Every finding on record at Alden Estates of Countryside, Inc

Based on record review, interviews, and facility policy review, the facility failed to ensure that resident grievances and concerns were investigated in accordance with the facility's policy and procedure for one of 12 sampled residents (Resident (R) 2) reviewed for grievances. This failure had the potential to affect all residents expressing grievances or concerns, requiring investigation and intervention by the facility. Findings include: Review of R2's Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE] with diagnosis including cerebral palsy. Review of R2's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/23/26 and located under the MDS tab of the EMR revealed R2 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated R2 had moderately impaired cognition. The admission assessment also revealed R2 was occasionally incontinent of urine and needed some help from another person to complete self-care with toileting. Review of R2's quarterly MDS assessment with an ARD of 04/22/26 and located under the MDS tab indicated R2 was frequently incontinent of urine. Review of R2's care plans, dated 02/04/26 and located under the Care Plan tab, revealed a care plan focus which revealed Bowel and Bladder support is required secondary to Bladder Incontinence. The goal revealed Dignity will be maintained during personal care activities. Interventions/Tasks listed, Use adult incontinence product as needed. Ensure use of properly fitting adult incontinence product. During an interview with R2 on 06/05/26 at 9:20 AM, when asked about the assistance he received, he stated he could use the urinal for urination but needed the staff to help him with the use of the urinal. R2 said that he reported during a resident council meeting his concerns about the call light response. R2 could not recall the date of the meeting he reported his concern. During an interview on 06/05/26 at 11:00 AM, Certified Nursing Assistant (CNA) 3 stated she got R2 up that morning. CNA3 said that R2 was a one assist with transfers and would tell you when he needed to use the bathroom but could not hold his ability to urinate. Review of the resident council minutes for the previous six months (01/25 to 05/26) prior to the survey provided by the facility, revealed that there were no documented concerns by residents about call light response times. During an interview with the Activities Director (AD) on 06/05/26 at 9:38 AM, it was revealed she was aware of the concern about call light responses mentioned during a resident council meeting by R2. She stated she filled out a concern form after he reported his concern about the call light response and placed it in the Administrator's box. When asked what happened next, the AD said that the Administrator would distribute the concern to whomever was most appropriate to address it. Review of the CONCERN FORM provided by the facility indicated This form shall be utilized to provide written documentation of any concern expressed by a Resident or Resident's Representative and to record the follow-up action and results. A CONCERN FORM, dated 05/18/26 and signed by the AD, revealed Nature of Concern: (Describe in detail): [R2] attended Resident Council this afternoon. He was unhappy with his call light response time. The documented follow-up action taken indicated, Staff educated on call light response times with DON [Director of Nursing]/ADON [Assistant Director of Nursing] doing Random Pop INS for the Night Shift moving forward. This was signed by the DON. The Time, date and person notified of outcome of concern were, the AD, Staff and ADON. The Administrator signed the form on 05/19/26. The form did not include an interview with R2 about his specific concern or need for using his call light and the time for response. There were no documented observations of call lights and response times or interviews conducted after the concern was received to ensure that the concern was resolved. During an interview on 06/05/26 at 11:54 AM, the DON was informed that R2 had attended a Resident Council Meeting and reported a concern with call light response times. The completed CONCERN FORM was shared with the DON and asked what was done to address R2's concerns. The DON stated that the documentation on the form was the only investigation that she had done. During an interview with the Regional [NAME] President of Operations (RVPO) and the Administrator on 06/05/26 at 3:10 PM, the RVPO stated that the concern form was the only document utilized for concerns and that it listed the actions taken for the concern. The RVPO stated that staff came in on night shift to speak to the staff about the answering of call lights. The surveyor expressed a concern that there was no documented interview with R2 about his concern and what was done to investigate the concern in accordance with the grievance policy. The RVPO stated that the concern was addressed on the form. Review of the facility's policy titled, GRIEVANCES/COMPLAINTS, revision date of 01/17, revealed A. POLICY The facility assists residents, their legal representatives, other interested family members, or resident advocates in filing grievances or complaints when such requests are made. PROCEDURE 5. Upon receipt of a grievance and/or complaint, the Administrator and/or designee will investigate the allegations. As necessary, immediate action will be taken to prevent further potential violations of any resident rights while the alleged violation is being investigated. 7. The resident or person filing the grievance/and or complaint, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Such report will be made orally by the Administrator, or his or her designee, in a timely fashion of the filing of the grievance or complaint. A written summary of the report will then be completed and also be provided to the resident if requested.

Based on observation, interview, record review, and policy review, the facility failed to implement and maintain an effective infection prevention and control program to ensure proper use, cleaning, and disinfection of shared glucometer (a medical device used to record blood sugar levels) for three of three residents (Resident (R) 7, R13 and R12) of 12 sample residents. Specifically, Licensed Practical Nurse (LPN) 3 failed to properly disinfect a shared glucometer and practice proper hand hygiene. This deficient practice had the potential of placing residents at risk for transmission of bloodborne pathogens and cross-contamination. Findings include: 1. Review of R7's Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 06/05/23, with the following diagnoses: type two diabetes mellitus with diabetic neuropathy. 2. Review of R13's Face Sheet located in the EMR under the Profile tab, revealed an admission date of 11/15/23, with the following diagnoses: type two diabetes mellitus with diabetic neuropathy. 3. Review of R12's Face Sheet located in the EMR under the Profile tab, revealed an admission date of 12/21/21, with the following diagnoses: type two diabetes mellitus with diabetic neuropathy. Review of the undated manufacturer's guidelines titled, Assure Platinum, glucose monitoring system provided by the facility, revealed The meter must be cleaned and disinfected after each patient/resident use to prevent transmission of blood borne pathogens.use only EPA [environmental protection agency]-registered disinfectant products compatible with the device. Follow the wipe manufacturer's instructions, including required wet/contact time for effectiveness. Ensure all external surfaces of the meter are wiped. The device should remain visibly wet for the required contact time to achieve proper disinfection. During observations on 06/04/26 at 11:10 AM, LPN3 removed the glucometer from a shared basket and placed the device on unclean environmental surfaces, including sink ledges, bathroom counters, and bedside tables, without the use of a clean barrier. During an observation with R7, the nurse donned gloves, placed the glucometer on a sink ledge, cleansed the resident's fingers, performed a fingerstick, and obtained a blood glucose reading. The glucometer was then placed back onto the counter surface. LPN3, while clutching in her right hand the used lancet, transported R7 via wheelchair to his original location before the lancet was disposed of. No disinfection of the glucometer was observed. In a subsequent observation, LPN3 retrieved R13 from the milieu (shared resident area) without gloves, adjusted the residents' heel floats and entered the facilities' shower room. After entering the shower room, the nurse donned gloves, placed the glucometer on the sink ledge, and obtained a blood glucose reading. The glucometer was placed on the counter following use and was not disinfected between resident uses, including use between the R7 and R13. She then proceeded to R12's room where the nurse removed the glucometer from the basket and placed it directly on the bedside table without a barrier, performed the fingerstick, and then returned the device to the basket. The nurse performed hand hygiene after the procedure and stored the glucometer on the medication cart without observed disinfection. Across all observations, the glucometer was not cleaned or disinfected between resident uses, and staff demonstrated inconsistent adherence to hand hygiene and glove use protocols. During an interview conducted on 06/04/26 at 11:30 AM immediately following the third observation, LPN3 confirmed that blood glucose monitoring was performed using a shared glucometer stored in a basket with testing supplies. When asked to describe appropriate infection control practices, LPN3 initially stated that hand hygiene and glove use should be performed prior to resident contact. However, upon further questioning, LPN3 acknowledged that hand hygiene was not consistently performed prior to obtaining blood glucose readings, stating it was performed sometimes but not all the time. When questioned regarding proper handling of the shared glucometer, LPN3 reported that the device was occasionally removed from the basket and placed on environmental surfaces, including bedside tables and sinks. LPN3 stated that these surfaces were believed to be clean and further indicated, I have not been called out on it, and reported no formal instruction regarding maintaining the glucometer on a clean barrier during use. When asked about infection prevention practices between residents, LPN3 was unable to clearly articulate that the glucometer must be disinfected between each resident use. LPN3 stated she had not received, or did not recall receiving, specific training on the requirement to clean and disinfect the glucometer between resident uses. During an interview on 06/04/26 at 2:45 PM, the Nursing Consultant (NC) revealed he had gone down to speak with LPN3, and LPN3 was asked to walk him through what happened or the concern, she started the process, and stopped and stated, I forgot to disinfectant the glucose meter. The NC continued to share LPN3 was being pulled off the floor for further training. During an interview on 06/05/26 at 3:00 PM, the Administrator revealed that it was her expectation that all nursing staff were properly trained, provided with support before being allowed to provide patient care. Review of the facility's policy titled, Bloodborne Pathogens, dated 09/20, revealed the facility is committed to providing a safe and healthful work environment. Review of the facility's policy titled, Infection Control, dated 09/20/24, revealed .the hand hygiene procedures to be followed by staff involved in direct resident care.

Based on observations, policy review, and interviews, the facility failed to ensure that staff performed hand hygiene before and after wearing gloves during blood glucose checks for five of five resident (Resident (R) 5, R6, R7, R8, and R9) observed during blood glucose checks. This failure had the potential to place residents at risk for the spread of infection and cross-contamination.Findings include: The following was observed during observation of blood sugar administration starting on 10/03/25 at 7:07 AM with Licensed Practical Nurse (LPN)1. LPN1 was observed performing hand hygiene at her cart. LPN1 picked up a previously cleaned glucometer from the cart, before going into R5's room. LPN1 entered R5's room, donned a pair of gloves, and performed a fingerstick glucose check on R5. LPN1 exited R5's room still wearing gloves and discarded her gloves and lancet at the medication cart on 10/03/25 at 7:10 AM. LPN1 performed hand hygiene.On 10/03/25 at 7:11 AM, LPN1 donned a pair of gloves without performing hand hygiene and cleaned the glucometer. LPN1 performed hand hygiene at the cart, picked up the previously cleaned and disinfected glucometer, a lancet, and a testing strip. and proceeded to R6's room.There was an Enhanced Precautions sign on R6's room and a supply cart at the door. The sign indicated gloves and gown were to be worn during high contact resident care activities. LPN1 donned a gown and gloves from the cart and entered R6's room. LPN1 accidentally dropped the lancet on the R6's floor. LPN1 took off gown and gloves and placed them on the supply cart outside the room. LPN1 returned to her cart to retrieve a fresh lancet and returned to R6's room. On 10/03/25 at 7:16 AM, LPN1 picked up a new gown and pair of gloves from the supply cart. No hand hygiene was performed before donning gloves. LPN1 picked up the glucometer and performed the blood glucose check. LPN1 took off her gown and gloves and added them to the ones already on the supply cart. LPN1 stated she needed to get a garbage bag to dispose of the gowns. When asked why she did not place them in the trash can in the resident's room, she had no response. LPN1 wheeled R6 back to the breakfast area and then performed hand hygiene at her medication cart on 10/03/25 at 7:19 AM. On 10/03/25 at 7:20 AM, LPN1 donned a pair of gloves and cleaned the glucometer, removed the gloves, and performed no hand hygiene. LPN1 documented on her computer, touched the keyboard and mouse, reached into her pocket for cart keys, opened cart, and retrieved a lancet and testing strip. LPN1 picked up the previously cleaned glucometer and went to R7's room. On 10/03/25 at 7:21 AM, LPN1 performed hand hygiene and donned gloves. LPN1 checked R7's blood sugar and removed her gloves. LPN1 did not perform hand hygiene before applying a fresh pair of gloves to apply a topical medication on R7. After applying the topical, LPN1 removed her gloves and performed hand hygiene. On 10/03/25 at 7:26 AM, LPN1 picked up the glucometer and returned it to her medication cart. LPN1 donned a pair of gloves, cleaned the glucometer, and took off the gloves. LPN1 did not perform hand hygiene and touched the cart, the computer, and mouse. LPN1 reached into her pocket for cart keys and retrieved a lancet and testing strip.On 10/03/25 at 7:28 AM, LPN1 picked up the clean glucometer and headed to R8's room. R8's room had an enhanced precaution sign on the door. LPN1 wore a gown and gloves from the supply cart outside the room, no hand hygiene, and entered R8's room. LPN1 performed blood sugar check on R8. On 10/03/25 at 7:31 AM, LPN1 discarded the gown and gloves in the trash. LPN1 held the glucometer in one hand and placed the other hand to collect some hand sanitizer from the wall dispenser in R8's room. LPN1 cupped the sanitizer in her hand but did not use it, until she stepped out of R8's room into the hallway and reached her mediation cart. LPN1 placed the glucometer on the cart and then brought her hand together to rub the sanitizer.On 10/03/25 at 7:32 AM, LPN1 donned a pair of gloves and proceeded to document on her computer with gloves on. When she finished documenting, LPN1 cleaned the glucometer. LPN1 doffed her gloves and did not perform hand hygiene.On 10/03/25 at 7:34 AM, LPN1 went to R9's room. LPN1 performed hand hygiene, performed the blood glucose check and discarded the gloves when done, without performing hand hygiene. LPN1 wheeled R9 back to the dining area.On 10/03/25 at 7:37 AM, LPN1 performed hand hygiene, wore a pair of gloves to clean the glucometer. LPN1 doffed her gloves and did not perform hand hygiene. She proceeded to document on the computer and put hands in her pocket.On 10/03/25 at 7:43 AM, LPN1 wheeled R10 back to the dining area. LPN1 donned a pair of gloves, performed no hand hygiene, and cleaned the glucometer. LPN1 doffed her gloves and did not perform hand hygiene.During an interview on 10/03/25 at 7:47 AM, the foregoing observations were discussed with LPN1. LPN1 acknowledged she had failed to perform hand hygiene before and after wearing gloves.During an interview on 10/03/25 at 1:40 PM, Infection Preventionist (IP) stated it was her expectation that staff perform hand hygiene before and after entering resident's rooms and before wearing gloves and after taking gloves off.Review of the policy titled Infection Prevention and Control Manual General Policies dated 2023 revealed:Cleaning and Disinfecting Blood Glucose Meters Policy:It is the policy of the facility to clean and disinfect multi-patient use blood glucose meters. Resident-to-resident transmission of blood-borne pathogens is a well-known risk when using lancets, needles, and syringes. Blood glucose monitors that are shared among residents must be cleaned and disinfected between each use.Procedure:1. Apply gloves before performing a blood glucose test. Glucose monitoring, administration of insulin, and any other procedure that involves potential exposure to blood or body fluids.2. Do not carry meter, supplies or medications in pockets.3. Unused supplies and medications taken to a patient's bedside during fingerstick monitoring or insulin administration should never be used on another resident .5. Remove gloves and perform hand hygiene.6. Apply new gloves.7. Thoroughly clean all visible soil or organic material (e.g., blood) from glucometer before disinfection.8. Perform hand hygiene (i.e., hand washing with soap and water or use of an alcohol-based hand rub) immediately after removal of gloves and before touching other medical supplies intended for use on other residents.9. Follow manufacturers' guidelines for cleaning and disinfecting glucose meters. Specific guidelines for glucose meters may vary with the manufacturer.10. In the absence of manufacturer's recommendations, the glucometer is considered a semi-critical device, follow policy for cleaning semi-critical devices.

Based on interview and record review, the facility did not ensure that residents are free of any significant medication errors for 1 of 3 residents (R2) reviewed for medication errors.R2 was prescribed Levetiracetam (Keppra) (a medication used to treat seizures) for 7 days as a seizure prophylaxis. The facility failed to clarify, transcribe, and follow the physician order. R2 continued to receive the medication. This resulted in actual harm when R2 experienced a decline and was readmitted to the hospital, for Acute metabolic encephalopathy - Multifactorial at this point including continued use Keppra (serious condition characterized by diffuse brain dysfunction due to metabolic disturbances, often leading to confusion, memory loss or loss of consciousness; it's critical to identify and treat the underlying cause, it's often reversible with prompt treatment) requiring intravenous fluids, monitoring, and the discontinuation of the medication. The facility did not thoroughly investigate this medication error. This is evidenced by:Facility policy, titled Medication Errors, dated 09/2020, states in part, Policy: A medication error is defined as: any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the health care professional or resident. Such events may be related to professional practice, health care products, procedures and systems, including prescribing; order communication; product labeling; packaging; compounding; dispensing; distribution; administration; education; monitoring, and use.On 11/25/25 at 11:13 AM, Surveyors interviewed DON B (Director of Nursing). DON B indicated the facility had no medication errors since 10/4/25.R2 admitted to the facility on [DATE] after being discharged from the hospital. R2 had been admitted to the hospital from [DATE] to 10/8/25 after falling at home and was diagnosed with a traumatic subdural and subarachnoid hemorrhage (bleeding between the brain's outermost covering and the brain and bleeding between the space between the brain and its second outermost layer) and diffuse traumatic brain injury with loss of consciousness status unknown (widespread brain injury). R2 also has diagnoses that include, in part: chronic kidney disease stage 3 (moderate kidney damage where the kidneys are not filtering blood as effectively as they should be), chronic combined systolic and diastolic heart failure (the heart's inability to pump blood and fill with blood properly), and dysphagia (difficulty swallowing). R2's admission Minimum Data Set (MDS) dated [DATE] indicates R2 has a Brief Interview for Mental Status (BIMS) of 10 out of 15, indicating he is moderately cognitively impaired.R2's facility progress note, dated 10/8/25 at 2:30 PM, states, Arrived to unit in w/c (wheelchair). Denies pain. Very hard of hearing even with hearing aids in. Pivot transfer with one assist.R2's hospital Discharge summary, dated [DATE], states in part, Hospital Course: (including consults and procedure details) .Keppra was initiated for 7 days for seizure prophylaxis per neurosurgical and neurology recommendations.Discharge Medications and Allergies.Start taking these medications.Levetiracetam (Keppra) 500 mg tablet - Disp (dispense)-2 tablet, R (refills)-0, Take 1 (one tablet by mouth 2 times daily, ePrescribe.R2's transfer orders for receiving facility, dated 10/8/25, states in part, Current Discharge Medication List.Start taking these medications.Levetiracetam 500 mg tablet, commonly known as Keppra, Quantity dispensed: 2 tablet / Instructions: Take 1 (one) tablet by mouth 2 times daily.R2's health facility transfer chart, dated 10/8/25, states in part, Assessment and Plan.Traumatic brain injury with intracranial hemorrhage (ICH): -Admit to ICU -CCM (chronic care management) consulted by ED (emergency department) MD (medical doctor) -Neurosurgery consulted, appreciate recs. (recommendations) -Keppra 500 mg BID (two times per day) for 7 days from injury for seizure ppx (prophylaxis). Hospital MAR (medication administration record): .Levetiracetam (Keppra) tablet 500 mg, Dose: 500 mg, Freq: 2 times daily, Route: PO (oral), Start: 10/04/25 1015, End: 10/10/25 0759.According to an article published by the University of Texas Health Science Center at Houston in 8/2005 and last reviewed 7/2024, titled, Post-Traumatic Seizure Prophylaxis in Patients with Traumatic Brain Injury Clinical Practice Guideline, post-traumatic seizures can occur following a traumatic brain injury (TBI) and levetiracetam is one of the top two commonly used anti-epileptic drugs for prophylaxis. The article states, Based on the American Academy of Neurology (AAN) and Brain Trauma Foundation (BTF) recommendations, using anti-seizure drugs during the first seven days after an injury has become the standard of care for PTS prophylaxis in severe TBI patients (https://med.[NAME].edu/surgery/post-traumatic-seizure-prophylaxis-in-patients-with-traumatic-brain-injury-clinical-practice-guideline/). According to the Epilepsy Foundation, Levetiracetam (Keppra) is a seizure medication. The website provides the following precautions and side effects, in part: How does the body digest Levetiracetam? .The body gets rid of the drug through the kidneys. This may affect how much levetiracetam a person with kidney problems takes and how often they take it. Who should not take Levetiracetam? . People with kidney disorders need to be extra careful, however. Levetiracetam may be given at a lower dose to prevent build up to a high level. What are the effects of Levetiracetam on Seniors? A very low dose of levetiracetam may need to be used when starting it in older adults. The dose of medicine would then be increased more slowly.Seniors may be more sensitive to the side effects of this medicine.What are the most common side effects of Levetiracetam? .Some side effects may include: dizziness, headache, irritability, loss of strength and energy, mood and behavior changes, sleepiness. (https://www.epilepsy.com/tools-resources/seizure-medication-list/levetiracetam). R2's October 2025 MAR included the following order: Levetiracetam oral tablet 500 mg - Give 1 tablet by mouth two times a day for 1 week. Order date: 10/08/25. R2 received the levetiracetam at 8:00 AM and 5:00 PM from 10/08/25 to 10/22/25. Note: On 10/08/25, R2 only received the 5:00 PM dose and on 10/22/25, R2 only received the 8:00 AM dose. R2's Nurse Practitioner (NP) Note, dated 10/17/25, includes the following, in part: (NP D) Neurological history with traumatic brain injury and subdural hemorrhage. Patient is receiving physical, occupational, and speech therapy to support functional recovery and is on Keppra for seizure prevention. Daughter was concerned the Keppra was causing patient to be lethargic and not want to participate in therapy, etc., wanted the dose lowered. Spoke with daughter and explained this is a common side effect but typically goes away over time. Daughter verbalized understanding. Continue Keppra at current dose.R2s Progress Notes, dated 10/22/25 at 11:00 AM, include in part:DON B: Late Entry - Note Text: Writer and social services met with family, family inquiring about keppra and if medication could be contributing to residents [sic] decreased appetite, decline in mobility and flat affect. Writer spoke with NP (Nurse Practitioner). Received new orders to taper Keppra to 500 mg daily x 7 days then discontinue. Writer confirmed with medical records that CT (computerized tomography) and neurology follow up is in the process of being scheduled. Writer updated POA (power of attorney) and daughter. Family in agreement with plan. On 11/25/25 at 4:05 PM, Surveyors interviewed NP D via telephone about R2's Keppra order. NP D indicated a brief review of the discharge summary is completed for new patients. NP D indicated she did not recall reading anything about the Keppra order for R2 except the start and continue information. NP D indicated R2's family had noted a decline with R2 - specifically being more sleepy - and had brought it up. NP D indicated she was not familiar with the long-term effects of this medication, but had looked it up and told the family it was a typical effect that usually subsides. NP D stated, I don't really mess with the Keppra, and had noted R2 had an upcoming neurology appointment and felt more comfortable letting neurology adjust the medication. R2's October 2025 MAR included the following order change: Levetiracetam oral tablet 500 mg - Give 1 tablet by mouth one time a day for 1 week. Order date: 10/22/25 / Discontinue Date: 10/27/25. R2 received the levetiracetam at 8:00 AM on 10/23/25 and 10/24/25.R2s Progress Notes, dated 10/24/25, include in part: -1:25 PM - Interdisciplinary Team Note: Note Text: Resident has triggered for a weight loss of 5.4 percent in 3 weeks since admissions. Residents [sic] PO intake is poor with less then 25 percent. Resident has supplements in place. Resident is more lethargic during daytime. Labs ordered and waiting results and plan of DON to consult with NP and family regarding plan of care.-3:21 PM - Nurse's Note: Note Text: Family at resident's bedside and had concerns r/t (related to) decreased LOC (level of consciousness) and audible lung sounds. Family called 911 to take resident to hospital. EMS (emergency medical services) took resident around 1515 (3:15 PM).-9:13 PM - NP D Progress Note - Note Text: Service Date: 10/23/25. Current Level of Function: PT (Physical Therapy) 10/23. Therapist participated in care conference with pt (patient) family and facility staff with pt not present per family request. Pt is incapacitated and has a recent medical decline.Staff reporting increased difficulty with transfers. Pt has demonstrated a decline in mobility. Pt instructed in use of EZ stand. Pt completed x 3 stands with pt unable to maintain standing position. After 10 seconds demonstrates hanging in machine. Pt notes 'no I can't' when cued to stand erect. Pt downgraded to a hoyer for transfers with caregiver training completed.(of note: R2 has had a decline from being able Pivot transfer with one assist to now needing to be transferred with a Hoyer (full body lift) and experience weight loss in approximately 2 weeks.)R2's Progress Notes, dated 10/31/25 at 2:23 PM, indicate R2 was readmitted to the facility. R2's hospital discharge documentation, dated 10/31/25, indicates R2 was admitted to the hospital from [DATE] to 10/31/25. Final diagnoses for his hospital stay include, in part: acute metabolic encephalopathy, aspiration pneumonia, and AKI (acute kidney injury). R2's treatment included, in part, being started on IV fluids and discontinuing Keppra. The documentation includes the following hospitalist notes, in part:-10/24/25 at 6:49 PM: Assessment/Plan: 1. Acute metabolic encephalopathy - Multifactorial at this point including continued use Keppra, UTI and probably pneumonia. Manage underlying problems. Supportive care.-10/27/25 at 2:28 PM: Subjective: .On admission Keppra was not continued. Assessment/Plan: 1. Acute metabolic encephalopathy: Resolving, has been hydrated, has been taken off chronic diuretic and for now Entresto (chronic heart failure medication) is on hold, Creatinine (level to measure how well the kidneys are filtering waste) has normalized from 2.6 down to 1.1.(Of note: The reference range for creatinine is 0.6-1.30 mg/dL in the hospital discharge paperwork. A number above 1.3 indicates the kidneys may not be filtering waste efficiently.)-10/29/25 at 12:18 PM: Subjective - [R2].was at [hospital] between October 2 to October 8, was started on Keppra to avoid posttraumatic seizures which was planned for 7 days total, but was continued at [nursing home facility] longer.On 11/25/25 at 1:53 PM, Surveyor interviewed PT H (Physical Therapist). PT H indicated she had worked with R2 from his admission to the facility on [DATE] to his hospital stay on 10/24/25. PT H indicated R2 had started making progress, plateaued, then declined.On 11/25/25 at 1:55 PM, Surveyor interviewed PT Supervisor E. PT Supervisor E reviewed R2's PT and OT (occupational therapy) notes from 10/08/25 to 10/23/25. The notes indicated the following, in part: -10/9/25 (PT): Ambulated 10 feet with therapist and walker with moderate assistance-10/13/25, 10/14/25 (PT): Worked on transfer training with minimal to moderate assistance-10/15/25 (OT): Hand strength near normal range, (PT): Ambulated 20 feet-10/20/25 (PT): Ambulated 10 feet-10/21/25 (OT): Not feeling good, declined therapy. Reported to nursing.-10/23/25 (PT): Unable to stand for required amount of time (1-3 minutes) for EZ stand for transfers, so was downgraded to a Hoyer lift. PT Supervisor H indicated R2 participated on and off in therapy during this time, and there was no noticeable decline until 10/23/25. PT Supervisor H reviewed PT notes from 10/31/25 to 11/14/25, when R2 was readmitted to the facility following his hospital stay. PT Supervisor H indicated R2 was very willing to participate in PT upon his return to the facility. Notes indicate the following, in part:-11/05/25 (PT): Able to stand on own-11/06/25 (PT): Walked 22 feet with minimal assistance On 11/25/25 at 2:15 PM, Surveyor interviewed CNA F (Certified Nursing Assistant). CNA F worked with R2 while he was at the facility. CNA F indicated R2 was up and down with being willing to participate in ADLs (activities of daily living) before he was admitted to the hospital on [DATE]. CNA F indicated R2 had more weakness, needed more help with transfers, and his appetite declined before being admitted to the hospital on [DATE]. When R2 returned to the facility on [DATE], CNA F indicated he was back to his normal self. He was more willing to get up and his appetite was good - he wanted to eat again.On 11/25/25 at 2:20 PM, Surveyor interviewed CNA G. CNA G worked with R2 while he was at the facility. CNA G indicated R2 displayed progressive weakness and a decreased appetite before he was admitted to the hospital on [DATE]. When R2 returned from the hospital on [DATE], CNA G indicated he was like a different person. He had a happier personality, was more talkative, and his appetite increased.Surveyor reviewed R2's power of attorney form and noted it was activated on 10/16/25 and inactivated on 11/11/25.On 11/25/25 at 2:43 PM, Surveyors interviewed DON B and RNC C (Corporate RN) regarding how medication orders are entered for new admissions to the facility. DON B indicated a nurse receives a resident's discharge summary and orders, calls a physician to verify the orders, then enters the orders into the facility's system. RNC C indicated the discharge medication list is verified by a nurse with a physician or NP, then the nurse is given the okay to process the orders. DON B indicated a second or third nurse then checks the order to verify it is correct. The order is initially pended and then must be confirmed by a second person. This may also be done by a remote nurse who audits medication orders. DON B indicated floor nurses, nurse leadership, the MDS coordinator, and interdisciplinary teams looks over the hospital discharge paperwork. Surveyors asked DON B and RNC C about R2's Keppra orders and pointed out the discharge paperwork indicated only two tablets should be dispensed. DON B indicated the dispense amount indicates how many tablets are in the current prescription and does not affect medications going forward. (Of note: The order had indicated 0 refills for the prescription.) Surveyors asked DON B and RNC C about the discrepancy on the hospital transfer discharge summary report that indicated the end date for the Keppra prescription was 10/10/25. RNC C indicated this information cannot be used for facility orders, as it is a hospital MAR. Surveyors asked if the end date of 10/10 would warrant further clarification. RNC C answered yes. Surveyors asked if a dispense amount of two tablets would prompt the facility to call the hospital to clarify the order. RNC C indicated this issue could be seen from two angles - someone should have called to clarify the order, but the hospital discharge paperwork should also indicate exactly what should happen with medications. There had been no end date listed for the Keppra order. Surveyors pointed out the discharge summary mentioned the Keppra was only for a 7-day time span multiple times. RNC C indicated the facility should not have to scan through the H&P (history and physical) notes and summary to obtain this information. DON B indicated NP D had tapered the dose and decided to continue it until R2's neurology review date. DON B was unsure when the neurology review date was scheduled for. Surveyors asked if the neurologist was ever consulted if NP D wasn't comfortable with stopping the medication without tapering it. RNC C indicated they could not speak to that and said the neurologist did not order the Keppra to begin with. (Of note: The hospital discharge summary indicated neurology had been consulted and had given recommendations.)RNC C indicated the facility had investigated the discrepancy with the hospital orders and the facility orders when it was brought to their attention. They were unable to provide documentation of the investigation.R2 was prescribed Levetiracetam (Keppra; a medication used to treat seizures) for 7 days as a seizure prophylaxis. The facility failed to clarify, transcribe, and follow the physician order. R2 continued to receive the medication. This resulted in actual harm when R2 experienced a decline and was readmitted to the hospital, for Acute metabolic encephalopathy - Multifactorial at this point including continued use Keppra requiring intravenous fluids, monitoring, and the discontinuation of the medication. The facility did not thoroughly investigate this significant medication error.

4.) R91 was admitted to the facility on [DATE] with diagnoses that included gout, congestive heart failure, obesity, type 2 diabetes mellitus, chronic kidney disease and inflammation of right lower extremity. The most recent Annual MDS (minimum data set), dated [DATE], documents that R91 has a BIMS (brief interview for mental status) of 13 indicating R91 is cognitively intact. R91 is at risk for developing a pressure injury and at the time did not have any unhealed areas of skin impairment. Surveyor conducted a review of R91's individual plan of care and noted the following: R91 is with actual alteration in skin integrity r/t (related to) red groin, and MASD (moisture associated skin damage), immobility and incontinence. Res (resident) refusing air mattress and prefers to have a foam pressure reducing mattress. Hx (history): edema and diabetic and stasis ulcers to bil (bilateral) lower extremities. Skin tears to RLE (right lower extremity) noted. Resident takes off own dressings at times if dressings on and prefers not re-dressed at times. Date Initiated: [DATE] o Skin will remain grossly intact thru next review. Date Initiated: [DATE] o Absorbent to wick up moisture. Date Initiated: [DATE] o Barrier cream to areas exposed to moisture/incontinence. Date Initiated: [DATE] o Bathe with mild soap. Date Initiated: [DATE] o Elevate heels off bed (non-arterial). Date Initiated: [DATE] o Engage resident and/or family in risk reduction interventions. Date Initiated: [DATE] o Inspect skin daily with care. Date Initiated: [DATE] o Monitor labs, weight and/or intake. Date Initiated: [DATE] o Monitor nutritional status. Date Initiated: [DATE] o monitor RLE skin tears for s/s (signs/symptoms) of infection, until healed. Date Initiated: [DATE] o Pericare after incontinent episodes. Date Initiated: [DATE] o Position body with pillows/support devices. Date Initiated: [DATE] o Pressure reduction support on wheelchair. Date Initiated: [DATE] o Teach resident to shift weight in the wheelchair. Date Initiated: [DATE] o Treatment as ordered Date Initiated: [DATE] o Use assistive devices to decrease friction (Hoyer lift, draw sheet). Date Initiated: [DATE] o Weekly wound progress assessment by nurse. Date Initiated: [DATE] Nursing note dated [DATE] at 1:27 PM; Pressure injury to left buttocks and blood blister to right great toe reported by CNA's this AM. NP (nurse practitioner), VA (Veteran's Administration), family notified. Treatments in place. Nursing note dated [DATE] at 1:31 PM; Pressure injury to left buttock measuring 4 x 4 cm. Further review of R91's medical record did not provide evidence that a comprehensive assessment had been completed for the pressure injury to the left buttocks or blood blister to the right great toe. On [DATE] at 4:00 PM a physician order was obtained as the following: Betadine to right great toe 2 x (2 times) daily until healed, two times a day. An additional review of the individual plan of care was completed and it was noted it was not updated to reflect the pressure injury to the left buttocks or the blood blister to the right great toe. No additional interventions were put into place to aide in healing these areas. On [DATE] at 8:00 AM; a physician order was obtained for zinc oxide to left buttock, cover with mepilex until healed. one time a day for Skin Condition Nursing note dated [DATE] at 1:26 PM; Notified NP, that wound on buttocks is not improving and needs to be evaluated, notified management at morning nurse's meeting of the same. Surveyor continued the review of the medical record for R91 and did not see any further documentation regarding the NP's response, if a further comprehensive assessment had been completed to the wound on the buttocks or that the plan of care was updated with interventions to prevent the worsening of the area or aide in healing. On [DATE], a NP progress note was written (no time of visit/assessment documented) indicating R91 is receiving ongoing care for bilateral lower extremity wounds at the VA wound clinic. R91 wears compression stockings on both legs to manage swelling, which is noted in his bilateral lower extremities. Additionally, R91 has wounds on his right great toe and left buttock, which is being managed by the facility wound team. Physical Examination: Skin- wound to great toe and left buttock. On [DATE], the facility completed a Braden Scale for Pressure Injury Risk indicating that R91 is at mild risk for pressure injuries. On [DATE] at 11:45 AM, Surveyor interviewed DON (Director of Nursing)-B regarding R91's areas of skin impairment. Surveyor requested to review any comprehensive assessment of R91's pressure injury to the left buttocks or blister to the right great toe. DON-B stated that she had conducted a skin sweep starting 6/16-[DATE] to identify any new areas of skin impairments. DON-B stated that this information had not been uploaded into the medical record yet. Surveyor asked DON- B if there was any follow-up to the nursing note dated [DATE] that documents the wound to the left buttocks was worsening and needed further evaluation. DON- B stated that R91 does not have a pressure injury, it's a moisture area. On [DATE], DON- B did provide a copy of the skin sweep documentation, dated [DATE] for R91. The skin notes state that 4 x 2 (does not indicate whether centimeter of milimeter) thickness area of MASD (moisture associated skin damage) to the left buttocks area has no signs/ symptoms of infection noted. R91 was previously using urinal and now calls for assistance and more episodes of incontinence. Right great toe stable eschar measuring 1 x .5 centimeters. Betadine continues. NP updated. This documentation was written by DON- B. Surveyor noted the skin sweep documentation does not include additional details to help distinguish if the area on R91's buttock is MASD vs (versus) a pressure injury such as whether the shape is irregular, inflamed, etc. On [DATE] at 12:15 PM, Surveyor interviewed Agency Licensed Practical Nure (LPN)- RR regarding the completion of the treatments for R91 to the buttocks and right great toe. Agency LPN- RR stated she didn't see the area to the buttocks because the CNA's (Certified Nursing Assistants) do the Zinc applications. Agency LPN- RR stated that she only did a treatment to R91's toe. Surveyor asked why she had signed out on the Treatment Medication Administration Record for [DATE] that she did the treatment for zinc oxide to left buttock, cover with mepilex. Agency LPN- RR stated she signed it as completed because she will make sure the CNA applied it. On [DATE] at 12:22 PM, Surveyor interviewed DON- B regarding R91's treatment to the left buttocks being completed by a CNA. DON- B stated that the CNA's definitely are not supposed to being doing any treatments and that she will immediately talk with Agency LPN- RR about this. Surveyor asked DON- B if she was able to find any follow-up to the [DATE] nursing note about the worsening area to R91's buttocks. DON- B stated she was not able to find any follow-up, but the area did not worsen. It once measured 4 x 4 and now it is 4 x 2, clean and healthy. Surveyor asked if there had been any comprehensive assessment of this area and the right great toe. DON- B stated that she had only done a skin sweep of all of the residents and was only looking for new areas. DON-B stated that she has another week (to meet requirement of weekly comprehensive skin assessments) to address these areas. DON- B confirmed that she is the facility's Wound Nurse. On [DATE] at 2:15 PM, Surveyor requested to review the weekly skin check that was signed out as completed on [DATE]. DON- B stated that the nurse's don't document anything when they complete the weekly skin assessment unless there is a new area. Surveyor asked DON-B how the staff would know if there was a new area or not. DON-B stated that they would know because there would be a treatment in place. Surveyor then asked why there had not been a comprehensive assessment of R91's buttocks a right great toe wounds and why the plan of care had not been updated. DON- B was unable to provide any additional information at this time. 2.) R51 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following a cerebral infarction, diabetes, heart failure, legal blindness, bilateral hearing loss, adjustment disorder with mixed anxiety and depressed mood, and mild cognitive impairment. R51's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R51 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and had impairment to the left arm and left leg. R51's Activities of Daily Living Care Plan, initiated on [DATE], documented R51 used a full body mechanical lift for transfers. R51's At Risk for Skin Breakdown Care Plan was initiated on [DATE] with the following interventions in place on [DATE]: -Absorbent to wick up moisture. -Barrier cream to areas exposed to moisture/incontinence. -Bathe with mild soap. -Inspect skin daily with care. -Monitor for signs/symptoms of infection. -Monitor labs, weight, and/or intake. -Monitor nutritional status. -Monitor wound related pain and administer pain medication as appropriate. -Peri care after incontinent episodes. -Position body with pillows/support devices. -Pressure reduction support on wheelchair. -Turn and reposition every two hours and as needed. -Use assistive devices to decrease friction. -Weekly wound progress assessment by nurse. -Wound care consultation as ordered. On [DATE] at 4:50 AM in the progress notes, nursing documented the nurse requested an air mattress due to R51's decline in condition to avoid pressure wounds. Surveyor noted R51's Care Plan was not revised to include an air mattress at that time. R51 was seen weekly by the wound physician for diabetic ulcers to the left ankle and the right big toe prior to [DATE] when R51 was admitted to the hospital due to altered mental status. R51 was readmitted to the facility on [DATE]. On [DATE] on the Initial Nursing Assessment form, nursing documented R51 had a new pressure injury to the coccyx and the outer left great toe; the ulcer to the left heel remains. A Wound and Skin Assessment (WASA) form was completed at the same time documenting the right buttock pressure injury measured 0.2 cm x 0.1 cm with 50% epithelial tissue and 50% granulation tissue. Surveyor noted the pressure injury was not staged and had no depth measurement. Surveyor noted no treatments for the wounds were obtained. On [DATE], R51 was seen by the wound physician who documented R51 had a Deep Tissue Injury (DTI) of the left medial foot that was present on readmission. The DTI measured 1 cm x 1 cm with intact purple/maroon discolored skin. A treatment of skin prep to the left medial foot was ordered at that time. No documentation was found by the wound physician of the coccyx pressure injury that was documented on [DATE]. In an interview on [DATE] at 11:02 AM, Director of Nursing (DON)-B stated DON-B thought the coccyx/right buttock wounds that were noted on readmission on [DATE] were moisture associated dermatitis and not pressure so were not assessed by the wound physician. R51 was seen by the wound physician weekly and the left medial foot was comprehensively assessed with treatment changes as indicated. On [DATE], R51 started hospice services with an admitting diagnosis of cerebral infarction. On [DATE], R51 was seen by the wound physician who documented the left medial foot pressure injury was Unstageable measuring 1.5 cm x 1.4 cm x not measurable with 100% thick adherent devitalized necrotic tissue. R51's At Risk for Skin Breakdown Care Plan was revised on [DATE] with the intervention of a pressure reduction foam mattress or pressure redistribution support (low air or alternation air) in bed. On [DATE] at 9:34 AM, Surveyor observed R51 sitting in a Broda chair in R51's room with a cloth heel boot on the left foot and a sock on the right foot. An air mattress was in place on R51's bed. R51 stated R51 had a bad sore on the left foot. Surveyor noted R51 had documentation of a diabetic ulcer to the left outer ankle and a pressure injury to the left medial foot. No dressings could be observed due to the cloth heel boot on R51's left foot. On [DATE] at 3:52 PM, Surveyor observed R51 in bed lying on an air mattress. A cloth heel boot was in place to the left foot and a gripper sock was on the right foot. R51's left leg was bent at the hip and knee with outward rotation. The outer left foot was resting on the heel boot which ended mid foot and the left fifth toe was resting on the mattress. On [DATE] at 10:41 AM, Surveyor observed R51's wound care performed by Licensed Practical Nurse (LPN)-BB and assisted by Certified Nursing Assistant (CNA)-CC. R51 was lying in bed with egg crate heel boots on that covered the heel only. The left medial foot Unstageable pressure injury was located on the bunion area of the foot. LPN-BB was unsure of how the wound developed. Surveyor noted DTIs to the left lateral foot and the left fifth toe. Surveyor asked LPN-BB if LPN-BB was aware of those areas. LPN-BB stated there was no treatment to those areas that LPN-BB was aware of and had not seen those pressure wounds before. CNA-CC stated CNA-CC worked two days ago, [DATE], and that was when CNA-CC first saw those areas of concern. CNA-CC stated the pressure areas came from R51's shoes because they stopped having R51 wear shoes last week. LPN-BB stated R51's regular boot is in the laundry and LPN-BB pulled the cloth boot out of the laundry basket in R51's closet. LPN-BB stated the pressure wound to the left outer foot came from that boot because the edge of the boot, with the stitched seam, lines up with the edge of the foot where the pressure injury is. LPN-BB stated the egg crate boots must have come from hospice, but LPN-BB would get R51 some new boots. LPN-BB stated LPN-BB would let DON-B know about the new areas as well as notify the Nurse Practitioner and the wound physician. On [DATE] at 5:10 PM in the progress notes, LPN-BB documented R51 had new skin alterations to the left lateral foot and the fifth digit of the left foot that was noted during wound treatment that morning. The DON/wound nurse was notified, and the wound physician was updated. A daily treatment order was obtained and completed that morning. On [DATE], DON-B documented comprehensive assessments of the DTI to the left fifth digit and the left medial foot. On [DATE], the wound physician documented the left foot pressure wounds noted are related to R51's spasticity and inability to adequately offload the wounds despite pressure offloading boots and repositioning by the facility. R51 has attempted to be compliant with this but unfortunately due to underlying medical factors, R51 is unable to maintain offloading position. Surveyor noted R51's care plan did not address the floating of heels or address R51's tendency to position the left leg with outward rotation to prevent the development of pressure injuries. On [DATE] at 9:28 AM, Surveyor observed R51 sitting in a Broda chair. R51 had socks on both feet that were resting directly on the foot board/footrest. Surveyor noted the eggcrate heel boots were on the windowsill in R51's room. R51's left foot was rotated slightly so the side of the foot was touching the foot board where the new DTI areas were discovered on [DATE]. No pillows or heel boots were in place. On [DATE] at 11:02 AM, Surveyor shared with DON-B the concerns that R51's skin was not comprehensively assessed when readmitted to the facility on [DATE], the DTI to the left medial foot was not discovered or assessed until [DATE] when R51 was seen by the wound physician, and R51's care plan did not address R51's positioning with the outward rotation of the left leg to prevent pressure injuries. R51 developed two DTI's that were discovered during wound care on [DATE] when Surveyor was observing, and CNA-CC stated those areas were present two days prior. DON-B stated hospice provided the eggcrate heel boots, and the wound physician said the wounds were unavoidable because of contractures and positioning, the air mattress, and the boots should help and not hinder pressure areas. Surveyor shared with DON-B the concern R51 had known positioning challenges and those were not addressed through assessment or care planning. 3.) R93 was admitted to the facility on [DATE] with diagnoses of dementia, diabetes, congestive heart failure, and anemia. R93's admission Minimum Data Set (MDS) assessment dated [DATE] documented R93 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 5 and was dependent for dressing, personal hygiene, transferring, and bed mobility. The Pressure Ulcer Care Area Assessment (CAA) from R93's Significant Change MDS dated [DATE] documented R93 was at risk for the development of a pressure injury. R93's Potential for Alteration in Skin Integrity Care Plan was initiated on [DATE] with the following interventions: -Barrier cream to areas exposed to moisture/incontinence. -Bathe with mild soap. -Daily foot check as (R93) will allow. -Elevate heels off bed as (R93) will allow; (R93) declines frequently. -Inspect skin daily with care. -Moisturize dry skin. -Monitor nutritional status. -Pericare after incontinent episodes. -Position body with pillows/support devices; (R93) will decline use of these. -Pressure reduction support on wheelchair. -Treatment as ordered. -Use of equipment for fragile skin. On [DATE], R93's Potential for Alteration in Skin Integrity Care Plan was revised with the following interventions: -Absorbent to wick up moisture. -Dietary referral as needed; encourage acceptance of supplements. -Educate (R93) and/or family regarding pressure injury management. -Monitor/manage diabetes, assess lower extremities for arterial insufficiency and/or appropriate foot and nail care. -Pressure reduction foam mattress or pressure redistribution support (low air or alternating air) in bed. Surveyor noted no documentation was found for R93's Potential for Alteration in Skin Integrity Care Plan to be revised on [DATE]; no alteration in skin documentation was found or skin assessments documenting any new pressure injury concerns. On [DATE] at 3:37 PM in the progress notes, nursing documented R93 had a large intact blister to the left heel. A new treatment for skin prep to the left heel every shift was initiated. On [DATE] on the Wound and Skin Assessment (WASA) form, Director of Nursing (DON)-B documented the left heel Deep Tissue Injury (DTI) presented as a fluid filled blister that measured 8.5 cm x 11 cm. Surveyor noted this was the first comprehensive assessment after the discovery of the pressure injury three days prior. On [DATE] on the WASA form, DON-B documented the DTI measured 8.5 cm x 9 cm and presented as a deflated blister with exposed dermis. Surveyor noted the exposed dermis was not a characteristic of a DTI but the development into a Stage 3 pressure injury or Unstageable. DON-B assessed R93's left heel pressure injury weekly with the wound evolving into a stable heel cap with 100% eschar on [DATE] and progressing to an Unstageable pressure injury on [DATE] with 100% eschar. Surveyor noted the pressure injury was staged as a DTI while there was 100% eschar from [DATE] until [DATE]. The left heel pressure injury was Unstageable from [DATE] until [DATE] when the wound bed was 100% granulation and staged at a Stage 3. Surveyor noted no wound depth was documented from the development of the wound until [DATE]. On [DATE] at 1:55 PM, Surveyor observed Licensed Practical Nurse (LPN)-BB complete wound care with R93. Surveyor observed LPN-BB apply skin prep to bilateral heels. Surveyor noted R93 did not have any open areas on either heel at that time. In an interview on [DATE] at 10:56 AM, Surveyor asked DON-B what the facility process was for a resident that developed a pressure injury while at the facility. DON-B stated the nurse on the floor would either complete a comprehensive assessment at that time or if it was an LPN that discovered the wound, a Registered Nurse (RN) that was in-house would be notified to come and assess. DON-B stated it would be situational about when the wound would be assessed. DON-B stated the wound physician is in the building weekly and they may wait until the wound round day to have the resident seen by the wound physician. DON-B stated the wound physician would then see the resident weekly for the weekly assessments. Surveyor shared the concern R93 developed a pressure injury to the left heel on [DATE] and was not comprehensively assessed until [DATE]. DON-B stated the facility had an Assistant DON (ADON) that was a wound nurse, but DON-B could not recall if the ADON saw R93 at all during that time. Surveyor shared the concern with DON-B the wound measurements did not include a depth measurement until [DATE]. DON-B stated the wound was superficial, but agreed a depth should have been documented. 5.) R79 was admitted to the facility on [DATE] with pertinent diagnoses that include type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood) and chronic diastolic (congestive) heart failure (occurs when the heart's left ventricle becomes stiff and doesn't relax properly, hindering its ability to fill with blood). Surveyor noted R79 has a physician order dated [DATE] documenting cleanse right fourth toe with soap and water and change band aid daily every day shift for Wound cleansing. R79's Quarterly Minimum Data Set (MDS) with an assessment reference date of [DATE], documents a Brief Interview for Mental Status (BIMS) assessment score of 12, meaning moderate cognitive impairment. The MDS documents that R79 was not assessed to have any behaviors during the look back period. The MDS documents that R79 is at risk of pressure injuries, however no skin concerns were documented. R79's most recent Braden Scale for Predicting Pressure Score Risk evaluation dated [DATE] documented that R79 was assessed to have a score of 15, indicating R79 is at mild risk of developing a pressure injury. R79's care plan documents R79 is with actual alteration in skin integrity r/t (related to) DM (diabetes mellitus), incontinent, moisture, decreased activity, assistance needed with ADL's(activities of daily living). Swelling. Resident is with rashes to skin at times. Right lower extremity Date Initiated: [DATE] The care plan documents the following interventions: o Educate resident and/or family about risk for pressure ulcer/injury Date Initiated: [DATE] o Inspect skin daily with care Date Initiated: [DATE] o Moisturize dry skin Date Initiated: [DATE] o Pressure reduction foam mattress or pressure redistribution support (low air or alternating air) in bed Date Initiated: [DATE] o Treatment as ordered Date Initiated: [DATE] R79's Nursing Weekly Summary dated [DATE] documents No New Skin Conditions. R79's Nursing Weekly Summary dated [DATE] (no time indicated) documents No New Skin Conditions. R79's progress note written on [DATE], at 9:18 pm, documents Resident has a small open area on his RLE (right lower extremity). Area was washed with warm water and patted dry. Writer applied an oil emulsion dressing, ABD (abdominal) and secured with rolled gauze. Resident tolerated well. NP (Nurse Practitioner) notified. Surveyor noted there is not a comprehensive assessment of this small open area on R79's RLE. The progress note does not specify where the area is located on R79's RLE. R79's Nursing Weekly Summary dated [DATE] documents both Skin intact and No New Skin Conditions. The sections If Skin Condition present - Document Site, type of condition, TX (treatment), and progress and Additional comments are left blank on the three Nursing Weekly Summary reports reviewed. Surveyor noted [DATE] R79's open area was found, and it was not documented on the [DATE] Nursing Weekly Summary and on the next week's [DATE] Nursing Weekly Summary documents R79's skin was intact. Surveyor noted no update to R79's care plan after the open area was discovered to the right lower extremity on [DATE]. R79's physician order dated [DATE] documents Clean area with warm soapy water, cover with oil emulsion dressing, ABD, and wrap with rolled gauze every day shift for Skin Condition. R79's physician order dated [DATE] documents SKIN CHECK COMPLETED, every day shift every Tue (Tuesday). This was not marked as completed on [DATE]. R79's Skin Sweep form was completed on [DATE], by Director of Nursing (DON)-B that documents 1 x 1 full thickness opened blister, tx (treatment) order in place with the 4th right toe circled on the body chart. Surveyor noted the documentation of a full thickness wound would indicate the pressure injury is either an unstageable, stage 3 or stage 4 pressure injury based upon being a full thickness wound. There is no staging noted by the facility. On [DATE], at 11:40 AM, Surveyor interviewed DON-B regarding the progress note written on [DATE] related to the right lower extremity open area found on R79. Surveyor asked if an assessment was completed. Per DON-B there is probably a paper assessment that was done during the skin sweep. Surveyor noted that R79's 4th right toe was the only skin concern documented on the Skin Sweep form. On [DATE], at 11:56 AM, Surveyor interviewed Registered Nurse (RN)-PP about R79's treatment. RN-PP stated the treatment had already been done for the day. Surveyor stated it was not marked as administered under treatments and RN-PP replied that they write down what need to do then cross off on the paper, R79's treatment is crossed off. RN-PP will document the administration at the end of the shift. Surveyor asked RN-PP to describe the wound to R79's right lower extremity and was told it is a skin tear that the scab came off. When RN-PP did the treatment, the wound was dry with no drainage. The wound bed was pink. On [DATE], at 12:20 PM, Surveyor was provided R79's Skin Sweep form and Surveyor noted only the 4th right toe was documented. There is no reference to the RLE wound receiving a treatment. On [DATE], at 12:27 PM, Surveyor interviewed DON-B regarding the right lower extremity open area not being on R79's Skin Sweep form and was told when DON-B saw R79 on the evening of 17th there was nothing there. Surveyor stated a treatment was in place and should have been seen during sweep. DON-B stated she needs to look into this. Surveyor noted being unable to locate documentation of an assessment of R79's right lower extremity open area. Surveyor noted there was a treatment order that was charted on [DATE] through [DATE]. Surveyor noted the care plan was not updated after discovery of the open area. On [DATE], at 02:52 PM, Surveyor shared with Nursing Home Administrator (NHA)-A, DON-B and Corporate-AA that the extended survey has been completed, the immediate jeopardy has not been removed due to concerns with two additional residents that were reviewed. R79's progress note written [DATE] identified an open area on the right lower extremity. A physician order was obtained and documented. Surveyor was unable to locate assessment information, and the care plan was not updated. This area should have been identified on the skin sweep as there was an active order for a treatment in place. No further information was provided at the time of write up regarding an assessment of R79's open area on the right lower extremity. Based on observation, interview, and record review, the facility did not ensure 5 of 7 residents (R) reviewed (R17, R51, R93, R91 and R79) had a comprehensive assessment and care plan to prevent and heal pressure injuries. * R17 was admitted to the facility on [DATE]. Upon Minimum Data Set (MDS) admission assessment and subsequent MDS assessments, R17 was assessed to be at risk for pressure injuries. R17 had admitting left and right anterior shin open areas. On [DATE], R17 developed a left toe and left ankle venous wounds. On [DATE], R17 was readmitted to the facility following a hospitalization with a venous wound left ankle, diabetic wound left dorsal foot, and diabetic left 4th toe wound. On [DATE], R17 developed a skin tear to the left shin and on [DATE], R17 developed a skin tear to the left leg. On [DATE], Occupational Therapy advised R17 that he should no longer self-propel his wheelchair with his arms and hands due to shoulder, pain and begin to self-propel with his legs and heels. On [DATE], R17 developed a non-pressure wound to the left great toe and on [DATE], the etiology changed from non-pressure wound to arterial wound to the left great toe. On [DATE], R17 developed an arterial wound to the right great toe. On [DATE], R17 had an appointment at the Wound Clinic and the wound Medical Doctor (MD) discovered a new unstageable left heel pressure injury. The wound MD wrote orders that R17 cannot self-propel with his heels and would need staff to push him in wheelchair. The care plan does not indicate use of an air mattress, heel offloading or pressure reducing boots as interventions prior to [DATE] when R17 developed the unstageable left heel pressure injury. There is no care plan for diabetic foot assessment or monitoring. The facility does not have evidence of any discussion with R17 regarding risk and benefits of self-propelling in his wheelchair with his legs and heels. On [DATE], R17 had left great toe amputated. On [DATE], R17's left heel was debrided and now presents as a Stage 4 pressure injury. On [DATE], R17 had a Magnetic Resonance Imaging (MRI) with results R17 has osteomyelitis (inflammation of the bone causing infection) with edema (swelling caused by excess fluid) enhancement of left heel. R17 was scheduled for a partial left heel removal on [DATE], however this did not occur as R17 was hospitalized on [DATE] and expired on [DATE]. The facility's failure to assess R17's risk for the development of pressure injuries and to establish preventative interventions to address R17's risk led to R17 developing a facility acquired, avoidable stage 4 pressure injury with osteomyelitis. The facility did not establish a care plan to assess R17's diabetic feet daily. The facility encouraged R17 to propel himself using his legs and heels to improve mobility but neglected the likelihood of R17 developing pressure injuries based on his extensive comorbidities and frail skin by using the same repetitive motion causing friction and pressure on the heels. R17 self-propelled with his legs and heels from [DATE] until the pressure wound developed, consequently, discovered by the wound physician on [DATE]. These failures created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility's failure to prevent the development of a facility acquired stage 4 pressure ulcer with osteomyelitis by ensuring assessment, prevention, and treatment in accordance with current standards of practice created a finding of immediate jeopardy (IJ) that began on [DATE] and has not yet removed by closure of survey on [DATE]. On [DATE] at 03:27 PM, Surveyor notified facility of the IJ. Facility staff present include Nursing Home Administrator (NHA)-A, Assistant Nursing Home Administrator (Assistant Administrator)-F, Senior Leader-H, Assistant Nursi[TRUNCATED]

Based on observation, interview, and record review, the facility did not ensure food was prepared and served in a sanitary manner. This practice had the potential to affect 111 of 111 residents dining in the facility. Staff did not wear beard restraints consistently in the kitchen. Findings include: The facility policy and procedure titled, Hair Covering dated 5/24, states in part: Policy Hair will be covered when in the kitchen operations areas. Purpose To prevent physical contamination of food Procedure 1. While in the kitchen operations area staff will cover hair to prevent physical contamination of food . 3. Staff with facial hair, with the exception of eyebrow and eyelashes, will wear a beard cover. Mustache or beard restraints shall be used for any facial hair exceeding half (1/2) inch in length. On 06/09/25, at 10:30 AM, Surveyor observed Dietary Director-C preparing rue with beard net not pulled up over mustache. On 06/09/25, at 10:36 AM, Surveyor observed Dietary Director-C stirring pots on stove with beard net not pulled up over mustache. On 06/09/25, at 10:48 AM, Surveyor observed Cook-W enter kitchen and start prepping food without donning a beard net. On 06/10/25, at 10:46 AM, Surveyor observed Cook-W prepping food with no beard net. On 06/10/25, at 10:51 AM, Surveyor interviewed Dietary Director-C regarding expectations for facial hair coverings. Surveyor relayed concern to Dietary Director-C of two observations of no beard net on Cook-W. Also, observations of Dietary Director-C with mustache exposed. On 06/10/25, at 03:13 PM, during the end of day meeting, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the concern that observations were made during food preparations of beards and mustaches not covered. On 06/11/25, at 11:47 AM, NHA-A asked Surveyor to swap out the policy for hair covering that had been given previously, stating that a newer version was found. The new policy states mustache or beard restraints shall be used for any facial hair exceeding half (1/2) inch in length. Surveyor noted that the first policy given stated mustache or beard restraints shall be worn, without a length specified. On 06/11/25, at 03:33 PM, during the end of day meeting, Surveyor discussed with NHA-A and DON-B that the State of Wisconsin regulation is 1/2 inch, but the federal regulation is that no facial hair can be exposed.

Based on interview and record review, the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect all 111 residents residing in the facility. Staffing information for Quarter 2 ([DATE] - [DATE]) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS. Findings include: The CMS Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated [DATE], indicates: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS .1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate .Report Quarter: staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows: Fiscal Quarter, Date range: (quarter) 1 [DATE]-[DATE], (quarter) 2 [DATE]-[DATE], (quarter) 3 [DATE]-[DATE], (quarter) 4 [DATE]-[DATE] . Surveyor reviewed the PBJ Staffing Data Report, CASPER Report 1705D, for Fiscal year 2025 (run on [DATE]) which indicated the Facility had excessively low weekend staffing and a one star staffing rating for the 2nd Quarter ([DATE]-[DATE]). Surveyor reviewed the Facility's weekend schedules from [DATE] to [DATE]. Surveyor noted licensed nurses and certified nursing assistants present on each shift, for each unit. Surveyor noted these schedules included call ins, agency staff and staff who picked up shifts. Surveyor noted there did not appear to be excessive call-ins. On [DATE], at 10:47 AM, Surveyor interviewed Scheduler-X regarding staffing. Per Scheduler-X the lowest number staffed, per 24-hour period, is 20 aides and 12 nurses scheduled. The goal for a 24-hour period is 27 aides and 14 nurses/medication technicians. Surveyor reviewed the Facility Assessment and noted for Licensed Nurses/Medication Aides the minimum is 11 and Certified Nursing Assistants the minimum is 20 per 24-hour period, this was compared to the provided schedules. No discrepancies were found. On [DATE], at 12:16 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding how the facility functions when at the minimums for nursing staff per the Facility Assessment. Per NHA-A ideally, they would like more staff than those minimums, but you cannot account for call ins. The numbers in the Facility Assessment are the absolute minimum to run the facility. Surveyor stated that the facility triggered for one star staffing and low weekend staffing, was there an issue with how the data was reported to CMS. NHA-A stated they were confused because don't get much info from CMS, NHA-A got a report from CMS and quickly went through it. NHA-A thought there was a reporting error, then went back through and then figured out it was ancillary staff. Surveyor asked if it was the ancillary staff then why not trigger every quarter and NHA-A didn't know. Corporate sends information from payroll department and agency hours pull in as well, all hours get sent. NHA-A then stated that there was one error with reporting. A Licensed Practical Nurse graduated in December and got licensed in December or early January. The nurse was still being reported as an aide. This was just changed a couple weeks ago so will be fixed for second quarter. On [DATE], at 01:47 PM, Surveyor interviewed Scheduler-X regarding each unit having multiple residents that use the mechanical lift. If a NOC shift person calls in, then the remaining aides split a unit. Surveyor asked how the unit is covered. Per Scheduler-X the nurse oversees the unit, and the remaining two aides watch the call lights and switch off on answering. All residents still get the regular two-hour rounds. Surveyor asked if residents were safe with staffing at the minimum numbers. Scheduler-X replied that residents aren't not (sic) being attended to, they aren't not (sic) getting care. Per Scheduler-X some staff will come in early to help when there are call ins. Surveyor asked if Scheduler-X had access to call light logs and was told no. Surveyor stated there are 35 residents who have elected full code, how can two nurses on NOC handle that. Scheduler-X stated that there are two full time night shift aides that took the cardiopulmonary resuscitation (CPR) class. The Medication Technicians have taken CPR class as well. On [DATE], at 02:14 PM, Surveyor spoke with NHA-A regarding the data regarding staffing not being accurately submitted. No additional information was provided. On [DATE], at 07:25 AM, Per NHA-A they spoke with corporate, and the payroll system being used was changed to a new vendor. The reporting was supposed to be fixed for 1st quarter, but it was not. NHA-A stated this has been taken care of.

Based on observation, interview, and record review the facility did not provide adaptive eating equipment to 1 (R95) of 1 sampled resident reviewed for assistive eating devices. Surveyor observed R95 did not receive therapy recommended assistive eating devices needed to maintain or improve R95's ability to eat or drink independently during 2 out of 3 Surveyor observed meals. Finding include: Facility Clinical Practice Guidelines titled; Feeding a Resident dated 09/20. Policy: Residents who need assistance will be fed a well-balanced meal, by a nurse, C.N.A. (certified nursing assistant), or an individual who has completed a state approved feeding course Procedure: 3. Check the tray before serving the meal to make sure everything is on the tray and it is accordance with the resident's diet. Correct anything wrong 9. Use appropriate utensil and adaptive equipment to feed the resident R95 was initially admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia (a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, language, and judgment), Vitamin D deficiency (nutritional deficiency of vitamin D), and Deficiency of other specified group B vitamins (nutritional deficiency of B vitamins). R95's Quarterly Minimum Daily Set (MDS) with an assessment reference date of 3/13/25 documents Under Section C cognitive patterns a Brief Interview for Mental Status score of 6 indicating R95 having severe cognitive impairment. Under section GG Functional abilities and goals documents R95 as being independent with eating. R95's GG (functional abilities and goals) screener dated 6/10/25 documents for eating, R95 completes activity. Assistance may be provided throughout the activity or intermittently. R95's Occupational Therapy note dated 5/29/25. At 04:20 PM documents, This OTA (occupational therapy assistant) spoke with OTR (occupational therapist registered) on 5/28/25 about patient's recent right-hand wrist drop issue. Right hand appears to have a small bruise on right wrist area. Patient stated I don't even know how I hurt my hand. Right versus left measurements are as follows hand grip is 2#/30#, and 3-point pinch is 1#/2#. This OTA provided patient instruction on how to use built up handled spoon with left hand to inc (increase) her I (independence) while feeding herself. OTR plans on S/U (setting up) goals for self-feeding d/t (due to) recent issue. R95's Occupational Therapy note dated 5/30/25, at 11:31 AM documents, Staff were instructed in wear and care of right hand WHO (wrist hand orthotic) and use of tubigrip under for skin integrity management. Patient reported comfort with use. Discussed lack of active wrist extension and digit extension with floor nurse, as well as lean to right side this morning. Nursing agreed with change of condition and was communicating with appropriate medical team. OT (occupational therapist) spoke with kitchen and requested 2 handle cups with lids and built-up utensils on trays. Therapeutic activities: dynamic balance activities during sitting and fine motor coordination training. Review of R95's CNA Task: GG-Eating indicates: built up handles on silverware, 2 handled cups with lid and cut food into small pieces during meals had daily documentation by certified nursing assistants on R95's functional ability every meal since 5/30/25, when these adapted utensils were implemented by therapy. On 06/10/25, at 08:28 AM, Surveyor observed R95 sitting bent over, with R95's head in their lap, sleeping at a table during the breakfast meal. Surveyor observed R95's cereal all over table surrounding R95's cereal bowel. Surveyor observed there were no staff by R95's table helping R95. Surveyor observed R95 had no adaptive spoons or 2 handled cups to assist in R95's meal as recommended by occupational therapy on 5/30/25. On 06/10/25, at 0829 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-I about R95's current condition. Surveyor asked LPN-I if R95 needed help in the dining room. LPN-I informed Surveyor that they are speaking today and that the family is looking at hospice for R95. LPN-I informed Surveyor that R95 has declined in abilities recently. Surveyor asked LPN-I if R95 needed help eating. LPN-I informed Surveyor it depends on R95's cognitive abilities for the day, but often R95 will still feed still herself with set up. LPN-I informed Surveyor that R95 is weaker today. On 06/10/25, at 12:20 PM, Surveyor observed lunch on the unit where R95 resides. Surveyor observed Certified Nursing Assistant (CNA)-N initially helping R95 eat and drink. Surveyor observed CNA-N was standing over R95 while helping R95 eat the meal. (Cross-reference F550). Surveyor observed that CNA-N was the only staff helping in the dining area. On 06/10/25, at 12:24 PM Surveyor observed R95 feeding self with the built-up adaptive spoon but no 2 handled cups. On 06/10/25, at 12:25 PM, Surveyor observed CNA-N came over to sit by R95 because R95 started to fall asleep. Surveyor observed CNA-N give R95 verbal cues to eat. On 06/11/25, at 08:36 AM Surveyor observed breakfast on the unit where R95 resides. Surveyor observed R95 eating cereal with a regular spoon and a regular single handle cup was in front of R95. Surveyor observed R95 feeding self very slowly with regular spoon. Surveyor observed R95 had no adaptive spoon or 2 handled cups. On 06/11/25, at 11:32 AM, Surveyor interviewed LPN-I about R95's adaptive eating equipment and R95's ability to feed herself. LPN-I informed Surveyor R95 was more independent the early part of June 2025 but now R95 often needs more encouragement and set up from staff. Surveyor asked LPN-I if staffing for meals was adequate because Surveyor noted one staff available to help during one of the meals. LPN-I informed Surveyor staffing is good, we get our stuff done. Surveyor asked LPN-I why the adaptive spoon and cups were not always being used for R95. LPN-I informed Surveyor that it must been accidentally overlooked by staff because R95 needs to use the built-up spoon. Surveyor asked where staff would find the information about the adaptive eating equipment. LPN-I informed Surveyor that LPN-I doesn't really know where the CNA's would find that information because the CNA's charting is different than nursing's charting. On 06/12/25, at 09:12 AM Surveyor interviewed Occupational Therapist (OT)-J about R95's therapy and use of special equipment for meals. Surveyor asked OT-J when R95 started using the adaptive utensils at meals to facilitate independence with R95 feeding herself. OT-J informed Surveyor that OT-J believed it was sometime after 5/30/25, maybe 6/2/2025. OT-J informed Surveyor that OT-J spoke with kitchen to have built up handles on the spoons and 2 handle cups with a lid. OT-J informed Surveyor the OT-J would have to look at OT-J's notes to confirm and get back to the Surveyor. On 06/12/25, at 02:06 PM, OT-J gave Surveyor therapy notes indicating that OT-J had seen R95 on 5/30/25 and implemented the adaptive eating utensils for R95 because of R95's contractures and that OT-J informed the unit staff and the kitchen staff of R95's need for adaptive utensils at meals. OT-J informed Surveyor that it was OT-J that implemented these adaptive eating utensils for R95 on 5/30/25. Surveyor asked OT-J why these items had not made it to R95's care plan yet. OT-J informed Surveyor that OT-J gives the facility education sheet to the restorative nurse and doesn't keep a copy. OT-J informed Surveyor the restorative nurse puts these types of interventions in the resident's care plan. OT-J informed Surveyor that OT-J had spoken to staff and the kitchen and that they were made aware of the adaptive eating equipment for R95. On 06/12/25, at 09:31 AM, Surveyor interviewed Registered Nurse (RN)-G and CNA-T about R95's care plan not showing the adaptive eating equipment. RN-G informed the Surveyor that restorative will place it in the task section of the certified nursing assistants charting but that restorative is not allowed to place dietary interventions into the resident's care plan. RN-G informed Surveyor that interventions for the dietary care plan will come from an order. RN-G informed Surveyor that restorative doesn't get dietary orders because it is the dietary managers responsibility to get dietary orders. On 06/12/25, at 09:42 AM, Surveyor interviewed Dietary Supervisor-C about R95's recommendation for adaptive eating utensils. Dietary Supervisor-C informed Surveyor that nursing needs to put in the order and then it comes into the nutrition management program and then Dietary Supervisor-C will update the resident care plan. Dietary Supervisor-C informed Surveyor R95's order for adaptive equipment has not come through the nutrition management system yet so the care plan has not been updated. On 06/12/25, at 11:03 AM, Surveyor interviewed Corporate-AA, Assistant Administrator-F, Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A about R95's adaptive eating equipment not being used in 2 out 3 meals Surveyor observed. Surveyor asked who should have placed the order for R95's therapy's recommendation for R95 having adaptive eating equipment to maintain independence for self-feeding. NHA-A informed Surveyor that would be restorative nurse responsibility. NHA-A informed Surveyor Restorative is responsible to place that order. Surveyor expressed concern about the resident not having adaptive utensils on 2 or 3 meals and that the 5/30/25 recommendation had not been ordered or put in the care plan as of today (6/12/25). Surveyor informed NHA-A the CNA's task section had the adaptive eating equipment listed and documented by the CNA's. NHA-A informed Surveyor that the restorative nurse was new and may not have realized that these orders were the responsibility of the restorative department. NHA-A informed Surveyor the facility would make sure R95's order for adaptive eating equipment would be addressed. On 06/16/25, at 08:12 AM, NHA-A gave Surveyor a training done for R95's built up silverware done on 6/13/25 with only 4 staff signatures on the sheet. The sheet was done by a speech language pathologist. Surveyor noted on the training sheet, R95's adaptive eating equipment was documented as now being used as needed. On 06/16/25, at 08:52 AM, Surveyor interviewed OT-J on why R95's adaptive equipment was changed to being used as needed. OT-J informed Surveyor this training sheet is not from OT-J. Surveyor asked when this became an as needed intervention because in previous interviews OT-J and LPN-I informed Surveyor R95 needed the adaptive eating equipment. OT-J informed Surveyor OT-J doesn't know why the speech language pathologist wrote this as needed because OT-J was the one addressing that area. Physical Therapist (PT)-K informed Surveyor that the speech language pathologist informed PT-K that hospice asked Speech Language Pathology to reevaluate R95's need for the adaptive eating equipment on 6/13/25 because R95 was admitted to hospice on 6/13/25.

Based on interview and record review, the facility did not ensure residents were free from abuse affecting 2 (R67 and R513) of 3 residents reviewed for abuse concerns. R513 had behaviors of agitation, wandering, and physical behaviors toward others. On 4/5/2025, R513 entered R67's room and was hitting and kicking R67 after R67 had fallen to the ground. Supervision of R513 was not increased with the heightening of behaviors to prevent abuse to R67. Findings include: The facility policy and procedure titled Abuse Policy dated 9/2020 documents: POLICY: . This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. ABUSE PREVENTION PROGRAM . 3. Prevention: The facility desires to prevent abuse, neglect and theft by establishing a resident sensitive and resident secure environment. d. As part of the social service assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis. R67 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, adjustment disorder with mixed anxiety and depressed mood, atrial fibrillation, hypertension, and mitral valve insufficiency. R67's Annual Minimum Data Set (MDS) assessment dated [DATE] documented R67 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 10 with no behaviors. R67's Activities of Daily Living Care Plan initiated on 3/4/2024 documented R67 was independent with ambulation and R67's At Risk for Falls Care Plan initiated on 3/4/2024 documented R67 was at risk for falls due to weakness and a history of falls. R67 had an activated Power of Attorney (POA). R67's At Risk for Abuse Care Plan was initiated on 3/12/2024 due to R67's incapacitated status, impaired cognition, and mental health diagnosis of adjustment disorder with depressed and anxious mood with the following interventions: -At onset of behavior, calmly and firmly attempt to redirect to socially acceptable behaviors. -Check and assure physical comfort. -Compliment (R67) for appropriate social interactions. -Consider past patterns, personal and medical/psych history, interests, family/friends accounts to past incidents. -Consider possible antecedents: fear, fatigue, loss of control over a situation. -Determine preferred setting and approach and then offer health care accordingly. -Encourage (R67) to participate in activities. -Encourage/reassure/redirect/repeat as needed. -Investigate accusation. -Maintain a calm soothing approach/environment and smile/pay compliments to promote feelings of belonging and importance with (R67). -Monitor and report signs/symptoms of abuse. -Remind other to try to let comments/loud repetitive noises go in one ear and out the other, to ignore, to move away from. -Respond with reassurance; do not argue. -Simplify tasks, reduce stimulation, give more time or space if showing signs of feeling too challenged. R513 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, severe dementia with other behavioral disturbance, major depressive disorder, anxiety disorder, and cognitive communication deficit. R513's Annual MDS assessment dated [DATE] documented R513 was severely cognitively impaired with a BIMS score of 3 and had the following behaviors during the 7-day lookback period: delusions, physical behaviors toward others daily, verbal behaviors toward others 1-3 days, rejection of care 4-6 days, and wandering daily. R513's Cognitive Loss/Dementia Care Area Assessment (CAA) and Behavioral Symptoms CAA documented R513 has diagnoses of Alzheimer's Disease and Dementia with behavioral disturbance. R513 has mental health diagnoses as well that could contribute to behaviors. A care plan would be developed to address cognition and behaviors. R513 had an activated POA. R513's Psychotropic Medication Care Plan was initiated on 7/10/2021 for the use of the antipsychotic quetiapine and antidepressant duloxetine with the following pertinent interventions in place on 4/5/2025: -Attempt dosage reduction gradually as able. -Delusions interventions: 1. Redirection. 2. One-on-one interaction. 3. Encouragement from staff. -Hallucinations interventions: 1. Redirection. 2. One-on-one interaction. 3. Encouragement from staff. 4. Reality orientation to things in the present and in the environment. -Physically resistive to care interventions: 1. Redirect. 2. Reapproach. 3. Anticipate needs. 4. Two staff to provide cares as able. R513's At Risk for Abuse Care Plan was initiated on 7/12/2021 due to R513's major depressive disorder and dementia as well as behaviors with the following interventions in place on 4/5/2025: -At onset of behavior, calmly and firmly attempt to redirect to socially acceptable behaviors. -Check and assure physical comfort. -Compliment (R513) for appropriate social interactions. -Consider past patterns, personal and medical/psych history, interests, family/friends accounts to past incidents. -Consider possible antecedents: fear, fatigue, loss of control over a situation. -Determine preferred setting and approach and then offer health care accordingly. -Encourage (R513) to participate in activities. -Encourage/reassure/redirect/repeat as needed. -Investigate accusation. -Maintain a calm soothing approach/environment and smile/pay compliments to promote feelings of belonging and importance with (R513). -Monitor and report signs/symptoms of abuse. -Regularly assess (R513) for possible thoughts of self-harm. -Remind other to try to let comments/loud repetitive noises go in one ear and out the other, to ignore, to move away from. -Respond with reassurance; do not argue. -Simplify tasks, reduce stimulation, give more time or space if showing signs of feeling too challenged. Surveyor noted R513's At Risk for Abuse Care Plan interventions were the same as R67's interventions and not personalized to the individual. R513's At Risk for Elopement Care Plan was initiated on 4/1/2024 due to exit-seeking and wandering behavior with the interventions: -Check and assure physical comfort. -Consider past patterns, personal and medical/psych history, interests, family/friends accounts to past incidents. -Consider potential variables: boredom, thirst, hunger, need for toileting, pain, exercise, companionship, exhaustion and over stimulation. -Determine preferred setting. -Encourage/reassure/redirect/repeat as needed. -For wandering: 1. Redirection. 2. Check and ensure (R513) safety. 3. Calmly and positively guide (R513) back to (R513's) room/unit or towards whichever activity (R513) may be currently attending. 4. Assess (R513's) mood and address any mood related issues that may be occurring. 5. Provided one-on-one interaction with encouraging, uplifting comments. -If (R513) shows agitation regarding the Wanderguard, remind (R513) it is in place for safety due to night terror and sleepwalking. -May initiate frequent checks and supervision. -Monitor behaviors. -Offer alternative activities of daily living that may be engaging. -Utilize Wanderguard as appropriate. -Wanderguard on wheelchair for exit seeking behaviors; check for placement and function as required. Surveyor noted R513 did not have a care plan to address the aggressive behaviors exhibited by R513 towards staff and potentially other residents. On 3/29/2025 at 2:06 PM in R513's progress notes, a Registered Nurse (RN) documented R513 opened a fire door and was redirected immediately back into the facility. Management and R513's POA was notified. On 3/30/2025 at 7:58 PM in R513's progress notes, a Licensed Practical Nurse (LPN) documented R513 was agitated throughout the shift. R513 went to the front desk often stating R513 was waiting for a cab and leaving, many times trying to go outside. When the LPN was called, the LPN offered to take R513 outside. R513 would refuse, get upset, and raise voice at the LPN. The LPN called R513's POA after three separate incidences and the POA told the LPN to sit in a chair in R513's way and wait for R513 to get tired. On the fourth attempt at R513 trying to leave, the LPN sat next to R513 in a chair and R513 immediately hit the LPN, began to kick the LPN, and attempted to push the chair over that the LPN was sitting in. R513 was very agitated that the LPN would not leave R513 alone and get R513 a cab to go home. The LPN attempted to reorient R513 without success, informing R513 that it was Sunday and that the cabs stop running at 7:00 PM and it was now 7:45 PM. Eventually R513 got tired and went back to the room with another nurse. On 4/3/2025 at 10:16 PM in R513's progress notes, an LPN documented R513 was increasingly combative with staff while wandering. Management was notified and was advised to call the on-call physician. An order for Trazadone 50 mg to be given one time was received. Trazadone is an antidepressant used to treat depression and anxiety. R513 refused the medication and was currently calm and sleeping. On 4/5/2025 at 5:17 PM in R513's progress notes, RN-KK documented R513 was behavioral at that time. Attempts were made to call R513's POA and R513's son but was unsuccessful. An order was received to give R513 the scheduled dose of Seroquel 50 mg, an antipsychotic, at that time instead of in the evening as ordered. On 4/5/2025 at 5:40 PM in R513's progress notes, the on-call physician documented R513 was agitated and trying to elope out of the facility. R513 was trying to bite other residents and refusing to take medications. The physician documented the restlessness and agitation were worsening due to progressive dementia and ordered the Seroquel to be given early. On 4/5/2025 at 9:42 PM in R513's progress notes, the on-call physician documented per the facility nurse, R513 went into another resident's room, hit the resident on the back of the left shoulder and kicked the other resident. Per the nurse, the other resident (R67) does not have any injuries, and the resident denies being hit or kicked by R513. R513's POA was with R513 at that time and R513 is more calm. On 4/5/2025 at 10:35 PM in R513's progress notes, RN-KK documented R513 was very combative throughout the shift this afternoon/evening. R513 would not be redirected by staff despite many attempts to do so. R513 wheeled about the facility, going onto every unit. R513 would kick, hit, and even pull staff members' hair when they attempted to take R513 back to R513's unit. R513 also made several unsuccessful attempts to leave the facility. R513 required continuous monitoring from staff. Several attempts had been made by RN-KK to contact R513's POA to come to the facility to be with R513. R513's POA would come to the facility whenever asked. R513's POA was not answering the phone. Finally, R513's POA answered the phone and arrived at the facility at 8:00 PM and stayed with R513 until R513 went to sleep. On 4/5/2025 at 10:38 PM in R67's progress notes, the on-call physician documented R67 lost their balance while attempting to get another resident to leave R67's room. Per the nurse, R67 got up independently and was sitting on the bed when staff arrived. R67 sustained a skin tear to the left shin. Per the nurse, another resident came into R67's room and hit R67 on the back of the left shoulder and kicked R67. R67 did not recall where R67 was kicked. No signs of injury were found post altercation. On 4/6/2025 at 3:18 PM in R67's progress notes, an LPN documented R67 was telling staff that a resident came into R67's room and was kicking R67. R67 stated three staff members came in when R67 yelled for help and took the other resident out of R67's room. R67 stated R67 was fine and was talking with peers and laughing. On 4/7/2025 at 11:01 AM in R67's progress notes, RN-Y documented the interdisciplinary team (IDT) met to review R67's incident on 4/5/2025. The root cause of R67's fall was most likely R67 stood up and lost balance and fell. R67 was startled as another resident entered R67's room. The immediate intervention was to ensure R67 was safe and remove the other resident from R67's room. R67's care plan was updated. R67's Impaired Cognitive Functioning Care Plan was revised on 4/7/2025 with the intervention to remind R67 that R67 is safe when feeling anxious or scared. Surveyor noted the IDT met and the care plan was updated two days after the incident. R513 continued to have agitation, elopement attempts, and physical behaviors until R513 was transferred to a memory care facility on 5/12/2025. R513's care plan was not revised with any interventions after the physical altercation with R67. Supervision was not increased to protect other residents from R513. The facility reported the incident to the State Agency. The facility investigation of the event included a recap of the incident and interviews with staff members that were working in the facility on 4/5/2025. Nursing Home Administrator (NHA)-A wrote the recap of the event: R513 wandered into R67's room and when R67 stood up to redirect R513, R67 lost their balance and fell. While R67 was on the ground, R513 wheeled over and began hitting and kicking at R67. The residents were immediately separated and R67 was assessed for the fall and incident. R513 was supervised until R513's POA was able to come and sit with R513 to assist with calming R513 down. After some time, R513 did settle down and went to sleep. The staff statements showed R513 had been agitated all day with wandering into other resident rooms. -CNA-LL's statement indicated after 6:00 PM, a family member of a resident on the 300 unit told CNA-LL there was someone in the resident's room. CNA-LL went in and attempted to redirect R513 out of the room. CNA-LL touched R513's shoulder and R513 immediately tried to scratch CNA-LL. CNA-LL called for the nurse to assist. The nurse came and grabbed the back of the wheelchair while CNA-LL moved things out of the way so R513 could not throw anything. Together they removed R513 from the unit and called the 600 unit to come and retrieve R513. At about 7:30 PM or 8:00 PM, CNA-LL was in the hallway about to put someone in bed when CNA-LL heard R67 yell out for help. R513 was in R67's room at the foot of R67's bed. CNA-LL asked R513 to leave and R513 started to kick at CNA-LL. R513 followed CNA-LL to the doorway where CNA-LL was able to grab the front of the wheelchair to pull R513 out of the room. CNA-LL shut the door behind R513 and R513 followed CNA-LL towards the kitchen. CNA-LL attempted to make a phone call to the 600 unit. When CNA-LL turned to see if R513 was behind CNA-LL, R513 was not there. CNA-LL ran to R67's room and found R67 on the floor with the feet by the closet and the face facing the bed. R513 was in front of R67 attempting to kick R67. CNA-LL could not see if R513 kicked R67. CNA-LL grabbed R513's chair and again got R513 out of R67's room. CNA-LL ran and grabbed the nurse and DON-B. They helped get R513 off the unit and contacted the 600 unit to get R513. -An LPN statement indicated R513 was wandering the facility and entered the 300 unit and into another resident's room. The LPN had to assist a Certified Nursing Assistant (CNA) to get R513 out of that room and was brought to the community wing area. While continuously trying to redirect R513, R513 was hitting, kicking, grabbing, and pulling at the nurses and CNAs. R513 wandered into the conference room and the LPN returned to the unit. The CNA from the 600 unit was with R513 and requested assistance as R513 was throwing trash, the trash can and pulling cords. R513 wandered to the outside of the 400 unit. The LPN contacted the charge nurse and the 600 unit nurse to come help redirect R513. There were four staff attempting redirection. R513 was kicking and swinging arms and grabbed the 600 unit CNA's ponytail. After the situation deescalated, the LPN returned to their unit. Later in the shift around 7:30 PM, R513 was again wandering the facility and ended up entering the 300 unit with staff at 7:40 PM unsuccessfully redirecting R513. -A CNA statement indicated R513 was seen on the 200 unit around 4:00 PM entering resident rooms. Staff redirected R513 into the dining room where R513 attempted to open the patio door. Staff tried to redirect but R513 was able to open the door and set off the alarm. The 600 unit staff was called to come and get R513. Later in the shift the 600 staff came over to the 200 unit to ask if they had seen R513. The 200 unit staff had not seen R513 and asked if they should call a code for a missing resident. R513 was found with no code needing to be initiated. -A CNA statement indicated the CNA had worked a 16-hour shift and during about 14 of those hours, R513 attempted to bite the CNA as well as other CNAs. The CNA witnessed R513 display high aggression at other CNAs. R513 ran over the CNA with the wheelchair, kicked several times, punched, scratched, had hair pulled, and was grabbed in the groin area. R513 was also destructive to the facility property. R513 was found in other resident rooms often. R513 tried to get outside and would check every door handle to see if they were unlocked as R513 went down the hallway. -A CNA statement indicated a resident on the 400 unit called at 3:00 PM to get R513 out of their room. R513 attempted to bite the CNA's arm and then kicked the CNA. At 4:30 PM, R513 came back to the 400 unit with a CNA walking behind R513 and R513 tried to kick the CNA. After dinner at about 5:30 PM, R513 was back on the 400 unit and the CNA assisted another CNA to take R513 back to the 600 unit. -A CNA statement indicated around 4:30 PM on the 400 unit, R513 was very agitated, kicking, trying to bite, pulling shirts and arms of staff. The CNA walked R513 back to the 600 unit holding R513's hand because R513 would not let go and gave R513 a doll to hold. After 30 minutes, R513 was back on the 400 unit, making statements that R513 had to get out of there because they want me dead. R513 was very agitated as before. R513 became more agitated with redirection. R513 tried to leave the building through the front door and then again on the 600 unit causing the alarm to go off. -An LPN statement indicated R513 was seen wandering the halls in the wheelchair. R513 came onto the 200 unit around 4:00 PM and began attempting to enter other residents' rooms. R513 attempted to open the patio door initiating the alarm. Staff tried to redirect R513 but was unsuccessful and R513 continued to wander. The 600 unit staff came looking for R513 eventually. Around 9:00 PM, the LPN saw R513 with R513's POA. R513 was becoming combative with R513's POA so the LPN offered assistance. The LPN allowed R513's POA to wheel R513 around the 200 unit as long as R513 stayed out of residents' rooms. Surveyor noted with all the interviews, R513 had been agitated all day with physical aggression and going into multiple resident rooms with no initiation of continuous supervision to keep other residents safe. In an interview on 6/10/2025 at 4:04 PM, RN-KK stated R513 did not have the behaviors when first admitted but as the dementia progressed, R513 became very difficult to handle. RN-KK stated R513 would try to get out of doors that were locked and had hitting behaviors before R513 was discharged from the facility. RN-KK stated R513 would give a staff member a hug and then would kick the staff member. RN-KK stated R513 kept going to the other side of the building and that is where stuff happened. Surveyor clarified with RN-KK that stuff referred to R513 hitting and kicking R67. RN-KK stated yes. RN-KK stated R513 needed to be one-on-one constantly because R513 was not safe for themselves or other people around them. RN-KK stated RN-KK would wait as long as possible to call R513's POA to come in, but that was the only avenue they had to keep a constant eye on R513. Surveyor asked RN-KK how the one-on-one staff member was assigned. RN-KK stated RN-KK was the one-on-one while still doing all the other nursing duties that were required. RN-KK stated the facility does not have sitters or a single staff member assigned just for the one-on-one. RN-KK stated the facility accepts new admission residents that need one-on-one for safety, and it is upsetting to the staff and the family of the resident when they cannot provide one-on-one. Surveyor noted the facility did not get a statement from RN-KK for the incident on 4/5/2025. In an interview on 6/11/2025 at 3:52 PM, Surveyor asked CNA-LL if CNA-LL recalled R513. CNA-LL stated R513 wandered quite a bit, constantly trying to elope, and came to the other side of the facility all the time. CNA-LL stated R513 was aggressive, kicking and hitting. CNA-LL stated CNA-LL was always trying to remove R513 from other residents' rooms so no one would get hurt. Surveyor asked CNA-LL if CNA-LL was working with R67 on 4/5/2025 when R513 came into R67's room. CNA-LL stated CNA-LL was working on R67's unit that day and did not know R513 was in R67's room until CNA-LL went into R67's room, saw R67 on the floor and R513 was in a wheelchair kicking towards R67. CNA-LL stated CNA-LL could not see if R513 made contact with R67 or not. Surveyor asked CNA-LL if R513 had ever been a one-on-one. CNA-LL stated R513 was never a one-on-one; no one was assigned to specifically watch R513. CNA-LL stated, Should (R513) have been? Yes. Surveyor asked CNA-LL what would happen when R513 was on the opposite side of the facility from R513's room/unit. CNA-LL stated the staff would have to call R513's unit or bring R513 back to the unit themselves. CNA-LL stated R513 was really hard to watch, but the family came in to watch R513 and walk around with R513. CNA-LL stated it would have been nice to have someone assigned to R513. CNA-LL stated there are a few residents currently that would benefit from having a one-on-one. CNA-LL stated staff are pulled in different directions, so it is hard to watch those residents with behaviors and keep everyone safe. In an interview on 6/16/2025 at 10:49 AM, Surveyor asked DON-B about the resident to resident altercation on 4/5/2025 between R513 and R67. DON-B stated DON-B was with R513 from 6:00 PM until 8:00 PM on 4/5/2025. DON-B stated DON-B had taken R513 back to R513's unit where R513 had calmed down. DON-B stated DON-B was getting ready to leave the facility and found out R513 had gone back into R67's room where the incident occurred. Surveyor asked DON-B if R513 ever had one-on-one supervision to keep R513 safe as well as other residents. DON-B stated R513 never had a specific CNA assigned to do one-on-one with R513. DON-B stated there is a float CNA that would take that role, but otherwise nursing staff would take turns watching R513 and activities would help as well. DON-B stated it became line of sight monitoring because R513 would get more agitated if someone was right next to R513. DON-B stated on 4/5/2025, R513's behaviors would go away once R513 was resting; they did not anticipate R513 getting back up and being agitated again. DON-B stated R513 did not always have behaviors, R513 would just wander around the building. Surveyor shared with DON-B the concern R513 had been having behaviors all that day and there was no increased supervision to protect R67 from physical abuse. Surveyor shared R513's care plan indicated R513 was to have one-on-one with wandering and behaviors that was not implemented at any time. Surveyor shared interviews with staff said R513 never had one-on-one supervision and that would have been very effective. Surveyor shared with DON-B the concern that staff removed R513 from R67's room without any incident on 4/5/2025, but with the behaviors R513 was exhibiting and not increasing supervision, R513 was able to return to R67's room where R67 fell and was potentially physically assaulted by R513.

Based on observation, interview and record review, the facility did not ensure 2 (R97, R39) of 5 residents reviewed were free from chemical restraints. *The facility has no evidence of Abnormal Involuntary Monitory Scale (AIMS) monitoring prior to administrating R97's psychotropic medications. * The facility has no evidence of Abnormal Involuntary Monitory Scale (AIMS) monitoring prior to administrating R39's psychotropic medications. Findings Include: The facility's policy titled Psychotropic Medications - Use of, dated 09/2020, documents the following: .A baseline AIMS assessment will be initiated when receiving antipsychotic medications. (A re-assessment will be completed every six months.) . 1.) R97 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a progressive brain disorder that slowly destroys memory, thinking skills, and eventually, the ability to carry out the simplest tasks) and dementia (memory loss). Surveyor reviewed R97's Electronic Medical Record (EMR) including current physician orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR). R97 is prescribed Quetiapine Fumarate (Seroquel) Tablet 25 mg, an antipsychotic medication for Alzheimer's disease, Rivastigmine Tartrate (Exelon) Capsule 1.5 mg, a cholinesterase inhibitor (medication to improve memory function) for Dementia and Memantine HCl (Namenda) Oral Tablet 10 mg, a medication used to treat Dementia. On 6/11/25, Surveyor notes R97's EMR did not include an Abnormal Involuntary Movement Assessment (AIMS) score. On 6/11/25 at 3:15 PM, Surveyor requested an AIMS assessment for R97 from the facility. On 6/12/25 at 9:10 AM, Surveyor followed up with the facility regarding R97's AIMS assessment. The facility was unable to provide Surveyor with R97's AIMS assessment. On 6/12/25 at 12:55 PM, Surveyor shared concern with Nursing Home Administrator (NHA)-A that R97 is receiving psychoactive medications, including Quetiapine Fumarate, an antipsychotic medication. No additional information was provided by the facility at this time. 2.) R39 is a [AGE] year-old resident who was admitted to the facility on [DATE]. R39's diagnoses include pulmonary embolism (blood clot in the lungs), paraplegia (a type of paralysis that affects the lower half of the body), Parkinson's Disease (a progressive nervous system disorder that affects movement), Alzheimer's disease (a progressive brain disorder that slowly destroys memory, thinking skills, and eventually, the ability to carry out the simplest tasks), dementia (memory loss), mood disturbance and anxiety, depression, and anxiety disorder. R39's Quarterly Minimum Data Set (MDS) completed on 5/27/25, documents R39 as having a Brief Interview for Mental Status (BIMS) score of 14, indicating R39 is cognitively intact. Surveyor reviewed R39's Electronic Medical Record (EMR) which documents R39's current physician orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR). R39 is prescribed Memantine HCL ER (Namenda) 28 mg by mouth in the morning related to Alzheimer's Disease ordered on 4/4/25, at 7:14 AM. R39 is prescribed Mirtazapine (Remeron) 15 mg by mouth at bedtime for sleep disturbance ordered on 4/3/25, at 6:55 PM. Surveyor notes R39's EMR did not include an AIMS assessment. On 6/12/25, at 9:38 AM, Surveyor requested an AIMS assessment for R39 from the facility. Surveyor was provided a copy of R39's AIMS report dated 5/25/25. On 6/12/25, at 3:18 PM, Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of concerns with R39 taking psychotropic medications without having an AIMS assessment performed. Surveyor acknowledged the AIMS assessment dated [DATE] however, notified the facility of concerns with no AIMS assessment being performed prior to R39 taking psychotropic medications (Mirtazapine and Memantine). NHA-A and DON-B acknowledged the concern. Surveyor requested additional information if available.

Based on observations, record review and staff interviews, the facility did not ensure 2 out of 6 residents (R92 & R95) reviewed for being at high risk for falls, received adequate supervision and assistance devices to prevent accidents. R92 is at high risk for falls and had 4 unwitnessed falls at the facility. The facility did not ensure they thoroughly investigated each fall to determine the root cause and to assure that all interventions were in place at the time of the fall and were effective. R95 is at high risk for falls and has experienced several falls while at the facility. The facility did not ensure that they followed R95's toileting plan, which would reduce the chance that R95 would try to toilet herself and potentially fall. In addition, Surveyor observed R95 being transferred with a gait belt and 1 staff member when the plan of care indicates she needs a hoyer lift for transfers. Findings include: Policy Review Fall Management Program, dated 08/2020 The facility is committed to minimizing resident falls and/or injury as to maximize each resident's physical, mental and psychosocial wellbeing. While preventing all resident falls is not possible, it is the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies and facilitate a safe environment. Procedure: 1.) Complete a fall risk assessment upon admission, re-admission, with significant change, post fall, quarterly and annually. 2.) Educate patient, family or responsible party related to: a. fall prevention b. Call, don't fall for cognitive residents 3.) Educate staff members to check during room rounds the 4 P's a. pain b. positioning c. placement of personal items d. personal needs 4. Plan of care reviewed and updated at time of occurrence, quarterly and as needed in order to minimize risk for fall incidents. 5. Use standard fall/ safety precautions for all residents: a. All staff will be trained on the Fall Management Program b. At the time of admission, and in accordance with the plan of care the resident will be orientated to, use the nurse call device. The nurse call device will be placed within the residents reach. c. Call lights to be answered promptly. d. The bed will be maintained in a position appropriate for resident transfers. e. The bed locks will be checked to assure they are in locked position. f. Personal possessions will be within reach when possible. Assistive devices will be within reach if resident is capable of using independently. g. The resident's environment will be kept clear of clutter. Lighting will be appropriate for the time of day. 1.) R92 was originally admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Lewy body Dementia, congestive heart failure and tremors. The most recent quarterly MDS (Minimum Data Set), dated 5/15/25 documents R92 has a BIMS (brief interview for mental status) score of 15 (intact cognitive function). R92 has experienced falls at the facility since admission, 2 or more without injury. There has been no falls with major injury. The facility conducted falls assessments on 5/6/25, 5/14/25, 6/5/25 and 6/10/25. These assessments all indicated R92 is at high risk for falling. On 10/10/24, the facility initiated a plan of care documenting R92 is at Risk for falls r/t (related to) weakness, Parkinson's disease, and neurocognitive disorder, use of assistive device and need for staff assistance. (R92) is unaccepting of his limitations. Parkinson's, acute encephalopathy (R92) prefers wife not be notified of falls to avoid causing her and himself emotional distress. (R92) continues to transfer self w/o (with out) staff and needs reminders that he is a HOYER (sic). Interventions included: Will accept interventions to help prevent falls through next review. Date Initiated: 01/26/2025. Assist resident to get up and out of bed during the night when resident is not feeling sleepy. Date Initiated: 10/10/2024. Dycem to wheelchair. Date Initiated: 01/26/2025. Encourage and offer rest periods when walking. Date Initiated: 10/10/2024. Encourage resident to Call, don't fall. Date Initiated: 10/10/2024. Encourage resident to keep room free of obstacles. Date Initiated: 05/04/2024. Encourage use of and provide a Reacher as needed to assist resident with getting items from hard-to-reach areas. Date Initiated: 02/24/2025. Ensure adequate lighting for tasks. Date Initiated: 05/04/2024. Keep bed in lowest appropriate position. Date Initiated: 01/26/2025. Keep frequently used items within reach in room. Date Initiated: 10/10/2024. Surveyor conducted a review of R92's medical record and noted the following falls: 4/7/2025 at 02:45 a.m., Post Occurrence Documentation Description of occurrence: Nurse called to (R92's) room to observe resident lying in the supine position on the floor next to his bed. (R92) stated, I tried getting out of bed by myself, slid out of bed on the floor. I was told that I could do this by myself. (R92) denies any pain, resident denies hitting his head. (R92) did not want nurse to call his wife, and stated, Do not wake her up at 0300, I will tell her when she comes to see me today. (R92) was educated on the importance of using his call light for help, and that he still needs the assistance of staff to transfer. Resident verbalized understanding. Charge nurse was called. VS (vital signs) obtained and stable. Neuro checks started. RN completed a head-to-toe assessment. Resident was assisted back to bed via hoyer and 3 staff members. On 4/7/2025 at 11:43 a.m, Interdisciplinary Team (IDT) Note Text: IDT met to review R92's fall incident on 4/7. Root cause is most likely self-transfer. No pain, no injury. Care plan updated. Surveyor conducted a review of the facility's fall investigation dated 4/7/25. Immediate intervention was to re-educate on calling for assistance and placing call don't fall signs in his room. Surveyor verified that the intervention for CALL DON'T FALL sign in room was added to the plan of care back on 10/10/24. In addition, on 4/7/25 the intervention was to continue to remind (R92) to call when needing assistance with transfers. The facility's fall investigation includes a staff statement that documents that R92's call light was turned on. The investigation does not include how long the call light was activated prior to staff finding R92. The investigation does not indicate what other interventions were in place at the time of the fall; for example; was bed in lowest position. Surveyor noted if R92's call light was on R92 did what was expected by R92 to prevent a fall, the investigation does not include a review on if staff implemented the care plan to prevent falls after R92 requested assistance with the call light. On 4/25/2025 at 11:45 p.m., Post Occurrence Documentation: Description of occurrence: (R92) had unwitnessed fall in his room. Found lying on the floor by the door, w/c (wheelchair)and walker by the bathroom door. (R92) was ambulating independently using a walker. Slipped d/t (due to) wet floor and fell. Res. (resident) was in regular socks. No injuries noted. Denied discomfort and hitting his head. On 4/28/2025 at 11:00 a.m., Interdisciplinary Team Note Text: Clinical IDT met to review (R92's) fall from 4/25. No injury noted. R92 slipped on ice chips he dropped on the floor while attempting to walk to obtain a soda. Administrator to provide education with R92 and family regarding asking for assistance and calling for help. Surveyor conducted a review of the facility's falls investigation for the fall that occurred on 4/25/25. R92 did not have gripper socks on due to resident prefers to go to bed around 9:30 p.m. Fall happened approximately 8:45 p.m. 45 minutes prior to R92's preferred bedtime. The investigation did not indicate if the other falls interventions were in place at the time ( i.e. call light in reach). The fall investigation did not include review of whether this was a usual pattern for R92 or steps staff could take to help ensure R92's safety. On 5/3/2025 at 10:17 p.m., Nurses Note Text: (R92) had a fall while self-transferring from recliner to w/c. Educated resident on need to ask for assistance to remain safe. Intervention: ensure w/c is locked so that when resident decides to self-transfer, he is able to do so. On 5/5/2025 at 10:52 a.m., Interdisciplinary Team Note Text: IDC (interdisciplinary clinical) Team reviewed fall on 5/4/25 ([sic] documentation is wrong date, fall was 5/3/25). The goal of the facility is resident safety. R92 continues to be noncompliant with safety education on not (sic) self-transferring. A new intervention was implemented. Family notified. Review of R92's care plan includes the following added interventions: Encourage resident to keep room free of obstacles. Date Initiated: 05/04/2024. Ensure adequate lighting for tasks. Date Initiated: 05/04/2024. Surveyor noted the initial recommendation was to ensure R92's wheelchair was locked for safety, this was not added to the care plan. 5/6/2025 at 03:00 a.m., Post Occurrence Documentation; Description of occurrence: CNA reported (R92) called on call light and as she entered room to answer call light resident was noted to be sitting on floor. Writer entered room and noted resident sitting on floor in front of his recliner. (R92) stated while he was trying to grab his blanket he slipped out of his recliner chair onto floor in sitting position. Resident denies hitting head. Resident denies pain or discomfort. Resident was assessed. VSS (vital signs stable). No injuries noted. MAE's (mobility assessment of extremities) per his norm. Assisted up x2 (with 2 staff) via hoyer lift into recliner. Resident instructed to call for assistance and voiced understanding. Surveyor conducted a review of the facility's fall investigation for the 5/6/25 fall - (R92) and wife were educated regarding fall management program and following interventions. Staff stated (R92) put on call light at approximately 3:00 a.m Staff stated she was doing rounds, finished what she was doing and went to R92. The light was not on long, estimates just a few minutes. A review of the facility's investigation documents (R92) had activated the call light and CNA did enter the room and found R92 to be sitting on the floor. (R92) says he tried to grab his blanket, he slipped out of his recliner chair on to the floor. The investigation did not indicate why R92 was sleeping in recliner and not his bed and how long the call light was activated before staff arrived in R92's room. Surveyor noted R92 again did follow the care plan by activating the call light as instructed by the facility however, a fall still occurred. The facility did not review the effectiveness of this intervention. 5/12/2025 at 02:15 a.m., Post Occurrence Documentation: Description of occurrence: Nurse was entering (R92's) room to check his oxygen saturation and observed R92 laying on the floor between his bed and recliner, (bare) feet under the bed and head near recliner. Resident was rolled slightly onto his left side and had a blanket under him; he was not yelling for help. (R92) states he was reaching for a blanket and that he was in his bed (there were multiple blankets in his bed). He denies hitting his head or having any pain. Head to toe assessment complete with full range of motion and no signs of injury, vital signs and neuro check also complete. Resident was transferred into his recliner via hoyer, call light was clipped to his shirt, and he was reeducated about calling for assistance and not attempting to self-transfer for his safety. Surveyor conducted a review of the facility's investigation for the fall that occurred on 5/12/25. (R92) likes to be warm but not hot and will kick off coverings/socks if he is hot. The facility's falls investigation did not include information if the falls interventions were in place at the time of the fall such as the call light being in reach, low bed etc. Surveyor note this the the second fall R92 experienced reaching for a blanket, care plan interventions initiated 10/10/24 included to keep frequently used items within reach in room. On 5/12/2025 at 11:30 a.m., Interdisciplinary Team Note Text: Clinical IDT met to review fall from 5/12. The goal of the facility is resident safety. A new intervention was implemented. All parties notified. Review of R92's fall care plan does not indicate what the new intervention is that has been implemented. 06/12/25 03:16 PM Surveyor interviewed Nursing Home Administrator (NHA)- A and Director of Nursing (DON) -B regarding the fall investigations for R92. Surveyor asked if the facility had investigated the call-light response times on the occasions were R92 activated the call light for assistance and still was found to have an unwitnessed fall. In addition, Surveyor asked if the facility, included in their investigations, whether all falls care planned interventions were in place at the time of the falls for R92. As of the time of the exit, no additional information had been provided. 2.) Facility Policy titled Transfer dated 3/10/2022 documents: Definition: Transfer refers to activities provided to improve or maintain the resident's self-performance in moving between surfaces or planes either with or without assistive devices. These activities are individualized to the resident's needs, planned, monitored, evaluated, and documented in the resident's medical record. General Transfer Guidelines: 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe transfers of residents. 2. Manual lifting or residents should be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual resident's needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan Such assessment shall include: b. Resident's mobility (degree of dependency) d. Weight bearing ability e. Cognitive status 4. Staff responsible for direct resident care with be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices . General Transfer Procedure: 9. Use a transfer/gait belt . R95 was initially admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia (a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, language, and judgment), and history of falling. R95's Quarterly Minimum Daily Set (MDS) with an assessment reference date of 3/13/25 documents Under Section C cognitive patterns a Brief Interview for Mental Status score of 6 indicating R95 having severe cognitive impairment. Under section GG Functional abilities and goals assesses R95's toileting hygiene as: needing supervision or touching assistance. Helper provides verbal cues or touching/steadying assistance as resident completes activity. Under section GG Functional abilities and goals assesses R95's toileting transfer as: set up or clean up: resident completes activity. R95's Care Area Assessment (CAA) with assessment reference date of 12/7/24 identified R95 as a fall risk. CAA section analysis of finding documents: R95 is admitted following a fall at home with pelvis fracture. Pt (patient) with right subdural hematoma (brain bleed) right scalp hematoma, right posterior rib fractures and left symphysis pubis and inferior pubic ramus fracture (pelvic fracture) . Resident since admission fell resulting in injury Resident requires assistance from staff for activities of daily living (ADLS), transfers. R95's Physical Therapy treatment note dated 6/9/25 at 01:55 PM, documents R95 dependent with squat pivot transfer x 2 assist. R95 demonstrated increased agitated behavior. Nursing informed and R95 downgraded to Hoyer (full body mechanical lift) for transfers at this time. R95's Mechanical Lift care plan documents R95 requires the use of a mechanical lift for transfers. Date Initiated: 06/09/2025. The interventions section documents: Resident will tolerate total body (Hoyer) lift transfers from surface to surface with staff assistance. Date Initiated: 06/09/2025 Target Date: 09/10/2025. Instruct resident prior to transferring him/her. Date Initiated: 06/09/2025. Never leave the resident unattended when in the lift. Date Initiated: 06/09/2025. Provide 2 staff assistance for transferring. Date Initiated: 06/09/2025. Use total body (Hoyer lift) when transferring resident. Date Initiated: 06/09/2025. R95's fall care plan documents R95 is at RISK for falls r/t (related to) history of falls, poor safety awareness r/t dementia, impaired balance, (R95) will self-transfer, resident is impulsive with self-transfers. Family is aware of fall risk Date Initiated: 11/20/2024. R95's interventions section documents: Toilet Use prompt voiding upon waking up, before or after meals and before bed Date Initiated: 02/18/2025. Call don't fall sign initiated for visual reminders Date Initiated: 05/05/2025. Encourage resident to be out of her room when she is awake. Date Initiated: 05/20/2025. enc (encourage) use of grip nonskid socks when in bed for safety Date Initiated: 05/30/2025. Encourage resident to Call, don't fall. Date Initiated: 02/18/2025. Surveyor note call do not fall is a duplicated intervention with two dates of initiation on R95's care plan. R95's Interdisciplinary team (IDT) review on 2/18/25, after R95 had a fall, documents: Root cause of incident was resident attempting to self-transfer to go to the bathroom. Immediate intervention was resident was assisted to the toilet. RN assessed prior to movement. Vitals WNL (within normal limits), neuros (neurological checks) initiated, provider, family notified. Obtained swelling and small bump on head. Physician aware. NNO (no new order). Resident last fall was in December 2024. BIMS (Brief interview for Mental Status) score is 7. Will do prompted voiding with resident. Care plan updated. R95's Nursing Note on 6/9/25 at 9:00 PM, charted by LPN-I documents Note Text: Resident resides at (name of facility) for LTC (long term care) w/dxs (with diagnosis) of dementia, COPD (chronic obstructive pulmonary disease), HTN (hypertension), polyneuropathy, fall hx (history), anxiety, sleep disorder, chronic pain and hearing loss, A&O x 1 (alert & oriented times 1), meds (medications) whole w (with)/water, self-transfers, mobilizes in wheelchair which she self-propels, Gen (general) diet/Reg tex (texture)/Thin liquids, feeds self, APAP (acetaminophen) for pain control, penicillin allergy, bowel/bladder continent usually, calm, polite and cooperative, HOB (head of bed) elevated due to SOB (shortness of breath) while lying flat. Resident's transfer status has been changed to a Hoyer due to decline in condition. Resident is a DNR (do not resuscitate), incapacitated. Review of R95's Certified Nursing Assistant (CNA) care Kardex located during the survey in the resident care binder: Toileting: Toilet Use prompt voiding upon waking up, before or after meals and before bed Date Initiated: 02/18/2025. Transfer: Provide 2 staff assistance for transfer. TRANSFER: HOYER (mechanical lift). On 06/11/25, at 11:03 AM, Surveyor asked LPN-I if R95 was in R95's room. Surveyor followed LPN-I into R95's room after knocking to check on R95. LPN-I asked Surveyor to step back because LPN-I had to get R95 off toilet. Surveyor stepped back to door then came back in to ask are you transferring R95 off the toilet. LPN-I informed Surveyor yes LPN-I needed to get R95 to the wheelchair. Surveyor observed LPN-I placing R95 back into a wheelchair with no gait belt. LPN-I informed Surveyor R95 had transferred herself to the toilet and LPN-I helped R95 back to the wheelchair. LPN-I informed Surveyor R95 is not safe to transfer on her own but will impulsively self-transfer to the toilet without informing staff. Surveyor observed LPN-I explain to R95 to ask for help and to be safe. LPN-I informed Surveyor we have signs on the wall to remind R95 to not transfer without asking for help. LPN-I informed Surveyor we keep providing education to turn R95's light on. LPN-I informed Surveyor there is nothing we can do about it because R95 just transfers when R95 wants to transfer. Surveyor asked LPN-I if R95's cognition and transfer ability had declined recently. LPN-I informed Surveyor R95 has declined physically and mentally but was not always compliant before the decline. LPN-I again informed Surveyor there not much we can do because R95's impulsiveness. Surveyor asked if R95 was on a prompted toileting program would that help decrease R95's self-transfers. LPN-I informed Surveyor R95 would self-transfer even if R95 was placed on a toileting program. On 06/11/25, at 11:26 AM, Surveyor interviewed CNA-S. Surveyor asked CNA-S if R95 is taken to the bathroom by staff. CNA-S informed Surveyor usually the staff recently but, R95 used to be independent up until about a week ago. CNA-S informed Surveyor R95 is more confused now. Surveyor asked CNA-S when does staff take R95 to the bathroom. CNA-S informed Surveyor that CNA-S didn't usually work the morning shift, and that CNA-S usually worked on the PM shift. Surveyor asked CNA-S what the toileting schedule was for R95 on the PM shift. CNA-S informed Surveyor that when CNA usually works the PM shift, R95 will stay in dining room on the PM shift. Surveyor asked CNA-S if R95 ever needed to go to the bathroom when she was in the dining room on the PM shift. CNA-S informed Surveyor if CNA-S sees R95 in R95's room then CNA-S will ask R95 if R95 needs to go to the bathroom. CNA-S informed Surveyor that is when CNA-S will help R95 to the bathroom. Surveyor asked CNA-S why wouldn't staff follow R95's toileting schedule. CNA-S informed Surveyor the staff will toilet R95 when the staff thinks R95 needs to go to the toilet, that R95 is not on a toileting schedule. Surveyor asked CNA-S if the staff on PM shift use a one assist to transfer R95 to the toilet. CNA-S informed Surveyor that yes, staff did need to use 1 assist for R95 more recently with R95's recent decline in health. Surveyor asked CNA-S if R95 continues to toilet herself, as of the last few days. CNA-S informed Surveyor R95 has continued to toilet herself recently but that R95 was more independent until R95's recent decline in health. Surveyor asked how CNA-S and other staff were transferring R95 now. CNA-S informed surveyor what CNA-S was doing and thought others, probably, were transferring R95 with one assist also. Surveyor asked CNA-S where CNA-S could get information on R95's transfers and toileting schedules. CNA-S informed Surveyor CNA-S wasn't sure where that information was kept. Surveyor asked CNA-S if the facility had more staff could CNA-S toilet R95 more frequently. CNA-S informed Surveyor staff really don't have a chance on PMs to take R95 to the bathroom. Surveyor asked CNA-S how the staff knew what toileting programs residents might be on and how to care for the residents, especially if a staff member was new. CNA-S informed Surveyor staff just know how to care for the residents. Surveyor asked CNA-S if the staff knowledge came just from their experience. CNA-S informed Surveyor yes, staff just know and that R95 has recently just declined and needs 1 assist of staff to transfer now but, R95's decline is still new to us. Surveyor asked CNA-S to explain what R95's decline is new to us meant. CNA-S informed Surveyor that R95 was more independent until very recently and R95 has just become a 1 assist transfer recently. On 06/11/25, at 11:32 AM, Surveyor interviewed with Licensed Practical Nurse (LPN)-I about R95's interventions to prevent falls including R95's toileting schedule. Surveyor asked LPN-I to explain the CNA charting which shows R95 self-toileting, especially in early June of 2025, while R95 needed staff assistance for transfers, noting as of 2/18/25 R95 was to transfer using a hoyer lift. LPN-I informed Surveyor that R95 was more able to self-toilet back early part of June 2025. LPN-I informed Surveyor R95 just recently declined. LPN-I pointed out in the task charting that staff have been helping R95 more in the later weeks of June of 2025. Surveyor asked LPN-I if R95 required staff assistance and a mechanical lift for transfers why R95 would be self-toileting and be on a toileting program since 2/18/25. LPN-I informed Surveyor that R95 was impulsive and transferred herself no matter how much staff prompted R95 not to self-transfer. Surveyor asked the LPN-I where CNAs get their information for resident care and toileting programs like the one R95 is on related to falls. LPN-I informed Surveyor that LPN-I did not really know where the CNA would find the toileting programs for residents. LPN-I informed Surveyor that LPN-I just knew the nursing end of the charting and LPN-I has little familiarity with that (referring to CNA documentation) charting. RN-G called over to Surveyor from RN-G's office that R95 was recently made a Hoyer (sic)(mechanical lift) and the family doesn't want anything else done for R95 and the doctor thinks R95 had a stroke recently. On 06/11/25, at 12:39 PM, Surveyor interviewed Occupational Therapist (OT)-J. OT-J informed Surveyor that R95 was being discharged from therapies because R95 is not tolerating therapy at this time. OT-J informed Surveyor the facility is a no lift facility, so therapy makes recommendations for safe staff transfers. OT-J informed Surveyor therapy will turn in a care giver training plan to restorative and RN-G implements that transfer status. Physical Therapist (PT)-K came into the office and informed Surveyor that R95 was downgraded to a Hoyer lift from a 1 assist transfer because of R95's recent decline. OT-J informed Surveyor therapy will train the facility staff and on 6/9/25 nursing was informed that R95 was downgraded to using a Hoyer lift for all transfers. On 06/11/25, at 03:20 PM, Surveyor informed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Senior Leader-H of concerns with LPN-I transferring R95 alone, without a gait belt despite R95's care plan going back to February indicating a hoyer lift and two staff were to be used. Surveyor informed NHA-A that staff Surveyor interviewed were not aware of R95's prompted toileting fall intervention placed on the care plan on 2/18/25 to prevent falls and that R95 required the use of a Hoyer with 2 staff for transfers.

Based on interview and record review, the facility did not ensure residents received the necessary behavioral health care and services to maintain the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 (R51) of 8 residents reviewed for mood concerns. R51 told a Certified Nursing Assistant (CNA) they did not want to live. No documentation was found that a suicidal evaluation was completed, the physician was notified, or a Care Plan was developed to address R51's depression. Findings include: The facility policy and procedure titled Suicidal Ideation dated 10/2024 documents: POLICY: Facility staff will accurately assess, differentiate, and respond appropriately to individuals expressing suicidal ideation or passive death wishes, ensuring safety, appropriate intervention, and documentation. DEFINITIONS: Suicidal Ideation (SI): Thoughts of ending one's life, which may include a plan, intent, or means to act. Passive Death Wish (PDW): A desire to be dead or not wake up, without an active plan, intent, or behavior to end one's life. PROCEDURE: 1. Residents will be screened for mood disturbances using the PHQ-9 upon admission and, at minimum, quarterly thereafter. 2. If resident expresses passive death wishes, resident will be offered psychosocial support, which may include a referral to the psychologist. 4. If resident does not express a feasible plan with intention, suicidal ideation should be considered passive and care plan should be developed. R51 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following a cerebral infarction, diabetes, heart failure, legal blindness, bilateral hearing loss, adjustment disorder with mixed anxiety and depressed mood, and mild cognitive impairment. R51's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R51 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and did not have any symptoms of depression with a PHQ-9 (patient health questionnaire) score of 0. R51 had received psychological services from an outside provider that came to the facility for visits. R51 had discontinued services in February 2024 due to stabilization of depressed mood. Surveyor noted no Care Plan was initiated to address R51's depression to include how depression was manifested for R51 or interventions to address those manifestations. On 4/7/2025, R51 was seen by a psychologist to evaluate R51 for depression. The psychologist conducted a PHQ-9 and R51 scored 8 indicating mild depression. R51 displayed depressed mood, loss of interest, fatigue, poor concentration, difficulty relaxing and fears. The psychologist documented R51 denied having a poor appetite however was having a difficult time staying awake during meals due to hypersomnia. R51 denied any suicidal ideation. The treatment plan was to have individual psychotherapy 2-4 times per month to remediate symptoms of mental health such as depressed mood, anxious mood, and pain management through use of evidence-based adaptive coping strategies and skill. R51 agreed to the psychological consult and treatment. On 4/14/2025 at 11:21 PM in the progress notes, Registered Nurse (RN)-Y documented a CNA reported to RN-Y that R51 was refusing cares and meals. R51 does not want to live. RN-Y advised the CNA to report this to Social Services. At 11:38 PM in the progress notes, RN-Y documented Nursing Home Administrator (NHA)-A was updated on R51's status. No documentation was found indicating an assessment was completed after R51 verbalized the desire not to live. No Care Plan was initiated to address R51's statement of not wanting to live. No documentation was found indicating R51's psychologist was informed of R51's statement of not wanting to live. On 5/2/2025, R51 was admitted to the hospital with altered mental status and was readmitted to the facility on [DATE]. On 5/14/2025, R51 was admitted to hospice services with an admitting diagnosis of cerebral infarction. A Hospice Care Plan was initiated at that time and addressed discussion and acceptance of impending end of life. R51's Significant Change MDS assessment dated [DATE] documented R51 was cognitively intact with a BIMS score of 13 and was moderately depressed with a PHQ-9 score of 10. The Care Area Assessment (CAA) for Mood documented R51 had moderate depressive symptoms, and a care plan should be developed to address R51's mood. Surveyor noted no mood care plan was initiated. On 5/27/2025, R51 was seen by the psychologist and the psychologist documented R51 was receiving hospice services and may benefit from psychiatric treatment as opposed to psychotherapy at this point. No documentation of follow up to a psychiatrist was found. In an interview on 6/11/2025 at 11:16 AM, Surveyor asked RN-Y if RN-Y could recall the event on 4/14/2025 and the conversation with a CNA stating R51 did not want to live. RN-Y reviewed the progress notes from 4/14/2025 and recalled being told R51 was refusing cares and meals and made the statement R51 did not want to live, but could not recall which CNA had approached RN-Y. RN-Y stated RN-Y told the CNA to let the social worker know but was not sure who the social worker was at that time. RN-Y was not sure what happened with R51 after the statement was made. RN-Y stated RN-Y informed NHA-A because that is what RN-Y documented but did not have any further information. RN-Y stated RN-Y did not follow up with R51 as to R51's state of mind at that time. RN-Y stated something should have been implemented but did not know what that would be. RN-Y stated R51 had recently been put on hospice. In an interview on 6/11/2025 at 11:37 AM, Surveyor asked Director of Social Services (DSS)-Z when DSS-Z started working at the facility. DSS-Z stated DSS-Z started working at the facility in March 2025. Surveyor asked DSS-Z if DSS-Z was aware of R51's statement on 4/14/2025 of not wanting to live. DSS-Z read R51's progress notes from 4/14/2025 out loud so NHA-A, who was in the room, could hear what the progress note said. DSS-Z stated R51 is not suicidal. DSS-Z stated R51 was failure to thrive and declining in condition, so they had a conversation about hospice and R51 was admitted to hospice services. DSS-Z stated the verbiage of not wanting to live is not suicidal. DSS-Z stated they have parameters that they would put in place at that time if someone was suicidal. Surveyor asked how the facility would determine if a resident was suicidal or not. DSS-Z stated they would do a depression assessment, the PHQ-9, to show that. Surveyor asked DSS-Z if the facility did a PHQ-9 at that time. DSS-Z stated R51 was not suicidal. Surveyor noted no assessment was completed to determine if R51 was or was not suicidal or what was meant by R51's statement of not wanting to live. No documentation was found indicating anyone approached R51 at that time to determine R51's state of mind. Surveyor stated to NHA-A that RN-Y documented NHA-A was told of R51's statement of not wanting to live. NHA-A had no recollection of being informed of R51's statement. In an interview on 6/12/2025 at 1:16 PM, Surveyor shared with DSS-Z the concern R51 did not have a care plan to address depression. DSS-Z stated behaviors and depression are addressed in different sections of the care plan. Surveyor shared with DSS-Z the concern R51's manifestations of depression are not documented and there are no interventions to address the depression. Surveyor noted the care plan with behavioral symptoms are for agitation but not for depression. On 6/12/2025 at 3:01 PM, Surveyor shared with NHA-A and Director of Nursing (DON)-B the concern R51 refused cares and meals on 4/14/2025 and stated R51 did not want to live. The statement was never followed up on with an assessment to determine the degree of depression, no call was made to psych services that R51 already had in place, and no mood or depression care plan was created even after the Significant Change MDS assessment triggered the Mood CAA where it was documented a care plan would be initiated to address mood.

Based on interview and record review, the facility did not ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist, and that irregularities identified by the pharmacist were reviewed, and action was taken to address them, for 1 (R39) of 5 residents reviewed. R39 did not have regular monthly reviews performed by the pharmacist. Findings include: The facility's policy titled, Medication Regimen Reviews (MMR) Scheduled and Interim and dated 01/2022, documents the following: The consultant pharmacist will review the medication regimen, as required by State and Federal regulations. This review should include a review of the resident's medical record. The consultant pharmacist's MMR report or the interim MMR report will be given to the director of nursing (or designee), upon completion of all medication regimen reviews. The facility nursing staff will follow up with the prescribing physician and record the response on the report and/or the interim review and make changes as ordered by this physician, within a reasonable time frame. The completed original reports and/or interim reviews will be kept at the facility. R39 is a [AGE] year-old resident who was admitted to the facility on [DATE]. R39's diagnoses include pulmonary embolism (blood clot in the lungs), paraplegia (a type of paralysis that affects the lower half of the body), Parkinson's Disease (a progressive nervous system disorder that affects movement), Alzheimer's disease (a progressive brain disorder that slowly destroys memory, thinking skills, and eventually, the ability to carry out the simplest tasks), dementia (memory loss), mood disturbance and anxiety, depression, and anxiety disorder. R39's Quarterly Minimum Data Set (MDS) completed on 5/27/25, documents R39 as having a Brief Interview for Mental Status (BIMS) score of 14, indicating R39 is cognitively intact. Surveyor reviewed R39's Electronic Medical Record (EMR) which documents the Registered Pharmacist (RPh) performed the following monthly medication reviews: 5/12/25 - no recommendations after review from RPh 3/11/25 - no recommendations after review from RPh 2/3/25 - no recommendations after review from RPh 12/20/24 - no recommendations after review from RPh Surveyor notes R39's EMR did not include monthly medication reviews in January 2025 and April 2025. On 6/12/25, at 12:55 PM, Surveyor notified Nursing Home Administrator (NHA)-A that R39's EMR did not include monthly medication reviews in January 2025 and April 2025 and requested documentation if available. On 6/12/25, at 3:18 PM, Surveyor notified NHA-A and Director of Nursing (DON)-B of concerns with R39 not having a monthly pharmacy review performed in January 2025 and April 2025. NHA-A and DON-B acknowledged the concern. DON-B stated R39 was hospitalized in April and did not trigger again for the pharmacist to review after R39 had returned from the hospitalization. Surveyor requested additional information if available.

2.) R94 was admitted to the facility on [DATE]. R94's diagnoses include Atrial Fibrillation (a heart condition that causes an irregular pulse rate) and Hypertension (High blood pressure). R94's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/25/25 documents R94 as being rarely to never understood. R94's Quarterly MDS with an ARD of 4/25/25 documents that R94 received an anticoagulant (a medication that thins ones blood to prevent clotting) medication during the 7 day assessment period. Surveyor reviewed R94's Electronic Medical Record (EMR) which documents R94's current physician orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR). R39 is prescribed Eliquis 5 mg two times a day for Atrial Fibrillation, last ordered on 10/25/24. Surveyor reviewed R94's MAR and TAR. Surveyor noted there is no documented monitoring of R94's Eliquis, an anticoagulant medication, for potential signs and symptoms of an adverse effect from this medication, such as bleeding, bruising, or fatigue. On 6/12/25 at 12:45 PM, Surveyor notified Nursing Home Administrator (NHA)-A of R94 receiving Eliquis, an anticoagulant medication, with no documented monitoring for signs and symptoms of potential side effects. No further information was provided by the facility at this time. Based on record review and interview the facility did not ensure 2 (R39 and R94) of 5 residents drug regime reviewed was free from unnecessary medications. *R39 receives an anticoagulant (Eliquis) in which the facility did not adequately monitor. *R94 receives an anticoagulant in which the facility did not adequately monitor. Findings include: 1.) R39 is a [AGE] year-old resident who was admitted to the facility on [DATE]. R39's diagnoses include pulmonary embolism (blood clot in the lungs), paraplegia (a type of paralysis that affects the lower half of the body), Parkinson's Disease (a progressive nervous system disorder that affects movement), Alzheimer's disease (a progressive brain disorder that slowly destroys memory, thinking skills, and eventually, the ability to carry out the simplest tasks), dementia (memory loss), mood disturbance and anxiety, depression, and anxiety disorder. R39's Quarterly Minimum Data Set (MDS) completed on 5/27/25, documents R39 as having a Brief Interview for Mental Status (BIMS) score of 14, indicating R39 is cognitively intact. Surveyor reviewed R39's Electronic Medical Record (EMR) which documents R39's current physician orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR). R39 is prescribed Eliquis 5 mg two times a day for history of pulmonary embolism, last ordered on 4/3/25. Surveyor reviewed R39's MAR and TAR, and notes there is no monitoring of R39's Eliquis for potential signs and symptoms of an adverse effect from this medication, such as bleeding, bruising, fatigue, dizziness, etc. On 6/12/25, at 12:54 PM, Surveyor interviewed Registered Nurse (RN)-U who indicates staff monitor residents who are taking an Anticoagulant such as Eliquis for potential side effects. RN-U states staff look for bleeding or bruising and document in the MAR or TAR. RN-U states if a resident has a fall and is taking an Anticoagulant, the resident will be sent out to the emergency room (ER) for evaluation. On 6/12/25, at 3:18 PM, Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of concerns with R39 taking Eliquis with no monitoring for signs and symptoms for potential side effects. NHA-A and DON-B acknowledged the concern. Surveyor requested a policy for Anticoagulant monitoring if available. DON-B notified Surveyor the facility does not have a policy for Anticoagulants such as Eliquis or Xarelto however, the facility has a policy for Warfarin monitoring. No further information was provided by the facility at this time.

Based on observation, interview and record review, the facility did not ensure food was prepared and served in a form designed to meet individual needs for 1 (R25) of 1 residents reviewed for a mechanically-altered diet. R25 has a mechanical soft diet order, R25 was served a regular diet meal. Findings include: The Facility Policy titled Regular Ground/Mechanical Soft dated 7/2023, documents (in part): Purpose The regular mechanical soft diet is for adults who have difficulty chewing. This diet is similar to the regular diet with some modifications to hard to chew foods. This diet is not intended to be used for modifications required by the National Dysphagia Diets. Rationale Foods that are difficult to chew are replaced with foods that have been altered into a form that can be easily swallowed. Food that may be modified because they are tough and difficult to chew include meats, poultry, fish, raw vegetables, and other fibrous foods . According to Healthline.com A mechanical soft diet is a texture-modified diet that restricts foods that are difficult to chew or swallow. It's considered Level 2 of the National Dysphagia Diet in the United States. Foods can be pureed, finely chopped, blended, or ground to make them smaller, softer, and easier to chew. It differs from a pureed diet, which includes foods that require no chewing. Surveyor observed lunch being served in the 600 unit. Aide-V prepared one plate with food that was to be a mechanical soft consistency and serve the plate to a resident. Aide-V later plated a second mechanical soft meal, which the Dietary Director-C declined taking. The plate was set to the side. The mechanical soft meal included minced ham, soft cooked broccoli, macaroni and cheese, and a dinner roll. On 06/09/25, at 12:01 PM, Surveyor interviewed Aide-V and asked how many residents on the unit were prescribed a mechanical soft diet and was told two. Surveyor stated that only one was served, the other plate was set to the side. Aide-V walked over to the table where the two residents prescribed mechanical soft diets sat and removed the regular diet plate that was served incorrectly to R25. R25's physician order with a start date of 1/14/25 documents Mechanical Soft texture, Thin Liquids consistency. On 06/10/25, at 10:51 AM, Surveyor discussed the concern of the mechanical soft meal not being served to R25 with Dietary Director-C. On 06/10/25, at 03:13 PM, during the end of day meeting, Surveyor informed Nursing Home Administrator-A and Director of Nursing-B of the concern that R25 had a regular diet meal served instead of a mechanical soft meal. No further information was provided as to why the wrong diet was served to R25.

3.) R64 was admitted to the facility on [DATE], with diagnoses including Anxiety Disorder, Chronic Kidney Disease, encounter for fitting and adjustment of Urinary Device. R64's comprehensive Minimum Data Set (MDS), dated [DATE], indicates a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. R64 has an indwelling catheter and no trial of a toileting program. R64's Care Plan, date initiated 5/13/25, documents, a focus area of Bowel and Bladder support is required. The goal is R64 will maintain current of bowel incontinence and R64 will show no complications secondary to catheter use. Interventions document, in part, .Keep drainage bag covered to promote privacy. R64's Physician orders, dated 5/12/25, documents, CATHETER: INDWELLING URINARY CATHETER CARE DAILY AND PRN (as needed) every night shift related to ENCOUNTER FOR FITTING AND ADJUSTMENT OF URINARY DEVICE AND as needed related to ENCOUNTER FOR FITTING AND ADJUSTMENT OF URINARY DEVICE (sic). On 06/09/25 at 10:15 AM, Surveyor observed R64 in her room, resting in her recliner, with the door open. R64 has an indwelling catheter, and the catheter bag attached to walker did not have a privacy cover. R64's catheter bag could be seen from the hallway. On 06/10/25 at 12:37 PM, Surveyor observed R64 in her room, resting in her recliner, with the door open. R64's catheter bag was attached to walker and did not have a privacy cover. R64's catheter bag could be seen from the hallway. On 06/11/25 at 08:01 AM, Surveyor observed R64 eating breakfast in the dining room with other residents. R64's catheter bag was attached to her wheelchair and did not have a privacy cover. On 06/11/25 at 08:07 AM, Surveyor interviewed Registered Nurse (RN)-FF, asking what is the practice for privacy covers. RN-FF stated that drainage bags should always be covered with a blue privacy covering. Surveyor stated that R64 does not have a privacy cover on her catheter drainage bag and RN-FF stated, she should. RN-FF immediately notified Certified Nursing Assistant (CNA)-QQ and CNA-QQ wheeled R64 back to R64's room and placed a privacy cover on R64's catheter drainage bag. On 06/11/25 at 08:11 AM, Surveyor interviewed R64 and asked R64 about the cover on the catheter bag. R64 stated, if she goes out of out or if she goes to therapy or other places in facility. R64 stated her drainage bag it is not always covered wherever she goes in the building but sometimes it is. On 06/12/25 at 03:09 PM, Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of concern regarding R64's dignity due to no privacy cover on R64's catheter drainage bag, observed on three different occasions. Based on observation and interviews, the facility did not ensure each Resident is treated with dignity and respect that promoted maintenance or enhancement of quality of life. This occurred for 3 (R95, R94, R64) of 23 Residents reviewed for dignity. *R95 was observed by Surveyor to be fed by staff while standing over resident. R95 was observed in dining area sleeping face down in lap with food noted all around R95's bowl on the table while seated with other diners, in dining room. *Surveyor observed staff call across dining room referring to R94 as a feeder. Surveyor observed R94 alone at a table with R94's food still sitting in front of R94. *R65 was observed by Surveyor with catheter bag exposed without privacy cover for 3 days. Finding include: Facility Policy titled; Dignity dated 06/23. A. Policy: The facility will promote care for residents in a manner that promotes and enhances their sense of well-being, level of satisfaction with life, and feelings of self-worth and esteem. B. Procedure: 1. Residents should be treated with dignity and respect. 2. The facility's culture supports dignity and respect by honoring resident goals, choices, preferences, values and beliefs. 3. Individual needs and preferences are assessed upon admission and quarterly thereafter on the activity assessment. 4. Residents may exercise their rights without interference or coercion, discrimination or reprisal from any person or entity associated with the facility. 5. When assisting with care, residents are supported in exercising their rights. 6. Residents' private space and property should be respected, unless there is a reasonable suspicion to believe there is property that may pose a risk of harm to the resident or others in the facility. 7. Residents' rights to personal privacy will be respected. 8. Residents will be dressed in a manner that preserves dignity, which includes wearing garments that are not over revealing. 1.) R95 was initially admitted to the facility on [DATE] with diagnoses (dx) that included Unspecified Dementia (a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, language, and judgment), Vitamin D deficiency (nutritional deficiency of vitamin D), and Deficiency of other specified group B vitamins (nutritional deficiency of B vitamins). R95's Quarterly Minimum Daily Set (MDS) with an assessment reference date of 3/13/25 documents Under Section C cognitive patterns a Brief Interview for Mental Status score of 6 indicating R95 having severe cognitive impairment. Under section GG Functional abilities and goals documents R95 as being independent with eating. R95's GG (functional abilities and goals) screener dated 6/10/25 documents that R95's eating ability as resident completes activity. Assistance may be provided throughout the activity or intermittently. R95's hearing loss care plan documents: R95 is noted to have hearing loss in the right ear. Date Initiated: 03/05/2025. R95's intervention section documents: Face R95 when speaking. Date Initiated: 03/05/2025. R95's impaired cognition care plan documents R95 has Impaired cognition due to dx of dementia. Date Initiated: 11/30/2024. R95's intervention section documents: When speaking to resident, establish and maintain eye contact, reduce environmental distractions, and use resident's preferred name to maintain attention. Date Initiated: 12/03/2024. On 06/10/25, at 08:28 AM, Surveyor observed R95 sitting bent way over with their head in R95's lap sleeping at a table during the breakfast meal. Surveyor observed other diners around R95 including residents seated at R95's table. Surveyor observed R95's cereal all over table surrounding R95's cereal bowl. Surveyor observed there were no staff by R95's table helping R95. Surveyor observed R95 had no adaptive spoons or 2 handled cups to assist in R95's meal as recommended by occupational therapy on 5/30/25. On 06/10/25, at 0829 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-I about R95's current condition. Surveyor asked LPN-I if R95 needed help in the dining room. LPN-I informed Surveyor that R95 is not speaking much today and that the family is looking at hospice for R95. LPN-I informed Surveyor that R95 has declined in abilities recently. Surveyor asked LPN-I if R95 needed help eating. LPN-I informed Surveyor it depends on R95's cognitive abilities for the day, but often R95 will feed herself with set up. LPN-I informed Surveyor that R95 is weaker today. On 06/10/25, at 12:20 PM, Surveyor observed lunch on the 400 unit. Surveyor observed Certified Nursing Assistant (CNA)-N initially helping R95 eat and drink. Surveyor observed CNA-N was standing over R95 while helping R95 eat the meal. Surveyor observed that CNA-N the only one helping in the dining area. On 06/11/25, at 09:09 AM, Surveyor interviewed Resident Care Coordinator (RCC)-E about what education the staff receive on dignity and assisting the residents with eating. Surveyor asked RCC-E if RCC-E did the education for the certified nursing assistants (CNA). RCC-E informed Surveyor the RCC-E did the education for the CNA's and other staff. Surveyor asked if it was appropriate for staff to stand over residents while they are assisting to feed them or should staff sit next to them at eye level. RCC-E informed Surveyor the staff need to be at eye level and sit by them to maintain dignity. Surveyor asked RCC-E who does the training on feeding assistance for residents. RCC-E informed Surveyor that RCC-E does the training for staff regarding feeding assistance and that staff are taught by RCC-E to sit at Resident level. RCC-E clarified to Surveyor definitely at the eye level of the resident. RCC-E informed Surveyor that is what RCC-E teaches. On 06/11/25, at 11:26 AM, Surveyor interviewed R95. Surveyor attempted to question R95 about R95 needing assistance eating. R95 became teary and informed Surveyor I am okay. R95 provided Surveyor no other information. On 06/11/25, at 03:20 PM, Surveyor informed NHA-A, DON-B, of Surveyors concerns with dignity issues of staff standing over a resident while assisting in feeding, leaving food in front of resident who is unable to feed themselves. Surveyor informed NHA-A during an interview, RCC-C informed Surveyor that this was appropriate resident treatment. NHA-A informed Surveyor the NHA-A agreed it was not appropriate resident treatment. 2.) R94 was initially admitted to the facility on [DATE] with diagnosis that included Cerebral Infarction (a condition where blood flow to the brain is blocked causing brain tissue damage), Aphasia (a language disorder from damage to areas of the brain), Dysphagia oropharyngeal phase (difficulty swallowing that occurs in the mouth or throat). R94's Quarterly Minimum Daily Set (MDS) with an assessment reference date of 4/25/25 documents Under Section C cognitive patterns a Brief Interview for Mental Status score of unable to complete assessment rarely or never understood indicating R94 has severe cognitive impairment. Under section GG Functional abilities and goals documents R94 as being completely dependent on staff with eating (Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident). R94's restorative eating care plan documents R94 is in a program secondary to requiring assistance to eat meals. Difficulty focusing on task. Date Initiated: 04/11/25. R94's intervention section documents: Position resident at the dining room table. Provide napkin or other clothing protection per resident reference. Date Initiated: 04/11/2025. Prompt and cue resident to remain seated throughout the meal. Date Initiated: 04/11/2025. Prompt and encourage resident to maintain intake. Date Initiated: 04/11/2025. R94's activities of daily living (ADL) care plan documents that R94 has an ADL Functional Performance Deficit r/t (related to) cerebral infarction, expressive and receptive aphasia, poor cognition, weakness, is unable to follow direction of staff, and is in need of extensive assist with cares. Res has dentures however does not utilize and Family is in agreement that this is fine, collaboration with Hospice to ensure that resident is comfortable, and Hospice CNAs visits occur as well. Uses Broda chair for comfort Date Initiated: 10/22/2024. R94's intervention section documents: Assist/prompt resident to bring cup to mouth for drinking during meals. Date Initiated: 11/04/2024. Assist/prompt resident to bring food to mouth during meals. Date Initiated: 11/04/2024 On 06/10/25, at 12:38 PM, Surveyor observed during the lunch meal Licensed Practical Nurse (LPN)-M calling across the room to Certified Nursing Assistant (CNA)-P asking if there were any feeders the staff still needed help with. Surveyor observed CNA-P reply to LPN-M she's a feeder over here pointing to R94. LPN-M walked over to table and sat down by R94. On 06/10/25, at 12:58 PM, Surveyor returned to dining room and observed R94 sitting at the table alone with R94's food set out in front of R94. Surveyor asked CNA-Q if R94 was supposed to be alone at a table with food in front of R94. CNA-Q informed Surveyor R94 is a total assist with feeding and dependent on staff to eat. CNA-Q informed Surveyor CNA-Q did not know why the food is placed it in front of R94 and why R94 was left alone. CNA-Q stated R94 sitting alone with food was not appropriate because R94 cannot feed herself and R94 needs supervision and assistance at meals. Surveyor observed CNA-Q sit down to finish assisting R94 to eat the lunch meal. Surveyor observed that R94 continued to eat R94's meal with CNA-Q's help. On 6/16/25, at 11:55 AM, Surveyor observed R94 at the dining table with a family member waiting for lunch. On 06/11/25, at 09:09 AM, Surveyor interviewed Resident Care Coordinator (RCC)-E about what education the staff receive on dignity and assisting the residents with eating. Surveyor asked RCC-E if it was appropriate that staff should call across the room and ask if there are feeders over there. RCC-E informed Surveyor it is not appropriate to call residents who need assistance to be fed by staff as feeders. RCC-E asked Surveyor what staff did that and that RCC-E would talk to them because that was inappropriate for staff to refer to residents in that manner. RCC-E informed Surveyor that is not what we teach the staff, we teach them to maintain dignity and respect. On 06/11/25, at 03:20 PM, Surveyor informed NHA-A and DON-B, of staff leaving food in front of resident who is unable to feed themselves, calling residents feeders across the dining room.

Based on interview and record review, the facility did not ensure medical records contained documentation related to COVID-19 immunizations for 3 (R19, R109, and R163) of 5 residents reviewed for immunizations. *R19's medical record does not contain any documentation as to whether R19 was offered, received, or declined the COVID-19 immunization. * R109's medical record does not contain any documentation as to whether R109 was offered, received, or declined the COVID-19 immunization. * R163's medical record does not contain any documentation as to whether R163 was offered, received, or declined the COVID-19 immunization. Findings include: The facility's policy and procedure titled, Covid-19 Vaccinations, dated 02/2025 was reviewed. The policy documents in part: Policy: When recommended vaccines are available, the facility will ensure COVID-19 vaccines are readily accessible to both residents and staff. COVID-19 vaccinations can be administered to residents and staff at the facility by a contractor provider, or the facility can assist staff in finding an offsite pharmacy provider. The facility will not cover any expenses related to vaccines. General Guidelines 1. Information will be posted for families, visitors, residents and staff that encourages them to be vaccinated. 2. The facility will actively encourage all residents and healthcare personnel to receive COVID-19 vaccinations, particularly before the peak of fall respiratory season. All recommended doses will be offered in a timely manner to ensure protection during peak infection periods . 4. Before offering the COVID-19 vaccine, all staff members, residents or their representative will be provided with education regarding the benefits and risks and potential side effects associated with the vaccine . 6. The resident, resident representative, or staff member has the opportunity to accept or refuse a COVID-19 vaccine and change their decision . Resident Documentation Guidelines 1. The residents medical record includes documentation that indicates, at a minimum the following: a. That the resident or resident representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine; and b. Each dose of COVID-19 vaccine administered to the resident; or c. If the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. 1.) R19 was admitted to the facility on [DATE] with pertinent diagnoses that include pulmonary embolism (occurs when a blood clot gets stuck in an artery in the lung, blocking blood flow to part of the lung), lobar pneumonia (a type of pneumonia characterized by the infection and inflammation of one or more lobes of the lung), acute and chronic respiratory failure with hypoxia (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), and chronic systolic (congestive) heart failure (occurs when the left ventricle can't pump blood efficiently). R19's Medicare 5 day Minimum Data Set (MDS) with an assessment reference date of 5/21/25, documents a Brief Interview for Mental Status (BIMS) assessment score of 14, indicating that R19 is cognitively intact. Surveyor reviewed R19's electronic medical record and was unable to locate whether R19 was offered, received, or declined the COVID-19 immunizations. On 06/11/25, at 01:44 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-D who stated they thought they didn't have to ask about vaccinations for short term residents. ADON-D got consents today. ADON-D wasn't aware about asking at admission. Facility just had a vaccination clinic in April, ADON-D is catching up now. ADON-D will be working with pharmacy for another clinic date. On 06/11/25, at 03:33 PM, during the end of day meeting, Surveyor shared concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R19 was not offered the COVID-19 vaccination until today after evidence of the vaccination was requested. Surveyor noted no further evidence of documentation of R19 being offered or refusing the COVID-19 vaccination at admission to the facility was provided. 2.) R109 was admitted to the facility on [DATE] with pertinent diagnoses that include enterocolitis (an inflammation that occurs throughout your intestines), type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), chronic obstructive pulmonary disease (lungs become inflamed, damaged and narrowed) and heart failure (occurs when the heart muscle doesn't pump blood as well as it should). R109's Medicare 5 day Minimum Data Set (MDS) with an assessment reference date of 5/26/25, documents a Brief Interview for Mental Status (BIMS) assessment score of 15, indicating that R109 is cognitively intact. Surveyor reviewed R109's electronic medical record and was unable to locate whether R109 was offered, received, or declined the COVID-19 immunizations. On 06/11/25, at 01:44 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-D who stated they thought they didn't have to ask about vaccinations for short term residents. ADON-D got consents today. ADON-D wasn't aware about asking at admission. Facility just had a vaccination clinic in April, ADON-D is catching up now. ADON-D will be working with pharmacy for another clinic date. On 06/11/25, at 03:33 PM, during the end of day meeting, Surveyor shared concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R109 was not offered the COVID-19 vaccination until today after evidence of the vaccination was requested. Surveyor noted no further evidence of documentation of R109 being offered or refusing the COVID-19 vaccination at admission to the facility was provided. 3.) R163 was admitted to the facility on [DATE] with pertinent diagnoses that include cellulitis of right and left lower limb (a bacterial infection of the skin and underlying tissues, commonly caused by bacteria like streptococcus or staphylococcus), and sepsis (a life-threatening condition that arises when the body's response to an infection spirals out of control, damaging its own tissues and organs). R163's Medicare 5 day Minimum Data Set (MDS) with an assessment reference date of 6/3/25, documents a Brief Interview for Mental Status (BIMS) assessment score of 15, indicating that R163 is cognitively intact. Surveyor reviewed R163's electronic medical record and was unable to locate whether R163 was offered, received, or declined the COVID-19 immunizations. On 06/11/25, at 01:44 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-D who stated they thought they didn't have to ask about vaccinations for short term residents. ADON-D got consents today. ADON-D wasn't aware about asking at admission. Facility just had a vaccination clinic in April, ADON-D is catching up now. ADON-D will be working with pharmacy for another clinic date. On 06/11/25, at 03:33 PM, during the end of day meeting, Surveyor shared concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R163 was not offered the COVID-19 vaccination until today after evidence of the vaccination was requested. Surveyor noted no further evidence of documentation of R163 being offered or refusing the COVID-19 vaccination at admission to the facility was provided.

Based on interview and record review, the facility did not ensure residents Pneumococcal immunizations were offered, or refused, as eligible. This was observed with 3 (R19, R109, and R163) of 5 residents whose immunization records were reviewed. *R19, is [AGE] years old, admitted on [DATE] and did not have documentation of Pneumococcal vaccine being offered until 6/11/25, after Surveyor asked for records, then a verbal consent was obtained from R19's Power of Attorney (POA) * R109, is [AGE] years old, admitted on [DATE] and did not have documentation of Pneumococcal vaccine being offered until 6/11/25, after Surveyor asked for records. * R163, is [AGE] years old, admitted on [DATE] and did not have documentation of Pneumococcal vaccine being offered until 6/11/25, after Surveyor asked for records. Findings include: The facility's policy and procedure titled, Pneumococcal Vaccination, dated 01/2025 was reviewed. The policy documents in part: Policy: It is the policy of this facility that residents will be offered immunizations against pneumococcal disease in accordance with The Advisory Committee on Immunization Practices (ACIP) recommendations. Procedure: 1. The pneumococcal vaccine as recommended by the CDC and ACIP varies by resident's age. 2. Vaccination Age Categories per Center for Disease Control (CDC): a. age [AGE] years or older who have: i. Not previously received a dose of PCV13 (Pneumococcal Conjugate Vaccine), PCV15, or PCV20 or whose previous vaccination history is unknown: 1 dose PCV15 or 1 dose PCV20 . b. age [AGE]-64 years with certain underlying medical conditions or other risk factors who have: i. Not previously received a PCV13, PCV15, or PCV20 or whose previous vaccination history is unknown: 1 dose PCV15 or 1 dose PCV20 . 3. If consented or declined, it will be documented in the residents' medical records. Historical information will be entered if available. 1.) R19 was admitted to the facility on [DATE] with pertinent diagnoses that include pulmonary embolism (occurs when a blood clot gets stuck in an artery in the lung, blocking blood flow to part of the lung), lobar pneumonia (a type of pneumonia characterized by the infection and inflammation of one or more lobes of the lung), acute and chronic respiratory failure with hypoxia (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), and chronic systolic (congestive) heart failure (occurs when the left ventricle can't pump blood efficiently). R19's Medicare 5 day Minimum Data Set (MDS) with an assessment reference date of 5/21/25, documents a Brief Interview for Mental Status (BIMS) assessment score of 14, indicating that R19 is cognitively intact. R19 is over [AGE] year. There isn't documentation of any pneumococcal vaccinations being offered or refused upon admission to facility. The Wisconsin Immunization Registry (WIR) does not have any pneumococcal vaccine administration on record. R19 would be eligible for the PCV15, or PCV20. On 06/11/25, at 01:44 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-D who stated they thought they didn't have to ask about vaccinations for short term residents. ADON-D got consents today. ADON-D wasn't aware about asking at admission. Facility just had a vaccination clinic in April, ADON-D is catching up now. ADON-D will be working with pharmacy for another clinic date. On 06/11/25, at 03:33 PM, during the end of day meeting, Surveyor shared concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R19 was not offered the pneumococcal vaccination until today, after evidence of the vaccination was requested. Surveyor noted no further evidence of documentation of R19 being offered or refusing the pneumococcal vaccine upon admission to the facility was provided. 2.) R109 was admitted to the facility on [DATE] with pertinent diagnoses that include enterocolitis (an inflammation that occurs throughout your intestines), type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), chronic obstructive pulmonary disease (lungs become inflamed, damaged and narrowed) and heart failure (occurs when the heart muscle doesn't pump blood as well as it should). R109's Medicare 5 day Minimum Data Set (MDS) with an assessment reference date of 5/26/25, documents a Brief Interview for Mental Status (BIMS) assessment score of 15, indicating that R109 is cognitively intact. R109 is over [AGE] year. There isn't documentation of any pneumococcal vaccinations being offered being offered or refused upon admission to facility. The Wisconsin Immunization Registry (WIR) does not have any pneumococcal vaccine administration on record. R109 would be eligible for the PCV15, or PCV20. On 06/11/25, at 01:44 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-D who stated they thought they didn't have to ask about vaccinations for short term residents. ADON-D got consents today. ADON-D wasn't aware about asking at admission. Facility just had a vaccination clinic in April, ADON-D is catching up now. ADON-D will be working with pharmacy for another clinic date. On 06/11/25, at 03:33 PM, during the end of day meeting, Surveyor shared concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R109 was not offered the pneumococcal vaccination until today, after evidence of the vaccination was requested. Surveyor noted no further evidence of documentation of R109 being offered or refusing the pneumococcal vaccine upon admission to the facility was provided. 3.) R163 was admitted to the facility on [DATE] with pertinent diagnoses that include cellulitis of right and left lower limb (a bacterial infection of the skin and underlying tissues, commonly caused by bacteria like streptococcus or staphylococcus), and sepsis (a life-threatening condition that arises when the body's response to an infection spirals out of control, damaging its own tissues and organs). R163's Medicare 5 day Minimum Data Set (MDS) with an assessment reference date of 6/3/25, documents a Brief Interview for Mental Status (BIMS) assessment score of 15, indicating that R163 is cognitively intact. R163 is [AGE] years old. There is no documentation of any pneumococcal vaccinations being offered being offered or refused upon admission to facility. The Wisconsin Immunization Registry (WIR) does not have any pneumococcal vaccine administration on record. R163 would be eligible for the PCV15, or PCV20 per PneumoRecs VaxAdvisor. On 06/11/25, at 01:44 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-D who stated they thought they didn't have to ask about vaccinations for short term residents. ADON-D got consents today. ADON-D wasn't aware about asking at admission. Facility just had a vaccination clinic in April, ADON-D is catching up now. ADON-D will be working with pharmacy for another clinic date. On 06/11/25, at 03:33 PM, during the end of day meeting, Surveyor shared concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R163 was not offered the pneumococcal vaccination until today, after evidence of the vaccination was requested. Surveyor noted no further evidence of documentation of R163 being offered or refusing the pneumococcal vaccine upon admission to the facility was provided.

Based on observations, interviews, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (R32, R74) of 6 residents observed. *R32 was readmitted to facility on 5/13/25 with a hospital acquired stage 3 pressure injury. R32 was placed on Enhanced barrier precautions (EBP) on 5/13/25. Surveyor observed on 6/9/25 R32 had no indication that R32 was on EBP. Care Plan documents R32 continued EBP until 6/12/25 when the facility discontinued EBP for a stage 3 pressure ulcer not yet healed. Surveyor observed R32's wound care on the stage 3 coccyx pressure ulcer on 6/11/25 with nurse not following EBP during R32's treatment. *R74 was observed by Surveyor on 6/9/25 [NAME] with drainage on R74's bandaged leg wounds and not in Enhanced Barrier Precautions (EBP) until 6/10/25. R74's care plan has no documentation of R74 being on EBP for R74's 4/25/25 hospital readmission to the facility with a hospital acquired stage 3 coccyx pressure injury. Findings include: Facility policy titled ENHANCED BARRIER PRECAUTIONS dated 12/24 POLICY: Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) in nursing homes. As well as to prevent multi-drug resistant organism acquisition of those with an increased risk of acquiring MDROs including residents with a chronic wound or an indwelling medical device. GUIDELINES: 1. EBP involves gown and gloves use during high-contact resident care activities for residents known to be infected or colonized with MDROs when contact precautions do not otherwise apply. As well as residents with a chronic wound and/or indwelling medical device. 2. The facility will use a risk-based approach (critical thinking} to determine which type of precautions, if any, are warranted. After completing the risk based assessment (critical thinking) the facility will determine if residents with more common MDROs (MRSA, VRE, and ESBL-producing Enterobacterales) need EBP. 3. A subset of targeted MDROs is considered an extensively drug resistant organism (XDRO). ALL those infected or colonized with an XDRO will require EBP for the duration of their stay at the facility, unless contact precautions are warranted. a. Candida auris (CA). b. Carbapenemase-producing Enterobacteriaceae (CRE). c. Carbapenemase-producing Acinetobacter baumannii (CRAB). d. Carbapenemase-producing Pseudomonas aeruginosa (CRPA). PROCEDURE: 1. High-Contact Resident Care Activities include the following: a. Dressing. b. Bathing/Showering. c. Transferring. d. Changing linens. e. Providing hygiene. f. Changing briefs or assisting with toileting. g. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. h. Wound care. 2. Residents that have indwelling medical devices, regardless of MDRO status, will be on EBP. a. Some examples may include central vascular line (including hemodialysis catheter), urinary catheter, feeding tube, tracheostomy, and ventilator (excludes peripheral IVs). b. Devices that are fully embedded within the body (e.g., pacemakers) would not be an indication for ESP. c. Other devices such as a colostomy, ileostomy, or a Jackson Pratt (JP) drain would not require EBP. 3. Residents that have a wound requiring a dressing, regardless of [NAME] status, will require ESP. a. Types of wounds where ESP would be indicated include, but are not limited to: pressure ulcers, diabetic foot ulcers, arterial, chronic wounds (e.g., wound vacs) a wound that is not well-approximated (not healing as intended) and chronic venous stasis ulcers. b. Fresh/healing surgical wounds is not an indication for EBP. c. Residents with draining wounds that cannot be contained (e.g., residents who cannot maintain adequate hygiene), or the resident has an infection or condition listed in CDC's (Centers for Disease Control) Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007). d. Post the CDC EBP sign outside of the resident's room. e. Gown and gloves use prior to the high-contact care activity (change PPE before caring for another resident). f. Eye protection may be needed if performing activity with risk of splash or spray (e.g., wound irrigation). 4. Make PPE available and accessible outside of the resident's room (each room does not need their own set-up). 5. Ensure that alcohol-based hand rub is accessible for hand hygiene as needed. 6. Provide a trash receptacle at the exit of the resident's room for discarding PPE after removal and before exiting the room, or before providing care to another resident in the same room. 7. When entering the resident's room for reasons other than to provide high contact resident care activities, use of gown and gloves are not required. Instead, perform hand hygiene prior to entering and exiting the room. 8. Residents are not restricted to their rooms or from group activities when EBP is in place. 9. EBP does not replace existing guidance for the use of contact precautions for other pathogens. Contact precautions still need to be used for infected or colonized residents in certain situations, including but not limited to, C. difficile, norovirus, scabies, shingles (until the lesions are dry), etc. 10. EBP can be discontinued when chronic wounds heal or indwelling medical devices are removed. Memorandum QSO-24-08-NH on 3/20/24 from the Center for Clinical Standards and Quality/Quality, Safety & Oversight Group documents: Subject: Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs). EBP are indicated for residents with any of the following: o Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or o Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid®) or similar dressing. Examples of Page 3 of 5 chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Document/Room Signage titled, (STOP) Enhanced Barrier Precautions documents: Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following activities. Dressing, Bathing/Showering, Transferring, Changing Linens, providing hygiene, changing briefs or assisting with toileting. Device care or use: central line, urinary catheter. Feeding tube, tracheostomy. Wound Care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. 1.) R32 was initially admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive pulmonary Disease (lung disease that stops air flow), Congestive Heart Failure (Chronic condition causing heart to not pump blood efficiently), Polyneuropathy (central nervous system disorder causing numbness, weakness, pain primarily in distal parts of the arms and legs). R32's significant change in condition Minimum Daily Set (MDS) with an assessment reference date of 3/24/25 documents Under Section C cognitive patterns a Brief Interview for Mental Status score of 15 indicating R74 has intact cognition. Under section M Skin Conditions documents R74 as having 0 pressure injuries. R32's (name of a wound physician group) wound consultation completed 5/13/25, the day of R32's readmission from hospital, documents R32's stage 3 coccyx wound: Wound Size (L x W x D): 3 x 1 x 0.2 cm Surface Area: 3.00 cm² Exudate: Moderate Sero - sanguineous R32's (name of a wound physician group) wound consultation day of R32's readmission from hospital dated 6/03/25 documents R32's stage 3 coccyx wound: Wound Size (L x W x D): 2 x 0.7 x 0.1 cm Surface Area: 1.40 cm² Exudate: Light Sero - sanguineous Granulation tissue: 100 % Wound progress: Improved evidenced by decreased surface area R32's Nursing Note dated 5/13/25, at 08:19 AM, documents Late Entry: Day of Antibiotic Therapy: DAY 1. What day if beyond 14: Temperature: T 98.8 - 5/13/2025 04:43 Route: Forehead (non-contact) What antibiotic being used for: Other. Other Type: Sepsis Antibiotic & Delivery Method: Ertapenem Sodium 1 GM IV via midline x 2 days Reaction to Medication: NO Sign and Symptoms of Infection: NO Signs or Symptoms of infection Exhabiting {SIC} the following signs & symptoms: Precautions: Contact Summary (if applicable): Enhanced Barrier Precautions r/t (related to) midline and wound R32's Alteration in Skin integrity care plan documents: Pressure ulcer(s) on coccyx present on admission date initiated 05/13/25. Intervention section documents: Enhanced Barrier Precautions will be implemented during high contact resident care activities for chronic wounds including, but not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis Ulcers Date Initiated: 05/13/2025 Resolved Date: 06/12/2025. R32's physician's order dated 05/13/25 at 09:33 AM and discontinued 6/3/25 at 01:13 PM, documents: Maxorb II 2 X 2, Apply to coccyx topically every day shift, every Tue, Thu, Sat for Skin Condition CLEANSE AREA W/NS, AND APPLY medihoney, f/b alginate and a foam border. R32's physicians order dated 6/3/25, at 01:12 documents: Zinc Oxide Ointment 20 % Apply to coccyx topically every shift for Skin Condition. On 6/9/25, at 0936 AM, Surveyor interviewed R32. Surveyor asked R32 if R32 had any concerns. R32 informed Surveyor that R32 has a big sore on R32's bottom. Surveyor asked R32 how R32 developed that sore on her bottom. R32 informed Surveyor R32 had a stay in the hospital and that R32 went for my heart a couple months ago. Surveyor asked R32 if R32 ever had people care for R32 in the last month wearing gowns, masks and gloves and a little cart outside of the room or heard the word precautions or isolation. R32 informed Surveyor that R32 did not recall that happening. On 06/10/25, at 12:44 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-M R32 was placed into placed into EBP after R32's readmission in mid-May 2025. LPM-M informed Surveyor that LPN-M could not recall if R32 was in EBP since May 2025. Surveyor asked LPN-M if LPN-M could find out if R32 was placed in EBP. LPN-M informed Surveyor that LPN-M would find out for the Surveyor. On 06/10/25, at 12:55 PM, Surveyor was approached by LPN-M. LPN-M informed Surveyor that LPN-M spoke to Director of Nursing DON-B and DON-B informed LPN-M that the infection control-Assistant Director of Nursing (ADON)-D makes the decision which residents go into EBP. On 06/10/25, at 01:17 PM, Surveyor interviewed ADON-D about the facilities enhanced barrier precaution procedures. Surveyor asked ADON-D why if R32 placed into EBP after R32's readmission from the hospital. ADON-D informed Surveyor the ADON-D could not recall off hand if R32 was placed in EBP, but could check with DON-B. ADON-D informed Surveyor we have no wound nurse currently, so DON-B is the acting wound nurse, and she sees residents on wound rounds with the wound doctor weekly. Surveyor asked ADON-D when ADON-D should place a resident in EBP. ADON-B informed Surveyor any chronic wounds, wounds needing dressings to contain drainage, Foley catheters, Multi Drug Resistant Organisms) MDRO's, PICC (long term intravenous) lines, tube feeding, pressure ulcers, and diabetic ulcers. Surveyor asked ADON-D if all stage 3 pressures ulcers would be placed into EBP. ADON-D informed Surveyor that stage 3 pressure ulcers would be placed into EBP. Surveyor asked ADON-D if a resident still some drainage from a wound had (Surveyor noted the wound note for R32's stage 3 coccyx documented on 6/3/25 light serosanguineous drainage), and especially if it was a stage 3 pressure ulcer would the resident typically be in EBP. ADON-D informed Surveyor stage 3 pressure ulcers are typically placed in EBP. On 06/11/25, at 07:19 AM, interviewed Occupational Therapist (OT)-J about R32's therapy. Surveyor noticed therapies went into R32's room. Surveyor asked OT-J if OT-J remembered any EBP that R32 was may have been in recently when therapy worked with R32. OT-J informed Surveyor that OT-J couldn't recall if R32 was in EBP or not. On 06/11/25, at 09:21 AM, Surveyor interviewed R32 about R32's pressure injury of the coccyx. R32 informed Surveyor that R32's bottom getting better and that the cushion in R32's chair helped with R32's comfort. On 06/11/25, at 01:52 PM, Surveyor observed Therapy working with R32 with no personal protection equipment. On 06/11/25, at 01:59 PM, Surveyor observed R32's wound care with DON-B. DON-B informed Surveyor that the wound has epithelial tissue closing around wound and R32's wound was getting close to being closed. Surveyor observed good hand hygiene with gloves with no other enhanced barrier precautions (EBP) being followed. Surveyor noted R32's care plan documents R32 is still in EBP. Surveyor noted small area in middle of R32's stage 3 pressure area is still open and R32 was wearing a disposable brief. On 06/11/25, at 02:11 PM, Surveyor interviewed DON-B following R32's treatment by DON-B. Surveyor asked DON-B if DON-B found the information Surveyor requested on basing pressure ulcers as chronic wounds must be over 30 days and if pressure ulcers had to have a traditional dressing. DON-B informed Surveyor that DON-B and corporate are still looking for that information. DON-B informed Surveyor that R32's wound was not draining and that it had no dressing so R32 should not be in EBP any longer. Surveyor asked DON-B while R32's wound is almost closed it is not completely closed and DON-B could not provide when R32's EBP ended. Surveyor informed DON-B that as of today R32's care plan indicates that R32 is still in Enhanced barrier precautions. DON-B replied to Surveyor oh. On 06/11/25, at 09:57 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and DON-B Surveyor asked DON-B you would agree with the ADON-D that stage 3 pressure ulcers should be in EBP. Surveyor asked DON-B why R32 did not have an EBP sign and cart outside R32's room when R32 was in EBP and had a stage 3 pressure ulcer. DON-B informed Surveyor that yes stage 3 pressure wounds should be in EBP, but that any wound that no longer needing a dressing did not require EBP and that DON-B was checking with corporate for the information to verify that. 2.) R74 was initially admitted to the facility on [DATE] with diagnosis that included Chronic Obstructive pulmonary Disease, Type 2 Diabetes Mellitus, and Congestive Heart Failure. R74's Quarterly Minimum Daily Set (MDS) with an assessment reference date of 4/29/25 documents Under Section C cognitive patterns a Brief Interview for Mental Status score of 15 indicating R74 has intact cognition. Under section M Skin Conditions documents R74 as being readmitted on [DATE] with a stage 3 pressure ulcer. R74's (name of a wound physician group) wound consultation dated 4/29/25 documents R74's stage 3 coccyx wound: Wound Size (L x W x D): 1.5 x 1 x 0.2 cm Surface Area: 1.50 cm² Exudate: Moderate Sero - sanguineous Slough: 20% Granulation tissue: 80% R74's (name of a wound physician group) wound consultation dated 6/3/25 documents R74's stage 3 coccyx wound: Wound Size (L x W x D): 0.3 x 0.3 x 0.1 cm Surface Area: 0.09 cm² Exudate: Light Sero - sanguineous Granulation tissue: 100% Wound progress: Improved evidenced by decreased depth, decreased necrotic tissue, decreased surface area R74's nursing noted dated 6/4/25, at 06:12 PM, documents, Day of Antibiotic Therapy: DAY 5 What day if beyond 14: Temperature: T 98.2 - 6/4/2025 09:32 Route: Tympanic What antibiotic being used for: Cellulitis Other Type: Antibiotic & Delivery Method: Cephalexin Tablet 500 MG q (every) 12 hrs (hours) x (for) 7 days Reaction to Medication: NO Sign and Symptoms of Infection: Signs and Symptoms of infection are present (Describe below) Exhibiting the following signs & symptoms: skin is red, warm, swollen, and draining Precautions: Not Applicable Summary (if applicable): R74's physician's order dated 04/30/25, at 10:53 PM, discontinued on 06/03/25 at 08:36 PM documents: Maxorb II 2 X 2, Apply to left buttock/coccyx topically every day shift for Skin Condition CLEANSE AREA W/NS (with normal saline) apply Maxorb and foam border, R74's physician's order dated 06/02/25, at 02:25 PM, discontinued on 06/04/25 at 02:23 PM, documents: Clean & dry BLE (bilateral lower extremities). Apply ABD (abdominal) pads to weeping areas & cover with Kerlix & tubigrips. every day shift for SKIN CARE. R74's physician's order dated 06/08/25, at 02:05 PM, discontinued on 06/15/25 at 03:53 PM, documents: Vaseline Petrolatum Gauze External Pad (Wound Dressings) Apply to BLE topically every morning and at bedtime for Wound Therapy On 6/9/25, at 10:45 Surveyor interviewed R74. Surveyor asked R74 how R74 was doing today. R74 informed Surveyor that R74 was doing fair. Surveyor asked R74 if people ever had taken care of R74 with gowns and a cart outside of R74's for R74's wound on their bottom or leg. R74 informed Surveyor that R74 thought that when R74 was sick a while back but doesn't remember. (Surveyor did note in the medical record that R74 was in contact and droplet precautions when R74 returned from hospital on 4/25/25 and removed from precautions on R74's care plan on 4/28/25 for Metapneumovirus). CNA-MM entered R74's room during the interview. Surveyor asked CNA-MM if R74 was ever in EBP or is in EBP. CNA-MM informed Surveyor that CNA-MM did believe that R74 was on precautions recently. On 6/10/25 Surveyor noted R74 was placed in EBP. On 06/10/25, at 12:44 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-M on why R74 was placed into EBP today, 6/10/25. LPN-M informed Surveyor LPN-M's guess was that Director of Nursing (DON)-B placed R74 in Enhanced Barrier precautions because of R74's bilateral wounds to R74's lower legs but was not sure. LPN-M shared they would find out for the Surveyor. Surveyor asked LPN-M if LPN-M recalls if R74 was in EBP after R74's return from the hospital in late April 25 or Early May 25. LPN-M informed Surveyor that LPN-M did not recall if R74 was in EBP prior to 6/10/25. On 06/10/25, at 12:55 PM, Surveyor was approached by LPN-M. LPN-M informed Surveyor that LPN-M spoke to Director of Nursing DON-B and DON-B informed LPN-M that the infection control-Assistant Director of Nursing (ADON)-D makes the decision which residents go into EBP. On 06/10/25, at 01:45 PM, Surveyor observed CNA-Q discussing with another CNA outside of R74's door that CNA-Q wasn't aware of why EBP was started on 6/10/25 for R74. On 06/10/25, at 01:17 PM, Surveyor interviewed ADON-D about the facility's enhanced barrier precaution procedures. Surveyor asked ADON-D why was R74 placed into EBP. ADON-D informed Surveyor R74 had closed, acute wounds that are now chronic and weeping. ADON-D informed Surveyor that DON-B noted during wound rounds this morning with the wound doctor that R74's legs were weeping and draining. Surveyor asked ADON-D about nursing notes documenting R74 had drainage back on 6/4/25. ADON-D informed Surveyor we have no wound nurse currently, so DON-B is the acting wound nurse, and she sees residents on wound rounds with the wound doctor weekly. Surveyor asked ADON-D when ADON-D should place a resident in EBP. ADON-B informed Surveyor any chronic wounds, wounds needing dressings to contain drainage, Foley catheters, Multi Drug Resistant Organisms) MDRO's, PICC (long term intravenous) lines, tube feeding, pressure ulcers and diabetic ulcers. ADON-D informed Surveyor that residents with stage 3 pressure ulcers would be placed into EBP. Surveyor asked if the wounds on R74's legs were chronic before today. ADON-D informed Surveyor ADON-D did not believe R74's legs were chronic. ADON-D informed Surveyor that with R74's lymphedema that it was unlikely they would heal quickly. Surveyor asked ADON-D if R74 was ever in EBP for R74's hospital acquired pressure injuries and when were those precautions removed. ADON-D informed Surveyor that ADON-D was not sure if R74's pressure injuries were chronic or if R74 was ever on EBP or if R74 was ever removed from EBP. Surveyor asked ADON-D if R74 had a stage 3 pressure injury. ADON-D informed Surveyor that R74 had a stage 3 pressure injury but it was resolved today 6/10/25. Surveyor asked ADON-D if a resident has some drainage from a wound and if it was a stage 3 pressure injury would the resident typically be in EBP. ADON-D informed Surveyor resident with stage 3 pressure injuries are typically placed in EBP. (Surveyor noted the wound note on 6/3/25 documents R74's stage 3 coccyx pressure injury had light drainage). Surveyor asked ADON-D which staff can place a resident on EBP. ADON-D informed Surveyor that ADON-D will place a resident on EBP, but that the floor nurses can place a resident on EBP for the same reasons ADON-D gave Surveyor earlier. On 06/11/25, at 09:57 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and DON-B concerning observing wound treatments for R74. Surveyor asked DON-B why R74 was not placed into EBP until 6/10/25. DON-B informed Surveyor that in DON-B's research a chronic wound is anything greater that 30 days. DON-B informed Surveyor R74 had started with leg wounds with fluid filled blisters but the leg wounds did not start draining until over the weekend of 6/7/25; and that is why we started EBP on 6/10/25. DON-B informed Surveyor R74's wounds were dry last week. Surveyor asked DON-B why the delay until 6/10/25 placing R74 on EBP when drainage started over the weekend. DON informed Surveyor DON-B did not see R74's wounds until 6/10/25 during wound rounds with the wound doctor. DON-B informed Surveyor R74 was on EBP for R74's stage 3 pressure injury but does not know when R74's EBP precautions came down because, no one informed DON-B that R74's EBP had been removed. DON-B Informed Surveyor that DON-B put R74 back on EBP on 6/10/25 after DON-B saw R74 on wound rounds and noted R74's leg drainage.

Based on interview and record review, the facility did not ensure 1 (R1) of 3 residents reviewed received care and services based on a comprehensive assessment, person centered care plan, and resident's and/or responsible party's choices. The evening of [DATE], Certified Nursing Assistant (CNA)-W transferred R1 with assist of 1 and a pivot transfer. R1's care plan documents R1 was assessed to require an EZ-stand and assist of 1 for transfers. Early morning of [DATE], R1 complained of left knee pain at a ,d+[DATE] which R1 stated began after the transfer the night before with CNA-W. A telehealth visit was completed the morning of [DATE] and Voltaren gel and ice packs were ordered. No imaging was ordered as R1 was receiving hospice services and comfort focused measures were implemented. R1 did have prior PRN (as needed) orders for Morphine and Tramadol. R1 continued to report pain levels of ,d+[DATE], ,d+[DATE], and ,d+[DATE]. R1 began to refuse assistance with cares, to get out of bed, and meals. A thorough assessment of R1 including vitals was not completed after the telehealth visit which occurred the early morning hours of [DATE]. R1 continued to decline after the telehealth visit and the facility did not consult with R1's physician or responsible party to discuss the potential need to alter R1's plan of care. R1 experienced another change of condition on [DATE] requiring oxygen due to pursed lip breathing. R1 passed away at the facility on [DATE]. An autopsy was conducted which identified the primary reason for R1's death was a fracture of the distal left femur. The facility's failure to complete ongoing, thorough assessments and communicate assessment results to R1's physician, hospice, and responsible party to allow for consultation, collaboration, and informed decisions to be made related to R1's plan of care created a finding of immediate jeopardy that began on [DATE]. On [DATE], at 2:50 PM, Nursing Home Administrator (NHA)-A, Assistant Nursing Home Administrator (ANHA)-C, ANHA-T, Director of Nursing (DON)-B, Regional Director (RD)-V, and Corporate Consultant (CC)-S were notified of the immediate jeopardy. The immediate jeopardy was removed on [DATE], however, the deficient practice continues at a scope and severity (s/s) level of E (potential for more than minimal harm/pattern) as the facility continues to implement their action plan. Findings include: The facility policy titled, Change in Condition (Resident), dated ,d+[DATE], documents, Purpose: To ensure that the resident's physician/physician on call/NP (Nurse Practitioner) and responsible party is kept informed regarding the residents change in condition. Policy: The attending physician/physician on call/NP and responsible party will be notified with changes in the resident's condition. Procedure: 1. Attending physicians or physicians on call/NP and responsible party will be notified of all changes in condition. 2. Follow framework for reporting changes in vital signs or laboratory values based on AMDA (American Medical Directors Association) Guidelines. 3. Follow suggested guidelines for reporting clinical problems based on AMDA guidelines. 4. Document time of call, physician or nurse practitioner or other person spoken to; reason for call and result or orders received. 5. Place call to responsible party to notify them of the resident's change in condition. History: Gather details about the injury's cause, pain characteristics, functional limitations, and any associated symptoms. Physical Examination: Perform inspection, palpation, range-of-motion tests, and stability assessments to identify potential injuries. Gently palpate the knee to identify areas of tenderness, swelling, or abnormalities.Assess for joint effusion by checking for fluid accumulation around the patella. Imaging and Tests: Use X-rays to detect fractures and MRIs (Magnetic Resonance Imaging) for soft tissue injuries and to rule out or confirm fractures, dislocations, or degenerative changes. R1 was admitted to the facility on [DATE] with diagnoses that include, Parkinson's Disease, Dysphagia, Chronic Kidney Disease, Congestive Heart Failure, Aneurysm, Old Myocardial Infarction, and Dysphagia. R1 was admitted to Hospice Care on [DATE] with a primary diagnosis of atherosclerotic heart disease and other co-morbidities. R1 has a Power of Attorney for Health Care (POA-HC), dated [DATE]. R1's POA-HC was not activated. R1's Minimum Data Set (MDS) quarterly assessment, dated [DATE], documents R1 has a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition, a Patient Health Questionnaire (PHQ-9) score of 0, indicating no depressive symptoms, and no indicators of psychosis including no hallucinations or delusions. R1 was assessed to require substantial/maximum assistance for the activities of sit to stand, chair/bed to chair transfer, sit to lying, lying to sitting, and toilet transfer. R1's MDS annual assessment, dated [DATE], documents R1 required the same level of assistance, substantial/maximum for the activities of sit to stand, chair/bed to chair transfer, sit to lying, lying to sitting, and toilet transfer. R1's Care Area Assessment (CAA), dated [DATE], documents R1 is triggered for self-care mobility, psychotropic drug use, urinary incontinence, falls, nutritional status, and pressure ulcer/injury. R1's Care Plan, dated [DATE], documents Focus: R1 has an ADL (Assistance with Daily Living) Self Care Performance Deficit r/t (related to) Parkinson's, weakness and the need for staff to assist with ADLs. Is currently enrolled in [Name] Hospice for end-of-life comfort care related to ASHD (Atherosclerotic Heart Disease). Continued collaboration between Hospice staff and [Facility] staff for the continuance of care and Hospice staff visits for assistance in cares provided. Date initiated: [DATE]. Interventions/Tasks: Allow enough time for completion of ADL tasks. Do not rush the resident, lock wheelchair brakes for transfers, provide needed level of assistance and support to complete Activities of Daily Living, Transfers: EZ stand, 1 assist, all with date initiated of [DATE]. R1's Facility Incident Report dated [DATE], at 3:40 AM documents: Bruise: Resident: [R1], Incident Location: Resident's room, Person Preparing Report: [RN-G.] Incident Description: Nursing Description: CNA (Certified Nursing Assistant) called nurse into room d/t (due to) resident complaining of left knee pain. R1 was laying (sic) in bed with a pillow under her knees. Resident Description: Resident stated that the CNA on PMs did not use the EZ stand to transfer her to bed and that her left knee is now hurting. When asked if she fell stated she had not and when asked if she had hit her knee on anything she again stated she had not. Was the incident witnessed: No. Immediate Action Taken: Description: Focused assessment findings: swelling to left knee and hematoma to lateral aspect of left knee. Localized pain of ,d+[DATE] reported and resident was given PRN (as needed) tramadol at 3:48 AM. After speaking with the on-call provider an ice pack was applied to her left knee for 20 minutes. Injuries Observed at Time of Incident: Injury Type: No Injuries observed at time of incident Injury location: No documentation Level of Pain: Level of Consciousness: No documentation Mobility: No documentation Mental Status: (Check Box) Oriented to Person: unchecked Oriented to Time: unchecked Oriented to Place: unchecked Injuries Report Post Incident: Injury Type: No injuries Observed Post Incident Injury Location: No documentation Level of Pain: No documentation R1's Physician Orders document on [DATE], at 3:48 AM, by RN-G, Tramadol HCI Tablet 50 mg (milligrams), Give 1 tablet by mouth every 6 hours as needed for Pain Management for 14 Days for severe pain. Left knee pain ,d+[DATE]. Elevated on Pillows. On [DATE], at 4:17 AM, R1's telehealth visit written by Advanced Practice Nurse (APN)-H documents (service start time 3:58 AM) Exam findings per nurse and video observation Physical Exam- Notes: GEN (General): alert, NAD (nothing abnormal detected), R1 is alert, flat affect, simple responses. Left knee effusion, no erythema or warmth, left knee pain and effusion noted, swelling left (greater than) right, pain with flexion and mobility, left lateral knee with ecchymosis no noted fall, Tramadol available PRN, Morphine PRN available, Tylenol scheduled. Will add voltaren 1% topical gel TID (three times per day), ice TID, no imaging at this time as comfort focused measures. This is an acute new problem. Condition is stable. Orders: Voltaren 1% topical gel TID PRN, Ice to left knee TID 20 minutes x 48 hours. Notify a clinician of any change in condition. Disposition: Stay at Facility. Technology used: Audio and video with patient and nurse present. On [DATE], at 4:19 AM, R1's medical record documents TEH (Telehealth) consulted for evaluation of pain to left knee and swelling-new onset, pain rated ,d+[DATE]. Patient is on Hospice, she is on tramadol 50 mg (milligrams) po (by mouth) q (every) 6 hours PRN, she has Tylenol scheduled. R1 uses easy stand, noted to be x 1 (assist 1) transfer last evening. No falls or injury known, but she does have left lateral knee ecchymosis blue-ish discoloration. R1 has restriction in her mobility and flexion in her left knee. R1 states pain started post transfer last night. Review of Systems: ROS (Review of Systems) as per HPI (History of Present Illness), all other systems reviewed and are negative PMH (Past Medical History) and SH (Social History). Reviewed PMH and SH and Medications Source. Vital Signs: T (Temperature): 98.4 F (degree Fahrenheit), HR (Heart Rate): 68 BP Sys (Blood Pressure Systolic): 167 mm/Hg (millimeters of mercury)/ bmp (beats per minute), / (over) D (Diastolic): 85 mm/Hg, RR (Rate Respirations): 20 rpm (rate per minute), O2 (Oxygen): 94%. Progress note written by Registered Nurse (RN-G). R1's February 2025 Physician Orders document: -Aspirin oral tablet chewable 81 mg (Milligrams), give 1 tablet by mouth at bedtime for DVT (Deep Vein Thrombosis) Prophylaxis, date ordered, [DATE], -Acetaminophen Tablet 500 mg, give 1 tablet by mouth three times a day related to Parkinson's disease, date ordered, [DATE], -pain evaluation every shift, date ordered [DATE], -Hyoscyamine Sulfate oral tablet 0.125 MG, give 1 tablet by mouth every 2 hours as needed for respiratory symptoms related to Dysphagia, crush and use syringe, -Morphine Sulfate tablet 15 MG, give 1 tablet by mouth every 1 hours as needed for pain or trouble breathing, date ordered, [DATE], -Tramadol tablet 50 MG, give 1 tablet by mouth every 6 hours as needed for pain management for 14 days for server pain, date ordered, [DATE], -Voltaren external gel 1%, apply to left knee topically every 8 hours as needed for left knee pain related to Rheumatoid Arthritis for 14 days, date ordered, [DATE], -Skin Check every evening shift every Thursday, date ordered, [DATE], -Ice Cold therapy and apply cold pack to left knee for 20 minutes TID (three times a day) every shift for 2 days, date ordered, [DATE]. R1's Facility Nurses Note on [DATE] at 4:30 AM, RN-G documents, R1 is complaining of new onset of left knee pain ,d+[DATE], swelling and hematoma to lateral aspect of left knee. Contacted on call (APN-H), who saw R1 and gave new orders for ice pack to left knee 20 minutes TID for 2 days and voltaren gel TID PRN. Called Hospice and left a detailed message for her case manager. R1's Hospice Progress Note on [DATE] at 4:27 AM, documents, TC (Telephone Call) from facility staff, [RN-G] wanting to report an update on patient. Patient having more pain to left knee. [RN-G] got new orders from [APN-H] for Voltan (sic) TID and ice for 20 minutes BID (two times a day). [RN-G] reported that patient has dx (diagnosis)) of arthritis and that when staff assisted her to bed they did a pivot transferred (sic) instead of a mechanical lift. R1's Facility Orders Note on [DATE] at 7:30 AM, Registered Nurse (RN)-R documents, Tramadol HCI Tablet 50 mg (milligrams) PRN (as needed), Give 1 tablet by mouth every 6 hours as needed for Pain Management for 14 Days for severe pain. PRN Administration was ineffective. R1's Facility Order Note on [DATE], at 7:37 AM, RN-R documents, Morphine Sulfate Tablet 15 mg, Give 1 tablet by mouth every 1 hours as needed for Pain or Trouble Breathing. Surveyor notes there was no documentation if this medication was effective. R1's Facility Order Note on [DATE], at 12:13 PM, RN-R documents, Morphine Sulfate Tablet 15 mg, Give 1 tablet by mouth every 1 hours as needed for Pain or Trouble Breathing. PRN Administration was: Effective. R1's Facility Nurses Note, on [DATE], at 1:38 PM, documents, Able to make needs known. Soft spoken/slow to respond. Continues with cares. Extensive assist with ADLs (Assistance with Daily Living). EZ stand for transfers and wc (wheelchair) for mobility. R1's Hospice Progress Note on [DATE], at 2:04 PM, documents, Check in call to facility to assess patients knee pain after injury. Spoke with charge nurse [Hospice staff] patient was having pain and received Tramadol and staff is obtaining Volteren (sic) gel to apply as well. R1's Facility Order Notes on [DATE], at 1:21 AM, RN-G documents, Tramadol 50 mg, Give 1 tablet by mouth every 6 hours as needed for Pain Management for 14 Days for severe pain. Left knee pain ,d+[DATE], elevated and ice packs applied. R1's Facility Order Notes on [DATE], at 2:24 AM, RN-G documents, Tramadol 50 mg, Give 1 tablet by mouth every 6 hours as needed for Pain Management for 14 Days for severe pain. PRN Administration was: effective. R1's Facility Order Notes on [DATE], at 7:29 AM, RN-R documents, Tramadol 50 mg, Give 1 tablet by mouth every 6 hours as needed for Pain Management for 14 Days for severe pain. L (Left) knee pain. R1's Facility Order Notes on [DATE], at 12:28 PM, RN-R documents, Tramadol 50 mg, Give 1 tablet by mouth every 6 hours as needed for Pain Management for 14 Days for severe pain. PRN Administration was: effective. R1's Facility Order Notes on [DATE], at 3:18 PM, Licensed Practical Nurse (LPN)-Z documents, Tramadol 50 mg, Give 1 tablet by mouth every 6 hours as needed for Pain Management for 14 Days for severe pain. Resident complains of pain her left knee. R1's Facility Order Notes on [DATE], at 3:55 PM, LPN-Z documents, Tramadol 50 mg, Give 1 tablet by mouth every 6 hours as needed for Pain Management for 14 Days for severe pain. Resident complains of pain her left knee. R1's February 2025, Medication Administration Record (MAR) documents, Acetaminophen tablet 500 MG was administered three times a day as ordered, from [DATE] to [DATE]. R1's February 2025 MAR documents, Morphine Sulfate tablet 15mg was administered as needed and per order, on [DATE] at 7:37 AM. R1's February 2025 MAR documents, Tramadol tablet 50 mg was administered as needed and per order, on [DATE] at 11:01 AM, [DATE] at 9:07 AM, [DATE] at 3:48 AM and 12:14 PM, [DATE] at 1:21 AM, 7:29 AM and 3:18 PM, and [DATE] at 11:19 AM. R1's February 2025 Treatment Administration Record (TAR) documents, Voltaren External gel 1%, with order to apply to left knee topically every 8 hours as needed for left knee pain was not signed as having been applied at anytime after the order was given. R1's February 2025 TAR documents, ice cold therapy pack to left knee for 20 minutes twice a day was administered as ordered on [DATE] and [DATE]. R1's February 2025 TAR documents, pain evaluation for every shift recorded as ordered, from [DATE] to [DATE]. Surveyor notes pain level is scored from 0 to 10 scale with 10 being the worst. -[DATE] Days: 0 Evening: 0 Night: 0 -[DATE]: Days: 0 Evening: 0 Night: 0 -[DATE] Days: 0 Evening: 3 Night: 0 -[DATE] Days: 4 Evening: 4 Night: 0 -[DATE] Days: 0 Evening: 3 Night: 0 -[DATE] Days: 0 Evening: 0 Night: 0 -[DATE] Days: 9 Evening: 7 Night: 0 -[DATE] Days: 10 Evening: 10 Night: 0 -[DATE] Days: 10 Evening: 10 Night: 0 -[DATE] Days: 7 Evening: 0 Night: 0 -[DATE] Days: 1 Evening: 9 Surveyor notes there are no nurses' notes documented on [DATE], only medication administration documentation. R1's meal intake monitoring documents: -On [DATE], ,d+[DATE]% consumption for breakfast, ,d+[DATE]% consumption for lunch, and 26%-50% for dinner. -On [DATE], ,d+[DATE]% consumption for breakfast, resident refused for lunch, and no documentation for dinner. -On [DATE], resident refused for breakfast and lunch, and 51% - 75% for dinner. -On [DATE], ,d+[DATE]% for breakfast and, resident unavailable for lunch and dinner. R1's Facility Nurses Note on [DATE] at 8:16 AM, LPN-F documents, R1 had swelling of the outer aspect of her left knee over weekend. Staff got order for Voteran (sic) Gel to knee prn and ice pack to knee every shift for 3 days. Knee remains swollen and warm to touch, R1 declined ice pack or pain medication at this time, R1 is also less cognitive today than last week. R1's Facility Nurses Note on [DATE] at 11:20 AM, LPN-F documents, R1 has been doing some pursed lip breathing, O2 (Oxygen) at 76%, R1 was started on Oxygen at 2L (Liters), recheck ,d+[DATE] hour later O2 at 91%. Hospice was notified of this change. R1's Hospice Progress Note on [DATE] at 12:00 PM documents, Call received from [LPN-F] at [Facility] reporting, I found out this morning that over the weekend, staff attempted to transfer patient without a lift and dropped her on the floor. She has significant swelling to her L (left) outer knee and is complaining of pain. Looks like the nurse over the weekend got an order for voltaren gel, but nothing was mentioned regarding the fall. My management will investigate we are counting it as a fall. They also got an order for an ice pack to use every shift for the next 3 days. When I gave her (R1) scheduled Tylenol this morning, she did say her pain level was fine. I think someone should look at it as it is quite swollen, and I think it's more than arthritis. Call log reviewed and no mention of a fall but did report increased pain with new orders. MAR (Medication Administrative Record) reviewed, and no tramadol order is listed. We do have an active order on our end. [LPN-F] aware RN will make a visit today to complete fall assessment, and writer will update MAR with tramadol order. R1's Hospice Progress Note on [DATE] at 1:26 PM documents, Return call received from facility nurse [LPN-F] who reports, I went in to check her pain level, and I noticed her lips were blue. I checked her oxygen and it was 78% on RA (Room Air). I did apply oxygen at 2L (liters) via NC (nasal cannula), and saturations increased to 92%. [LPN-F] aware RN will be seeing patient today. R1's Hospice Progress Note on [DATE] at 2:13 PM, [R1's] [Responsible Party] called with concern that [R1] needs a visit today. He reports staff dropped her on her head and didn't tell anyone until my son was here today and now she is unresponsive. Writer updated [Responsible Party] that facility did contact [name of hospice] hospice today that a nurse is scheduled to see her. The RN (registered nurse) will call him with an update if he is no longer present at the facility. He was very upset with her condition. Visit RN [Responsible Party] updated to call him during visit if he is not present. R1's Facility Nurses Note on [DATE] at 3:47 PM, late entry, Assistant Nursing Home Administrator (ANHA)-C, documents, [Responsible Party] stated that he is convinced that someone dropped R1. He stated that Responsible Party was in on Saturday morning, and all was normal with R1. The Responsible Party then again visited on Sunday morning and stated they noticed a change in condition from the previous day. He stated he thinks she was dropped on her knee and head and has facial swelling. At the time, I was only aware that her knee was swollen. I stated that we will be doing a thorough investigation as to what happened and that we are still unclear as to what had happened. I then had the nurse [LPN-F] go look at her face, and LPN-F stated that her eye did not seem swollen, just droopy. R1's Hospice Progress Note on [DATE] at 7:03 AM documents, Call from facility staff [LPN-F] updating that minimal responsiveness continues today. Some terminal congestion present and no hyoscyamine ordered. Refill queued up in wise [sic] and orders faxed over. BP (Blood Pressure) ,d+[DATE], 90% P (Pulse) 86. [LPN-F] aware that [Hospice staff] will be seeing patient today. R1's Hospice Progress Note on [DATE] at 10:01am documents, per RNCM (Registered Nurse Case Manager), RN visits increased to daily. Recurring schedule updated. R1's Hospice Collaboration Note on [DATE] at 11:05 am documents, Writer received a call from [DON- B] following writer's message to facility that she would like to update PCP (Primary Care Physician). [PCP-I] per [name of hospice] hospice protocol following fall visits. [DON-B] called and wished to clarify with writer that the incident was currently under investigation. Writer acknowledged that the form she is currently completing is an occurrence report, and that in the report it was uncertain what happened and that staff nurse [LPN-F] had informed writer that the incident was under investigation. [DON-B] was able to inform writer that [PCP-I] was off over the weekend when the incident occurred but that she had been informed as of Monday, yesterday. Writer thanked [DON-B] for letting her know that [PCP-I] was aware. R1's Hospice RN Comprehensive Assessment Visit Nursing on [DATE] at 2:21 pm documents, [R1] is in bed with eye's slightly open and unresponsive. She does not respond to touch or sounds. [LPN-F] reports that Sat (Saturday) am around 2:30 CNA (Certified Nursing Assistant) from [Facility] was doing pivot transfers and dropped patient. [R1] is sit to stand for transfers. Large bruise to left side of knee and knee is swollen during assessment today. Unknown if patient hit her head. No bumps or bruising to head noted at visit today. Unknown if patient had medical episode at time of fall. Patient did not go to ER (emergency room ) per [LPN-F]. She reports that HCPOA (Health Care Power of Attorney) had not been contacted by the night staff. An order was obtained to apply ice to left knee and voltaren cream to left knee. [LPN-F] reports that she found patient Monday morning and lips were blue and she was gasping for air. [LPN-F] placed [R1] on oxygen at that time. Writer contacted [Responsible Party]. [Responsible Party] reports he was not contacted the morning of the fall. [Responsible Party] reports family member contacted him Sunday to come see [R1], as she was minimally responsive at that time. RN had seen [R1] on Monday for follow up visit d/t (due to) change in condition. [Responsible Party] was offered to have patient be seen in ER (emergency room ) if he wishes. [Responsible Party] denied the need at this time for patient to go to the ER. Writer discussed holding her other medications and putting patient on comfort medications at this time. [Responsible Party] was in agreement and writer contacted NP to get order to DC (discontinue) all meds except comfort medications. Team updated on change in condition. R1's Facility Nurses Note on [DATE] at 2:42 pm, LPN-F documents, Hospice aide here for cares, during cares, R1 passed. [name of hospice] Hospice informed and on the way. PCP-I and management aware. R1's Hospice Progress Note on [DATE] at 3:07 pm, documents, Call received from HHA (Home Health Aide) [Name] who is currently at facility and reporting, [R1] has died . No family present at this time. R1's Hospice Progress Note on [DATE] at 3:09 pm, documents, Call placed to [Responsible Party] HCPOA, to notify of death. Okay, we will head back to the facility. Will be about an hour or so. Condolences provided over the phone and told [Responsible Party] to take his time. [Responsible Party] aware PM (evening) nurse starts at 4:30pm and writer will have PM nurse star (sic) at [Facility]. Okay thank you. R1's Facility Nurses Note on [DATE] at 4:42 pm, ANHA-C documents, I spoke with [Responsible Party] prior to him seeing R1 before she passed away, . He stated he thinks it is clear, cut and dry that she was dropped on her head due to someone transferring her without the EZ stand and he was not contacted for two days and now she is dead. I stated I understood. He then thanked me again . R1's Hospice Visit Information on [DATE], documents, Reportable death due to patient fall with injury: Reported a fall on [DATE] and head strike may have occurred. Patient did have a change in condition following the fall including increased swelling to left knee, decreased verbal communication and inability to feed self. R1's Hospice Visit Information on [DATE], documents, Death Visit Note Narrative: Triage received a phone call stating patient has passed away. No response to physical stimuli. Pupils fixed and dilated. No auscultated bilateral respirations or heart tones for a complete minute. Patient pronounced at 1655 (4:55pm). Family coping: Family coping well considering frustration with rapid decline following fall. Left leg has bruising from thigh to knee. Right leg has bruising on shin to foot. The facility completed an investigation related to R1's left knee swelling and bruising. Staff statements document: Staff Statement dated [DATE], RN-G documented, I was called into R1's room on Saturday [DATE] around 3:40 am d/t (due to) left knee pain. After a focused assessment I noted swelling and hematoma to the lateral aspect of her left knee, which was new. R1 was clearly communicating with me and speaking in full sentences at this time-she usually doesn't say much or will respond with single words. When I asked her if she knew what happened to her knee she said the CNA on PM shift did not use the EZ stand when transferring her to bed. I asked her if she hit it on something or fell and she said that neither of those things had happened. I administered PRN Tramadol at 3:48am and contacted the on-call physician APN-H immediately. She saw resident through the iPad and gave me new orders for ice pack to left knee 20 minutes TID x (for) 2 days as well as voltaren gel TID PRN. I then called [name of hospice] Hospice and left a detailed message with the on call nurse who said she would update her case manager. I explained that the on call provider didn't order x-rays because she believed it was tissue related and that the resident was on hospice-the on call hospice nurse agreed and said that they wouldn't be ordering an x-ray either. New orders were followed and R1 was checked on frequently over the next two nights I was here. Saturday night [DATE] I administered PRN Tramadol at 1:21am and R1 was back to her of not saying much or responding with more than one word at a time. Sunday night she was sleeping whenever I was in her room to check on her and she did not wake up when I put an ice pack on her knee. There were no signs over the weekend that she was declining or would pass away within the next couple of days. LPN-Z's statement dated [DATE] documents, On Friday, [DATE]. I worked the pm shift. At approximately 2130 (9:30pm), I noted that resident in [room number] was still up. I requested the CNA to assist resident to bed. The CNA responded Ok. I was not aware of any incidents that occurred during the CNA/resident interaction. On Saturday [DATE], I worked the PM shift. I was told in report that R1 had a swollen knee and it was unsure how it happened. I went and observed resident first, I noted swelling to bruising to the L (Left) knee. I asked resident what happened, and resident reported, I hit my knee on the ground. I also asked if the EZ stand was used and resident responded, No. Resident received prn pain medication per her request. Resident remained in her bed throughout the shift. On Sunday, Resident continued to stay in bed throughout the shift. Resident continued to request prn medication which were administered. I applied iced and observed her knee. Resident continued to have bruising and swelling. LPN-F's statement dated [DATE] documents, I, LPN-F got report Monday morning from (RN-G). It was reported that she was called to [R1's] room early in the morning on Saturday morning because resident was complaining of knee pain. After assessment was completed she notified [Telehealth] and received orders for ice packs and voltaren gel for her left knee. It was discussed the CNA had pivot transferred her and not used the EZ stand. It was noted that the resident had left knee pain, swelling, hematoma was getting ice pack q (every) shift and the ordered (sic) ended 7:59 this morning. At approximately 7:30am writer went to administer medications. Resident was not opening her mouth enough to administer medications she had pursed lip breathing and had bluish lips, O2 (Oxygen) was checked and at 76%, 2 L (Liters) of O2 was administered and rechecked in 30 mins (minutes) she was at 88%, rechecked 30 min later and she had dropped to 82%, O2 increased to 3L. Hospice notified spoke with triage nurse [Name]. Writer reported O2 was not maintaining and bumped it up to 3L, discussed the knee pain, swelling, and warmth. Writer reported, I was unaware of how the injury happened but management was aware and investigating. Informed that on call nurse would call back and be out for visit. [Responsible Party] was notified during in person visit between 8:00am and 9:00am. Writer asked if family was aware of bruising and swelling to left knee. [Responsible Party's Family] stated he was unaware of any changes. Updated on complaint of knee pain over the weekend and change of condition. [Responsible Party] came approx. 9:30am, I reported that I had spoke with hospice and updated on condition, he (responsible party) reported that she had swelling and bruising to her head. The [Responsible Party] and I went to room, writer assessed and did not note any swelling, bumps or abrasions to head I asked resident, when the incident happened over the weekend, did you hit your head at all. She responded, no, I was dropped. [Responsible Party] had made statements about resident getting transferred to the hospital. Nurse encouraged [Responsible Party] to reach out to hospice number. PRN medications were offered around lunch time and resident indicated she was not in any pain. [Responsible Party] was in and out throughout shift, hospice nurse on call come at approximately 2:30pm. On ,d+[DATE], during shift to shift report, I was updated that resident ate a couple of bites for dinner, was unable to drink out of straw, was minimally responsive. Resident was noted to not be taking medications well, gurgling noted. Hospice updated, orders to hold all non-comfort medications and new order for hyoscyamine. Resident was comfortable, hospice nurse [Name] was in for a visit. Approximately 2pm hospice CNA was assisting with cares and notified nurse that resident was no longer breathing. Charge Nurse notified and assessed, Hospice Nurse updated. CNA-P's statement, not dated, documents, I, [CNA-P] Sat morning noticed [R1] [room] was restless in her bed, when normally she sleeps most all nights. I went to her and asked if she was all right, I said your (sic) not sleeping yet is everything okay, this was around 1:00 AM. She told me her knee was hurting her. I looked at it n (sic) it was all swollen. I ask [R1] what happened, [R1] said she dropped me, I asked [R1] now, did she use the easy (sic) stand, R1 said No! She picked me up! I asked her if she needs an ice pack, and then she said n (sic) a pain pill. She is very soft spoken and she clearly asked for a pain pill, she never asks for a pain pill. I called the nurse and told her R1 said she dropped me and would like a pain pill. [RN-G] came and assed (sic) her knee and called another nurse and gave her pain pill and ice pack. Sunday morning [R1] said she didn't want [TRUNCATED]

Based on interview and record review, the Facility did not ensure 1 (R1) of 3 resident reviewed for accidents had adequate supervision, and associative devices to prevent accidents. Certified Nursing Assistance (CNA)-W transferred R 1 with assist of 1 and a pivot transfer. R1's care plan documents R1 is assessed to require assist of 1 and an EZ stand for transfers. R1 complained of pain at a level of 10/10 with swelling and bruising noted following the transfer. R1 experienced a change of condition following the transfer and passed away four days after the transfer. An autopsy was conducted and it was determined R1 suffered a fracture of the left distal femur related to the transfer. The Medical Examiner determined the femur fracture was the cause of R1's death. Findings include: The Facility policy titled, Fall Management Program, dated 8/20, documents, .Policy: The facility is committed to minimizing resident falls and/or injury so as to maximize each resident's physical, mental and psychosocial wellbeing. While preventing all resident falls is not possible, it is the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies and facilitate a safe environment. Procedure: . 4. Plan of care reviewed and updated at time of occurrence, quarterly and as needed in order to minimize risk for fall incidents. 5. Use standard fall/safety precautions for all residents: a. All staff will be trained on the Fall Management Program.d. The bed will be maintained in a position appropriate for resident transfers. e. The bed will be checked to assure they are in locked position at all times. The Facility policy titled, Management of Falls, dated 8/20, documents, .Policy: The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care in order to minimize the risks for fall incidents and/or injuries to the resident. Procedure: Complete a Fall Risk Assessment upon admission, re-admission, with significant change, post-fall, quarterly, and annually. Orient resident to room, call light, unit and location of the nurse's station upon admission to the facility. Develop a plan of care to include goals and interventions which address resident's risk factors. Risk factors may include but are not limited to the following: Contributing diagnoses/disorders/disease processes/active infections/other comorbidities, history of fall incidents, Incontinence, Medications (Narcotics, Antihypertensives, etc.), assistance required with ADL's (Assistance with Daily Living), gait/transfers/balance issues, Behaviors, and/or cognitive status. Monitor for changes in medical condition and notify physician as necessary to manage changes in status of the resident. Conduct Care Plan Meetings with the Resident, Responsible Party, and Facility Interdisciplinary Team quarterly and as needed. Review and/or modify the resident's plan of care at least quarterly and as needed in order to minimize risk for fall incidents and/or injury. The Facility policy titled, Change in Condition (Resident), dated 9/20, documents, Purpose: To ensure that the resident's physician/physician on call/NP (Nurse Practitioner) and responsible party is kept informed regarding the residents change in condition. Policy: The attending physician/physician on call/NP and responsible party will be notified with changes in the resident's condition. Procedure: Attending physicians or physicians on call/NP and responsible party will be notified of all changes in condition. Follow framework for reporting changes in vital signs or laboratory values based on AMDA (American Medical Directors Association) Guidelines. Follow suggested guidelines for reporting clinical problems based on AMDA guidelines. Document time of call, physician or nurse practitioner or other person spoken to; reason for call and result or orders received. Place call to responsible party to notify them of the resident's change in condition. R1 was admitted to the facility on [DATE], with diagnoses that include, Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors.), and Old Myocardial Infarction (heart attack). R1 was admitted to Hospice Care on 6/15/23 with a primary diagnosis of atherosclerotic heart disease and other co-morbidities. R1 has a Health Care Power of Attorney and it was not activated. R1's Minimum Data Set (MDS) quarterly assessment, dated 2/4/25, documents R1 has a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition, a Patient Health Questionnaire (PHQ-9) score of 0, indicating no depressive symptoms, and no indicators of psychosis including no hallucinations or delusions. Sit to stand, chair/bed to chair transfer, sit to lying, lying to sitting and toilet transfer are with substantial/maximum assist. R1's MDS annual assessment, dated 5/9/24, R1 was assessed to require the same level of assistance as the 2/4/25 Quarterly MDS, substantial/maximum assistance sit to stand, chair/bed to chair transfer, sit to lying, lying to sitting and toilet transfer. R1's Care Area Assessment (CAA), dated 5/9/24, documents, triggered for self-care mobility, psychotropic drug use, urinary incontinence, falls, nutritional status, and pressure ulcer/injury. Resident is 1 assist with assistance with daily living (ADL's) and transfers with EZ stand. R1's Care Plan, dated 6/13/23, documents, Focus: R1 has an ADL Self Care Performance Deficit r/t (related to) Parkinson's, weakness and the need for staff to assist with ADL's. Is currently enrolled in [Name] Hospice for end-of-life comfort care related to ASHD (Atherosclerotic Heart Disease) Date initiated: 6/13/23. Interventions/Tasks: Allow enough time for completion of ADL tasks. Transfers: EZ stand, 1 assist, all with date initiated of 6/12/23. Focus: R1 is at risk for falls r/t (related to) Parkinson dx (diagnosis), weakness and limited mobility. Res (Resident) is dependent on staff for transfers and mobility needs. R1's Facility Incident Report dated 2/8/25, at 3:40 AM documents: Bruise: Resident: R1, Incident Location: Resident's room, Person Preparing Report: Registered Nurse (RN)-G. Incident Description: Nursing Description: Certified Nursing Assistant (CNA) called nurse into room d/t (due to) resident complaining of left knee pain. R1 was laying (sic) in bed with a pillow under her knees. Resident Description: Resident stated that the CNA on PMs (evening shift) did not use the EZ stand (sit to stand) to transfer her to bed and that her left knee is now hurting. When asked if she fell stated she had not and when asked if she had hit her knee on anything she again stated she had not. Was the incident witnessed: No. Immediate Action Taken: Description: Focused assessment findings: swelling to left knee and hematoma to lateral aspect of left knee. Localized pain of 10/10 reported and resident was given PRN (as needed) tramadol at 3:48 AM. After speaking with the on-call provider and ice pack was applied to her left knee for 20 minutes. Injuries Observed at Time of Incident: Injury Type: No Injuries observed at time of incident Injury location: No documentation Level of Pain: Level of Consciousness: No documentation Mobility: No documentation Mental Status: (Check Box) Oriented to Person: unchecked Oriented to Time: unchecked Oriented to Place: unchecked Injuries Report Post Incident: Injury Type: No injuries Observed Post Incident Injury Location: No documentation Level of Pain: No documentation R1's [Telehealth Health] Physical Exam dated 2/8/25, at 4:17 AM, Advanced Practice Nurse (APN)-H documents, (service start time 3:58 AM) Exam findings per nurse and video observation Physical Exam- Notes: GEN (General): alert, NAD (nothing abnormal detected), R1 is alert, flat affect, simple responses. Left knee effusion, no erythema or warmth. Left knee effusion, no erythema or warmth, left knee pain and effusion noted, swelling left (greater than) right, pain with flexion and mobility, left lateral knee with ecchymosis no noted fall, Tramadol available PRN, Morphine PRN available, Tylenol scheduled. Will add voltaren 1% topical gel TID (three times per day), ice TID, no imaging at this time as comfort focused measures. This is an acute new problem. Condition is stable. Orders: Voltaren 1% topical gel TID PRN, Ice to left knee TID 20 minutes x (for) 48 hours. Notify a clinician of any change in condition. Disposition: Stay at Facility. Technology used: Audio and video with patient and nurse present. R1's Facility Nurses Note dated 2/8/25, at 4:19 AM, Registered Nurse (RN)-G documents, TEH (Telehealth) consulted for evaluation of pain to left knee and swelling-new onset, pain rated 10/10. Patient is on Hospice, she is on tramadol 50 mg (milligrams) po (per oral) q (every) 6 hours PRN, she has tylenol scheduled. R1 uses easy stand, noted to be x 1 (assist 1) transfer last evening. No falls or injury known, but she does have left lateral knee ecchymosis blue-ish discoloration. R1 has restriction in her mobility and flexion in her left knee. R1 states pain started post transfer last night. Review of Systems: ROS (Review of Systems) as per HPI (History of Present Illness), all other systems reviewed and are negative PMH (Past Medical History) and SH (Social History). Reviewed PMH and SH and Medications Source. Vital Signs: T (Temperature): 98.4 F (degree Fahrenheit), HR (Heart Rate): 68 BP Sys (Blood Pressure Systolic): 167 mm/Hg (millimeters of mercury)/ bmp (beats per minute), / (over) D (Diastolic): 85 mm/Hg, RR (Rate Respirations): 20 rpm (rate per minute), O2 (Oxygen): 94%. R1's Facility Nurses Note dated 2/8/25, at 4:30 AM, RN-G documents, R1 is complaining of new onset of left knee pain 10/10, swelling and hematoma to lateral aspect of left knee. Contacted on call APN (APN-H), who saw R1 and gave new orders for ice pack to left knee 20 minutes TID for 2 days and voltaren gel TID PRN. Called Hospice and left a detailed message for her case manager. R1's Hospice Progress Note, dated 2/8/25 at 4:27 AM, documents, TC (Telephone Call) from facility staff, [RN-G] wanting to report an update on patient. Patient having more pain to left knee. [RN-G] got new orders from [APN-H] for Voltan (sic) TID and ice for 20 minutes BID (two times a day). [RN-G] reported that patient has dx (diagnosis) of arthritis and that when staff assisted her to bed they did a pivot transferred instead of a mechanical lift. R1's Hospice Progress Note, dated 2/8/25, at 2:04 PM, documents, Check in call to facility to assess patients knee pain after injury. Spoke with charge nurse [Hospice staff] patient was having pain and received Tramadol and staff is obtaining Volteren (sic) gel to apply as well. Surveyor notes, there are no nursing notes documentation on 2/9/25. R1's Facility Nurses Note, dated 2/10/25, at 8:16 AM, Licensed Practical Nurse (LPN)-F documents, R1 had swelling of the outer aspect of her left knee over weekend. Staff got order for Voteran (sic) Gel to knee prn and ice pack to knee every shift for 3 days. Knee remains swollen and warm to touch, R1 declined ice pack or pain medication at this time, R1 is also less cognitive today than last week. R1's Facility Nurses Note, dated 2/10/25, at 11:20 AM, LPN-F documents, R1 has been doing some pursed lip breathing, O2 (Oxygen) at 76%, R1 was started on Oxygen at 2L (Liters), recheck 1/2 hour later O2 at 91%. Hospice was notified of this change. R1's Hospice Progress Note, dated 2/10/25, at 12:00 PM, documents, Call received from [LPN-F] at [Facility] reporting, I found out this morning that over the weekend, staff attempted to transfer patient without a lift and dropped her on the floor. She has significant swelling to her L (left) outer knee and is complaining of pain. Looks like the nurse over the weekend got an order for voltaren gel, but nothing was mentioned regarding the fall. My management will investigate we are counting it as a fall. They also got an order for an ice pack to use every shift for the next 3 days. When I gave her scheduled Tylenol this morning, she did say her pain level was fine. I think someone should look at it as it is quite swollen, and I think it's more than arthritis. Call log reviewed and no mention of a fall but did report increase pain with new orders. MAR (Medication Administrative Record) reviewed, and no tramadol order is listed. We do have an active order on our end. [LPN-F] aware RN will make a visit today to complete fall assessment, and writer will update MAR with tramadol order. R1's Hospice Progress Note, dated 2/10/25, at 2:13 PM, [R1's] [Responsible Party] called with concern that [R1] needs a visit today. He reports staff dropped her on her head and didn't tell anyone until my son was here today and now she is unresponsive. Writer updated [Responsible Party] that facility did notify [Name of Hospice] hospice today that a nurse is scheduled to see her. The RN (registered nurse) will call him with an update if he is no longer present at the facility. He was very upset with her condition. Visit RN [Responsible Party] updated to call him during visit if he is not present. R1's Facility Nurses Note, dated 2/10/25, at 3:47 PM, late entry, Assistant Nursing Home Administrator (ANHA)-C, documents, [Responsible Party] stated that he is convinced that someone dropped R1. He stated that Responsible Party was in on Saturday morning, and all was normal with R1. The Responsible Party then again visited on Sunday morning and stated they noticed a change in condition from the previous day. He stated he thinks she was dropped on her knee and head and has facial swelling. At the time, I was only aware that her knee was swollen. I stated that we will be doing a thorough investigation as to what happened and that we are still unclear as to what had happened. I then had the nurse LPN-F go look at her face, and LPN-F stated that her eye did not seem swollen, just droopy. R1's Hospice Collaboration Note dated 2/11/25, at 11:05 AM, documents, Writer received a call from [DON- B] following writer's message to facility that she would like to update PCP (Primary Care Physician). [PCP-I] per [name of hospice] hospice protocol following fall visits. [DON-B] called and wished to clarify with writer that the incident was currently under investigation. Writer acknowledged that the form she is currently completing is an occurrence report, and that in the report it was uncertain what happened and that staff nurse [LPN-F] had informed writer that the incident was under investigation. [DON-B] was able to inform writer that [PCP-I] was off over the weekend when the incident occurred but that she had been informed as of Monday, yesterday. Writer thanked [DON-B] for letting her know that [PCP-I] was aware. R1's Hospice RN Comprehensive Assessment Visit Nursing dated 2/11/25, at 2:21 PM, documents, R1 is in bed with eye's slightly open and unresponsive. She does not respond to touch or sounds. [LPN-F] reports that Sat (Saturday) am (morning) around 2:30 CNA (Certified Nursing Assistant) from Facility was doing pivot transfers and dropped patient. [R1] is sit to stand for transfers. Large bruise to left side of knee and knee is swollen during assessment today. Unknown if patient hit her head. No bumps or bruising to head noted at visit today. Unknown if patient had medical episode at time of fall. Patient did not go to ER (emergency room ) per [LPN-F]. She reports that HCPOA (Health Care Power of Attorney) had not been contacted by the night staff. An order was obtained to apply ice to left knee and voltaren cream to left knee. [LPN-F] reports that she found patient Monday morning and lips were blue and she was gasping for air. [LPN-F] placed R1 on oxygen at that time. Writer contacted [Responsible Party]. [Responsible Party] reports he was not contacted the morning of the fall. [Responsible Party] reports family member contacted him Sunday to come see R1, as she was minimally responsive at that time. RN had seen R1 on Monday for follow up visit d/t (due to) change in condition. [Responsible Party] was offered to have patient be seen in ER (emergency room ) if he wishes. [Responsible Party] denied the need at this time for patient to go to the ER. Writer discussed holding her other medications and putting patient on comfort medications at this time. [Responsible Party] was in agreement and writer contacted NP to get order to DC (discontinue) all meds except comfort medications. Team updated on change in condition. R1's Facility Nurses Note dated 2/11/25, at 2:42 PM, LPN-F documents, Hospice aide here for cares, during cares, R1 passed. Hospice informed and on the way. PCP-I and management aware. R1's Facility Nurses Note dated 2/11/25, at 4:42 PM, Assistant Nursing Home Administrator (ANHA)-C documents, . [Responsible Party] stated he thinks it is clear, cut and dry that R1 was dropped on her head due to someone transferring her without the EZ stand and he was not contacted for two days and now she is dead. R1's Hospice Visit Information dated 2/11/25, documents, Reportable death due to patient fall with injury: Reported a fall on 2/8/25 and head strike may have occurred. Patient did have a change in condition following the fall including increased swelling to left knee, decreased verbal communication and inability to feed self. R1's Hospice Visit Information dated 2/11/25, documents, Death Visit Note Narrative: Triage received a phone call stating patient has passed away. No response to physical stimuli. Pupils fixed and dilated. No auscultated bilateral respirations or heart tones for a complete minute. Patient pronounced at 1655 (4:55 PM). Family coping: Family coping well considering frustration with rapid decline following fall. Left leg has bruising from thigh to knee. Right leg has bruising on shin to foot. Facility's investigation staff statements: RN-G's Staff Statement dated 2/11/25, documents I was called into R1's room on Saturday 2/8/25 around 3:40 AM d/t (due to) left knee pain. After a focused assessment I noted swelling and hematoma to the lateral aspect of her left knee, which was new. R1 was clearly communicating with me and speaking in full sentences at this time-she usually doesn't say much or will respond with single words. When I asked her if she knew what happened to her knee she said the CNA on PM shift did not use the EZ stand when transferring her to bed. I asked her if she hit it on something or fell and she said that neither of those things had happened. I administered PRN Tramadol at 3:48 AM and contacted the on-call physician Advanced Practice Nurse (APN)-H immediately. She saw resident through the iPad and gave me new orders for ice pack to left knee 20 minutes TID (three times a day) x (for) 2 days as well as voltaren gel TID PRN. I then called [name of hospice] Hospice and left a detailed message with the on call nurse who said she would update her case manager. I explained that the on call provider didn't order x-rays because she believed it was tissue related and that the resident was on hospice-the on call hospice nurse agreed and said that they wouldn't be ordering an x-ray either. New orders were followed and R1 was checked on frequently over the next two nights I was here. Saturday night 2/9/25 I administered PRN Tramadol at 1:21 AM and R1 was back to her baseline of not saying much or responding with more than one word at a time. Sunday night she was sleeping whenever I was in her room to check on her and she did not wake up when I put an ice pack on her knee. There were no signs over the weekend that she was declining or would pass away within the next couple of days. LPN-Z's Staff Statement dated 2/12/25, documents On Friday, 2/7/25. I worked the pm shift. At approximately 2130 (9:30 PM), I noted that resident in [room number] was still up. I requested the CNA to assist resident to bed. The CNA responded Ok. I was not aware of any incidents that occurred during the CNA/resident interaction. On Saturday 2/8/25, I worked the PM shift. I was told in report that R1 had a swollen knee and it was unsure how it happened. I went and observed resident first, I noted swelling to bruising to the L (Left) knee. I asked resident what happened, and resident reported, I hit my knee on the ground. I also asked if the EZ stand was used and resident responded, No. Resident received prn pain medication per her request. Resident remained in her bed throughout the shift. On Sunday, Resident continued to stay in bed throughout the shift. Resident continued to request prn medication which were administered. I applied iced and observed her knee. Resident continued to have bruising and swelling. LPN-F's Staff Statement dated 2/12/25, documents I, [LPN-F] got report Monday morning from [RN-G]. It was reported that she was called to R1's room early in the morning on Saturday morning because resident was complaining of knee pain. After assessment was completed she notified Telehealth and received orders for ice packs and voltaren gel for her left knee. It was discussed the CNA had pivot transferred her and not used the EZ stand. It was noted that the resident had left knee pain, swelling, hematoma was getting ice pack q (every) shift and the ordered (sic) ended 7:59 this morning. At approximately 7:30 am writer went to administer medications. Resident was not opening her mouth enough to administer medications she had pursed lip breathing and had blueish lips, O2 (Oxygen) was checked and at 76%, 2 L (Liters) of O2 was administered and rechecked in 30 mins (minutes) she was at 88%, rechecked 30 min later and she had dropped to 82%, O2 increased to 3L. Hospice notified spoke with triage nurse, [Name]. Writer reported O2 was not maintaining and bumped it up to 3L, discussed the knee pain, swelling, and warmth. Writer reported, I was unaware of how the injury happened but management was aware and investigating. Informed that on call nurse would call back and be out for visit. [Responsible Party] was notified during in person visit between 8:00 AM and 9:00 AM. Writer asked if [Responsible Party] was aware of bruising and swelling to left knee. [Responsible Party] stated he was unaware of any changes. Updated on complaint of knee pain over the weekend and change of condition. [Responsible Party] came approx. (approximately) 9:30 AM, I reported that I had spoke with hospice and updated on condition, he reported that she had swelling and bruising to her head. The [Responsible Party] and I went to room, writer assessed and did not note any swelling, bumps or abrasions to head I asked resident, when the incident happened over the weekend, did you hit your head at all. She responded, no, I was dropped. CNA-P's Staff Statement, not dated, documents, I, [CNA-P] Sat (Saturday) morning noticed R1 [room number] was restless in her bed, when normally she sleeps most all nights. I went to her and asked if she was all right, I said your (sic) not sleeping yet is everything okay, this was around 1:00 AM. She told me her knee was hurting her. I looked at it n (sic) it was all swollen. I ask R1 what happened, R1 said she dropped me, I asked R1 now, did she use the easy stand, R1 said No! She picked me up! I asked her if she needs an ice pack, and then she said n (sic) a pain pill. She is very soft spoken and she clearly asked for a pain pill, she never asks for a pain pill. I called the nurse and told her R1 said she dropped me and would like a pain pill. [RN-G] came and assed (assessed) her knee and called another nurse and gave her pain pill and ice pack. Sunday morning R1 said she didn't want to get up n (sic) in to her chair. Same on Monday morning when I would change her. She would just say ouch softly. I reported to both am nurses and that R1 is in pain n (sic) doesn't want to get up today. On 3/31/25, at 11:01 AM, Surveyor interviewed [Responsible Party] who states, he could not visit R1 on 2/8/25 due to a snowstorm and this is the only day either himself or someone from his family has not been to the Facility to see R1 in 1 year and 7 months. On 2/9/25, when one of his family members visited R1, she could not even tell family what was wrong. Family had to try to feed her, and she could barely talk. Family member went to ask nurse what was wrong, and she just replied with, she is having a bad day. On 2/10/25, Responsible Party went to see R1 early morning. R1 could not eat, could barely talk and just making noises. He went up to a nurse and asked her what was wrong with R1 and she said she has been this way since night staff dropped her. Responsible Party spoke with Nursing Home Administrator (NHA)-A and expressed his concerns by telling her R1 was dropped, and no one has done anything about it for days and now she is comatose. NHA-A states, she did not know of any incident and would investigate it and get to him. Responsible Party states NHA-A never called him back. Responsible Party states R1's legs were all bruised and he took pictures. On 3/31/25, at 1:00 PM, Surveyor interviewed Medical Examiner (ME)-U, who states, she typically does not order autopsy's except if abuse, neglect or injury is suspected. She ordered an autopsy for R1. ME-U states she had a phone conversation with NHA-A and DON-B on 2/12/25 which revealed the following: NHA-A states R1 was transferred from chair to bed via pivoting and not EZ stand. ME-U asked NHA-A for a fall report and NHA-A states, they did not have one as CNA-W states she did not drop her, nor did R1 fall and did not have complaint of pain during transfer. ME-U asked if anyone was called and NHA-A states, Hospice was called. NHA-A states, Family was not called because R1 was her own decision maker. NHA-A states, there was a telehealth visit made around 4:00 AM in the morning on 2/8/25 because of R1's knee. Voltaren gel and ice packs was ordered. NHA-A states, R1 had a soft tissue injury and not a bone injury and no x-rays were ordered at this time. R1 was bed bound the remainder of the weekend. NHA-A states, R1 was minimally responsive on 2/10/25 and needed Oxygen. DON-B, states, she specifically looked at R1's knee and noticed bruising with nothing else noted. Prior to knee injury, R1 was baseline. R1 did not need Morphine and used Tramadol as needed. ME-U states the preliminary results of the autopsy on 2/14/25, reveal the primary reason for R1's death is fracture of the distal left femur, and the secondary reason is natural occurring diseases. ME-U asked the physician who completed the autopsy, Medical Doctor (MD)-X, if the injury was from a pivot transfer or a blunt fall injury and MD-X states, this would be consistent with a fall/drop and much less consistent with her hitting the side of the bed or something like that with transfers. On 4/1/25 at 8:39 am, Surveyor was provided a timeline of events dated 2/10/25, no author, documents, in part, .Writer contacted CNA-W regarding statement. CNA-W reported she does not work that unit often and could not remember resident. Writer attempted to explain the resident and CNA-W continued to state she could not remember. Writer asked CNA-if she knew how residents transfer. CNA-W reported that it was listed in the book and she would take report from the previous shift. CNA-W also stated that if she was un-sure she would ask the nurse. CNA-W reported she would not deviate from what was care-planned for resident. Tuesday, February 11, 2025, Writer spoke with CNA-W, . asked if she could recall any additional information. CNA-W then reported that she asked the nurse how the resident transferred and she stated 1 assist, so she transferred R1 as a 1 assist. CNA-W denied R1 falling or any known incidents during transfer. Writer requested to have aide come give demonstration of how R1 was transferred and to obtain a written statement. Writer contacted [Name] Hospice RN (Registered Nurse) [Name], Writer reported to Hospice RN [name] that facility was investigating reports of a fall and at this time facility has ruled out a fall based off statements obtained from staff. Writer reported that resident was transferred incorrectly. Writer assessed resident on 2/11/25 approximately 1 PM. Resident was unresponsive in her room, appeared comfortable, no swelling, lumps or bruising noted to her head or face. Writer assessed Left knee to have increased swelling and bruising to the lateral side of the knee. Resident did not have any indicators of pain at this time. On 4/1/25, at 9:57 AM, Surveyor interviewed Hospice RN-HH, who states, she knew R1 was transferred via a pivot transfer when she should have been a sit to stand transfer. The Facility did not tell Hospice R1 fell . If Facility would have told Hospice R1 fell , Hospice would have gone out right away for a follow up visit. Hospice RN-HH stated hospice would have approved an x-ray only if family requested and then decide if they wanted something done about the results. On 4/1/25, at 9:00 AM, Surveyor interviewed CNA-D who states, she knows how to care for the residents by reviewing their care cards located in a binder that tells them everything about the residents. CNA-D stated they would never use a different transfer method other than what is stated on the care plan or per therapy direction. On 4/1/25, at 12:08 PM, Surveyor interviewed telehealth APN-H who states, she remembers R1 to have side of the knee bruising. She was told R1 uses an EZ stand and a pivot transfer as completed. APN-H did not order an x-ray because she is just addressing the urgent needs which was pain and swelling. APN-H stated after that the primary team can change the Plan of Care or diagnose. APN-H was not aware if family was updated or what family wishes were as it was not discussed during the visit. APN-H states she is called during off hours when the primary team is unavailable. She is not there to diagnose, just to address the acute need until the primary team is back to address issues. On 4/1/25, at 1:58 PM, Surveyor interviewed, Medical Examiner (ME)-U who states, during the autopsy, Medical Doctor (MD)-X, indicates R1 did have severe cardiac disease and remote infarct (prior stroke) but no signs of an acute (new) cardiac event or stroke. On 4/1/25, at 3:37 PM, Surveyor interviews LPN-F who states, she did not work the weekend on 2/8/25 or 2/9/25 and when she came in on Monday, 2/10/25, the night shift RN provided very little information to her regarding R1's condition. She did administer medication for R1's pain due to bruising but did not know how she was bruised. A family member approached LPN-F with concerns regarding R1's condition and LPN-F informed family member it may be because of her pain from bruising. LPN-F states family member did not know she was bruised. LPN-F and family member went into R1's room and LPN-F asked R1 how she got her bruises and R1 states, she was dropped. LPN-F reported this information during morning stand up meeting to NHA-A and DON-B. LPN-F reports R1's knee was bruised, red, swollen from mid-thigh all the way down to calf. On 4/2/25 at 3:05 PM, the Survey Team, notified NHA-A, DON-B, ANHA-C, ANHA-T,Corporate Consultant (CC)-S, and Regional Director (RD)-V of the concerns R1 was transferred with assist of 1 and pivot and not with an EZ stand and assist of 1 as documented on R1's care plan. R1 complained of left knee pain at 10/10, bruising and swelling following the transfer. R1 told staff she was dropped, her knee hit the ground, and she was transferred without the EZ stand. R1 continued to physically and cognitively decline following the incorrect transfer and passed away on 4/11/25. An autopsy was performed and the preliminary cause of death was identified as a left distal femur fracture.

Based on interview and record review, the facility did not ensure 2 (R3 & R2) of 2 residents received adequate supervision and assistance devices to prevent accidents. * On 5/25/24 while the night Certified Nursing Assistant (CNA) was providing incontinent cares to R3, R3 indicated she couldn't hold onto the transfer device and rolled out of bed sustaining a laceration to the forehead and a right femur fracture. According to CNA-Q's statement she guided R3 out of bed however, when Surveyor spoke to R3, R3 informed Surveyor the CNA watched her roll out of bed. The facility did not conduct a thorough investigation, as there isn't a statement from the nurse who assessed R3 or a statement from R3, there are no details as to what the position of the bed was in relation to where R3 fell , and whether care plan interventions were in place at the time of the fall. R3's care plan does not address the air mattress on the bed. * R2 sustained multiple falls with one fall resulting in injury. A thorough investigation after every fall was not completed to determine root cause analysis. Some Interventions established were not specific to prevent further falls. Findings include: The facility's policy titled, Management of Falls and dated 8/2020 under Policy documents The facility will assess hazards and risk, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care in order to minimize the risks for fall incidents and/or injuries to the resident. Under Procedure documents .3. Develop a plan of care to include goals and interventions which address resident's risk factors. Risk factors may include but are not limited to the following: Contributing diagnoses/disorders/disease processes/active infections/other comorbidities, history of fall incidents, Incontinence, Medications (Narcotics, Antihypertensives, etc.), assistance required with ADL's (activities daily living), gait/transfer/balance issues, Behaviors, and/or cognitive status. 1.) R3 was originally admitted to the facility on [DATE]. R3's diagnoses includes multiple sclerosis, chronic inflammatory demyelinating polyneuritis (disorder that involves nerve swelling & irritation that leads to a loss of strength or sensation), contracture of muscle of right & left hand, hypertension, paraplegia, diabetes mellitus, depressive disorder, and anxiety disorder. R3 was admitted with a Stage 3 right gluteal pressure injury. Review of R3's care plans document: The [R3's first name] has an ADL (activities daily living) functional performance deficit r/t (related to) paraplegia, MS (multiple sclerosis), atrophy, contractures, impaired AROM (active range of motion) and DM2 (diabetes mellitus). Has need to assist with mobility and repositioning with use of bilateral quarter assist rails to bed initially initiated 4/18/24 & last initiated date of 10/4/24 documents the following interventions: * Enhanced Barrier Precautions will be implemented during high contact resident care activities. Initiated 4/18/24. * Assist with ADL tasks as needed. Initiated 4/18/24. * Allow enough time for completion of ADL tasks. Do not rush the resident. Initiated 4/29/24. * Ask resident if room temperature is okay. If not contact Maintenance. Initiated 4/29/24. * Assist resident with oral care daily as needed. Initiated 4/29/24. * Assist resident with set up for supplies of bathing as needed. Initiated 4/29/24. * Assist with locomotion as needed. Initiated 4/29/24. * Assist with personal hygiene as needed. Initiated 4/29/24. * Assist with toileting needs as necessary. Initiated 4/29/24. * Assist with transfers as needed. Initiated 4/29/24. * Barrier cream with incontinence care. Initiated 4/29/24. * Check skin for changes during bathing. Initiated 4/29/24. * Encourage to eat slowly. Initiated 4/29/24. * Encourage use of call light for assistance when needed. Initiated 4/29/24. * Encourage use of positioning device for bed mobility as needed. Initiated 4/29/24. * Prompt and use hand over hand assist as needed to enable increased independence with bed mobility and repositioning with aide of bilateral assist rails to bed. Use of bed ladder was not effective. Initiated 4/30/24. * Provide needed level of assistance and support to complete Activities of Daily Living. Document in POC (plan of care). Initiated 11/12/24. * Transfers: Hoyer. Initiated 4/29/24. The at risk for falls care plan initiated 4/18/24 and last revised 10/4/24 documents the following interventions: * Encourage appropriate use of wheelchair. Initiated 4/18/24. * Promote placement of call light with in reach. Initiated 4/18/24. * Encourage resident to keep room free of obstacles. Initiated 4/29/24. * Ensure adequate lighting for tasks. Initiated 4/29/24. * Fall risk assessment quarterly and as needed. Initiated 4/29/24. * Keep frequently used items within reach in room. Initiated 4/29/24. * Monitor resident for tolerance and endurance. Schedule tasks accordingly. Initiated 4/29/24. * Notify family and MD (medical doctor) of any new fall. Initiated 4/29/24. * Provide an environment clear of clutter. Initiated 4/29/24. * Apply pillow/pillows to side when doing cares to prevent rolling out of bed. Initiated 5/28/24. R3's fall risk assessment dated [DATE] has a score of 4 which indicates at risk for falls. The admission MDS (minimum data set) with an assessment reference date of 4/26/24 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R3 is assessed as not having any behavior. R3 is assessed as being dependent for chair/bed to chair transfer & toileting hygiene and substantial/maximal assistance for roll left and right. R3 is assessed as being frequently incontinent of urine and bowel. R3 is assessed as not having any falls prior to admission or since admission. R3 is 5 feet 10 inches in height & 179 pounds. The falls CAA (care area assessment) dated 5/1/24 under analysis of findings for nature of problem/condition documents Resident came to [NAME] long term transfer from nursing home in NC (North Carolina). Resident has MS, G-tube that receives fluids and meds (medication) through. Also treatment in place for PU (pressure ulcer) Stage 3 to gluteal fold right. Res (Resident) pain assessment completed. Res is noted to have c/o pain at times occasionally and is noted to be utilizing both PRN (as needed) and scheduled pain medications via G tube. Res is alert and is able to make her needs known and can alert staff about her discomfort. Res does not utilize glasses for vision and is able to see without them. Res is noted to have upper dentures. Res receives a mechanical altered diet and also tube feeding according to the amount that is eaten. Resident is incontinent of bowel and bladder. Resident requires assistance from staff for ADLs/IADLS. Under care plan considerations documents Staff will ensure room is well lit and free from clutter. Staff will follow policies and procedures for bed mobility and transferring a dependent patient utilizing equipment appropriately. The occupational therapy note for date of service of 4/29/24 and written by OTR (Occupational Therapist Registered)/DOR (Director of Rehabilitation)-O documents Physician's order received, chart reviewed, hx (history) noted, evaluation completed and POT (program of treatment) developed on this date. Due to mm (muscle) atrophy, contractures and impaired AROM (active range of motion) throughout B UE's (bilateral upper extremities), all joints, ulnar nerve symptoms B L including (bilateral left including) hyperextension of MCPs (metacarpophalangeal joint) (knuckle joint of the finger) and flexion of PIPIs (proximal interphalangeal joint) (middle joint of finger), throughout B (bilateral) hands, pt (patient) is unable to roll or reposition herself in bed when needed/desired. She is able to make weak fists B L in order to pull herself over onto her sides. Due to OA (open area) buttock pt is only up for 4 hours in her wc (wheelchair) and spends the rest of her day in bed, and must be repositioned side to side each time by staff. With assist rails pt is able to participate in mobility and reposition in bed to reach items as she chooses, which may not be anticipated prior. Diagnoses which make I (independent) use of body difficult included: paraplegia, chronic inflammatory demyelinating polyneuritis, unspecified pain and MS. Recommend B (bilateral) assist rails. Pt trialed use of wc (wheelchair) next to bed to pull over using arm rests on w/c which was difficult and additionally required mod (moderate) A (assist) to roll R (right) when supine. However wc will be plugged in at night to charge in another room. She attempted reaching to L by grabbing window sill, which was ineffective, and pulling self over with bed ladder however it didn't position high enough to reach and pull. The CNA (Certified Nursing Assistant) Kardex dated 5/25/24 under the category for bed mobility documents Bilateral assist rails to bed to enable participation in bed mobility and repositioning. Prompt and use hand over hand assist as needed to enable increased independence with bed mobility and repositioning with aide of bilateral assist rails to bed. Use of bed ladder was not effective. Under the category for safety documents Elevate the head of the bed while napping or sleeping to avoid shortness of breath while lying flat. Encourage appropriate use of wheelchair. Monitor and report signs/symptoms of abuse. The nurses note dated 5/25/24, at 0735 (7:35 a.m.), by Nursing-P includes documentation of Patient had a fall this AM (morning) witness out of bed, she had a laceration above her left eye pain rated 10/10 to her right leg. Per RN (Registered Nurse) her right knee had a deformity sent out prior to page d/t (due to) urgency. The incident report dated 5/25/24 under incident description for nursing description documents Paged on the radio for help in resident room, on arrival found resident on the floor. Under resident description documents I couldn't hold the rail anymore, I let go. Under the section immediate action taken for description documents Assessed v/s (vital signs) and skin for abrasions and lacerations. Applied pressure to laceration to the forehead. called 911. Under other info (information) documents CNA providing incontinent cares in bed. [R3's first name] was unable to continue holding onto rail and began to slide out of bed to floor. Under statements CNA-Q's statement documents @ (at) 5:00 I entered [R3's first name] room [number] to do her cares. I got all of her essentials needed to perform them as I did proceed to talk with her to let her know that I was going to start cares on her. [R3's first name] replied Ok [NAME]! I asked [R3's first name] to turn as I helped her into the position she was propped up on her left side as I cleaned her bottom, and when doing so she said was slipping out of bed, I tried to ease ger (sic) to the floor as safe as possible without her harming herself. I then proceeded to call for help. Surveyor noted CNA-Q is not listed as a current employee on the staff list provided by the facility. Under the note section dated 5/28/24 by Assistant Administrator (AA)-E documents IDC (interdisciplinary care) Team reviewed fall on 5/25/24. The goal of the facility is resident safety. The root cause was resident was holding onto side rail during cares, let go and fell . Resident was sent to hospital post fall. The interventions will be a larger bed for positioning during cares and pillow placement if necessary for positioning during cares. Staff member was also educated by DON (Director of Nursing) [Regional Nurse Consultant-C's first name]. [R3's first name] notified and in agreement. Under the note section dated 5/31/24 by RNC (Regional Nurse Consultant)-C documents [R3's name] is a 73 y/o (year old) that admitted on [DATE] for LTC (long term care) from out of state SNF (skilled nursing facility). She has the following medical conditions: chronic inflammatory demyelinating polyneuritis, paraplegia, type 2 diabetes mellitus, with polyneuropathy, multiple sclerosis, major depression, copd (chronic obstructive pulmonary disease), pressure injury stage 3, chronic pain, hypertension, anxiety disorder and achalasia. [R3's first name] is alert and oriented to person, place, time and situation and has a BIMS score of 15. She is able to assist with turning side to side with use of the bilateral transfer bed rails and 1 assist. She is non-ambulatory, and a total lift is required for transfers. On 5/25 @ approx (approximately) 0500 (5:00 a.m.) [R3's first name] was on her left side for peri-care following incontinence, was unable to hold onto transfer rail and slipped off her bed. Due to c/o (complaint of) right leg discomfort and laceration to head she was transferred to the hospital and admitted with right femur fracture. The hospital discharge summary dated 5/28/24 under chief complaint documents Fall out of bed while doing bed change at [NAME] this morning. Head injury, no LOC (loss of consciousness). Under admission information documents Patient is a [AGE] year-old female nursing home resident who is wheelchair-bound from numerous medical issues and who was being helped in bed and ruled (sic) out and fell on the floor. Patient sustained significant pain and deformity of the right leg and was brought in for evaluation. In the ER (emergency room ) patient is found to have a right hip fracture causing 8/10 pain and worse with movement. Under physical exam for Musculoskeletal documents Right leg in cast from upper thigh to toe, does not have sensation in feet at baseline, but is able to wiggle toes, and feet are equal warmth. On 12/2/24, at 9:35 a.m., Surveyor observed R3 using the electric wheelchair in the hallway. R3 asked Surveyor who Surveyor was. After Surveyor identified self, R3 informed Surveyor she would like to speak with Surveyor. During this conversation, Surveyor asked R3 if she has had any falls at the facility. R3 replied oh sure she rolled me out of bed and I broke my femur. R3 explained she told them she needed a wider bed, they did put rails on and she rolled over the rail. R3 informed Surveyor she was in a cast for 8 weeks. Surveyor asked if she had any falls after this fall. R3 replied no. R3 informed Surveyor she had to wait until her insurance to kick in to get a wider bed which was June 1st. R3 informed Surveyor she is now on hospice and has a hospice bed. R3 informed Surveyor she transfers with a hoyer lift and has never fallen out of the hoyer lift. On 12/2/24, at 11:08 a.m., Surveyor observed R3 in her electric wheelchair going down the hallway from the front entrance. On 12/2/24, at 12:09 p.m., Surveyor observed R3 sitting in her wheelchair with an over bed table across and her lunch on the over bed table. On 12/2/2, at 1:59 p.m., Surveyor observed R3 sitting in her wheelchair in her room with visitors. On 12/3/24, at 7:17 a.m., Surveyor observed R3 on her back with the head of the bed elevated sleeping in bed. There are two quarter side rails up and there is an air mattress on the bed. On 12/3/24, at 11:03 a.m., Surveyor asked DON (Director of Nursing)-B who Surveyor should speak with regarding R3's fall on 5/25/24. DON-B informed Surveyor she thinks RNC (Regional Nurse Consultant)-C was the acting DON at that time. On 12/3/24, at 11:35 a.m., Surveyor observed R3 reclined slightly back in her wheelchair in the room. Surveyor asked R3 if Surveyor could talk to her again about her fall in May when she fractured her femur. Surveyor asked R3 if she could tell Surveyor what happened again. R3 replied she rolled me off the bed. She purposely turned me. I told her I wouldn't be able to hold on. Surveyor asked if there was one or two staff in the room. R3 replied one. Surveyor asked R3 if the CNA rolled her away from her (the CNA). R3 replied yes. R3 informed Surveyor at the time of the fall she had smaller bars on her bed than she has now. R3 stated I just rolled, she didn't put the bed against the wall as I asked her. I rolled right out. Surveyor asked R3 before rolling out of the bed was she holding onto the bar. R3 replied yes. Surveyor asked R3 what did the CNA do when she started to roll off the bed. R3 replied watched me go to the floor. Surveyor asked R3 if anyone spoke to her about the fall. R3 replied there was a lot of people. Surveyor asked if she remember who spoke with her. R3 replied no was after I came back, probably not even here. On 12/3/24, at 12:14 p.m., Surveyor met with RNC-C to discuss R3's fall on 5/25/24. RNC-C informed Surveyor she thought R3's fall was on the day shift but when she spoke with the day shift CNA, the night CNA was already gone. RNC-C explained CNA-Q from nights was changing R3 & cleaning her up as R3 was incontinent and when R3 has a BM (bowel movement) it is usually large. R3 was holding on the transfer rail, just said she can't hold on and slide down. RNC-C indicated CNA-Q tried to guide her with the sheet and went to the floor. The nurse came in and assessed her. Surveyor inquired who was the nurse. RNC-C informed Surveyor it was a [name of agency] nurse. Surveyor asked RNC-C if she spoke with R3. RNC-C replied afterward, after she came back from the hospital. Surveyor asked RNC-C if she could recall what R3 said. RNC-C informed Surveyor she said she couldn't; hold on. Surveyor asked RNC-C if she knew how the bed was positioned. RNC-C informed Surveyor it wasn't super high but not down all the way, the CNA had put the bed up. RNC-C informed Surveyor R3 likes the bed closer to the wall kind of the same as now. Surveyor asked which way she fell . RNC-C informed Surveyor R3 fell to the right, before she fell she was on the right side. Surveyor asked RNC-C what investigation was done. RNC-C informed Surveyor she had the CNA in the room, had her show her what she was doing, the cares and how R3 came off the bed to the floor. Surveyor asked RNC-C if R3 was close to the edge of the bed. RNC-C replied probably with being turned, the CNA didn't indicate she was at edge of the bed. Surveyor asked RNC-C if she asked the CNA if R3 was at the edge of the bed. RNC-C replied yes and explained R3 has legs which externally rotate, her legs don't go straight from admission. Surveyor asked RNC-C what the nurse did when she came into R3's room as Surveyor did not note any statement from the nurse. RNC-C informed Surveyor went into the room, talked with R3, let the charge nurse know she had discomfort and called 911 to the hospital. RNC-C informed Surveyor R3 has a different bed now and has signed onto hospice so hospice will be getting R3 a bigger bed. Surveyor asked RNC-C if there was any education provided following R3's fall with fracture. RNC-C informed Surveyor they do education all the time and stated she didn't think specifically for this incident. Surveyor showed RNC-C documentation provided regarding R3's fall and asked if there is any additional information. RNC-C informed Surveyor she doesn't think there is anything else. Surveyor informed RNC-C there's isn't a statement from the nurse who assessed R3, what the position of the bed was in relation to where R3 fell , what R3 said had occurred, etc for a thorough investigation of the fall. Surveyor informed RNC-C R3 informed Surveyor the CNA had turned her away. RNC-C replied that doesn't make sense because she bumped her head on the night stand, that's how she got the laceration. Surveyor informed RNC-C R3 informed Surveyor she rolled out of bed and the CNA watched her roll out of the bed. Surveyor asked RNC-C if the CNA guided her to the floor how did she sustain the laceration and femur fracture. On 12/3/24, at 2:42 p.m., Surveyor asked RNC-C at the time of R3's fall did she have an air mattress on her bed. RNC-C replied I believe so at that time. Surveyor asked RNC-C if R3 was assessed as requiring substantial/maximal assistance for bed mobility and dependent for toileting hygiene how did the facility determine R3 could be provided cares with one CNA and had the strength to support her body during cares. RNC-C informed Surveyor with the transfer assist rails R3 could hold on and using a pad or sheet you could pull the person towards you. RNC-C stated she (R3) was alert, orientated, able to follow commands at that time and R3 had talked about assist rails since coming to the building as she had them at the other facility. Surveyor asked RNC-C if she had reviewed R3's ADL care plan. RNC-C informed Surveyor she has reviewed the care plan in the past. Surveyor discussed with RNC-C R3's care plan isn't patient centered as the interventions document to assist as needed which could be for most residents in the facility. Surveyor informed RNC-C the care plan doesn't address R3's air mattress, how long R3 may be able to be on her side holding onto the rail, etc. On 12/3/24, at 3:15 p.m., RNC-C informed Surveyor a moderate assist is an assist of one. R3 is alert, orientated, able to follow commands and wanted independence. R3 had the endurance, that's why it was appropriate for assist rails. On 12/3/24, at 3:33 p.m. NHA (Nursing Home Administrator)-A, DON-B, Regional Nurse Consultant-C and Assistant Administrator-D were informed of the above. Surveyor asked if there is any additional information regarding R3's fall to email to Surveyor. As of 12/5/24 at 2:31 p.m. Surveyor did not receive any additional information. 51014 2.) R2 was admitted to the facility on [DATE] with primary diagnoses of cerebral infarction due to embolism of left middle cerebral artery (stroke), aphasia, abdominal aortic aneurysm, moderate protein-calorie malnutrition, encounter for attention to gastrostomy, unsteadiness on feet, muscle weakness and age-related physical debility. R2's Admission MDS (Minimum Data Set) assessment dated [DATE], documented R2 is severely cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 0 with both short- and long-term memory problems. MDS section GG, documents R2 is dependent with oral hygiene, toileting, shower/bathing, upper/lower body dressing and putting on footwear. R2 needs substantial to maximum assistance with eating and personal hygiene. MDS section H, documents R2 is frequently incontinent of both urine and bowel. MDS, section K, documents R2 has a feeding tube and is on a mechanically soft diet requiring change in texture of food or liquids. Record review of R2's Falls Risk assessment dated [DATE] documents a score of an 8, indicating R2 is at risk for falls. The assessment documents for mobility R2 has an unsteady gait and/or use of ambulatory device. Predisposing conditions documented, include CVA, (cerebral vascular accident) and visual deficit. R2's assessed mentation documents, R2 has impaired memory. R2 has had no falls in the past 3 months. Record review of R2 care plan dated 10/19/24 documents resident is at risk for elopement related to cognitive impairment and will attempt to walk and wander on her own. A Wanderguard was implemented for safety. Interventions include determine preferred setting, consider potential variables such as boredom, thirst, hunger, need for toileting, pain, exercise, companionship, exhaustion and over stimulation. Staff is directed to redirect, calmly and positively guide back to her room, provide 1:1 interaction with encouraging, uplifting comments and attempt to address any agitation. Additionally, staff is to initiate frequent checks and supervision. Record review documents R2's falls occurred on 10/21/2024, 11/05/2024 and 11/24/2024. Review of R2's progress notes dated 10/21/2024 at 11:18 am, documents a post occurrence with a complete body check completed with no injuries. Description of occurrence was [R2] was noted on her knees in from of her closet. [R2] unable to give reason. On 10/21/2024 a Falls Investigation Report was completed which documented, under incident description, CNA (Certified Nursing Assistant) called nurse to resident's room to note resident on her knees in front of her closet. Resident unable to give description. Immediate action taken documented, resident assessed for injuries and pain, neuros completed and assisted off the floor. Resident taken to the dining room for supervision. NP (Nurse Practitioner) guardian, DON, Administrator notified. No injuries observed at time of incident and no hospitalization . Pain is documented at a score of 0. Level of consciousness documented as alert. The following was not documented, mental status, predisposing environmental factors, predisposing physiological factors, and predisposing situation factors to include no known time last seen or last time toileted. There were no staff statements documented nor was a root cause analysis completed. The Falls Risk assessment dated [DATE] following R2's first fall, documents a score of 11, indicating R2 is at risk for falls. R2's mobility includes unsteady gait and/or use of ambulatory device and decreased mobility. Predisposing conditions documented for R2 include, CVA and no visual deficit. R2's mentation assessment is documented as confused. R2 has a history of 1-2 falls in the past 3 months. Documented under medications assessed as risk factors is drugs that have a diuretic effect or increased GI (gastrointestinal) motility. Drugs that affect the thought process. Drugs that create a hypotensive effect. R2's care plan fall interventions documented the following additions post first fall on 10/21/2024: Offer resident to be in common areas while awake. Date initiated, 10/22/2024. Monitor for changes in ability to navigate the environment. Date initiated, 10/23/2024. Keep frequently used items within reach in room. Date initiated, 10/23/2024. Ensure adequate lighting for tasks. Date initiated, 10/23/2024. Encourage resident to report falls. Date initiated, 10/23/2024. Encourage resident to keep room free from obstacles. Date initiated, 10/23/2024. Encourage resident to call, don't fall. Date initiated, 10/23/2024. Encourage participation in activities to keep resident focused and on task. Date initiated, 10/23/2024. Review of R2's progress notes dated 11/05/2024 at 12:06 pm document a post occurrence with a complete body check completed with no injuries. No description of occurrence. On 11/05/2024 a Falls Investigation Report was completed which documented under incident description, Summoned to resident room to observe resident sitting by her doorway by the white trash can. Resident was fully clothed with shoes and socks on Resident unable to give description. Immediate action taken documented, neuros taken No injuries observed at time of incident and no hospitalization . Pain is documented at a score of 0. Mental status documented as orientated to person. Level of consciousness documented as lethargic (drowsy). Predisposing environmental factors documented, wheelchair. Predisposing physiological factors documented incontinent, confused, weakness, gait imbalance, impaired memory, and poor safety awareness. Predisposing situation factors documented, resident last toileted is checked but does not specify a time and resident last observed indicated, staff reports just checking on her prior to event and she was in recliner. There were no staff statements documented nor was a root cause analysis completed. Revised care plan fall interventions for R2 documented the following additions post second fall on 11/05/2024: Medication adjustment and reviews. Resident also likes to crawl/place self in doorway and repeat hi at staff. Date initiated: 11/06/2024. Aromatherapy to promote calmness and relaxation. Date initiated: 11/06/2024. On 11/05/2024 a Falls Investigation Report was completed which documented under incident description, Summoned to resident room to observe resident sitting by her doorway by the white trash can. Resident was fully clothed with shoes and socks on Resident unable to give description. Immediate action taken documented, neuros taken No injuries observed at time of incident and no hospitalization . Pain is documented at a score of 0. Mental status documented as orientated to person. Level of consciousness documented as lethargic (drowsy). Predisposing environmental factors documented, wheelchair. Predisposing physiological factors documented incontinent, confused, weakness, gait imbalance, impaired memory, and poor safety awareness. Predisposing situation factors documented, resident last toileted in a check box but does not specify a time and resident last observed indicated, staff reports just checking on her prior to event and she was in recliner. There were no staff statements documented nor was a root cause analysis completed. Surveyor noted following the 10/21/24 fall R2's care plan indicates to offer to R2 to be in a common area. There is no documentation to indicate if this was offered to R2 and R2 refused or if the care plan had not been implemented to prevent this fall. Record review of R2's Falls Risk Assessment documented on 11/5/24, following second fall, assessed R2 to have a of 10, indicating R2 is at risk for falls. Mobility documented includes unsteady gait and/or use of ambulatory device. Predisposing conditions documented, CVA with no visual deficit. R2's mentation is documented as confused. History of falls documents R2 has had 1-2 falls in the past 3 months. Medications documented includes drugs that have a diuretic effect or increased GI motility. Drugs that affect the thought process. Drugs that create a hypotensive effect. Care plan fall interventions documented the following additions post second fall on 11/05/2024: Medication adjustment and reviews. Resident also (patterns herself) likes to crawl/place self in doorway and repeat hi at staff. Date initiated: 11/06/2024. Aromatherapy to promote calmness and relaxation. Date initiated: 11/06/2024. Surveyor noted the fall risk assessment dated [DATE] references medication effects that could increase R2's risk for falls. However, it is not documented or individually assessed what specific medications R2 takes in the risk categories and how they may impact R2's falls. On 11/24/2024 at 8:43 pm, progress notes document a post occurrence with a complete body check completed with injury, bruising and hematoma over right eye. Description of occurrence was [R2] was noted on her knees in front of her closet. [R2] unable to give reason. Note text documented, CNA notified writer that resident was noted to be sitting on the floor, near the door of her room. Writer notified RN to come assess, as well as notify the charge RN. When asked what happened resident repeated, no Hello. Hello! I don't know. I don't know. Resident noted to be alert and oriented only to self. It is noted that this is her mental base line for orientation. Upon assessment it was noted that an approximately 5 x 4 cm (centimeter) hematoma was over her R (right) eye, on her forehead. No deformities noted upon head-to-toe assessment. ROM (range of motion) in BUE (bilateral upper extremities) and BLE (bilateral lower extremities) to baseline, able to bear weight. Non-slip socks noted on her feet. Neuro checks immediately initiated and noted to be baseline. Resident is PERLLA, (pupils are equal, round and reactive to light and accommodation). Resident refused to have her blood pressure taken repeatedly. Gathered vitals noted to baseline. Resident not showing any signs of SOB, (shortness of breath). Resident noted to be restless and very challenging to redirect. Writer educated resident to please remain still and remain in the same place until further assessment could be completed, however she continued to move around and even scooted across the floor and placed herself onto the edge of the bed. Staff continued to attempt to attempt to redirect without success. (Name of) , (Medical Doctor), (name of tele-medical group) contacted and provided order to send this resident to the ER (emergency room ). Writer reached out to residents Son/POA, (Power of Attorney) (name of) , conveyi [TRUNCATED]

Based on interview and record review, the facility did not ensure that staff promptly consulted with a physician when 1 of 1 resident (R414) experienced a significant change in condition. R414 had unwitnessed falls on 10/27/23 and 10/29/23. After each fall, R414 experienced a significant change in condition with signs that are consistent with a head injury. Despite these changes, the Hospice nurse assigned to R414's case declined to send R414 to the emergency room for evaluation. The facility did not consult with the Hospice provider, R414's primary physician, or the Medical Director regarding R414's continued decline. R414 subsequently passed away. The facility's failure to promptly consult with the MD regarding R414's significant change in condition and for failing to get direction from the MD as to whether the resident should be sent out for further evaluation created a finding of immediate jeopardy that began on 10/27/23. Surveyor notified the Director of Nursing (DON)-B of the Immediate Jeopardy on 3/18/24 at 10:09 am. The immediate jeopardy was removed on 3/19/24. The deficient practice continues at a scope and severity of an E (potential for harm/pattern) as the facility continues to implement their action plan. Findings include: The facility's policy titled Change in Condition (Resident) dated 9/2020 states: Purpose: to ensure that the resident's physician/physician on call/Nurse Practitioner (NP) and responsible party is kept informed regarding the resident's change in condition. Policy: The attending physician or physician on call/NP and responsible party will be notified with changes in a resident's condition. Procedure: 1. Attending physicians or physicians on call/NP and responsible party will be notified of all changes in condition. 2. Follow framework for reporting changes in vital signs or laboratory values based on AMDA Guidelines. 3. Follow suggested guidelines for reporting clinical problems based on AMDA guidelines. 4. Document time of call, physician or NP or other person spoken to; reason for call and result or orders received. 5. Place call to responsible party to notify them of the resident's change in condition. R414 was admitted to the facility on [DATE] with diagnosis of dementia, depression, panic disorder, anxiety, a-fib, obstructive uropathy, urine retention, [NAME] syndrome, and failure to thrive. R414 was his own person at the time of admission. R414's Admission Minimum Data Set (MDS) assessment completed on 8/24/23 indicates a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. R414 requires extensive assistance with one person and physical assistance with bed mobility, transferring, dressing, and toileting. R414 is not steady and is only able to stabilize himself with staff assistance while moving on and off the toilet. R414 has an indwelling urine catheter and is always continent of his bowels. R414's care plan indicates he is at high risk for falls related to limited mobility and impaired balance, dated 8/17/23. R414's Care Plan indicates R414 is at high risk for falls related to limited mobility and impaired balance dated 8/17/23. R414 was admitted to hospice due to Monoclonal Gammopathy (condition in which abnormal proteins are found in the blood.). R414's medical record indicates R414 had a prescreening for a possible discharge from hospice due to ineligibility on 10/17/23 as R414's health status was stable. On 3/18 /24 at 9:17 am, Surveyor interviewed Hospice Director of Social Work (SW)-P who indicated there was a pre-discussion of possible ineligibility for R414 due to showing improvement. The Hospice Director of Social Work-P stated a pre-discussion of hospice care takes place when recertification time is approaching. The Hospice Director of SW-P indicated once a resident is deemed ineligible for hospice, the hospice staff have 2 days to develop a plan of care for discharge. Hospice Director of SW-P indicated R414 had continued hospice care due to the change in condition after the unwitnessed falls. On 10/27/23 at 1730 (5:30 pm), the facility documentation indicates the CNA found R414 on the bathroom floor. R414 had an elevated blood pressure (BP) and was noted to have altered mentation; R414 was unable to convey where he was, day of the week, nor the month. R414's baseline orientation is fully oriented to person, place, time, and event. The facility charge nurse and Hospice were notified of the unwitnessed fall. R414 had an improvement with his vital signs and mentation after Hospice arrived at the facility at 6:45 pm. On 10/27/23 at 5:34 pm, the facility documentation indicates R414 was found lying on his back flat on the bathroom floor and R414 had hit his head. R414 had complaints of pain in his upper back between his shoulder blades, altered mentation, and high blood pressures and low pulse rates. R414 had a brown emesis while being transferred with a Hoyer lift back to his bed. Documentation states hospice was updated. Hospice instructed the facility to administer Zofran for vomiting. There is no evidence the facility and/or hospice staff identified vomiting as a sign/symptom of a head injury. The facility documentation indicates family was informed of R414 having a change in condition by the hospice staff. Facility documentation states the resident hit his head. There is no evidence this was relayed to the hospice staff or MD at the time of the change in condition and it is unclear if family was updated on R414 hitting his head along with symptoms of altered mentation. It is unclear if the power of attorney was given the option for R414 to seek evaluation for the significant change in condition that is unrelated to R414's hospice diagnosis. Surveyor reviewed the hospice visit note from the hospice RN dated 10/27/23 at 6:45 pm. Documentation indicates R414 is fully oriented with pupils being equal and reactive to light. Documentation reports R414 denies hitting his head. R414 was provided Tylenol and reports his last bowel movement being 3 days ago. Hospice changed R414's MiraLAX from every other day to every day during this visit. Documentation indicates the MD on call and POA were notified of updates however, Surveyor notes there is no documentation indicating what was discussed with the MD at the time of the update from hospice staff. Surveyor notes R414 denying hitting his head however, R414 was noted to have altered mentation at the time of his fall and was unable to recall place and time while being evaluated. There is no evidence the facility increased monitoring of R414's bowel pattern or need for assistance with toileting. Neuro check documentation dated 10/28/23 at 3:47 am indicates R414 was having rambling speech with a weak right-hand grasp. This is not R414's baseline. There is no evidence that hospice or the MD were notified or consulted with regarding this significant change in condition with R414 having weak right-hand grasps and rambling speech. Facility documentation dated 10/28/23 at 9:58 am indicates the facility nurse notified hospice with a significant change in condition. R414 was feeling off, hands were shaky, he was lethargic, and he needed assistance with eating breakfast. R414 did not previously require assistance with eating. Documentation indicates R414 indicated to the nursing staff he hit his head and acknowledged he notified hospice on 10/27/23 that he did not hit his head. This was relayed to the hospice staff by the facility staff via phone call. Surveyor notes the MD was not consulted after R414 notified staff he hit his head and his having a significant change in condition. On 10/28/23 at 10:28 am, hospice was contacted again when R414 was hunched over in his wheelchair with increased fatigue. The facility staff requested hospice evaluation. There is no evidence the facility staff or hospice staff consulted with R414's MD to discuss R414's continued decline and changes in condition after the fall. On 10/28/23 at 2:19 pm, the documentation from hospice indicates R414 was having poor coordination, increased sleep, lethargy, and Foley draining concentrated clear urine. There is no evidence the MD was notified of the significant change in condition and no evidence new interventions were placed after hospice was notified of R414 hitting his head. Surveyor reviewed the Neuro check performed on 10/28/23 at 4:00 pm which indicates R414 had a change in condition with having slurred speech. R414 has a strong right-hand grasp, and the left hand was not documented as assessed. There is no evidence facility staff consulted with the MD about the ongoing decline in R414's condition. Surveyor reviewed the post fall documentation on 10/28/23 at 8:00 pm which indicates R414 is alert with confusion and fatigue is noted. R414 can answer questions appropriately but did mumble stories about siblings that were nonsensical. Documentation reports R414 hit his head on 10/27/23 and Surveyor notes there is no evidence the MD was consulted with regarding this change in condition at the time of the post fall documentation. Documentation from 10/29/23 at 9:10 pm indicates R414 was found on the floor lying on the left side of the bed with the call light and nightstand base under him. R414 was moaning in pain with c/o (complaints of) pain in his back, left arm and left shoulder. R414 had a head injury with blood present on the floor. R414 was noted to have cognitive impairment, intermittent nonsensical verbalization, pinpoint eyes, eyes wrenching, a left forehead hematoma measuring 4 cm x 3 cm with a 2 cm laceration to the middle of the hematoma, and no urine output in the urine Foley bag. The charge nurse and hospice were notified. Hospice instructed the facility staff to not send R414 out for evaluation prior to hospice doing an evaluation. The facility nurse applied pressure to R414's head injury site and remained with R414 in the fall position until hospice arrived for evaluation. There is no evidence the MD was consulted regarding the significant change in condition. Documentation from Hospice Progress notes dated 10/29/23 at 9:34 pm indicates R414 had an unwitnessed fall and sustained a head injury. R414 denied pain but was observed to be wincing with movement. Notes indicate an as needed (PRN) pain medication was given due to R414 likely being sore and probably having a headache. R414 was observed to be alert and oriented and tolerating changing his shirt without the facility staff in R414's room. Hospice reports facility staff chose to leave R414 on the floor with a pillow under his head until hospice arrived for evaluation. R414 was assisted back to bed using a Hoyer lift. Hospice attempted to contact R414's POA who was unavailable and a message was left. The hospice nurse applied steri strips to R414's head wound and a new Foley catheter was inserted with 2400 cc of dark amber urine and large amounts of thick fibrous tan drainage was noted. There is no evidence the MD was consulted related to R414's significant change in condition with R414's fall and his retaining large amounts of urine or the discrepancies in the facility and the hospice notes and recommendations. Surveyor interviewed Licensed Practical Nurse (LPN)-S on 3/14/23 at 11:00 am. LPN-S indicated R414 was typically alert and oriented and able to make his needs known. LPN-S reported R414 was weak and requires assistance of one with ambulation, toileting, and transferring. LPN-S stated the facility staff had to frequently remind R414 to contact staff when needing to transfer as R414 frequently ambulated independently without calling for assistance. LPN-S indicated she could clearly tell R414 had a head injury on 10/29/23 at 9:10 pm after R414 had a second unwitnessed fall from his bed while reaching for the call light that was out of reach. LPN-S indicated she applied pressure to R414's head to help control bleeding and stayed with R414 for approximately 30-40 minutes in the fall position while she waited for hospice to come and evaluate R414. LPN-S stated she thought residents had the option to be sent out for evaluation with a significant change in condition even though they are receiving hospice care. LPN-S indicated R414's change in condition was not related to his hospice diagnosis but she was told by hospice to not send R414 out for evaluation. LPN-S stated she did not feel comfortable with this decision as she knew R414 clearly had a brain injury with R414's eyes being dilated and changed. LPN-S was unsure if R414's POA was contacted to discuss the significant change in condition and whether the POA was given the option to send R414 out for evaluation. LPN-S indicated she was fearful of the head and neck injury R414 sustained. LPN-S indicated she noticed no urine output in R414's urine Foley catheter bag while holding pressure on R414's head injury and notified hospice upon arrival. LPN-S indicated she does not recall if the MD was notified by the hospice nurse. Surveyor interviewed DON-B on 3/18/24 at 10:09 am. DON_B indicated facility staff are to contact hospice regarding any residents receiving hospice care and experiencing a change in condition. Surveyor reviewed with DON-B that facility staff were interviewed and reported not feeling comfortable with coordination and care being provided to R414 by hospice staff on 10/29/23 at the time of R414 having a second unwitnessed fall. DON-B indicated staff are to contact clinical leadership if they do not feel comfortable with orders given by the hospice staff. DON-B indicates she was not aware of the facility staff not feeling comfortable with orders being provided by hospice indicating R414 is to not be evaluated due to being on hospice. DON-B indicated clinical leadership should have been notified with this significant change on 10/29/23 and the facility staff not feeling comfortable with hospice recommendations to not send resident out for evaluation. Surveyor reviewed the facility fall investigation dated 10/29/23 at 9:10 pm. The investigation indicated R414 sustained a hematoma and laceration to the face along with a skin tear to the left hand. R414 is oriented to person, the facility NP was notified on 10/30/23 at 3:53 pm, and POA was notified on 10/30/23 at 3:29 pm. This is over 18 hours after the fall occurred. There is no documentation as to what information was shared with the NP and the POA. There is no evidence the MD was consulted after the fall with a significant change in condition. On 3/18/24 at 8:57 am, Surveyor spoke with Medical Director (MD)-O of the facility. Surveyor reviewed the change in condition with R414 that occurred on 10/29/23. MD-O indicated he does not recall being notified of the change in condition with R414 on 10/29/23. MD-O stated, if the facility does not agree with hospice recommendations, the facility is to reach out to the MD to discuss the change in condition with the resident. MD-O indicated the resident has the option to go to the emergency room for further evaluation while receiving hospice services. Surveyor reviewed the facility neuro check documentation on 10/30/23 at 1:00 am which indicates R414's pupils not being equal in size, with the right pupil being fixed, left pupil being sluggish, and R414 being unable to grasp hands. There is no evidence of MD consultation regarding this change in condition. Surveyor reviewed the facility neuro check documentation on 10/30/23 at 2:00 am which indicates R414 is aphasic (a person who is unable to communicate), right pupil is fixed, left pupil is sluggish, and unable to grasp hands. There is no evidence of MD consultation regarding this change in condition. Facility progress note dated 10/30/23 at 2:59 am indicates the facility placed a call to hospice with an update on R414's neuro checks and R414 being unresponsive. Hospice advised the facility to continue with keeping R414 comfortable and provided no additional interventions. There is no indication clinical leadership and the MD were notified of these changes. Facility progress note dated 10/30/23 at 3:04 am indicates the facility contacted R414's POA with an update. There is no documentation as to what was discussed with R414's POA and if options to send R414 out for evaluation were provided. There is no evidence clinical staff and the MD were updated of the significant changes in condition with R414. Surveyor reviewed facility progress note dated 10/30/23 at 3:13 am which indicated the facility contacted hospice with updates on neuro checks and R414 being non-responsive. Hospice stated if R414 had a brain bleed that there is nothing that can be done for his condition. There is no evidence MD and clinical leadership were updated at this time. Surveyor reviewed hospice progress note dated 10/30/23 at 9:15 am which indicated R414 requires meals set up, has decreased appetite, increased dysphagia, choking and coughing with thinned liquids, increased pain, total dependence with bathing, and is bedbound with assistance of a Hoyer lift after two unwitnessed falls on 10/27/23 and 10/29/23. R414 is requiring head support with a rolled towel to prevent neck pain and is unable to move his own head/neck. Urine is noted to be dark concentrated with sediment in Foley catheter tubing. Surveyor reviewed the Interdisciplinary Team (IDT) note dated 10/30/23 at 11:42 am which indicated the 10/27/23 fall for R414 was reviewed for safety and a new intervention was placed. Surveyor notes the 2nd fall from 10/29/23 was not reviewed, the MD was not consulted with regarding the significant changes in condition, and there was one change to the care plan to include medication adjustments per hospice for R414 being a high risk of falls. Surveyor also notes it is unclear if clinical leadership was present for the IDT meeting. Surveyor reviewed the Hospice Comprehensive Review Assessment note dated 10/30/23 at 11:21 pm which indicates hospice sent an email to the POA and DON-B regarding R414 having an increase in lethargy, rambling speech, reduced appetite, and trouble swallowing post falls. Facility progress note dated 10/31/23 at 12:30 am indicates the facility contacted hospice with concerns of R414 having a low-grade fever, elevated BP and R414 complaints of neck pain. Hospice instructed the facility to administer Morphine for pain and apply a cool cloth to reduce the fever. There is no indication the MD was notified of this change. Surveyor reviewed the facility progress note dated 10/31/23 at 2:05 pm which documented the POA was visiting with R414 and expressed concerns with hearing cracks in R414's neck when he moves. The facility progress note indicates Morphine was administered to R414 for neck pain and the charge nurse and hospice were contacted with an update. There is no indication the MD was consulted regarding this significant change. Hospice Progress note dated 10/31/23 at 3:30 pm indicates R414 is in pain, increased sleeping, withdrawn, minimal responsiveness, barely opening his eyes, abdominal respirations, slow capillary refill in his nail beds, pallor, crackles in his lungs (fluid building up in the lungs), skin cool to touch, skin mottled in areas (lack of blood flow to the skin), and unable to respond to tell staff how he feels. Surveyor reviewed the Hospice Progress Note dated 11/1/23 at 10:00 am which document R414 is unresponsive, having irregular heart rates, breathing through his mouth, eyelids barely opening, shallow respirations, crackles to his lungs, coughing to clear his airway, unresponsive to touch or voice however, R414 jerks and gasps when the hospice nurse swabs R414's lips. Documentation indicates the hospice nurse noted no PRN medications (Lorazepam and Morphine) given since last visit on 10/31/23 at 3:30 pm. Hospice updated the POA however, Surveyor notes documentation does not indicate what was discussed with POA. Surveyor notes the facility documentation on 11/2/23 at 2:48 am indicates R414's POA contacted the Nursing Home Administrator (NHA)-A regarding R414's current condition. The POA expressed concerns with R414 needing to eat more. NHA-A educated the POA on the risk of intake when R414 is not alert and oriented. The NHA-A suggested the POA reach out to hospice for additional support. Surveyor notes the POA is not comprehending the severity of R414's current prognosis and significant change in condition and the NHA-A advised POA to contact hospice. Hospice Progress Note dated 11/2/23 at 11:00 am notes R414 to have an elevated pulse, rapid respiratory rate (RR) of 36 (normal RR is 16), gasping for air, abdominal respirations, using accessory muscles with breathing, coughing, short of breath, and moderate discomfort with breathing. Documentation indicates hospice updated the POA and administered 1 dose of Morphine for shortness of breath. Facility progress note dated 11/2/23 at 10:50 pm states a CNA called the nurse into R414's room. R414 was pulseless and not breathing. Hospice and the facility charge nurse were notified by the facility staff. On 3/18/24, at 10:09 AM Surveyor notified Nursing Home Administrator-A and Director of Nursing-B of the above concerns. The immediate jeopardy was removed on 3/19/24 when the Facility complete the following -All Residents were reviewed for changes in condition, falls, and hospice services and the care plan were updated as indicated. -The Nurse Consultant educated the Director of Nursing when to notify the physician when a change of condition occurs with a resident, notifying the resident's representative when a change in condition occurs, proper care coordination with the hospice provider regarding when it would be appropriate to discuss a change in the treatment/care plan of the residents based on residents's needs, properly assessing the patient, including hospice patients, and when a patient should be transferred out to the hospital. - All nursing staff and clinical managers were reeducated by the Director of Nursing or designee when to notify the physician when a change of condition occurs with a resident, notifying the resident's representative when a change in condition occurs, proper care coordination with the hospice provider regarding when it would be appropriate to discuss a change in the treatment/care plan of the residents based on residents's needs, properly assessing the patient, including hospice patients, and when a patient should be transferred out to the hospital. -All professional nursing staff were competency tested by the Director of Nursing or designee on hospice coordination of care and notification requirements. -The Facility Director of Nursing, Nursing Home Administrator, Nurse Consultants and Medical Director reviewed policies and procedures on the change in condition and comprehensive care plan. -Audits for compliance related to notification to the physician and resident representative were conducted. The audits will be conducted 4 times a week for 4 weeks, 3 times a week for 4 weeks and monthly for three months. -Results of the audits will be reviewed monthly by the Facility Interdisciplinary Team and QAPI (Quality Assurance and Performance Improvement) team to determine any necessary changes. -An emergency QA (Quality Assurance) meeting was held 3/18/24 by the Nursing Home Administrator with the Interdisciplinary Team and Medical Director.

Based on interview and record review, the facility failed to ensure Hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 (R414) of 1 resident. The facility did not consistently update the physician or the power of attorney (POA) with changes in R414's condition; in failing to do so, the facility did not ensure collaboration of care between hospice, the facility, the physician, and the power of attorney. R414 had a change in condition with an unwitnessed fall on 10/27/23. R414 was noted to have hit his head, to have altered mentation, vomiting while being transferred to his bed using a Hoyer lift and fluctuating unstable blood pressure (BP) readings (BP 158/84, 80/40 and 200/94) at the time of the fall. On 10/28/23, R414 presented with further changes with confusion, rambling and slurred speech, weak hand grasp, poor coordination, being hunched over in wheelchair, lethargy, hands shaking, and needing assistance with eating. On 10/29/23, R414 sustained a second unwitnessed fall while reaching for his call light. R414 was found on the floor lying on his left side next to the bed lying over the call light and night stand base. R414 sustained a head injury, was moaning in pain, and in and out of cognition with intermittent nonsensical verbalization. R414 was left in this fall position for approximately 30-40 minutes until Hospice Registered Nurse (RN) arrived for evaluation. The facility nurse contacted hospice and was instructed not to send resident out for evaluation. The facility nurse indicated she did not agree with recommendations from hospice. The facility nurse did not contact clinical leadership with for further evaluation and to discuss discrepancies of recommendations between hospice and the facility at this time. Facility failure to coordinate care to the resident provided by the facility staff and hospice staff in collaboration with the MD and resident/family to ensure that the needs of the resident are addressed are met 24 hours per day, created a finding of immediate jeopardy that began on 10/27/23. Surveyor notified the Director of Nursing (DON)-B of the immediate jeopardy on 3/18/24 at 10:09 am. The immediate jeopardy was removed on 3/19/24. The deficient practice continues at a scope and severity of a D potential for harm/isolated as the facility continues to implement their action plan. Findings include: The Nursing Facility Services Agreement between [name of] Hospice Care and [Name of] Facility dated 7/18/2013 states: Definitions: Facility Services means those personal care and room and board services provided by facility as specified in the Plan of Care for a hospice patient including, but not limited to; 1. Contacting family/legal representative for purposes unrelated to the terminal condition; 2. Arranging for the provision of medications not related to the management of the terminal illness. Hospice Physician means a duly licensed Doctor of Medicine or osteopathy employed or contracted by hospice who, along with the hospice patient's attending physician (if any) is responsible for the palliation and management of a hospice patient's terminal illness and related conditions. Hospice Services means those services provided to a hospice patient that are reasonable and necessary for the palliation and management of such hospice patient's terminal illness and are specified in a hospice patient's plan of care. Responsibilities of Facility: Facility shall comply with hospice patient's plan of care and shall ensure hospice patients are kept comfortable, clean, well-groomed, and protected from negligent and intentional harm including, but not limited to, accident, injury, and infection. Facility's primary responsibility is to provide facility services. It is facility's responsibility to provide facility services that meet the personal care and nursing needs that would have been provided by a hospice patient's primary caregiver at home, and facility shall perform facility services at the same level of care provided to each hospice patient before hospice care was elected. Coordination of Care: Facility shall immediately inform hospice of any change in the condition of a hospice patient. This includes, without limitation, a significant change in a hospice patient's physical, mental, social, or emotional status, clinical complications that suggest a need to alter the plan of care, a need to transfer the hospice patient to another facility, or death of a hospice patient. Term and Termination: Notwithstanding the above, either party may immediately terminate this agreement if a party fails to perform its duties under this agreement and the other party determines in its full discretion that such failure threatens the health, safety, or welfare of any patient. R414 was admitted to the facility on [DATE] with diagnoses of dementia, depression, panic disorder, anxiety, a-fib, obstructive uropathy, urine retention, [NAME] syndrome, and failure to thrive. R414 is his own person. R414's Admission Minimum Data Set (MDS) assessment completed on 8/24/23 indicates a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. R414 requires extensive assistance with one-person and physical assistance with bed mobility, transferring, dressing and toileting. R414 is not steady and is only able to stabilize himself with staff assistance while moving on and off the toilet. R414 has an indwelling urine catheter and is always continent of his bowels. R414's Care Plan indicates R414 is at high risk for falls related to limited mobility and impaired balance dated 8/17/23. Surveyor reviewed R414's medical records which indicate, Hospice performed a prescreening of possible discharge from hospice due to ineligibility on 10/17/23. Hospice social work will continue to support R414 and be evaluated 1-2 times per month and on an as needed basis. On 3/18/24 at 9:17 am Surveyor interviewed Hospice Director of Social Work (SW)-P who indicated there was a pre-discussion of possible ineligibility for R414 due to showing improvement. Pre-discussion of hospice care starts to take place when recertification time is approaching. The Hospice Director of SW-P indicated once a resident is deemed in eligible for hospice, the hospice staff have 2 days to develop a plan of care for discharge. Hospice Director of SW-P indicated R414 had continued hospice care due to the change in condition. On 10/27/23 at 1730 (5:30 pm), the facility documentation indicates the CNA found R414 on the bathroom floor. R414 had an elevated BP and was noted to have altered mentation with being unable to convey where he was, day of the week nor the month. R414's baseline orientation is fully oriented to person, place, time, and event. The facility charge nurse and Rainbow Hospice were notified of the unwitnessed fall. R414 had an improvement with his vital signs and mentation after Hospice arrived at the facility at 6:45 pm. On 10/27/23 at 5:34 pm, the facility documentation indicates R414 was found lying on his back flat on the bathroom floor and R414 hit his head. R414 had complaints of pain in his upper back between his should blades, altered mentation, along with high blood pressures and low pulse rates. R414 had a brown emesis while being transferred with a Hoyer lift back to his bed. Documentation states hospice was updated however, it is unclear as to whether hospice was updated on R414 hitting his head. Hospice instructed the facility to administer Zofran for vomiting. The facility documentation indicates family was informed of R414 having a change in condition by the hospice staff. Surveyor notes the resident hit his head and it is uncertain if this was relayed to the hospice staff or MD at the time of the change in condition and it is unclear if family was updated on R414 hitting his head along with symptoms of altered mentation. It is unclear if the power of attorney (POA) was given the option for R414 to seek evaluation for the significant change in condition that is unrelated to R414's hospice diagnosis. The hospice visit note from the hospice RN dated 10/27/23 at 6:45 pm. indicates R414 is fully oriented with pupils being equal and reactive to light. Documentation reports R414 denies hitting his head. R414 was provided Tylenol and reports his last bowel movement being 3 days ago. Hospice changed R414's Miralax from every other day to every day during this visit. Documentation indicates the MD on call and POA was notified of updates however, Surveyor notes there is no documentation indicating what was discussed with the MD at the time of the update from hospice staff. Surveyor notes R414 denying hitting his head however, R414 was noted to having altered mentation at the time of his fall and was unable to recall place and time while being evaluated. Facility Neuro check documentation dated 10/28/23 at 3:47 am indicates R414 had rambling speech with a weak right-hand grasp. Surveyor notes there is no documentation indicating hospice or the MD were notified of this significant change in condition with R414 having weak right-hand grasps and rambling speech. Facility documentation dated 10/28/23 at 9:58 am indicates the facility nurse notified hospice with a significant change in condition. R414 was feeling off, hands being shaky, lethargic, and needing to be fed for breakfast. R414 did not previously require assistance with eating. Documentation indicates R414 indicated to the nursing staff he hit his head and acknowledged he notified hospice on 10/27/23 that he did not hit his head. This was relayed to the hospice staff by the facility staff at the time of phone call to hospice. Surveyor notes the MD was not notified of R414 notifying staff he hit his head and having significant change in condition. Documentation indicates a second call was placed by the facility to hospice on 10/28/23 at 10:28 am indicating R414 is hunched over in his wheelchair with increased fatigue. The facility staff requested hospice evaluation. On 10/28/23 at 2:19 pm the documentation from hospice indicates R414 having poor coordination, increased sleep, lethargy, and urine Foley draining concentrated clear urine. Surveyor notes there is no documentation that the MD was notified of the significant change in condition and no new interventions were placed after hospice was notified of R414 hitting his head. There is no collaboration between the facility, hospice, MD, and family to discuss treatment options. Surveyor reviewed the Neuro check performed on 10/28/23 at 4:00 pm which indicates R414 with a change in condition with having slurred speech. R414 has a strong right-hand grasp, and the left hand was not documented as assessed. Surveyor notes the MD was not notified of the significant change in slurred speech. Surveyor reviewed the post fall documentation on 10/28/23 at 8:00 pm which indicates R414 is alert with confusion and fatigue is noted. R414 can answer questions appropriately but did mumble stories about siblings that were nonsensical. Documentation reports R414 hit his head on 10/27/23 and surveyor notes the MD was not notified of this change in condition at the time of the post fall documentation. Documentation from 10/29/23 at 9:10 pm indicates R414 was found on the floor lying on his left side of the bed with the call light and nightstand base under him. R414 was moaning in pain with c/o pain in his back, left arm and left shoulder. R414 had a head injury with blood present on the floor. R414 was noted to have cognitive impairment, intermittent nonsensical verbalization, pinpoint eyes, eyes wrenching, a left forehead hematoma measuring 4 cm x 3 cm with a 2 cm laceration to the middle of the hematoma, and no urine output in the urine Foley bag. The charge nurse and hospice were notified. Hospice instructed the facility staff to not send out R414 for evaluation prior to hospice doing an evaluation. The facility nurse applied pressure to R414's head injury site and remained with R414 in the fall position until hospice arrived for evaluation. Documentation from Hospice Progress notes dated 10/29/23 at 9:34 pm indicates R414 had an unwitnessed fall and sustained a head injury. R414 denied pain but was observed to be wincing with movement. Documentation from Hospice indicates as needed (PRN) pain medication was given due to R414 likely being sore and probably having a headache. R414 was observed to be alert and oriented and tolerating changing his shirt without the facility staff in R414's room. Hospice reports facility staff chose to leave R414 on the floor with a pillow under his head until hospice arrived for evaluation. R414 was assisted back to bed using a Hoyer lift. Hospice attempted to contact R414's POA who was unavailable. Hospice left a message. The hospice nurse applied steri strips to R414's head wound and a new Foley catheter was inserted with 2400 cc of dark amber urine and large amounts of thick fibrous tan drainage was noted. Surveyor notes there is no documentation of collaboration of care between the facility, hospice, the MD or the POA to discuss treatment options for R414's significant change in condition with R414's fall and retaining large amounts of urine nor discussing the option of evaluation after this significant change. Surveyor interviewed Licensed Practical Nurse (LPN)-S on 3/14/23 at 11:00 am. LPN-S indicated R414 is typically alert and oriented and able to make his needs known. LPN-S reported R414 being weak and requires assistance of one with ambulation, toileting and transferring. LPN-S stated the facility staff had to frequently remind R414 to contact staff when needing to transfer as R414 frequently ambulated independently without calling for assistance. LPN-S indicated she could clearly tell R414 had a head injury on 10/29/23 at 9:10 pm after R414 had a second unwitnessed fall from his bed while reaching for the call light that was out of reach. LPN-S applied pressure to R414's head to help control bleeding and stayed with R414 for approximately 30-40 minutes in the fall position while she waited for hospice to come and evaluate R414. LPN-S described herself as being old school and thought residents had the option to be sent out for evaluation with a significant change in condition even though they are receiving hospice care. LPN-S indicated R414 wasn't dying from his hospice diagnosis and was told not to send out R414 for evaluation by hospice. LPN-S stated she did not feel comfortable with this decision as she knew R414 clearly had a brain injury with R414's eyes being dilated and changed. LPN-S was unsure if R414's POA was contacted to discuss the significant change in condition and whether the POA was given the option to send R414 out for evaluation. LPN-S indicated she was fearful of the head and neck injury R414 sustained. LPN-S indicated she noticed no urine output in R414's urine Foley catheter bag while holding pressure on R414's head injury and notified hospice upon arrival. LPN-S indicated she does not recall if the MD was notified by the hospice nurse. Surveyor interviewed DON-B on 3/18/24 at 10:09 am who indicates facility staff are to contact hospice with any residents having a change in condition. Surveyor reviewed with DON-B that facility staff were interviewed and reported not feeling comfortable with coordination and care being provided to R414 by hospice staff on 10/29/23 at the time of R414 having a second unwitnessed fall. DON-B indicated staff are to contact clinical leadership if they do not feel comfortable with orders given by the hospice staff. DON-B indicates she was not aware of the facility staff not feeling comfortable with orders being provided by hospice indicating R414 is to not be evaluated due to being on hospice. DON-B indicated clinical leadership should have been notified with this significant change on 10/29/23 and the facility staff not feeling comfortable with hospice recommendations to not send resident out for evaluation. Surveyor reviewed the facility fall investigation dated 10/29/23 at 9:10 pm indicating R414 sustained a hematoma and laceration to the face along with a skin tear to the left hand. R414 is oriented to person, the facility NP (Nurse Practitioner) was notified on 10/30/23 at 3:53 pm, and POA was notified on 10/30/23 at 3:29 pm. Surveyor notes the MD was not notified of the significant change in condition. Surveyor also notes the facility NP and POA were notified the following day approximately 18+ hours after the significant change in condition. Surveyor notes documentation does not state was what discussed with the facility NP and POA at that time of phone call and if it the option for R414 to seek further evaluation was discussed. There is no collaboration of care between the facility, hospice, the MD or the POA. On 3/18/24 at 8:57 am, Surveyor spoke with Medical Director (MD)-O of the facility. Surveyor reviewed the change in condition with R414 that occurred on 10/29/23. MD-O indicated he does not recall being notified of the change in condition with R414 on 10/29/23. MD-O stated, if the facility does not agree with hospice recommendations, the facility is to reach out to the MD to discuss the change in condition with the resident. MD-O indicated the resident has the option to go to the emergency room for further evaluation while receiving hospice services. Surveyor notes, facility documentation does not reflect the change in condition with R414 being discussed with MD-O. Surveyor reviewed the facility neuro check documentation on 10/30/23 at 1:00 am indicating R414's pupils not being equal in size, with the right pupil being fixed, left pupil being sluggish, and R414 being unable to grasp hands. Surveyor reviewed the facility neuro check documentation on 10/30/23 at 2:00 am indicating R414's is aphasic (a person who is unable to communicate), right pupil is fixed, left pupil is sluggish, and unable to grasp hands. Facility progress note dated 10/30/23 at 2:59 am was reviewed by the surveyor and notes the facility placed a call to hospice with an update on R414's neuro checks and R414 being unresponsive. Hospice advised the facility to continue with keeping R414 comfortable and provided no additional interventions. Surveyor notes clinical leadership and the MD were not notified of these changes. There was no collaboration of care between the facility, hospice, the MD, and the POA. Facility progress note dated 10/30/23 at 3:04 am indicates the facility contacted R414's POA with an update. Surveyor notes the facility did not document what was discussed with R414's POA and if options to send out R414 for evaluation was provided. Surveyor also notes clinical staff and MD were not updated of the significant changes in condition with R414. Surveyor reviewed facility progress note dated 10/30/23 at 3:13 am indicating the facility contacted hospice with updates on neuro checks and R414 being non-responsive. Hospice stated if R414 had a brain bleed that there is nothing that can be done for his condition. Surveyor notes MD and clinical leadership were not updated at this time. Surveyor reviewed hospice progress note dated 10/30/23 at 9:15 am indicating R414 requires meals set up, decreased appetite, increased dysphagia, choking and coughing with thinned liquids, increased pain, total dependence with bathing, and is bedbound with assistance of a Hoyer lift after two unwitnessed falls on 10/27/23 and 10/29/23. R414 is requiring head support with a rolled towel to prevent neck pain and is unable to move his own head/neck. Urine is noted to be dark concentrated with sediment in Foley catheter tubing. Surveyor reviewed the Interdisciplinary Team (IDT) note dated 10/30/23 at 11:42 am indicating the 10/27/23 fall for R414 was reviewed for safety and a new intervention was placed. Surveyor notes the 2nd fall from 10/29/23 was not reviewed, the MD was not notified of the significant changes in condition, and there was one change to the care plan to include medication adjustments per hospice for R414 being a high risk of falls. Surveyor also notes it is unclear if clinical leadership is present for the IDT meeting. Surveyor reviewed the Hospice Comprehensive Review Assessment note dated 10/30/23 at 11:21 pm indicating hospice sent an email to the POA and DON-B with R414 having an increase in lethargy, rambling speech, reduced appetite, and trouble swallowing post falls. Facility progress note dated 10/31/23 at 12:30 am indicates the facility contacted hospice with concerns of R414 having a low-grade fever, elevated BP and R414 complaining of neck pain. Hospice instructed the facility to administer Morphine for pain and apply a cool cloth to reduce the fever. Surveyor notes the MD was not notified of this change. Surveyor reviewed the facility progress note dated 10/31/23 at 2:05 pm indicating the POA was visiting with R414 and expressed concerns with hearing cracks in R414's neck when he moves. The facility progress note indicates Morphine was administered to R414 for neck pain and notified the charge nurse and hospice with an update. Surveyor notes the MD was not notified of this significant change. Hospice Progress note dated 10/31/23 at 3:30 pm indicates R414 is in pain, increased sleeping, withdrawn, minimal responsiveness, barely opening his eyes, abdominal respirations, slow capillary refill in his nail beds, pallor, crackles in his lungs (fluid building up in the lungs), skin cool to touch, skin mottled in areas (lack of blood flow to the skin), and unable to respond to tell staff how he feels. Hospice Progress Note dated 11/1/23 at 10:00 am indicates R414 is unresponsive, having irregular heart rates, breathing through his mouth, eyelids barely opening, shallow respirations, crackles to his lungs, coughing to clear his airway, unresponsive to touch or voice however, R414 jerks and gasps when the hospice nurse swabs R414's lips. Documentation indicates the hospice nurse noted no PRN medications (Lorazepam and Morphine) given since last visit on 10/31/23 at 3:30 pm. Hospice updated the POA however, Surveyor notes documentation does not indicate what was discussed with POA. Surveyor notes the facility documentation on 11/2/23 at 2:48 am indicates R414's POA contacted the Nursing Home Administrator (NHA)-A regarding R414's current condition. The POA expressed concerns with R414 needing to eat more. NHA-A educated the POA on the risk of intake when R414 is not alert and oriented. The NHA-A suggested the POA reach out to hospice for additional support. Surveyor notes the POA is not comprehending the severity of R414's current prognosis and significant change in condition and the NHA-A advised POA to contact hospice. Hospice Progress Note dated 11/2/23 at 11:00 am notes R414 is having an elevated pulse, rapid respiratory rate (RR) of 36 (normal RR is 16), gasping for air, abdominal respirations, using accessory muscles with breathing, coughing, short of breath, and moderate discomfort with breathing. Documentation indicates hospice updated the POA and administered 1 dose of Morphine for shortness of breath. The facility progress note dated 11/2/23 at 10:50 pm indicates the CNA called the nurse into R414's room. R414 was pulseless and not breathing. Hospice and the facility charge nurse were notified by the facility staff. Surveyor interviewed RN-U with Hospice on 3/14/24 at 11:42 am. RN-U indicated if a resident has a significant change in condition the MD is notified by hospice staff. RN-U indicated the whole care team including hospice and the facility MD are notified with any significant change in condition. RN-U reported the family and/or POA are contacted to discuss possible hospital evaluations and options for care after a significant change in condition. RN-U stated hospice can have portable x-rays performed in the facility for residents with suspected changes in conditions related to a fall. RN-U indicated these options such as portable x-rays and emergency room (ER) evaluation are to be discussed with the MD with any significant changes in condition. Surveyor notes portable x-rays and ER evaluation were not documented that they were discussed with R414 or his POA after the changes in conditions related to his head and neck injuries. Surveyor interviewed Hospice DON-Q on 3/14/24 at 1:21 pm who indicated hospice documentation did not reflect that hospice was aware of R414 hitting his head on 10/27/23. Hospice DON-Q indicated hospice will talk with the family and the POA to give options to seek treatment with any significant changes in condition. Hospice DON-Q reported it is a collaborative effort with the facility and hospice staff to discuss changes in condition and treatment options. Hospice DON-Q indicated hospice documentation does not state R414 was offered to be evaluated in the ER. Hospice DON-Q indicated the facility and hospice are to discuss all options with R414 and the POA after the significant change occurred on 10/27/23. Hospice DON-Q reports there is no documentation from hospice indicating further treatment was discussed with R414 or R414's POA on 10/27/23 through 11/2/23. On 3/18/24, at 10:09 AM, Surveyor notified Nursing Home Administrator-A and Director of Nursing-B of concerns with the following: ~ Assessments between the facility and hospice being contradictory. ~ Interview with facility staff not being comfortable with recommendations provided by hospice staff. ~ The lack of education for facility staff on how to move forward if facility staff are not in agreement with resident care. ~ The failure of coordination of care between hospice and the facility. The facility documented the assessments with the significant change in condition with R414 and R414 continued to decline. ~ The failure of the facility designating a member of the interdisciplinary team who is responsible for collaborating with hospice representatives and coordinating facility staff in the significant change in condition for R414. ~ MD not being updated with R414's significant changes in condition on 10/28/23, 10/29/23, 10/30/23, 10/31/23, and 11/1/23 for possible alterations in treatment. ~ Interview with MD-O indicated he was unaware of the change in conditions occurring with R414. DON-B notified MD-O would have discussed the options for further evaluation should he have been updated. MD-O indicated the facility is to contact him should there be a conflict between hospice and facility recommendations. ~ Facility staff did not contact clinical leadership on 10/29/23 when not agreeing and feeling uncomfortable with recommendations from hospice for R414 to not receive further evaluation after significant changes. The facility's failure to establish a communication process to ensure that the needs of R414 are addressed/met, designate a member of the facility's interdisciplinary team who is responsible for working with hospice to coordinate care for R414, and ensure a plan of care to attain and maintain R414's highest practicable well-being delayed medical intervention for R414 and increased a reasonable likelihood for serious harm, thus creating a finding of Immediate Jeopardy. The Immediate Jeopardy was removed on 3/19/24 when the Facility completed the following: -All residents receiving hospice care were reviewed for changes in condition, falls and hospice service and care plans were updated as indicated. -All nursing staff and clinical managers were educated by the Director of Nursing or designee to notify the physician when a change of condition occurs with a resident. -All nursing staff and clinical managers were educated by the Director of Nursing or designee on proper collaboration with the hospice provider. This education included when it would be appropriate to discuss a change in the treatment/care plan of the residents based on the resident's needs. -All nursing staff and clinical managers were educated by the Director of Nursing or designee on hospice collaboration and the need to ensure resident choice is honored while providing the care and treatment to their highest practicable level of care. -A meeting with the hospice company in question was held. All other hospice companies were contacted to improve collaboration and responsibilities of both the facility and the hospice company. -The Nursing Home Administrator, Director of Nursing, Nurse Consultant, and Medical Director reviewed policies and procedures as it related to the hospice service. -The DON or designee is responsible for coordinating services between the hospice provider and the facility. -A review for compliance using a Quality Assurance audit tool was completed and will be conducted 4 times a week for 4 weeks, and monthly for three months. -The results of the audits will be reviewed by the Facility QAPI team including the Medical Director to determine and necessary changes. -An emergency QA meeting was held on 3/18/24 by the Nursing Home Administrator with the Interdisciplinary Team and Medical Director. In the meeting the team discussed collaboration between the Facility and the hospice agency.

Based on interview and record review the facility failed to identify and eliminate all known and foreseeable accident hazards in 1 (R414) of 1 resident reviewed with a significant change in condition. The facility had assessed R414 as being at high risk for falls. On [DATE], R414 had an unwitnessed fall. Facility charting on [DATE] at 5:30 pm indicates the CNA found R414 on the bathroom floor. R414 was noted to have hit his head and was experiencing altered mentation with being only oriented to self. R414's baseline orientation is to person, place, time, and event. The facility did not do a post-fall investigation on this date to determine the circumstances surrounding the fall to analyze what occurred and what could be done to prevent further falls. On [DATE], R414 sustained a second unwitnessed fall while reaching for his call light that was not within reach (contrary to the care plan, which directed staff to keep the call light within reach). R414 was found on the floor lying on his left side next to the bed lying over the call light and nightstand base. R414 sustained a head injury, was moaning in pain, and in and out of cognition with intermittent nonsensical verbalization. The facility did not do a post-fall investigation to analyze what occurred and what could be done to prevent further falls. R414 died on [DATE]. The facility's failure to prevent accidents to the extent possible created a finding of immediate jeopardy that began on [DATE]. Surveyor notified the Director of Nursing (DON)-B of the Immediate Jeopardy on [DATE] at 10:09 am. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope and severity of an E as the facility continues to implement their action plan. Findings include: The facility policy titled Management of Falls dated ,d+[DATE] states: Policy: The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care in order to minimize the risks for fall incidents and/or injuries to the resident. Procedure: 1. Complete a Fall Risk Assessment upon admission, re-admission, with significant change, post fall, quarterly, and annually. 2. Orient resident to room, call light, unit, and location of the nurse's station upon admission to the facility. 3. Develop a plan of care to include goals and interventions which address resident's risk factors. Risk factors may include but are not limited to the following; Contributing diagnoses/disorders/disease processes/active infections/other comorbidities, history of fall incidents, incontinence, medications (Narcotics, Antihypertensives, etc.), assistance required with Activities of Daily Living (ADL's), gait/transfer/balance issues, behaviors, and/or cognitive status. 4. Provide assistive devices for mobility, hearing and vision as appropriate for the resident. 5. Assess appropriateness for resident to participate in skilled therapy or restorative programming in order to maintain or improve physical function of resident. 6. Assess and monitor resident's immediate environment to ensure appropriate management of potential hazards. 7. Monitor for changes in medical condition and notify physician as necessary to manage changes in status of the resident. 8. Conduce care plan meetings with resident, responsible party, and facility interdisciplinary team quarterly and as needed. 9. Review and/or modify the resident's plan of care at least quarterly and as needed in order to minimize risk for fall incidents and/or injury. R414 was admitted to the facility on [DATE] with diagnoses of dementia, depression, panic disorder, anxiety, a-fib, obstructive uropathy, urine retention, [NAME] syndrome, and failure to thrive. R414 is his own person. R414's Admission Minimum Data Set (MDS) assessment completed on [DATE] indicates a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. R414 requires extensive assistance with one-person and physical assistance with bed mobility, transferring, dressing and toileting. R414 is not steady and is only able to stabilize himself with staff assistance while moving on and off the toilet. R414 has an indwelling urine catheter and is always continent of his bowels. R414's Care Plan indicates R414 is at high risk for falls related to limited mobility and impaired balance dated [DATE]. Interventions include; 1. Assist R414 resident get up and out of bed during the night when resident is not feeling sleepy, Date Initiated: [DATE], 2. Encourage R414 to call, don't fall, Date Initiated: [DATE], 3. Complete frequent checks, Date Initiated [DATE], 4. Keep frequently used items within reach in room, Date Initiated [DATE], 5. Monitor for changes in ability to navigate the environment, Date Initiated [DATE], 6. Notify family and MD of any new fall, Date Initiated [DATE], 7. Promote placement of call light within reach, Dated Initiated [DATE]. On [DATE] at 1730 (5:30 PM), the facility documentation indicates the CNA (Certified Nursing Assistant) found R414 on the bathroom floor. R414 had an elevated BP (Blood Pressure) and noted to have altered mentation with being unable to convey where he was, day of the week nor the month. R414's baseline orientation is fully oriented to person, place, time, and event. The facility charge nurse and Hospice were notified of the unwitnessed fall. R414 had an improvement with his vital signs and mentation after Hospice arrived at the facility at 6:45 pm. On [DATE] at 5:34 pm, the facility documentation indicates R414 was found lying on his back flat on the bathroom floor and R414 hit his head. R414 had complaints of pain in his upper back between his should blades, altered mentation, along with high blood pressures and low pulse rates. R414 had a brown emesis while being transferred with a Hoyer lift back to his bed. Hospice instructed the facility to administer Zofran for vomiting. There is no documentation of a post-fall investigation to determine the circumstances that led to R414's fall and to determine what changes might be made to the care plan to prevent further falls. Surveyor reviewed the facility Neuro check documentation dated [DATE] at 3:47 am indicating R414 having rambling speech with a weak right-hand grasp. Surveyor notes there is no documentation indicating hospice or the MD were notified of this significant change in condition with R414 having weak right-hand grasps and rambling speech. Facility documentation dated [DATE] at 9:58 am indicates the facility nurse notified hospice with a significant change in condition. R414 was feeling off, hands being shaky, lethargic, and needing to be fed for breakfast. R414 did not previously require assistance with eating. Documentation indicates a second call was placed by the facility to hospice on [DATE] at 10:28 am indicating R414 is hunched over in his wheelchair with increased fatigue. Surveyor reviewed the post fall documentation on [DATE] at 8:00 pm which indicates R414 is alert with confusion and fatigue is noted. R414 can answer questions appropriately but did mumble stories about siblings that were nonsensical. Documentation reports R414 hit his head on [DATE] and surveyor notes the MD was not notified of this change in condition at the time of the post fall documentation. Documentation from [DATE] at 9:10 pm indicates R414 was found on the floor lying on his left side of the bed with the call light and nightstand base under him. R414 was moaning in pain with c/o pain in his back, left arm and left shoulder. R414 had a head injury with blood present on the floor. R414 was noted to have cognitive impairment, intermittent nonsensical verbalization, pinpoint eyes, eyes wrenching, a left forehead hematoma measuring 4 cm x 3 cm with a 2 cm laceration to the middle of the hematoma, and no urine output in the urine Foley bag. The charge nurse and hospice were notified. Hospice instructed the facility staff to not send out R414 for evaluation prior to hospice doing an evaluation. The facility nurse applied pressure to R414's head injury site and remained with R414 in the fall position until hospice arrived for evaluation. Documentation from Hospice Progress notes dated [DATE] at 9:34 pm indicate R414 had an unwitnessed fall and sustained a head injury. R414 denied pain but was observed to be wincing with movement. Documentation from Hospice indicates as needed (PRN) pain medication was given due to R414 likely being sore and probably having a headache. R414 was observed to be alert and oriented and tolerating changing his shirt without the facility staff in R414's room. Hospice reports facility staff chose to leave R414 on the floor with a pillow under his head until hospice arrived for evaluation. R414 was assisted back to bed using a Hoyer lift. Hospice attempted to contact R414's POA who was unavailable, and hospice left a message. The hospice nurse applied steri strips to R414's head wound and a new Foley catheter was inserted with 2400 cc of dark amber urine and large amounts of thick fibrous tan drainage was noted. Surveyor interviewed Licensed Practical Nurse (LPN)-S on [DATE] at 11:00 am. LPN-S indicated R414 is typically alert and oriented and able to make his needs known. LPN-S reported R414 being weak and requires assistance of one with ambulation, toileting and transferring. LPN-S stated the facility staff had to frequently remind R414 to contact staff when needing to transfer as R414 frequently ambulated independently without calling for assistance. LPN-S indicated she could clearly tell R414 had a head injury on [DATE] at 9:10 pm after R414 had a second unwitnessed fall from his bed while reaching for the call light that was out of reach. LPN-S applied pressure to R414's head to help control bleeding and stayed with R414 for approximately ,d+[DATE] minutes in the fall position while she waited for hospice to come and evaluate R414. LPN-S stated she knew R414 clearly had a brain injury with R414's eyes being dilated and changed. Surveyor reviewed the facility fall investigation dated [DATE] at 9:10 pm indicating R414 sustained a hematoma and laceration to the face along with a skin tear to the left hand. R414 is oriented to person, the facility NP was notified on [DATE] at 3:53 pm, and POA was notified on [DATE] at 3:29 pm. Surveyor notes the MD was not notified of the significant change in condition. Surveyor also notes the facility NP and POA were notified the following day approximately 18+ hours after the significant change in condition. Surveyor notes documentation does not state was what discussed with the facility NP and POA at that time of phone call and if it the option for R414 to seek further evaluation was discussed. Surveyor reviewed the facility neuro check documentation on [DATE] at 1:00 am indicating R414's pupils not being equal in size, with the right pupil being fixed, left pupil being sluggish, and R414 being unable to grasp hands. Surveyor reviewed the facility neuro check documentation on [DATE] at 2:00 am indicating R414's is aphasic (a person who is unable to communicate), right pupil is fixed, left pupil is sluggish, and unable to grasp hands. Surveyor reviewed hospice progress note dated [DATE] at 9:15 am indicating R414 requires meals set up, decreased appetite, increased dysphagia, chocking and coughing with thinned liquids, increased pain, total dependence with bathing, and is bedbound with assistance of a Hoyer lift after two unwitnessed falls on [DATE] and [DATE]. R414 is requiring head support with a rolled towel to prevent neck pain and is unable to move his own head/neck. Urine is noted to be dark concentrated with sediment in Foley catheter tubing. Surveyor reviewed the Interdisciplinary Team (IDT) note dated [DATE] at 11:42 am indicating the [DATE] fall for R414 was reviewed for safety and a new intervention was placed. Surveyor notes the 2nd fall from [DATE] was not reviewed, the MD was not notified of the significant changes in condition, and there was one change to the care plan to include medication adjustments per hospice for R414 being a high risk of falls. Hospice Progress note dated [DATE] at 3:30 pm indicates R414 is in pain, increased sleeping, withdrawn, minimal responsiveness, barely opening his eyes, abdominal respirations, slow capillary refill in his nail beds, pallor, crackles in his lungs (fluid building up in the lungs), skin cool to touch, skin mottled in areas (lack of blood flow to the skin), and unable to respond to tell staff how he feels. Surveyor reviewed the Hospice Progress Note dated [DATE] at 10:00 am indicating R414 is unresponsive, having irregular heart rates, breathing through his mouth, eyelids barely opening, shallow respirations, crackles to his lungs, coughing to clear his airway, unresponsive to touch or voice however, R414 jerks and gasps when the hospice nurse swabs R414's lips. Documentation indicates the hospice nurse noted no PRN medications (Lorazepam and Morphine) given since last visit on [DATE] at 3:30 pm. Surveyor reviewed the Hospice Progress Note dated [DATE] at 11:00 am indicating R414 is noted to have an elevated pulse, rapid respiratory rate (RR) of 36 (normal RR is 16), gasping for air, abdominal respirations, using accessory muscles with breathing, coughing, short of breath, and moderate discomfort with breathing. Documentation indicates hospice updated the POA and administered 1 dose of Morphine for shortness of breath. Facility progress note dated [DATE] at 10:50 pm indicating the CNA called the nurse into R414's room. R414 was pulseless and not breathing. Hospice and the facility charge nurse were notified by the facility staff. On [DATE], at 10:09 AM, Surveyor notified the Nursing Home Administrator-A and Director of Nursing-B of the concerns with the following: ~ No root cause analysis performed for [DATE] and [DATE] unwitnessed falls to minimize future falls or harm. ~ Lack of determining what may have caused or contributed to the fall, including what R414 was trying to do before he fell . ~ Revising R414's plan of care to reduce the likelihood of another fall. Including no additional monitoring after increasing Miralax on [DATE]. ~ Call light was not within reach on [DATE]. R414 was reaching for his call light and sustained a fall on [DATE]. ~ MD indicated R414 was not to ambulate independently. R414 was noted to be in the bathroom independently on [DATE] at the time of his unwitnessed fall. The facility's failure to keep R414 free from hazards, reduce the risk of all known and foreseeable accident hazards that cannot be eliminated, provide appropriate and sufficient supervision to R414 to prevent an avoidable falls increased a reasonable likelihood for serious harm, thus creating a finding of Immediate Jeopardy. The Immediate Jeopardy was removed on [DATE] when the Facility completed the following: -All residents were reviewed for changes in condition, falls, and hospice services and the care plans were update as indicated. -All nursing staff were educated by the Director of Nursing, Nurse Consultant or designee regarding assessing for changes in condition post fall and notifying the primary care provider of those changes in condition. -All nursing staff were educated by the Director of Nursing, Nurse Consultant, or designee on the facility's fall prevention policy. -All nursing staff were educated by the Director of Nursing, Nurse Consultant, or designee on the facility's change in condition policy. -All nursing staff were educated by the Director of Nursing, Nurse Consultant, or designee on conducting a root cause analysis post fall to further assess resident's needs, addressing risk factors such as the resident's medical condition(s), facility environmental issues and/or staffing issues. - All nursing staff were educated by the Director of Nursing, Nurse Consultant, or designee on ensuring interventions were established to prevent further falls based on the root cause analysis/assessment. -The facility Nursing Home Administrator, DON, and Nurse Consultants reviewed policies and procedures on falls, change in condition, and comprehensive care plan with the Medical Director. -The Nursing Home Administrator and Director of Nursing conducted a review of compliance using a Quality Assurance audit tool for falls, changes in condition post fall, and root cause analysis post fall. Interventions were established and included in the comprehensive plan of care based on the root caused analysis/assessment to prevent further falls. -Audits well be completed three times a week for four weeks, then weekly for four weeks, then monthly for 3 months, then randomly by the Nursing Home Administrator, DON, Assistant Director of Nursing/designee until compliance is maintained. -The results of the audits will be reviewed monthly by the Facility QAPI team to determine any necessary changes. -An emergency QA meeting was held on [DATE] by the Nursing Home Administrator with the Interdisciplinary Team and Medical Director. The meeting included discussion of a fall resulting in a change in condition, root cause analysis post fall, and implementation of a comprehensive care plan with interventions reflective of the root cause analysis.

Based on interview and record review, the facility did not ensure they provided the necessary care, consistent with professional standards of practice, to prevent the development of pressure ulcers for 1 out of 5 residents (R38) reviewed who were at high risk. R38 returned to the facility following surgical repair to the left knee. R38 was to wear an immobilizer to the left lower extremity for 6 weeks after the surgery. The facility did not provide monitoring of R38's skin under the immobilizer and R38 developed a stage 4 pressure ulcer to the back of her left lower leg. This is evidenced by: R38 was readmitted to the facility on [DATE] following an acute left distal femoral fracture with surgical repair. Hospital discharge instructions included, wound/skin care: may reinforce left knee dressing; otherwise leave in place until ortho follow-up. Stage #3 coccyx pressure injury - silicone boarded foam change 3 times a week, offload from pressure. Surveyor conducted a review of the physician orders for November 2023. R38 had an order that stated, may reinforce left knee dressing; otherwise leave in place until ortho follow-up. As needed for wound healing. Start date 11/10/23. (d/c date 12/27/23). A review of the plan of care for R38 indicates: R38 Requires an immobilize to LLE (Left Lower extremity) secondary to Limitation in ROM (Range of Motion) from recent surgery. Date Initiated: 11/17/2023. Interventions include: o Will tolerate splint use through next review. Date Initiated: 11/17/2023 o Apply splint/brace per MD (Medical Doctor) order to affected area. Date Initiated: 11/17/2023 o Monitor splint for cleanliness, need for refitting, repair, or fit as needed. Date Initiated: 11/17/2023 o Report any changes in ability to use the affected area. Date Initiated: 11/17/2023 R38 has alteration in skin integrity r/t (related to) non-removable medical device stg (stage) 4 to LLE, Left thigh/knee wound near surgical incision, decreased mobility, need for staff assistance for ADLs (Activities of Daily Living) and transfers, diagnosis of lymphedema, hemiplegia and hemiparesis, epilepsy, anemia, hx of falls, poly osteoarthritis. Recurrent shingles/zoster, rashes, dx (diagnosis) atopic neurodermatitis. Non-compliance with repositioning/chair time. Date Initiated: 09/05/2023 Interventions include: o Skin will show s/s (signs/symptoms) of healing thru next review Date Initiated: 09/05/2023 o Absorbent to wick up moisture. Date Initiated: 06/25/2023 o Barrier cream to areas exposed to moisture/incontinence. Date Initiated: 09/26/2021 o Bathe with mild soap. Date Initiated: 09/18/2021 o Inspect skin daily with care Date Initiated: 09/05/2023 o LAL (Low Air Loss) mattress to bed. Date Initiated: 11/10/2023 o Moisturize dry skin Date Initiated: 09/26/2021 o Monitor nutritional status Date Initiated: 09/26/2021 o Monitor wound related pain and administer pain medications as appropriate. Date Initiated: 06/25/2023 o Position body with pillows/support devices Date Initiated: 09/26/2021 o Pressure reduction support on wheelchair with LLE calf support in W/C (wheelchair) Date Initiated: 09/26/2023 o Remind of importance of frequent position changes. Explain risks of prolonged sitting in her w/c. Date Initiated: 11/27/2023 o Treatment as ordered Date Initiated: 09/18/2021 R38 had a follow up Orthopedic consult on 11/22/23. The progress note indicates there is a slow stable fracture alignment. Staples removed today. May allow running water over incision. No soaking under water. Steri strips may be removed after 1 week. Continue non-weight bearing on left lower extremity. No rx (prescription) changes. The facility conducted a comprehensive assessment on 12/19/23 for R38's development of a pressure ulcer to the left lower leg (rear). Pressure Ulcer is unstageable. 5.0 centimeters in length by 2.0 centimeters in width and depth is less than 0.1 centimeters. Area described as superficial. 25% granulation, 75% slough, and 0 eschar. Margins are irregular, peri-wound is intact. Comments: Unstageable pressure ulcer noted to left lower extremity. New orders received. Low air loss mattress in place. Education on importance of repositioning with R38, who verbalized understanding. On 12/18/2023 at 6:01p.m., Physician progress note: DATE OF SERVICE: 12/19/2023 CHIEF COMPLAINT: Mobility and ADL dysfunction secondary to h/o (history of) of CVA (Cerebral Vascular Accident) with left ORIF (Open Reduction and Internal Fixation) distal femur with removal of hardware. REASON FOR RE EVALUATION: R38 was discharged on ,d+[DATE] and was re admitted in the facility due patient undergone left ORIF distal femur with removal of hardware. HOSPITAL COURSE: R38 is a [age and sex of R38] who is a LTC (Long Term Care) resident with h/o of CVA with left ORIF distal femur with removal of hardware in the presence of multiple medical comorbidities leading to a functional decline. Patient admitted to the SNF (Skilled Nursing Facility) on 09/16/2021 for skilled nursing and rehab. Patient asked to be seen by primary team to optimize therapy, pain control and discharge planning. Patient's plan and progress was discussed with nursing staff and therapy. HPI (History of Present Illness): R38 seen and examined. R38 is going out for an appointment today. Unfortunately, R38 has a pressure injury from rubbing from knee immobilize brace which she has had at all times located on that left LE (left extremity). She does not feel a lot of pain there which she states she has not report it to nursing. She does have PRN (as needed) pain medication available. Spoke with nursing and will follow-up with her team today. Hopefully will get the immobilizer switch (sic) out to something that will allow for relief. Pain is a 0/10 today at rest. Pain is well controlled on pain medications. No reported side effects. On 12/19/2023, the facility conducted an Unavoidable Pressure Injury or Condition Review of clinical Manifestations. The progress note states R38 has a non-removable brace to LLE. Does not like to reposition. Chooses not to drink nutritional supplement to aide in healing. Nursing note dated 12/19/2023 at 4:36 p.m.: R38 returned from ortho appointment with orders for NWB (Non Weight Bearing) x (for) 6 more weeks to dc (discontinue) immobilizer, follow up in 6 weeks, to also consult with [name of doctor] for the wound on her left calf and heel noted and carried out. On 12/26/23, the facility conducted a weekly comprehensive assessment of R38's pressure ulcer to the left lower extremity (rear). Stage is assessed to be a stage 4 measuring 5.5 cm in length by 2.5 cm in width by 0.1 cm in depth. 25% epithelization, 25% granulation, and 50% slough. Margins are irregular. Moderate exedute. This area is offloaded with pillow. R38 complains of pain with washing, subsides when completed. Wound is healing. NP (Nurse Practitioner) updated and continue treatment. On 1/2/24, the facility's weekly skin assessment indicates R38 has a stage 4 pressure ulcer to the left lower extremity-rear measuring 5.6 cm by 2.3 cm by 0.1 cm. This area is offloaded with pillow. Wound bed is 25% epithelization, 50% granulation and 25% slough. No eschar present. Continue treatment. On 1/9/24, the facility's weekly skin assessment indicated R38 had a stage 4 pressure ulcer to the left lower extremity-rear measuring 4.5 cm by 2.0 cm and depth is unable to measure. 10% slough and 90% eschar. Continue treatment. On 1/16/24, the facility's weekly skin assessment indicates R38 has a stage 4 pressure ulcer to the left lower extremity-rear measuring 3.4 cm by 1.0 cm by 0.4 cm. Description - cavity or crater. On 1/23/24, the facility's weekly assessment indicates that R38 has a stage 4 pressure ulcer to the left lower extremity measures 3.5 cm by 1.1 cm by 0.5 cm depth. 100% granulation. This area is offloaded with pillow. NP updated. Continue treatment, improved. Continued weekly assessments were completed by the facility. The pressure ulcer continued to improve towards healing which was indicated by decrease in size of the area. On 3/5/24, the weekly skin assessment indicated that the pressure ulcer to R38's left lower extremity is noted to be healed. On 03/13/24 at 1:31p.m., Surveyor interviewed Director of Nursing (DON) - B regarding R38's acquired pressure ulcer to her left lower extremity-rear. Surveyor asked DON-B if the staff should have been monitoring R38's skin underneath the leg immobilizer. DON-B stated Nursing should have been looking at the skin and typically this would have been conducted each shift. DON-B stated she would need to investigate this further and get back to Surveyor to confirm skin assessments. Surveyor asked DON-B how the pressure ulcer was discovered. DON-B stated that I went to conduct a skin check, I was just doing random skin checks and I found the area. DON-B confirmed that no other staff had reported discovering the pressure ulcer prior to her finding it. DON B stated staff reported looking at the skin under the immobilizer and that CNAs would wash the left lower leg and put lotion on it. Surveyor reviewed with DON-B the facility's assessment that the pressure ulcer development was unavoidable because the brace R38 was wearing was non-removable and how did the facility staff wash and apply lotion if the immobilizer was not to be removed. DON-B was unable to provide additional information at this time and stated she would follow-up. On 03/13/24 at 03:11 p.m., Surveyor shared concerns about the development of the stage 4 pressure ulcer that developed under R38's immobilizer on her left lower extremity-rear. Surveyor shared concerns the facility staff were not checking R38's left lower extremity daily knowing that R38 was at high risk for developing a pressure ulcer. The facility did provide evidence R38's skin was checked weekly, every day shift on Mondays with her shower however, the information did not document if the staff removed the immobilizer during the skin checks. In addition, the facility provided discharge documentation from 11/7/23 stating R38 is non-weightbearing to her left lower extremity for at least the next 6 weeks. Knee immobilizer to remain in place. Surveyor noted the order did not indicate if the skin under the immobilizer should or should not be checked and there is no documentation this was clarified with R38's physician. No additional information has been provided as of the time of exit from the facility.

Based on observation, record review, and interview, the facility did not ensure residents received care consistent with professional standards of practice in the development and healing of pressure injuries for 1 (R72) of 3 residents reviewed for pressure injuries. R72 developed deep tissue injuries (DTI) to the left heel and the left outer ankle on 7/28/2022, the right heel on 9/27/2022, and the right and left buttocks on 11/22/2022. The left heel DTI healed on 9/20/2022. The left outer ankle DTI was recategorized as a diabetic ulcer and then reclassified as a DTI with eschar. The definition of a DTI by the National Pressure Injury Advisory Panel (NPIAP) is a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. A DTI is not open, covered by eschar, or have any other type of tissue present. The right heel DTI developed eschar and the staging of the pressure injury did not reflect the new tissue type. R72 was readmitted to the facility on [DATE] with an Unstageable pressure injury to the left lateral heel. Findings include: R72 was admitted to the facility on [DATE] after hospitalization for right shoulder surgery with diagnoses of hemiplegia and hemiparesis following cerebral infarction, seizures, diabetes, heart failure, chronic kidney disease, depression, anxiety, anemia, and history of myocardial infarction. On 7/7/2022 on the Initial Nursing Assessment form, nursing charted in the skin section of the form R72 had a healing incision to the right shoulder and a small abrasion from glasses to the right side of the nose. Nursing charted in the additional notes section R72 did not have any open areas to the skin. On 7/7/2022, R72's Braden scale was 17 indicating mild risk for skin breakdown. R72's Skin Integrity Care Plan was initiated on 7/8/2022 with the following interventions: -Absorbent to wick up moisture. -Bathe with mild soap. -Encourage mobility and/or ambulation. -Inspect skin daily with care. -Monitor for signs/symptoms of infection. -Monitor nutritional status. -Monitor wound related pain and administer pain mediation as appropriate. -Pericare after incontinent episodes. -Pressure reduction support on wheelchair. -Treatment as ordered. Surveyor noted there are no interventions for heel/foot protection or offloading. There also are no individualized interventions for repositioning despite R72 having hemiplegia and and hemiparesis. R72's admission Minimum Data Set (MDS) dated [DATE] indicates R72 is cognitively intact with a Brief Interview of Mental Status (BIM) score of 14. R72 is identified as needing extensive assistance of two plus staff for bed mobility. R72 was identified as being at risk for pressure injuries and did not have any pressure injuries. The MDS also indicated R72 did not demonstrate any behaviors including refusal of cares. On 7/14/2022, R72's Braden score was 14 indicating moderate risk for skin breakdown. On 7/21/2022, R72's Braden score was 15 indicating mild risk for skin breakdown. On 7/28/2022, R72 developed a DTI to the left outer ankle. The facility uses a form entitled WASA to document wounds. On the WASA form, nursing charted the left outer ankle DTI measured 1.5 cm (centimeters) x 1.4 cm x 0 cm that was maroon/purple and not open or draining. In the additional comments section of the form, nursing charted R72 had two new areas to the left foot both maroon/purple non-blanching: one area to the outer ankle bone and one area to the outer heel. Nursing charted R72 stated they sleep mostly on the left side and spends most time in bed. Surveyor noted the left heel did not have any measurements documented. Surveyor noted there were no changes to R72's care plan. On 8/4/2022, on the WASA form, nursing charted the left outer ankle DTI measured 1.2 cm x 1 cm that was purple in color. In the additional comments section nursing charted R72 wears heel boots to prevent further or new skin conditions. On 8/4/2022 on the WASA form, nursing charted the left heel DTI measured 1 cm x 0.6 cm that was purple in color. In the additional comments section nursing charted R72 wears heel boots to prevent further or new skin conditions. Surveyor noted this was the first comprehensive assessment of the left heel DTI. R72's left outer ankle DTI and left heel DTI were comprehensively assessed weekly from 8/4/2022 through 9/7/2022. On 9/7/2022 on the WASA form, nursing charted R72's left outer ankle DTI measured 1.4 cm x 1.5 cm x unknown depth with 100% eschar. Surveyor noted a DTI does not have eschar and the pressure injury was now Unstageable. In the additional comments section, nursing charted R72 had a low air mattress in place. On 9/7/2022 on the WASA form, nursing charted R72's left heel DTI measured 1 cm x 0.5 cm and was dry and intact. On 9/13/2022 on the WASA form, nursing charted R72's left outer ankle wound was a diabetic ulcer that measured 2 cm x 2 cm x unknown depth with 100% eschar. Surveyor noted no explanation was documented as to the change from a pressure injury to a diabetic ulcer. On 9/13/2022 on the WASA form, nursing charted R72's left heel DTI measured 0.8 cm x 0.4 cm with 100% eschar. Surveyor noted a DTI does not have eschar and the pressure injury was now Unstageable. In the additional comments section, nursing charted the DTI was intact with treatment in place. On 9/20/2022 on the WASA form, nursing charted R72's left outer ankle diabetic ulcer measured 1.8 cm x 1.8 cm with 100% eschar. On 9/20/2022 on the WASA form, nursing charted R72's left heel DTI had healed. On 9/27/2022 on the WASA form, nursing charted R72's left outer ankle wound was a DTI that measured 2.0 cm x 2.8 cm x 0 cm with 100% granulation and the wound was no longer covered with eschar. Surveyor noted a DTI does not have granulation tissue and the wound should have been staged if it was a pressure injury. On 9/27/2022 a new pressure area was discovered on R72's right heel. On the WASA form, nursing charted the right heel DTI measured 2.5 cm x 4.0 cm x 0 cm. On 10/4/2022 on the WASA form, nursing charted the left outer ankle DTI measured 1.8 cm x 2.8 cm x 0 cm with 100% granulation. Surveyor noted a DTI does not have granulation tissue and the wound should have been staged. On 10/4/2022 on the WASA form, nursing charted the right heel DTI measured 2.5 cm x 3.8 cm x 0 cm. On 10/9/2022 on the WASA form, nursing charted the left outer ankle DTI measured 1.6 cm x 2.6 cm x 0.1 cm with 100% eschar. In the additional comments section, nursing charted the wound bed was a mix of white and black soft tissue with no slough identified and R72 had an appointment scheduled at the wound clinic on 10/10/2022 for evaluation and treatment. Nursing charted R72 was immobile and required turning every 1-2 hours, R72 gets up to chair after breakfast, and heels floated with pillows due to refusal of the Prevalon boots. Surveyor noted a DTI does not have eschar and should have been documented as Unstageable. On 10/9/2022 on the WASA form, nursing charted the right heel DTI measured 2 cm x 3.6 cm x 0 cm with 100% eschar. In the additional comments section, nursing charted the wound bed was black, dry, and intact with margins peeling up from the peri wound. Nursing charted the total dry area measured 4.6 cm x 4 cm x 0 cm with the eschar being in the center measuring 2 cm x 3.6 cm x 0 cm. Nursing charted R72 was immobile and required turning every 1-2 hours, R72 gets up to chair after breakfast, and heels floated with pillows due to refusal of the Prevalon boots. Surveyor noted a DTI does not have eschar and should have been documented as Unstageable. R72's Skin Integrity Care Plan was revised on 10/10/2022 with the following intervention: float heels as tolerated and to comfort. Surveyor noted the interventions documented in R72's nurses notes are not included in the care planned interventions to ensure implementation. R72's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R72 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and coded R72 as needing extensive assistance with all activities of daily living including bed mobility and was always incontinent of bowel and bladder. The MDS indicates R72 has two unstageable-deep tissue injuries and is at risk for pressure injuries. Review of the behavior section indicated R72 did not demonstrate any behaviors including refusal of cares. R72's left outer ankle wound and right heel wound were measured weekly from 10/14/2022 through 11/7/2022. The wounds were charted as being DTIs with 100% eschar. Surveyor noted a DTI does not have eschar and the wounds should have been documented as Unstageable. R72 was in the hospital from 11/9/2022 through 11/14/2022. On 11/15/2022 on the WASA form, nursing charted the left outer ankle DTI measured 2.5 cm x 1.9 cm x 0.1 cm with 50% granulation, 25% slough, and 25% clean non-granulation tissue. Surveyor noted a DTI does not have granulation, slough, or any other type of tissue in the wound bed and the wound should have been staged. On 11/15/2022 on the WASA form, nursing charted the right heel DTI measured 3.2 cm x 3.3 cm x 0 cm with 100% eschar. In the additional comments section, nursing charted R72 continued to refuse heel boots and would kick pillows away; R72 was re-educated on the risks of continued pressure to areas such as wound deterioration, infection, pain, loss of feet and to potential death. R72 verbalized understanding. R72 was to have a follow up appointment at the wound clinic. Surveyor noted a DTI does not have eschar and the wounds should have been documented as Unstageable. On 11/15/2022 on the WASA form, nursing charted the left lateral heel Unstageable pressure injury measured 5.0 cm x 2.0 cm x 0 cm with 100% eschar. In the additional comments section, nursing charted R72 returned from the hospital with this wound. On 11/22/2022 on the WASA form, nursing charted the left outer ankle DTI measured 2.5 cm x 1.1 cm x 0.2 cm with 50% granulation and 50% slough. In the additional comments section, nursing charted R72 was noncompliant with heel lift boots and risks of not following recommendations were discussed. Nursing charted the wound edges had epiboly. Surveyor noted a DTI does not have granulation, slough, or any other type of tissue in the wound bed and the wound should have been staged. On 11/22/2022 on the WASA form, nursing charted the right heel DTI measured 3.0 cm x 3.4 cm x 0 cm with 100% eschar. Surveyor noted a DTI does not have eschar and the wounds should have been documented as Unstageable. On 11/22/2022 on the WASA form, nursing charted the left lateral heel Unstageable pressure injury measured 5.0 cm x 3.5 cm x 0 cm with 100% eschar. On 11/22/2022, R72 developed a DTI to the right buttock and the left buttock. On 11/22/2022 on the WASA form, nursing charted the right buttock DTI measured 3.5 cm x 0.5 cm x 0 cm with red/purple non-blancheable area that was not open. On 11/22/2022 on the WASA form, nursing charted the left buttock DTI measured 1.0 x 1.8 cm x 0 cm with red/purple non-blancheable area that was not open. In the additional comments section, nursing charted education was provided to R72 on the importance of allowing staff to reposition side to side while in bed; R72 verbalized understanding and agreed on allowing staff to reposition. Nursing charted R72 had a low air loss mattress in place. On 11/28/2022, an Unavoidable Pressure Injury or Condition form was completed indicating comorbidities and risk factors. The physician and wound nurse Registered Nurse (RN)-I completed the form and determined the pressure injuries were unavoidable and all preventative measures had been in place. R72's Skin Integrity Care Plan was revised on 11/28/2022 with the following interventions: -Pressure reduction foam mattress or pressure redistribution support (low air or alternation air) in bed. (Surveyor noted this intervention had been in place prior to putting it in the Care Plan.) -Turn and reposition every two hours and as needed. On 11/29/2022 on the WASA form, nursing charted the left outer ankle DTI measured 2.5 cm x 1.2 cm x 0.1 cm with 50% granulation and 50% slough. Surveyor noted a DTI does not have granulation, slough, or any other type of tissue in the wound bed and the wound should have been staged. On 11/29/2022 on the WASA form, nursing charted the right heel DTI measured 3.2 cm x 3.4 cm x 0 cm with 100% eschar. Surveyor noted a DTI does not have eschar and the wounds should have been documented as Unstageable. On 11/29/2022 on the WASA form, nursing charted the left lateral heel Unstageable pressure injury measured 5.2 cm x 3.5 cm x 0 cm with 100% eschar. On 11/29/2022 on the WASA form, nursing charted the right buttock DTI measured 3.3 cm x 0.5 cm x 0 cm that was purple/red in color. On 11/29/2022 on the WASA form, nursing charted the left buttock DTI measured 2.0 cm x 1.6 cm x 0 cm that was purple/red in color. On 11/29/2022, R72 developed a pressure injury to the back of the left ankle. On the WASA form, nursing charted the Unstageable pressure injury measured 3.0 cm x 1.0 cm x 0 cm with 100% eschar. Surveyor reviewed R72's medical record and multiple refusals of pressure reducing devices and non-compliance were noted. On 11/29/2022 at 9:31 AM in the progress notes, nursing charted a return call was received from the wound clinic and the etiology of wounds were discussed; the wound physician stated the wound to bilateral lower extremities were pressure ulcers however they are worsened by ischemia as evidenced by the ankle-brachial index on the right and left that indicated severe resting ischemia. R72 failed a stent and has a return appointment to the vascular clinic on 12/2/2022. The wound clinic was updated by the facility that R72's family was considering hospice services. On 11/29/2022 at 2:32 PM, Surveyor observed R72 sleeping in bed on an air mattress with feet elevated off the mattress. On 11/30/2022 at 3:26 PM, Surveyor observed R72's wound treatments by RN-I and assisted by Certified Nursing Assistant (CNA)-H. R72 had heel boots on both feet that were removed by CNA-H. Both feet were wrapped in Kerlex. Surveyor observed the following wounds: the left outer ankle wound measured approximately 3 cm x 3 cm with slough in the center and eschar on the outer edge of wound, the right heel had an eschar cap that measured approximately 4 cm x 4 cm, the left lateral foot by the base of the fifth toe measured approximately 2 cm x 1 cm with eschar, the left posterior heel by the Achilles tendon had 2 areas each measuring approximately 1 cm x 1 cm with eschar, the left buttock had an open area measuring approximately 1 cm x 1 cm with light pink tissue, and the right buttock had no pressure areas. RN-I stated the right buttock had healed and the left buttock had opened since last observation. Treatments were completed to all areas and heel boots were put back on R72 before leaving the room. Surveyor noted the locations of wounds observed did not correlate with the locations of wounds that had been documented on. The facility documented on the left lateral heel and the back of the left ankle. Surveyor noted wounds to the left lateral foot and two wounds to the back of the left heel at the Achilles tendon. In an interview on 12/5/2022 at 9:38 AM, Surveyor asked RN-I why wounds were charted as DTI with eschar present. RN-I stated RN-I did not have an answer; the nurses that charted those assessments were no longer employed at the facility. Surveyor showed RN-I the charting completed by RN-I on 11/15/2022 where DTI was listed as the status of the pressure injury even when eschar or other tissue types were observed. RN-I stated the wounds should have been charted as Unstageable with eschar present and with other tissue types, they should have been staged a Stage 3. RN-I stated RN-I had just started working at the facility and did not know what previous nurses had been instructed to chart when it came to wounds. In an interview on 12/5/2022 at 10:20 AM, RN-I stated RN-I talked to Nurse Consultant-D and was told not knowing the depth, even if it has eschar, they do not change the staging from a DTI. RN-I stated the wound with eschar wound be an Unstageable pressure injury and not a DTI at that point. RN-I stated wound education needs to be done so that will be RN-I's focus. RN-I stated some education had been done regarding wounds, but the nurses may not be retaining it. No further information was provided at that time.

Based on interview and record review, the facility did not ensure that residents who entered the facility without a Pressure Injury (PI) did not develop a PI and received appropriate care, treatment and preventative measures to promote healing for 4 (R79, R13, R57 & R106) of 7 Residents reviewed for pressure injuries. On 11/11/20 R79 developed a pressure injury on the left lateral side of his fifth toe measuring 1.8 x 1 x 0.5 with 10% slough, 60% granulation, and 30% epithelial tissue. The Facility incorrectly staged this pressure injury as a Stage 2. A treatment order for normal saline followed by [MEDICATION(S)] was received. This treatment was not started until 11/18/20, one week later. The Facility continued to incorrectly stage this pressure injury until it was identified as a Stage 4 on 3/10/21. The Facility did not assess R79's pressure injury weekly and did not consistently complete a comprehensive assessment as percentage of wound bed was not completed or did not add up to 100% of the wound bed. There were no assessments from 11/19/20 to 12/6/20. An assessment was conducted on 12/7/20 and then the next assessment was 11 days later on 12/18/20. R79's potential for skin impairment care plan was not revised when R79 developed the pressure injury and an actual skin impairment care plan was not developed until 12/7/20. Even though R79 developed the pressure injury on 11/11/20 there was no nutritional interventions until 1/19/21. The Facility's failure to identify R79's left 5th metatarsal pressure injury until it was a Stage 3 despite R79 receiving daily diabetic foot checks, the failure to correctly Stage this pressure injury, and implement treatment orders according to physician orders, the failure to consistently assess the pressure injury weekly & complete a comprehensive assessment and failure to ensure R79's foot was offloaded led to the deterioration of R79's pressure injury. On 3/10/21 the pressure injury was staged as Stage 4 with tendon observed. On 3/12/21 R79 was started on an antibiotic for infection of this pressure injury. On 8/9/21 at 3:01 p.m. Administrator-A and RN Consultant-D were informed of the Immediate Jeopardy findings which began on 3/10/21. The immediate jeopardy was removed on 8/13/21. The deficient practice continues at a scope severity of a G (actual harm/isolated) related to the example involving R13 and as the facility continues to implement its action plan. * R13 developed a deep tissue injury to the right heel on 5/28/21 and a treatment order was obtained. There is no documentation R13 received treatment to this pressure injury until 6/15/21. Weekly assessments were not completed and R13's pressure injury was incorrectly staged. * R57 was readmitted to the facility on [DATE]. The Facility did not assess, measure, or stage R57's sacral or upper back pressure injuries upon readmission. There are wound consultation notes dated 8/28/20, 9/1/20, & 9/22/20 but there are no other assessments from Facility staff from 8/17/20 to 11/20/20. * R106 was admitted to the facility on [DATE] with an unstageable sacral pressure injury and a treatment was ordered by the physician on 4/8/21. R106 did not receive this treatment until 4/11/21. Findings include: The Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Identify residents at risk for developing pressure injuries. 2. Identify the presence of pressure injuries and/or other skin alterations. 3. Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan. Under procedures includes documentation of: 3. Pressure injuries, Venous, Arterial, Diabetic ulcers and DPTI's (deep tissue pressure injuries) will be assessed weekly or as needed by facility staff or consulting clinician, by utilizing a WASA or other consulting clinicians' evaluation. 5. Develop a Care plan for either Actual or Potential Alteration in skin integrity and change as needed. 6. Complete a Comprehensive Pressure Injury Evaluation for identified pressure injuries. 10. Revise Care Plan approaches as needed based on resident's response and outcomes. Pressure Injury Stages (NPIAP) (National Pressure Injury Advisory Panel) dated 2/25/21 under pressure injury definition documents Stage 2 Pressure injury: Partial-thickness skin loss with exposed dermis. Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI) or traumatic wounds (skin tears, [CONDITION(S)], abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location: areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. 1.) R79's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility staff were documenting on R79's monthly TAR (treatment administration record) R79 was receiving diabetic foot checks on the evening shift. The potential for alteration in skin integrity care plan initiated 6/23/16 includes interventions of * Inspect skin daily with cares. Initiated 6/23/16. * Monitor/mange diabetes, assess BLE (bilateral lower extremities) for arterial insufficiency and/or appropriate foot and nail care. Initiated 7/12/16. * Pad equipment to protect fragile skin. Initiate 6/23/16. * Patient to wear lift boots and heels floating to promote wound healing and protection. Initiated 7/16/20. The nurse's note dated 7/16/20 documents discovered resident getting foot stuck in holes of foot bed. the bed is owned by the patient and does not want to change bed. [name of family member] will be providing body pillow to help protect, signs posted in room to remind staff to boost patient up if he slides down in bed, tasks and treatment entered. will continue to monitor progress. The facility updated the care plan on this date to include: * Signs posted to remind staff to boost patient up towards hob (head of bed) to ensure feet do not touch footboard. Initiated 7/16/20. The skin/wound progress note dated 9/16/20 for left lateral foot abrasion under comments documents RESOLVED. The quarterly MDS (minimum data set) with an assessment reference date of 10/9/20 documents a BIMS (brief interview for mental status) score of 11 which indicates moderately impaired. R79 Requires extensive assistance with two plus person physical assist for bed mobility, transfer & toilet use. R79 is always incontinent of urine and frequently incontinent of bowel. R79 is at risk for pressure injury development and is coded as not having any pressure injuries. The nurses note dated 11/11/20 documents Seen by podiatry today and he reported res had a 1x1 open area on the left upper side of foot. I checked the site which didn't appear opened but macerated by the b/a with ointment placed on it by podiatry. I updated the NP (nurse practitioner) today on all the above. The NP note dated 11/11/20 under HPI (history present illness) includes documentation of He was seen today at request of nursing following podiatry visit with report of wound. Patient noted to have ulcer to left lateral 5th metatarsal head. He has had a wound there in the past. No s/s (signs/symptoms) of infection. Patient reports no pain. Under assessment documents Left foot wound: prior regimen of [MEDICATION(S)]. Wound treatment nurse to evaluate. Monitor for s/s of infection. The WASA (weekly assessment of skin alteration) dated 11/11/20 is checked for pressure ulcer for type of wound. Under site it is documented: 52) Left toe(s) and description 5th metatarsal 1.8 X (times) 1.0 X 0.5. Stage is documented as II (2). Length 1.8, width 1.0 and depth 0.5. Wound bed is 30% epithelialization, 60% granulation and 10% slough. Under additional comments documents Alerted by NP that resident had noted area open on his metatarsal that was open. Podiatrist reviewed with unit RN (Registered Nurse)-[H]. Discussed with [name of] NP and recommendations for cleanse with NS (normal saline), [MEDICATION(S)] and cling gauze to wrap foot as this is an area that will have dressing fall off. Surveyor noted this pressure injury was incorrectly staged as a pressure injury with 10% slough should be a Stage 3 and there was no revision in R79's potential for skin integrity care plan. Surveyor reviewed R79's November 2020 TAR (treatment administration record) and noted the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The WASA dated 11/18/20 is checked for pressure ulcer for type of wound. Under site documents 52) Left toe(s) and description documents see comments. Stage is documented as II (2). Length 1.2, width 1.2 and depth 0.2. Under the section wound bed there are no percentages for epithelialization, granulation, slough or eschar. Under additional comments documents Left 5th metatarsal continue with current orders until healed. Left lateral foot the 5th metatarsal head review notes from podiatrist. Wound is open [NAME] edge-calloused around outer wound bed. Wound bed is pale pink with some darker pink spots. exudate minimal 1.2 x 1.2 x 0.1 and cleaned with normal saline applied [MEDICATION(S)]. order soft booties to wear while in bed and in wheel chair. Surveyor noted R79's pressure injury continues to be incorrectly staged and there was no revision in R79's potential for skin integrity care plan. Surveyor noted there is not a weekly assessment for R79's pressure injury for the weeks of 11/22/20 to 11/28/20 and 11/29/20 to 12/5/20. The NP note dated 12/2/20 under HPI includes documentation of He was seen today at request of nursing to evaluate left lateral 5th metatarsal head. There is not a dressing in place while patient is up in wheelchair. Wound is draining onto sock. Wound bed now with slough and purple center. Patient has no pain. There is no s/s of infection to surrounding tissue at this time. Under assessment documents Left foot wound: change from [MEDICATION(S)] to daily Santyl and alginate d/t (due to) slough and increased drainage. Monitor for s/s of infection. Pressure relieving booties have been ordered. will update treatment nurse. Surveyor reviewed R79's TAR (treatment administration record) and noted this treatment did not start until 12/4/20 and the NP note dated 12/2/20 does not include measurements of R79's pressure injury. Surveyor noted there was no revision in R79's potential for skin integrity care plan and the actual alteration in skin integrity care plan was not developed until 12/7/20. The Braden assessment dated [DATE] has a score of 13 which indicates moderate risk for pressure injury development. The WASA dated 12/7/20 is checked for pressure ulcer for type of wound. The left toe 5th metatarsal is documented as having a stage 2 wound measuring 2 x 2 x 0.1 cm. Under the section for wound bed there are no percentages for epithelialization, granulation, slough or eschar. Under additional comments documents resident states has no feeling in his left foot. His feet were down when in chair. Left foot has a boot. Recommend feet lifted when sitting in a chair. 5th metatarsal ulcer 2 x 2 x 0.1 exudate 50% scant amount of bleeding, pink wound bed. no pain or feeling noted. Surveyor noted R79's pressure injury continues to be incorrectly staged. Surveyor noted there is no contact with a physician despite statement R79 is indicating they have no feeling in the left foot. The actual alteration in skin integrity r/t (related to) Pressure Ulcer(s) on his 5th metatarsal base on left foot and a scab on great toe lt (left) foot initiated 12/7/20 documents interventions of: * Elevate heels off bed (non-arterial) and in chair. Initiated & revised 12/7/20. * Monitor/manage diabetes, assess lower extremities for arterial insufficiency and/or appropriate foot and nail care. Initiated 12/7/20. * Neuropathic/Diabetic wound interventions: Prevent trauma, proper fitting footwear, pressure relief to heals (heels), optimize blood flow to extremities, keep legs in neutral position. Initiated 12/7/20. * Position body with pillows/support devices. Initiated 12/7/20. * Pressure reduction support on wheelchair. Initiated 12/7/20. * Inspect skin daily with cares diabetic foot checks daily. Initiated 12/7/20 & revised 3/8/21. * Monitor for s/s (signs/symptoms) of infection. Initiated 12/7/20. * Turn and reposition frequently. Initiated 12/7/20 & revised 7/2/21. The WASA dated 12/18/20 is checked for pressure ulcer for type of wound. The left toe 5th metatarsal is noted to have a stage 2 pressure injury measuring 2.2 x 2.1 x 0.1 cm. (which is slightly larger than the last measurement). Under the section wound bed there are no percentages for epithelialization, granulation, slough or eschar. Under additional comments documents resident states has no feeling in his left foot. He is in bed with a prevalon boot on the left foot. 5th metatarsal ulcer 2.2 x 2.1 x 0.1 exudate non measurable able scan, pink wound bed. Some hard black scab at inferior end of wound covering 25%. Changing dressing order. reevaluate next week. Surveyor noted this assessment is 11 days later and R79's pressure injury continues to be incorrectly staged. The WASA dated 12/25/20 is checked for pressure ulcer left toe 5th metatarsal measuring 2 x 2 cm. x (no depth charted) with 100% epithelization. Under additional comments documents skin and diabetic foot check. resident states has no feeling in his left foot. His feet were down when in chair. Left foot has a boot. Recommend feet lifted when sitting in a chair. 5th metatarsal ulcer 2 x 2 exudate 50% scant amount of bleeding red, pink wound bed. no pain or feeling noted. no wounds rest of body. some moles present in back and abdomen. red buttocks from sitting moisture free. Surveyor noted R79's pressure injury continues to be incorrectly staged. Surveyor noted R79's care plan dated 12/7/20 indicates to elevate heels when in a chair there is no indication the facility initiated monitoring to ensure this occurs despite noting R79 is seated with legs/heels down and is recommending two assessments in a row to lift feet when sitting in a chair. Surveyor was unable to locate a WASA for the week of 12/27/21 to 1/2/21. The skin/wound progress note dated 12/30/21 under comments documents 5th metatarsal 2.2 x 1.7 red scant amount of blood, no exudate noted. Buttocks Left cheek superior 1 x 0.4 and inferior has 0.7 x 0.3 x 0.1 excoriation and redness noted. Surveyor noted this skin/wound note does not include the percentage of the wound bed and is not a comprehensive assessment of R79's pressure injury. The Braden assessment dated [DATE] has score of 13 which indicates moderate risk for pressure injury development. The WASA dated 1/8/21 is checked for pressure ulcer left toe 5th metatarsal measuring 2 x 1.9 x 0.1 cm, stage 2. 100% epithelialization. Under additional comments documents Floor nurse completed wound care. see progress note from 1/8/21 RN-[N]. Surveyor noted R79's pressure injury continues to be incorrectly staged. The skin wound progress note dated 1/8/21 documents for location Pressure injury to left foot/5th metatarsal. Wound bed color pink, Drainage small amount of tan drainage noted to old dressing, measurement 2 x 1.9 x 0.1, and under comments documents Tx (treatment) completed per orders. Pt (patient) tolerated well. No s/sx (signs/symptoms) of infection noted. Heel lift boot reapplied post tx. On 1/11/21 the facility amended R79's care plan to include: * Trapeze to bed. * Provide supplements, calories and vitamins as ordered to aide in wound healing. * Use assistive devices to decrease friction (Hoyer lift, draw sheet). * Venous insufficiency interventions: leg elevation. * Weekly wound progress assessment by nurse. The WASA dated 1/15/21 is checked for pressure ulcer left toe 5th metatarsal, stage 2, measuring 1.5 x 2 x 0.0 cm. and having 100% epithelization. Under additional comments documents white with red, scant amount of bleeding. 1.5 x 2 He is up in chair with no protective covering on his feet. Looks like he may have kicked off the right prevalon boot because it was in front of him. Spoke with wife about wounds as well. No concerns at this time. Surveyor noted R79's pressure injury is on the left toe and the pressure injury continues to be incorrectly staged. The RD (registered dietitian) note dated 1/19/21 includes documentation of 1/8 WASA L (left) toes stage 2 PI (pressure injury) tx (treatment) orders in place. may benefit from Pro T gold to enhance wound healing, will recommend. Continue to monitor po intake weights skin. On 1/20/21 Pro T Gold Liquid Protein was ordered with directions to give 30 ml (milliliters) every day shift. Surveyor noted this recommendation was two months after R79 developed the pressure injury. The WASA dated 1/21/21 is checked for pressure ulcer left toe 5th metatarsal, which is charted as being 1.5 x 1.7 x (no depth documented), 100% epithelization. Surveyor noted R79's pressure injury continues to be incorrectly staged and the percentage for the wound bed is documented as 100% epithelialization but under the comments documents pink wound bed with granulation. The skin/wound progress note dated 1/29/21 and crossed out in R79's electronic health record under comments documents 5th metatarsal 1.7 x 2 red 100 granulation wound bed superficial. Small amount drainage on dressing yellow. No pain noted. resident slept through dressing change. On 8/9/21 at 9:46 a.m. ADON-C informed Surveyor the crossed out note is accurate for R79. The WASA dated 2/5/21 documents that the left toe 5th metatarsal has a stage 2 pressure injury measuring 1.7 x 2 x (blank for depth), 100% epithelialization. A pressure injury is also documented as being present on the left heel, 1.7 x 2.1 cm with superficial varying color of pink 100%. margins varying some white 25% some soft black 10% CDI (clean dry intact) 65% periwound CDI with black CDI area at 2 O'clock. Surveyor noted R79's pressure injury continues to be staged incorrectly and this is the first documentation regarding the left heel. Surveyor noted there was no revision in R79's actual skin integrity care plan until 2/23/21. The NP note dated 2/11/21 under HPI includes documentation of He was seen today to evaluate left foot ulcer. No s/s of infection. Under assessment documents Left foot wound: arterial US (ultrasound) completed per request of Corporate RN (Registered Nurse) with no evidence of insufficiency. continue current wound care. Monitor for s/s of infection. Pressure relieving booties have been ordered. will update wound treatment nurse. The WASA dated 2/12/21 is checked for pressure ulcer on left toe 5th metatarsal measuring 2 x 1.9 x 0.0 cm, stage 2, 100% epithelialization. Under additional comments documents Wound bed is moist no exudate. [MEDICATION(S)] on dressing. Prevalon boots wore (sic) all the time. Air loss mattress. Surveyor noted R79's pressure injury continues to be staged incorrectly and there is no documentation regarding the left heel. The WASA dated 2/17/21 is checked for pressure ulcer left toe 5th metatarsal, 1.7 x 1.7 x 0.0 cm, stage 2, 10% epithelialization. There are no other percentages documented for the remainder of the wound bed. Under additional comments documents Resident had two pillows under calf. Resident stated he did not want the boot on while in bed. Dressing was CDI. No feeling in foot and the Vascular Study was negative. The WASA dated 2/23/21 is checked for pressure ulcer left toe 5th metatarsal, stage 2, measuring 2.2 x 2.1 x 0.0 cm, 10% epithelialization. There are no other percentages documented for the remainder of the wound bed. Under additional comments documents Resident has a scant amount of bleeding on wound bed. He had no boot one (sic). He said he did not want it on. A pillow was under calf and his dressing was CDI. He has no feeling in his left foot. A new treatment in placed. Monitor for healing. Wife was informed. Surveyor noted this is the second WASA noting boots not in place and resident preference to offload using pillows. There is no indication this preference was added to R79's plan of care or that risks/benefits were discussed with R79 regarding wearing of boots vs using pillows for off-loading until 3/9/21. The facility updated R79's care plan on 2/23/21 to include: * Pressure reduction foam mattress or pressure redistribution support (low air or alternation air) in bed. * Air loss mattress in bed. * Pericare after incontinent episodes. * Barrier cream to areas exposed to moisture/incontinence. * Educate Resident and/or family about pressure ulcer/injury. On 3/1/21 the facility added: * Staff to assess dressing per shift for CDI (clean dry intact) and/or change dressing PRN (as needed). The WASA dated 3/4/21 is checked for pressure ulcer left toe 5th metatarsal, 3 x 2.5 x 0.1 cm, stage 2. There are no percentages for epithelialization, granulation, slough or eschar. Additional comments are blank. Surveyor noted R79's pressure injury continues to be incorrectly staged and a comprehensive assessment was not completed as there is no description of the wound bed. Surveyor noted the Facility did not revise R79's actual skin integrity care plan after R79's pressure injury declined until 3/9/21 when the following was added: * EZ Boot on in bed and/or pillows under bilateral calves. Resident noted to kick off boots and kick around pillows while in bed. Lowered foot board to help support offloading of toes. The WASA dated 3/10/21 is checked for pressure ulcer left toe 5th metatarsal, 3 x 2.6 x 0.3 cm. It is now a stage 4. Under the section wound bed for slough % (percentage) documents 10. There are no other percentages documented for the remainder of the wound bed. For exudate type is Foul Purulent. Under additional comments documents Wound bed has opened up with slough in center of wound bed. Cleansed and tendon showing. No pain or feeling noted. Cultures were ordered and sent to lab. Antibiotic treatment started. Family notified Pressure relieving mattress, pillows, prevalon boot, Ez boot LT (left) Hx (history) of PVD (peripheral vascular disease), venous stasis, [CONDITION(S)], DM (diabetes mellitus), peripheral [CONDITION(S)] (no feeling knee to toes), foot heel ulcer, bumping and abrasions to current wound area, arthrosclerosis disease. Previous arterial doppler ordered and was negative. Surveyor noted the Facility revised R79's actual skin integrity care plan on 3/12/21 with an intervention to promote healing to buttocks. On 3/12/21 R79 was started on the antibiotic [MEDICATION(S)] 500 mg (milligrams) QID (four times daily) for 14 days for wound infection. Also on 3/12/21, the facility revised the care plan to include: * Resident is encouraged to lay flat and reposition frequently to promote healing to buttocks. On 3/15/21 the RD added double portion meat all meals to further enhance wound healing; continue to monitor po [oral] intake, weight, skin progress. The nurses note dated 3/16/21 documents for the question what is the antibiotic used for: Pressure Ulcer, other type left 5th metatarsal, antibiotic & delivery method documents [MEDICATION(S)] po (by mouth), exhibiting the following signs & symptoms documents positive culture, slough on wound. On 3/21/21 the facility updated R79's care plan to include: * Encourage a support to lift lower extremities when in his wheel chair due to impaired circulation. * Encourage family to bring in healthier options. Subsequent WASAs generally note something to the effect of Pressure relieving mattress, pressure relieve cushion, pillows, dressing change orders as wound changes. He often forgets why his feet needs to be elevated and crosses legs. Resident had an abrasion evolved to a stageable injury, resident foot naturally lays pointed outward. Resident kicks off boot when in chair and due to now feeling when bumps wound cannot feel it. Resident has dementia and needs reminders of wound. On 6/22/21 R79 was enrolled in hospice services. The most recent WASA dated 8/6/21 is checked for pressure ulcer on 5th metatarsal base, left toe, measuring 1.3 x 1.5 x 0.0 cm. Stage 4. 100% epithelization. Under additional comments documents Wound bed is brown firm scab. Wound healing as evidence by size and shape. No pain verbalized as resident has no feeling due to [CONDITION(S)]. Resident elevate his leg when in wheel chair by holding up and kicks off the boot. Wearing socks and tennis shoes Resident on hospice and does treatment 1-2 times a week. Family notified. Airloss Mattress, pressure relieve cushion, pillows, dressing change orders no changes. He often forgets why his feet need to be elevated and crosses legs. Resident had an abrasion evolved to a stage able injury, resident foot naturally lays pointed outward. Resident kicks off boot when in chair and due to now feeling when bumps wound cannot feel it. Resident has dementia and needs reminders of wound. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/2/21 at 1:23 p.m. Surveyor observed R79 in bed on his right side with the head of the bed slightly elevated on an air mattress. Surveyor observed there is a pillow between R79's legs but his feet are not being offloaded. On 8/3/21 at 8:01 a.m. Surveyor observed R79 dressed for day sitting in a high back wheel chair in the dining room with his breakfast on an over bed table in front of him. Surveyor observed R79 is wearing only socks and his legs are not elevated. On 8/3/21 at 9:10 a.m. Surveyor observed RN (Registered Nurse)-N wheel R79 into his room, place gloves on and ask R79 if he was having any pain. RN-N removed R79's sock from his left foot then stated the dressing is kind of coming off and informed Surveyor she will change it. RN-N removed the dressing from the left 5th metatarsal base of R79's foot. Surveyor noted RN-N did not apply [MEDICATION(S)] on R79's wound bed according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/3/21 at 10:06 a.m. Surveyor observed R79 sitting in a high back wheelchair in his room with the TV on. R79 continues to be wearing only socks and his legs are not elevated with his feet on the floor. On 8/3/21 at 10:43 a.m. Surveyor observed R79 continues to be sitting in a wheelchair in his room. R79 continues to be wearing only socks and his legs are not elevated with his feet on the floor. On 8/3/21 at 3:35 p.m. Surveyor observed R79 in bed on his left side on an air mattress. R79's feet are not being offloaded and are resting on a pillow. On 8/4/21 at 1:47 p.m. Surveyor verified R79's treatment orders with ADON (Assistant Director of Nursing)-C. Surveyor informed ADON-C RN-N did not follow R79's treatment orders during an observation on 8/3/21 as RN-N did not apply [MEDICATION(S)] to the wound bed. ADON-C informed Surveyor she'll provide education to RN-N. On 8/9/21 at 9:46 a.m. Surveyor met with ADON -C to inquire how pressure injury rounds are conducted at the Facility. ADON-C informed Surveyor she was the treatment nurse from 11/1/20 to 2/1/21 and then became ADON. ADON-C informed Surveyor the treatment nurse position was resolved. ADON-C informed Surveyor she oversees the wound program and ADON-F oversees the infection control program. Surveyor asked how often pressure injuries are assessed. ADON-C indicated they do an assessment every week and when the nurses are doing a treatment they should be doing an assessment. Surveyor asked where this assessment is documented. ADON-C replied they usually will document in a progress note and explained if they see something is changing they need to address it and call the NP to get orders. Surveyor asked if a pressure injury has slough what should it be staged as. ADON-C replied 3 or 4. Surveyor asked when would the stage be 3 versus 4. ADON-C replied depends on the location and depth. Surveyor asked who revises Resident's care plans. ADON-C informed Surveyor anyone in the building can revise a care plan. Surveyor asked if RN (Registered Nurse)-BB still works at the Facility. ADON-C replied no, she was here before I came. Surveyor informed ADON-C R79's skin assessment dated [DATE] was incorrectly staged as a Stage 2 and should have been staged as a Stage 3 with slough. Surveyor informed ADON-C the 11/18/20 assessment continued to be staged at a 2 when it should have been a Stage 3 and the percentage of wound bed was not completed. ADON-C informed Surveyor she was new to the position and was relying on resources. ADON-C explained the resources were the corporate nursing consultants. ADON-C indicated she was still learning at this time and is still learning. Surveyor also informed ADON-C the treatment did not start until 11/18/20. Surveyor informed ADON-C Surveyor was unable to locate an assessment from 11/22/20 to 11/29/20. ADON-C informed Surveyor she would get back to surveyor. Surveyor informed ADON-C the skin assessment dated [DATE] continues to be staged incorrectly and there is no percentage of wound bed. Surveyor asked ADON-C if R79 developed the pressure injury on 11/11/20 why wasn't the actual skin integrity care plan developed until 12/7/20. ADON-C replied can't answer for that and explained the nurses should have been doing the care plan. Surveyor informed ADON-C the next assessment wasn't for 11 days on 12/18/21. ADON-C informed Surveyor she just learned a month or two ago it's supposed to be 7 days. Surveyor informed ADON-C Surveyor was unable to locate an assessment for the week of 1/24/21 to 1/30/21. ADON-C informed Surveyor she will get back to Surveyor. Surveyor informed ADON-C the skin assessment 2/5/21 continues to be staged incorrectly and there is documentation of a heel ulcer but couldn't find any further information on the heel ulcer after 2/5/21. ADON-C informed Surveyors she will get back to Surveyor. Surveyor informed ADON-C the weekly assessment continues to be staged incorrectly and the wound beds are either not completed or have only 10% completed. ADON-C informed Surveyor at the time there was miscommunication with her resources if the wound bed needed to add up to 100%. Surveyor informed ADON-C on 3/10/21 R79's pressure injury is Staged at a Stage 4 and asked why the pressure injury declined. ADON-C informed Surveyor staff weren't offloading and R79's foot was on the floor. ADON-C explained R79's left foot was laying on that one side so that's why it got worse. ADON-C informed Surveyor R79 is also non-compliant with his diet. Surveyor asked ADON-C what she meant. ADON-C informed Surveyor R79's family brings in candy & soda and he's a diabetic. ADON-C indicated they have educated the family it's not good for wound healing and we try to hide the candy. ADON-C informed [TRUNCATED]

Based on record review and interview, the facility did not ensure 1 (R165) of 1 residents reviewed for baseline care plans included healthcare information and instructions necessary to provide effective person-centered care and to properly care for R165. R165 was admitted into the facility for short term respite care on 6/30/21. Preadmission paperwork provided to the facility includes a medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Preadmission paperwork from R165's health care provider documents problems with strictures of esophagus. This document also includes R165 with having dependence with eating and according to R165's wife as having issues with swallowing, cannot have milk which causes phlegm and will cough, they try to limit drinking while eating as R165 will cough/choke if drinking and eating at the same time, and to usually try to do the meal first, drink after and monitor closely. R165's concerns with eating and swallowing along with instructions were not incorporated into R165's baseline care plan. The facility did not develop a baseline care plan to identify R165 as having swallowing issues and did not instruct staff on the level of supervision R165 required while eating. On 7/4/21, after eating dinner, R165 became increasingly congested, coughing up copious amounts of mucous and saliva. R165's oxygen saturation was at 87%. On 7/4/21, 911 was called and R165 was sent to the emergency room and was admitted into the hospital for aspiration pneumonia. Findings include: The facility BASELINE PLAN OF CARE policy and procedure, dated November 2017, documents; 1.) The baseline plan of care will include but not be limited to: a. initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] b. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] c. Dietary orders; d. Therapy services . 2.) The baseline plan of care will remain in place while the staff is completing the initial, comprehensive Resident assessment to gather information to further develop the comprehensive, person centered plan of care. The baseline plan of care may be updated as need dictates prior to the completion of the initial, comprehensive plan of care. 3.) A summary of the baseline plan of care will be provided to the Resident and or the resident representative, if applicable, by a member of the Interdisciplinary Team prior to the completion of the initial, comprehensive care plan. Documentation that this summary was provided will be placed in the EHR [electronic health record]. This summary will include, but is not limited to: a. The initial care plan goals of the Resident; b. A listing of the resident's medications and dietary instructions; c. A listing of any services or treatment to be administered by facility staff or staff acting on behalf of the facility; d. Any updated information based on the details of the comprehensive care plan as needed and appropriate. R165 was admitted to the facility on [DATE] for respite care. Pre-admission paperwork provided to the facility documents on R165's problem list Schatzki's ring (a narrow ring of tissue in the lower part of the esophagus which can cause narrowing of the esophagus) and dementia. The paperwork includes R165's medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .patient has significant progressive dementia and physical limitations leading to need for significant assistance with all daily activities. Patient family meeting short-term respite care to allow them to rest and recover from the constant daily demands of taking care of him. Their goal is to continue to keep him home and out of the nursing home at this time, but it is getting more difficult. He has other significant past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This healthcare power of attorney has been signed and is active. R165's pre-admission paperwork includes a report from his health care provider related to activities of daily living, dated 6/14/21. The report documents problems including strictures of esophagus .history of several dilations, and hiatus hernia. The record documents, Question 4 eating: How well can you manage eating by yourself? Eating by yourself means drinking and eating without help from anybody else, but you can use special utensils and straws. It also means cutting most foods on your own. Would you say that you: *3= Need and get some personal help with feeding or someone needs to be sure that you don't choke? Value: [3] Dependence: [*] - [Wife] reports that . [R165] has some issues w/ [with] swallowing. Cannot have milk as he gets too much phlegm and will cough. They also try to limit drinking while he eats as he will cough/choke if drinking and eating at same time; usually try to do meal first, drink after and monitor closely. Review of R165's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Hydration assessment, dated 6/30/21, documents yes to Difficulty in swallowing and requires thickened liquids and yes to Dementia in which resident forgets to drink or forgets how to drink. R165's physician orders, with a start date of 6/30/21, include General diet, Regular texture. Progress notes on 6/30/21 at 12:26 pm by RN (Registered Nurse)-H document, [AGE] year VA [Veterans Affair] pt [patient] admitted today for respite cares. Pt is alert but very hoh [hard of hearing], has dementia with short term and long term memory issues, most needs met by staff. One assist with cares and transfers. Has a 4 ww [wheeled walker] that he can ambulate with. Wife is poa [power of attorney] and gave all info on pt and he is a DNR [do not resuscitate] status. He has dx [diagnosis] of right knee pain, ulcer to left lower leg, corn on feet, callus on feet. Pt also has a swallowing issues with increased [MEDICATION(S)] and cant have milk. Family introduced to room and they filled out inventory sheet. Update to NP [nurse practitioner] with arrival, meds [medication] and DNR status. Other dx includes hx of dvt [history of [CONDITION(S)]]. Now in the mdr [main dining room] to eat lunch. On 8/5/21 at 12:39 pm the surveyor interviewed RN-H. RN-H recalled assisting R165 with his admission, and she thought she met with the daughter and wife. The surveyor asked if she had been given any specific instructions for eating for R165. RN-H stated it has been quite awhile but she did remember something about R165 getting phlegmy, that he had a phlegm problem. The surveyor asked RN-H if she recalled if the family gave her anything regarding swallowing precautions. RN-H stated yes, it was on a hand written sheet that she attached to his admission paperwork [review of R165's medical record did not contain this sheet]. RN-H stated she thought she even made a copy so the CNAs would know what him phlegmy. RN-H stated she believes it had something on there, but was mostly his medications. RN-H stated she thinks she handed it to one of the CNAs and thought they would have put it in the unit binder. The facility was unable to provide the surveyor with evidence of this hand written sheet. RN-H was unable to recall specifically what was on the sheet. The surveyor informed RN-H of being unable to find a careplan related to R165 having swallowing issues. RN-H stated she did not recall the resident having issues, that she didn't see anything the family was telling her about [related to R165's eating]. RN-H stated they have a table with residents who require total assistance with feeding, so staff is always in the dining room when residents are eating. RN-H recalled R165 needed assistance at times and staff would set up him up, but did not recall any coughing episodes or other issues while he was eating. The surveyor asked how staff would know if someone has swallowing precautions or other restrictions such as being unable to have milk. RN-H stated it would be given verbally in report and on the residents care card which are reviewed by the CNAs. The facility was unable to provide the surveyor with a care card for R165. R165's plan of care includes a focus area for Resident has an ADL [activities of daily living] Self Care Performance Deficit initiated 6/30/21. Interventions initiated on 6/30/21 include Assist with ADL tasks as needed and Cue resident verbally for parts of the tasks that can be done independently. R165's plan of care also includes a focus area for Is noted to have potential for dehydration initiated on 6/30/21. Interventions initiated on 6/30/21 include Encourage fluids unless contraindicated and Monitor for decreased ability to drink and eat without assistance from staff. A baseline care plan assessment, dated 6/30/21, includes a section for ASPIRATION PRECAUTIONS This section is not checked as being a focused area and does not check any interventions related to aspiration precautions. R165's plan of care does not include interventions related to his dysphagia, does not instruct staff on the level of supervision R165 requires while eating, and does not include the information included in R165's pre-admission paperwork to limit drinking while eating, no milk, and to monitor closely. Progress notes on 7/2/21 at 8:54 am by RN-H document, Pt is alert to self with short term and long term memory issues. He is confused, restless at times and has very poor safety awareness. skin warm and dry. Intake varies due to his dementia. He does sit at the feeder table for assistance and encouragement. no aspiration issues noted. No cardiac or GI [gastrointestinal] complaints. He does have bouts of inc [incontinence] and is toileted frequently . he can become aggressive and yells out. He is currently up in his wc [wheelchair] with extensive assist and feeding self. No verbals or nonverbal's of pain. Bruise to right ear noted from fall with bruising to arms noted. Known to misplace and take out his hearing aides. no [CONDITION(S)]. supervised at all times. Progress notes on 7/4/21 at 9:43 PM by RN-I document, After eating dinner, resident grew increasingly more congested and coughing up copious amounts of mucous and saliva. 02 Sat [oxygen saturation] 87% room air. [Medical group] contacted and message left for on call NP [Nurse Practitioner] to return call. No return call. Call out to wife to update on situation and stated she could not be to facility in less than an hour time. 911 called and resident sent to . ER (emergency room ). Attempted to call back wife to give update and not answering home or cell phone. Son's listed number is out of order. Charge nurse notified. On 8/5/21 at 10:57 AM the surveyor interviewed RN-I. RN-I recalled R165 and that she had worked a double on 7/4/21 on R165's unit. The surveyor asked if R165 was independent with eating. RN-I stated he needed some encouragement and assistance to remind where things were, and supervision, always ate in the dining room. RN-I stated she would have been in the area while residents were eating, but the aid would be assisting and supervising the resident. RN-I was unable to recall who would have assisted R165 that evening. RN-I stated if she remembered correctly R165 had some respiratory symptoms that got increasingly worse and that was why he was sent out best she could remember. RN-I stated it seemed to happen pretty rapidly after dinner when cleaning up, and had been through 2 other meals with R165 that day as was working a double. RN-I stated R165 seemed to be at his baseline up until after dinner. RN-I stated she did not recall the resident having any coughing or choking or anything that would have alerted her of anything during the meals. The surveyor asked if R165 had any swallowing issues that RN-I was aware of. RN-I stated not that she was aware of. The surveyor asked how RN-I would know if someone had any swallowing precautions. RN-I stated it would be all within their paperwork, would be in a progress note, and care planned for them. RN-I stated there also may be an additional note in the MAR [medication administration record] and if speech was working with them, they would keep in communication with the nurses. Review of R165's medical record did not contain any information related to R165's swallowing difficulties in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/5/11 at 11:44 AM the surveyor interviewed CNA (certified nursing assistant)-G. CNA-G believed he had cared for R165 on 7/4/21, recalled R165 was an active guy and had to keep an eye on him as he would wander. The surveyor asked CNA-G how he would know how to care of someone. CNA-G stated it would be on a care card in the resident's bathroom and in the Karda in the computer. The surveyor asked CNA-G if he recalled if R165 required assistance with eating. CNA-G stated he believed we had to keep an eye him. The surveyor asked if R165 had anyway swallowing issues that he recalled. CNA-G stated they had to watch R165 a little more than others, remembered something with bites and taking a drink, and keeping an eye on him to see how much he ate and how much he drank. The surveyor asked if CNA-G recalled him having any issues with dinner on 7/4/21. CNA-G stated not right away, stated it was after dinner he seemed to start having issues and was sent out. R165 was admitted to the hospital 7/4/21-7/8/21. R165's discharge summary documents [R165] is a [AGE] year-old gentleman with history of advanced Alzheimer's disease. He was at [facility] for respite due to his wife having heart issues and is primarily care taker. He was brought to the emergency room while he was eating he developed a coughing fit and congestion. He was coughing up frothy sputum. There was no vomiting of food. He has not had any fever, chills, nausea or emesis. Patient has dementia and unable to get any information .Emergency Department Findings: WBC [white blood cell] count was normal but chest X-ray shows hazy opacity in the low both lower lungs in addition to nodule opacity in both lungs concern for super imposed additional dye focal infection. There was concern for aspiration pneumonia .Reason for Admission: Continue management of his aspiration pneumonia. Hospital course documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The summary documents Family decision to take patient home with the support of [Hospice Company]

Based on observation, interview and record review the facility did not ensure that 1 (R2) of 3 residents reviewed with diabetes mellitus and 1 (R1) of 2 residents with skin impairments received care and services to meet their physical needs. -R2 was admitted to the facility with [DIAGNOSES REDACTED]. The facility did not have a plan of care in place to monitor for adverse effects related to R2's [DIAGNOSES REDACTED]. intake. R2 experience a hypoglycemic episode requiring hospitalization . - R1 developed MASD (moisture associated skin damage). The physician was not immediately notified of the area, there is no documentation of treatment to the area on 10/26/18, 10/27/18, and 10/28/18. The area was not documented as being assessed at least weekly, and R1's plan of care had no updated interventions related to the MASD from when the area developed on 10/26/18-11/30/18 when R1 was hospitalized . Findings include The facility's Diabetes Management Policy and Procedure, dated 6/16, states the purpose of the policy is to 3. Recognize signs and symptoms of [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. 4. Recognize, treat or prevent complications commonly associated with diabetes. The policy continues to state GENERAL GUIDELNES FOR ASSESSMENT MAY INCLUDE, BUT ARE NOT LIMITED TO: 1. Blood sugar level 3. Hunger and/or thirst .5. Weakness 8. Percentage of meals consumed and refusal of food. R2 has [DIAGNOSES REDACTED]. 1.) R2 was admitted to the facility on [DATE] through 1/27/19 following a hospitalization [DATE]-[DATE]. An after hospital care plan documents You were hospitalized for [REDACTED].You will be going to a skilled nursing facility so that you can get ongoing therapy and closer monitoring than you would at home .You should also make sure you (sic) blood glucose is being well controlled. You were on insulin while in the hospital but you required very few sliding scale doses. We are returning you to your home diabetic medication regimen on discharge. R2's medications ordered upon admission to the facility included glimepiride (a drug used to treat diabetes) 4mg twice a day and [MEDICATION NAME] (a drug used to treat diabetes) 1000mg twice a day. R2's progress notes on 1/23/19 document Admit note: .Ambulating independently .Appetite good at dinner with assist/cues. Progress notes on 1/25/19 document .Transferred with EZ stand this pm, gait very weak, unsteady with R (right) sided weakness. Denies discomfort. Swallow intact, appetite good at dinner . The state agency received a complaint stating R2 had not eaten for a period of a couple days and did not receive assistance to eat. Physician orders [REDACTED]. Chin tuck and swallow x 2 following thin liquids. Small sips and bites, alternate solids and liquids. 1 on 1 supervision with eating. The surveyor reviewed R2's percentage of meal eaten documentation. On 1/25/19 there is documentation at 10:16 am that 51-75% of was meal was eaten and at 2:21 pm that 26-50% of meal was eaten. Progress notes on 1/25/19 at 3:30 pm document ADL (activities of daily living) assistance required Needs Assistance Eating. The surveyor noted this was a decrease from 1/24/19, when R2 is documented as eating 75-100% for 3 meals. There is no documentation for the percentage of meal eaten for the dinner meal on 1/25/19. The surveyor noted documentation for 1/26/19 at 1:36 pm and 1:39 pm documenting R2 ate 51-75%. There is no documentation after 1:39 pm documenting R2's dinner intake. Progress notes on 1/26/19 at 9:05 pm document under ADL Assistance Required: .Independent Eating . Progress notes on 1/26/19 at 9:05 pm document Appetite poor at dinner. No N/V (nausea/vomiting) The progress note does not document assessment of R2 to ensure that his blood glucose levels were being well controlled, despite documentation of receiving glimepiride 4mg and [MEDICATION NAME] 1000mg on the evening of 1/26/19 and documentation of a poor appetite. Progress notes on 1/27/19 at 7:39 am document Called by CNA (certified nursing assistant) to (R2's) room this AM she stated 'I can't wake him up'. Sternal rub and shaking pt (patient's) arm, light in eyes provided no response. (R2) was breathing, snoring and then would have 5-10 second periods of apnea. VS (vital signs) obtained while getting B/P blood pressure noted (R2) was sweating. BS (blood sugar) obtained and was 41. 3 injections [MEDICATION NAME] given BS (blood sugar) remained at 41. EMS (emergency medical services) called. Upon EMS arriving (R2) was awake his BS was now 50 . Progress notes on 1/27/19 at 6:13 pm document FHC (Fort Health Care) called and resident has been admitted for observation of blood sugars. The surveyor reviewed R2's physician orders [REDACTED]. The surveyor noted no orders for emergency hypoglycemic medications. On 2/12/19 at 3:30 pm the surveyor interviewed RN (registered nurse)-E. The surveyor asked how she would know if someone should have blood sugar checks. RN-E stated if someone is on insulin would (get orders to check blood sugar). The surveyor asked what if someone is on oral medications to treat diabetes. RN-E stated sometime they do and sometimes they don't, would depend if they are stable or not. The surveyor asked how she would know if someone is stable or. RN-E stated if they didn't have hospital orders then would assume they are stable. Surveyor noted R2 started to present signs of unstable intake that was not assessed to determine how it would impact R2's blood sugar levels and lead to instability requiring hospitalization . Surveyor noted upon review of R2's medical record there was no baseline plan of care for R2 including a baseline plan of care to safeguard against adverse events related to poor intake and R2's diabetes mellitus management. (Cross-reference F655). On 2/14/19 the facility provided the surveyor with a statement from Medical Director-L, who was not R2's primary physician, stating I have reviewed the case of (R2) (admitted Jan (January) 23 and discharged on the 27th) and have identified that this gentleman was a stable diabetic as evidenced by review of his blood sugar monitoring pre-admission. There was no need for additional routine blood sugar checks post admission to Alden Estate of Jefferson unless the resident became symptomatic. I concur with the attending physician and the facility's approach to diabetes management for this resident. 2.) The facility's PREVENTION AND treatment of [REDACTED]. PR[NAME]EDURE: .3. Pressure injuries, Venous, Arterial, Diabetic ulcers and DTI's (deep tissue injuries), will be assessed weekly or as needed by facility staff or consulting clinician, by utilizing a WASA or other consulting clinicians' evaluation. 4. Non Pressure skin alterations ie: skin tears, abrasions, surgical wounds, MASD (moisture associated skin damage), [MEDICAL CONDITION], rashes will be documented on treatment administration record or weekly skin progress note if using EHR (electronic health record) .8. At least daily, staff should remain alert for potential changes in the skin condition during resident care .10. Revise Care Plan approaches, as needed, based on resident's response, outcomes and needs. R1 has [DIAGNOSES REDACTED]. The state agency received a complaint that R1 had a skin impairment to his buttocks that was not treated. On 2/11/19 at 3:50 pm the surveyor interviewed CNA (certified nursing assistant)-N. CNA-N recalled R1 and stated she worked with him frequently. The surveyor asked CNA-N if she recalled R1 having any open areas on his bottom. CNA-N stated yes, (R1) had a bad bottom, that he would always be sitting in his wheelchair and that he was very incontinent. Progress notes on 10/26/18 at 11:22 pm document Res (resident) has noted acute scrotal/groin excoriation and denuded areas appearing to L (left) buttock. Wound nurse was notified to assess and make specialty treatment recommendation. Am shift to update family .Res tolerated the barrier ointment applied. Pillowed used for reposition. There is no documentation of measurements of the wound or description of the wound bed on R1's left buttock on 10/26/18-10/28/18. There is no documentation of physician or family notification of the new area on 10/26/18-10/28/18. The surveyor reviewed R1's plan of care. R1's plan of care included a focus area of Alteration in skin integrity Incontinent of bladder/bowel, Non-compliance, Mild Risk, Friction due to constant movement, Alzheimer's or Dementia, wears briefs, Dietary and vitamin supplements, h/o (history of) MASD (moisture associated skin damage) in groin and buttocks. Lesion to for head MASD left inner buttock ( 2 spots) healed Stg (stage) 2 left buttock with an initiated date of 2/25/15. The surveyor reviewed the interventions on the plan of care related to the focus area and noted no new interventions were put into place after the area was noted as developed on 10/26/18 through the time when R1 was discharged on [DATE]. On 2/12/19 at 2:04 pm the surveyor interviewed Nurse Consultant-C. Nurse Consultant-C confirmed she was currently doing weekly assessments on residents' wounds. Nurse Consultant-C informed the surveyor the nurse who finds the wound does the basic identification of the wound and then notifies her. The surveyor asked who would notify the physician. Nurse Consultant-C stated generally the nurse or herself. The surveyor asked about when the area is 1st discovered. Nurse Consultant-C stated the nurse who discovered the area. The surveyor informed Nurse Consultant-C of no documentation of physician notification or change in treatment to R1's excoriation and denuded areas on 10/26/18, 10/27/18, or 10/28/18. Progress notes on 10/29/18 at 10:47 am document Resident has 0.5 cm x 0.5 cm <0.1 and 0.5 cm x 0.5 cm < 0.1 MASD (moisture associated skin damage) to left inner buttocks. Area washed and [MEDICATION NAME] applied. Wound nurse notified. A skin progress notes on 10/29/18 at 7:43 pm documents Wound Type/Location: Left Inner Buttocks MASD, 2 spots .Measurement (Length X Width X Depth in cm): 0.5 x 0.5 x<0.1, 0.5 x 0.5 x <0.1 small MASD areas on left inner buttocks noted by dayshift unit nurse. Episodes of incontinence, wears briefs. Treated with [MEDICATION NAME]. The surveyor reviewed R1's TAR (treatment administration record) for the month of October. The surveyor noted an order for [REDACTED]. Progress notes on 11/1/18 document Skin has some excoriation from incontinence and barrier ointment applied per order . Progress notes on 11/15/18 at 1:41 pm document Family request for zinc oxide for bottom. NP (nurse practitioner) aware. The surveyor noted there is no documentation of assessment of the area from 10/30/18-11/16/18. Skin progress notes on 11/17/18 at 2:34 pm by Nurse Consultant-C document MASD to inner lower buttock and scrotal area. Scrotal area with 2 superficial eroded areas. Wound Color: Red .Measurement (Length x Width x Depth in cm): scrotal areas 0.5 x 0.5 x s/f (superficial) .Advancing dementia with reduced appetite, increased sleeping while up in chair and gradual weight change-loss. Is incontinent of B & B (bowel and bladder). Peri-care and treatment completed. On 2/12/19 at 1:15 pm the surveyor interviewed RN (registered nurse)-O. The surveyor asked who monitors residents' wounds. RN-O stated the nurses as well as the wound nurse. RN-O stated she recalled R1 had wounds but was unable to recall specifics. On 2/12/19 at 2:04 pm the surveyor interviewed Nurse Consultant-C, who is currently the facility's wound nurse. The surveyor asked if the scrotal area was new on 11/17/18 (as the note on 11/29/18 documented a skin impairment to the left inner buttocks). Nurse Consultant-C stated as far she knew, and that she thought the area was on and off. The surveyor informed Nurse Consultant-C of no documentation of assessment of R1's MASD from 10/29/18-11/17/18. The surveyor asked for any additional information related to the lack of documented assessment from 10/29/18-11/17/18. No additional information was provided. Progress notes on 11/27/18 at 8:09 pm document Res (resident) declined supper and did not want to get up into w/x (wheelchair) d/t (due to) pain from o/a (open area) on buttocks. Res given PRN (as needed) [MEDICATION NAME] with good effect. Treatment applied per order. Will continue to monitor. There is no documentation of assessment of the open area when R1 complained of pain to the open areas on his buttock. On 11/30/18 R1 was admitted to the hospital for treatment after a fall. There is no documentation of assessment of the open area including, measurements and description of the wound bed from 11/18/18-11/30/18 when R1 was hospitalized .

Based on observation, record review and interview, the facility did not investigate and prevent further abuse for at least 8 of 8 allegations of Resident to Resident abuse, involving R18, R17, R37, R34, R35, R36, R8, R9. On 9/20/18, the facility admitted R9 whose prior hospital information indicated R9 exhibited swinging out at hospital nursing staff and of striking others lightly with an open hand. While at the facility, R9 resided on the 300 unit which had 20 residents. Throughout R9's stay at the facility from 9/20/18 until discharge 10/26/18, R9 exhibited abusive behaviors towards multiple residents and staff, causing residents to be fearful. The facility did not conduct thorough investigations into these allegations of abuse and did not prevent potential further abuse. (Cross Reference F600.) * R18 experienced mental abuse from R9 resulting in R18 being intimidated, fearful, and moving to a different unit. On 10/25/18 R9 barricaded herself in her room because she was afraid of R9. There was little information pertaining to R18 in the facility's concern/grievance file with no investigation noted. * R17 was hit by R9 and was restarted on her anti-anxiety medications because of being afraid of R9. There were 2 resident concern/grievances noted in the facility's file; however, a thorough investigation was not completed. * Through interviews, record reviews, and review of concerns brought forth to the facility, R37, R34, R35, and R36, were also abused by R9. The facility did not have investigations into these allegations of abuse. Progress notes in R9's medical record reflects aggressive behaviors toward residents however, residents were not always identifiable as the facility did not conduct investigations into these allegations. * R8 was not free from abuse by R9, when R8 had physical altercations with R9 on three occasions. * R9 was not free from abuse by R8 when R8 retaliated against R9. R8 had previously informed the facility that she might retaliate against R9 by striking him. The facility did not investigate the allegations of resident abuse and prevent further potential abuse for R8 and R9. The facility's failure to investigate and prevent further abuse of residents created a situation of immediate jeopardy beginning on 9/30/18. The facility's Administrator and Director of Nursing were informed of the immediate jeopardy on 10/29/18 at 3:40 pm. The immediate jeopardy was removed on 10/30/18 when the facility implemented an action plan. The deficient practice continues at a scope/severity level of a E (potential for more than minimal harm) as the facility continues to implement its action plan. Findings include: On 10/25/18 at 11:32 am, Surveyor met with Administrator A regarding R9's behaviors and altercations he had with residents in the facility. Administrator A stated R9 has had altercations with other residents on the 300 unit and was aware of R18's desire to be away from him. Administrator A stated 1:1's were provided in the evenings with the unit managers and (R9) is redirected if seen by other residents. Administrator A stated (R9) is expected to return to his group home tomorrow. During this conversation, Administrator A stated the facility had documentation regarding (R9). In addition, Administrator A stated they followed the Division of Quality Assurance abuse reporting chart. Administrator A reported due to (R9's) [DIAGNOSES REDACTED]. (Note: Willful means the resident intended the action (e.g., of hitting); a hit would be not willful only if the hit resulted from an involuntary movement. Because R9 intended his actions, the actions were willful.) Administrative A stated the facility had a file on R9 which would be provided to Surveyor. The file provided to Surveyor from Director of Social Services (SSD) J contained a few Resident concern forms and some notes; however, there were either no investigations pertaining to specific resident to resident altercations or the concern form did not contain a thorough investigation into the allegations. A review of the facility's Abuse Policy dated 02/2017 states in part; Abuse means any physical or mental injury or sexual assault inflected upon a resident other than by accidental means in the facility. Abuse is the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful means the individual acted deliberately, not that the individual must have intended the injury or harm .Residents and families will be informed of the facility's concern/grievance procedure .Employees are required to report any occurrences of potential mistreatment they observe, hear about, or suspect to a supervisor or administrator. Investigation: Appoint an investigator. Once an allegation has been made, the administrator or designee will investigate the allegation and obtain a copy of any documentation related to the incident .The final investigation will be completed within five working days of the reported incident. The final report shall include facts determined during the process of the investigation, review of medical records, personnel files and interview of witnesses. The final investigation shall also include a conclusion of the investigation based on known facts . 1. On 10/25/18 at 1:55 pm, Surveyor observed R18 sitting in her wheelchair up against the back of the door to her room, barricading herself in her room. R18 stated The naughty man (referring to R9) was loose this morning, he was in a place where I was. I thought I'd be secure. I got frightened . R18 stated, . he hit a bunch of us, he's terribly quick, I am frightened .I am terribly frightened, I was going out of the dining room and he was right behind me. I was told he wouldn't be here, he hits people and is running loose. They say we can't do things, he's been doing this for 15 days, they say they can't do anything and they let him go. He has not hit me but he came into my room [ROOM NUMBER] times in one night. He hit the person across the hall from me and after that I am afraid of him, I am going to be 100. I should fight at my age. I pray he does not come in here. They are not keeping an eye on him. 3 times they made promises to me he wouldn't be on the floor, why should I watch that guy, he hasn't come down this way just to the dining room. I am frightened all the time. Two weeks ago I had a small stroke. I am so frightened, a bunch of people are concerned, everyday he gets loose from somebody .he hit the female across the hall about 2 weeks ago, she's not afraid but I am, he hit the nurses too but they are afraid of their jobs. I think I will leave when he's gone. I wake up at night, sweaty, I have [MEDICAL CONDITION]. During surveyor's interview with R18, CNA F entered R18's room. In reference to R9, CNA F stated, I cannot have him over here, as soon as he comes, I try to get him off the unit, he already came over here (200 unit) and hit someone too .(R18) wanted to go back by here friends once in awhile too . A review of R18's medical record progress notes include in part: 10/14/18 (R18) .was readmitted yesterday after having a TIA (stroke). She is alert and oriented able to verbalize needs .voiced concerns over male peer coming into her room and she wants to move .(R18) at times is blocking her door so no one can come in. Explained to (R18) that staff need to be able to come in to check on her and make sure she is OK . Resident daughter here visiting and per discussion with other daughter and facility this resident will move to room (200 unit) to sleep for the evening as daughter (s) state resident is uncomfortable and panicky about staying in her current room .Resident moved with overnight belongings to room .for the night . 10/16/18 Information received from administrator that daughter relayed that resident is to stay 24/7 in room (2 .) due to irreconcilable differences with another resident on 300 unit .Med tech on the unit stated at 1330 (1:30 pm) resident came back to 300 unit and refusing to go back to 200 unit where she previously moved to earlier today. Med tech placed calls to resident's daughter and left message . 10/17/18 .Also spoke with daughter about staying on the unit, she said that was fine as long as Mom feels safe and not anxious about that man. On 10/29/18 at 9:25 am, Surveyor spoke to the Social Service Director (SSD) J regarding R18 and was later provided with concern forms and notes that were registered with SSD J. SSD J stated (R18) requested to move rooms for a short term basis. She (R18) was afraid of (R9) and caused her anxiety. She (R18) wanted to move off the unit, she (R18) felt he (R9) went into her room [ROOM NUMBER] times. That's not the only resident room he went in. Surveyor was provide with a notes from the facility's concern file. A typed note dated 10/11/18 states, Administrator and Social Service Director walked 300, to provide support counseling to residents in needs, in regards to (R9's) behaviors. Additionally this typed note included, spoke with room number listed (R18) and daughter. They are very concerned, wanted resident (referring to R9) arrested/restrained/liberty to be restricted. Expressed our inability to take those very specific steps. Expressed unrest and anxiety over the whole situation. Continued to reiterate understanding of their feelings and the facility was taking resident safety and wellness very seriously. A handwritten note in the concern file was dated 10/14/18 indicating (R18's) daughter requested change off 300 unit, changed same day, move to room (200 unit). 10/15 Resident moved self back to room (300 unit.) 10/16 Daughters requested move back and allow to be in both rooms .advised she could be in either, not both .currently resident (R18) is residing in room (200 unit) but is occupying both rooms. The facility had no investigation into R18's allegations of R9 entering her room [ROOM NUMBER] times. There is no investigation as to when this occurred nor information pertaining to the circumstances surrounding this incident which caused R18 to be terribly frightened, moving to a different unit, and barricading her self in her room. There was no investigation as to whom R9 may have hit on the 200 unit as mentioned by CNA F. The facility implemented an intervention to keep R18 safe by allowing her to move to a room on a different unit. However, R9 was allowed to roam throughout the facility and R18 did not feel safe even in her new room. 2. On 10/25/18 at 2:34 pm, Surveyor interviewed R17. R17 stated she was attacked 3 times by another Resident (R9), he was running free at the time and no one was supposed to watch him, they did change it so that he has supervision, my whole family has complained. There is a social worker and she will take him in the afternoon . R17 then went on to describe the 3 incidents of attack. R17 stated, the first time within the last month, I was coming back up from downstairs (per resident, the facility calls the center area where the 3 wings meet and where the fish tank is 'downstairs') and I was not feeling that good. He (R9) was trying to grab the bag behind my wheelchair. I said, 'No' and he starting hitting me in the jaw, I saw stars with this. R17 pointed to being hit near the right temple area and in the back . R17 stated the second time either while walking down the hallway or in the TV room can't remember, he came up behind me and started hitting me on the back. You don't know what he will do or if someone will come get him. This occurred a couple of weeks ago .I called my daughter-in-law and told her I was attacked again . R17 reported the 3rd incident was the most traumatic of all and is a doozy, it happened this past Saturday 10 pm, 3 of us were at a table, we had to go to the bathroom, he (R9) came up to our table, I said get someone to read a book, he kept raising his hands (at other resident)(R18) who said 'if we don't say anything he may go away.' He was going to swing at (R18), I said don't touch her, he came to me, I hollered at him to get away go back to your room, someone come please. R17 told (R9) you need to go away from us and he gave me a whack between the neck and the back. On 10/25/18 at 5:00 pm, Surveyor shared concerns regarding the supervision of R9 and the fears expressed R17. Administrator A and DON B stated they were aware of R17 having an incident with R9 but were not sure about the second and third incidents as described by the resident. Administrator A stated the 3rd alleged incident was investigated and they could not substantiate it as occurring. Surveyor was provided with an incident report dated 10/10/18 1730 (5:30 pm) which read, A male resident in wheelchair came up behind resident (R17) tried to grab cell & purse and resident (R9) hit her in mouth. Daughter-in-law present. APNP (Advanced Practice Nurse Practitioner) visit with resident on 10/11/18, MD here 10/15/18. Heat pack for neck. Surveyor reviewed R17's medical record progress notes which state in part; 10/2/18 Resident has had periods of anxiety on and off. Tonight resident was washing face in bathroom and yelled because she though she was falling-she was sitting in her wheelchair. Then when she couldn't get out of the bathroom, she started crying and called her son. Her son questioned writer about another resident on the unit who (R17) told him has been hitting people and she is afraid of him. Writer assured (R17's) son that we are keeping an eye on him. 10/9/18 Resident asked last night and tonight if she can have something for anxiety. Her son asked about it last night and her (other) son asked about it tonight. Writer explained that she does not have anything scheduled PRN (as needed) but that I will leave a message for the nurse practitioner. Resident is going to be having an evaluation with hospice tomorrow 10/13/18 Heard (R17) screaming ran into her room and found male peer in room. He was removed from her room immediately. (R17) was scared and shaking SOB (shortness of breath), face flushed. Spent some time with (R17) and she did calm down. On 10/29/18 at 10:20 am, Surveyor interviewed LPN I who works full time on the 300 unit. LPN I informed surveyor, It was reported (R9) came into her room (R17) and hit her so in the early morning when she would hear his voice she (R17) would go into like a panic attack. We got her an anti-anxiety [MEDICATION NAME] ([MEDICATION NAME]) was started. (R17) was on [MEDICATION NAME] for awhile, she saw psych before coming here however with (R9) she really went into a panic attack when she heard his voice in the hallway, he had been in her room before either in the PM or night shift. The plan was to watch (R9) and after finding out he was hitting residents the plan was 1:1 with him. That is what they were telling families. I thought it was to be all the time (referring to 1:1), by what families were telling me and what was passed on in report that Management or the front desk could watch him. I would take him up there (to the front desk) if it was 1 CNA and me. I would take him up front and they would take him for 15 minutes and push him back down here. I would say you need to do constant (1:1) on first shift for close supervision. I would be giving medications and helping the CNA getting residents up and he's pretty quick, for me trying to watch him at the same time, I would tell the Manager on Duty, the receptionist, they needed to help me which they did for a few minutes and the he was back to me. LPN I stated on 10/13/18 she (R17) had a panic attack due to peer being in her room. On 10/15/18 R17 had another one. I was in there and she called the family. The daughter-in-law came in, I called the nurse practitioner several times .got [MEDICATION NAME] for anxiety pretty much because of (R9), she does have a history of anxiety and hallucinating however (R9) triggered her to get bad again. I did ask her if she had any history of male issues and she couldn't recall . On 10/30/18 at approximately 5:00 pm, Surveyor interviewed R17 again. R17 stated with (R9) leaving it makes things much better, it's been tolerable, there was a lot of tension we had to go through while he was here. There was a lot of times I woke up screaming because of him, they didn't watch him like they said they would. He kept coming in and I screamed to get him out, they'd come in as soon as they could. He never made it to my bed, I would start crying and they would give me something to calm me down. R17 stated she started seeing a psychologist, that guy had a lot to do with it, the psychologist and the psychologist's nurse asked if staff ever hurt me and I said no not staff but he (R9) attacked me 3 times .they said you have to let it go . On 10/29/18 at 9:25 am, Surveyor spoke to the Social Service Director (SSD) J regarding R17, and was later provided with concern forms and notes which were registered with SSD J. In regards to R17, SSD J stated she knew of 2 incidents between (R17) and (R9). The first incident occurred on 10/10/18 where it was reported that (R17) was hit in the mouth which occurred on pms and that Administrator A and SSD J went to see (R17). The second incident occurred the weekend of (MONTH) 20 stating (R17) reported being hit in the back of the neck by (R9). SSD J stated this was not witnessed by anyone. SSD J stated she just received a second concern on Friday 10/26/18 regarding (R17) for the 10/20/18 incident which staff did not witness (R17) being hurt however a staff member came upon the incident. SSD J provided Surveyor with 2 concern forms submitted for R17. The first concern form for R17 was dated 10/10/18 indicated at approximately 5:30 pm. The concern was that (R17) was returning to the unit .(R9) came up behind (R17) and was trying to grab a cell phone and a purse that belonged to (R17). Once (R17) gently told him he couldn't have her stuff. Before (R17) knew what was happening (R9) hit her in the mouth. (R17) said it was a very hard hit and thought she might tip over.(R17) reports her mouth and teeth hurt/sting .I stayed on the unit .after meal was served I was in (R17's) room. When I came out of her room, (R9) had just spit in (R37's) face and (R8) was attempting to intervene .I provided (R17) with a .heat pack for her neck .This was signed by Unit Manager C. Follow up action consisted of (R17) was assessed, with no injury. Nursing Home Administrator and Social Services Director provided supportive conversations to (unit) 300 residents. Resident listed as aggressor placed on 1:1's. Administrator A also signed this concern form on 10/11/18. Although the facility intervened by placing R9 on 1:1, this intervention was not consistently implemented and it allowed two more physical assaults to occur. A second concern form not dated involving (R17) indicated on 10/23/18 .around 10:25 pm .I came into the dining room and (R17) was crying .(R17) was a foot away from (R9) and (other resident-R18) was on the other side of (R9). (R17) said (R9) hit her and grabbed the wet floor sign for protection but she didn't have to use it. Nobody was yelling out when I was around. The scene didn't look aggressive. I took (R17) to her room and she called (daughter-in-law) . There was no investigation as to the circumstance of R9 entering R17's room on 10/13/18. There was no investigation into R17's allegations of being physically attacked 3 times and no thorough investigation regarding the 10/10/18 and 10/23/18 allegations of abuse. There was no investigation into R37 being spit in the face with (R8) was attempting to intervene as documented on R17's 10/10/18 concern form. 3. On 10/29/18 at 10:20 am, Surveyor interviewed LPN I who works full time on the 300 unit. LPN I stated, (R9) could be nice one minute and hitting and spitting the next especially if there was food he wanted. Surveyor asked LPN I if R9 hit other residents. LPN I stated, When I returned from vacation I heard (R9) did (hit) (R34, R35, R36). On 10/29/18 at 9:25 am, Surveyor spoke to the Social Service Director (SSD) J and was later provided with concern forms and notes which were registered with SSD J. There was no investigation into the allegation that R34 had been hit by R9 as mentioned by LPN I. 4. On 10/29/18 at 10:20 am, SSD J mentioned R35 to Surveyor. SSD J stated she was not aware of specifics and that (R35's) daughter was not hit and was OK. SSD J stated (R9) was trying to get (R35's) dessert and (R35's) daughter was trying to stop him. There was no investigation into the allegation of R35 being hit as per LPN I nor information regarding R35's daughter. 5. SSD J provided Surveyor a concern file registered by R36 dated 10/17/18 documented on 10/16/18, R36 very upset this morning and telling staff and peers to keep (R9) away from her. The Concern form documents, He grabbed my arm and pinched me and was pulling my shirt down signed by LPN. There was no investigation into the allegation of abuse involving the circumstances of 10/16/18 with R9 grabbing and pinching R36's arm and pulling down her shirt. In addition, it is unclear if this incident was the same incident as mentioned by LPN I of R36 being hit. 6. On 10/29/18 at 9:25 am, Surveyor spoke to the Social Service Director (SSD) J. SSD J informed Surveyor (R9) lived next to (resident-R8) and that he had been chasing and following her (R8) around in a circle .this incident occurred possibly on 9/24/18. SSD J also reported meeting with (R8's) managed care organization regarding the increased physical aggression and (R8's) negative reactions toward (R9), who was thinking this was a game. (R8) then physically struck out at (R9) in the arm . A written note in the concern file regarding R8 dated 10/5/18 indicated (R8) expressed feeling discomfort with resident in room (R9) stating she was being singled out by his attention. Advised to also not aggress with him (i.e. videotape, drive scooter etc) overall not engage, she (R8) agreed that changing approach would be help. Meanwhile informed that various interventions were being trialed with him and efforts were ongoing. According to the 9/24/18 Progress Notes, R8 requested to meet with Social Service Director (SSD) - J to discuss an altercation that had occurred with R9 on the prior evening. R8 reported that R9 hit her, spit on her, and chased her around the unit. R8 said that she was not scared of R9; but she would strike back if this were to occur again. SSD - J said that R8 should stay away from R9 and that SSD - J would discuss with the team to discuss interventions. Although Administrator - A was aware of this altercation, there was no evidence that the facility had investigated this allegation of abuse and prevented further potential abuse for R8. The 10/11/18 Progress Notes documented the following altercation between R8 and R9. Residents, including R8, were in the kitchen, eating a snack. R9, who is reported to be food seeking, approached the group. He didn't even get within two feet of the table when (R8) rolled her wheelchair in front of him and yelled 'No!' and shook a finger in his face. She would not let the other resident (R9) around and the other resident (R9) scratched her arm and (R8) stood up and scratched him on both hands and said 'Do you want to know what it feels like?!' and then hit him (R9) in the chest with both hands, pushing him backwards . Although Administrator - A was aware of this altercation, there was no evidence that the facility had investigated this allegation of abuse and prevented further potential abuse for R8 and R9. The 10/18/18 Progress Notes documented the following. R8 reported that R9 had slapped her across the face. R8 reported that a peer had witnessed this. Although Administrator - A was aware of this altercation, there was no evidence that the facility had investigated this allegation of abuse and prevented further potential abuse for R8. When interviewed on 10/30/18, Administrator - A said that she was aware of the above mentioned altercations. Administrator - A said that she had not investigated the allegations because she had determined that R9 had not acted willfully due to his [DIAGNOSES REDACTED]. 7. A review of R9's progress notes included the following in part: 9/21/18 (sic) 01:07 Resident arrived at approximately 1730 (5:30 pm) via ambulance . Swinging out at peer that came near him and yelling at her. 9/24/18 23:22 (11:22pm) Peer and CNA reported he was chasing peer around the room tried spitting and was swinging at her. (R9) was redirected and peer and (R9) were separated. 9/30/18 11:05 All morning has been going up to peers and touching them kissing their hand and kept going into the kitchen and going through cupboards. Redirection not effective .At 0830 this morning followed peer back to her room and hit her in the left arm. Resident was removed from the area, but kept going back to her room. Also swinging out at CNA (Certified Nursing Assistant) and spitting. PRN pain meds were given and took scheduled meds. Charge nurse informed. 9/30/18 21:47 (9:47pm) Resident was witnessed hitting resident (room .) in right side of face. No injuries occurred, no redness to right side of face. The resident was separated from the interaction that took place and was reminded that hitting is not acceptable and not to express himself in that way again . 10/10/18 21:56 (9:56pm) Has been hitting many resident today. Hit (R17) in the mouth. No teeth were broken but her mouth hurts and stated to another staff member that it stings. Hit a resident's daughter and (R35) .so many people afraid of this resident. 10/11/18 19:15 (7:15pm) Post Occurrence Documentation: initial 3-11 shift, body check: Skin Tear/Laceration. Scratches to back of both hands .Resident was in dining room after dinner. Another resident had some Halloween treats that she didn't want to hang up so she threw them out. Another student said he would like to eat them, took them out of the garbage, opened them, and dumped them on the table to share with other residents. (R) saw this and headed over to see if he could get some. Another resident pulled in front of him to keep him from getting to the table and pointed in his face and said, No! (R) scratched resident who stood up and scratched both his arms and yelling at him. She then hit him in the chest with both hands, pushing him back. Writer separated residents, (R) into his room and the other resident into her room, called charge nurse, RN, and looked over both residents . 10/12/18 12:14 (R) was yelling all morning. Given food and was toileted. Going into peers rooms. Provided one on one. Hit staff member in the chin when she went to redirect him he started spitting at her. One on one continued and he hit out a couple more times. Reason unknown. Brought back to unit. 10/12/18 13:23 (1:23pm) Post Occurrence Documentation; days 7-3. Has been yelling out most of shift. Needs constant redirection. Goes up to peers and grabs them squeezes their hands sometimes hard and sometimes he is gentle. Sometimes was seen kissing peers hands. 10/13/18 01:54 (R) grabbed out at a resident at front entrance and resident reported (R) hit him on the right shoulder. 10/13/18 09:30 Has been going behind the counter in the kitchen was redirected several times he can not go back there. Went into peers rooms. 10/14/18 15:23 (3:23pm) Going into peers room while she is sleeping and kept taking her blankets off. Went into another female peers room causing female to scream. And while another female was on the toilet he went into her room. (R) was removed from each peers room and redirected which was not effective. He has been yelling out hitting and spitting at staff . 10/14/18 22:47 (10:47pm) Resident was brought back to unit at 1930 (7:30pm) and immediately started going after other residents and tried to go into two other residents rooms. Tried to hit staff and spit at staff. Was given PRN (as needed) Tylenol after saying yes when asked if he was in pain. At around (YEAR) (8:15pm) was put to bed and fell asleep shortly after. Reception had been watching over him and stated that he had tried hitting him tonight as well. 10/16/18 22:07 (10:07pm) One-on-one at beginning of shift with activity volunteer. Volunteer reported that resident became combative with her when she attempted to redirect him from taking sweets up front .Resident struck out at activity staff while activity staff were working with him one-on-one. Per shift report from day shift, resident went to another unit and struck a resident in the head .No apparent injuries from striking other resident. Resident hit writer after writer was done getting vital signs on him. Resident sat in recliner in TV room and had periods of calling out and hitting the side of the chair and striking out at other residents on unit. No other residents injured this shift. Given APAP for NVPI with good effect. Will continue to monitor. 10/17/18 16:24 (4:24pm) Writer was in nurses station heard yelling went to unit and found (R) and peer yelling hitting and kicking each other. Separated the 2 and (R) went up front for some one on one time. 10/18/18 15:18 (3:18pm) (R) yells out on and off, needs reminders to use inside voice. Peer stated this morning he slapped her and another peer stated yes he did see it. Was not witnessed by writer. CNA reported that he slapped her across the face when she stated he could not go in the kitchen. Redirection not effective. 10/19/18 08:28 Resident had been awake and walking around on N[NAME] (night) shift. He also had tried entering rm ., but was stopped by the N[NAME] (night) aide. Resident was placed in his wheelchair and then the living room recliner. He had gotten out of the recliner on his own. He was then placed in his wheelchair again. Resident began to swat at the aide. 1:1 supervision was then provided for the remainder of the shift. 10/21/18 1600 (6:00pm) Post Occurrence Documentation; Initial: 3-11 shift. Resident was the one hitting people. Resident hit multiple people today, including two residents from the 300 unit, a kitchen staff, a CNA and two nurses. Also spit at staff members. 10/22/18 Post Occurrence Documentation: .Res is aggressor and strikes other resident . Continue to keep res away from other residents when he is becoming agitated. Continue to monitor. 10/24/18 (R) was in the hallway. Another resident came out of his room for a drink and (R) purposely tried to roll his wheelchair in his way. Other resident tried to go around (R) and (R) wheeled into the resident and hit him on his left arm. The other resident grabbed (R) by the arms and yelled, Get out of my (explicative) way you (explicative) creep and pushed (R) backwards. The facility had no investigations into the above resident to resident altercations. Surveyors were able to connect some of these incidents to residents in the facility based off of resident and staff interviews, as well as through reviewing the resident concern file. The facility not investigating allegations of abuse and protecting residents from potential further abuse created a finding of immediate jeopardy. The immediate jeopardy was removed on 10/30/18 when the facility completed the following: Facility Administration reviewed the Abuse Policy and State Operations Manual definitions, including Wisconsin DQA Resident-to-Resident Altercation Flowchart Regional Director of Operations re-educated all IDT (interdisciplinary team) including but not limited to: Administrator, Social Services, Director of Nursing, Activity Director, and line staff on types of abuse and reporting. Regional Director of Operations re-educated Administrator on components of investigation and report

Based on observation, record review and interview, the facility did not ensure at least 8 of 20 Residents (R18, R17, R8, R34, R35, R36, R37, R9) residing on the 300 unit were free from abuse. On 9/20/18, the facility admitted R9 whose prior hospital information indicated R9 exhibited swinging out at hospital nursing staff and of striking others lightly with an open hand. Hospital information also included R9's [DIAGNOSES REDACTED]. While at the facility, R9 resided on the 300 unit which had 20 residents. Throughout R9's stay at the facility from 9/20/18 until discharge 10/26/18, R9 exhibited abusive behaviors towards multiple residents and staff, causing residents to be fearful. * R18 experienced mental abuse from R9 resulting in R18 being intimidated, fearful, moving to a different unit and on 10/25/18 was found barricading herself in her room. * R17 was hit by R9 and was restarted on her anti-anxiety medications because of being afraid of R9. * R8 was not free from abuse by R9, when R8 had physical altercations with R9 on three occasions. * R9 was not free from abuse by R8 when R8 retaliated against R9. R8 had previously informed the facility that she might retaliate against R9 by striking him. Through interviews, record reviews, and review of concerns brought forth to the facility, R34, R35, R36, and R37 were also abused by R9. The facility's failure to prevent abuse of residents created a situation of immediate jeopardy beginning on 9/30/18. The facility's Administrator and Director of Nursing were informed of the immediate jeopardy on 10/29/18 at 3:40 pm. The immediate jeopardy was removed on 10/30/18 when the facility implemented an action plan. The deficient practice continues at a scope/severity level of a E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. Findings include: As a result of multiple complaints registered with the Division of Quality Assurance Southeastern Regional Office regarding residents being fearful of aggressive behaviors exhibited by another Resident, Surveyor conducted Resident observations, interviews and record reviews. On 10/25/18 at 9:05 am, Surveyor entered the 200 unit and observed 8 residents finishing their breakfast in an open dining room. Surveyor observed R9, who resides on the 300 unit, across from this dining room. R9 was sitting in his wheelchair in the TV area. R9 was eating snacks, while the unit nurse, RN E, was administering medications to the residents. A Certified Nursing Assistant (CNA) was also present in the dining room. 1. On 10/25/18 at 9:20 am, Surveyor observed R18 wheeling herself away from the 200 unit dining room. R18 was saying to UM C, Are you watching that guy he was in here when I was eating, that guy who was hitting the woman. UM C informed R18, You are on a different unit, he is still on the old unit where your old room was, he's being discharged tomorrow, he's not here, you are safe here on the unit. R18 continued saying to UM C, He should not stay here, he's not supposed to be here, he waved at me, he shouldn't wave at me, I'm not sleeping here tonight, I got to get out of here, I'm nervous right now, take me back to my room. UM C asked RN E if he saw R9. RN E stated he (R9) was here but went back to the 300 unit. He came to get food. I gave him crackers and he's back on the (300) unit now. UM C then told R18, He's not here, you moved to this room to remove yourself from him, for the most part it is working, you can go back over there (300 unit), this is just temporary until he discharges. On 10/25/18 at 9:25 am, Surveyor observed R9 was no longer on the 200 unit. On 10/25/18 at 11:10 am, Surveyor observed R9 in the center area near the fish tank of Unit B which comprises of 3 units (200, 300, and 400 units) all which extend off the center area near the fish tank. R9 was with the Social Worker and Activity aide at the time. On 10/25/18 at 1:55 pm, Surveyor knocked on R18's door in order to speak with R18. R18 asked who was at the door and when told to come in, Surveyor observed R18 up against the back of the door to her room, sitting in her wheelchair, barricading herself in her room. Surveyor asked R18 what she was doing sitting in her wheelchair up against the door to her room. R18 stated, The naughty man was loose this morning, he was in a place where I was. I thought I'd be secure. I got frightened, I've had a recent stroke. Surveyor questioned R18 as to whether she was trying to block the door to her room from opening. R18 stated, Yes, he hit a bunch of us, he's terribly quick, I am frightened. R18 reported she was keeping the door to her room shut stating, I am terribly frightened, I was going out of the dining room and he was right behind me. I was told he wouldn't be here, he hits people and is running loose they say we can't do things, he's been doing this for 15 days. They say they can't do anything and they let him go. He has not hit me but he came into my room [ROOM NUMBER] times in one night. He hit the person across the hall from me and after that I am afraid of him, I am going to be 100. I should fight at my age. I pray he does not come in here. They are not keeping an eye on him. 3 times they made promises to me he wouldn't be on the floor, why should I watch that guy, he hasn't come down this way just to the dining room. I am frightened all the time. Two weeks ago I had a small stroke. I am so frightened, a bunch of people are concerned. Everyday he gets loose from somebody .he hit the female across the hall about 2 weeks ago, she's not afraid but I am. He hit the nurses too but they are afraid of their jobs. I think I will leave when he's gone, I wake up at night, sweaty, I have [MEDICAL CONDITION]. During surveyor's interview with R18, CNA F entered R18's room. In reference to R9, CNA F stated, I cannot have him over here, as soon as he comes, I try to get him off the unit, he already came over here and hit someone too .(R18) wanted to go back by her friends once in awhile too . A review of R18's medical record indicates an annual Minimum Data Set ((MDS) dated [DATE] which reflects R18 has adequate hearing, clear speech, is understood and understands. R18 was not able to complete the BIMS (Brief Interview for Mental Status) however, staff assessment of her mental status indicates R18 has modified independence with daily decision making skills and has both short and long term memory problems. The MDS indicates R18 has no behaviors, no rejection of cares and no [MEDICAL CONDITION]. R18 has range of motion limitations to 1 side of her lower extremities. R18's Progress notes were reviewed from 9/2/18 through 10/29/18 which, in part, state: 9/2/18 .had a nightmare near 19:30 (7:30 pm) resident screaming . 9/26/18 MD progress note: .denies history of psychiatric disease .anxiety and forgetful, alert and oriented to person, place and time . 10/14/18 (R18) .was readmitted yesterday after having a TIA (stroke). She is alert and oriented able to verbalize needs .voiced concerns over male peer coming into her room and she wants to move .(R18) at times is blocking her door so no one can come in. Explained to (R18) that staff need to be able to come in to check on her and make sure she is OK . Resident daughter here visiting and per discussion with other daughter and facility this resident will move to room (200 unit) to sleep for the evening as daughter (s) state resident is uncomfortable and panicky about staying in her current room .Resident moved with overnight belongings to room .for the night . 10/16/18 Information received from administrator that daughter relayed that resident is to stay 24/7 in room (2 .) due to irreconcilable differences with another resident on 300 unit .Med tech on the unit stated at 1330 (1:30 pm) resident came back to 300 unit and refusing to go back to 200 unit where she previously moved to earlier today. Med tech placed calls to resident's daughter and left message . 10/17/18 .Also spoke with daughter about staying on the unit, she said that was fine as long as Mom feels safe and not anxious about that man. On 10/25/18 at 1:05 pm, Surveyor observed R9 self propelling his wheelchair down toward the center fish tank area from the 300 unit where R9 resides. On 10/25/18 at 1:11 pm, Surveyor observed R9 wheeling himself onto the 200 unit by himself and was then observed sitting outside of the dining room area, near a dining room table. Surveyor observed a staff member enter the area acknowledged R9 and then left. UM C stated, You gotta watch out for that one he's violent. Another Resident stated, Is he here? Surveyor observed R9 making noise then wheeling himself to the other side of the table. CNA F informed Surveyor, he occasionally comes onto the 200 unit, he's got room (R18) worked up. I keep him off the unit, he'll start eating off the tables if they are not cleaned up. Surveyor observed there were 14 plates with left over food on the tables in the 200 unit and 4 residents not done eating. Surveyor observed R18's door to her room on the 200 unit remains closed. On 10/25/18 at 1:25 pm, Surveyor observed the 300 unit. Housekeeper G informed Surveyor R9 was leaving tomorrow. CNA H who was also on the 300 unit stated, Lots of times, R9 is 1:1, he's everywhere we usually keep an eye on him unless activities or someone in the office can keep an eye on him, most of the time he's OK . CNA H provided surveyor with R9's CNA care card dated 9/20/18 which indicated R9 is confused. The CNA care card does not indicate what type of supervision R9's needs. On 10/25/18 at 2:30 pm, Surveyor observed R9 back on the 300 unit sitting in a chair by the TV. R9 had been given soda. At this time, Surveyor interviewed CNA/Med Tech N (on the 300 unit) who stated, If I am doing medications, I keep an eye on him, that he's on the floor. He should be watched, he puts his hands to his mouth when hungry, he should be watched for hitting out, he tries to bat out his arm. CNA/Med Tech N was not aware of R9 hurting any one. CNA/Med Tech N stated R18 used to be on the 300 unit, however R18 wanted to speak to the social worker and when CNA/Med Tech N came back, R18 had been moved to the 200 unit. CNA/Med Tech N stated, R18's items are still in her room on the 300 unit. 2. On 10/25/18 at 2:34 pm, Surveyor interviewed R17. R17 stated she was attacked 3 times by another Resident (R9), he was running free at the time and no one was supposed to watch him, they did change it so that he has supervision, my whole family has complained. There is a social worker and she will take him in the afternoon, so he is supervised she will then free him and bring him back. They are to move him Friday, they don't like you to say anything to him, he will take food off plates, he has smacked some of the older ladies living here. R17 then went on to describe the 3 incidents of attack. R17 stated, the first time within the last month, I was coming back up from downstairs (per resident, the facility calls the center area where the 3 wings meet and where the fish tank is 'downstairs') and I was not feeling that good. He (R9) was trying to grab the bag behind my wheelchair. I said, 'No' and he starting hitting me in the jaw, I saw stars with this. R17 pointed to being hit near the right temple area and in the back. R17 stated, I started screaming and there was no one around except some little ladies at a table. I was trying to get away and hollering for help. 2 nurses came and neither one asked how I was doing or if I was hurt. My lip was bleeding just a little. It was just a little before dinner .I can't remember if they helped me to my room, I was crying hysterically, I was so afraid of my foot (fx), later on someone said, do you know you were attached to his wheelchair .if it weren't for the ladies hollering for him to stop, they did more than the employees . R17 stated the second time either while walking down the hallway or in the TV room can't remember, he came up behind me and started hitting me on the back. You don't know what he will do or if someone will come get him. This occurred a couple of weeks ago .I called my daughter-in-law and told her I was attacked again. They said to stay right there, I'll be in as quick as I can, she was livid. Daughter-in-law met with the Social Worker who was going to talk to them, guaranteed placement for him and is leaving Friday, Social Worker told me everything is being taken care of. I think they said they would have someone watch him all the time but the nurses don't realize what he had done. They act like why are you so scared it's supposed to be that you cannot be near him at all and supervised and maybe put him in a room. R17 reported the 3rd incident was the most traumatic of all and is a doozy, it happened this past Saturday 10 pm, 3 of us were at a table, we had to go to the bathroom, he (R9) came up to our table, I said get someone to read a book, he kept raising his hands (at other resident)(R18) who said 'if we don't say anything he may go away', he was going to swing at (R18), I said don't touch her, he came to me, I hollered at him to get away go back to your room, someone come please. There was 1 aide and 1 nurse how can they help anyone. The nurse came in and stated if he bothers you that much go to your room or he can come with me. He followed her to the fish tank area, than the nurse came back saying has anyone found ( R9). He had come back and was in the kitchenette, they were trying to pacify him with sweets. She just left him wandering. R17 told (R9) you need to go away from us and he gave me a whack between the neck and the back. R17 said there was only one person who couldn't help him and I kind of lost it here. There were 3 elderly people and she couldn't take care of his needs .they knew he was to be watched. At 3:15 pm, during Surveyor's interview with R17 a psychologist came to visit with R17 and Surveyor concluded the interview. On 10/25/18 at 5:00 pm, Surveyor shared concerns regarding the supervision of R9 and the fears expressed by R18 and R17. Administrator A stated they did not know of R9's behavior problems prior to R9's admission. Administrator A said there was nothing (in the hospital) paperwork to indicate behaviors. Administrator A reported R9 was held at the hospital until the Level 2 screen could be completed. Administrator A and Director of Nursing (DON) B stated that R18 may have had some similar behaviors in the past (re: barricading herself in her room) with a different resident, however; surveyor did not see this type of behavior identified in R18's care plan, nor were behaviors identified on R18's annual MDS dated [DATE]. Administrator A and DON B stated they were aware of R17 having an incident with R9 but were not sure about the second and third incidents as described by the resident. Administrator A stated the 3rd alleged incident was investigated and they could not substantiate it as occurring. Surveyor was provided with an incident report dated 10/10/18 1730 (5:30 pm) which read, A male resident in wheelchair came up behind resident (R17) tried to grab cell & purse and resident (R9) hit her in mouth. Daughter-in-law present. APNP (Advanced Practice Nurse Practitioner) visit with resident on 10/11/18, MD here 10/15/18. Heat pack for neck. Surveyor reviewed R17's medical record. R17's initial MDS dated [DATE] indicates R17's hearing is adequate, with clear speech and is able to make self understood and understands. The BIMS score was a 6 indicating R17 is severely cognitively impaired for daily decision making skills. A not yet completed quarterly MDS dated [DATE] has R17's BIMS score at 11 which indicates R17 is moderately impaired for daily decision making skills. The initial MDS indicates no for hallucinations and no for delusions, no for behavioral symptoms and no for rejection of cares. A review of progress notes from 9/4/18 through 10/28/18 in part documents: 9/14/18 Confusion on and off. Redirection not effective . 9/19/18 MD progress note: .dementia, anxiety .complaining anxiety .appropriate affect, alert and oriented to person, place and time . 10/2/18 Resident has had periods of anxiety on and off. Tonight resident was washing face in bathroom and yelled because she though she was falling-she was sitting in her wheelchair. Then when she couldn't get out of the bathroom, she started crying and called her son. Her son questioned writer about another resident on the unit who (R17) told him has been hitting people and she is afraid of him. Writer assured (R17's) son that we are keeping an eye on him. 10/9/18 Resident has been very anxious the past few days- hallucinating 10/9/18 Resident asked last night and tonight if she can have something for anxiety. Her son asked about it last night and her (other) son asked about it tonight. Writer explained that she does not have anything scheduled PRN (as needed) but that I will leave a message for the nurse practitioner. Resident is going to be having an evaluation with hospice tomorrow 10/13/18 Heard (R17) screaming ran into her room and found male peer in room. He was removed from her room immediately. (R17) was scared and shaking SOB (shortness of breath), face flushed. Spent some time with (R17) and she did calm down. A review of R17's (MONTH) (YEAR) Medication Administration Record [REDACTED] The (MONTH) (YEAR) MAR indicated [REDACTED] On 10/15/18 the order was revised for [MEDICATION NAME] 0.25 mg 1 tablet by mouth every 6 hours as needed for anxiety from 10/15/18 to 10/22/18. On 10/22/18, the [MEDICATION NAME] 0.25 mg 1 table by mouth every 6 hours as needed for anxiety was again reordered. The (MONTH) (YEAR) MAR indicated [REDACTED]. On 10/29/18 at 10:20 am, Surveyor interviewed LPN I who works full time on the 300 unit. LPN I stated, (R9) could be nice one minute and hitting and spitting the next especially if there was food he wanted. Surveyor asked LPN I if R9 hit other residents. LPN I stated, (R8) reported being hit by (R9). LPN I stated, When I returned from vacation I heard (R9) did (hit) R34, R35, R36. LPN I informed surveyor, It was reported (R9) came into her room (R17) and hit her so in the early morning when she would hear his voice she (R17) would go into like a panic attack. We got her an anti-anxiety [MEDICATION NAME] ([MEDICATION NAME]) was started. (R17) was on [MEDICATION NAME] for awhile, she saw psych before coming here however with (R9) she really went into a panic attack when she heard his voice in the hallway, he had been in her room before either in the PM or night shift. The plan was to watch (R9) and after finding out he was hitting residents the plan was 1:1 with him. That is what they were telling families. I thought it was to be all the time (referring to 1:1), by what families were telling me and what was passed on in report that Management or the front desk could watch him. I would take him up there (to the front desk) if it was 1 CNA and me. I would take him up front and they would take him for 15 minutes and push him back down here. I would say you need to do constant (1:1) on first shift for close supervision. I would be giving medications and helping the CNA getting residents up and he's pretty quick, for me trying to watch him at the same time, I would tell the Manager on Duty, the receptionist, they needed to help me which they did for a few minutes and then he was back to me. LPN I stated on 10/13/18 she (R17) had a panic attack due to peer being in her room. On 10/15/18 R17 had another one. I was in there and she called the family. The daughter-in-law came in, I called the nurse practitioner several times .got [MEDICATION NAME] for anxiety pretty much because of (R9), she does have a history of anxiety and hallucinating however (R9) triggered her to get bad again. I did ask her if she had any history of male issues and she couldn't recall . On 10/30/18 at approximately 5:00 pm, Surveyor interviewed R17 again. R17 stated with (R9) leaving it makes things much better, it's been tolerable, there was a lot of tension we had to go through while he was here. There was a lot of times I woke up screaming because of him, they didn't watch him like they said they would. He kept coming in and I screamed to get him out, they'd come in as soon as they could. He never made it to my bed, I would start crying and they would give me something to calm me down. R17 stated she started seeing a psychologist, that guy had a lot to do with it, the psychologist and the psychologist's nurse asked if staff ever hurt me and I said no not staff but he (R9) attacked me 3 times .they said you have to let it go . 3. On 10/29/18 at 9:25 am, Surveyor spoke to the Social Service Director (SSD) J regarding R9, R18, and R17 and was later provided with concern forms and notes that were registered with SSD J. SSD J stated she was not familiar with (R9's) aggression prior to (R9) coming here. SSD J reported, The (Administrator A) takes admission and I do as well, I didn't see anything regarding physical aggression. SSD J stated, They talked about splitting up 1:1's between the Manager on Duty (MOD), receptionist, activity aide, all taking turns to keep an extra eye on him for physical aggression. We initiated the 1:1 especially in the evening as he attended therapy which was discontinued on 10/25 & 10/26/18 and some activities during the day. SSD J stated, We started the 1:1 on the pm shift from 3 to 8pm at which time (R9) is ready to go to bed. The 1:1's were initiated on 10/11/18 even though the care plan says 10/19/18. SSD J also reported all staff are aware of (R9) and to keep an eye on him. SSD J stated, We noticed an increase in behavior and the support care plan provided by managed care did not seem effective. SSD J stated the Manager on Duty is a rotated position between herself, activities, dietary, medical records, and other staff. SSD J provided Surveyor with an (MONTH) (YEAR) monthly calendar with MOD providing 1:1. SSD J reported the following regarding the various residents: SSD J stated R18 requested to move rooms for a short term basis. She was afraid of (R9) and caused her anxiety. She wanted to move off the unit, she (R18) felt he went into her room [ROOM NUMBER] times. That's not the only resident room he went in. Surveyor was provided with a notes from the facility's concern file. A typed note dated 10/11/18 states, Administrator and Social Service Director walked 300, to provide support counseling to residents in needs, in regards to (R9's) behaviors. Additionally this typed note included, spoke with room number listed (R18) and daughter. They are very concerned, wanted resident (referring to R9) arrested/restrained/liberty to be restricted. Expressed our inability to take those very specific steps. Expressed unrest and anxiety over the whole situation. Continued to reiterate understanding of their feelings and the facility was taking resident safety and wellness very seriously. A handwritten note in the concern file was dated 10/14/18 indicating (R18's) daughter requested change off 300 unit, changed same day, move to room (200 unit). 10/15 Resident moved self back to room (300 unit.) 10/16 Daughters requested move back and allow to be in both rooms .advised she could be in either, not both .currently resident (R18) is residing in room (200 unit) but is occupying both rooms. In regards to R17, SSD J stated she knew of 2 incidents between (R17) and (R9). The first incident occurred on 10/10/18 where it was reported that (R17) was hit in the mouth which occurred on pms and that Administrator A and SSD J went to see (R17). The second incident occurred the weekend of (MONTH) 20 stating (R17) reported being hit in the back of the neck by (R9). SSD J stated this was not witnessed by anyone. SSD J stated she just received a second concern on Friday 10/26/18 regarding (R17) for the 10/20/18 incident which staff did not witness (R17) being hurt however a staff member came upon the incident. SSD J provided Surveyor with 2 concern forms submitted for R17. The first concern form for R17 was dated 10/10/18 indicated at approximately 5:30 pm. The concern was that (R17) was returning to the unit .(R9) came up behind (R17) and was trying to grab a cell phone and a purse that belonged to (R17). Once (R17) gently told him he couldn't have her stuff. Before (R17) knew what was happening (R9) hit her in the mouth. (R17) said it was a very hard hit and thought she might tip over.(R17) reports her mouth and teeth hurt/sting .I stayed on the unit .after meal was served I was in (R17's) room. When I came out of her room, (R9) had just spit in (R37's) face and (R8) was attempting to intervene .I provided (R17) with a .heat pack for her neck .This was signed by Unit Manager C. Follow up action consisted of (R17) was assessed, with no injury. Nursing Home Administrator and Social Services Director provided supportive conversations to (unit) 300 residents. Resident listed as aggressor placed on 1:1's. Administrator A also signed this concern form on 10/11/18. A second concern form not dated involving (R17) indicated on 10/23/18 .around 10:25 pm .I came into the dining room and (R17) was crying .(R17) was a foot away from (R9) and (other resident-R18) was on the other side of (R9). (R17) said (R9) hit her and grabbed the wet floor sign for protection but she didn't have to use it. Nobody was yelling out when I was around. The scene didn't look aggressive. I took (R17) to her room and she called (daughter-in-law) . SSD J also mentioned R35 during Surveyor's interview with her. SSD J stated she was not aware of specifics and that (R35's) daughter was not hit and was OK. SSD J stated (R9) was trying to get (R35's) dessert and (R35's) daughter was trying to stop him. Surveyor also observed in the concern file a Patient Concern form registered by R36 dated 10/17/18 documenting on 10/16/18, R36 very upset this morning and telling staff and peers to keep (R9) away from her. The Concern form documents, He grabbed my arm and pinched me and was pulling my shirt down signed by LPN. SSD J informed Surveyor (R9) lived next to (another resident-R8) and that he had been chasing and following her (R8) around in a circle .this incident occurred possibly on 9/24/18. SSD J also reported meeting with (R8's) managed care organization regarding the increased physical aggression and (R8's) negative reactions toward (R9), who was thinking this was a game. (R8) then physically struck out at (R9) in the arm . A written note in the concern file regarding R8 dated 10/5/18 indicated (R8) expressed feeling discomfort with resident in room (R9) stating she was being singled out by his attention. Advised to also not aggress with him (i.e. videotape, drive scooter etc) overall not engage. She (R8) agreed that changing approach would help. Meanwhile informed that various interventions were being trialed with him and efforts were ongoing. 4. R8 first altercation between R8 and R9: According to the 9/24/18 Progress Notes, R8 requested to meet with Social Service Director (SSD) - J to discuss an altercation that had occurred with R9 on the prior evening. R8 reported that R9 hit her, spit on her, and chased her around the unit. R8 said that she was not scared of R9; but she would strike back if this were to occur again. SSD - J said that R8 should stay away from R9 and that SSD - J would discuss with the team to discuss interventions. Although R8 stated that she was not afraid of R9, this incident appeared to upset her as evidenced by the following progress note. On 10/2/18, SSD - J and Nursing Home Administrator (NHA) - A met with R8. R8 had left a voicemail stating that she was going to stop taking her medications starting tomorrow due to R9's aggressive behaviors. NHA - A informed R8 that the inter-disciplinary team was working on interventions to address R9's aggressive behavior. Second altercation between R9 and R8 with R8 retailiating abuse towards R9: The 10/11/18 Progress Notes documented the following altercation between R8 and R9. Residents, including R8, were in the kitchen, eating a snack. R9, who is reported to be food seeking, approached the group. He didn't even get within two feet of the table when (R8) rolled her wheelchair in front of him and yelled 'No!' and shook a finger in his face. She would not let the other resident (R9) around and the other resident (R9) scratched her arm and (R8) stood up and scratched him on both hands and said 'Do you want to know what it feels like?!' and then hit him (R9) in the chest with both hands, pushing him backwards . Prior to this altercation, no interventions were developed to prevent R8 from retaliating with aggression if R9 aggressed against her. R8's care plan was reviewed and no behavioral interventions were added to the care plan until 10/30/18. This was after the survey team informed the facility that there were concerns with R9's multiple acts of aggression towards R8 and other residents. Third altercation between R9 and R8: The 10/18/18 Progress Notes documented the following. R8 reported that R9 had slapped her across the face. R8 reported that a peer had witnessed this. Interview with Surveyor: On 10/29/18 R8 requested to speak with the surveyor. She reported that she had been attacked multiple times by R9. R9 had spit on her and hit her. R8 said that R9 knew exactly what he was doing. R8 reported that R9 would wait until the CNAs left the area and he would then aggress against her. R8 reported that if an altercation occurred in the common TV area of the unit; staff would direct R8 to go to her room. R8 said that this was a problem because she did not have a TV in her room and she wanted to watch TV. (The surveyor interviewed R8 in her room and observed that she did not have a TV in her room.) R8 said that the staff told her that R9 did not know what he was doing because he had an Intellectual Disability. Interview with Administrator: When interviewed on 10/30/18, Administrator - A said that she was aware of the above mentioned altercations. Administrator - A said that she had not seen the altercations as abuse because she had determined that R9 had not acted willfully due to his [DIAGNOSES REDACTED]. 5. A review of R9's medical record indicated the following: R9 was admitted into the facility on [DATE] from the hospital for short term rehab. Hospital records indicate R9 was found to have a right femour (sic) fracture and is now s/p (status [REDACTED]. The hospital record indicates a Problem List/Past Medical History ongoing which included; anxiety disorder, disruptive behavior disorder, mood disorder, nonpsychotic mental disorder due to organic brain damage, [MEDICAL CONDITION] disorder, severe mental [MEDICAL CONDITION] . Hospital medications included [MEDICATION NAME]/[MEDICATION NAME] (anti-anxiety) TID (3 times a day) and HS (night time), [MEDICATION NAME]/[MEDICATION NAME] (anti-psychotic) BID (2 times a day), [MEDICATION NAME]/[MEDICATION NAME] (anti-depressant) daily and [MEDICATION NAME]/Oleptro (anti-depressant) HS. A hospital Occupational Therapy (OT) note documents, .Patient at times will lightly strike out with his open hand. This appears to be more of an attention seeking behavior A night shift nursing summary in the hospital notes dated 9/19/18 states, Pt started shift agitated and pulling at his bedding .writer assessed pt (patient) and believed pt was in distress because of pain .it was agreed for pt to have 0.2 mg of [MEDICATION NAME] for immediate relief and 1 [MEDICATION NAME] to maintain comfort in the long term. Pt did well with this until later when pt again appeared to be in pain. Pt had been resisting taking oral medications and slapped writer . R

Uncorrected on Follow Up visit. Based on observation, staff interview and resident interviews, the facility did not provide services by sufficient numbers to provide nursing care on a 24 hour basis to all residents in accordance with resident care plans. The facility did not provide sufficient licensed nurses and other nursing personnel including but not limited to nurse aides. This had the potential to affect 26 out of 111 residents in the facility (R1, R3, R4, R7, R8, R9, R10, R13, R15, R17, R18, R21, R22, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R41, R42.) Residents were not afforded consistent care in sufficient numbers to address: -Lack of sufficient staff to provide transfers and assistance in and out of bed due to inavailability of staff to operate mechanical lift equipment properly, affecting R15 and R3; -Lack of sufficient staff to provide prompt assistance to the toilet for R27 and R22 which resulted in bowel incontinence; -Residents interviewed indicated slow or no response to call lights (R27, R13) and periods of time when the living unit had no staff on it. R1 expressed ongoing concerns with staffing on the 200 unit. R3 expressed concerns of worry if no nurse would be able to come and attend to her if she were to have a coughing spell. -Lack of sufficient staff in dining at a reasonable amount of time so food did not get cold affecting R32, R33 and R34. -Interviews with licensed nurses and nurse aides reflected insufficient staff to render desired care due to work loads that could not be met. Interview with residents indicate a concern regarding staffing (R1 & R31). -Insufficient staff to give residents' baths and showers according to their preferences affecting R4, R21, R28, R29, R30, R41 and R42. (Cross Reference F677) -Behavior of R9 towards other residents, in which abusive acts were allowed to occur by R9 due to lack of proper management of maladaptive resident behaviors affecting 8 of 8 residents, (R18, R17, R8, R34, R35, R36, R37, R9); (Cross Reference F600) - Lack of sufficient staff supervision to ensure R8 did not fall when standing up from her wheelchair to reach for a TV clicker, and a blanket from the linen closet. R8 placed a second blanket on R10 who was sitting in a lounge chair in the TV area. R10 was not able to cognitively or physically give input into the care R8 was placing upon R10 which was a second blanket. -Lack of sufficient staff supervision to manage residents who were at high risk for falling affecting R7, who had 18 falls without adequate supervision to prevent them; (Cross Reference F689) 12 Formal complaints regarding insufficient staffing patterns to meet resident needs were received by the State of Wisconsin, Division of Quality Assurance, between the dates of 9/11/18 to 11/5/18 indicating insufficient staffing. Inadequate staffing adversely affected residents' dignity and their quality of life. Residents wet or soiled themselves because staff could not answer call lights timely, did not get showered or assisted out of bed because staff did not have time to assist them, and lived in fear of something happening and having no staff to respond. Findings include: The facility assessment included the following information about the facility: The number of residents licensed to provide care for = 120. -Number of beds: B200 = 22 beds, B300 = 22 beds, B400 = 22 beds, C500 = 18 beds, C600 = 18 beds, C700 =18 beds. -The facility average daily census ranges from 104-112. -The facility utilizes an interdisciplinary pre-admission screening process for identifying patients that may need further review or consideration prior to acceptance. Similarly, the facility utilizes an interdisciplinary review process to review acuity of current residents who have developed conditions the facility has not previously supported. -In describing the acuity of the residents, the facility self identified that over the past year 57% of the residents are at the facility for rehabilitation, 7% clinically complex, 4.5% with behavior symptoms and cognitive performance and 16.94% having reduced physical functioning. -In the section, titled Other, the facility assessment indicates that other pertinent facts or descriptions of the resident population that must be taken into account when determing staffing and resource needs, are sleeping preferences, which is used to tailor each resident's care needs and preferences, bathing preferences, which assists the staff in tailoring each resident's care needs and preferences. -In the section that lists the types of care that your resident population requires and that you provide your resident population, the specific care or practices section includes, responding to requests for assistance to the bathroom/toilet promptly in order to maintain continence and promote resident dignity, preventing abuse and neglect and identifying hazards and risks for residents. In the section of the Facility Assessment identifying Facility Resources needed to provide competent support and care for our resident population evey day and during emergencies, the facility identified a staffing plan that consists of the following: Full Time numbers needed to promote continuity of care: Licensed nurses 13, Certified Nursing Assistants 24, 1 Director of Nursing, 1 Assistant Director of Nursing, 1.4 Resident Care Coordinator, 2 Hospitality Aides. There is provision in this staffing plan that staffing may be adjusted based on resident needs. In this section of the Facility Assessment, individual staffing assignments are determined at the facility level and take into consideration the current support/care needs of the residents that include, but are not limited to medical/physical conditions, acuity, physician orders, therapeutic needs, infection prevention and control needs, behavioral support as well as any other special care needs as identified. The surveyors interviewed the Director of Nursing (DON) B and Administrator A on 10/25/18 at 5:00 pm regarding the current facility staffing. The Administrator indicated that the census was 111 and the facility ideal staffing ratio would be 1:10 and had been 1:8 in the past but we don't have residents with high acuity. The Administrator then described the building as having 2 sides to it. Each side of the building has 3 separate living units for the residents and the desired staffing should be: Side B units 200, 300, 400: Day shift: 5-7 CNAs (Certified Nursing Assistants), 3 Nurses (8-10 nursing staff) Evening shift: 5 CNAs, 2 Nurses (7 nursing staff) Night shift: 3 CNAs, 1 Nurse, 1 Charge nurse (5 nursing staff) Side C units 500, 600, 700 would be the same. Day shift: 5 CNAs and 3 nurses (8 nursing staff) Evening shift: 4 CNAs and 2 nurses (6 nursing staff) Night shift: 3 CNAs 1 nurse (4 nursing staff) The Administrator indicated that the facility is still admitting new residents. 1. On 10/25/18 the staffing schedule reviewed by the surveyors included: Day shift: 5 CNAs for both sides of the building when there should be 10, 5 licensed nurses when there should be 6. The Assistant Director of Nursing is one of the licensed nurses. Evening shift: 4 CNAs when there should be 9 CNAs, 3.5 licensed nurses when there should be 4 Night shift: 6 CNAs and 3 licensed nurses. 2. The surveyor reviewed the medical record regarding a complaint filed about R15 not being assisted out of bed on 9/22/18 until after 1:30 PM. The medical record does not reflect any information about care refusals on 9/22/18 or other information as to why R15 should remain in bed. The surveyor spoke with CNA-Z on 10/29/18 at 12:52 PM. CNA-Z remembered R15 and the day in question. CNA-Z admitted not getting resident out of bed because there was no staff available to assist her in transferring R15. CNA-Z indicated he did get washed in bed that day. CNA-Z said she was alone on the unit that day and unable to find another staff member to assist her in getting R15 out of bed. 3. R27 and his wife wished to speak with surveyors on 11/5/18 at 8:48 AM. R27 indicated he had just been admitted to the facility the previous week, on 10/31/18 and was concerned about care needs not getting met, including call light wait time of 40 minutes on 11/2/18 on the evening shift. R27 indicated he needs prompt assistance as he was on intravenous antibiotics and having urgency with bowel movements. R27 indicated he has had bowel incontinence episodes in his brief due to not receiving prompt assistance with toileting needs. R27 indicated he is having incontinence episodes about 2 times a day and is concerned about skin breakdown. R27 also expressed concerns to the surveyor that he needs to have 2 staff to operate the lift device that helps him in and out of bed. R27's wife indicated that she is staying at the facility with the resident and sleeping in his room to make sure he gets the care he needs. R27's wife indicated that there are many times at night when no staff are on the unit and she must leave the unit to find staff to assist R27. R27's wife also indicated that the IV (intravenous) medication pump beeps when there is air in the line and she has to hunt someone down to deal with the IV pump beeping. R27's wife also indicated that R27 did not get served breakfast on Saturday, 11/3/18, until 9:30 AM because R27 was still in his room and in bed. Then lunch came again at noon. R27's wife also indicated that R27 requests to go to bed every day at 2:30 PM if he knows the next shift is short-staffed because he is afraid of not getting assistance to get to bed when he wants and would have to sit up in his wheelchair all night. 4. On 10/24/18, at 11:58 AM, R13 was observed in bed. The surveyor asked R13 questions about his care. R13 indicated he was paralyzed and needed total assistance from the staff for all of his needs. R13 told the surveyor that he doesn't always get checked on during the night and there have been times when he has called out for help up to 3 hours. The surveyor asked R13 what he was calling for and he indicated it was usually for a drink, to get his pillow moved or for the fan to be turned off. R13 also indicated that facility staff will get him up when he asks, but getting back to bed is often a problem, so he chooses to stay in his bed most of the time. R13 also indicated he has a history of pressure ulcers and there have been times when he has had to sit up longer than he was suppose to, up to 2 hours longer. R13 indicates he does not use a call light and yells out to get staff attention. The annual Minimum Data Set (MDS) with a target date of 10/5/18 places R13's Brief Interview for Mental Status at a score of an 11 which indicates R13 is moderately cognitively impaired for daily decision making skills. 5. Dining observation, 700 unit: The surveyor was on the 700 unit on 10/24/18 at 12:18PM. While on the 700 unit, the nurse (LPN)-P was observed to be finishing up her medication pass and on the telephone with a family member when food was being served from the kitchen area. There were no other nurse aides observed on the unit. The surveyor observed one table in the dining room where 3 residents, who required eating assistance, were seated. All 3 had been served their food and were not touching it. According to R32's MDS on 10/1/18, R32 required extensive assist of 1 person and was moderately cognitively impaired. R32 was asleep in her wheelchair with a full, untouched plate of food in front of her. R33 whose medical record MDS on 9/12/18 identified her as being on Hospice care and having severe cognitive deficit, required extensive assistance with eating. R34 was also seated at this table; her MDS of 12/18/17 indicated she required extensive assistance with eating. At 12:23 PM, LPN-P was observed to leave her med cart and give verbal assist to another resident at a table near the 3 residents who needed eating assistance. At 12:24 PM, the surveyor heard LPN-P calling on the unit telephone indicating there were no staff available on the unit to help with dining. At 12:24 PM, CNA-Q walked down the hallway towards the dining room and the surveyor asked CNA Q if she worked the unit. CNA-Q said she did but could not assist in the Dining room because she was in a resident room assisting her to eat in her room. At 12:26 PM, CNA-S showed up in the dining room. The surveyor asked CNA-S where she was working and CNA-S indicated she was from Activities and was a CNA. At 12:32 PM, LPN-P indicated she was now done with her med pass. LPN-P then sat down to assist the 3 residents, R32, R33 and R34 who were at the eating assist table and began to assist them to eat, cutting up their food and encouraging them to open their mouths for food 14 minutes after the surveyor first saw them with untouched food in front of them. At 12:35 PM, R33 was still asleep while up in her Broda chair and food was untouched in front of her. At 12:35 PM, CNA-S felt the plate of R33 and indicated the plate was cold. CNA-S then was observed to go to the microwave to heat the food up. At 12:44 PM, LPN-P then went to R34 to assist her to eat and R34 was not interested in eating the food. The surveyor asked if she could feel the bottom of R34's plate and the surveyor felt the plate to be cold. LPN-P then heated the food up in the microwave. At 12:52 PM, CNA-R then came to the table to sit with all 3 residents and offer assistance with eating to them. 6. The surveyor went to the 200 unit on 10/24/18 at 1:10PM, the surveyor could hear a R38 calling out for help from her room. No staff were visible on the unit. A Yellow star was on the frame of the door of R38's room. CNA F was then observed wheeling R39 down the hall to her room while R38 was still calling out from the bathroom of her room. CNA-F went into R39's room and shut the door, telling R38 she would be there as soon as possible and to not go to the bathroom by herself. At 1:14 PM, the surveyor heard R38 groaning loudly from her bathroom of her room. At 1:15 PM, CNA-F came out of R39's room. CNA-X then showed up telling the surveyor that she is floating in between 2 units that day, unit 200 and 400. At 1:16 PM, CNA-F entered R38's room with a lift device and CNA-X entered the room shutting the door. At 1:24 PM, CNA-X exited R38's room with the mechanical lift and shut the door. CNA-F stayed in the bathroom to assist R38. At 1:25 PM, CNA-F exited the R38's room and indicated R38 made it onto the toilet. The surveyor interviewed CNA-F asking her what was not being done for the residents due to the staffing levels that day. CNA- F indicated that residents had to eat in bed that morning instead of getting up out of bed to get into the dining room for their meal. 7. R22 spoke with the surveyor on 10/24/18 at 1:32 PM. R22 indicated to the surveyor that she has been up in her wheelchair from 11:00 AM to 11:30 PM recently when she was only suppose to be up in her wheelchair for 2 hours. R22 indicated that she currently has a catheter in place but is using a bedpan in bed. R22 indicated that she cannot always get a bedpan in time, or when assisted onto the bedpan sits on it too long. R22 has a BIMS (brief interview of mental status) of 15, on her 10/16/18 MDS (minimum data set) which indicates she is cognitively intact. On 10:24 PM, at 1:34 PM, Certified Nursing Assistant (CNA)- F told R22, in the presence of the surveyor, not to worry as she promised to return to assist the resident with getting into bed before CNA- F left for the day. The surveyor then asked CNA- F about her work duties and CNA- F indicated she was pushed to the max and when she came over to the unit R22 lived on that morning, there were no other staff on the unit, so she began to do care rounds and did the best she could. CNA- F indicated she does the best she can for all of the residents but there are times when residents have to eat meals in bed because there is no staff to get residents up and out of bed for meals. CNA-F indicated that R22 was not able to wait for CNA-F to get to her before having a bowel accident in her bed that morning. CNA-F indicated that R22's call light had been on but CNA-F could not get to her in time. The surveyor reviewed the staffing schedule for 10/24/18 and did see that one staff member who was scheduled on the 200 unit had called in. CNA-F was working this unit alone on this 22 bed unit with another CNA floating to the 200 unit from the 400 unit. 8. On 10/25/18 at 9:14 AM, the surveyor was on the 600 unit. The Med Tech (MT)-W told the surveyor that she can only give oral medications and nurses from other units have to come over and do all skin treatments with open skin, give insulins, IV medications and charting. MT-W told the surveyor that transfers have to wait, repositioning of residents has to wait for those who are 2 person transfers. If residents require 2 people to ambulate, then they must wait until we have 2 staff available. 9. On 10/25/18 at 10:05 AM, CNA-Q indicated she had come into work at 2:30 AM because there was no staff working on the night shift and that she was doing care for 15 residents that day, bathing, dressing, toileting and assistance with dining and the nurse helps when they are not doing meds and treatments. 10. On 10/25/18 at 2:12 PM, R3 asked to see the surveyor. R3 indicated that the facility is short staffed and that staff can't work like this anymore. R3 indicated that she chooses to be the last person up each day and the last to go to bed to help the staff out so they can attend to other residents. R3 indicated that she observes one nurse aide trying to feed 5 residents in the evenings and the nurses come over to the unit to pass medications, then have to leave to go work another unit. R3 indicated there are times when she must wait 30 minutes to use the bathroom before staff can answer her call light and R3 has had incontinent accidents. R3 indicated that one night she had a coughing spell and asked an aide to get a nurse and the aide indicated she could not find a nurse as the nurse was on the other end of the building. R3 indicated she was able to finally clear, but now worries that if she was choking there would be no nurse. R3 indicated she has been here over 3 years and this year has been the worst with staffing. R3's medical record indicated a MDS completed on 8/29/18 which showed a BIMS score of 11. A score of 8-12 indicates one is moderately cognitively impaired. 11. On 10/31/18 at 9:30 AM, the surveyor was on the 300 unit. The surveyor observed LPN-I passing medications from the med cart. The surveyor asked LPN-I if she was still passing her 8:00 AM medications. The LPN indicated yes and she was behind because of staffing because of assisting residents with breakfast and helping the nurse aides with cares. LPN-I told the surveyor that in the last 6 months, they have been working the unit with 1 nurse, 1 nurse aide and maybe one nurse aide to float. LPN-I indicated showers were getting missed, oral hygiene was lacking, walking in the hallways was not always able to be done and treatments are done, but late and sometimes charting and other documentation gets put off. 12. On 10/31/18 at 11:40 AM, the Nursing scheduler-T was interviewed by the surveyors. Scheduler-T told the surveyors that she tries to get as many people in the building as possible each day and currently has several calls out for workers to come in to fill the gaps. Scheduler-T indicated she looks at the daily census and tries to get 28 nurse aides in the building per day if the census is 115-120, 27 nurse aides in the building if census is 109-114 and 26 nurse aides in the building if census is 103-108. The scheduler told the surveyors that on day shift they try and get 10-12 nurse aides in the building, but today, 10/31/18, they only had 6 for the day shift. On the evening shift they try and get 8-10 nurse aides, but generally they get 6 and on the night shift they try to get 6 nurse aides in but they will work with 5 and the nurse has to work as a nurse aide. Looking at the schedule on 10/31/18 with the scheduler, the scheduler told the surveyors that 11 nurse aides were scheduled, 1 went home sick, 1 was on light duty, 1 bumped up to a Med Tech and 1 was off because she worked a double shift on Monday. The Scheduler said she goes through the list of all employees and at times have exhausted all resources. The scheduler will ask the therapy nurse aides and activity nurse aides to also pick up shifts and anyone with a CNA certification has been asked to take one of the holes. The scheduler said that the Administrator, the Director and Assistant Director of Nursing have also filled slots when necessary. 13. On 10/22/18 the state agency received a complaint indicating that R21 had not received a shower from 9/7 - 9/30/18 while he was at the facility for respite care. The 9/16/18 Minimum Data Set (MDS) for R21 documented the following. R21 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) for personal hygiene. For bathing, it was documented Activity did not occur. The MDS also documented that rejection of care was not exhibited. According to the medical record, R21 was scheduled to receive a shower on Mondays and Thursdays. Surveyor reviewed R21's documentation of showers/baths and noted that between 9/7/18 and 9/30/18 (23 days) there was no documentation of R21 receiving a shower/bath. Surveyor reviewed R21's medical record and was unable to find documentation that R21 had refused a shower/bath. On 10/29/18 at 12:39 PM, DON (Director of Nursing) - B was interviewed. Surveyor requested information and documentation regarding any shower/bath given. DON-B responded, He doesn't have any. No additional information or documentation was provided. 14. During the survey, Anonymous CNA - K was asked if there was sufficient staff on the unit to allow her to assist residents with their ADL's (hygiene). CNA - K said that when she is the only CNA on the unit, she is unable to bathe residents. This is because she would be in the bathing area and no staff would be available to assist/monitor residents on the unit. When interviewed during the survey, CNA - K was the only CNA on the unit during her shift. On 10-31-18 R4 requested that the state survey agency attend the resident council meeting to hear residents' concerns related to insufficient staff. The surveyor attended the meeting at 2 PM. At their previous meeting on 9/20/18, residents indicated that it took too long for their call lights to be answered. The group discussed staffing as their first order of business on 10/31/18. R4 reported that he had not had a shower for one month. They never have enough time. There is only one (staff) person on the floor. R4's Minimum Data Set (MDS), dated [DATE], noted that he is cognitively intact. R28 said that she had one shower in the past month. They say they don't have enough staff. Although her current care plan noted a mild cognitive impairment; R28's (MONTH) (YEAR) psychological assessment provided additional information. R28 is alert and oriented to person, place, and time. R28's insight is intact. R28's Immediate, Recent, and Remote Memory is Grossly Intact. R29 said that she is scheduled to have a shower every Monday and Friday. R29 said that her sister needs to assist her because there is insufficient staff. Although her 8/29/18 MDS noted that R29's cognition impairment is moderately impaired; data in her record indicated that she had not received showers as she had alleged and in accordance with her scheduled plan. (See F677 for additional information) R30 reported that she had not had a shower for three weeks. R30's Minimum Data Set (MDS), dated [DATE], noted that she is cognitively intact. R31 said that she receives a shower on Monday and Thursday nights. R31 said that at the beginning of the shift, staff tell her that they will see if they can get to her shower. Although R31 reported that she had received her showers; she said that she feels bad because each time she is unsure whether or not she will receive her scheduled shower. R31's MDS, dated [DATE], noted that R31 is cognitively intact. Although her current care plan noted that she has cognitive deficits; the 8/20/18 psychological assessment provided the following information. She is cognitively intact. 15. During this onsite complaint investigation, Surveyor identified that the facility did not ensure at least 8 of 20 Residents (R18, R17, R8, R34, R35, R36, R37, R9) residing on the 300 unit were free from abuse. (Cross Reference F600) On 9/20/18, the facility admitted R9. Throughout R9's stay at the facility from 9/20/18 until discharge 10/26/18, R9 exhibited aggressive behaviors towards multiple residents and staff, causing residents to be fearful. R18 experienced mental abuse from R9 resulting in R18 being intimidated, fearful, moving to a different unit and on 10/25/18 was found barricading herself in her room. R17 was hit by R9 and was restarted on her anti-anxiety medications because of being afraid of R9. R8 was not free from abuse by R9, when R8 had physical altercations with R9 on three occasions. R9 was not free from abuse by R8 when R8 retaliated against R9. R8 had previously informed the facility that she might retaliate against R9 by striking him. Through interviews, record reviews, and review of concerns brought forth to the facility, R34, R35, R36, and R37 were also abused by R9. The facility did not have sufficient staff provide for the supervision of R9 to ensure the safety of R9 as well as the residents residing on the 300 unit of the facility. On 10/29/18 at 9:25 am, Surveyor spoke to the Social Service Director (SSD) J regarding R9. SSD J stated, We started the 1:1 on the pm shift from 3 to 8pm at which time (R9) is ready to go to bed. The 1:1's were initiated on 10/11/18 even though the care plan says 10/19/18. SSD J also reported all staff are aware of (R9) and to keep an eye on him. On 10/29/18 at 10:20 am, Surveyor interviewed LPN I who works full time on the 300 unit. LPN I informed surveyor, The plan was to watch (R9) and after finding out he was hitting residents the plan was 1:1 with him. That is what they were telling families. I thought it was to be all the time (referring to 1:1), by what families were telling me and what was passed on in report that Management or the front desk could watch him. I would take him up there (to the front desk) if it was 1 CNA and me. I would take him up front and they would take him for 15 minutes and push him back down here. I would say you need to do constant (1:1) on first shift for close supervision. I would be giving medications and helping the CNA getting residents up and he's pretty quick, for me trying to watch him at the same time, I would tell the Manager on Duty, the receptionist, they needed to help me which they did for a few minutes and the he was back to me. On 10/29/18, Surveyor interviewed Director of Nursing (DON) B. Surveyor asked DON B regarding (R9)'s 1:1's. DON B stated 1:1's were on pms with the MOD (Manager on Duty) as Resident and MOD could tolerate it. DON B reported, We don't offer 1:1's. Nursing & Social Worker tried 1:1, facility does not have the availability of staff for 1:1 on days. Social Services tried to call the group home to provide him with 1:1 but they did not do so. We asked if family could do 1:1 to make residents feel secure, he was mobile on his own, moment to moment things would change . The facility did not have sufficient staffing to provide for 1:1 supervision of R9 during the day to ensure residents were safe from R9's aggressive behaviors. Cross reference F600. 16. On 10/25/18 at 9:05 am, Surveyor observed the 200 unit. Surveyor observed RN E administering medications and 1 CNA in the dining room. R1 who was in the dining room requested to speak to surveyor. On 10/25/18 at 9:25 am, Surveyor interviewed R1, (resides on the 200 unit), who stated, I want to discuss the shortage. I know it's happening all over the country but this is ridiculous. The same women are working they are faithful, they come in when they are sick .they are getting worn out. They keep piling people (residents) in here. When one (resident) leaves they fill with another person .It was nice when I came in here 4 years ago, you don't have people care for you, now you have to wait. For the 2:30 to 10:30 pm shift they have 1 person who comes. When no one comes we take what's left over, we don't know whose coming, they call in sick, not coming to work, if there is someone they call in .we don't have that many people working, they do the washing and the laundry and when laundry is not done they save that. They get us washed up and to bed with 1 person and she is getting tired. The nurse gives out the medications, the evening nurse does not help the 1 CNA and does not assist with getting residents getting to bed, washed or transferred. The nurses are different ones, I don't know them all. I feel sorry for the 1 coming in for the next shift she will be here all alone and will have to put the resident's left over to bed, do the laundry and dishes all by herself. The other day she had 3 days of laundry .no there haven't been any improvements (referring to staffing). This week when you are here noticed those in the office are here a bit. The one running this place keeps bring people in .I complain at the Resident Council. On 10/31/18 at 10:40 am, Surveyor interviewed RN EE who was on the 200 unit who stated there are 19 residents right now normally 22 residents. RN EE stated she has worked as the charge nurse for the house and the nurse for the 200 unit. RN EE stated she has 1 CNA today who is currently on break. RN EE stated all of the residents on the unit should be toileted every 2 hours and this is not always being done. RN EE stated with 1 CNA I help with toileting, it's a lot even with 1 CNA and with floats, it requires 2 CNAs to toilet people and with 2 meals. In addition, it takes 2 people to transfer and there are 2 residents who require Hoyer lifts. I did (R1's) wound vac today. I stay until all treatments are done. There has been no improvement with staffing (since the last time the state was here.) RN E stated the unit has 3 independent residents. 17. On 10/30/18 at 3:40 pm, Surveyor observed the 300 unit. Surveyor observed R8 wheeling herself around the dining room and TV area. R8 appeared highly anxious repeating to Surveyor that there was no nurse on the unit and I really need a breathing treatment .there is no nurse. CNA (Certified Nursing Assistant) DD stated she was the only staff member on the unit and called for a nurse from another unit. Surveyor observed there were 19 residents currently residing on the unit and at this time the staffing ratio for CNA DD was 1:19 residents. Surveyor observed a nurse come from a different unit and provided R8 with her breathing treatment at 3:50 pm. while in the hallway and then left the 300 unit hallway. Surveyor observed R8 being very anxious when no nurse was observed on the unit and wanting her breathing treatment. In addition the CNA ratio of 1 CNA to 19 residents did not meet the Administrator and Director of Nursing B's ideal staffing ratio. Surveyor interviewed CNA DD who stated she usually works this unit and prefers this unit usually working second shift. CNA DD stated she was the only staff member on the unit and that a nurse from the 400 unit helped her earlier by giving another resident their nebulizer treatment. CNA DD stated she thought it would be better to have 2 staff on the unit rather than 1. Surveyor questioned CNA DD if she would be giving showers tonight. CNA DD stated she would not be giving showers if there is only 1 CNA on duty tonight and that she had not had a chance to look at the shower schedule. Surveyor and CNA DD then obser

Based on interview and record review the facility did not ensure there was sufficient nursing staff available at all times to provide nursing and related services to meet residents needs in a manner that promotes each resident's physical, mental, and psychosocial well-being for 4 (R4, R1, R6 and R3) of 6 sampled residents -R4 was not ambulated per his plan of care. R4 and staff indicated there is not enough staff to ambulate residents, and not being put to bed until 2 hours after his preferred time due to insufficient staffing. -R1 became tearful when reporting to the surveyor there is not enough staff to change her as frequently as she should be changed. -R6 reported having to wait 2 hours for help, that she was supposed to get showered and was unable to to because there wasn't enough help, so that staff just washed her hair. R6 reported having to wait 2 hours incontinent while she waited for help. -R3 reported having to wait longer to go to bed because the facility is short staffed. R3 reported having incontinent episodes from having to wait for staff and that they bring up short staffing at Resident Council meetings. Findings include: 1. R4 has [DIAGNOSES REDACTED]. R4's annual Minimum Data Set assessment (MDS), dated [DATE], documents the activity of walking in room and walking in the corridor did not occur. R4's care plan documents (R4) requires assistance with ambulation from RA ([MEDICAL CONDITION] arthritis) and joint deformities. Balance problems, Decreased ability to walk from RA and need for walker and assist from staff. R4's goal is that he will ambulate 100 feet twice a day with platform/walker and one assist gaitbelt with one pushing w/c (wheelchair) behind him with an initiation date of 8/14/2018. The surveyor reviewed R4's task for Walk in corridor-ambulate with platform walker BID per (physician) for the last 30 days. The surveyor noted the activity is documented as not occurring from 8/8/18-9/6/18. A physician's progress note with an encounter date of 7/12/18 documents He notes strength has continued to improve. He is walking into the hall with a platform walker. He notes he does this a few times a week, and would like to do more often, but staff has to be available, which does not always occur. The physician documents the plan as Noted to have them ambulate him in the hall, try to do at least twice a day using that platform walker. On 9/6/18 at 9:47 am the surveyor interviewed R4. R4 informed the surveyor there are not enough staff. R4 informed the surveyor that he is on a walking program, to be walked two times a day and stated I may have been walked twice last month. R4 stated his restorative program has never happened, and the doctor ordered it. R4 informed the surveyor that he is to be showered twice a week on Wednesday and Saturday, but he does not remember the last time he had his Saturday shower. R4 informed the surveyor there are times he has not been assisted to bed until midnight even though he wants to go to bed at 10 pm. R4 informed the surveyor NHA (Nursing Home Administrator)-A thinks one aide can handle putting everyone to bed in 1 hour. On 9/6/18 at 11:34 am the surveyor interviewed CNA (certified nursing assistant)-C. The surveyor asked CNA-C about R4's task of being walked in corridor being documented by her as not occurring for 9/6/18 and the reason why he was not being walked. CNA-C informed the surveyor she is covering all 3 units and helping out where she can. CNA-C stated we do not have time to walk people with the amount of people to care of. 2. R1's Minimum Data Set Assessment, dated 7/25/18, documents R1 requires extensive assistance of one person's physical assistance for toileting, and that R1 is always incontinent of bladder and frequently incontinent of bowel. On 9/6/18 at 10: 18 am the surveyor interviewed R1. R1 informed the surveyor that there are not enough staff. The surveyor asked R1 what does not get done when there is not enough staff. R1 became tearful and informed the surveyor that her bottom is sore because she is not getting changed enough. R1 informed the surveyor the other night, over the weekend she had to wait 5 hours for staff to change her. 3. R6's Minimum Data Set Assessment, dated 8/31/18, documents R6 required extensive assistance of one person's physical assistance for toileting and required physical help in part of bathing activity of one person's physical assistance. On 9/6/18 at 9:30 am the surveyor interviewed R6. R6 informed the surveyor the facility does not have the help that it needs. R6 informed the surveyor the other night she had to wait 2 hours for help. R6 informed the surveyor that she was supposed to get showered and was unable to because there wasn't enough help so the staff just washed her hair. R6 informed the surveyor she usually has to wait 30 minutes for staff to help, but other times it is an hour plus. R6 informed the surveyor that over the weekend she had to wait 2 hours incontinent, while she waited for someone to help her. 4. R3's Minimum Data Set Assessment, dated 8/31/18, documents R3 required extensive assistance of one person's physical assistance for toileting and transfers. On 9/5/18 at 12:05 pm the surveyor interviewed R3. R3 informed the surveyor the facility desperately needs more help. R3 informed the surveyor she has to wait longer to go to bed because the facility is short staffed. R3 informed the surveyor that she has had incontinent accidents from having to wait for staff. R3 informed the surveyor they bring up the short staffing in Resident Council meetings The surveyor reviewed the Resident Council meeting notes and noted the (MONTH) 21, (YEAR) notes document Staffing is a concern but did share at this week's orientation we hired 2 LPNs (Licensed Practical Nurse), 2 CNAs (Certified Nursing Assistants) and 3 dietary . Minutes from the (MONTH) 23, (YEAR) meeting document Concerned that the staff we have work too hard and would like to see them have more workers .Some felt they wait too long for their call lights to be answered, others did not feel it was a problem .CNA:Would like to see more of them but feel that the ones we have work very hard and do the best they can Administration: would like to see more staff hired.