**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, Physician interview, Emergency Medical Service (EMS) interview, and facility policy review, the facility failed to provide adequate care and services to maintain the highest functional status for 1 of 2 residents with gastronomy tube (GT) (Resident #2). Resident #2 had an order to have his head of bed elevated while receiving his feeding. As the nurse gave Resident #2 his feeding, they had the head of bed lowered. When Resident #2 started to vomit, the nurse stopped the feeding, but failed to elevate Resident #2's head of the bed. When the certified nurse aides attempted to assist the nurse, the nurse told them to have him lay flat. Resident #2 suffered from aspiration pneumonia and septic shock. With not having Resident #2's head of the bed raised during administration of his feeding, the facility placed Resident #2 at an immediate jeopardy due to the likelihood of serious harm and/or death. The facility identified a census of 33. The Department notified the facility of the immediate jeopardy on 7/16/24 at 11:45 AM, that started on 6/28/24. The facility removed the immediacy on 7/16/24 by completing the following information: a. The Director of Nursing (DON) completed observational audits on 7/16/24 related to receiving enteral (feeding via a feeding tube) and elevation of their head of bed during their feeding as required, with no concerns observed. b. The DON educated the licensed nurses between 7/15/24 and 7/16/24. Any nurse who didn't complete the education on 7/16/24 must complete the education prior to the beginning of their next scheduled shift. c. The DON or designed will conduct audits weekly for 12 weeks to ensure the licensed nurses continue to elevate the residents head of bed during enteral feeding as required. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedure. Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Resident #2 rejected cares 1 to 3 days. Resident #2 required total assistance from staff with activities of daily living (ADL's), including repositioning. Resident #2 had functional limitation on both sides of his upper and lower extremities with range of motion (ROM). The MDS listed Resident #2 as non ambulatory. The MDS reflected Resident #2 had a catheter and a G tube (feeding tube). The MDS included diagnoses of pneumonia, pharyngeal phase dysphasia, drug induced secondary to parkinsonism, dysarthria, hypertension (htn or high blood pressure), schizophrenia, dementia, psychotic disorder, and delusions. The Care Plan included the following Focus areas and Interventions as dated: a. 12/27/23: Resident #2 used psychotropic medications related to (r/t) the disease process of Paranoid Schizophrenia. b. 5/16/23: Resident #2 required a tube feeding r/t swallowing problems. i. Revised 5/16/23: Dependent on staff with tube feedings and water flushes. ii. 5/16/23: Monitor, document and report to the Physician as needed (PRN) for the following: Aspiration, shortness of breath (SOB), abnormal breath/lung sounds and nausea and vomiting. iii. Revised 5/16/23: Resident #2 required the head of bed (HOB) elevated 45 degrees during and thirty minutes after a tube feeding. c. 2/1/24: A nutritional problem or potential for a nutritional problem r/t dysphasia and dependence on g tube feeds with met 100% of his needs. d. 2/5/24: An indwelling catheter. e. 3/21/24: Resistive to cares r/t Schizophrenia. f. 5/16/23: ADL self-care deficit. i. 5/16/23: Required two (2) staff assistance with bed mobility. (revised 5/16/23) ii. 5/16/23: Nothing by mouth (NPO). Resident #2's June 2024 Medication Administration Record (MAR) included a Physician's order for enteral feeding three times a day (TID) for 30 minutes before, after, and during meals at 9 AM, 1 PM, and 7 PM. Resident #2's Medication Admin Audit Report for 6/28/24 indicated he received his enteral feeding at 1:09 PM. During an interview on 7/16/24 at 2:19 PM Staff D, Certified Nursing Assistant (CNA), confirmed she repositioned Resident #2 before lunch and left him at a 30-degree angle. Staff D described Resident #2 as very tired that day, they described that as normal for him around that time. Staff D confirmed Resident #2 coughed a lot and sounded like he had stuff in his lungs, so they reported her observations to Staff B, Licensed Practical Nurse (LPN). During an interview on 7/15/24 at 2:27 PM Staff C, CNA, indicated Staff B came to her and reported Resident #2 just threw up and she needed assistance to reposition him. When the staff members entered Resident #2's room, they found him responsive but lethargic. Resident #2 requested they elevate his left arm the staff members repositioned him up further in the bed and elevated his arm on a pillow. Staff C confirmed Resident #2's HOB at approximately 15 degrees and that he threw up. Staff C cleaned up the emesis of tube feeding formula at which time Staff B directed her to lay Resident #2 flat. Staff C questioned Staff B why she wanted him lying flat and she replied, yes because he just threw up. Staff C only left Resident #2 flat for 1 2 minutes just long enough to pull out the chux pad out from under Resident #2. When she left Resident #2's room Staff C indicated she left Resident #2's HOB at a 30-degree angle. During an interview on 7/15/24 at 2:43 PM Staff B stated let me think when asked about the event on 6/28/24. Staff B recalled Resident #2 as congested and that she typically gave him his tube feeding at 1:00 PM. On 6/28/24 she found him more lethargic than normal but they had adjusted his pain medications, so she didn't think anything about it. Staff B checked Resident #2's gastric residual with no return prior to administering his tube feeding while positioned at a 30-degree angle. Staff B indicated she denied remembering any further events and requested time overnight to gather her thoughts. On 7/16/24 at 9:42 AM Staff B confirmed she administered Resident #2's feeding on 6/28/24 with the HOB elevated. When he had an emesis, she stopped the feeding and went to get Staff A, LPN, for a second opinion. Staff B described Staff A as a more experienced and very competent nurse, as she told him she planned to hold Resident #2's medications. Staff B reported that she couldn't recall anything else. During an interview on 7/15/24 at 1:23 PM Staff A indicated on 6/28/24 around 1:50 PM or 1:55 PM, Staff B came to him and said she planned on not administering Resident #2's medications because he threw. Staff A asked Staff B if he was OK, and she indicated he was fine. So, Staff A stated he would go talk to him. At approximately 2:05 PM, Staff A entered Resident #2's room he observed Resident #2 positioned in a supine position with his head on a pillow, tube feeding formula draining from his nose, and Resident #2 non responsive. Staff A immediately raised the HOB close to a 90-degree angle. Staff A assessed Resident #2 and found an O2 (oxygen) saturation rate of 84 88%, so he increased Resident #2's oxygen to 5 liters (L) because he first thought the low oxygen saturation level caused the non responsiveness. Staff A called the Physician from Resident #2's room and received an order within approximately four (4) minutes to have transferred Resident #2 via ambulance to the local hospital. Staff A remained in the room and completed a thorough assessment. Staff B described Resident #2's blood pressure (B/P) as low, an elevated pulse (P), and a low O2 saturation. Staff B failed to complete any assessment or intervention prior to informing Staff A about the medications or Resident #2's actual condition. Staff A described Resident #2's lungs sounds as congested in the upper lobes. Staff A instructed Staff B to stay with Resident #2 while he made all of the required calls and prepared the paperwork. Resident #2 had a code status of full code (wanted life-saving measures) and they shouldn't leave him alone. As Staff A prepared Resident #2 for transfer, he observed Staff B as she entered the nurse's station. Staff A asked her what she was doing, she replied she was thirsty. Staff A directed Staff B to take her drink back down to Resident #2's room immediately. During an interview on 7/15/24 at 1:49 PM the DON indicated she didn't recall the incident on 6/28/24 as Resident #2 had a lot going on and so did the facility. The DON indicated she spoke with Resident #2 prior and he didn't want to lay flat but rather requested the HOB at 45 degrees or less because of his pain. During an interview on 7/15/24 at 4:45 PM the facilities Interim Administrator indicated the DON informed her on 6/28/24 she escorted the EMS crew to Resident #2's room and observed his HOB elevated. After explaining to the Administrator that the DON didn't report that during her interview, the DON joined the interview. She confirmed she escorted the EMS crew to Resident #2's room but never entered the room. She added she identified Resident #2's HOB as elevated because she observed Resident #2's face as she stood in the doorway of his room. The Surveyor explained a person could observe Resident #2's face from the doorway even if he laid supine, the DON shook her head with the gesture (up and down) that indicated she agreed. An eInteract Transfer V3 form dated 6/28/24 at 2:52 PM included the following documentation but failed to address Resident #2's urinary status and catheter: a. Blood pressure (B/P) = 84/48 (low) (average 120/80). b. Pulse = 119 (high) (expected 80-100 beats per minute) c. Respirations (R) = not assessed d. Temperature (T) = 101.3 degrees Fahrenheit (F) (average temperature 98.6) e. Oxygen (O2) saturation = 84% (low) (expected greater than 90%). A County Emergency Medical Services (EMS) Patient Care Report indicated the facility called the EMS crew at 2:55 PM with an arrival time of 3:00 PM. The EMS crew found the patient as he laid in bed basically unresponsive but made noises when moved. The general impression of the patient had been an elderly man with Parkinson's and severe contractures. Staff reported they went to feed Resident #2 and he vomited. Resident #2 had a feeding tube and can't eat. Resident #2 had a temperature (T) of 104 degrees Fahrenheit (F). The crew transferred the patient to the gurney and transported him to the County Regional Hospital at 3:21 PM. During an interview on 7/15/24 at 3:57 PM one of the EMS crew members that responded to the call confirmed when they arrived on the scene, Resident #2 laid in a supine position. The EMS crew members reported finding him in bed like that, wasn't the 1st time the crew found the same resident in the supine position to transport him. The crew member verbalized concern over Resident #1's position. The County Regional Hospital emergency room (ER) Progress Notes dated 6/28/24 at 3:25 PM reflected Resident #2 presented nonresponsive with a fever. Resident #2 had a history of Methicillin resistant Staph coccus Aureus (MRSA) (infection resistant to some medications) sepsis (full-body blood infection) in February 2024 from aspiration presented unresponsive from the nursing facility with a T of 104 degrees F. According to Staff A, Licensed Practical Nurse (LPN), a nursing home nurse, the last time staff saw him well was around 10 AM. They brought in his G tube feeding that afternoon just prior to arrival, he vomited and became unresponsive. The patient moaned to verbal and painful stimuli. A Radiology Results dated 6/28/24 at 3:51 PM reflected Resident #2 had nonspecific opacities (hazy gray areas in the lungs caused by a decreased ratio of gas to soft tissue in the lungs) present in the right hemithorax (right side of the chest) most prominent in the medial (middle) lung base concerning for aspiration or pneumonia. The impression identified the new opacities in the right lung, most confluent in the lung base, concerning for aspiration or pneumonia. A County EMS Patient Care Report indicated the County Regional Hospital dispatched the crew at 5:18 PM, and they arrived on the scene at 5:30 PM. At 5:41 PM the crew transferred Resident #2 to a higher level of care hospital and arrived 6:19 PM. The Hospital's History of Present Illness report dated 6/28/24 indicated Resident #2 presented from the emergency department (ED) of an outlying facility for septic shock. The nursing facility found him unresponsive, covered with vomit, and running high fever of 104. This prompted an immediate transfer to the local ED. The last time they reported him as well at 10 AM on 6/28/24. He moaned to verbal and painful stimuli. His blood pressure on arrival at the outlying facility ED was 60s systolic (average systolic blood pressure 120), they gave 2 liters (L) of normal saline fluid bolus, but due to his persistent hypotension (low blood pressure), they started peripheral Levophed (medication used to increase blood pressure). His chest x-ray showed multiple patches likely concerning for aspiration pneumonia (infection caused by breathing particulates into the lungs. The nursing home reported Resident #2 had a blocked indwelling catheter, his bladder scan showed greater than 920 milliliters (ml), the ED flushed the catheter. Chocolate milk-like fluid returned after the flush. The ED gave him one dose of vancomycin (antibiotic), Zosyn (antibiotic), DuoNeb (nebulizer treatment to open the lungs), started on 6 L of high flow nasal cannula, and transferred him to a larger hospital for further management. Upon arrival to the critical care unit (CCU), Resident #2 noted unresponsive with a Glasgow coma score (GCS) of 4 (indicative of severe traumatic brain injury), fever of 102, blood pressure of 68/34 systolic (average 120/80) on 30 of Levophed and started vasopressin (medication used to increase blood pressure) and emergently intubated him. The team had difficultly intubating Resident #2 due to an enlarged tongue, when the team tried to intubate, his oxygen saturation dropped to 38% (expected greater than 90%). The team removed the laryngoscope (equipment used to visualize the throat while intubating a person) and bagged him with an Ambu bag (medical equipment used to breathe for a person), his oxygen saturation improved to 90%. During that time, Resident #2 had bilious vomitus (green or yellow vomit) coming out of his mouth. The team attempted to intubate with a D blade (curved intubation equipment), successfully. The team completed a bronchoscopy to suction out the vomitus from the lungs. The team started a central access and then started on broad-spectrum antibiotics. An Operative/Procedure Report form dated 6/28/24 at 5:27 PM indicated a Physician at the Hospital performed an Endotracheal Intubation for airway protection and respiratory failure. During an interview on 7/15/24 at 3:29 PM Resident #2's Physician confirmed he expected the staff elevate Resident #2's head of his bed as far as possible but agreed to 45 degrees for Resident #2's comfort. The Physician confirmed if Resident #2 laid flat that would have caused Aspiration. During an interview on 7/16/24 at 10:45 AM Resident #2's family member described Resident #2's current condition as gravely ill but still in the hospital. The staff at the hospital questioned brain damage due to oxygen deprivation. The family member also confirmed he observed Resident #2 positioned in a supine position during his tube feeding on two (2) separate occasions. He redirected the staff but he described them as incompetent and failed to listen. The Enteral Feeding policy and procedure revised May 2016 included the Purpose as administration of intermittent or continuous feeding by means of a tube when the oral route or oral intake had been insufficient. The form directed the staff to assist a resident/patient to a 30 45-degree semi-Fowler's position and notify the Physician of any changes or concerns

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, facility policy and procedure review, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers from developing and from deteriorating on a resident with a history of pressure ulcers for one of two residents reviewed (Resident #2). The facility failed to identify the root cause and implement appropriate interventions. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began April 13, 2023 on June 7, 2023 at 4:30 p.m. Facility staff removed the Immediate Jeopardy on June 8th, 2023 through the following actions: a. Head to toe assessments will be completed on 6/8/23 by the Regional Directors of Clinical Services (RDCS) or designee to ensure pressure injuries have been identified and treatment plans implemented. An audit was completed by the Regional Director of Clinical Services or designee to ensure preventive measures have been implemented for residents with pressure injuries or history/risk of pressure injuries. b. The RDCS or designee will complete education with licensed beginning 6/7/23-6/8/23 related to the requirements of implementation interventions to reduce the risk for pressure injuries for any residents with current pressure injuries or history/risk of pressure injuries. c. An audit will be completed by the Director of Nursing or designee weekly for 12 weeks to ensure licensed nurses continue to implement preventive measures for residents with pressure injuries or history/risk of pressure injuries. The results of these of these audits will be presented to the QAQI committee monthly for 3 months for review and recommendations as needed. The Director of Nursing is responsible for monitoring and follow-up as needed. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedure. The facility reported a census of 38 residents. Findings include: 1. An admission Minimum Data Set (MDS) completed for Resident #2 with an Assessment Reference Date (ARD) of 3/12/23, documented diagnoses which included hypertension, neurogenic bladder, paraplegia, schizophrenia, and stage 2 pressure ulcers of sacral area. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no impaired cognitive decisions and no impairments for hearing or the ability to be understood and understand others. The resident required extensive assistance of one staff for dressing, toilet use, and personal hygiene and independent with bed mobility, transfers, and locomotion on and off the unit. The MDS also documented functional limitation in range of motion to lower extremities on both sides and a wheelchair as primary mode of transportation. The MDS also documented the resident admitted with 3 stage 2 pressure ulcers (partial thickness of dermis presenting as a shallow open ulcer with a red or pink wound bed without slough) and pressure reducing device for chair & bed and pressure ulcer/injury care. The Braden scale for predicting pressure sores, dated 2/27/23 at 2:17 p.m., documented a score of 16, which indicated low risk for developing pressure ulcers. The Care Plan with a focus area initiated 2/27/23, indicated the resident had (3) pressure ulcer or potential for pressure ulcer development related to history of ulcers, immobility. Interventions include: *Administer treatments as ordered and monitor for effectiveness *(3/4/23) Stage 2 pressure ulcer times 3: coccyx every Monday, Wednesday, Saturday: cleanse with wound cleanser, place Aquacel Ag on wound base cover with sacral border, and as needed. *(3/4/23) Assess/record/monitor wound healing weekly, measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing process. Report improvements and declines to the Medical Doctor. *(4/20/23) Cushion in wheelchair *(3/4/23) Follow facility policies/protocols for the prevention/treatment of skin breakdown. A Medical/Nursing Communications form dated 4/1/23 at 9:46 p.m., documented, after bathing during a transfer from chair to bed resident obtained a 0.3 cm by 0.3 abrasion to right ischeum. No bleeding or pain. Bumped on wheelchair pedal per resident reports. After cleansing, border dressing placed for protection. Will change on bath days and as needed until healed then will discontinue. The Non-Pressure Weekly Skin Record dated 4/2/23 at 10:47 a.m., documented, first observed on 4/1/23 a small bruise on right buttock. Measurements: 0.3 centimeters (cm) by 0.3 cm. A Physician Order dated 4/13/23, instructed staff to apply Mepilex to right hip reassure wound every day until healed. Monitor for signs of infection. Off load with position changes every 2 hours. A Nursing Home Progress Note dated 4/13/23 with no time, documented, nursing staff noticed a sore on his right hip. He has had a coccyxgeal sore that had been healing. He started to notice this area on his right hip and they did place a Mepilex on it last night. It has not had a lot of drainage. Denies any fevers or chills. *SKIN= Stage 2 pressure ulcer noted on the right hip. Measuring tool not available at time of evaluation but appears to be about 2 cm in diameter. No surrounding erythema or drainage. Mepilex placed back over the area. *PLAN= continue stage II pressure ulcer treatment with wound cleanser and Aquacel Ag in the wound base and then a sacral border every Monday, Wednesday, and Saturday until healed. Plan to do same cares to the Stage II pressure ulcer on the right hip. The Non-Pressure Weekly Skin Record dated 4/15/23 at 8:04 p.m., documented first observed on 4/15/23, a bruise to the right buttock, with the wound surface has a strong odor, measurements of 0.3 cm by 0.4 cm with no exudate, yes to odor, and progress as declining. A Physicians Order dated 4/16/23 with no time, instructed staff to cleanse the wound with cleanser, and Aquacel Ag to wound base of right hip pressure ulcer along with Mepilex every Monday, Wednesday and Saturday until healed. A Wound Clinic Progress Note dated 4/20/23 at 10:53 a.m., documented, diagnosis= pressure ulcer of right hip. Patient paraplegic currently in a loaner wheelchair with a gel cushion. He is getting custom wheelchair cushion when he discharges home which is possibly next week. He self transfers and is up in a wheelchair most of the day. Location= right hip Stage=unstageable Size=3.2 cm by 4.0 cm by 0.2 cm Drainage color= serosangionous Drainage amount=large Drainage odor=moderate Wound base= 90% slough. 10% pink Wound Care= Recommend new evaluation for wheelchair cushion. Instructed patient to lay down between meals and limit time spent in wheelchair. Reposition off wound while in bed every 2 hours. A Non-Pressure Weekly Skin Record dated 4/22/23 at 3:33 p.m., documented first observed on 4/3/23, a right buttock pressure ulcer, with wound measurements as 4.0 cm by 4.0 cm by 3.0 cm. Exudate=yes Type of Exudate= serosanguinous; thin, watery, pale, red/pink drainage Amount of Exudate= moderate Odor=yes Tissue Type/Wound Bed= slough A Pressure Injury Weekly assessment dated [DATE] at 3:42 p.m., documented pressure ulcer to right buttock which measures 3.0 cm by 4.0 cm by 2.5 cm as a Stage I. Exudate= serosanguinous, large amount Odor= present Wound bed appearance= slough A Pressure Injury Weekly assessment dated [DATE] at 12:43 p.m., documented pressure ulcer to right buttock which measures 4.0 by 4.0 by 3.0-4.0 as a Stage III Exudate= serosanguinous, large amount of purulent drainage Odor=present Wound bed appearance= slough, necrotic tissue A Pressure Injury Weekly assessment dated [DATE] at 8:45 p.m., documented pressure ulcer to right buttock which measures 5.0 cm by 3.0 cm by 3.0 cm, Stage IV. Exudate= purulent drainage, heavy amounts Odor=strong Wound bed appearance=necrotic Comments=current treatment is not effective, resident states he goes to see the wound doctor on Monday. A Wound Clinic Progress note dated 5/15/23 at 9:00 a.m., documented, patient is a paraplegic after falling off a ladder in October 2022, he has the wound for a month. Wound location= right buttock Wound Measurements= 3.5 cm by 4.5 cm by 4.9 cm Exudate=large Exudate type=purulent Wound odor=yes Slough=100% Assessment/Plan=Pressure injury of right buttock. Stage 4. Patient presents today for initially treatment evaluation in this clinic of the pressure injury on the lateral right buttock near the trochanter. The wound is 100% necrotic with a foul odor. Patient does not recall noting an odor of bleach with the dressing changes. Patient has the appropriate wheelchair waiting for him when he is discharged form the nursing home. Apparently there is some rule that prevents the use of that chair in the facility. Explained to patient this is going to take along time to heal. Offloading= He will need a better wheelchair cushion, instructed to remain off of the right side while in bed as much as possible. Plan= This is a medical device related pressure injury from an old fitting wheelchair. A Wound Clinic Progress note dated 5/17/23, documented, chief complaint=pressure ulcer right hip, patient still in wheelchair from last week with no adjustments. Continue current treatment. Area worsened. Needs wheelchair adjustment or new wheelchair! A Pressure Injury Weekly assessment dated [DATE] at 1:48 p.m., documented a pressure injury on the right buttock which measures 10.0 cm by 7.0 cm by 5.0 cm an unstageable. Exudate=purulent and copious amounts Odor=very strong Wound bed appearance=completely covered with slough and eschar Comments= current treatment does not seem effective and wound progressively getting worse A Wound Clinic Progress note dated 5/23/23 at 10:00 a.m., documented, this patient presents for wound assessment. Wound location=right buttock Wound measurements=4.4 cm by 5.4 cm by 4.5 cm Exudate=large Exudate type=purulent Wound odor=yes Slough=100% Assessment/Plan= Patient presents for follow up of right buttock wound. He has not discharge from the rehabilitation facility yet. Tissue in the wound bed still consists of majority necrotic/slough. Discussed offloading/pressure relief, patient states he will try to remind himself to reposition more often. Discussed emergency room precautions. The Progress notes dated 3/23/23 at 11:49 a.m., documented, coccyx resolved. discontinue treatment. Education provided on support surfaces, may need different wheelchair cushion, if area reoccurs such as a Roho cushion. He will need pressure relieving mattress if he doesn't already have one. He is able to move himself in bed and turns from side to side at night. He already knows to reposition chair, lifts while in wheelchair. The Progress notes dated 4/1/23 at 9:41 p.m., documented, after bathing during a transfer from chair to bed he obtained a 0.3 cm by 0.3 cm abrasion to right ischeum. No bleeding or pain. Bumped on wheelchair pedal. he reports. After cleansing, bordered dressing placed for protection. Will change on bath days and as needed until healed then discontinue. The Progress notes dated 4/13/23 at 00:19 a.m., documented, Doctor notified of 2.6 cm by 0.7 cm open area to right ischeum with odor and drainage. I understand you will see him on rounds today. Do you desire wound nurse to see him? The Progress notes dated 4/13/23 at 9:04 a.m., documented, received physician orders paper after doctor complete rounds. Mepilex to right hip pressure wound every day until healed. monitor for signs of infection. Off load with position changes every 2 hours. The Progress notes dated 4/17/23 at 8:31 a.m., documented, received facsimile from doctor related to new physicians orders wound cleanser and Aquacel Ag to wound base of right hip pressure ulcer along with Mepilex every Monday, Wednesday and Saturday until healed. The Progress notes dated 4/20/23 at 1:02 p.m., documented, resident saw wound nurse today. Wound nurse assessed right hip at this time and cleansed with wound cleanser and Aquacel Ag to wound base and covered with border foam. Wound nurse recommended we get new wheelchair cushion which we have gotten. Wound nurse instructed patient to lay down between meals and decrease time spent in wheelchair. Repositioning often. The Progress notes dated 4/22/2023 at 1:38 p.m., documented, Return fax, new orders received from Doctor. Cleanse with wound cleaner, apply Aquacel AG and cover with Mepilex on Monday, Wednesday, Friday. The Progress Notes dated 4/26/2023 at 3:52 p.m., Wound Care Nurse: Weekly Assessment Note Text: wound nurse here to see resident. orders to cleanse area with Normal Saline. apply 1/4 strength Dakins solution moistened gauze into wound base, cover with abdomen pad and secure with tape. change 2 times a day and as needed. continue offloading area when in bed and laying down in between meals. will see again in 2 weeks The Progress notes dated 4/28/2023 at 3:18 p.m.,documented, Resident stated he is getting new custom wheel chair through insurance once he makes the move. Insurance will not cover custom chair until he moves out the facility The Progress notes dated 5/5/2023 at 4:59 a.m., documented,dressing change to left hip wound. Drainage purulent, strong order, necrotic wound bed,0.5 cm deep tunneling area normal surrounding wound color. Expressed concern to resident, wound nursing following. Will update DON in AM. Extensive time teaching the importance of off loading hip and mobilization. Verbalized understanding and was very receptive to teaching. The Progress notes dated 5/9/2023 at 00:18 a.m., documented, Continues with bactrim for treatment of skin concern right trochanter. No adverse reaction to antibiotic. Temperature 98.4. Good amount of fluid drank. Dressing is clean, dry, intact. The Progress notes dated 5/10/2023 10:30 p.m., documented, Continues with antibiotic to promote wound healing to right hip without adverse reaction. Wound nurse saw resident today; continue same treatment. M.D. updated. The Progress notes dated 5/11/2023 9:05 a.m., documented: seen by wound clinic on 5/10/23, progress note sent to doctor to review. The Progress notes dated 5/13/2023 1:14 a.m., documented: Continues with antibiotic for right hip wound without adverse reaction. Decreased drainage of wound noted. Temperature 97.4. The Progress notes dated 5/13/2023 3:02 p.m., documented: Resident continue with antibiotic therapy for right hip wound. Resident with no adverse effects to medication at this time. Resident without s/s of increased infection and remains afebrile. The Progress notes dated 5/15/2023 2:37 a.m., documented: Resident remains on antibiotic treatment to promote wound healing. Will be ending May 19, 2023. No adverse effects noted from therapy thus far. Resident remains afebrile, free of pain, and off loading of right hip. Able to verbalize needs, no concerns at this time. The Progress notes dated 5/15/2023 at 12:24 p.m., documented: resident returned from his wound care appointment with new orders: cleanse with Dakins and rinse with normal saline. then use Dakins soaked gauze roll for packing in the wound. secondary dressing is secured with tape. twice per day. it is important that half strength Dakins solution is used in this dressing change The Progress notes dated 5/17/2023 3:00 p.m., documented: Wound nurse here today for pressure ulcer to right hip. Resident with measurements of 4.7 x 5.0 x 5.0 cm with Serosanguinous drainage of moderate large amount. Foul odor,undermining noted at 3 and 7 at 2.5. 10% of wound bed is pink with 90% black and slough tissue. peri wound intact and edge is well defined The Progress notes dated 5/17/2023 at 3:07 p.m., documented: Orders to continue current treatment. Area worsened. Needs new wheel/ac or for his to be adjusted. Will be seen in 1 week if still facility. Has wound appointment set up with discharge. The Progress notes dated 5/23/2023 3:39 p.m., documented: Resident returned from wound appointment. Consultation form states to continue same wound care. Ensure packing is 1 whole piece and not multiple/separate pieces. Zinc oxide cream or skin barrier to surrounding skin to prevent breakdown. Periods of repositioning while in bed and in wheel/chair. Remind resident to reposition himself in the wheel/chair to relieve pressure. Interview on 5/24/23 at 3:05 p.m., the maintenance supervisor confirmed and verified that Resident #2 came into the facility with that wheelchair and that the black hard plastic piece is in the right place for an open area on the resident right hip and that the facility failed to intervene with an intervention to prevent a pressure ulcer from occurring. Interview on 5/24/23 at 9:05 a.m., Physical Therapy Assistant, confirmed and verified that Resident #2 came into the facility with that wheelchair and that the facility failed to do an evaluation on the recommendation from the Wound Clinic for a new pressure cushion and it is expected that staff follow through with that recommendation. In reviewing the wheelchair it is possible that the black hard plastic positioning device could be the culprit of the pressure ulcer and that it is expected that the staff notify the therapy department of any new orders or evaluation for positioning. Interview on 5/24/23 at 2:05 p.m., Staff A, Certified Nursing Assistant (CNA), stated that Resident #2 would position themselves on the right side of the buttocks and would need to be reminded to position in the center of the wheelchair seat and keep the right hip off the hard black plastic piece on the right side of the wheelchair. Resident #2 would use a slide board and transfer from the bed to the wheelchair independently. Interview on 5/24/23 at 1:05 p.m., Staff B, Certified Medication Aide (CMA), stated that Resident #2 was independent with self transfer by the use of a slide board and would need reminded to center the buttock in the center of the wheelchair due to Resident #2 would position the right hip on the hard black plastic piece on the right side of the wheelchair. Interview on 5/24/23 at 1:30 p.m., Staff C, Licensed Practical Nurse (LPN), stated that Resident #2 would transfer from the bed to the wheelchair independently with the use of a slide board and would need reminded to position the buttock in the center of the wheelchair cushion to take the pressure off the right hip that would be positioned on the hard black plastic piece on the right side of the seat of the wheelchair. Interview on 5/25/23 at 12:05 p.m., Staff E, (Physician) confirmed and verified that the pressure ulcer on the right hip was a mechanical device pressure ulcer and that the pressure ulcer was avoidable if the facility would have followed the recommendation to look at the device in the wheelchair that was causing the pressure ulcer. Interview on 5/30/23 at 5:05 p.m., Staff D, Registered Nurse (RN), stated that Resident #2 would transfer from the bed to the wheelchair independently with the use of a slide board and would not position in the center of the wheelchair cushion and would need to be reminded to keep off the right hip. It is the expectation of the facility staff to intervene and attempt different interventions to keep a pressure injury from developing. Interview on 5/31/23 at 2:20 p.m., the facility corporate quality assurance nurse confirmed and verified that it is the expectation of the facility staff to intervene with alternative interventions to keep a pressure injury from developing and implementing measures or interventions from deteriorating. The Skin Care and Wound Management Treatment Protocol for Stage II Pressure Ulcer dated 9/11 documented: A Stage II pressure ulcer is defined as a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Procedure: *Obtain a physician order for treatment. Verify resident/patient has an order for pain medication. *Implement treatment protocol as ordered. *Document wound measurements and characteristics on the Skin Grid-Pressure no less than weekly. More frequent documentation may be indicated based on change in condition of wound. *Review effectiveness of treatment plan every 2 weeks and revise as needed. The Skin Care and Wound Management Treatment Protocol for Stage III and IV Pressure Ulcer dated 6/15 documented: *A Stage III pressure ulcer is defined as a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. *A Stage IV pressure ulcer is defined as a full thickness loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Procedure: *Read and select the treatment protocol. Consider the type of wound, drainage, and depth when selecting the treatment options. *Obtain a physician order for treatment. *Implement treatment protocol as ordered. *Verify prevention interventions are in place. *Review effectiveness of treatment plan every 2 weeks and revise as needed.

Based on observation, clinical record review, staff and resident interview and facility policy review the facility failed to provide the necessary assessments for 1 of 7 residents reviewed with a condition change, (Resident #2). A determination was made the facility's non-compliance placed residents in the facility in immediate jeopardy, beginning on 9/17/22. The facility identified a census of 33 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 8/31/22 documented Resident#2 with diagnosis that included psychoactive substance abuse, bipolar, depression, deep vein thrombosis (DVT), hypertension (HTN) and a hip fracture. The assessment documented the resident with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact), with verbal behavioral syptoms directed towards others and rejection of cares 1-3 days a week in the look back period, non-ambulatory and required extensive assistance of two staff with bed mobility, transfers, dressing, toilet use and hygiene. The resident's Care Plan failed to address his illegal drug use. The residents Progress Notes entries included the following: a. On 9/13/22 at 3:22 p.m. - Received a fax from the resident's Physician for an order for a urinalysis (UA) with culture and a drug panel. The staff obtained the UA and sent it to the lab. 1. A Lab Report form dated 9/13/22 at 3:38 p.m. documented the resident as positive for methamphetamine. b. On 9/17/22 at 1:27 p.m. - The resident screamed at staff over a TV that he claimed was his that had been a facility TV but the resident changed rooms. The resident stated Get me my f'ing (explicit) tv right now or I am going to start breaking shit! The resident had a tv in his room already. The resident then went in to another resident's room and ripped off his oxygen. The staff told this resident to stay out of other resident's rooms, Resident #2 stated I don't give a f*$# (explicit), I am going to start tearing shit apart!' c. On 9/22/22 at 2:48 a.m. - A nurse documented the resident had been very difficult and the police came to the facility several times the past week but they could not do anything as the resident refused for the police or staff to go through his belongings. Earlier that evening the evening nurse walked into the resident's room while he smoked methamphetamine from a methamphetamine pipe. The police returned that evening and searched the room and found 3 methamphetamine pipes and white residue in a bag and in a bag on his knee scooter that tested positive for methamphetamine. d. On 10/12/2022 at 10:07 p.m. - A nurse documented I said I don't know but we did find Methamphetamine in your room with pipes it does bother me. e. On 10/28/2022 at 1:48 p.m. (the actual time of occurance 10 a.m.) - The staff approached this nurse to state it smelled bad in the resident's room which gave them a headache. This nurse went to the resident's room and could smell methaphetamine before entrance into the room. It smelled very strong. The resident had been advised to keep the door shut but he refused. When staff shut the door the resident opened the door back up. The residents record lacked documentation of staff assessment and/or intervention according to the given circumstance. f. On 10/28/2022 at 1:30 p.m. (the actual time of occurance 10:30 a.m. - 11 a.m.) - The resident in the morning had been found as he cleaned his room with a broom and then cleaned the toilet and sink with the dirty broom, he was also taking his clothes washing them in the sink and then putting them in the toilet and then back into the sink, when the staff went in to ask him if he needed help he told them to leave his room and that he would be fine without their help. The residents record lacked documentation of staff assessment and/or intervention according to the given circumstance. g. On 10/28/2022 at 12:55 p.m. - The Business Office Manager (BOM) and Social Services Designee (SSD) went into the resident's room to talk about discharge plans. The staff found the resident resting in his chair and hard to arouse with a lot of drool coming from his mouth. The resident would not open his eyes while they visited with him. The staff asked if he would like them to set up a treatment facility for discharge, he said I don't know. The staff attempted many times to ask what his plans had been for discharge and asked if he would accept help from Home Health and he had been unsure. The BOM and SSD left the room and let him know they would return. The residents record lacked documentation of staff assessment and/or intervention according to the given circumstance. h. On 10/28/2022 at 1:27 p.m. - Resident was in his room, positioned in his wheel chair, with his arms crossed and his head down, drooling and very hard to arouse. The resident answered the nurse but he had been alert that morning as he conversed with staff and cleaned his room and toilet with a broom. i. On 10/28/2022 at 1:28 p.m. - The staff placed a call the resident's physician related to his lethargy. j. On 10/28/2022 at 1:32 p.m. - Resident #2's vital signs were, Temperature - 97.8 degrees Fahrenheit (F), pulse 77, respirations16, oxygen saturation rate at 99% and his blood pressure registered 130/90. k. On 10/28/2022 at 1:35 p.m. - Staff assisted the resident to bed with 2 assistance. The resident assisted but continued with slurred speech. During an interview on 10/21/22 at 2:30 p.m. the resident confirmed staff caught him in his rom as he smoked methamphetamine not to long ago. According to an email dated 11/9/22 at 10:42 a.m. the Interium Director of Nursing documented the expectation when nurses performed skin assessments to have completed a head to toe assessments, with the proper form and measurements documented for each area identified. A Clinical Change in Condition Management form dated 6/2015 included the following procedural directives: a. Assessment of the resident's clinical status with a condition change to have included but not limited to: 1. Vital signs, lung sounds, pulse oximeter, mental/neurological satus, bowel sounds, skin color/turgor and temperature and pain. 2. Contact the Physician and family. On 10/28/22 at 2:15 PM the facility was notified of the immediate jeopardy at F684 and was given the IJ Template. The facility provided staff education on substance abuse disorder and education given to staff members to report to nurse if they observe any signs and symptoms. The nurse is to complete an assessment and notify doctor, family, and DON/Administrator if signs and symptoms exist. After the surveyor verified implementation of the removal plan the immediate jeopardy was removed on 10/29/22 and the scope and severity was lowered to a D.

Based on observation, clinical record review, staff interview and facility policy review the facility failed to provide sufficient staff with appropriate competencies and skills to provide nursing and related services to assure resident safety for one resident with psychosocial disorders, (Resident #2). A determination was made the facility's non-compliance placed residents in the facility in immediate jeopardy, beginning on 9/17/22. The facility identified a census of 33 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 8/31/22 documented Resident#2 with diagnosis that included psychoactive substance abuse, bipolar, depression, deep vein thrombosis (DVT), hypertension (HTN) and a hip fracture. The assessment documented the resident with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact), non-ambulatory and required extensive assistance of two (2) staff with bed mobility, transfers, dressing, toilet use and hygiene. The resident's Care Plan failed to address his illegal drug use. The residents Progress Notes entries included the following: a. On 9/13/22 at 3:22 p.m. - Received a fax from the resident's Physician for an order for a urinalysis (UA) with culture and a drug panel. The staff obtained the UA and sent it to the lab. 1. A Lab Report form dated 9/13/22 at 3:38 p.m. documented the resident as positive for methamphetamine. b. On 9/17/22 at 1:27 p.m. - The resident screamed at staff over a TV that he claimed was his that had been a facility TV but the resident changed rooms. The resident stated Get me my f'ing (explicit) tv right now or I am going to start breaking shit! The resident had a tv in his room already. The resident then went in to another resident's room and ripped off his oxygen. The staff told this resident to stay out of other resident's rooms, Resident #2 stated I don't give a f*$# (explicit), I am going to start tearing shit apart!' c. On 9/22/22 at 2:48 a.m. - A nurse documented the resident had been very difficult and the police came to the facility several times the past week but they could not do anything as the resident refused for the police or staff to go through his belongings. Earlier that evening the evening nurse walked into the resident's room while he smoked methamphetamine from a methamphetamine pipe. The police returned that evening and searched the room and found 3 methamphetamine pipes and white residue in a bag and in a bag on his knee scooter that tested positive for methamphetamine. d. On 10/12/2022 at 10:07 p.m. - A nurse documented I said I don't know but we did find Methamphetamine in your room with pipes it does bother me. e. On 10/28/2022 at 1:48 p.m. (the actual time of occurrence 10 a.m.) - The staff approached this nurse to state it smelled bad in the resident's room which gave them a headache. This nurse went to the resident's room and could smell methaphetamine before entrance into the room. It smelled very strong. The resident had been advised to keep the door shut and but he refused. When staff shut the door the resident opened the door back up. f. On 10/28/2022 at 1:30 p.m. (the actual time of occurrence 10:30 a.m. - 11 a.m.) - The resident in the morning had been found to be cleaning his room with a broom and then found to be cleaning the toilet and sink with the dirty broom, he was also taking his clothes washing them in the sink and then putting them in the toilet and then back into the sink, when the staff went in to ask him if he needed help he told them to leave his room and that he would be fine without their help. g. On 10/28/2022 at 12:55 p.m. - The Business Office Manager (BOM) and Social Services Designee (SSD) went into the resident's room to talk about discharge plans. The staff found the resident resting in his chair and hard to arouse with a lot of drool coming from his mouth. The resident would not open his eyes while they visited with him. The staff asked if he would like them to set up a treatment facility for discharge, he said I don't know. The staff attempted many times to ask what his plans had been for discharge and asked if he would accept help from Home Health and he had been unsure. The BOM and SSD left the room and let him know they would return. h. On 10/28/2022 at 1:27 p.m. - Resident is in his room, positioned in his wheel chair, with his arms crossed and his head down, drooling and very hard to arouse. The resident answered the nurse but he had been alert that morning as he conversed with staff and cleaned his room and toilet with a broom. i. On 10/28/2022 at 1:28 p.m. - The staff placed a call the resident's physician related to his lethargy. j. On 10/28/2022 at 1:32 p.m. - Resident #2's vital signs were temperature - 97.8 degrees Fahrenheit (F), pulse 77, respirations 16, oxygen saturation rate at 99% and his blood pressure registered 130/90. k. On 10/28/2022 at 1:35 p.m. - Staff assisted the resident to bed with 2 assistance. The resident assisted but continued with slurred speech. During an interview on 10/21/22 at 2:30 p.m. the resident confirmed he was caught in the room smoking methamphetamine in his room at the facility not to long ago. During an interview on 11/16/22 at 10:50 a.m., Staff J, nursing assistant (NA) confirmed the facility failed to educate her on how to manage residents with an active drug addiction prior to the most recent education provided. During an interview 11/16/22 at 10:52 a.m., Staff B, CNA/CMA confirmed the facility failed to educate her on how to manage residents with an active drug addiction prior to the most recent education provided. On 10/28/22 at 2:15 PM the facility was notified of the immediate jeopardy at F741 and was given the IJ Template. The facility provided staff education on substance abuse disorder and education given to staff members to report to nurse if they observe any signs and symptoms. The nurse is to complete an assessment and notify doctor, family, and DON/Administrator if signs and symptoms exist. After the surveyor verified implementation of the removal plan the immediate jeopardy was removed on 10/29/22 and the scope and severity was lowered to a D.