m. MD-E's physician note indicated resident #1 needed help with feeding. There was no mention of hydration needs or decline in intake. On 10/20/10 at 11:00 a.m. surveyor # spoke with MD-E. The physician verified he was aware resident #1's intake had declined. MD-E indicated, when he saw resident #1 on 9/30/10, he was not given any specifics regarding the extent of the decline in the resident's intake of fluids from 9/23/10 to 9/30/10. MD-E indicated resident #1 looked mildly dehydrated, in that her lips were dry, but her tongue appeared okay. MD-E felt resident #1's issue on 9/30/10 was her pain control due to her swelling and bruising from her fall on 9/21/10. The physician indicated he believed the resident's dry lips were attributed to her stitches and swelling of her mouth. MD-E indicated he did talk with the family about the resident's condition but would not have started IV hydration at that point. Nurses' notes and intake records for resident #1 from 9/30/10 to 10/3/10 showed: 9/30/10 - 840 cc's 10/1/10 - 520 cc's 10/2/10 - 390 cc's - 6:00 a.m. Shook head "no" for pain. Only stared - gave no response to writer's questions. Refused greater than 10 cc's fluid during night, incontinent times 2. 2:20 p.m. - Ate 25% breakfast, 75% lunch. 10/3/10 - 5:30 a.m. - Continues to stare and not respond if asked questions, alert. Refused more than 10 ml (milliliters) of water during night. Nurses' notes on 10/3/10 at 10:00 a.m. documented resident #1's family was in to see the resident and stated she was unresponsive. Vital signs were documented at 99.2. The writer explained resident #1 was on Tylenol #3, which could cause confusion and lethargy. Per the documentation, resident #1's daughter stated she was very concerned and wanted the resident sent to the hospital for an evaluation. At 10:15 a.m. the physician was notified. At 10:25 a.m. orders were received to send resident #1 to the hospital for evaluation and treatment, "...per family request." Nurses' notes, meal/fluid intake records and I&O records from 9/30/10 to 10/3/10 showed resident #1 was deficient in fluid intake and had altered level of consciousness on 10/2/10 and 10/3/10. The facility did not notify the physician of those changes. During the 10/20/10 11:00 a.m. interview with surveyor # , MD-E verified he was not informed of any decline in resident #1's intake by the facility from 9/30/10 to 10/3/10, when the resident was transferred to the hospital and found to be dehydrated. The vital sign sheet for resident #1 on 10/3/10 showed her vitals to be a temperature of 99.2 degrees with blood pressure of 120/78. On 10/19/10 at 1:30 p.m. surveyor # interviewed RN-A and RN-B regarding resident #1. RN-A indicated she felt resident #1 just started to show a decline on 10/3/10 when her temperature was 99.2 degrees. RN-A indicated resident #1 was still voiding four to five times a shift, but the RN did not know how much the resident voided. RN-A said resident #1 had no constipation; however, resident #1's MAR (Medication Administration Record) showed she received various medications of [MEDICATION NAME], Fleets Enema, and [MEDICATION NAME] suppository to promote bowel movements on 9/24/10, 9/27/10, 10/1/10, 10/2/10 and 10/3/10. RN-B confirmed any change of condition should be reported to the physician that same shift. RN-B confirmed the physician should have been called with resident #1's episodes of unresponsiveness; and after 9/30/10, the physician should have been notified of resident #1's decline in fluid intake. During a telephone interview with surveyor # on 10/19/10 at 9:12 a.m., FM-C indicated family attended resident #1's care conference on 9/29/10. Family was concerned resident #1 was not eating and drinking well. The facility told them they would watch it. On 10/3/10, when FM-C came to visit, resident #1 was just staring into space and not responding. FM-C was upset the facility hadn't notified the family about resident #1's decline. FM-C said the nurse on duty (unidentified) told her resident #1's vital signs were normal, and they weren't concerned. FM-C insisted resident #1 be sent to the hospital. Only then did the facility call resident #1's physician, who had the resident sent to the hospital. Nurses' notes on 10/3/10 documented a call was received from the hospital indicating resident #1 was being admitted for decreased level of consciousness and dehydration. The hospital emergency report dated 10/3/10 indicated, "The patient presents today from the nursing home because for the last 2 days, she has had a decrease in her mental status and really is not speaking the last day or two. Patient was hydrated and has some slow improvement. Will admit for hydration and further workup. Diagnoses: [REDACTED]." Hospital labs for resident #1 on admission on 10/3/10 indicated: Sodium - 149 (normal 136 - 144) BUN - 128 (normal 6 - 20) Creatinine - 2.70 (normal .4 - 1.0) Calculated Serum Osmolality was 361 mmol/KG (millimoles per litre/Kilogram). Standards of Practice from The University of Iowa College of Nursing Research Institute 2/04 indicate 280 to 300 mmol/Kg would indicate impending dehydration, and greater than 300 mmol/KG would indicate dehydration. The hospital History and Physical dated 10/3/10 indicated resident #1 was found to be in acute [MEDICAL CONDITION] with creatinine 2.7, up from 1.5 as her baseline (May 2010). The resident was hypernatremic and was felt to be significantly dehydrated. The hospital's impression and plan indicated: 1. Mental status change. It was documented there was probably at least some degree of dehydration contributing to that. 2. Acute or chronic [MEDICAL CONDITION]. Documentation indicated that was likely due to dehydration. Hydration was planned. 3. [MEDICAL CONDITION]. Documentation indicated it was suspected this was related to the resident's dehydration and deficiency of free water. The plan indicated hospital staff would use half normal saline for the resident's hydration and follow her sodium level. 6. Diabetes mellitus. The resident's blood sugar was quite high. Documentation indicated that would probably improve somewhat just with hydration. The hospital discharge summary for resident #1 dated 10/8/10 indicated the episode of [MEDICAL CONDITION] most likely related to dehydration had resolved. Acute [MEDICAL CONDITION] present on admission was resolved. The history of her present illness and hospital course indicated that, upon evaluation in the emergency room , resident #1 was found to be in acute [MEDICAL CONDITION]. Her nephrotoxic medications were held. She was started on IV fluid resuscitation. Labs for resident #1 improved on hospital discharge on 10/8/10 following hydration and indicated: Sodium - 137 BUN - 18 Creatinine 1.0 On 10/19/10 at approximately 3:30 p.m. RN-A, RN-B, DM-I and ADM-J were asked by surveyors # and # about their method of determining appropriate intakes to prevent dehydration. RN-A was manager for the west wing where resident #1 resided. RN-A indicated she did not know what resident #1's needs were but estimated them to be approximately 1,000 cc's per day. RN-B indicated she had just calculated resident #1's needs based on the resident's 140 pound weight to be 1900 cc's per day. DM-I and ADM-J indicated they did not identify fluid needs for each resident and did not know what they were for resident #1. The University of Iowa Gerontological Nursing Interventions Research Center standards of practice 2/04 indicated the mean amount of fluids for community dwelling elders was 2100 cc per day for a 132 pound resident. Resident #1 weighed 139.8 pounds. Based on the intake needs of 1900 cc's per day for resident #1, calculated by RN-B, resident #1 should have consumed 15,200 cc's from 9/22/10 to 9/29/10. Facility fluid records showed resident #1 consumed 2,820 cc's, which was a deficit of 12,380 cc's or an 81% deficit. From 9/30/10 to 10/3/10 resident #1 should have consumed 5,700 cc's. Facility fluid records showed the resident consumed 1,750 cc's, which was a deficit of 3,950 cc's. (or a 69% deficit). The facility policy and procedure for hydration dated 4/23/10 indicated the facility should consult the dietician or dietary manager to complete a fluid assessment and evaluate fluids served at meals and adjust as needed. The policy did not address what to do when a resident experienced a decline. It did not address how to calculate a resident's hydration needs. There was no indication of who should monitor the daily intake records to determine which residents had experienced a decline in their daily intake. On 10/19/10 the facility provided surveyor # the Roster/Sample Matrix, which identified residents #4, #5, #6, #7, #8, #9, #10 and #11 at risk for dehydration. The facility did not identify the risk factors of dehydration for resident #1. The facility did not develop and implement a plan of care to prevent dehydration for the resident. When the resident's risk factors increased, the facility did not recognize them and implement interventions. Facility staff did not alert the physician to the resident's inadequate fluid intake. The facility's actions created a situation of Immediate Jeopardy for resident #1. The facility removed the Immediate Jeopardy situation on 10/21/10 when training for all staff was initiated related to signs and symptoms of dehydration, recognizing risk factors, interventions and notification.