Every finding on record at Amethyst Health of Brown Deer

Based on interview and record review, the facility did not ensure 4 (R9, R90, R81, and R28) out of 9 sampled residents were provided and administered medications based upon physician orders and standards of practice for ensuring accurate administration of ordered medications. *R9 did not receive Olanzapine 2.5 mg (milligrams) and Atorvastatin Calcium 40 mg at bedtime and Memantine 5 mg at 2000 (10:00 PM) on 4/7/26 and 4/28/26. R9's medication administration record (MAR) did not accurately detail why R9's medications were not administered on 4/5-4/6/26 when R9 was hospitalized . *R90 had multiple administrations of medications not documented as given during March and May of 2026. *R81 had multiple administrations of medications not documented as given during April and May of 2026. *R28 did not receive Gabapentin 400 mg (milligrams) and Baclofen 20 mg at 2000 (8:00 p.m.) and did not receive Tylenol 650 mg at 1800 (6:00 PM) on 4/8/26 and 4/27/26. Findings include: The facility's policy titled, Documentation of Medication Administration, April 2007, documents, Policy heading: The facility shall maintain a medication administration record to document all medications administered. Policy Interpretation and Implementation: 1. A nurse or certified medication aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR). 2. Administration of medication must be documented immediately after (never before) it is given. 3. Documentation must include, as a minimum: a. name and strength of the drug; b. dosage; c. method of administration (e.g., oral, injection (and site), etc.); d. date and time of administration; e. reason(s) why a medication was withheld, not administered, or refused (as applicable); f. signature and title of the person administering the medication; and g. resident response to the medication, if applicable (e.g., PRN, pain medication, etc.) 1.) R9 was readmitted to the facility on [DATE] with an initial admission date of 8/30/24. R9 has a diagnoses that include Cognitive Communication Deficit, Hypertensive Heart Disease, Congestive Heart Failure, Pulmonary Arterial Hypertension, Hemiplegia and Hemiparesis following Cerebral Infarction (stroke), Dementia and other behavioral disturbances, and Depression. R9's quarterly Minimum Data Set (MDS) assessment, dated 3/17/26, documents R9 has a Brief Interview for Mental status (BIMS) of 5, indicating severe cognitive impairment. R9's Medication Administration Record (MAR) for April 2026, documents the following medications are to be administered, in part . Atorvastatin Calcium oral tablet 40 mg (milligrams) – Give 1 tablet by mouth at bedtime for lower cholesterol in blood. Start date: 3/10/26, Olanzapine oral tablet 2.5 mg – by mouth at bedtime for gradual dose reduction. Start date 3/18/26 and, Memantine HCI oral tablet 5 mg – Give 1 tablet by mouth two times a day for dementia at 0800 (8:00 AM) and 2000 (10:00 PM). Start date: 3/10/26. R9's MAR does not document R9 received medication administration from 4/5/26 to 4/9/26 nor does it include details to indicate why it may have not been administered. Surveyor reviewed progress notes and determined R9 was hospitalized during this time. The MAR does not reflect the medications were held due to hospitalization. R9's MAR does not document R9 received Olanzapine 2.5 mg (milligrams) and Atorvastatin Calcium 40 mg at bedtime and Memantine 5 mg at 2000 (10:00 PM) on 4/7/26 and 4/28/26. Surveyor reviewed R9's Progress Notes and did not find any evidence as to why R9's medications were not received on 4/7/26 and 4/28/26.R9's Care Plan Focus Area, revision dated 8/19/25, documents, Resident utilizes antianxiety/antidepressant/antipsychotic medications r/t dx of UNSPECIFIEDDEMENTIA, UNSPECIFIED SEVERITY, WITH PSYCHOTIC DISTURBANCE (sic). Interventions include, in part. Administer PSYCHOTROPIC medications as ordered by physician, revision dated 03/13/25. R9's Care Plan Focus Area, revision dated 3/20/25, documents, The resident has impaired cognitive function/dementia or impaired thought processes r/t Difficulty making decisions, Impaired decision making. Interventions include, in part. Administer medications as ordered. Monitor/document for side effects and effectiveness revision dated, 03/13/25. On 5/20/26 at 9:24 AM, Surveyor interviewed Licensed Practical Nurse (LPN) -D. Surveyor asked LPN-D how does LPN-D document when a medication is administered to a resident. LPN-D stated LPN-D documents in the MAR after LPN-D has given the medication. On 5/20/26 at 10:13 AM, Surveyor interviewed LPN-C asking about different factors that could be a possible reason for a resident to not be administered medications. Surveyor asked LPN-C what LPN-C does when there is not a medication available for a resident. LPN-C stated If the medication is a stock medication, LPN-C will obtain it from the central supply, if the medication is a prescription, LPN- C will obtain it from the facility's contingency supply and then call the pharmacy to reorder the medication for the resident. Surveyor asked LPN-C, what does LPN-C do if a resident refuses medication. LPN-C stated, LPN-C will indicate the refusal in the Medication Administration Record (MAR), place resident on the 24-hour board, notify the physician, management, and Power of Attorney (POA) if applicable, and then document in a progress note. On 5/20/26 at 9:33 AM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked DON-B if anyone verifies the nurses have documented medication administration. DON-B stated DON-B and management complete random spot checks to audit medication administration has been provided and documented. If a nurse has missed documenting, DON-B will call the nurse within 24 hours to find out if the medication was administered and if yes, assure the nurse documents. If not, find out the reason why and follow up accordingly. Surveyor notified DON-B that R9 did not receive the listed above medications on 4/7/26 and 4/28/26. Surveyor asked who the staff member was that was working the East unit, evening shift, on these dates. On 5/20/26 at 10:52 AM, DON-B provided the evening schedule for the East unit for 4/7/26 and 4/28/26. DON-B stated LPN-H was responsible for administering medication to R9 on these dates. Surveyor asked DON-B if there was a concern or pattern with LPN-H not documenting medication administration and DON-B stated, yes, LPN-H was someone who would frequently forget to chart and had to be told to complete documentation. 2.) On 5/19/26, at 10:27 AM, Surveyor Interviewed R90. R90 stated they feel like they don't always get all of their medications as prescribed on 2nd and 3rd shifts. R90 denied knowing the names of specific staff that do not give R90 all of the medications ordered. R90 denied knowing what specific medications are missing. On 5/19/26, at 11:30 AM, Surveyor reviewed R90's Medication Administration Record (MAR) from February 2026 to May 2026. Medications were noted to be blank for multiple dates. Surveyor noted the following medications and dates not administered to R90 in March 2026; Fluoxetine 40 mg capsule 1 time a day not given from 3/6/26 – 3/8/26; Quetiapine 50 mg 1 time a day not given 3/6/26 – 3/8/26, 3/20/26, 3/3026, and 3/31/26; Vraylar 1.5 mg 1 time a day not given from 3/6/26 – 3/8/26, 3/20/26, 3/21/26, and 3/30/26; buspirone 5 mg 1 tablet 2 times a day not given on 3/6/36 bedtime, 3/7/26 morning, 3/8/26 morning, 3/13/26 morning, and 3/20/26 morning; hydralazine 10 mg 1 tablet 2 times a day 3/6/26 morning and bedtime, 3/7/26 morning and bedtime, and '3/8/26 morning. On 3/9/26, the following medications were not administered in the morning to R90: Duloxetine HCL delayed release 60 mg 1 capsule by mouth 1 time a day, Fluoxetine 40 mg capsule 1 time a day, Pantoprazole delayed released 40 mg 1 time a day, Vraylar 1.5 mg 1 time a day, buspirone 10 mg 1 tablet 2 times a day, Fluticasone Salmeterol 100-50 1 puff 2 times a day, gabapentin 300 mg 2 capsules 2 times a day, hydralazine 10 mg 1 tablet 2 times a day, lisinopril 10 mg 1 time a day, and metoprolol tartrate 100 mg 1 tablet 2 times a day. On 5/7/26 at (HS) bedtime the following medications were not administered to R90 Seroquel 25 mg tablet 1 tablet at bedtime, Trazodone HCL 50 mg tablet give 2 tablets by mouth, Baclofen 10 mg tablet give 1 tablet by mouth 2 times a day, Buspirone 5 mg tablet give 1 tablet by mouth 2 times a day, Fluticasone Salmeterol 100-50 1 puff 2 times a day, Gabapentin 300 mg 2 capsules 2 times a day, hydralazine 10 mg 1 tablet 2 times a day, Metoprolol Tartrate 100 mg tablet 1 tablet 2 times a day, Surveyor noted the following medications and dates not administered to R90 in May 2026; Duloxetine HCL delayed release 60 mg 1 capsule by mouth 1 time a day not given on 5/8/26, buspirone 5 mg 1 tablet 2 times a day not given on 5/8/26, Lidocaine external patch 5% topically every day shift was not given on 5/14/26, Surveyor reviewed R90's Electronic Medical Record and did not identify any progress notes addressing why R90 did not receive medications as ordered on the dates listed above. On 5/20/2026, at 9:53 AM, Surveyor Interviewed Director of Nursing (DON) – B and Regional Nurse (RE)-E regarding missing medication administrations for R90. DON-B expected Nursing staff to sign out the medication as it is given and if the medication cannot be given the Nurse needs to call the resident's physician and document why the medication wasn't given and if there were new orders from the resident's physician. RE-E stated the facility will do spot checks to affirm medications are being dispensed as ordered. On 5/20/26, at 10:00 AM, Surveyor shared the concern of R90 not receiving ordered medications with Nursing Home Administrator (NHA)-A, DON-B, and RE-E. 3.) On 5/19/26 at, 12:00 PM, Surveyor reviewed R81's MAR from February 2026 to May 2026. Medications were noted to be blank on multiple dates. Surveyor noted the following medications and dates not administered to R81 in April 2026; Umeclidinium – Vilanterol inhalation aerosol powder breath activated 62.5 – 25 mcg/act 1 puff inhale orally one time a day for COPD not given on 4/10/26 and 4/13/26 and Zolpidem Tartrate 5 mg give 1 tab by mouth at bedtime not given at on 4/16/26 and 4/27/26. Surveyor noted the following medications and dates not administered to R81 in May 2026; Pramipexole 1 mg tablet give 1.5 mg by mouth at bedtime not given on 5/7/26, Zolpidem Tartrate 5 mg give 1 tab by mouth at bedtime not given on 5/7/26, and Metformin HCL tablet 500 mg 1 tablet by mouth 2 times a day was not given on 5/7/26 at bedtime. Surveyor reviewed R81's Electronic Medical Record and did not identify any progress notes addressing why R81 did not receive medications as ordered on the dates listed above. On 5/19/26, at 12:51 PM, Surveyor Interviewed R81. R81 denied knowing if any medications are missing when medications are dispensed to R81. Surveyor reviewed R81's Electronic Medical Record and did not identify any progress notes addressing why R81 did not receive medications as ordered on the dates listed above. On 5/20/2026, at 9:53 AM, Surveyor Interviewed Director of Nursing (DON) – B and Regional Nurse (RE)-E regarding missing medication administrations for R81. DON-B expected Nursing staff to sign out the medication as it is given and if the medication cannot be given the Nurse needs to call the resident' s physician and document why the medication wasn't given and if there were new orders from the resident's physician. RE-E stated the facility will do spot checks to affirm medications are being dispensed as ordered. On 5/20/26, at 10:00 AM, Surveyor shared the concern of R81 not receiving ordered medications with Nursing Home Administrator (NHA)-A, DON-B, and RE-E. 4.) R28's diagnoses include bipolar disorder (mental disorder characterized by periods of depression and periods of abnormally elevated mood), quadriplegia (partial or total paralysis of all four limbs and torso), other chronic pain, & other muscle spasms. R28's resident has a diagnosis of chronic pain r/t (related to) disease processes and neuropathy care plan initiated 6/2/22 & revised 5/20/23 includes an intervention of Administer analgesia as per orders. Give 1/2 hour before treatment or care initiated 6/2/22 & revised 2/15/23. R28's resident is on pain medication therapy r/t (related to) disease process care plan initiated & revised 7/10/22 documents an intervention of Administer analgesic medications as ordered by physician. Monitor/document side effects and effectiveness Q (every) shift. Initiated 7/10/22. R28's significant change MDS (minimum data set) with an assessment reference date of 3/20/25 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. On 5/19/26, at 9:59 a.m., during a conversation with R28, Surveyor asked R28 if anyone refused to give him his medication. R28 replied, not necessarily refused but slow and late. Surveyor asked if he ever didn't receive his medication. R28 informed Surveyor he doesn't recall not receiving his medication. Surveyor reviewed R28's physician orders and noted the physician orders include: *Gabapentin Oral Tablet 400 mg (milligrams) (Gabapentin) Give 1 tablet by mouth two times a day for pain with an order date of 3/26/26. *Baclofen Oral Tablet 20 mg (Baclofen) Give 1 tablet by mouth four times a day for spasms with an order date of 4/1/24. *Tylenol Tablet 325 mg (Acetaminophen) Give 2 tablet by mouth every 6 hours for pain with an order date of 4/1/24. Surveyor reviewed R28's April 2026 MAR (medication administration record) and noted on 4/8/26 R28 did not receive Gabapentin 400 mg at 2000 (8:00 p.m.) & Baclofen 20 mg at 2000 (8:00 p.m.) and Tylenol 650 mg at 1800 (6:00 p.m.). On 4/27/26 R28 did not receive Gabapentin 400 mg at 2000 (8:00 p.m.) & Baclofen 20 mg at 2000 (8:00 p.m.) and Tylenol 650 mg at 1800 (6:00 p.m.). On 5/20/26, at 12:08 p.m., Surveyor asked Director of Nursing (DON)-B what the expectation is when a medication is administered. DON-B replied they sign off once it's been administered. Surveyor informed DON-B of R28 not receiving his evening medication on 4/8/26 & 4/27/26.

Based on interview and record review, the facility did not ensure 3 (R81,R90, and R73) of 3 sampled residents were free from significant medication errors. * R81 had a missing dose of Apixaban (Eliquis) 5 mg on 5/7/26 at 8:00 PM. * R90 had 2 missing doses of Apixaban (Eliquis) 5 mg on 5/7/26 at 8:00 PM and on 3/9/26 at 8:00 AM. *R73 admitted to the facility on [DATE] with an order for Truvada Oral Tablet 200-300mg. Give 1 tablet via G-Tube one time a day . Multiple doses were marked as not administered between 2/25/26 and 3/9/2026 due to waiting for pharmacy. Findings Include: The facility's policy titled Administering Oral Medications dated 8/1/2025 and last revised on 3/1/2026 documented: . Verify that there is a physician's medication order for this procedure. Review the resident's care plan to assess for any special needs of the resident. Notify the supervisor if the resident refuses the procedure. The facility's policy titled Documentation of Medication Administration dated 2001 and last revised 4/2007 documented: The facility shall maintain a medication administration record to document all medications administered. A nurse or certified medication aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR). Administration of medication must be documented immediately after (never before) it is given. Documentation must include, as a minimum: name and strength of the drug; dosage; method of administration (e.g., oral, injection (and site), etc.); date and time of administration; reason(s) why a medication was withheld, not administered, or refused (as applicable); signature and title of the person administering the medication; and resident response to the medication, if applicable (e.g., PRN, pain medication, etc.). 1.) R81 is a [AGE] year old resident who was admitted to the facility on [DATE]. R81's diagnoses include Paroxysmal Atrial Fibrillation (an intermittent condition where the upper chambers of the heartbeat chaotically and out of sync which can lead to blood pooling and blood clots) and takotsubo syndrome (sudden temporary weakening of the heart muscle). R81's Physician orders documented Apixaban 5 mg 1 tab by mouth 2 times a day for clotting. Start date 2/20/2026. On 5/19/26 at 12:00 PM, Surveyor reviewed R81's MAR from February 2026 to May 2026. Surveyor noted R81 did not receive Apixaban 5 mg on 5/7/26 at 8:00 PM as ordered. On 5/20/2026, at 9:53 AM, Surveyor Interviewed Director of Nursing (DON) – B and Regional Nurse (RE)- E regarding missing medications for R81. DON-B expected Nursing staff to sign out the medication as it is given and if it cannot be given the Nurse needs to call the resident' s physician and document why the medication wasn't given and if there were new orders from the resident's physician. RE-E stated the facility will do spot checks to affirm medications are being dispensed as ordered. 2.) R90 is a [AGE] year old resident who was admitted to the facility on [DATE]. R90's diagnoses include Other Venous Thrombosis and Embolism (Blood clots) and Long Term Current Use of Anticoagulants. R90's Physician orders documented Apixaban 5 mg 1 tab by mouth 2 times a day related to personal history of other venous thrombosis and embolism. Start date 3/5/2026. On 5/19/26, at 10:27 AM, Surveyor Interviewed R90. R90 stated they feel like they don't always get all of their medications as prescribed on 2nd and 3rd shifts. R90 denied knowing the names of specific staff that do not give R90 all of the medications ordered. R90 denied knowing what specific medications are missing. On 5/19/26, at 11:30 AM, Surveyor reviewed R90's Medication Administration Record (MAR) from February 2026 to May 2026. Surveyor noted R90 did not receive Apixaban 5 mg on 5/7/26 at 8:00 PM and on 3/9/26 at 8:00 AM as ordered. On 5/20/2026, at 9:53 AM, Surveyor Interviewed Director of Nursing (DON) – B and Regional Nurse (RE)- E regarding missing medications for R90. DON-B expected Nursing staff to sign out the medication as it is given and if it cannot be given the Nurse needs to call the resident' s physician and document why the medication wasn't given and if there were new orders from the resident's physician. RE-E stated the facility will do spot checks to affirm medications are being dispensed as ordered. On 5/20/26, at 10:00 AM, Surveyor shared the concern R90 not receiving ordered Apixaban with Nursing Home Administrator (NHA)-A, DON-B, and RE-E. 3.) R73 was readmitted to the facility on [DATE] with pertinent diagnoses that include cerebrovascular disease (a condition that affects the blood vessels and blood supply to the brain), encephalopathy (a group of conditions that cause brain dysfunction. Brain dysfunction can appear as confusion, memory loss, personality changes and/or coma in the most severe form), aphasia (complete inability or refusal to swallow), tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe (trachea)), and gastrostomy status (a surgically created opening in the abdomen that connects to the stomach, often for the purpose of feeding or administering medication). R73's Quarterly Minimum Data Set (MDS) with an assessment reference date of 4/13/2026, does not document a Brief Interview for Mental Status (BIMS) assessment. The MDS documents that R73 is comatose and has a feeding tube. R73's physician order dated 2/25/2026 documents Truvada Oral Tablet 200-300mg. Give 1 tablet via G-Tube one time a day . R73's progress note dated 3/1/2026 regarding Truvada Oral Tablet documents that the medication was not available. R73's progress note dated 3/5/2026 regarding Truvada Oral Tablet documents waiting for pharmacy. R73's progress note dated 3/6/2026 regarding Truvada Oral Tablet documents waiting for pharmacy, Director of Nursing (DON)-B, MD (Medical Doctor), pharmacy updated. R73's progress note dated 3/9/2026 regarding Truvada Oral Tablet documents waiting for pharmacy, MD aware. R73's MAR (medication administration record) documents on 2/25/2026, the first day for the medication to be administered, a 5 is documented which indicates to hold the medication. On 2/26/2026, a 9 is documented which indicates other. On 2/28/2026, there is no documentation whether given or not. On 3/1/2026, 3/5/2026, 3/6/2026, and 3/9/2026 for administration the MAR is documented as 9 for other. Surveyor noted six times between 2/25/2026 and 3/9/2026 the MAR was marked with checkmarks indicating the medication was administered, even though other nurses marked the medication as unavailable. On 5/20/26 at 10:13 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-C. Surveyor asked LPN-C what LPN-C does when there is not a medication available for a resident. LPN-C stated If the medication is a stock medication, LPN-C will obtain it from the central supply, if the medication is a prescription, LPN-C will obtain it from the facility's contingency supply and then call the pharmacy to reorder the medication for the resident. Surveyor asked LPN-C , what does LPN-C do if a resident refuses a medication. LPN-C stated, LPN-C will indicate the refusal in the Medication Administration Record (MAR), place resident on the 24-hour board, notify the physician, management, and Power of Attorney (POA) if applicable, and then document in a progress note. On 5/20/2026, at 10:51 AM, Surveyor interviewed DON-B regarding R73's Truvada medication not being available for administration and was told DON-B was not employed by facility at that time and will need to look into. No further information was provided as to why the facility did not ensure that R73's Truvada order was available for administration.

Based on interview and record review, the facility did not ensure a medication was administered with adequate monitoring for 1 (R91) of 1 sampled residents with parameters to hold medication based upon assessed blood pressures at time of medication administration.* The facility did not assure R91's blood pressures were assessed and documented prior to administering Midodrine HCL to R91 as ordered by the physician. Findings include;R91's diagnosis includes orthostatic hypotension (sudden, excessive drop in blood pressure that occurs when rising from a sitting or lying position). R91 was discharged from the facility on 4/19/26.R91's orders include Midodrine HCI Tablet 10mg (milligrams) Give 1 tablet by mouth three times a day for orthostatic hypotension hold SBP (systolic blood pressure) greater than 150 with an order date of 3/23/26.Surveyor reviewed R91's March 2026 & April 2026 MAR (medication administration record) and noted these MARs include Midodrine HCI 10 mg with administration times of 0800 (8:00 a.m.), 1200 (12:00 p.m.) & 1600 (4:00 p.m.). Surveyor noted there is only a box indicating whether the medication has been administered. There is not a box for R91's blood pressure value prior to administration of Midodrine 10 mg.Surveyor reviewed R91's blood pressure readings under the vital sign tab in R91's electronic medical record.Surveyor noted R91's blood pressure was not obtained prior to administering Midodrine 10 mg on the following dates & times:3/24/26 at 8:00 a.m., 12:00 p.m., & 4:00 p.m., 3/25/26 at 8:00 a.m., 12:00 p.m., & 4:00 p.m., 3/26/26 at 8:00 a.m., 12:00 p.m., & 4:00 p.m., 3/27/26 at 8:00 a.m., 12:00 p.m., & 4:00 p.m., 3/28/26 at 8:00 a.m., 12:00 p.m., & 4:00 p.m., 3/29/26 at 8:00 a.m., 12:00 p.m., & 4:00 p.m., 3/30/26 at 8:00 a.m. & 4:00 p.m., 3/31/26 at 8:00 a.m. & 12:00 p.m., 4/1/26 at 8:00 a.m., 12:00 p.m., & 4:00 p.m., 4/2/26 at 8:00 a.m. & 4:00 p.m., 4/3/26 at 8:00 a.m., 12:00 p.m., & 4:00 p.m., 4/4/26 at 8:00 a.m., 12:00 p.m., & 4:00 p.m., 4/8/26 at 8:00 a.m. & 4:00 p.m., 4/9/26 at 8:00 a.m., 12:00 p.m., & 4:00 p.m., 4/10/26 at 8:00 a.m., 12:00 p.m., & 4:00 p.m., 4/11/26 at 8:00 a.m. & 12:00 p.m. 4/12/26 at 8:00 a.m. & 4:00 p.m., 4/13/26 at 8:00 a.m. & 4:00 p.m., 4/14/26 at 8:00 a.m. & 4:00 p.m., 4/15/26 at 8:00 a.m. & 4:00 p.m., 4/16/26 at 12:00 p.m., & 4:00 p.m., 4/17/26 at 8:00 a.m., 12:00 p.m., & 4:00 p.m., 4/18/26 at 8:00 a.m., 12:00 p.m., & 4:00 p.m., and 4/19/26 at 8:00 a.m.On 5/20/26, at 8:11 a.m., Surveyor asked Licensed Practical Nurse (LPN)-I if a physician order has vital signs to be obtained prior to administering a medication to determine if the medication should be held; where would the vital sign be documented. LPN-I informed Surveyor sometimes the MD (medical doctor) order pops up in the MAR to document.On 5/20/26, at 8:15 a.m., Surveyor asked LPN-J if a physician order has vital signs to be obtained prior to administering a medication to determine if the medication should be held where; would the vital sign be documented. LPN-J informed Surveyor in the MAR.On 5/20/26, at 11:59 a.m., Surveyor asked Director of Nursing (DON)-B if a MD order has parameters to hold medication where the vital signs such as blood pressure are documented. DON-B informed Surveyor it would depend on how the order is written to include the vital sign. Surveyor informed DON-B R91 has an order for Midodrine 10 mg three times a day with instructions to hold the medication if systolic blood pressure is greater than 150. Surveyor informed DON-B there is not a box for the nurse to enter R91's blood pressure prior to administration and R91's blood pressure was not consistently obtained prior to administering the medication. DON-B informed Surveyor they pretty much put the order in without parameters.

Based on observation, interview, and record review, the facility did not implement effective infection prevention measures to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of communicable diseases and infections for 1 (R53) of 2 residents observed. *Certified Nursing Assistant (CNA)-F did not wear proper personal protective equipment (PPE) while performing peri care on R53 who was in Enhance Barrier Precautions (EBP). The facility's policy and procedure titled, Enhanced Barrier Precautions, implemented 3/25/2024, documents in part: Policy:It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.3. Implementation of Enhanced Barrier Precautions.b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities.4. High-Contact resident care activities include.b. Bathing.e. Changing linensf. Changing briefs or assisting with toileting. On 5/20/2026, at 8:06AM, Surveyor observed CNA-F performing peri care and a bed linen change on R53 without wearing a gown. Before entering the room Surveyor observed an EBP sign and cart of PPE supplies. R53's physician order written 3/31/2026 documents EBP- Use enhanced barrier precautions with all high risk cares and activities (refer to sign for guidance)-gloves and gown. On 5/20/2026, at 10:30AM, Surveyor interviewed CNA-G regarding what EBP means when the sign is on the door of a resident room and was told that staff need to wear a gown and gloves when they are doing cares on the resident. On 5/20/2026, at 10:33AM, Surveyor interviewed R53 as to whether staff wear PPE when caring for R53. R53 stated that CNA usually do and nurses always do. R53 pointed out the garbage can under the window for staff to put PPE in when they are done with cares. On 5/20/2026, at 11:17AM, Surveyor interviewed CNA-F regarding what EBP means and CNA-F stated that they messed up during the observation, they should have had a gown on, they were rushing to get it done before wound care and completely forgot. CNA-F stated they apologized to R53 after they realized the mistake. On 5/20/2026, at 11:20AM, Surveyor spoke with Director of Nursing (DON)-B, Nursing Home Administrator (NHA)-A and Regional Nurse-E regarding the concern that CNA-F was observed doing peri care on R53 without proper PPE on. No additional information was provided regarding the use of PPE for EBP when providing cares to R53.

Uncorrected on revisit Based on observation, record review and staff interviews, the facility did not ensure they provided necessary treatment and services in accordance with standards of practice to 3 out of 4 ( R73, R85, R6) sampled residents reviewed for pressure injuries. * R73 was assessed to be at high risk for developing a pressure injury. A weekly skin check was not completed on 3/21/26. On 3/26/26 it was determined R73 developed a facility acquired stage 2 pressure injury to the back of the left thigh. Although the facility obtained a treatment order for the wound, there was no evidence that the treatment was performed daily, per order, from 3/26/26- 3/30/26. When the facility re-assessed R73's pressure injury to the back of the left thigh on 3/30/26, the wound was now unstageable and noted to have 100% necrotic tissue. * R85 was admitted to the facility on [DATE] with an unstageable pressure injury to the right heel. R85's discharge orders from the hospital for daily wound care were not transcribed correctly into R85's Treatment Administration Record. R85 did not have a treatment completed to the right heel until after R85 was assessed by the wound physician on 3/23/2026. * R6 was readmitted to the facility on [DATE] with an unstageable coccyx pressure which R6 had developed prior to hospitalization. R6's coccyx treatment was not ordered until 4/10/26 and not implemented until 4/12/26. R6 has a pressure injury intervention dated 3/15/26 for an air mattress. R6's air mattress was not ordered until 4/12/26 and placed on R6's bed until 4/13/26, four days after readmission. R6 was observed with her heels not being offloaded. Findings include: The facility policy: Pressure Injury and Skin Impairment Prevention and Management with an Effective date of: 8/1/2025, and a revision Date of 3/10/26 states:IV. Procedural ComponentsA. Accountability1. The pressure Injury Prevention and Management Program identifies staff participation and accountability to include: a. Person responsible for program oversight and coordinationb. Staff involved in prevention and treatment (and their roles)c. Expectation of all caregivers to observe resident skin integrity during the daily provision of the resident's personal care. B. admission Skin Assessment and Management (includes)1. At the time of admission or readmission, discharge records from the prior facility are reviewed for information related to wounds or alterations in skin integrity. 2. Wounds are assessed at the time of admission (same shift) and if not possible, within 24-72 hours depending upon if weekend included.4. As risk areas are identified in the assessment tool, risk reduction measures are to be initiated.5. Orders for wound treatment are verified or obtained as needed. D. Process if a new in-house pressure injury is identified.1. A risk management report will be completed to include any information regarding the causing factors, resident statements, staff statements and interventions put in place. The risk management report will trigger a new Braden risk assessment to be completed and any changes identified will be reviewed and interventions will be implemented and care plans updated.2. The DON (Director of Nursing)/ designee will conduct a thorough investigation to determine the cause of each new in-house acquired pressure injury, in addition to determining if avoidable. 3. If a wound that was present on admissions reopens to the same stage and not a higher stage, the pressure injury will be coded as a present-on-admission wound. If the wound reopens at a higher stage than was present on admission, then it will be considered to be in-house acquired. 1.) R73 was initially admitted to the facility on [DATE] with diagnoses including Cerebrovascular Disease, Diabetes Mellitus, Dysphagia, flaccid hemiplegia, chronic respiratory failure with hypoxia, bed confinement, tracheostomy. R73's care plan for resident has potential/actual impairment to skin integrity r/t (related to) Incontinence Date Initiated: 09/16/2025Revision on: 03/26/2026 includes the following interventions: * The resident will maintain or develop clean and intact skin by the review date. Date Initiated: 09/16/2025* Follow facility protocols for treatment of injury. Date Initiated: 09/16/2025* Provide good nutrition and hydration in order to promote healthier skin per MD/RD orders. Date Initiated: 09/16/2025. Revision on: 09/25/2025* Provide pressure relieving devices including Low Air loss mattress, cushion for chair, Offloading Boots. Date Initiated: 09/16/2025. Revision on: 10/05/2025* Turn and position as necessary. 9/16/25 The facility conducted the following Braden Assessments (tool for assessing a patient's risk of developing a pressure injury) :2/14/26- assessed at high risk2/24/26- assessed at very high risk3/9/26- assessed at very high risk3/23/26- assessed at high risk3/30/26- assessed at high risk. Review of R73's physician orders includes an order with a start date of 3/21/26 to complete a weekly skin assessment. Surveyor conducted a review of the most recent quarterly MDS (Minimum Data Set), dated 3/26/26. According to the MDS, R73 is severely cognitively impaired and non-verbal. R73 is always incontinent of urine and bowel. R73 has impairments in her range of motion to both sides, both upper and lower extremities. R73 is dependent on staff for all activities of daily living. R73 is at risk of developing a pressure injury and currently has an unhealed pressure injury, Stage 2. R73 is documented to have a pressure reducing device for the bed and chair and is receiving pressure injury care. Surveyor conducted further review of R73's electronic medical record and noted the following: Skin note dated 3/26/2026 at 11:36 AM: Skin Issue: #001: New skin Issue. Location: Rear left thigh. Issue type: Pressure injury / injury. Progress: New: new wound. Pressure injury staging: Stage 2 Pressure injury / injury - partial thickness skin loss with exposed dermis. Wound acquired in-house. Exact date: 03/26/2026 Signs and symptoms of infection: None. Painful: No. Staged by: In-house nursing. Length (cm): 1.5 Width (cm): 3 Depth (cm): 0.1 Undermining: No. Tunneling: No. Granulation: 100%. Exudate amount: Moderate. Exudate type: Serous: clear watery fluid, which is separated from solid elements. Other wound bed: none. Periwound: Rolled edge (Epibole). Surrounding tissue: Intact. Induration: None present. Edema: No swelling or edema. Periwound temperature: Normal. Dressing appearance: Intact. Dressing saturation: Moderate 26-75%. Cleansing solution: Normal saline. Other primary dressing: Xeroform Gauze Other secondary dressing applied: Gauze Island Dressing Modalities: None. frequency of treatment: 1x / daily and as needed. Completed Clinical Suggestions: (none documented) Skin/ Wound noted dated 3/26/2026 at 11:39 AM; Reported to Writer, new skin issue noted by CNA (Certified Nursing Assistant), on inspection noted stage 2 to underside Left Buttock, measures 1.5 x 3.0 x 0.1, wound bed beefy red, peri wound tissue fragile, no drainage at this time, Wound MD, Nurse Consultant, POA (power of attorney), NP (Nurse Practitioner) updated, Treatment initiated of Cleanse with S/W (saline water), pat dry, apply Xeroform gauze and cover w (with)/Border foam as secondary dressing, Change Daily & PRN (as needed). Skin/ wound note dated 3/26/2026 at 11:54 AM: Clarification to wound location, actually located on Posterior Left leg, distal to left buttock. Skin/ wound note dated 3/26/2026 at 12:11 PM: Reported to Writer, new skin issue noted by CNA, on inspection noted stage 2 to underside Left Buttock, measures 1.5 x 3.0 x 0.1, wound bed beefy red, peri wound tissue fragile, no drainage at this time, (name of Wound MD-F), Nurse Consultant, POA, (Name of medical group) NP (Nurse Practitioner) updated, Treatment initiated of Cleanse with S/W, pat dry, apply Xeroform gauze and cover w/Border foam as secondary dressing, Change Daily & PRN. Surveyor verified a Physician order was obtained on 3/26/26 for Wound Care: LT (left) POSTERIOR LEG - Cleanse with normal saline, pat dry, apply XEROFORM GAUZE, cover with ISLAND BORDER DRESSING every, day shift AND as needed for wound care. On 3/27/26 an additional order was obtained for nursing acknowledgment of skin assessment completed. If new skin issue, notify Physician for orders, notify family and complete the NAdvance Skin check. Every, day shift for wound management. Surveyor conducted a review of the Treatment Administration Records (TARs) for March 2026. It was noted that the weekly skin assessment was not signed out as completed on 3/21/26 and 3/28/26. The daily skin assessment was not signed out as being completed on 3/27/26, 3/28/26, 3/30/26 and 3/31/26. The daily treatment for the pressure injury to the left posterior leg was also not documented as being completed on 3/26/26, 3/27/26, 3/28/26, 3/29/26, and 3/30/26. A review of R73's care plan documents R73 has a pressure injury to her Lt (left) Posterior Leg and has the potential for pressure injury development, is at risk for delayed wound healing, and is at risk for further alteration in skin integrity due to Anticoagulant therapy, Braden Scale Score, Cerebral Vascular Accident, Contractures, Diabetes, Head of bed evaluated due to medical necessity, Immobility, Infection- current or recent, Limited joint mobility. Date Initiated: 03/26/2026. Revision on: 04/10/2026.Interventions include: * Pressure injury will show signs of healing and remain free from infection by/through review date. Date Initiated: 03/26/2026. * Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 03/26/2026* Administer treatments as ordered and monitor for effectiveness. Date Initiated: 03/26/2026* Assess/record/monitor wound healing Daily, Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Date Initiated: 03/26/2026. Revision on: 03/26/2026* Float heels with pillows when in bed. Date Initiated: 04/07/2026* Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: 03/26/2026* Inform the resident/family/caregivers of any new area of skin breakdown. Date Initiated: 03/26/2026* Monitor dressing QS (each shift) to ensure it is intact and adhering. Report loose dressing to Treatment nurse. Date Initiated: 03/26/2026. Revision on: 03/26/2026* Monitor nutritional status. Serve diet as ordered, monitor intake and record. Date Initiated: 04/07/2026* Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length X width X depth), stage. Date Initiated: 03/26/2026* Offload bony areas with pillows/offloading devices. Date Initiated: 04/10/2026* The resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested.Date Initiated: 04/07/2026. Revision on: 04/07/2026* The resident requires LAL (low air loss) mattress on bed- settings per manufacture guidelines. Check placement and function. Date Initiated: 03/26/2026. Revision on: 04/06/2026 Surveyor noted there are interventions including the use of a low air loss mattress that was on R73's plan of care going back to 9/16/25 with revisions on 10/5/25. Skin Note dated 3/30/2026 at 12:40 PM; N Adv (nursing advanced) -Skin Issues: Skin Issue: #001: Skin issue has been evaluated. Location: Rear left thigh. Issue type: Pressure injury / injury. Progress: New: new wound. Pressure injury staging: Unstageable pressure injury / injury. Unstageable injury due to slough and/or eschar. Wound acquired in-house. Exact date: 03/26/2026 Signs and symptoms of infection: None. Painful: No. Staged by: Health care provider. Length (cm): 2 Width (cm): 3 Depth (cm): 0.1 Area (cm2): 6 Undermining: No. Tunneling: No. Eschar: 100%. Exudate amount: Moderate. Exudate type: Serous: clear watery fluid, which is separated from solid elements. Odor after cleansing: None. Other wound bed: none. Periwound: Attached. Surrounding tissue: Intact. Induration: None present. Edema: No swelling or edema. Periwound temperature: Normal. Dressing appearance: Intact. Dressing saturation: Moderate 26-75%. Cleansing solution: Normal saline. Other primary dressing: Xeroform Gauze Other secondary dressing applied: Gauze Island Dressing Modalities: None. frequency of treatment: 1x / daily and as needed. Completed Clinical Suggestions: Wound Physician-F progress note dated 3/30/26 documents R73 has an unstageable (due to necrosis) pressure injury to the left posterior thigh. Healing potential is fair. Wound size is 2 cm x 3 cm x 0.1 cm. Surface area measures 6 centimeters. There is 100% thick adherent devitalized necrotic tissue. No pain and no signs of infection. The treatment order is to apply Xeroform gauze once daily and as needed if saturated, soiled or dislodged. Also apply a gauze island with border once daily and as needed. On 3/31/26, Director of Nursing (DON)- B documented on the Mitigating Factors for the development/ Worsening of Pressure Injuries form: (R73) has an in-house acquired pressure injury to the left thigh (rear). The form does not include documentation of any measurements or staging of R73's pressure injury. The date of onset is 3/26/26. Diagnosis contributing to risk is documented as continuous urinary incontinence, Diabetes, chronic bowel incontinence, Hypertension, Chronic diarrhea and history of pressure injuries. Treatment contributing to risk: head of bed elevated most of day due to medical necessity. The following new interventions put into place: keep (R73) dry and clean, linens free of wrinkles, moisture barrier after each incontinence episode, head of bed no higher than 30 degrees unless indicated, low air loss mattress, off load heels, IV (intravenous) fluids, wound MD/ specialist consult, Dietician consult, surgical or mechanical debridement of wound, on-going assessment of wound to evaluate signs of deterioration and/ or improvement of wound or possible change of treatment. Based on findings above, this wound is determined to be unavoidable? - facility checked yes. It was noted that the facility nursing staff did not obtain information regarding factors that led to F73 developing a facility acquired, unstageable pressure injury. Surveyor noted there was not a thorough investigation, per facility policy, to determine the root cause of R73's. R73 is completely dependent on staff for all activities of daily living due to quadriplegia. R73 is non-verbal so they would not be able to provide possible causative factors. The facility would need to rely on facility staff to determine possible factors that caused the pressure injury to the rear left thigh for R73. Surveyor noted prior to R73 developing a stage 2 pressure injury that deteriorated to unstageable R73's care plan for at risk for pressure injuries was not revised as R73's risks changed to be individualized for R73's risk factors. On 4/2/2026 at 5:00 PM, R73 was assessed by APNP (advanced practice nurse practitioner)-D for SNF (skilled nursing facility) progress follow-up and wound care. The following was noted in the progress note; (R73) is seen for a skilled nursing facility progress visit. (R73) is up in a Broda chair and appears comfortable. She is adjusting to a recent room change. Vitals have been reviewed in the electronic medical record. She is on 35% oxygen via T-piece with oxygen saturations at 95%. Wound notes from March 30, 2026 have been reviewed. She has an unstageable right (sic) posterior thigh wound measuring 2 x 3 x 0.1 cm with treatment in place. She also has a skin tear wound on the right knee measuring 1 x 1 cm with treatment in place. The patient remains afebrile. SKIN- Unstageable right (sic) posterior thigh wound 2 x 3 x 0.1 cm, treatment in place, Skin tear wound right knee 1 x 1 cm, treatment in place. Assessment and Plan: Pressure injury of unspecified site, stage 3. * Skin tear wound on right knee measuring 1 x 1 cm documented on 3/30/2026 with treatment in place. Wound noted on today's exam with treatment in place. Continue current wound care regimen. Monitor for signs of infection and healing progression. Follow-up: Continue wound care for right (sic) posterior thigh and right knee wounds per wound care orders; reassess at next visit Skin Note dated 4/6/2026 at 09:30 AM; N Adv - Skin Issues: Skin Issue: #001: Skin issue has not been evaluated. Location: Rear left thigh. Issue type: Pressure injury / injury. Pressure injury staging: Unstageable pressure injury / injury. Wound acquired in-house. Exact date: 03/26/2026 Staged by: Health care provider. Undermining: No. Tunneling: No. Skin Issue: #002: Skin issue is resolved. Location: Front right knee. Issue type: Skin tear. Progress: Resolved: Wound healed and / or closed. Type 3: Total flap loss. Wound acquired in-house. It is unknown how long the wound has been present. Staged by: N/A. Undermining: No. Tunneling: No. Completed Clinical Suggestion (none noted). Skin Note dated 4/6/2026 at 09:31 AM; N Adv - Skin Issues: 0Skin Issue: #001: Skin issue has been evaluated. Location: Rear left thigh. Issue type: Pressure injury / injury. Progress: Improving: overall wound characteristics improved. Pressure injury staging: Unstageable pressure injury / injury. Unstageable injury due to slough and / or eschar. Wound acquired in-house. Exact date: 03/26/2026 Signs and symptoms of infection: None. Painful: No. Staged by: Health care provider. Length (cm): 1 Width (cm): 1.5 Depth (cm): 0.1 Area (cm2): 1.5 Undermining: No. Tunneling: No. Granulation: 80%. Eschar: 20%. Exudate amount: Moderate. Exudate type: Serous: clear watery fluid, which is separated from solid elements. Odor after cleansing: None. Other wound bed: none. Periwound: Attached. Surrounding tissue: Denuded. Induration: None present. Edema: No swelling or edema. Periwound temperature: Normal. Dressing appearance: Intact. Dressing saturation: Moderate 26-75%. Cleansing solution: Normal saline. Other primary dressing: Xeroform Gauze Other secondary dressing applied: Gauze Island Dressing Modalities: None. frequency of treatment: 1x / daily and as needed. 4/13/2026 07:32 N Adv - Skin Issues: Skin Issue: #001: Skin issue has been evaluated. Location: Rear left thigh. Issue type: Pressure injury / injury. Progress: Improving: overall wound characteristics improved. Pressure injury staging: Stage 3 Pressure injury / injury - full thickness skin loss. Wound acquired in-house. Exact date: 03/26/2026 Signs and symptoms of infection: None. Painful: No. Staged by: Health care provider. Length (cm): 0.5 Width (cm): 1 Depth (cm): 0.2 Area (cm2): 0.5 Undermining: No. Tunneling: No. Granulation: 100%. Exudate amount: Moderate. Exudate type: Serous: clear watery fluid, which is separated from solid elements. Odor after cleansing: None. Other wound bed: none. Periwound: Attached. Surrounding tissue: Intact. Induration: None present. Edema: No swelling or edema. Periwound temperature: Normal. Dressing appearance: Intact. Dressing saturation: Moderate 26-75%. Cleansing solution: Normal saline. Debridement: Autolytic. Other primary dressing: Xeroform Gauze Other secondary dressing applied: Gauze Island Dressing Modalities: None. frequency of treatment: 1x / daily and as needed. On 4/14/26 at 9:54 AM, Surveyor observed R73 in bed on the specialty air mattress. The facility staff performed the daily treatment to R73's pressure injury on the back of the left thigh. Surveyor noted the area to be 100% granulation, healing and pink scar tissue with small open area. R73 had heels floating on pillows and pillows placed on each side for positioning. On 4/14/26 at 11:36 AM, Surveyor interviewed DON- B regarding R73 developing a facility acquired pressure injury to the back of the left thigh. DON-B stated that she did get a physician order for a treatment to the pressure injury on 3/26/26. DON- B stated that R73 was already on a specialty low air loss mattress prior to developing the pressure injury. Surveyor asked DON- B why the skin assessments on 3/30/26, completed by Wound Physician-F documented that R73 had a new pressure injury, less than 1 day old to the left rear thigh. DON- B stated that she always puts new area until it is assessed by Wound Physician-F in case he wants to change the staging of the wound. DON- B verified that Wound MD-F did not assess the wound until 3/30/26 even though the wound was first observed on 3/26/26. Surveyor shared with DON- B the concerns regarding the March 2026 Treatment Administration Record not having documentation that the treatment was completed on 3/26/26, 3/27/26, 3/28/26. DON-B verified that yes, the treatment was not signed out as being completed on those days. Surveyor also mentioned that the weekly skin assessment was not signed out as completed on 3/21/26 and 3/28/26 and the daily skin assessment was not signed out as being completed on 3/27/26, 3/28/26, 3/30/26 and 3/31/26. DON- B also verified those dates were not signed out as being completed on the Treatment Administration Record. DON- B stated that she could not be sure if the skin assessments and treatments were completed or not and this would have been the responsibility of the Nurse Manager to make sure it was completed. DON- B stated that yes, the expectation is that staff are to sign/ initial completion on the Treatment Administration Record. DON- B stated that on 3/30/26, Wound Physician-F and a Nurse Consultant assessed the wound. DON- B confirmed that on 3/26/26, her assessment of the pressure injury was a stage 2 and on 3/30/26, the wound was now assessed as being unstageable due to being 100% necrotic. DON- B stated that currently the facility does not have a wound nurse in-house daily. The floor nurses are to make sure treatments are being done. DON- B stated that she is only responsible for entering the data into the medical record regarding the pressure injury. Surveyor asked DON- B if there were any new individualized interventions put into place after R73 developed the pressure injury to the left rear thigh. DON-B stated (R73) already had all of the things in place like the air mattress and turning and repositioning. DON- B was not able to provide any additional information on how the pressure injury may have developed to prevent further pressure injury development for R73. On 4/14/26 at 2:00 PM, Surveyor informed Administrator- A and DON- B the concerns about R73 and the development of the pressure injury to the rear left thigh. Surveyor discussed concerns that there is no evidenced the facility staff were checking the skin daily, per order starting 3/27/26. Additionally, there was no evidence that the treatment was completed on 3/26-3/29/26. When the area was first observed it was assessed to be a Stage 2. On 3/30/26, the area grew, in size, and was now 100 % necrotic. Surveyor discussed that the facility did not complete a root cause analysis to determine how the pressure injury may have developed and then updated the care plan with individualized interventions for further prevention. 2.) R85 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, anemia, Parkinsonism, and pulmonary hypertension. R85's admission Minimum Data Set (MDS) assessment dated [DATE] documented R85 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and an Unstageable pressure injury that was present upon admission. R85's hospital discharge paperwork documented an order for Mepilex border dressing daily over the wound area on the right leg. On 3/18/2026 on the admission Data Collection and Baseline Care Plan Tool, nursing documented R85 had a wound to the right heel. On the Clinical admission form, nursing documented R85 had an Unstageable pressure injury to the right heel measuring 4.0 cm x 4.0 cm x 0.1 cm with slough. No treatment to the right heel was found on the Treatment Administration Record (TAR). The physician orders documented to apply Mepilex border dressing to the right heel daily until healed. The order was entered into R85's medical record on 3/18/2026. The nurse that entered the order did not select a time for the treatment to be completed and therefore did not get entered into the TAR to be completed daily. On 3/21/2026 at 8:20 PM in the progress notes, nursing documented R85 requested to go to the hospital for pulmonary reasons. R85 was transported to the hospital. On 3/21/2026 in the emergency room documentation, R85 expressed discontent regarding wound care which R85 stated had not been done to the right heel wound. R85 was assessed and treated at the hospital and sent back to the facility that night with orders for the right heel pressure injury: remove old dressing, wash with gentle soap and water, rinse, pat dry, apply Iodosorb, cover with Allevyn, and change the dressing three times per week and as needed. This order was not transcribed into R85's TAR at the facility. On 3/23/2026, R85 was seen by wound physician-F on wound rounds. The wound physician assessed the right heel pressure injury and ordered a treatment to the wound. This order was transcribed on 3/24/2026 and the treatment was first signed out on 3/25/2026 as being completed. R85 discharged from the facility on 4/6/2026 and was not in the facility at the time of the survey. In an interview on 4/13/2026 at 1:34 PM, Surveyor asked Assistant Director of Nursing (ADON)-C what the facility process was for putting in hospital discharge/facility admission medication and treatment orders. ADON-C stated the nurse on the floor that is admitting the resident enters the hospital discharge orders from the Discharge Summary into the resident's medical record. ADON-C stated the nurse contacts the physician to verify the orders and a second check of the orders is done by the Unit Manager usually the next day. Surveyor asked ADON-C if a resident is admitted with a pressure injury, how are treatment orders obtained. ADON-C stated treatment orders normally come on the Discharge Summary, but if there are no treatment orders on discharge, the wound nurse or Registered Nurse will consult with the wound physician and verify what orders they would like in place. ADON-C stated the wound physician (F) comes weekly on Mondays and will look at all residents with pressure injuries. ADON-C stated the wound physician (F) will make an initial assessment of a new resident at that time and make the decision if the treatment is appropriate or if a different treatment would be better at that time. ADON-C stated there is an outside consultant that follows up with orders and interventions to make sure everything is in place for residents with pressure injuries. Surveyor shared with ADON-C concerns R85 was admitted on [DATE] with an Unstageable pressure injury to the right heel and the treatment order from the Discharge Summary was not on R85's TAR, a new wound treatment was ordered on 3/21/2026 after an emergency room visit that was not transcribed, and R85 went five days with no treatment to the right heel pressure injury. On 4/14/2026 at 11:55 AM, Surveyor shared with Director of Nursing (DON)-B the concerns R85 did not have a treatment order in place at the time of admission on [DATE] for the Unstageable pressure injury to the right heel, a treatment order obtained on 3/21/2026 was not transcribed, and the first treatment to the right heel pressure injury was 3/25/2026 after R85 was seen by the wound physician on 3/23/2026, two days later. At 1:56 PM, Surveyor shared the same concerns with Nursing Home Administrator (NHA)-A. 3.) R6's diagnoses include chronic respiratory failure (long term condition where the lungs cannot adequately exchange oxygen and carbon dioxide), dysphagia (difficulty swallowing), encephalopathy (general brain dysfunction characterized by alteration in brain function or structure), malignant neoplasm (cancer) of colon, and diabetes mellitus (high blood sugar) . R6's admission MDS (minimum data set) with an assessment reference date of 12/25/25 assesses R6's short term & long-term memory as ok. Cognitive skills for daily decision making is modified independence. Speech clarity is assessed as no speech. R6 is assessed as not having any behavior including refusal of care. R6 is assessed as being dependent for eating, toileting hygiene, roll left and right, and chair/bed to chair transfer. R6 is always incontinent of urine & bowel. R6 is at risk for pressure injuries and is assessed as not having any pressure injuries. R6's pressure injury CAA (care area assessment) dated 12/29/25 under analysis of findings for nature of problem/condition documents the resident has potential impairment to skin integrity. Under care plan considerations for describe impact of this problem/need on the resident and your rationale for care plan decisions it is documented Encourage good nutrition and hydration in order to promote healthier skin. R6's pressure injury care plan initiated 3/3/26 and revised 3/15/26 documents the following interventions: *Administer treatments as ordered and monitor for effectiveness. Initiated 3/3/26. *Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Initiated 3/3/26. *Follow facility policies/protocols for the prevention/treatment of skin breakdown. Initiated 3/3/26. *Inform the resident/family/caregivers of any new area of skin breakdown. Initiated 3/3/26. *Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length x (times) width x depth), stage. Initiated 3/3/26. *Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. Initiated 3/3/26 *The resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested. Initiated & revised 3/3/26. *The resident requires pressure reducing devices on bed/chair. Initiated & revised 3/3/26. *[Wound company name] wound MD (medical doctor) rounds. Initiated 3/3/26. *Weekly treatment documentation to include measurement of each area of skin breakdown's (sic) width, length, depth, type of tissue and exudate. Initiated 3/3/26. *Air mattress in place with appropriate settings and functioning properly. Initiated 3/15/26. *Encourage adequate nutrition to promote wound healing. Initiated 3/15/26. *Moisture barrier cream/ointment after each incontinent episode. Initiated 3/15/26. *Offload bony areas using pillows, foam wedges, and/or offloading devices. Initiated 3/15/26. *Pressure redistributing cushion to wheelchair. Initiated 3/15/26. *Provide incontinence care as needed. Initiated 3/15/26. *Reposition at least hourly while in wheelchair and as needed and Q (every) 2 hours while in bed. Initiated 3/15/26. Surveyor reviewed R6's wound MD-F assessment and noted a wound assessment dated [DATE] which documents an unstageable coccyx pressure injury. Measurements 1 x (times) 0.8 x 0.3 cm (centimeters) with 100% necrotic tissue and Stage 3 right buttocks pressure injury with measurements of 0.3 x 0.3 x 0.1 cm and wound bed 100% granulation. R6 was transferred to the hospital on 3/26/26 and returned to the facility on 4/9/26.R6's nurses note dated 4/9/26 at 16:22 (4:22 p.m.) written by Registered Nurse (RN)-E documents readmitted to room [number] per stretcher, via [Name] ambulance services, accompanied by 2 EMTs (emerg

Uncorrected on revisitBased on interview and record review, the facility did not ensure 1 (R88) of 9 sampled residents received treatment and care in accordance with physician/nurse practitioner orders.*R88's NP requested R88 have daily weight monitoring beginning 3/24/26, and the facility did not implement daily weight monitoring until 4/3/26. Findings include:R88 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, chronic kidney disease, and chronic diastolic (congestive) heart failure (a chronic condition when the heart cannot pump blood efficiently leading to blood backing up and fluid buildup in the lungs, legs, and body). R88's admission MDS dated [DATE] documents a BIMS score of 15 indicating intact cognition. A progress note in R88's EHR dated 3/24/26 written by Nurse Practitioner (NP)-D documents chronic diastolic (congestive) heart failure - monitor daily weights . follow up: continue daily weight monitoring. Surveyor reviewed R88's EHR and located the following weights:3/20/26 335.0 pounds4/3/26 332.8 pounds4/4/26 332.1 pounds4/7/26 333.0 pounds4/8/26 333.2 pounds4/9/26 332.8 pounds4/10/26 331.0 pounds4/11/26 333.0 pounds4/12/26 333.0 pounds4/13/26 334.7 poundsR88's physician orders document daily weight every, day shift with order date 4/2/26 and start date 4/3/26. Surveyor was unable to locate any evidence in R88's EHR that R88 was weighed daily between 3/24/26 and 4/3/26. In an interview on 4/14/26 at 11:55 AM, Director of Nursing (DON)-B stated if the NP makes any recommendations after seeing a resident, these recommendations are given verbally or in writing to the unit nurse manager on the floor. DON-B stated if the NP requested a resident be weighed daily, daily weights should be initiated within 24 hours of the NP's request. Surveyor shared concern with DON-B that R88's NP requested R88 be weighed daily starting 3/24/26 and the facility did not begin weighing R88 daily until 4/3/26. No additional information was provided. In an interview on 4/14/26 at 1:00 PM, NP-D stated if NP-D has a recommendation or new order after seeing a resident, NP-D notifies DON-B or one of the nurses at the facility. NP-D stated if NP-D recommends a resident is weighed daily, NP-D would expect the facility to begin daily weights by the following day. On 4/14/26 at 1:56 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that R10's NP (D) requested R88 be weighed daily starting 3/24/26 and Surveyor was unable to locate any evidence the facility completed this request until 4/3/26.

Uncorrected on revisitBased on interview and record review, the facility did not ensure 1 (R10) of 2 sampled residents with orders to reweigh related to fluxuations in weights.*R10's nurse practitioner (NP) requested R10 be reweighed on 4/9/26, and the facility did not follow up on this request. Findings include: R10 admitted to the facility on [DATE] with diagnoses including mild protein-calorie malnutrition. R10's quarterly Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 12 indicating moderately impaired cognition. Surveyor reviewed R10's electronic health record (EHR) and located the following weights:3/23/26 157.0 pounds4/5/26 157.0 pounds4/6/26 151.3 pounds A progress note dated 4/9/26 written by NP-D documents weight on 4/6/26 was 151.3 pounds, reweight is needed for accuracy . follow up: reweight for accuracy given significant weight decrease. Surveyor was unable to locate an updated weight in R10's EHR after R10's NP requested R10 be reweighed for accuracy, and the most recent weight listed in R10's EHR was from 4/6/26. In an interview on 4/14/26 at 11:55 AM, Director of Nursing (DON)-B stated if the NP makes any recommendations after seeing a resident, these recommendations are given verbally or in writing to the unit nurse manager on the floor. DON-B stated if the NP requested a resident be reweighed, this should be completed within 24 hours of the NP's request. Surveyor shared concern with DON-B that R10's NP requested R10 be reweighed on 4/9/26 and Surveyor was unable to locate evidence R10 was reweighed. No additional information was provided. In an interview on 4/14/26 at 1:00 PM, NP-D stated if NP-D has a recommendation or new order after seeing a resident, NP-D notifies DON-B or one of the nurses at the facility. NP-D stated if NP-D recommends a resident is reweighed for accuracy, NP-D would expect the facility to reweigh a resident within one day of that recommendation. On 4/14/26 at 1:56 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that R10's NP (D) requested R10 be reweighed on 4/9/26 and Surveyor was unable to locate any evidence the facility completed this request.

Based on interview and record review, the facility did not ensure residents requiring respiratory care was provided with oxygen for 1 (R85) of 4 residents reviewed on oxygen. R85 had orders on admission for oxygen therapy 2 liters/minute at night. This order was not transcribed. R85 received oxygen without an active order for oxygen. The oxygen order that was obtained three days after admission did not specify the amount of oxygen to administer and R85 was not being monitored on an ongoing basis to determine the needs of oxygen. Findings include: The facility policy and procedure titled Oxygen Administration dated 8/1/2025 documents: Preparation: 1. Verify there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed.Documentation: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. 4. The frequency and duration of the treatment. 5. The reason for p.r.n. (as needed) administration. 6. All assessment data obtained before, during, and after the procedure. 7. How the resident tolerated the procedure. 8. If the resident refused the procedure, the reason(s) why, and the intervention taken. 9. The signature and title of the person recording the data. The facility policy and procedure titled Physician Orders dated 8/1/2025 documents: Recording Orders . 3. Oxygen Orders - When recording orders for oxygen, specify the rate of flow, route and rationale. Example: Oxygen 3L/min per nasal cannula as needed for shortness of breath. R85 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, and pulmonary hypertension. R85's admission Minimum Data Set (MDS) assessment dated [DATE] documented R85 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and on oxygen. R85's hospital discharge paperwork documented an order for oxygen at 2 liters/minute nightly. On 3/18/2026 on the admission Data Collection and Baseline Care Plan Tool, nursing documented R85's oxygenation was 90% on room air and R85 uses oxygen. On the Clinical admission form, nursing documented R85 did not use supplemental oxygen. No order for oxygen was found in R85's medical record for the use of oxygen as ordered on the hospital discharge summary on 3/18/2026. Surveyor noted the admission Data Collection and Baseline Care Plan Tool conflicted in the use of oxygen. The admission Data Collection and Baseline Care Plan Tool initiated R85's Oxygen Care Plan. No interventions documenting the rate of oxygen or the frequency of oxygen was included in the Care Plan. On 3/19/2026 at 5:56 AM in the progress notes, nursing documented R85's oxygenation was 98% on 2 liters of oxygen per nasal cannula. At 10:00 AM in the progress notes, a Nurse Practitioner (NP) documented R85 was currently on 3 liters of oxygen which was increased from the home baseline of 2 liters of oxygen at night. The NP documented R85 had recently been requiring oxygen during the day as well and the current oxygenation was 90%. Surveyor noted R85 did not have an active order for oxygen use. On 3/21/2026, an order was entered into R85's medical record: titrate oxygen to keep SpO2 (oxygen level) greater than 90%. Surveyor noted the order did not indicate the rate of oxygen or the duration, continuous or at night only. R85 discharged from the facility on 4/6/2026 and was not in the facility at the time of the survey. In an interview on 4/13/2026 at 1:34 PM, Surveyor asked Assistant Director of Nursing (ADON)-C what the facility process was for putting in hospital discharge orders. ADON-C stated the nurse on the floor that is admitting the resident enters the hospital discharge orders from the Discharge Summary into the resident's medical record. ADON-C stated the nurse contacts the physician to verify the orders and a second check of the orders is done by the Unit Manager usually the next day. Surveyor shared with ADON-C the concern R85 was admitted on [DATE] with an order for oxygen at night that was not transcribed on admission and received oxygen without having an active order for the use of oxygen. On 4/14/2026 at 11:55 AM, Surveyor shared with DON-B the concerns R85 was admitted with orders for oxygen use which was not transcribed into R85's medical record. Documentation was found on 3/18/2026 and 3/19/2026 indicating R85 was using oxygen when R85 did not have an active order for oxygen use. Surveyor shared the concern the oxygen order that was obtained on 3/21/2026 did not specify the rate or duration of the oxygen nor was there monitoring of R85's oxygenation level to determine if R85 was staying above the ordered 90% oxygenation. At 1:56 PM, Surveyor shared the same concerns with Nursing Home Administrator (NHA)-A.

Based on observation, interview, and record review, the facility did not ensure that residents at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 1 of 2 residents (R3) reviewed for pressure injuries.R3 is at risk for developing pressure injuries. On 1/17/26, facility staff found a left breast abscess that was not comprehensively assessed when identified. On 1/22/26, facility staff documented a new skin issue on R3's upper right gluteus. A treatment order was not placed for this new skin issue until 2/25/26. On 2/2/26, Wound MD-Q assessed R3's wounds for the first time. In an interview, Wound MD-Q stated that after this initial assessment, R3's left breast wound etiology was changed from abscess to pressure. In addition, on 2/2/26, Wound MD-Q found a new left trochanter hip wound and recommended treatment that was not put in place by facility staff until 2/25/26. Wound MD-Q could not assess R3's wounds weekly because R3 is out at an off-site dialysis center when wound rounds take place. Facility staff did not complete comprehensive weekly assessments when wound appointments were missed. Facility staff did not always update R3's care plan when R3's pressure injuries deteriorated. On 2/20/26, Wound MD-Q ordered an antibiotic to be given 2 times a day for 14 days for R3's left breast pressure injury. Facility staff entered this order incorrectly and R3 missed 7 doses of the ordered antibiotic. R3 has a diagnosis of Diabetes. R3's daily diabetic foot checks were not documented as completed in the days prior to developing a facility acquired right heel Deep Tissue Pressure Injury on 2/24/26.Findings include:The facility's policy with an effective date of 9/2025 and titled Pressure injury and skin impairment prevention and management documents in part: . [Facility] is committed to providing a comprehensive pressure injury and skin impairment prevention and management program that is consistent with professional standards of practice to promote the resident's highest level of functioning and well-being and to prevent the development of in-house acquired pressure injury, unless the individual's clinical condition demonstrates they are unavoidable. The goal is that all residents receive prompt assessment and treatment for all skin conditions. Any resident with a pressure injury receives treatment and services consistent with promoting healing and preventing infection and new pressure injuries from developing. Weekly comprehensive wound assessment will be completed and documented in [electronic medical record (EMR)] skin and wound application. the assessment should include at least the following parameters: Location of wound which may provide information related to the etiology of the wound. Length, width, and depth measurements recorded in centimeters. Direction and length of tunneling and undermining. Appearance of the wound base. Type and percentage of tissue in wound (eschar, slough, granulation, epithelial). Drainage amount and characteristics including color, consistency.The facility's policy titled Medication Orders dated 8/2/22, last reviewed 10/21/25, documents in part: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Treatment Orders - When recording treatment orders, specify the treatment, frequency and duration of the treatment.R3 was admitted to the facility on [DATE] with diagnoses that include Type 2 Diabetes (chronic condition characterized by insulin resistance and high blood sugar levels,) Paraplegia (a form of paralysis, the inability to voluntarily move or control the lower parts of the body,) morbid obesity (severe obesity,) congestive heart failure (chronic condition where the heart is unable to pump blood effectively,) muscle weakness, and end stage renal disease with dependence on renal dialysis (final stage of kidney disease, where the kidneys can no longer function adequately to sustain life without treatment.)R3's Annual Minimum Data Set (MDS) assessment dated [DATE] documents R3 is cognitively intact. R3 is dependent on staff for all other cares, mobility, and transfers.R3 is always incontinent of bowel and bladder. R3 is at risk for pressure injuries but does not have any current pressure injury or skin problems.R3's Pressure injury Care Area Assessment (CAA) dated 12/29/25 documents in part: The resident has potential for pressure ulcer development [related to] [history] of ulcers, [diabetes mellitus], immobility and obesity. Follow facility policies/protocols for the prevention/treatment of skin breakdown.R3's comprehensive care plan documents the following pertinent interventions: Pressure relieving mattress and cushion in wheelchair. Encourage [R3] to wear Prevalon boots. [R3] often declines Prevalon boots and prefers pillow under bilateral legs and feet. Remind [R3] to float heels (initiated on 4/13/22). Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness (initiated on 4/9/23). Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning (initiated 4/26/23). Follow facility policies/protocols for the prevention/treatment of skin breakdown (initiated 4/26/23). If the resident refuses treatment, confer with the resident, [Interdisciplinary team (IDT)] and family to determine why and try alternative methods to gain compliance. Document alternative methods (initiated 4/26/23).R3 receives Hemodialysis outside of the facility every Monday, Wednesday, and Friday.R3's Braden scale assessments (an assessment completed to determine how at risk a resident is for developing pressure injuries) completed on 12/3/25 and 1/5/26 document a score of 15, indicating R3 is at risk for developing pressure injuries.R3's potential for pressure ulcer development care plan documents the following intervention initiated on 1/5/26: Resident agreeable to not wear bra until rash area resolves.Surveyor reviewed R3's progress notes, skin assessments, and EMR and did not locate any other documentation regarding R3's rash.R3's skin check assessment dated [DATE] documents: No skin issues.R3's skin check assessment dated [DATE] documents: No skin issues. No new skin issues found on this evaluation.R3's skin check assessment dated [DATE] documents: No skin issues.R3's progress note dated 1/17/26 at 9:43 PM documents in part: Writer found left breast abscess with purulent drainage leaking from wound and right upper buttock abrasion. Nurse notified Wound Care MD and [Director of Nursing] and received order to Clean Left breast with Dakins, apply calcium alginate and cover with border gauze.to start Resident on Doxycycline [two times a day for] 14 days. Staff educated on making sure resident has the correct brief size on at all times .R3's Skin issue assessment dated [DATE] documents in part: New skin issue: Left breast; Issue type: Abscess; Wound acquired in-house; Signs and symptoms of infection: Smell increased; Increased exudate; New skin issue: Buttocks, Right; Issue type: Abrasion; Wound acquired in-house.Surveyor noted R3's initial wound assessments on the left breast was not comprehensive and complete. The assessment did not include measurements or tissue type in wound per facility policy.R3's MD order with a start date of 1/18/26 documents:-Left Breast Abscess, Clean with 1/2 strength Dakins, apply calcium alginate cut to size, [followed by (f/b)] Border Gauze. One time a day.-Doxycycline Hyclate Oral tablet 100 [milligrams (mg)] two times a day for abrasion to left breast for 14 days.R3's MD orders with a start date of 1/19/26 document:-Obtain [ultrasound (US)] of left breast [related to] possible abscesses.-Refer to plastic surgeon clinic for flap [related to] abscesses left breast.Surveyor reviewed R3's medical record and noted that an ultrasound and plastic surgery referral was not completed by facility staff.R3's Skin issue assessment completed by Director of Nursing (DON)-B dated 1/19/26 documents in part: Writer in to measure [and] complete skin assessment on reported new concern to Left Breast, Noted superficial site of interrupted tissue, Measures 4.5 [centimeters (cm)] x 1.3 cm x 0.1 cm has small site of slough measuring 1.3 x 0.5 cm located inside of area, small serous drainage, no odor, peri wound of normal character. [Wound MD-Q] updated on assessment, no nodules or firmness noted to breast. [New order] to place hold on US (ultrasound) and Referral to Plastics, continue [antibiotics] until completion and change dressing to Xeroform Gauze [followed by] Border, change [every day].Surveyor noted R3's comprehensive left breast wound evaluation was completed 2 days after the wound developed. Surveyor noted R3's left breast wound was not comprehensively assessed when found and was not evaluated until 2 days later.On 2/26/26 at 11:23 AM, Surveyor interviewed Wound MD-Q. Surveyor asked about the MD orders of ultrasound and plastics referral. Wound MD-Q stated that originally the left breast wound was thought to be an abscess. Wound MD-Q stated Wound MD-Q was unable to assess the wound and had to rely on the description given by facility staff. Wound MD-Q stated Wound MD-Q believed the ultrasound was ordered to confirm abscess and that would be appropriate. Wound MD-Q stated Wound MD-Q did not remember ordering a plastics referral and did not know why a plastics referral was ordered. Surveyor asked if Wound MD-Q wanted the ultrasound or plastics referral completed even after antibiotics were completed. Wound MD-Q stated it was held because the description changed and was no longer needed.On 2/26/2026 at 12:03 PM, Surveyor interviewed DON-B. DON-B stated that R3's breast wound presented as an abscess. When DON-B assessed the wound at first, DON-B saw 3 little spots and the middle one had slough. DON-B updated Wound MD-Q about that assessment. DON-B stated that DON-B thought it could be from the fit of R3's wheelchair and the fact that R3 leans and lays on the left side all the time. Surveyor asked who ordered the ultrasound and plastics referral. DON-B stated that Wound MD-Q ordered them. Surveyor informed DON-B that Wound MD-Q did not remember ordering a plastics referral. DON-B stated again that DON-B thought it was Wound MD-Q but could have been the facility Nurse Practitioner too. Either way, after the assessment of the wound, the ultrasound and plastics referral were put on hold.R3's MD order with a start date of 1/21/26 documents: Left Breast-abrasion, Clean with 1/2 strength Dakins, apply Xeroform Gauze, [followed by] Border Gauze. Every day shift for Abscess to Left breast.R3's Skin issues assessment dated [DATE] documents in part: Left breast; Issue type: abrasion; Overall wound characteristics improved; 4 x 1 x 0.1; No undermining Cleansing solution: Soap [and] water. Xeroform.Surveyor noted on 1/26/26, R3's left breast was cleansed with soap and water. R3's MD order documents that R3's left breast wound should be cleansed with half strength Dakins.R3's Wound MD-Q Wound evaluation note dated 2/2/26 documents, in part: Wound of the left breast full thickness. Etiology-Infection/bacterial; 4 x 6 x 0.1. Cluster wound-open ulceration area of 19.20 cm. 80% granulation tissue. 20% skin; Treatment Plan: Xeroform gauze apply once daily and as needed. Gauze island [with border].Non-pressure wound of the left hip full thickness. Etiology-Trauma/Injury. Duration: >1 day; 2 x 4 x 0.1. 80% granulation. 20% skin. Treatment plan: Xeroform gauze apply once daily and as needed; Gauze Island [with border dressing].Surveyor noted that R3's left breast wound developed on 1/17/26 and the first time Wound MD-Q evaluated it in person was on 2/2/26.Surveyor noted Wound MD-Q's treatment plan for the Left breast was Xeroform and Gauze Island dressing. Surveyor reviewed R3's MD orders, MAR, and TAR, and noted facility staff continued to treat R3's left breast with half strength Dakins.Surveyor noted R3 has a new Left hip wound.Surveyor reviewed R3's MD orders, MAR and TAR, and noted that facility staff did not enter treatment MD orders for R3's new left hip wound or right buttock wound. R3's skin issues assessment completed by WC RN-G, dated 2/2/26 at 11:38 AM, documents in part: Rear left trochanter; Issue type: pressure ulcer; Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury. Wound acquired in-house. It is unknown how long the wound has been present.Surveyor noted that R3's new left hip wound was first assessed by Wound MD-Q on 2/2/26 and is documented as a pressure injury per facility staff. On 2/26/26 at 11:23 AM, Surveyor interviewed Wound MD-Q. Wound MD-Q stated that initially staff described the wound as an abrasion/abscess so Wound MD-Q went with that. Wound MD-Q stated, that was the story I was given. After Wound MD-Q saw R3's breast wound for the first time, Wound MD-Q changed the diagnosis/etiology to pressure.Surveyor noted that Wound MD-Q stated in interview that when Wound MD-Q assessed R3's breast wound for the first time on 2/2/26, Wound MD-Q changed the etiology from abscess/abrasion to pressure. Surveyor noted that despite this fact, Wound MD-Q's wound evaluation documented the left breast wound as bacterial/infection in R3's Wound note evaluation documentation.On 2/25/26 at 11:55 AM, Surveyor interviewed and observed WC RN-G. Surveyor asked about R3's Left trochanter hip wound. WC RN-G stated that it started because of pressure on R3's left hip from leaning to the left in bed and in R3's wheelchair. WC RN-G stated that at the first assessment of the wound it was determined to be an unstageable pressure wound.Surveyor noted the discrepancy between WC RN-G's documentation and Wound MD-Q's documentation about R3's left hip wound. Surveyor noted that despite Wound MD-Q documenting R3's left hip wound as non-pressure related, Wound MD-Q had not seen R3's left hip wound regularly and noted that WC RN-G had been treating R3's left hip wound regularly. Interview with WC RN-G revealed that the facility believed R3's left hip wound was caused by pressure as R3's leans to the left in bed and in R3's wheelchair and that R3's left hip wound was located over a bony prominence and was caused by pressure. R3's progress note dated 2/9/26 at 2:41 PM, documents: Resident not seen by wound MD today due to resident unavailable at a Dialysis appointment. MD rescheduled for next week.Surveyor reviewed R3's medical record and noted R3 did not have comprehensive wound assessments for R3's breast or left hip pressure injuries for the weeks of 2/9 through 2/15.On 2/26/26 at 12:03 PM, Surveyor interviewed DON-B. Surveyor asked how often residents with pressure injuries need to have thorough assessments of the wounds. DON-B stated that it is weekly. DON-B indicated that with R3, it has been difficult to assess R3's wounds because R3 goes to dialysis at the same time that Wound MD-Q comes to do wound rounds at the facility. DON-B stated that Wound MD-Q will go off of what we send him in regard to assessments and measurements.On 2/26/26 at 10:33 AM, Surveyor interviewed WC RN-G. Surveyor asked who assesses the resident if Wound MD-Q is unable to see the resident. WC RN-G stated that WC RN-G is the one who would have to do the weekly assessment.On 2/26/26 at 11:23 AM, Surveyor interviewed Wound MD-Q. Wound MD-Q stated that seeing and assessing R3's wounds was challenging because of R3's dialysis appointments. R3 is typically out to dialysis on Monday mornings when Wound MD-Q comes weekly for wound rounds at the facility. Wound MD-Q stated that Wound MD-Q is chasing R3 for weekly wound rounds.R3's MD order with a start date of 2/13/26 documents: Left breast abrasion, Clean with [normal saline], apply Xeroform gauze, [followed by] border gauze. Surveyor noted facility staff updated R3's wound care order for R3's left breast to match what Wound MD-Q recommended on 2/2/26, 11 days later. Surveyor also noted the discrepancy in Wound MD-Q's documentation which documents R3's left breast pressure injury as an abrasion despite Wound MD-Q confirming that R3's left breast wound was pressure related.Surveyor reviewed R3's MD orders, MAR, and TAR, and noted that facility staff have not entered treatment MD orders for R3's left hip wound Surveyor noted daily treatments for R3's left hip were not being documented as completed daily.R3's progress note dated 2/16/26 at 1:59 PM, documents in part: Resident seen by wound MD today. Resident has no new orders but encouraged to shift [R3's] weight and reposition every 2 hours to promote healing.R3's Wound MD-Q Wound evaluation note dated 2/16/26, documents in part: Wound of the left breast full thickness. Etiology: Infection/Bacterial; 7 x 20 x 0.1; Cluster wound: open ulceration area of 98 cm. 70% granulation. 30% skin; Treatment plan: Alginate calcium apply once daily and as needed. ABD pad. Surveyor noted the discrepancy in Wound MD-Q's documentation which documents R3's left breast wound as having an etiology of infection/bacterial, despite Wound MD-Q confirming that R3's left breast wound was pressure related.Non-pressure wound of the left hip full thickness; Etiology: trauma/injury; 2 x 4 x 0.1. 80% granulation. 20% skin; Treatment plan: Xeroform gauze apply once daily and as needed; Gauze Island [with border]. Surveyor noted the discrepancy in Wound MD-Q's documentation which documents R3's left hip wound as having an etiology of non-pressure, despite WC RN-G confirming that R3's left breast wound was pressure related.Surveyor reviewed R3's MD orders, MAR, and TAR, and noted that facility staff did not enter the new treatment order of Calcium Alginate to R3's Left breast wound that was recommended on 2/16/26. Surveyor noted that facility staff did not enter treatment MD orders for R3's left hip wound. Surveyor noted treatments for R3's left hip wound are not being documented as completed daily.On 2/26/26 at 10:33 AM, Surveyor interviewed WC RN-G. Surveyor confirmed that R3's breast wound was due to pressure. Surveyor asked if R3 has any intervention for offloading of R3's breast. WC RN-G stated that WC RN-G knows that R3 has an order to turn and reposition every 2 hours. WC RN-G thought WC RN-G put offloading of the breast in as well. WC RN-G checked R3's medical record and stated that it was not there but that WC RN-G will put that in right away.R3's MD order with a start date of 2/21/26 documents: Left breast abrasion, clean with half strength Dakins, apply Calcium Alginate gauze, [followed by] ABD pad two times a day.Surveyor noted the discrepancy in Wound MD-Q's documentation which documents R3's left breast wound as having an etiology of an abrasion, despite Wound MD-Q confirming that R3's left breast wound was pressure related.Surveyor noted facility staff updated R3's left breast wound treatment 5 days after Wound MD-Q recommended Calcium Alginate.R3's MD order with a start date of 2/20/26 documents: Doxycycline Hyclate oral tablet 100 mg. Give 1 tablet by mouth two times a day every 14 days for wound infection.On 2/25/26 at 11:55 AM, Surveyor interviewed WC RN-G. Surveyor asked why R3 was placed on antibiotics on 2/20/25. WC RN-G stated that the left breast wound had worsened so WC RN-G called Wound MD-Q, and the antibiotic was ordered two times a day for 14 days. WC RN-G stated that R3 is currently taking this for the left breast wound.Surveyor noted that R3's antibiotic Doxycycline order was supposed to be given 2 times a day for 14 days but instead was entered incorrectly in the medical record as 2 times a day EVERY 14 days. Facility staff recognized the error and corrected R3's antibiotic order on 2/24/26. Surveyor reviewed R3's MAR and noted that because of this transcription error, R3 missed 7 doses of R3's antibiotics.On 2/26/26 at 11:23 AM, Surveyor interviewed Wound MD-Q about R3's antibiotics. Wound MD-Q stated that Wound MD-Q was told that R3's breast wound was odorous. Wound MD-Q then ordered the antibiotics. Surveyor asked if Wound MD-Q was aware that R3 missed 7 doses of R3's antibiotics. Wound MD-Q stated that Wound MD-Q did not know about any missed medications.R3's progress note dated 2/23/26 at 12:39 PM documents: Resident was not seen by wound MD today due to the fact [R3] was at Dialysis. MD wants to send resident to wound care for more consistent follow up.Surveyor reviewed R3's medical record and noted facility staff did not comprehensively assess R3's wounds when R3's Wound MD was unable to assess R3's left breast and left hip pressure injuries.R3's progress note dated 2/24/26 at 3:51 PM, documents in part: Writer spoke with resident today about not being able to see the wound MD on a consistent basis due to her dialysis appointment every week. MD suggests that resident go out to wound clinic so that [R3] can have a consistent follow up on [R3's] wound treatment. Writer asked resident and [R3] declined to go to an outside wound clinic. Resident states [R3] wants to continue to be seen here at the facility and does not want to go to another wound clinic. Writer also educated resident on the importance of offloading [R3's] breast area where [R3's] wound is in order for the area to heal. Resident states [R3] will try but the difficulty [R3] has on laying on [R3's] right side prevents [R3] but [R3] will call the Dialysis Center. to try to get [R3's] chair time changed on Mondays in order to be seen by the wound MD.R3's Skin check assessment dated [DATE] at 6:04 and 6:11 PM, documents in part: Left breast. Issue type: Abrasion. Signs and symptoms of infection: Smell increased. 5 x 4 x 0.1.Surveyor noted the discrepancy in Wound MD-Q's documentation which documents R3's left breast wound as having an etiology of an abrasion, despite Wound MD-Q confirming that R3's left breast wound was pressure related.Right heel. Issue type: Pressure ulcer / injury. Stage 1 Pressure ulcer / injury - non-blanchable erythema of intact skin. Wound acquired in-house. Wound is new; Staged by: In-house nursing; 1.5 x 1; Cleansing solution: Normal saline. Other primary dressing: skin prep Secondary dressing: Foam.Surveyor noted a new Right heel pressure injury developed and was first assessed on 2/24/26.Surveyor noted R3 has a diagnosis of diabetes. Surveyor reviewed R3's diabetic foot checks for the month of February. R3's CNA task documents that foot checks are to be completed daily before bed. Surveyor reviewed CNA documentation and noted missing foot checks for the following days in February: 2/2, 2/6, 2/7, 2/9, 2/10, 2/11, 2/12, 2/17, 2/18, 2/20, 2/22, 2/23, and 2/24. Surveyor noted in the days prior to developing a right heel pressure injury, facility staff did not complete the ordered daily foot checks.On 2/26/26 at 12:03 PM, Surveyor interviewed DON-B. Surveyor asked if R3 should have foot checks. DON-B stated that R3 should have daily foot checks because R3 is diabetic. DON-B stated that the foot checks are completed by CNAs and should be documented daily in the EMR.R3's MD orders with a start date of 2/25/26 include:-Left Hip: Cleanse with [normal saline] apply Xeroform dressing [followed by] border gauze.-Right heel: skin prep to heel with foam dressing covering daily.Surveyor noted that R3's left trochanter hip pressure injury was found by Wound MD-Q on 2/2/26. The first treatment MD order was placed to start on 2/25/26. R3's left trochanter hip wound was not documented as treated daily per Wound MD-Q's treatment plan recommendations for 23 days. On 2/23/26 at 12:50 PM, Surveyor observed and interviewed R3 while she was seated in her wheelchair. R3 was in her room and stated that she recently got back from dialysis. R3 was wearing socks and tennis shoes and was well groomed. Cushion noted in R3's wheelchair. R3 has an air mattress that is on and functioning. Surveyor asked if R3 has any wounds. R3 stated she has a wound on her left hip, left breast, and a butt wound and they have been there for about a month. Surveyor asked how often facility staff change the dressings. R3 stated that it is supposed to be every day, but it depends on what staff is working. R3 stated that the wound doctor has come to see her but not as often as the facility wants. R3 stated she went to dialysis later last week so she could see the Wound MD.On 2/24/26 at 8:54 AM, Surveyor observed R3 on her back in bed. Head of bed was slightly elevated. Air mattress was on. R3's heels elevated with pillows. No heel boots noted. R3 is leaning to her left side and sleeping.On 2/25/26 at 11:55 AM, Surveyor interviewed and observed WC RN-G complete wound treatments on R3's wounds. WC RN-G stated that R3 has a left hip, right buttock, left breast, and right heel wound. WC RN-G started with R3's left breast wound. WC RN-G stated that the wound is due to pressure. WC RN-G stated that the wound started as one area of infection that Wound MD-Q called an abrasion. Then, with time, the wound had added pressure because of how R3 is positioned, and Wound MD-Q changed the etiology to pressure. WC RN-G stated that R3 tends to lean to the left. When in R3's wheelchair, the left arm rest and the way the chair is made puts pressure on R3's left side. WC RN-G took Surveyor to R3's wheelchair. Surveyor noted the chair has curved sides to the back that are meant to keep R3 sitting straight. In addition, the left arm has a curved side that cradles R3's elbow and forearm. WC RN-G stated that the way R3 leans in the chair puts pressure in the exact places that would cause pressure and is what caused R3's breast wound.WC RN-G then went to R3's side and removed R3's left breast dressing. Surveyor noted a wound the size of a small paper plate with cluster areas of slough noted. No eschar noted in the wound area. WC RN-G used half strength Dakins to cleanse the wound, then used calcium alginate and an ABD pad to cover the area. Next, WC RN-G moved to R3's left hip. Surveyor noted R3 did not have a bandage on the wound. Surveyor asked if R3 should have a dressing in place. WC RN-G stated that the dressing must have come off when staff washed R3 up this morning.WC RN-G then used normal saline to wash the wound. Surveyor asked what caused this wound. WC RN-G stated it was due to pressure. WC RN-G stated that it was initially an unstageable pressure injury but now it is healing well. Surveyor observed a dime sized area that was pink in color. No slough or eschar noted. WC RN-G then placed Xeroform and bordered gauze over the wound.WC RN-G then gathered supplies to complete the treatment to R3's right heel. WC RN-G stated that the area was found yesterday and assessed by WC RN-G. WC RN-G stated that R3 refuses to wear heel boots but does agree to float heels on pillows. R3 confirmed to Surveyor that she did not want to wear heel boots. WC RN-G educated R3 about risks and benefits of the boots. R3 then agreed to wear a heel boot on the right foot and will float her left heel on a pillow. WC RN-G stated that R3's heel wound developed because of pressure.WC RN-G held up R3's lower leg. Surveyor noted R3 did not have a dressing on her heel wound. Surveyor asked if there should be a dressing. WC RN-G stated that the dressing probably came off when CNAs put R3 back to bed after dialysis. WC RN-G then sprayed skin prep on R3's heel. Surveyor noted a circular blackened area the size of 2 half dollars on R3's heel. Surveyor asked what stage this wound was. WC RN-G stated that it is an unstageable deep tissue injury (DTI). WC RN-G then placed a foam dressing over the wound and put the boot on R3's right foot.Surveyor noted that during the wound treatment observation, R3 did not have dressings in place to R3's right heel and left hip wound as MD ordered.Surveyor noted that according to WC RN-G, R3's left breast wound, left hip wound, and right heel wound developed because of pressure.On 2/26/26 at 8:29 AM, Surveyor observed R3 in bed. R3 had a heel boot on her right foot. R3's left heel was elevated with pillow. Air mattress was on. R3 was leaning to her left side and sleeping.On 2/26/2026 at 8:28 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-Y. LPN-Y stated that if a wound is found, the nurse needs to do an assessment, call the doctor, and get a treatment order. LPN-Y stated that they would also let WC RN-G know of any new wound. LPN-Y stated whoever gets the treatment order should enter it as an MD order in the resident's medical record. Surveyor asked when R3's left breast wound started. LPN-Y stated LPN-Y was not sure when it started but stated that R3 lays on that area all the time. LPN-Y stated that R3 has a wedge sometimes when R3 is in the wheelchair and LPN-Y stated that LPN-Y believes the chair and wedge are causing friction and pressure. LPN-Y stated that the wedge is gone now, and staff are using a pillow instead.On 2/26/26 at 10:33 AM, Surveyor interviewed WC RN-G. WC RN-G stated that wound rounds are completed with Wound MD-Q every Monday morning. Wound MD-Q will see all residents with wounds at that time and will offer recommendations. The recommendations are reviewed and entered as MD orders after wound rounds are completed. WC RN-G stated that Wound MD-Q has been unable to assess R3 every week because of R3's dialysis appointments. That's why they wanted R3 to go to an outside wound care clinic. R3 did not agree to that so WC RN-G had R3 change her dialysis time on Monday mornings. Now, R3 will be able to be assessed by Wound MD-Q weekly. Surveyor asked how positioning at dialysis is for R3. WC RN-G stated that WC RN-G will get R3 sitting in the wheelchair before R3's dialysis appointments. R3 remains in the wheelchair at the appointment. WC RN-G stated that when R3 returns, she is back to leaning on her left side.On 2/26/26 at 12:23 PM, Surveyor interviewed Nursing staff-Z at R3's Dialysis center. Nursing staff-Z stated that Nursing staff-Z had been with the dialysis center since October of 2025. Surveyor asked if R3's facility staff had communicated any positioning concerns regarding R3's pressure injuries. Nursing staff-Z stated that Nursing staff-Z has not received any communication and there is no documentation stating that facility staff had communicated to the dialysis center about R3's pressure injuries.Nursing staff-Z stated that R3 has told Nursing staff-Z about her pressure injuries. Nursing staff-Z stated they do use a Hoyer lift to put R3 into the reclined dialysis chair so R3 can recline during dialysis.Surveyor noted that facility staff did not communicate any pressure injury interventions to the dialysis center.On 2/26/26 at 1:32 PM, Surveyor informed Nursing Home Administrator (NHA)-A of the concerns that facility staff did not always complete a comprehensive wound assessment when new wounds were found on R3 and Wound MD-Q's treatment orders are not always followed. On 2/2/26, Wound MD-Q assessed R3's wounds for the first time. In an interview, Wound MD-Q stated that after this initial assessment, R3's left breast wound etiology was changed from abrasion/abscess to pressure. In addition, on 2/2/26, Wound MD-Q found a new left trochanter hip wound and recommended treatment that was not put in place by facility staff until 2/25/26. Facility staff did not complete comprehensive weekly assessments when wound appointments were missed. Facility staff did not always update R3's care plan when R3's wound deteriorated. On 2/20/26, Wound MD-Q ordered an antibiotic to be given 2 times a day for 14 days for R3's left breast pressure injury. Facility staff entered this order incorrectly and R3 missed 7 doses of her antibiotic. R3's daily diabetic foot checks were not documented as complete in the days prior to developing a facility acquired right heel Deep Tissue Pressure Injury on 2/24/26.No additional information was provided.

Based on observation and interviews, the facility did not ensure the garbage and refuse were properly disposed in the outside garbage storage receptacles.This deficient practice has the potential to affect all 63 residing at the facility.Findings include:On 2/23/2026, at 9:15 AM, Surveyor went on a tour of the facility garbage area with dietary manager-M. Surveyor observed the following:- Two large dumpsters with lids open. Both dumpsters were full and both dumpsters had full garbage bags falling out and hanging out of both dumpsters. - Behind both dumpsters were piles of garbage that included large cans, open bags of garbage, Styrofoam cups, plastic lids, and straws. Surveyor was not able to see the ground behind the dumpsters due to the amount of garbage behind both dumpsters.- Gloves, and soiled briefs/depends were lying on the ground around the dumpster area not in an enclosed garbage bag.- [NAME] body towels and hand towels were lying on the ground between both dumpsters and several broken cardboard boxes were lying around both dumpsters.Surveyor asked Dietary Manager- M who manages/ monitors the dumpster area. Dietary Manager-M was not sure what staff managed the dumpster area and stated it may be maintenance.On 2/24/2026, at 12:56 PM, Surveyor toured the outside dumpster area with Maintenance Director-N. Surveyor shared observations of the ground surrounding the two dumpsters. Surveyor noted both dumpsters had been emptied and 1 dumpster had the lids closed while the other dumpsters' lids were open. Garbage was still noted to be around the dumpster area. Surveyor asked who was in charge of monitoring and maintaining the dumpster area.Maintenance Director-N stated the dumpster area is shared with the apartment complex next door. There is a dumpster for the facility that is labeled with (facility address numbers) and the second dumpster is labeled to indicate the apartment complex dumpster. Currently there is no one managing the dumpster area because no one knows if it should be the facility maintenance department or the apartment complex maintenance department managing the area or if it should be shared. Maintenance Director-N confirmed concerns of the area surrounding the dumpsters and the amount of garbage that is surrounding the dumpster area. Maintenance Director-N was unsure how often garbage came to empty the dumpster garbage's.On 2/24/2026, at 3:00 PM, Surveyor shared observations with Nursing Home Administrator (NHA)-A of the facility dumpster area outside the facility. Surveyor shared concern there was no monitoring or maintaining of the area and requested to review the facility policy for the maintenance of the outside garbage storage receptacles. On 2/25/2026, at 9:49 AM, NHA-A stated the facility did not have a policy for the maintenance of the outside garbage storage receptacles and understood Surveyors observations and concerns of the facility dumpster area. No further information was provided at the time of this write up.

Based on record review and staff interview, the facility's Quality Assessment and Assurance Committee did not meet at least quarterly to identify and evaluate quality issues through assessment and assurance activities. The deficient practice had the potential to affect all 63 residents in the facility.The Quality Assessment and Assurance (QAA) Committee did not meet on a quarterly basis to determine quality deficiencies within the facility and develop and implement plans of action to correct any deficiencies. The QAA Committee meeting was held on 9/30/25 and 2/13/26 and did not meet for Quarter 4 of 2025.Findings:On 2/26/26, at 12:46 PM, Surveyor asked Nursing Home Administrator (NHA)-A how often the QAA Committee meets. NHA-A stated the facility meets quarterly but they missed their last quarter (Quarter 4) 2025 QAA Committee meeting due to staff being out of the office. NHA-A stated the facility identified the facility was not compliant with the quarterly QAA Committee meetings on 1/26/26. NHA-A stated the facility has since met on 2/13/26 and 2/23/26 with plans to start meeting quarterly with the next meeting scheduled for 3/23/26. Surveyor shared concerns with QAA Committee missing quarterly meetings as required.NHA-A provided a Past Non-Compliance Plan to Surveyor which documents the following:*The facility identified the facility was out of compliance with QAA meetings on 1/26/26.*QAA Committee meeting was scheduled with the Medical Director for 1/26/26. The Director of Nursing was unable to attend the meeting and was rescheduled for 2/23/26.*The root cause was identified as sporadic changes in Nursing Home Administrator and Director of Nursing throughout the month of October and November.Immediate Correction Action documents the following:*The facility reviewed the Medical Director's schedule and concluded QAA Committee meetings will be held the 3rd Monday of the next month.*The facility has created a QAA Committee calendar and will audit QAA meetings quarterly.No additional information was provided.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program based upon current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 63 residents. * Staff were observed not wearing appropriate personal protective equipment (PPE) while providing gastrostomy tube (g-tube) cares for R25 and R26. Staff were also observed not performing appropriate hand hygiene during medication pass with R25 and R26. * The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: -Identify where control measures should be applied based on where Legionella could grow and spread -Include a process to confirm the WMP is being implemented and is effective. * Staff were observed not wearing appropriate personal protective equipment (PPE) while providing colostomy and indwelling catheter cares for R72. * Staff were observed not following appropriate personal protective equipment (PPE) precautions while providing wound care to R3. * Staff were observed not wearing appropriate personal protective equipment (PPE) while providing respiratory care to R6. Findings include: The facility's policy titled Standard Precautions, dated 8/1/25, documents the following: *Standard precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard precautions to presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. *Standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. *Hand hygiene refers to handwashing with soap (antimicrobial or non-antimicrobial) or use of alcohol-based hand rub (ABHR), which does not require access to water. *Hand hygiene is performed with ABHR or soap and water: -Before after contact with the resident. -Before performing an aseptic task. -Before moving from work on a soiled body site to a clean body site on the same resident. -After contact with items in the resident's room. -After removing gloves. Hands are washed with soap and water: -When visibly soiled with dirt, blood, or body fluids. -After contact with blood, body fluids, or contaminated surfaces. The facility's policy titled enhanced barrier precautions, dated 3/25/24, documents the following: *Enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of Multidrug-resistant organisms (MDRO) that employs targeted gown and gloves use during high contact resident care activities. *An order for enhanced barrier precautions will be initiated for residents with any of the following: -Wounds (chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and indwelling medical devices (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. -Infection or colonization with a Center for Disease Control (CDC)-targeted MDRO when Contact Precautions do not otherwise apply. *Personal Protective Equipment (PPE) for enhanced barrier precautions is only necessary when performing high contact care activities (listed below) and may not need to be donned prior to entering the resident's room. High contact resident care activities include: -Dressing -Bathing -Transferring -Providing hygiene -Changing linens -Changing briefs or assisting with toileting -Device care or use: center lines, urinary catheters, feeding tubes, tracheostomy ventilator tubes -Wound care: any chronic skin opening requiring a dressing The facility's policy titled Legionella Water Management Program, not dated, documents the following: *The purposes of the water management program are to identify areas in the water system where legionella bacteria can grow and spread and will reduce the risk of legionnaire's disease. *The water management program includes the following elements: The identification of areas in the water system that would encourage the growth and spread of legionella or other waterborne bacteria, including the following: -Storage tanks -Water heaters -Filters -Aerators -Shower heads and hoses -Misters, atomizers, air washers and humidifiers -Hot tubs -Fountains *The control limits or parameters that are acceptable and that are monitored. *A diagram of where control measures are applied. *A system to monitor control limits and the effectiveness of control measures. *Documentation of the program. 1.) On 2/24/26, at 8:23 AM, Surveyor observed LPN-R perform medication administration for R26. Surveyor observed LPN-R enter R26's room that had a sign on the entryway indicating R26 was in Enhanced Barrier Precautions (EBP). Surveyor observed LPN-R enter R26's room with no gown and applied gloves. LPN-R then administered medications through R26's gastrostomy tube (g-tube) while only donning gloves. After completing medication administration through R26's g-tube, Surveyor observed LPN-R remove her gloves, throw the gloves in the garbage and walk over to the medication cart without performing proper hand hygiene. Surveyor notes, LPN-R did not don a gown using EBP while administering medications through R26's g-tube and did not use appropriate hand hygiene throughout medication administration for R26. On 2/24/26, at 8:34 AM, Surveyor observed Licensed Practical Nurse (LPN)-R perform medication administration for R25. Surveyor observed LPN-R enter R25's room that had a sign on the entryway indicating R25 was in EBP. Surveyor observed LPN-R enter R25's room with no gown and applied gloves. LPN-R then administered medications through R25's g-tube while only donning gloves. After completing medication administration through R25's g-tube, Surveyor observed LPN-R remove her gloves, throw the gloves in the garbage and walk over to the medication cart without performing proper hand hygiene. Surveyor notes, LPN-R did not don a gown using EBP while administering medications through R25's g-tube and did not use appropriate hand hygiene throughout medication administration for R25. On 2/26/26, at 10:01 AM, Surveyor notified Nursing Home Administrator (NHA)-A of concerns with LPN-R not performing appropriate hand hygiene or donning appropriate EBP equipment while administering medications through R25 and R26's g-tube during observation of medication pass. NHA-A acknowledged these concerns. 2.) On 2/25/26, at 11:16 AM, Surveyor reviewed the facility's Water Management Program and was unable to locate documentation of where control measures should be applied based on where Legionella could grow and spread, and unable to locate documentation of implementation of monitoring to confirm if the water management program is effective. Surveyor notes the facility is unable to identify possible dead leg units identified and unable to confirm if flushing and monitoring has been completed routinely. On 2/26/26, at 10:35 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who provided additional flushing logs for the facility. Surveyor reviewed the flushing logs provided and noted detailed flushing logs completed in 2023 and noted to NHA-A there are no current flushing logs documented to indicate the facility has been implementing and monitoring the water management program. NHA-A stated the previous maintenance employee left the facility in September 2025 and NHA-A stated she has been implementing the water management program since September 2025. NHA-A stated the East unit was previously closed and is now open. NHA-A also stated housekeeping will go in and complete water flushing. Surveyor asked NHA-A for documentation and NHA-A stated the facility does not have documentation of flushing and monitoring of the water management program being completed. Surveyor notified NHA-A of concerns with the facility not implementing, monitoring and documenting the water management program as required. NHA-A acknowledged these concerns. 3.) R3 was admitted to the facility on [DATE] with diagnosis that include Paraplegia (a form of paralysis. The inability to voluntarily move or control the lower parts of the body), Muscle weakness and End stage renal disease with dependence on renal dialysis (final stage of kidney disease, where the kidneys can no longer function adequately to sustain life without treatment). R3's Annual Minimum Data Set (MDS) assessment dated [DATE] documents R3 is cognitively intact. R3 requires set up and clean up assistance for eating and oral hygiene. R3 is dependent on staff for all other cares, mobility and transfers. On 2/23/26 at 12:50 PM, Surveyor interviewed R3 in R3's wheelchair. Surveyor asked if R3 has any wounds. R3 stated that R3 has a wound on R3's left hip, left breast and a butt wound, and they have been there for about a month. On 2/23/2026, at 12:55 PM, Surveyor observed R3's door and noted there was an Enhanced Barrier Precaution (EBP) sign hanging. R3's active MD order documents: Enhanced Barrier Precautions. On 2/25/26 at 11:55 AM, Surveyor observed Wound Care Registered Nurse (WC RN)-G provide wound care treatments to R3. WC RN-G completed hand hygiene and put on gown and gloves before starting wound care. WC RN-G stated that R3 has a left hip, right buttock, left breast and right heel wound. WC RN-G started with R3's left breast wound. WC RN-G removed the dressing, removed gloves and completed hand hygiene before putting on clean gloves. WC RN-G then completed the cleansing and treatment of R3's left breast wound. WC RN-G removed gloves and completed hand hygiene. WC RN-G then left R3's room with used gown on to get supplies from WC RN-G's wound cart in the hallway. WC RN-G returned to R3's room with the same gown on. WC RN-G completed hand hygiene before putting on clean gloves. WC RN-G then completed cleansing and treatment of R3's left hip wound. Next, WC RN-G then moved R3 to R3's left side to do the treatment on R3's buttock. WC RN-G removed R3's dressing to R3's right buttock wound. WC RN-G removed gloves and completed hand hygiene. WC RN-G realized WC RN-G did not have any more clean gloves and left R3's room to retrieve gloves. WC RN-G left WC RN-Gs used gown on when going to get gloves. WC RN-G returned to R3's room with the same used gown on. WC RN-G completed hand hygiene and put on clean gloves. WC RN-G completed cleansing and treatment to R3's right buttock wound. WC RN-G then moved to R3's right heel. WC RN-G removed used gloves and completed hand hygiene. WC RN-G then left R3's room to gather more supplies for R3's right heel wound. WC RN-G left R3's room with the same used gown on. WC RN-G returned to R3's room with supplies. WC RN-G completed hand hygiene, put on new gloves and completed the wound treatment to R3's right heel. After all treatments were completed. WC RN-G removed gown and gloves, completed hand hygiene and left R3's room. Surveyor noted R3's trash can inside of R3's room did not have any used gowns disposed of in the trash can before WC RN-G put one gown in the can. Surveyor noted that during wound care observation, WC RN-G left R3's room [ROOM NUMBER] times with the same gown on. On 2/26/2026 at 12:03 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked if an EBP sign is posted outside of a resident's door, if staff are expected to follow Enhanced Barrier Precautions. DON-B stated yes. DON-B stated that the only time that a staff member does not have to put on gown and gloves is if the staff member is not touching the resident. Surveyor asked if during wound treatments, if staff can leave an EBP room with the same gown on. DON-B stated staff cannot walk out of the room with their gown on. DON-B stated staff are expected to take off gown when leaving the room and put on a new one when reentering the room. On 2/26/2026 at 1:32 PM Surveyor informed Nursing Home Administrator (NHA)-A of the concern that during wound treatment observation, WC RN-G left R3's room and returned to R3's room [ROOM NUMBER] times with the same used gown on. 4.) R72 was admitted to the facility on [DATE] and has diagnoses that include osteomyelitis of vertebra of the sacral and sacrococcygeal region, Stage 4 pressure injury. R72's admission minimum data set (MDS) dated [DATE] indicated R72 was admitted with an indwelling foley catheter, a colostomy to the right lower abdomen, a stage 4 pressure injury to the sacrum with chronic osteomyelitis, and unstageable pressure injuries to the right and left heels. On 2/23/2026, at 10:45 AM, Surveyor observed R72 lying in bed sleeping. Surveyor noted on R72's door there was an Enhanced Barrier Precaution (EBP) sign and behind it was a Contact Precaution sign. On 2/24/2026, Surveyor reviewed R72's medical record. Surveyor noted the following physician order:- Enhanced Barrier Precautions and Contact Precautions. Order date: 2/24/2026 On 2/25/2026, at 9:30AM, Surveyor observed certified nursing assistant (CNA)-O and CNA-P perform catheter and colostomy cares for R72. Surveyor noted CNA-O and CNA-P did not put on gowns when emptying R72's colostomy or foley catheter. CNA-O and CNA- did not put gowns on when repositioning R72. Surveyor asked if a resident has both EBP and contact precautions signs outside the door, how do staff know what the resident is supposed to be on or what personal protective equipment (PPE) is needed and when. CNA-O stated a gown only has to be worn if someone is on contact precautions for a certain issue. R72 stated R72 forgot to put on a mask and R72 should not be on contact precautions, that is why the EBP sign is in front of it. Surveyor asked if staff were supposed to wear a gown for EBP's CNA-O stated no, only gloves and a mask. Surveyor reviewed the EBP sign outside R72's door with the following recommendations:Enhanced Barrier Precautions: 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 High-Contact Resident Care Activities.- Dressing- Bathing/ Showering- Transferring- Changing linens- Providing Hygiene- Changing briefs or assisting with toiletingDevice care or use: .- Urinary catheter .- Wound Care: any skin opening requiring a dressing. Surveyor reviewed the contact precautions sign outside R72's door that is underneath the EBP with the following recommendations: CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO:- Put on gloves before room entry. Discard gloves before room exit- Put on gown before room entry. Discard gown before room exit . Surveyor confirmed neither EBP nor contact precautions require staff to wear a face mask, however both precautions require staff to wear a disposable gown during contact with the resident. On 2/25/2025, at 10:30 AM, Surveyor interviewed registered nurse (RN)-F who stated R72 is on contact precautions due to R72's pressure wound to R72 sacral areal and right and left heels. RN-F stated a gown should only be worn if provided wound care for R72. Surveyor asked what PPE should be wearing if providing other cares or repositioning R72. RN-F stated staff would have to look at the sign so see what PPE was needed. Surveyor asked how staff would know if R72 was supposed to be on EBP or contact precautions. R72 was not sure. On 2/26/2026, at 11:51, Surveyor interviewed director of nursing (DON)-B via phone. DON-B stated if a resident is on EBP and another sign is posted (such as contact precautions) the EBP always trumps the other precaution, so staff would follow the EBP PPE recommendations. Surveyor asked how staff would know why a resident is on contact or when to wear a gown since contact requires staff to wear a gown when entering room. DON-B stated staff would have to read the recommendations on the sign and determine if a gown is needed. Surveyors clarified with DON-B, DON-B's statement indicating if someone was on more than one precautions staff should always follow EBP recommendations first. DON-B stated correctly, staff need to look at the recommendations and ask questions if needed. On 2/26/2026, at 1:21 PM, Surveyor shared concerns with nursing home administrator (NHA)-A and regional nurse-D Surveyors observations of staff not wearing appropriate PPE when performing colostomy, catheter, and repositioning cares for R72. Surveyor shared concerns staff do not know when to wear appropriate PPE for residents that are on precautions other than EBP. NHA-A understood the concern; no further information was provided at the time of this writeup. 5.) R6 was admitted to the facility 6/25/2015 with diagnoses including chronic respiratory failure (long-term lung damage), chronic obstructive pulmonary disease (long-term lung disease leading to difficulty breathing), dependence on respirator (ventilator) status (reliance on a machine to breathe), and tracheostomy (surgically created opening in the windpipe) status. R6 had a guardian. R6's most recent minimum data set (MDS) assessment dated [DATE] documents R6 receives oxygen therapy via invasive mechanical ventilator with suctioning and tracheostomy care. R6's ventilator and respiratory care plan documents the following interventions with initiated dated 6/7/23 and revised date 3/20/24:-the resident requires enhanced barrier precautions related to presence of artificial opening and potential exposure to multidrug resistant organisms (MDRO)-apply personal protective equipment (PPE) per facility policy -implement enhanced barrier precaution R6's risk for MDRO transmission care plan documents the following interventions with initiated date 10/29/25:-follow enhanced barrier precautions when outside the resident's room when indicated-PPE for enhanced barrier precautions is only necessary when performing high contact care activities . high contact includes: . device care or use: . tracheostomy/ventilator . On 2/24/26 at 1:09 PM, Surveyor observed Respiratory Therapist (RT)-U perform suctioning care for R6's tracheostomy. Before entering the room, Surveyor observed a sign outside of R6's door documenting enhanced barrier precautions were in place. The sign 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 high-contact resident care activities. device care or use: . tracheostomy . Surveyor observed RT-U perform hand hygiene then don gloves, but RT-U did not don a gown prior to providing suctioning and tracheostomy cares to R6. On 2/24/26 at 1:20 PM, Surveyor interviewed RT-U regarding when a gown would be worn when providing resident care. RT-U replied not all residents require a gown, but RT-U would wear one if a resident were on droplet or contact precautions. Surveyor asked if RT-U would wear a gown if a resident were on enhanced barrier precautions, and RT-U said yes, RT-U would wear a gown if there were an enhanced barrier precautions sign outside of a resident's door. Surveyor asked why RT-U did not wear a gown when performing suctioning and tracheostomy cares for R6, and RT-U replied RT-U is the only RT working on the unit and has to constantly go in and out of resident rooms to answer the ventilator alarms and did not have time to put on a gown. In an interview on 2/26/26 at 12:16 PM with Director of Nursing (DON)-B via phone call, DON-B stated enhanced barrier precautions should be followed any time staff are performing tracheostomy cares, and proper PPE should be worn to include a gown and gloves. On 2/26/26 at 1:32 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and Regional Nurse-D that Surveyor observed RT-U perform tracheostomy care and suctioning without wearing a gown. No additional information was provided.

Based on interview and record review, the facility did not ensure a designated Infection Preventionist works at least part time at the facility for the responsibility of the facility's Infection Prevention Control Program. Director of Nursing (DON)-B was designated as the facility's Infection Preventionist (IP) in addition to performing DON responsibilities and working on the Ventilator Unit as a floor nurse, which resulted in the inability to implement an effective Infection Prevention Control Program. Findings include: Surveyor reviewed the Facility assessment dated 10/2023, last reviewed 02/2026, which documents the facility as having one (1) full-time Director of Nursing and one (1) full-time Infection Preventionist. On 2/26/26, at 12:19 PM, Surveyor interviewed Director of Nursing (DON)-B who stated she dedicates Mondays to the Infection Prevention Program. DON-B stated she works two (2) days a week on the Ventilator Unit as a floor nurse and three (3) days a week as the DON. Surveyor expressed concerns with DON-B not having enough dedicated time to perform the IP responsibilities. DON-B stated there is a new interim DON who has started at the facility which will allow DON-B to dedicate 2-3 days out of 10 days for IP responsibilities. DON-B stated she works 10 days in two (2) weeks and will dedicate 2-3 days out of that time to the Infection Prevention Program. On 2/26/26, at 10:01 AM, Surveyor notified Nursing Home Administrator (NHA)-A of concerns with the facility not having a dedicated full-time Infection Preventionist. NHA-A acknowledged these concerns. No additional information was provided.

Based in observation, interview, and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 3 (R56 R36, and R73) of 5 residents reviewed for falls and 1 (R39) of 1 resident reviewed for smoking. *R56 was observed walking without a 2 wheeled walker in the hallway. R56's care plan was not revised to indicate accurate transfer status for R56. *R36 had falls on 12/4/2025 and 1/27/2026 that were not thoroughly investigated. *R39 did not have a quarterly smoking assessments completed and R39's smoking care plan was not revised to indicate if R39 was to be supervised or unsupervised when smoking or if R39 was safe to hold onto own smoking materials. *R73 had a fall out of bed on 2/15/2026 that was not thoroughly investigated. Findings include: The facility policy titled Care Plan Goals, Objectives, Revisions dated 8/1/2025 documents: Purpose: Care plans shall incorporate goals and objectives that lead to the resident's/ patient's highest obtainable level of independence. General Guidelines: .2. When goals and objectives are not achieved, the individuals clinical record is documented to as why the results were not achieved and what new goals and objectives were established.5. Goals, objectives and interventions are reviewed and/ or revised: .b. When the desired outcome has not been achieved.c. When the resident/ patient has been re-admitted to the facility from a hospital/ rehabilitation stay.d. At least quarterly. The facility policy titled Smoking dated 8/1/2025 documents: Policy statement: This facility has established and maintains safe resident smoking practices.Policy Interpretation and Implementation: .6. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: .d. Ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation).8. A resident's ability to smoke safely is re- evaluated quarterly, . and as determined by staff.9. Any smoking- related privileges, restrictions and concerns (for example, need for close monitoring) are noted on the care plan . 1.) R56 was admitted to the facility on [DATE] and has diagnoses that include encephalopathy, vertigo, mild neurocognitive disorder, chronic pain syndrome, . and other symptoms and signs involving cognitive functions and awareness. R56's admission minimum data set (MDS) date 1/4/2026 indicated R56 has moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 11 and the facility assessed R56 as being independent with activities of daily living (ADL's) and used a walker for safety. The facility assessed R56 on 12/23/2025 to be a high risk for falls with a score of 8. R56's current functional care plan was initiated on 1/9/2026 with the following intervention:- Resident performance: Toilet use- Limited assist/one-person physical assist, patient will use 2 wheeled walker (2ww) to and from bathroom with assist of 1 staff member. R56's Impaired physical mobility care plan was initiated on 1/5/2026 with the following intervention:- Determined level of needed assistance based on ADLs evaluation. Surveyor noted R56's care plan was not revised after R56's ADL evaluation to indicate what assistance R56 required. R56's use of a safety device of standard wheelchair with cushion for long distances. 2ww for short distances to and from the bathroom with assistance of 1 staff member care plan was initiated on 1/9/2026 with the following intervention:- Resident will use 2ww to and from the bathroom with assistance of 1 staff member. Wheelchair for longer distances. R56's risk for falls care plan was initiated on 1/14/2026 with the following interventions:- Be sure residents' call light is within reach and encourage the resident to use it for assistance as needed.- Follow facility fall protocol. On 2/24/2026, at 8:54 AM, Surveyor observed R56 walking in the hallway without a walker. Surveyor asked R56 how R56's day was going. R56 stated having bad vertigo and gets dizzy at times. Surveyor asked if R56 is to have a walker when walking. R56 stated R56 is to have a walker but does not like to use it. Surveyor observed a 2ww in the corner of R56's bedroom. Surveyor observed staff walking by and saying Hi to R56 without encouraging to use R56's walker when out in the hallway. On 2/25/2026, at 9:12 AM, Surveyor observed R56 walking in the hallway with R56's right hand on a 2ww and R56's left hand holding a cup of water. On 2/25/2026, at 10:00 AM, Surveyor interviewed registered nurse (RN)-F who stated R56 usually walks around alone. RN-F stated sometimes R56 uses a walker and sometimes R56 does not use a walker. Surveyor asked RN-F if R56 should use a walker at all times when walking. RN-F stated R56 uses a walker if R56's vertigo is bad, otherwise does not use one. On 2/25/2026, at 10:36 AM, Surveyor interviewed certified nursing assistance (CNA)-K who stated it depended on how R56 felt if R56 used a walker or not. CNA-K stated on good days R56 did not use a walker and on bad days R56 did use a walker. CNA-K stated R56 does all ADLs without help unless R56 requested assistance with something. Surveyor asked CNA-K if R56 uses a wheelchair when going long distances. CNA-K stated not recalling R56 ever having a wheelchair, CNA-K stated R56 always walks everywhere. On 2/26/2026, at 8:00 AM, Surveyor observed R56 walking in the hallway without R56's 2ww. Surveyor asked R56 where R56 was going, R56 stated R56 was going to an appointment and would be back to the facility later. Surveyor observed RN-F tell R56 to have a good appointment. On 2/26/2026, at 11:00 AM, Surveyor interviewed director of rehab (DOR)-H who started employment with the facility January 2026. Surveyor asked DOR-H who is responsible for revising care plans after ADL evaluations are completed. DOR-H stated DOR-H is responsible for initiating/revising the residents care plan after the resident gets evaluated for ADLs. DOR-H stated the therapy staff will hand in the evaluations and notify nursing staff of any changes for the residents. DOR-H then revises the care plan based on the therapist's evaluation. DOR-H stated care plans are also discussed in the morning stand up meeting that occur every morning and care plans can also be revised at that time as well. DOR-H stated not knowing what the process was prior to DOR-H hire date in January 2026, however, that is the process currently. Surveyor asked what R56's current ADL status is. DOR-H was not familiar with R56 and requested to review therapy notes and get back to Surveyor. On 2/26/2026, at 11:34 AM, Surveyor shared concern with nursing home administrator R56's care plan was not revised to reflect R56's current ADL status and Surveyor has observations of R56 walking around without a walker. NHA-A stated NHA-A often observed R56 walking all over without a walker at times. On 2/26/2025, at 12:33 PM, DOR-H provided Surveyor with a summary of R56 therapy notes. Surveyor notes DOR-H notes document R56 was on therapy caseload 12/2025, at discharge from therapy it was recommended R56 use a 2ww with supervision for all mobility due to history of vertigo and cognitive impairment. Surveyor asked DOR-H to clarify what supervision assistance means. DOR-H stated supervision is observing the resident but does not require a contact guard assist, so the staff member does not have to hold or steady the resident but should observe for safety and encourage use of safety device in this case the walker for R56. DOR-H stated a staff member does not always have to be by R56's side, however, has to observe safety and encourage use of walker and safety measures. Surveyor asked if R56's care plan should have been revised when discharged from therapy to reflect what R56's current ADL status is. DOR-H stated R56's care plan should have been revised to reflect the proper status of R56's ADL status. 2.) R39 was admitted to that facility on 11/8/2023 and has diagnoses that include Chronic Obstructive Pulmonary Disease (COPD- progressive lung disease), depression, . and cognitive communication deficit. R39's annual minimum data set (MDS) dated [DATE] indicated R39 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14 and the facility assessed R39 as having no impairments to R39's upper and lower extremities and required minimal assistance with one staff for activities of daily living (ADLs). R39 has a guardian and is documented as being a resident that smokes. R39's smoking care plan has an initiated date of 6/30/2025 with the following interventions:- Assist with transportation to/from smoking area. (Initiated: 11/8/2023, Resolved: 11/29/2024)- Instruct resident about smoking/vaping risks and hazards and about smoking cessation aids that are available. (Initiated: 11/8/2023, Resolved: 11/29/2024)- Instruct residents about the facility policy on smoking/vaping: locations, times, safety concerns. (Initiated 6/30/2025)- Notify charge nurse immediately if it is suspected a resident has violated facility smoking policy.- Observe clothing and skin for signs of cigarette burns. R39's Care Kardex dated 2/25/2026 has the following interventions:Safety:- Notify charge nurse immediately if it is suspected resident has violated facility smoking policy.Monitors:- Observe clothing and skin for signs of cigarette burns.Monitoring:-Instruct residents about the facility policy on smoking/vaping: locations, times, safety concerns. Surveyor notes R39's care plan and Care Kardex do not indicate if R39 is to be supervised or unsupervised when smoking, or if R39 is able to hold onto R39's smoking materials or if the facility should hold onto R39's smoking materials. On 2/24/2026, at 9:00 AM, Surveyor observed R39 lying on R39's bed. Surveyor asked how R39's day was going. R39 stated R39 did not want to talk and waved Surveyor away. Surveyor reviewed R39's medical chart and noted smoking assessments completed on 11/8/2023 (admission assessment) and 6/30/2025 (quarterly assessment). Surveyor noted both assessments on 11/8/2023 and 6/20/2025 do not have documentation noting if R39 is to be supervised or unsupervised when smoking or if R39 is able to hold onto R39's smoking materials or if the facility has to hold onto R39's smoking materials. On 2/25/2026, Surveyor requested all smoking assessments for R39 for 2025. On 2/25/2026, at 10:00 AM, Surveyor interviewed registered nurse (RN)-F who stated R39 usually goes outside to smoke without supervision. Surveyor asked if R39 held onto R39's smoking materials or if facility held onto R39's smoking materials. RN-F stated R39 must hold onto R39's smoking materials because R39 never asked for smoking materials when going outside to smoke. Surveyor asked how often smoking assessments are completed. RN-F stated smoking assessments are completed yearly but was not sure. Surveyor asked RN-F who completes smoking assessments for residents. RN-F was not sure who completes smoking assessments for residents. On 2/25/2026, at 10:36 AM, Surveyor interviewed certified nursing assistant (CNA)-K who stated R39 will go outside to smoke by self. CNA-K stated R39 holds onto R39's smoking materials. Surveyor asked CNA-K where the information is located to see if a resident is safe to smoke unsupervised or needs supervision and if the resident can hold onto their own smoking materials. CNA-K stated usually it is documented on the resident's care Kardex, or through report with the previous shift. On 2/25/2026, at 2:55 PM, Surveyor asked nursing home administrator (NHA)-A and regional nurse-D if anymore of R39's smoking assessments could be located. Regional nurse-D stated the only assessments that could be located were R39' s admission smoking assessment on 11/8/2023 and a quarterly smoking assessment completed on 6/30/2025. Surveyor asked how often smoking assessments are to be completed. NHA-A stated smoking assessments should be completed on admission, then quarterly, or as needed if a change has occurred. Surveyor asked if it should be documented if a resident is safe to smoke supervised or unsupervised and if the resident can or cannot hold onto their own smoking materials. NHA-A stated the assessment should determine and document if a resident is safe to smoke supervised or unsupervised and if the resident could hold onto their own smoking materials. Surveyor shared concerns R39 did not have quarterly smoking assessments completed, and R39 smoking assessments completed on 11/8/2023 and 6/30/2025 and R39's care plan do not indicate if R39 is safe to smoke supervised or unsupervised and if R39 can hold onto R39's smoking materials or if the facility holds onto R39's smoking materials, NHA-A and regional nurse-D understood the concerns and no further information was provided. 3.) Review of Fall Prevention and Management Policy- effective date: 8/1/2025Purpose: It is the goal of [name of facility] to identify residents' risk of falls and to promptly implement interventions to decrease risk.Procedure: ( includes)3.) When a resident falls:a. Staff who witness the fall or is the first to find the resident who has fallen, stays with the resident to ensure they are safe.b. RN must assess the resident for injury when they are in the building, if a RN is not in the building the on-call RN will be updated.f. The Nurse of designee assigned to the neighborhood leads the fall investigation/root cause analysis via falls huddle. The Nurse documents the information on the Fall Scene Investigation Report. g. New interventions are implemented based on root cause analysis of the fall.h. The Nurse ensures all documentation occurs, including the care plan update and the CNA pocket note update. The fall is noted on the 24-hour report and the IDT progress notes. R36 was admitted to the facility on [DATE] with diagnosis that included paraplegia, morbid obesity. The most recent quarterly MDS (Minimum Data Set), dated 11/13/25, documents R36 has a BIMS (brief interview for mental status) score of 4, indicating R36 is severely cognitively impaired. The facility completed a falls risk assessment on 2/6/26, 1/31/26 and 12/4/25. All 3 assessments indicated R36 is at risk for falls. A review of the Individual Plan of Care documents R36 is at High risk for falls evidenced by MORSE FALL RISK Score of 80 r/t Gait/balance problems, Unaware of safety needs, and placing himself on the floor to pick up objection or adjusting items around his room. Actual Fall 7/27/25: Date Initiated: 04/23/2022. Revision on: 07/27/2025. Interventions include: R36 will not sustain serious injury through the review date. Date Initiated: 08/28/2025 Anticipate and meet R36's needs. Date Initiated: 04/23/2022 Educate R36 on the importance of allowing himself to fully wake before transferring to another surface. Date Initiated: 04/18/2025 Educate [name of resident]/family/caregivers about safety reminders and what to do if a fall occurs. Date Initiated: 08/08/2023 Encourage R36 to nap/or rest in bed after lunch. Date Initiated: 11/03/2023*Ensure that R36 is wearing appropriate footwear such as grippy-socks when ambulating or mobilizing in w/c (wheelchair). Date Initiated: 04/23/2022 Follow facility fall protocol. Date Initiated: 04/23/2022 Offer R36 to assist with retrieving things from floor when assistance is needed. Date Initiated: 05/19/2024 PT (Physical Therapy)/OT (Occupational Therapy) to Eval (evaluate) & Treat post fall: Anti-Rollbacks to wheelchair. 7/27/25 Date Initiated: 07/27/2025 R36 needs activities that minimize the potential for falls while providing diversion and distraction. Date Initiated: 08/08/2023 Soft touch call light to alert staff when [name of resident] has active movement in bed. Date Initiated: 03/28/2024 R36's Nursing Note dated 12/5/2025 at 02:28 AM; Post Fall Evaluation Fall Details: Date/Time of Fall: 12/04/2025, 9:50 PM, Fall was not witnessed. Fall occurred in the R36's room. R36 was reaching for item(s) at time of the fall. Reason for the fall was evident. Did an injury occur as a result of the fall: Yes. Injury details: Left eye bruised/Nosebleed. Did fall result in an ER visit/hospitalization: No. Provider: yes Time notified: 12/04/2025. Notified of: Resident fall and nosebleed and bruised left eye. R36's responsible party notified: Yes. Person contacted: son. Details of notification: Inform family of fall with injuries noted. Date of R36's responsible party notification: 12/04/2025 11:28 PM Fall Details Note: R36 in room yelled out for help. Staff LPN and staff CNA went to res room and found resident on floor with bleeding nose and Contributing Factors: Recent change in environment: No. Was fluid spilled on floor: No. Floor mat was on floor: No. Poor lighting in the area: No. Bed was at an improper height: No. Other furniture involved: No. It is unknown whether the wheelchair was involved in fall. Wheelchair was unlocked at time of fall. Wheelchair footrest(s) were not in the way at the time of fall. Wearing glasses at the time of the fall: No. Footwear at time of fall: Socks. R36 was not using cane/walker as instructed. R36 was not wearing oxygen as prescribed at time of fall. Incontinent at time of fall: No. Bedside call light on when R36 was found: No. Bathroom call light on when Resident was found: No. Personal alarm sounding when Resident found: No. Other Residents were not involved in fall. Cool compresses applied. PRN medication provided. See MAR (Medication Administration Record) for details. Skin: Skin note: Bruised 1Skin Issue: #001: Skin issue has not been evaluated. Location: Left eye. Additional location information: Nosebleed Issue type: Bruising. Wound acquired in-house. Exact date: 12/04/2025 Staged by: Health care provider. Undermining: No. Tunneling: No. Nursing note dated 12/5/2025 at 9:09 AM; R36 assessed this AM (morning) post fall, noted significant bruising to left face specifically eye, Pupils 1mm (millimeter) but reactive to light, Moves all extremities purposefully to command, A/O (alert and oriented) x 3-4. Doctor contacted via Zoom chat. NOR (new order) to send out to ER for further evaluation, [ambulance company] called and transported. Surveyor notes R36 returned to the facility the same day with no new diagnosis or new orders. On 2/2/5/26, Surveyor conducted a review of the facility's falls investigation dated 12/4/25. The report documents the nurse was called to unit per staff. Staff escorted R36 back to wheelchair after hearing him call out for help. R36 unable to give description. Immediate action taken: Staff attended to nosebleed and left eye black. Ice pack applied. Taken to hospital- noThe report asked if there are any injuries- documented yes bruise to face. The report asks to document any predisposing environmental factors physiological factors or situation factors. None is noted for all 3 categories. Statements: (no name documented) date 12/4/25. I was told by other night LPN (Licensed Practical Nurse) that they escorted resident off floor in room, resident had nosebleed and bruised eye. Surveyor notes no notifications found or additional notes regarding the fall had been documented. Surveyor notes the fall investigation does not provide the same documented information as the post fall evaluation on 12/5/25. It was noted in the fall's investigation R36 was unable to provide any description of what happened and there were no witnesses to the fall. The falls evaluation documents R36 was reaching for item(s) at the time of the fall. The falls investigation nor the falls evaluation do not document the last time R36 was seen by staff or when he was last provided assistance from the staff. The investigation does not include whether R36 had fallen from the bed, wheelchair or lounge chair in his room. The falls investigation does not include staff statements who may have had knowledge of R36's condition prior to the fall and what fall prevention interventions were in place at the time of the fall. There is no root cause identified, no new fall prevention interventions put into place to keep R36 safe from further falls. On 2/25/26 at 3:00 PM, Surveyor interviewed Nursing Home Administrator- A regarding R36's fall with injury on 12/4/25. Surveyor asked if the facility had conducted a comprehensive assessment of R36's fall, determined a possible root cause and then evaluated the need for additional interventions to be put in place to get R36 safe from further falls. Nursing Home Administrator- A stated she would need to review and get back to the Surveyor. As of the time of exit on 2/26/26, no additional information had been provided. 4) R73 was admitted to the facility on [DATE] with diagnosis that included Cerebrovascular Disease, dysphagia, chronic respiratory failure, significant spasticity, type 2 diabetes. The most recent quarterly MDS (Minimum Data Set), dated 12/24/25 documents R73 is in a comatose state. R73 has impaired range of motion on both sides, both upper and lower extremities. R73 is dependent on staff for all activities of daily living, R73 has not had any falls since admission. On 2/4/26, the facility conducted a fall risk evaluation and determine R73 was at risk for falls. Nursing note dated 2/15/2026 at 7:30AM; Called to room, R73 was found face down next to her bed. Res has an abraised area on the R (right) side of her forehead. R73 is non-verbal. Hips are intact bilaterally, no clicks heard or felt. No other visible signs of further injuries. [Name of ambulance company] ambulance called as per requested by Power of Attorney and will transport to [name of hospital] ER. Nursing note dated 2/15/2026 at 10:38 AM; Writer informed of unwitnessed fall occurring prior to writer arrival to unit. On arrival noted R73 laying on left side of bed on floor in supine position with head towards head of bed. all equipment intact, Assessed for injuries, EMS (Emergency Medical Services) here currently for transport. On 2/15/2026 at 11:10 AM, the facility documented on the Post Fall Evaluation Fall Details: Fall was not witnessed. Fall occurred in R73's room. Activity at the time of fall: Possibly coughed. The reason for the fall was not evident. Did an injury occur as a result of the fall: No. Did fall result in an ER visit/hospitalization: Yes.ER Visit/Hospitalization Details: Will review on R73's return. Provider: HUCU Time notified: 02/15/2026 Notified of: Fall Resident's responsible party notified: Yes. Person contacted: POA ( power of attorney) Details of notification: Fall Date of Resident's responsible party notification: 02/15/2026 8:10 AM Contributing Factors: Recent change in environment: No. Was fluid spilled on floor: No. Clutter present on the floor: No. Floor mat was on floor: No. Poor lighting in the area: No. Medication Changes: Recent change to Resident's medications: No. Vitals: BP 136/88 - 2/15/2026 10:45 Position: Lying l (left)/arm P: 76 - 2/15/2026 10:45 Pulse, Type: Regular R 20.0 - 2/15/2026 10:45, O2 (Oxygen) 98.0 % - 2/15/2026 10:45, Method: Oxygen via Mask, Pain: Indicators of pain: None. Skin: Skin warm & dry, skin color WNL (Within Normal Limits and turgor is normal. Skin warm and dry, skin color WNL, and turgor is normal. Physical Findings: Change in diagnosis status: No. Recent diagnosis of stroke, TIA or arrhythmia: No. Decrease in fluid intake: No. Change in blood glucose levels: No. Change in blood pressure: No. Change in mental status: No. Change in behaviors: No. Change in mobility status: No. Recent weight loss: No. R73 did not have a recent fever. R73 had a recent cough. R73 did not have a recent cold. Sensory impairment: No. R73 does not have orthostatic BP (Blood Pressure) changes. Physical findings note: R73 is notable unresponsive to any outside stimuli although eyes open spontaneously, no purposeful response. Surveyor conducted further review of R73's medical record and noted the plan of care was revised on 2/16/25 to include: R73 is at risk for falls: 2/15/26 Actual Fall (Unwitnessed) Date Initiated: 09/16/2025, Revision on: 02/16/2026. The resident will be free of injury through the review date. 2/15/26: For repositioning, Staff will utilize soft pillows. Date Initiated: 02/16/2026. Revision on: 02/16/2026 Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Date Initiated: 09/16/2025 Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Date Initiated: 09/16/2025 Ensure that the resident is wearing appropriate footwear. Date Initiated: 09/16/2025 Follow facility fall protocol. Date Initiated: 09/16/2025 Resident readmitted to facility 02/24/2026: bed in lowest position, fall mats on side of bed. Bolsters placed.Date Initiated: 02/24/2026.Revision on: 02/24/2026. Surveyor conducted a review of the facility's falls investigation dated 2/15/26 at 8:00 AM. The following was documented:Writer informed of unwitnessed fall occurring prior to writer arrival on unit. On arrival noted R73 laying on left side of bed on floor in supine position with head towards head of bed. All equipment intact. Assessed for injuries. EMS (Emergency Medical Services) here currently for transport. Not witnessed. Assessed to apparent notable injuries, transported to ER for further eval. No injuries observed at time of incident. Level of consciousness- alert, mobility wheelchair bound. Unable to note change in orientation as R73 is nonverbal. No injuries observed post incident. Predisposing Environmental Factors- none. Predisposing Physiological factors- none. Predisposing situation factors- none. Other Info- Resident has a very strong cough. POA notified 2/15/26, 8:05AM. Surveyor noted the falls investigation contained statements from staff that reported CNA1 (name unknown agency) and CNA 2 (name unknown agency) along with RT Therapist repositioned R73 at 7:15 AM on 2/15/26. By 7:21 Am on 2/15/26, CNA1 and CNA 2 walked past R73 and saw R73 on floor and notified RT (Respiratory Therapist) promptly. The adaptive devices are being used if incident was a fall: low bed, wedges, boots. Surveyor notes the fall investigation did not identify a root cause for the fall. On 2/26/26 at 11:50 AM, Surveyor interviewed Director of Nursing (DON)- B regarding R73's fall from bed on 2/15/26. DON- B stated she came to work because of a call in on the vent unit and arrived about 8:00 AM. At this time [name of ambulance company] ambulance had also arrived and reported was here for a fall for R73. DON- B stated she was surprised by this and went to R73's room. Staff were with R73 and DON-B conducted an assessment of R73. R73 was laying on the floor with her pillow. R73's bed was in the lowest position and DON-B did not observe any injuries or abrasions. DON- B immediately interviewed the Respiratory Therapist and the 2 Certified Nursing Assistants (agency staff) about what happened. It was reported that the 2 CNAs were repositioning R73 and providing cares. R73 does have an air mattress and regular staff know not to put R73 completely on her thigh when repositioning. Sometimes the bed sheets can come off the air mattress and R73 has been coughing. Surveyor notes it was DON- B's root cause analysis that R73 coughed and the way she was positioned on the air mattress and possible with the sheet un-done, R73 rolled from the bed. DON- B stated she called R73's POA and spoke with them. DON- B stated they did have questions because R73 is not able to move about the bed on her own and is nonverbal. DON-B stated she explained she thought R73 must have coughed really hard and the fitted sheet may have not been attached to the air mattress and R73 could not have been positioned in a way to prevent her from rolling out of bed. DON- B stated R73 is now in bed with bolsters to each side, mats on each side of the bed and bed in lowest position. As of the time of exit, the facility was not able to provide additional information as to how R73, who does not have any bed mobility on her own, was able to fall from the bed to the floor on 2/15/26.

Based on interview and record review, the facility did not ensure that 7 (R6, R3, R55, R7, R36, R8, and R78) of 7 residents reviewed for transfers or discharges received the proper written notice of transfer, written bed hold policy with reserve bed payment identified and that proper notification was sent to the State Long-Term Care Ombudsman. *R6 was transferred to the hospital 10/25/25, 11/9/25, and 1/5/26. The facility was unable to locate a written notice of transfer or bed hold notice from 10/25/25 or 11/9/25 transfers to the hospital. The bed hold notice dated 1/5/26 did not list the bed payment rate. The facility did not notify the State Ombudsman of R6's hospitalizations. *R3 was transferred to the hospital on [DATE]. The bed hold notice dated 12/16/25 did not list the bed hold payment rate. The facility did not notify the State Ombudsman of R3's hospitalization. *R55 was transferred to the hospital on [DATE], 12/3/25, and 1/12/26. The bed hold notices dated 10/9/25, 12/3/25, and 1/12/26 did not list the bed hold payment rate. The facility did not notify the State Ombudsman of R55's hospitalizations. *R7 was transferred to the hospital on [DATE]. The facility did not notify the State Ombudsman of R7's hospitalization. *R36 was transferred to the hospital on 1/28/26. The facility did not notify the State Ombudsman of R36's hospitalization. *R8 was transferred to the hospital on [DATE] and 1/12/26. The facility did not notify the State Ombudsman of R8's hospitalizations. *R78 was discharged from the facility on 1/13/26. The facility did not notify the State Ombudsman of R78's discharge. Findings include: The facility policy titled Bed Holds and Written Notice with effective date 8/1/25 documents: . Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies.All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these polices . at the time of transfer (or, if the transfer was an emergency, within 24 hours). Multiple attempts to provide the resident representative with notice . should be documented in cases where staff were unable to reach and notify the representative timely. The written bed-hold notices provided to the residents/representatives explain in detail: . the per-diem rate required to hold a bed (for non-Medicaid residents), or to hold a bed beyond the state bed-hold period (for Medicaid residents). Medicaid residents who exceed the state's bed-hold limit and/or non-Medicaid residents who request a bed-hold are responsible for the facility's basic per-diem rate while their bed is held. 1). R6 was admitted to the facility 6/25/2015. R6 had a legal guardian appointed. R6's most recent minimum data set (MDS) assessment dated [DATE] documented R6 had a brief interview for mental status (BIMS) score of 15, indicating intact cognition. Surveyor conducted a review of R6's electronic health record (EHR) and noted R6 was sent to the hospital on [DATE], 11/9/25, and 1/5/26 for further evaluation. Surveyor was unable to locate a written notice of transfer or bed hold notice in R6's EHR for dates 10/25/25 or 11/9/25. Surveyor located a written notice of transfer and bed hold notice in R6's EHR dated 1/5/26, but Surveyor notes the documents were signed by R6 instead of R6's guardian and the per diem rate to hold the bed is not documented on the bed hold notice. There is no evidence in R6's EHR that the written notice of transfer and bed hold notice on 1/5/26 were provided to R6's guardian. On 2/24/26 at 3:29 PM, Surveyor requested R6's written notice of transfer and bed hold notices from 10/25/25 and 11/9/25 and evidence the State Ombudsman was notified of R6's hospitalizations from Nursing Home Administrator (NHA)-A. During an interview on 2/25/26 at 10:32 AM, NHA-A stated NHA-A was unable to locate the written notice of transfer and bed hold notice for R6 for R6's transfers on 10/25/25 or 11/9/25. On 2/25/26 at 3:13 PM, NHA-A informed Surveyor the Ombudsman has not been notified of any resident hospitalizations since August 2025. Surveyor shared concern with NHA-A there is no evidence of written notice of transfer or bed hold for R6's hospitalizations on 10/25/25 or 11/9/25, R6's bed hold notice dated 1/5/26 did not document the per diem bed hold rate, there is no evidence R6's guardian was provided the notice of transfer or bed hold notice in writing, and that the Ombudsman was not notified of R6's hospitalizations on 10/25/25, 11/9/25, and 1/5/26. NHA-A understood the concerns and no additional information was provided. On 02/26/2026 at 11:08 AM, a Surveyor interviewed Director of Social Services (DSS)-L regarding the process for notifying the Ombudsman of discharged residents from the facility. DSS-L stated DSS-L has not sent the Ombudsman information as this task has gotten away from DSS-L. DSS-L stated DSS-L was always sending the Ombudsman notification at the beginning of the month for the previous month. DSS-L stated DSS-L will get back into it going forward. On 2/26/26 at 11:52 AM, Surveyor interviewed Business Office Manager (BOM)-T regarding bed hold notices. BOM-T stated BOM-T is alerted when a bed hold notice is required but the floor nurse responsible for sending a resident out to the hospital usually completes the form and gives it to the Director of Nursing (DON). BOM-T stated the floor nurse would be responsible for calling the resident's POA/guardian to notify them of the transfer and to obtain consent to hold the bed. BOM-T stated the floor nursing staff would not know the specific per diem rate because it is specific to each resident, so that is probably why it was not filled out on R6's bed hold notice on 1/5/26. BOM-T stated BOM-T will follow up with a resident's POA/guardian to provide the bed hold rate if the floor nurse was unable to provide that information, but BOM-T stated this information is not provided in writing to the POA/guardian and is only provided verbally. BOM-T stated the rate is discussed with residents and their POA/guardian on admission, but BOM-T will educate the nurses on the different rates to make sure that information gets added to the written bed hold notice. 2.) R3 was admitted to the facility on [DATE]. R3's Annual Minimum Data Set (MDS) assessment dated [DATE] documents R3 is cognitively intact. On 12/16/25, R3 experienced a change of condition and was transferred to the hospital. R3's written notice of transfer and bed hold notice in R3's Electronic Health Record dated 12/29/25 is signed but Surveyor notes the per diem rate to hold the bed is not documented on the bed hold notice. On 2/24/26 at 3:29 PM, Surveyor requested evidence the State Ombudsman was notified of R3's hospitalization from Nursing Home Administrator (NHA)-A. On 2/25/26 at 3:13 PM, NHA-A informed Surveyor the Ombudsman has not been notified of any resident hospitalizations since August 2025. Surveyor shared concern with NHA-A that R3's bed hold notice dated 12/16/26 did not document the per diem bed hold rate, and that the Ombudsman was not notified of R3's hospitalizations on 12/16/25. On 02/26/2026 at 11:08 AM, Surveyor interviewed Director of Social Services (DSS)-L regarding the process for notifying the Ombudsman of discharged residents from the facility. DSS-L stated that DSS-L has not sent the Ombudsman information as this task has gotten away from DSS-L. DSS-L stated that DSS-L was always sending the Ombudsman notification at the beginning of the month for the previous month. DSS-L stated DSS-L will get back into it going forward. On 2/26/26 at 11:52 AM, Surveyor interviewed Business Office Manager (BOM)-T regarding bed hold notices. BOM-T stated BOM-T is alerted when a bed hold notice is required but the floor nurse responsible for sending a resident out to the hospital usually completes the form and gives it to the Director of Nursing (DON). BOM-T stated the floor nurse would be responsible for calling the resident's POA/guardian to notify them of the transfer and to obtain consent to hold the bed. BOM-T stated the floor nursing staff would not know the specific per diem rate. BOM-T stated the rate is discussed with residents and their POA/guardian on admission, but BOM-T will educate the nurses on the different rates to make sure that information gets added to the written bed hold notice. 3.) R55 was admitted to the facility on [DATE]. R55's Annual Minimum Data Set (MDS) assessment dated [DATE] documents R55 is severely cognitively impaired. On 10/9/25, 12/3/25 and 1/12/26 R55 had a change of condition and was transferred to the hospital. R55's written notice of transfer and bed hold notice in R55's Electronic Health Record dated 10/9/25 is signed but Surveyor notes the per diem rate to hold the bed is not documented on the bed hold notice. R55's written notice of transfer and bed hold notice in R55's Electronic Health Record dated 12/3/25 is signed but Surveyor notes the per diem rate to hold the bed is not documented on the bed hold notice. R55's written notice of transfer and bed hold notice in R55's Electronic Health Record dated 1/12/26 is signed but Surveyor notes the per diem rate to hold the bed is not documented on the bed hold notice. On 2/24/26 at 3:29 PM, Surveyor requested evidence that the State Ombudsman was notified of R55's hospitalizations from Nursing Home Administrator (NHA)-A. On 2/25/26 at 3:13 PM, NHA-A informed Surveyor that the Ombudsman has not been notified of any resident hospitalizations since August 2025. Surveyor shared concern with NHA-A that R55's bed hold notices dated 10/9/25, 12/3/25 and 1/12/26 did not document the per diem bed hold rate, and that the Ombudsman was not notified of R3's hospitalizations. On 02/26/2026 at 11:08 AM, Surveyor interviewed Director of Social Services (DSS)-L regarding the process for notifying the Ombudsman of discharged residents from the facility. DSS-L stated that DSS-L has not sent the Ombudsman information as this task has gotten away from DSS-L. DSS-L stated that DSS-L was always sending the Ombudsman notification at the beginning of the month for the previous month. DSS-L stated DSS-L will get back into it going forward. On 2/26/26 at 11:52 AM, Surveyor interviewed Business Office Manager (BOM)-T regarding bed hold notices. BOM-T stated BOM-T is alerted when a bed hold notice is required but the floor nurse responsible for sending a resident out to the hospital usually completes the form and gives it to the Director of Nursing (DON). BOM-T stated the floor nurse would be responsible for calling the resident's POA/guardian to notify them of the transfer and to obtain consent to hold the bed. BOM-T stated the floor nursing staff would not know the specific per diem rate. BOM-T stated the rate is discussed with residents and their POA/guardian on admission, but BOM-T will educate the nurses on the different rates to make sure that information gets added to the written bed hold notice. 4.) R7 was originally admitted to the facility on [DATE]. Surveyor conducted a review of R7's medical record and noted R7 was transferred to the hospital for further evaluation on 12/22/25-12/30/25. There was no evidence provided by the facility that the State Ombudsman had been notified of R7's transfer to the hospital on [DATE]. On 02/26/2026 at 11:08 AM, Surveyor interviewed DSS (Director of Social Services)-L regarding the process for notifying the Ombudsman of discharged residents from the facility. DSS-L stated she has not sent the Ombudsman information as this task has it has gotten away from her/him. DSS-L stated that she/he was always doing them (notifications) at the beginning of month for the previous month. DSS-L stated she/he will get back into it going forward. 5.) R36 was admitted to the facility on [DATE]. Surveyor conducted a review of R36's medical record and noted R36 was transferred to hospital 1/28/26- 1/31/26 for further evaluation. There was no evidence the State Ombudsman had been notified of R36's transfer to the hospital on 1/28/26. On 02/26/2026 at 11:08 AM, Surveyor interviewed DSS (Director of Social Services)-L regarding the process for notifying the Ombudsman of discharged residents from the facility. DSS-L stated she has not sent the Ombudsman information as this task has gotten away from her/him. DSS-L stated she/he was always doing them (notifications) at beginning of month for the previous month. DSS-L stated she/he will get back into it going forward. 6.) R8 was admitted to facility on 10/26/25. Surveyor conducted a review of R8's medical record and noted R8 was transferred to the hospital 12/16/25-12/26/25 and 1/12/26-1/17/26. There was no evidence the State Ombudsman had been notified of R8's transfer to the hospital on [DATE] or 1/17/26. On 02/26/2026 at 11:08 AM, Surveyor interviewed DSS (Director of Social Services)-L regarding the process for notifying the Ombudsman of discharged residents from the facility. DSS-L stated that she has not sent the Ombudsman information as this task has gotten away from her/him. DSS-L stated that she/he was always doing them (notifications) at beginning of month for the previous month. DSS-L stated she/he will get back into it going forward. 7.) R78 was admitted to the facility on [DATE]. R78 discharged to an assisted living facility on 1/13/26. R78's medical record documented the physician signed discharge orders/medication list on 1/12/26. Facility progress notes dated 1/13/26 at 6:13 PM, documented: Pt (Patient) daughter came and told writer pt is being discharged today to go to assisted living and took pt belongings. Surveyor found no evidence the Ombudsman was notified of R78's discharge. On 2/25/26 at 12:00 PM, Surveyor asked Nursing Home Administrator (NHA)-A about R78's discharge. NHA-A stated, We were planning for his discharge but ultimately it did not go as planned. His daughter just showed up and said he was discharging to assisted living. Surveyor informed NHA-A of concern there is no evidence the ombudsman was notified of R78's discharge. NHA-A reported the facility does not have evidence the ombudsman was notified of discharge, stating We only have a list from August, and she wasn't doing them after. No additional information was provided.

Based on record review and interview, the facility did not complete and transmit entry tracking, Medicare 5 day, quarterly, or discharge assessments as required for 6 (R25, R28, R40, R44, R64, and R73) of 8 residents reviewed for Minimum Data Set (MDS) assessments and transmission.1.). R25's entry MDS dated [DATE] and quarterly MDS dated [DATE] were not transmitted.2.). R28's quarterly MDS dated [DATE] was not transmitted timely.3.). R40's quarterly MDS dated [DATE] was not transmitted timely. 4.). R44's modification to quarterly MDS dated [DATE] was not transmitted. 5.). R64's entry MDS dated [DATE] was not transmitted timely. 6.). R73's discharge MDS dated [DATE] was not transmitted timely. Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.19.1 dated October 2024, documents long-term care facilities participating in Medicare and Medicaid programs must meet the following conditions: Completion timing: -For all non-admission OBRA (Omnibus Budget Reconciliation Act) and PPS (Prospective Payment System) assessments, the MDS completion date (item Z0500B) must be no later than 14 days after the Assessment Reference Date (ARD) (item A2300). Transmitting data:-Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date (V0200C2 + 14 days). -All other MDS assessments must be submitted within 14 days of the MDS completion date (item Z0500B + 14 days). -For entry tracking records, information must be transmitted within 14 days of the event date (item A1600 + 14 days for entry records). The MDS must be transmitted (submitted and accepted) into iQIES (Internet Quality Improvement Evaluation System). 1). On 2/25/26, Surveyor reviewed R25's MDS assessments in R25's EHR. R25's entry tracking MDS assessment documented the entry date (item A1600) as 4/16/25; there was no accepted date documented on the assessment. R25's quarterly MDS assessment documented the completed date (item Z0500B) as 4/21/25; there was no accepted date documented on the assessment for tranmission. 2). On 2/25/26, Surveyor reviewed R28's MDS assessments in R28's EHR. R28's quarterly MDS assessment documented the completion date (item Z0500B) as 3/7/25 and the accepted date as 4/10/25, which is outside of the 14-day transmission window. 3). On 2/25/26, Surveyor reviewed R40's MDS assessments in R40's EHR. R40's quarterly MDS assessment documented the completion date (item Z0500B) as 3/7/25 and the accepted date as 4/10/25, which is outside of the 14-day transmission window. 4). On 2/25/26, Surveyor reviewed R44's MDS assessments in R44's EHR. R44's modification to quarterly MDS assessment documented the completion date (item Z0500B) as 4/8/25; there was no accepted date documented on the assessment for transmission. 5). On 2/25/26, Surveyor reviewed R64's MDS assessments in R64's EHR. R64's entry tracking MDS assessment documented the entry date (item A1600) as 3/22/25 and accepted date as 4/10/25, which is outside of the 14-day transmission window. 6). On 2/25/26, Surveyor reviewed R73's MDS assessments in R73's EHR. R73's discharge return anticipated MDS assessment documented the completion date (item Z0500B) as 2/8/26; there was no accepted date, and the MDS assessment documented submit by 2/22/26. On 2/25/26 at 1:50 PM, Surveyor shared the above concerns with Regional Nurse-D who confirmed all 6 of the above MDS assessments were completed or transmitted incorrectly. Regional Nurse-D stated Regional Nurse-D has been transmitting the facility MDS assessments for the last few months. Regional Nurse-D was not sure why the assessments were missed because Regional Nurse-D usually runs a report from the EHR which shows any MDS assessments that need to be submitted. On 2/25/26 at 2:59 PM, Surveyor shared the above concerns with Nursing Home Administrator (NHA)-A. No additional information was provided.

Based on observation and interview, the facility did not ensure the storage of drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys. 1 of 5 medication carts were observed to be unlocked and unattended in access to a public area of the facility. The deficient practice had the potential to affect 10 (vent unit) residents whose medications are stored in the medication cart. Findings include: The facility's policy titled Medication Labeling and Storage, dated 8/1/25, documents the following:The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner.Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. On 2/24/26, at 8:21 AM, Surveyor observed Licensed Practical Nurse (LPN)-R passing medications to residents on the vent unit. Surveyor observed LPN-R walk away from the vent unit medication cart, leaving the cart unlocked and unattended throughout LPN-R's morning medication pass. On 2/24/26, at 11:33 AM, Surveyor observed the vent unit medication cart unlocked and unattended. On 2/24/26, at 1:02 PM, Surveyor observed LPN-R walk away from the vent unit medication cart, leaving the vent unit medication cart unlocked and unattended. On 2/26/26, at 10:01 AM, Surveyor notified Nursing Home Administrator (NHA)-A of concerns with observation of the vent unit medication cart being unlocked and unattended throughout the day on 2/24/26. NHA-A acknowledged these concerns. No additional information was provided.

Based on observation and interview, the facility did not ensure that food was stored, prepared and served under sanitary conditions in 3 of 3 unit refrigerators. On 2/24/26, at 12:35 PM, a refrigerator was observed to have multiple food and drink items opened and not dated. This deficient practice has the potential to affect 10 residents on the Vent Unit of the facility. On 2/26/26, at 8:39 AM, a refrigerator was observed to have multiple food and drink items opened and not dated. This deficient practice has the potential to affect 14 residents on the Rehabilitation (Rehab) Unit of the facility. The Rehab Unit refrigerator temperature log was noted to have the following missing dates 2/16/26, 2/18/26, 2/21/26, and 2/24/26. On 2/25/26, at 8:44 AM, a refrigerator was observed to have multiple food and drink items opened and not dated. This deficient practice has the potential to affect 34 residents on the North and [NAME] Unit of the facility. Findings include: The facility's policy titled Food Storage, dated 8/1/25, documents:Foods shall be received and stored in a manner that complies with safe food handling practices.All foods belonging to residents are labeled with the resident's name, the item and the use by date.Refrigerators must have working thermometers and are monitored for temperature according to state specific guidelines.Beverages are dated when opened and discarded after seventy-two (72) hours.Other opened containers are dated and sealed or covered during storage. On 2/24/26, at 12:35 PM, Surveyor observed the Vent Unit refrigerator to have open drinks, a take-out Styrofoam container, multiple Styrofoam cups with lids, and an opened bottle of thickened lemon water that was not dated or labeled with a resident name. Surveyor observed the Vent Unit freezer to have a Culvers bag and a cardboard box full of food in grocery bags that were not labeled and not dated. On 2/26/26, at 8:39 AM, Surveyor observed the Rehab Unit refrigerator temperature log located on the front of the refrigerator that was noted to have the following missing dates 2/16/26, 2/18/26, 2/21/26, and 2/24/26. Surveyor observed the refrigerator to contain multiple grocery bags with food, a used Dominos pizza box, and a Qdoba take out bag that contained food that was not labeled with a resident name or dated. Surveyor observed the freezer to contain two opened water bottles, on opened and not sealed waffle bag with one waffle in it, and a grocery bag with contents that were not labeled with a resident name or dated. On 2/25/26, at 8:44 AM, Surveyor observed the refrigerator on the North and [NAME] Unit of the facility and noted 2 Styrofoam cups with caps on, 2 grocery bags with content, and a pitcher of pink juice about 2/3 full that was not dated or labeled with a resident name. On 2/26/26, at 10:01 AM, Surveyor notified Nursing Home Administrator (NHA)-A of concerns of the above findings. NHA-A acknowledged the concerns. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure 1 (R6) of 1 resident was assessed to self-administer medications. On 2/24/26, Surveyor observed Licensed Practical Nurse (LPN)-R set R6's medications down on R6's bedside table and exit the room. R6 did not have a self-administration assessment completed to identify if R6 was able to safely self-administer medications. Findings include:The facility policy titled Self Administer Medications with an effective date of 8/1/25 documents the following: . Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident: . The medication is appropriate for self-administration; . The resident can follow directions and tell time to know when to take the medication; . The resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and when to report these to staff; . The resident has the physical capacity to . remove medications from a container and to ingest and swallow . the medication; .If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical and/or decision-making status. Standing order obtained by Medical Director of residents to be able to self administer after assessment completed deeming them safe. R6 was admitted to the facility 6/25/2015 with diagnoses including chronic respiratory failure (long-term lung damage), chronic obstructive pulmonary disease (long-term lung disease leading to difficulty breathing), paroxysmal atrial fibrillation (abnormal heart rhythm), chronic diastolic (congestive) heart failure (the heart muscle cannot pump blood normally), chronic kidney disease (long-term kidney damage), hypertension (high blood pressure), anemia (low levels of healthy red blood cells), post-traumatic stress disorder (a mental health condition in people who have experienced or witnessed a traumatic event), and unspecified convulsions (seizures). R6 had a guardian. R6's most recent minimum data set (MDS) assessment dated [DATE] documents R6 has a brief interview for mental status (BIMS) score of 15, indicating intact cognition. During an interview with R6 on 2/24/26 at 8:19 AM, Surveyor observed LPN-R enter R6's room with R6's cup of medications and a cup of applesauce. Surveyor observed LPN-R set the medication cup containing approximately nine medications and applesauce on R6's bedside table then leave the room without watching R6 take the medications. Surveyor asked R6 if R6 always takes medications independently, and R6 nodded yes. During review of R6's electronic health record (EHR), Surveyor was unable to locate a self-administration medication assessment. Surveyor was unable to locate any documentation that R6 was assessed to be capable of self-administering medications in R6's care plan, orders, Medication Administration Record (MAR), or Treatment Administration Record (TAR).On 2/25/26 at 8:46 AM, Surveyor interviewed Registered Nurse (RN)-S regarding how a resident would be determined appropriate to self-administer medications. RN-S replied there would be a formal assessment in the resident's EHR and it would be in the resident's care plan. RN-S stated there would be documentation in the resident's chart stating medications can be left at bedside. RN-S was not sure if R6 was able to take medications independently but would be administering R6's medications shortly and would check R6's chart. On 2/25/26 at 9:13 AM, RN-S informed Surveyor there is nothing in R6's chart noting R6 can self-administer medications. RN-S would expect to see a task in the MAR (Medication Administration Record) or TAR (Treatment Administration Record) for self-administering medications and confirmed there is no such task in R6's MAR or TAR. On 2/25/26 at 10:32 AM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that Surveyor observed LPN-R leave R6's medications on R6's bedside table and Surveyor was unable to locate a self-administration assessment for R6. NHA-A responded LPN-R was educated. No further information was provided.

Based on interview and record review, the Facility did not ensure the medical record reflected the resident's accurate advanced directive wishes for 1 (R55) of 16 residents reviewed.*R55's Do Not Resuscitate form was signed on [DATE] and scanned into R55's medical record. On [DATE], at the start of Survey, R55's active MD order and Electronic Medical Record (EMR) dashboard documented R55 to have elected a full code status. Findings include: The facility policy with an effective date of [DATE], and titled, Cardiopulmonary Resuscitation and Automated external defibrillation, documents, in part: The purpose of this policy and procedure is to provide guidelines for the initiation of Cardiopulmonary Resuscitation (CPR) in victims of sudden cardiac arrest. Determine and record a code status for each resident in his or her [electronic medical record (EMR)], along with obtaining an order. The newest form will be kept in a binder at the nurse's station. When checking a resident for their code status, this binder will be the only place to find that information.R55 was admitted to the facility on [DATE] with diagnosis that included bladder cancer, Cerebral infarction (stroke), Cardiomyopathy (enlarged heart), Alzheimer's disease, Vascular dementia and Depression.R55's Discharge Minimum Data Set (MDS) assessment dated [DATE] documents R55 is moderately cognitively impaired. R55 is dependent on staff for all care, mobility and transfers.R55 has an activated Power of Attorney (POA).R55's Advance Directives Care Plan initiated on [DATE] documents, in part: CODE STATUS: Refer to orders/documentation.On [DATE] at 11:27 AM, Surveyor reviewed R55's EMR for R55's advanced directive wishes. When opening R55's EMR, the dashboard of R55's chart documents, Full code, Next to the words full code, is a hyperlink that reads, Advance Directives. Surveyor clicked and the hyperlink and was taken to a signed document titled, Emergency care DO NOT RESUSCITATE ORDER (DNR). Surveyor reviewed the DNR state form and noted it was signed by R55's POA and Nurse Practitioner (NP) on [DATE].Surveyor noted a discrepancy in R55's EMR documentation of whether R55 was a full code or DNR.Surveyor reviewed R55's EMR and noted another Emergency care DO NOT RESUSCITATE ORDER (DNR) state form that was signed by R55's POA and Doctor on [DATE]. On [DATE], R55 had an active order dated [DATE] which documented: Full code.R55's NP note dated [DATE] at 10:30 AM, documents, in part: Patient is DNR.Surveyor noted 2 days after a full code order was placed in R55's EMR, R55's NP documented that R55 is DNR. On [DATE], Surveyor asked Nursing Home Administrator (NHA)-A for all copies of R55's advanced directives. NHA-A provided two of R55's, Emergency care DO NOT RESUSCITATE ORDER (DNR) forms that were signed on [DATE] and [DATE]. Surveyor noted NHA-A did not provide any documentation that R55 had elected a full code status.On [DATE] at 3:49 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-HH and CNA-JJ. Surveyor asked how staff know the residents' advanced directive status. CNA-JJ stated that the nurse will address the code status with the resident and/or the POA. After that, the form designating full code or DNR is placed in the code binder at each nurse's station. The binder is in alphabetical order, so it is easy to find code status fast. Surveyor asked what R55's code status is. CNA-HH stated that R55 is a DNR. CNA-HH stated that CNA-HH remembers that R55 wears a DNR bracelet. CNA-JJ stated that CNA-JJ thinks that R55 is a full code. CNA-JJ stated R55 still goes out to the hospital for treatment so thinks R55 is a full code. CNA-JJ grabbed the code binder at the nurse's station. CNA-JJ found a full code order under R55's name. Surveyor observed the full code order sheet that had R55's name on it and designated R55 as a full code and the order sheet was undated. Surveyor noted full code was highlighted in pink at the top of the form.On [DATE] at 3:51 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked about how the facility documents advanced directives for residents. DON-B stated the process just recently changed earlier this month. Now, each unit has a code binder at the nurse's station. It is in alphabetical order, and the code status is highlighted in pink. DON-B stated all staff were educated on the new process. Surveyor asked what R55's code status is. DON-B stated R55 was a full code for a long time but now it is a DNR. DON-B stated let me look. DON-B looked in the EMR and stated R55 was listed as a full code but when clicked on the hyperlink, it leads DON-B to the signed DNR form. DON-B stated that DON-B would look into it and get back to Surveyor. On [DATE] at 7:47 AM, DON-B returned to Surveyor. DON-B stated DON-B had to call R55's POA to confirm R55's code status. DON-B stated R55's POA confirmed R55 is a DNR. DON-B stated that R55's POA can sometimes change their mind regarding DNR and FULL code, but they decided R55 is a DNR. DON-B stated DON-B did a verbal order and put the DNR order in R55's EMR and in the code binder. On [DATE] at 7:47 AM, Surveyor reviewed the code binder at R55's nurse's station. R55 had a physician order designating R55 as a DNR. This order was documented as signed on [DATE] by R55's NP.R55's MD order with a start date of [DATE] documents DNR (Do Not Resuscitate). On [DATE] at 8:15 AM, Surveyor reviewed R55's EMR. Surveyor noted R55 had both an active Full code MD order and an active DNR (DO Not Resuscitate) order. Surveyor also noted that in the dashboard of R55's EMR is listed both full code and DNR. On [DATE] at 2:00 PM, Surveyor reviewed R55's EMR. Surveyor noted R55's has one active MD order for DNR and one advanced directive, DNR, listed in the dashboard of R55 EMR.On [DATE] at 3:16 PM, Surveyor informed Nursing Home Administrator (NHA)-A of the concern R55's advanced directives/code status was not easily identified for the first 2 days of the Survey. NHA-A stated that audits are being completed on code status, and one was completed today. The audit fixed the issue of both advanced directives listed in R55's EMR.On [DATE], NHA-A provided additional information. NHA-A documented, in part: The center had two code statuses listed in EMR on [DATE] on the patient dashboard. The center conducted a complete code status audit on [DATE]. The center implemented a new policy/procedure for code status on [DATE]. The new procedure reflects: Each unit (East, North, West, Vent and Rehab) has a code status binder. The binder on the unit contains documentation of each individual resident's code status.Should a resident code, the staff are to reference the code status binder to know the respective residents code status.Important Note: The facility had the correct documentation (DNR) and ensured this was filed in the code status binder on [DATE]. Although the center had both DNR and CPR listed in the resident dashboard, both the order and the code binder reflected accuracy and remained compliant with the updated Policy and Procedure.Surveyor noted NHA-A documented the correct code status for R55 as of [DATE] was DNR. Surveyor noted that at the beginning of Survey on [DATE], R55's medical record had an active Full code order, Full code listed in the resident's dashboard and a full code order in R55's binder, which was confirmed by interview with CNA-JJ and DON-B.

Based on interview and record review, the facility did not ensure 1 of 1 resident (R3) received the necessary comprehensive assessment or care and treatment for indwelling catheter use. R3 was admitted to the facility on [DATE] with urinary incontinence and at some point, after the admission, the facility was unable to determine when, R3 received an indwelling catheter. There was no physician order for the indwelling catheter, no comprehensive assessment of the catheter and no comprehensive care plan directing the care and treatment of the catheter. On 5/31/25, R3 was discharged to the hospital for a change in condition and was diagnosed with septic shock secondary to UTI (urinary tract infection). The facility's failures contributed to R3 developing septic shock secondary to UTI due to an indwelling catheter. This created a finding of immediate jeopardy that began on 5/31/25. Surveyor notified Nursing Home Administrator (NHA) of the immediate jeopardy on 2/10/26 at 12:46 pm. The immediate jeopardy was removed on 2/13/26. However, the deficient practice continues at a scope/severity of D as the facility continues to implement its action plan.Findings include:The facility's catheter care, urinary policy and procedure with a review date of 11/2025 documents:Catheter Evaluation1. Review and document the clinical indications for catheter use prior to inserting. 2. Nursing and the interdisciplinary team should assess and document the ongoing need for a catheter that is in place. Use a standardized tool for documenting clinical indications for catheter use.3. Remove the catheter as soon as it is no longer needed.ComplicationsObserve the resident for complications associated with urinary catheters. Report unusual findings to the physician or supervisor immediately:If the resident indicates that his or her bladder is full or that he or she needs to void;If urine has an unusual appearance (i.e. color, blood, etc);In the event of bleeding, or if the catheter is accidently removed;If the resident complains of burning, tenderness, or pain in the urethral area; orIf signs and symptoms of urinary tract infection or urinary retention occur.R3 was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), anoxic brain damage, and heart failure. R3's admission Minimum Data Set (MDS) dated [DATE] documents R3 is severely cognitively impaired and is dependent on staff for all activities of daily living (ADLs). It also documents R3 is always incontinent of bladder. R3's admission Care Area Assessment (CAA) dated 1/27/25 documents R3 is incontinent of bladder and is dependent upon staff for incontinence care.The care plan for bladder incontinence related to anoxic brain damage was initiated on 4/7/25. The discharge-return anticipated MDS dated [DATE] documents R3 as having an indwelling catheter.The quarterly MDS dated [DATE] documents R3 has an indwelling catheter. R3's medical record does not include physician orders for an indwelling catheter, and the care plan does not address indications for the use of an indwelling catheter or the care and treatment required. There is also no evidence to show when the catheter started.R3's Medication Administration Record (MAR) dated 5/22/25 documents: Record foley output every shift. The nurses note dated 5/28/25 documents: lab work obtained to monitor R3's anemia and elevated white blood cell (WBC) count due to R3's recent prednisone use. The blood work was abnormal and an order to repeat the lab work on 5/30/25 was obtained. The lab work identified a Hemoglobin of 7.3 and Hematocrit of 24. Surveyor notes R3's Hemoglobin and Hematocrit are low.The nurses note dated 5/31/25 at 2:44 a.m., documents: the lab results were communicated with the on-call provider, and an order was received to repeat the lab work on 6/2/25.The nurses note dated 5/31/25 at 9:29 a.m., documents: R3's assessment revealed R3 was hypotensive, experiencing increased oxygen needs and increased secretions so an order was obtained to send R3 to the hospital.The hospital discharge summary for the hospitalization on 5/31/25 through 6/10/25 documents R3 was treated for septic shock secondary to urinary tract infection (UTI). Upon return from the hospital, there was no order for the catheter, and no care plan to direct the care and treatment staff should be completing related to the catheter. On 9/11/25, nearly 5 months after the placement of the catheter, R3's physician ordered a 16 French indwelling catheter to promote wound healing and change foley catheter as needed if blockage or obstruction. On 9/12/25, physician order documents to irrigate foley catheter with 30 milliliters (ml) of normal saline twice a day (BID)On 10/28/25, nearly 6 months after the placement of the catheter, a care plan for urinary catheter to promote wound healing was developed. On 2/5/26 at 11:30 a.m., Surveyor interviewed Director of Nursing (DON)-B about R3's catheter. DON-B stated she thinks when R3 came back from one of her earlier hospitalizations, she returned to the facility with a catheter, and the nurses didn't get an order or assess for use of the catheter. DON-B stated maybe at some point, one of the nurses consulted with Wound MD-R and it was agreed that the indwelling catheter was needed for wound healing. DON-B stated she didn't have an explanation for it. The facility's failure to comprehensively assess the need for the catheter, obtain a physician's order for its use, and develop a care plan for the care and treatment of the catheter created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The immediate jeopardy was removed on 2/13/26, however, continues at a scope/severity of D as the facility continues to implement the following action plan: *All facility nurses re-educated on ensuring that all residents with a foley catheter have an order for the foley catheter along with standard foley catheter orders such as catheter changes, catheter flushing, changing graduate, having a barrier under graduate when draining bag, changing catheter drainage bag, etc.*Director of Clinical Services (DCS) to assist with providing and explaining re-education to facility nurses.*DCS assisted with providing 1:1 education with Interdisciplinary team nurses on 2/10/26 to facilitate and ensure understanding and expectation(s) of processes and policy related to catheter care/orders and to include updating care plans.*DCS(s) will assist with updating/creating individualized care plans. Nursing staff re-educated to complete foley catheter care q shift and prn.* Nursing staff re-educated about changing out catheter materials biweekly and prn. Policy used as reference and guide during training. All training to floor staff to be completed by their next working shift.*All facility nurses re-educated on ensuring that all residents with a foley catheter have an order for the foley catheter along with standard foley catheter orders such as catheter changes, catheter flushing, changing graduate, having a barrier under graduate when draining bag, changing catheter drainage bag, et.* Director of Clinical Services (DCS) to assist with providing and explaining re-education to facility nurses.*DCS assisted with providing 1:1 education with Interdisciplinary team nurses on 2/10/26 to facilitate and ensure understanding and expectation(s) of processes and policy related to catheter care/orders and to include updating care plans.*DCS(s) will assist with updating/creating individualized care plans.*Nursing staff re-educated to complete foley catheter care q shift and prn. Nursing staff also re-educated about changing out catheter materials biweekly and prn. Policy used as reference and guide during training. All training to floor staff to be completed by their next working shift.*Audits will be conducted by DCS or designee on admissions and re-admissions with foley catheters to ensure foley catheter diagnosis and care orders are in place and that foley catheters are care planned appropriately per policy.*Audits will be conducted 2X a week for six weeks by DCS or designee to ensure competency and compliance with catheter care. Audits will be conducted 2x/week x six weeks to ensure compliance with changing out catheter care materials biweekly.*DCS or designee will review/audit POC charting Monday through Friday (Monday will include 72 hr review) to review catheter care tasks not completed - ad hoc education will be provided as indicated by DCS or designee for catheter care tasks not completed.*Audits will be reviewed at the monthly QAPI meeting to determine trends or patterns of concern and/or if further education is needed until substantial compliance has been achieved.

Based on observation, interview, and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 1 of 2 residents (R3) reviewed for pressure injuries.R3 was high risk for pressure injuries. R3 developed an unstageable sacral pressure injury (PI) which deteriorated to a stage 4 PI with eventual visible bone. The facility failed to correctly implement and/or enter treatment orders from the hospital and the wound MD and could not provide evidence an ordered CT scan was scheduled or completed. R3 was eventually admitted to the hospital and diagnosed with sepsis and sacral/coccygeal osteomyelitis with abscess requiring debridement and a partial coccygectomy (partial removal of tailbone.) Upon readmission, facility failed to follow wound MD treatment orders. R3 also developed an unstageable PI to the left buttock as well as deep tissue injuries to bilateral heels. Treatment orders were not implemented correctly nor timely. The facility's failure to provide services to promote healing, prevent pressure injury development, and ensure prompt and ordered treatments were implemented created a finding of immediate jeopardy that began on 5/26/25. Surveyor notified the Nursing Home Administrator (NHA)-A of the immediate jeopardy on 2/10/26 at 12:46 PM. The immediate jeopardy was removed on 2/13/2026, however, continues at a scope/severity level of E related to the residents at risk for the development of pressure injuries and as the facility implements its action plan. Findings include: The facility policy titled, Pressure Injuries and Non pressure Injuries, dated 8/2/22, last reviewed 10/21/25, documents, in part: This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries in our residents. For those residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. Upon admission: A head-to-toe body evaluation will be completed on every resident upon admission/readmission and will be documented on the admission/readmission evaluation . If skin is compromised. Ensure Primary Care Physician (PCP) is aware of wounds/location of wounds and current treatment orders. Ensure appropriate treatment orders for each wound area, as needed.Initiate the baseline plan of care related to current skin status and skin risk level. (The comprehensive care plan will be developed within seven days of the completion of the comprehensive assessment.) When determining skin risk status and appropriate interventions, consider the following: Braden Scale Score. Co-morbid conditions. Cognitive impairment. Presence of a medical device such as an indwelling catheter, trach. The need or request to elevate the HOB (head of bed). Exposure of skin to urinary and fecal incontinence.Assess current wounds at least every seven days, or more frequently as needed (e.g., decline in wound, presence of infection, wound healed).Mobility: As mobility scores decrease, concern about the adequacy of the support surface should increase-evaluate need for specialty [wheelchair] cushion and specialty mattress. Develop turning/repositioning schedule based on resident needs and risk factors. The facility's policy titled, Medication Orders, dated 8/2/22, last reviewed 10/21/25, documents, in part: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Treatment Orders - When recording treatment orders, specify the treatment, frequency and duration of the treatment. The facility's policy titled, Care Plans, Comprehensive Person-Centered, not dated, documents, in part: A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required Minimum Data Set (MDS) assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.The interdisciplinary team reviews and updates the care plan:*When there has been a significant change in the residents' condition;*When the desired outcome is not met;*When the resident has been readmitted to the facility from a hospital stay; and*at least quarterly, in conjunction with the required quarterly MDS assessment. R3 was admitted to the facility on [DATE] with diagnoses to include Cardiac arrest in 11/2024 which led to an anoxic brain injury (Brain deprived of oxygen causing cell death within minutes), Chronic respiratory failure (Long term condition where the lungs can't properly oxygenate blood or remove carbon dioxide), Chronic obstructive pulmonary disease (Progressive, incurable lung disease), Tracheostomy (A device in the neck that goes into the windpipe to provide an alternative airway), Ventilator-Dependent (Patient is unable to breathe independently for extended periods, requiring mechanical ventilation), Gastrostomy tube (Device inserted through the abdomen directly into the stomach to provide long-term nutrition), and Hypotension (Low blood pressure). R3's admission Minimum Data Set Assessment (MDS) dated [DATE] documents R3 is severely cognitively impaired. R3 is always incontinent of bladder and frequently incontinent of bowel. R3 is dependent on facility staff for all cares, mobility, and transfers. R3 is at risk for pressure injuries but does not have a current pressure injury. R3's Pressure injury Care Area assessment dated [DATE] documents, in part: Monitoring and preventative measures in place. R3's Braden scale assessments (an assessment completed to determine how at risk a resident is for developing pressure injuries) completed on 1/20/25 and on 2/21/25 document a score of 11, indicating the resident is at high risk for developing pressure injuries. Surveyor reviewed R3's Care Plan and noted that facility staff did not develop or implement a skin integrity or pressure injury care plan on admission even though R3 was assessed by facility staff to be at high risk for developing pressure injuries. R3 receives continuous enteral nutrition via a g-tube. Surveyor notes R3's head of bed needs to be elevated for the enteral feeds putting R3 at increased risk for the development of pressure injuries. R3 was admitted to the hospital on [DATE]. Surveyor notes R3's discharge MDS dated [DATE] documents R3 does not have an unhealed pressure injury. R3's hospital Discharge summary dated [DATE] documents, in part: Reason for hospitalization: vomiting. Discharge diagnoses: Recurrent [Small bowel obstruction]/ileus. Right arm [Peripherally inserted central catheter] line associated [Deep Vein Thrombosis]. R3 returned to the facility on 4/4/25. Facility entered an MD order for Eliquis (a blood thinning medication) two times a day on 4/4/25 due to a deep vein thrombosis (blood clot) that formed in R3's arm during R3's hospitalization. Surveyor reviewed R3's Care plan and noted facility staff did not implement a care plan for monitoring of R3 while on a blood thinning medication. R3's admission skin assessment dated [DATE] documents, in part: Sacrum. 4.2 [centimeters (cm)] x 3. 100% slough. Wound MD-R updated. New orders Xeroform foam border change daily. R3's MD order with start date of 4/5/25 documents: Sacrum Unstageable: Cleanse with wound cleanser [followed by (f/b)] pat dry f/b skin prep to surrounding peri tissue f/b xeroform to wound bed f/b bordered foam dressing every day shift as needed or if soiled or needs replacement. Surveyor noted the treatment order the facility entered for the Sacrum pressure injury was ordered as needed instead of daily as Wound MD-R ordered according to the admission skin assessment note. Surveyor reviewed R3's Treatment Administration Record (TAR) and noted R3's sacral wound treatment was completed on 4/5/26 but there is no documentation that treatment was completed by facility staff on 4/6/25. R3's potential/actual impairment to skin care plan initiated on 4/4/25 documents the following interventions: Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of injury. Implement pressure-reducing devices i.e. w/c (wheelchair) cushion, air-mattress, off-loading heels, etc., Provide pressure relieving device: [Alternating Pressure Mattress], Prevalon boots, repositioning pillow. Use a draw sheet or lifting device to move resident. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. R3's Certified Nursing Assistant (CNA) Kardex as of 2/4/26 documents, in part: Under Resident Care - The resident needs [Alternating Pressure Mattress], Prevalon boots, repositioning pillows to protect the skin while in bed. Use a draw sheet or lifting device to move resident. Under bed Mobility is listed Bowel Continence. Surveyor noted R3's Care plan and CNA Kardex did not include a person-centered intervention regarding a turning and repositioning schedule or off-loading of R3's sacrum. In addition, R3's CNA Kardex listed bowel continence under bed mobility. Surveyor noted no other instructions are listed under bed mobility when R3 is assessed to be completely dependent on staff for mobility. On 4/7/25, Wound MD-R completed wound rounds at the facility. Wound MD-R's Wound evaluation note dated 4/7/25 documents in part: Unstageable (due to necrosis) Sacrum full thickness pressure injury. 4.02 x 2.87 x 0.1. 80% slough (moist, yellowish, tan, green, brown or white tissue that is stringy and mucinous in texture). 20% granulation (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process).Treatment plan: Xeroform gauze apply once daily. Gauze Island with border. R3's MD order with a start date of 4/8/25, documents: Cleanse with wound cleanser f/b pat dry f/b skin prep to surrounding peri tissue f/b xeroform f/b bordered gauze every day shift for Wound protection/healing. On 4/19/25, R3 became lethargic and was sent to the hospital. R3's hospital Discharge summary dated [DATE], documents, in part: Reason for hospitalization: [R3] . presented to the [Emergency Department] with a chief complaint of lethargy. Discharge diagnoses: Ventilator associated pneumonia.R3 returned to the facility on 4/23/25. R3's admission skin assessment dated [DATE], documents, in part: Coccyx unstageable-bright pink wound bed with slough % and granulation % noted. 7cm in length, 3.5 in width. Treatment is as follows per wound care: Cleanse with wound cleanser f/b pat dry f/b skin prep to surrounding peri-tissue f/b xeroform f/b bordered gauze. Surveyor noted the percentage of slough and granulation was not documented and the same treatment that was in place before this hospitalization was followed upon readmission to the facility. R3's Wound MD-R wound evaluation note dated 4/28/25, documents, in part: Unstageable (Due to necrosis) sacrum full thickness . 5.72 x 2.77 x 0.1. 80% slough. 20% granulation. Treatment plan: Alginate calcium apply once daily and as needed. Gauze Island with border apply once daily. R3's MD order with a start date 4/29/25, documents: Sacrum Unstageable PI: cleanse with wound cleanser f/b pat dry f/b skin prep to surrounding peri-tissue f/b Ca Alginate f/b bordered gauze every day shift for wound protection/healing. On 5/3/25, R3 experienced a change of condition and was sent to the emergency room.R3 returned from the hospital and was readmitted to the facility on [DATE]. R3's Hospital Discharge summary dated [DATE] documents, in part: Reason for admission: Ventilator dependent, Pneumonia of left lower lobe. Final Discharge diagnoses: Acute on chronic respiratory failure hypoxemic on chronic ventilator. Left lower lobe pneumonia likely vent associated pneumonia. Discharge instructions: Per wound care. Wash sacral ulcer with soap and water, rinse and pat dry. Santyl to central slough followed by single layer vashe moist gauze. Cover with dry secondary dressing . R3's Skin Observation tool dated 5/20/25, documents, in part: Sacrum. 7.3 cm in length, 5 cm in width, and 1 cm in depth . R3's Readmissions Data Collection Tool dated 5/20/25 documents in part: Skin Condition: Coccyx. R3's progress note dated 5/20/25 documents, in part: . [R3] is returning from the hospital after being admitted for ventilator-associated pneumonia. [R3's] skin is clear and moist, and [R3] has normal skin turgor, and mucus membranes are moist and pink . [R3] has a wound on [R3's] buttocks that is 7.3cm in length, 5cm in width, and 1 cm in depth. [R3] has an order to wash the sacral ulcer with soap and water, rinse and pat dry, apply Santyl to the central slough, followed by a single layer of vasche moist gauze. Surveyor reviewed R3's MD orders and noted the recommended wound treatment documented on the hospital discharge summary and in the facility progress note was not entered as an MD order for facility staff to follow. Surveyor noted the admission skin assessment documentation completed by facility staff did not document wound descriptors, such as granulation, necrotic, or slough or the current stage of the pressure injury. Surveyor reviewed R3's Electronic Medical Record (EMR) and progress notes. Surveyor noted facility staff did not document why the hospital discharge wound treatment recommendations were not followed upon R3's return to the facility. On 2/4/26 at 11:47 AM, Surveyor interviewed Registered Nurse (RN)-S. RN-S stated with new admissions, staff should verify orders with the MD right away and review hospital paperwork. Within the first hour of admission, facility staff complete a full skin assessment with descriptors, but staff do not stage wounds, the wound care nurse will stage but we do measurements and describe wound. On 2/9/26 at 9:41 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-C. Surveyor asked what the process is for admission skin assessments. ADON-C stated the admitting nurse should contact the doctor and make sure orders are placed. The nurse should assess the skin. The assessment should include measurements of any area of concern. Surveyor asked if staging should be included in the admission assessment. ADON-C stated if a Licensed Practical Nurse (LPN) is completing the admission, then they just do measurements and do not stage. A Registered Nurse (RN) can then complete the skin assessment. The facility wound nurse is able to do a complete admission assessment with staging as well. Surveyor asked if wound descriptors like granulation, necrotic, or slough should be used. ADON-C stated yes and no. ADON-C stated that one person may think it's one thing and another may think it's another. The process should be that if an area is found, the nurse should call MD and the facility wound nurse right away and the wound nurse can do the full assessment. Surveyor reviewed R3's EMR and did not locate documentation of a different/additional admission wound assessment completed by the wound care nurse that documented the stage of R3's pressure injury on readmission back to the facility. Surveyor reviewed R3's TAR and noted facility staff treated R3's sacrum pressure injury with the previously entered treatment order of Calcium Alginate instead of the new treatment recommendations of Santyl documented on the Hospital Discharge Summary and the facility admission progress note. R3's MD order with a start date of 5/23/25 documents, in part: Sacrum [Pressure Injury (PI)]: Cleanse with wound cleanser f/b pat dry f/b skin prep to surrounding peri-tissue f/b calcium alginate to wound bed f/b bordered foam dressing every day shift for wound protection/healing. Surveyor noted the change to R3's sacrum treatment order included a change to the dressing. The previous dressing order included bordered gauze, the new treatment order included bordered foam dressing. Surveyor reviewed R3's EMR and did not locate another sacral skin assessment between 5/20/25 through 5/25/25. R3's Wound MD-R wound evaluation note dated 5/26/25, documents, in part: Stage 4 pressure wound sacrum full thickness. 5.86 x 4.58 x 0.1. 80% slough. 20% granulation. Additional wound detail: improved at readmission assessment but worsen [sic] from last visit before hospitalization. Treatment plan: Alginate calcium apply once daily. Surveyor noted this is the first documentation of the wound declining to a Stage 4 pressure injury. Surveyor reviewed R3's skin care plan and noted facility staff did not enter a new intervention after R3's wound was staged as a Stage 4 pressure injury, the care plan did not include person-centered interventions for turning or repositioning R3 and did not include an intervention regarding off-loading of R3's sacrum. On 5/31/25, R3 experienced a change in condition and was admitted to the hospital.R3 was readmitted back to the facility on 6/10/25. R3's 6/10/25 hospital discharge summary documents, in part: Diagnoses: Septic shock secondary to UTI (Urinary Tract Infection). R3's admission skin assessment dated [DATE] documents, in part: Sacrum. 8.5 x 6.5 x 1.5. Tunneling 12 o'clock-5 o'clock. Thick adherent slough covering 100% of wound bed. Surveyor reviewed R3's TAR and noted facility staff treated R3's Sacrum with the treatment order that was in place prior to this hospitalization. R3's Wound MD-R evaluation note dated 6/16/25 documents, in part: Stage 4 pressure wound sacrum full thickness. 7.36 x 8.65 x 3.5. 5cm, undermining at 9 o'clock. 80% slough. 20% granulation . Treatment plan: Alginate calcium with silver apply once daily. Surveyor reviewed R3's MD orders and noted facility staff updated R3's MD order to reflect the new treatment plan of Calcium alginate with silver. R3's Wound MD-R evaluation note dated 6/23/25 documents, in part: Stage 4 pressure wound sacrum full thickness. 6.72 x 7.26 x 3. 3cm undermining at 10 o'clock. 70% slough. 20% granulation. 10% bone. Treatment plan remained the same. Surveyor noted that MD-R documented 10% bone visualization within R3's sacrum wound. R3's skin care plan documented 2 new interventions initiated on 6/23/25 which included: X-ray [related to] 10% bone exposure. CT scan ordered to [rule out] osteomyelitis. R3's MD order with a start date of 6/23/25 documents: 2-view X-ray to sacrum. 10% bone exposure [rule out] osteomyelitis. R3's X-ray results of sacrum and coccyx dated 6/23/25 document, in part: No bony injury. Suboptimal evaluation due to excessive bowel gas and poor-quality images; lower sacral and coccygeal vertebrae not well visualized- repeat examination or CT scan of sacrum with coccyx is recommended. The x-ray results were entered into R3's medical record with a note dated 06/23/25 that states, Reviewed with [Wound MD-R] New order - CT scan. R3's progress note dated 6/23/25 at 4:30 PM documents, in part: X-ray results received. Impression reviewed with [Wound MD-R]. CT scan of sacrum with coccyx is recommended. [Wound MD-R] ordered CT scan. Order sent to [Wound MD-R], awaiting on signature of order to proceed with scheduling. Guardian . aware and agreeable, will be updated on date/time of scheduled CT scan. R3's MD order with a start date of 6/23/25 documents: CT scan of sacrum with coccyx [related to] Stage 4 pressure injury with 10% bone exposure. Surveyor reviewed R3's Medication Administration Record (MAR) and TAR and noted R3's CT scan order was checked off as completed on 6/23/25 at 5:43 PM. Surveyor reviewed R3's EMR for evidence that a CT scan was scheduled and did not locate a scheduled appointment or results of a CT scan. On 2/3/26 at 3:02 PM, Surveyor interviewed Director of Nursing (DON)-B. DON-B stated that DON-B was checking with Wound MD-R and the previous wound nurse who no longer works at the facility, Registered Nurse (RN)-O, to get more information about the CT scan. DON-B indicated it is unusual that it would not be scanned into the EMR but stated that DON-B would get back with Surveyor. On 2/4/26 at 12:51 PM, DON-B informed Surveyor DON-B spoke to Wound MD-R and RN-O about the ordered CT scan for R3. DON-B stated DON-B was told R3 ended up going to the hospital in July and the CT scan was completed then. DON-B stated DON-B also spoke with Receptionist-H, who oversees scheduling residents out of facility appointments. Receptionist-H did not have record that a CT scan needed to be scheduled for R3. On 2/4/26 at 12:58 PM, Surveyor interviewed Receptionist-H. Receptionist-H stated Receptionist-H reviewed the appointment calendar. From the start of R3's stay at the facility, the only time R3 needed an outside appointment scheduled was a GI procedure that occurred on 2/3/25. Receptionist-H stated Receptionist-H was not given an order to try to schedule a CT scan for R3. Receptionist-H stated the typical process is for the nurse to get the order and have it signed off by the doctor. From there, the order is given to Receptionist-H. Receptionist-H will then fax the order to the MD office or hospital. It takes 2 to 3 days to get a date for the appointment or test on the calendar. On 2/4/26 at 1:57 PM, Surveyor interviewed Wound MD-R. Wound MD-R stated the sacrum x-ray was negative. The CT was ordered but the resident ended up going to the hospital before the CT scan was completed. Wound MD-R stated it was not emergent to get the CT and stated R3 was not septic when the CT was ordered. Wound MD-R indicated if Wound MD-R was concerned about infection in R3's wound, Wound MD-R would have sent R3 to the emergency room for a CT scan. Surveyor noted despite the MD order for a CT scan, there is no evidence an appointment was scheduled for R3 to get a CT scan completed. R3's progress note entered by DON-B on 6/28/25 documents, in part: Writer in to assess due to during dressing change, Resident noted to have labored Respirations, blank stare, ruddy color to cheeks, with increased foul drainage to wound. [Vital signs] show Hypotension at 117/53, [pulse] 90. [Respiratory rate] in to provide Respiratory care and suction, Oral care, Resident appears more alert. [Wound MD-R], Wound Nurse & On Call [Nurse Practitioner (NP)] updated, [New order] to obtain CBC, BMP STAT . Wound Nurse here and also assessed wound with Writer. Will continue to monitor for any further changes. Dressing treatment order changed via Wound Team . Surveyor noted DON-B and previous wound nurse, RN-O, assessed R3's wound on 6/28/25 and noted an increased foul drainage to wound, which can be an indication of infection to the wound. R3's MD order with a start date of 6/28/25 documents: Sacrum PI: Cleanse with Dakin's 1/2 strength solution f/b pat dry f/b skin prep to surrounding peri-tissue f/b wet to moist gauze (soaked with Dakin's 1/2 strength solution) f/b bordered gauze dressing two times a day for wound protection/healing. Surveyor noted R3's wound treatments changed from daily to two times a day. R3's lab results dated 6/28/25 document R3's [NAME] Blood Cell (WBC) results as high at 14.1. The reference interval range for WBCs is from 4 to 10. In comparison, R3's previous WBC results completed on 6/25/25 were 7.6. Surveyor noted R3's WBC almost doubled in 3 days which can be an indication of infection. R3's progress note dated 6/28/25 at 4:20 PM, documents, in part: Lab results communicated . to on call NP. Elevated WBC 14.0. [New order] to obtain [urinalysis (UA), culture and sensitivity (C&S) and STAT chest x-ray] . Surveyor reviewed R3's EMR and noted the UA, C&S and STAT chest x-ray were completed. R3's chest x-ray results dated 6/29/25 document, in part: No significant interval changes as compared to the previous study, 5/23/25. Surveyor reviewed R3's lab results and noted the UA and C&S had resulted in a diagnosis of Urinary Tract Infection (UTI). A one-time dose of Fosfomycin Tromethamine was ordered and given by facility staff on 7/2/25. R3's Wound MD-R evaluation note dated 6/30/25 documents, in part: Stage 4 pressure wound sacrum full thickness. 6.72 x 7.26 x 3. 3cm undermining at 10 o'clock. 70% slough. 20% granulation. 10% bone. Treatment plan: Sodium hypochlorite solution (Dakins) apply twice daily . 1/2 strength cleanse and wet to moist to prevent odor and infection . Gauze Island with border . R3's WBC results dated 7/2/25 document a result of 12.8 (still elevated.) R3's Wound MD-R evaluation note dated 7/7/25 documents, in part: Stage 4 pressure wound sacrum full thickness. 4.4 x 4.8 x 2.5. 2.5cm undermining at 10 o'clock. Heavy Serous exudate (large volume of thin, watery, and clear or pale-yellow fluid draining from a wound). 70% slough. 20% granulation. 10% bone. Secondary dressing plan: foam with border. Surveyor noted R3's treatment remained the same but Wound MD-R recommended a change in the secondary dressing. Surveyor reviewed R3's MD sacrum PI treatment order with a start date of 7/7/25 and noted facility staff changed the MD order to reflect Wound MD-R's recommended secondary dressing. R3's Wound MD-R evaluation note dated 7/14/25 documents, in part: Stage 4 pressure wound sacrum full thickness. 5.9 x 6.2 x 2.5. 2.5cm, undermining at 10 o'clock. 50% slough. 40% granulation. 10% bone. Treatment plan remains the same. R3's Medical Doctor (MD)-Q note dated 7/14/25 at 10:15 AM, documents, in part: . Wound care just visited with [R3]. Wounds are stable. R3's WBC results dated 7/16/25 documents a high result of 12.8. Surveyor noted R3's WBC remained elevated. R3's progress note dated 7/19/25 at 2:26 PM, documents, in part: . [Certified Nursing Assistant] staff had emptied residents foley and noted a moderate amount of blood. Writer irrigated foley and changed tubing of resident's catheter to monitor for new blood . Writer updated care team. Writer returned to bedside where there continued to be blood in the catheter and urine bag. It had been approximately 15 minutes since previous vitals were taken, and writer ran another set. Blood pressure was now 100/62, . 101.9 temp. Writer updated care team of new vitals and that resident was being sent [to hospital] . R3 was sent to the hospital on 7/19/25. R3's hospital Discharge summary dated [DATE] documents, in part: Discharge Diagnoses: Shock, likely septic and hypovolemic (resolved), Sepsis [secondary to] sacral osteomyelitis +/- UTI +/- [pneumonia]. [R3 presented] from facility for hematuria, found to be hypotensive/febrile with imaging [concerning for] sacral osteomyelitis, [left lower lobe] pneumonia, and UTI all pointing towards septic shock. [Status post] [Operating Room] debridement 7/21/25. R3's Hospital certified wound nurse consult note dated 7/22/25 documents, in part: . [R3] hospitalized [due to] being febrile and hypotensive. CT done on 7/19 which resulted as Large sacral decubitus ulcer with lower sacral/coccygeal osteomyelitis and presacral abscess. [Acute Care Surgery] consulted and debrided coccyx with partial coccygectomy yesterday, 7/21. R3's Hospital Infectious Diseases consult note dated 7/22/25 documents, in part: . [R3]. admitted with septic shock. CT notable for sacral/coccygeal osteomyelitis with presacral abscess. Underwent debridement with [acute care surgery] on 7/21. Most likely source of [R3's] sepsis seems to be [R3's] sacral wound with associated abscess. Based on notes from [R3's] most recent outside hospitalization, [R3] appears to be close to [R3's] baseline ventilator requirement and is clear lungs on exam, so we have lower suspicion for pneumonia as a driving process. [Urine culture] not [consistent with] infection. R3's hospital after visit summary dated 8/15/25 documents the following instructions for wound care: Sodium hypochlorite 0.5% solution. Commonly known as Dakins (full strength) apply externally as needed for wound care. R3 was readmitted back to the facility on 8/15/25. R3's admission skin assessment dated [DATE] documents, in part: Sacrum - Unstageable. 8 x 11.5 x 4. Undermining 9 to 3 [with] deepest at 1 of 3cm. R3's admission summary progress note entered by DON-B, dated 8/15/25 at 4:26 PM, documents, in part: Wound Sacrum Unstageable. measures 8.0 cm x 11.5 cm x 4.0 cm with undermining from 9 o'clock to 3 o'clock deepest at 1 o'clock 3cm, moderate serosanguinous drainage, no odor, bone exposed, wound bed clean . NP updated . orders confirmed. Surveyor noted facility staff documented an admission wound assessment but staged the wound incorrectly as an Unstageable instead of a Stage 4 pressure injury. R3's MD order with a start date of 8/16/25 documents, Treatment to sacral wound: Cleanse with Dakins, loosely pack with Dakins soaked gauze and cover with ABD, change [two times a day] and [as needed]. R3's Wound MD-R evaluation note dated 8/18/25 documents, in part: Stage 4 pressure wound sacrum full thickness. 10.5 x 10 x 4. 5cm at 1 o'clock. 30% necrotic. 60% granulation. 10% bone. Treatment plan: Sodium hypochlorite solution (Dakins) apply twice daily . 1/2 strength cleanse and wet to moist to prevent odor and infection. Foam with border apply twice daily.Wound MD-R's recommendation for half strength Dakins and a foam with border dressing was not updated on R3's TAR; staff continued to treat the sacral pressure injury with full strength Dakins and covered the wound with an ABD pad. R3's Wound MD-R evaluation note dated 8/25/25 documents, in part: Stage 4 pressure wound sacrum full thickness. 13 x 7 x 4. 7cm undermining at 2 o'clock. 30 % necrotic. 60% granulation. 10% bone. Treatment plan: Sodium hypochlorite solution (Dakins) apply twice daily . 1/2 strength cleanse and wet to moist to prevent odor and infection. Foam with border apply twice daily. Surveyor noted R3's wound had grown. The facility did not update R3's skin care plan with any new interventions and there is still no intervention for turning and repositioning R3 or offloading the sacrum. Staff continue to treat R3's sacral pressure injury with full strength Dakins and cover the wound with an ABD pad instead of a foam with border dressing as ordered.MD-R continued to see R3 weekly for wound evaluation. MD-R recommended on 9/1, 9/8, 9/15, and 9/22 the treatment to R3's sacrum wound be Sodium hypochlorite solution (Dakins) apply twice daily . 1/2 strength cleanse and wet to moist to prevent odor and infection. Foam with border apply twice daily. R3's TAR indicated during the month of September, facility staff continued to treat R3's sacral pressure injury with full strength Dakins and cover the wound with an ABD pad instead of a foam-with-border dressing as ordered. R3's Wound MD-R evaluation note dated 9/29/25 documents, in part: Stage 4 pressure wound sacrum full thickness. 7 x 8 x 5. 6cm at 3 o'clock. 30% slough. 40% granulation. 30% bone. Treatment plan: Sodium

Based on interview and record review, the facility failed to assess resident's hydration status and supply sufficient fluid intake to maintain proper hydration and health for 1 (R1) of 3 residents reviewed. The facility's repeated and systemic failure to assess and address R1's hydration status and implement pertinent interventions based on such an assessment resulted in R1 being admitted to the Intensive Care Unit (ICU) for Hypernatremia, Acute Kidney Injury, and a Urinary Tract Infection. This created a finding of immediate jeopardy that began on 2/7/2025. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were notified of the immediate jeopardy on 3/05/25 at 10:14 AM. The immediate jeopardy was removed on 3/5/25. This deficient practice continues at a scope and severity of a D (potential for harm/isolated). Findings include: 1.) R1 was admitted on [DATE] with diagnoses that include Malignant Neoplasm of Posterior Wall of Bladder, Dysphagia following Cerebral Infarction, Alzheimer's Dementia, Vascular Dementia, Schizophrenia, and Major Depressive Disorder. R1's Significant Change in Condition MDS (Minimum Data Set) with an assessment reference date of 11/20/24, documents a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate impaired cognition for R1. Section K (Swallowing/Nutritional Status) documents R1 requires a mechanically altered diet of pureed food with honey consistent liquids. Section GG (Functional Abilities and Goals) documents R1's eating ability as substantial / maximal assist, indicating that facility staff provides more than half the effort for R1 to eat. R1's Hydration/Nutrition care plan dated 04/06/2024, with a revision date of 12/12/2024, documents: Resident is at risk for compromise in nutrition and hydration status d/t (due to) underweight status. Under the Goals section it documents: Resident will not have s/sx (signs and symptoms) of dehydration. Date Initiated: 04/06/2024, Target Date: 03/12/2025. Under the Interventions section it documents: o Monitor for s/s of dehydration Date Initiated: 04/06/2024 o Monitor for s/s of dysphagia and aspiration Date Initiated: 04/06/2024 o Obtain weights per facility protocol Date Initiated: 04/06/2024 o Provide diet as ordered Date Initiated: 04/06/2024 o Provide supplements as ordered: Magic Cup TID (3 times a day) Date Initiated: 04/06/2024 o RD (Registered Dietician) to assess nutrition needs and make recommendations as necessary. Date Initiated: 02/19/2024 o Offer meal substitute if resident consumes less than 50% of meal Date Initiated: 04/06/2024, revision 2/19/25. R1's Dehydration/Fluid Maintenance Care Area Assessment Summary (CAAS) dated 12/11/24 documents under the Care Plan Considerations section: R1 triggered CAA d/t (due to) pneumonia. R1's fluid status is monitored closely. No s/sx (signs and symptoms) of dehydration at this time. Nursing to continue to monitor R1's fluid status and for s/sx of dehydration. R1's Basic Metabolic Panel (BMP) (a blood test providing insights into dehydration, metabolism, electrolyte balance, and organ function) results, dated 11/25/24, documents R1's Blood Urea Nitrogen (BUN) level was documented to be 39. BUN normal levels are (6 to 23). R1's Sodium (NA) level was documented to be 151. NA normal levels are (136-145). R1's Chloride (CL) level was documented to be 120. CL normal levels are (98-107). Surveyor noted that at the bottom of R1's BMP order .dated 11/26/24 Will see tomorrow per Advanced Practice Nurse Practitioner (APNP)-G. R1's Nurse Practitioner note dated 11/27/24 and written by APNP-G documents under the Assessment and Plan section: Dehydration: Encourage hydration. Repeat BMP. Continue to monitor fluid status and electrolytes. No new orders were placed. R1's Basic Metabolic Panel (BMP) result dated 12/02/24, documents R1's BUN level to be 30. R1's Sodium (NA) level was documented to be 152. R1's Chloride (CL) level was documented to be 120. No new orders were placed. Surveyor noted that at the bottom of R1's BMP order .dated 12/2/24 N.N.O (no new orders) per APNP-G. R1's Nurse Practitioner note dated 12/4/24 and written by APNP-G documents under the Assessment and Plan section: Dehydration: Encourage hydration. Repeat BMP. Continue to monitor fluid status and electrolytes. Surveyor noted that no new orders for a BMP to be repeated were placed. Surveyor was unable to locate a BMP completed for R1 on 12/4/24. R1's Nurse Practitioner note dated 12/6/24 and written by APNP-G documents under the Assessment and Plan section: Dehydration: Encourage hydration. Repeat BMP. Continue to monitor fluid status and electrolytes. Surveyor noted that no new orders for a BMP to be repeated were placed. Surveyor was unable to locate a BMP completed for R1 on 12/6/24. R1's Nurse Practitioner note dated 12/13/24 and written by APNP-G documents under the Assessment and Plan section: Dehydration: Encourage hydration. Repeat BMP. Continue to monitor fluid status and electrolytes. Surveyor noted that no new orders for a BMP to be repeated were placed. Surveyor was unable to locate a BMP completed for R1 on 12/13/24. R1's Nurse Practitioner note dated 12/20/24 and written by APNP-G documents under the Assessment and Plan section: Dehydration: Encourage hydration. Repeat BMP. Continue to monitor fluid status and electrolytes. Surveyor noted that no new orders for a BMP to be repeated were placed. Surveyor was unable to locate any fluid and electrolyte monitoring in R1's medical record. R1's nursing note dated 2/7/25 at 10:13 AM, documents: Situation: The changing condition reported on this CIC (change in condition). Evaluation are/were tired, weak, confused or drowsy at the time of evaluation R1s. Vital signs, Weight and blood sugar were blood pressure 141 / 97 on 2/7/25 at 10:16 AM position: sitting right arm. Pulse 52 on 2/7/25 at 10:17 AM Pulse type: Regular. Respirations on 2/7/25 at 10:17 AM. Temperature 98 on 2/7/25 at 10:18 AM Route: Tympanic. Weight 99 pounds on 2/3/25 at 5:35 PM Scale: wheelchair. Pulse oximetry 98% on 2/7/25 at 10:19 AM Method: Oxygen via mask. Blood glucose 154 on 11/13/24 at 9:38 AM . Resident patient is in the facility for long term care. Relevant medical history is cancer, active chemo or radiation therapy dementia. Code status do not resuscitate and advanced directives are in place. R1 had the following medication changes in the last week. R1 is on Coumadin warfarin. Outcomes of physical assessment: positive findings reported on R1 evaluation for this change of condition were: Mental status evaluation: Increased confusion. Example Disorientation. Functional status evaluation: General weakness. Nursing observations, evaluation and recommendation are CNA provided activities of daily living (ADLs) . R1, per usual, stated R1 didn't look herself. Vital signs were taken by writer Blood pressure 141 / 97, pulse 52, Respirations 20 Temperature 98 axillary. Pulse oxygenation at 98% per nasal cannula at 2 liters. Resident was sitting up in wheelchair at the dining room table. Staff was assisting in giving fluids and writer noticed the fluids were drooling from the side of R1's mouth. R1, more lethargic than usual self. Writer updated R1's family/power of attorney (POA) at this time. Primary care provider feedback. Primary care provider responded with the following feedback. A Recommendations. Monitor condition and contact nurse practitioner if needed be. B New testing orders: C New intervention orders. Oxygen if available. R1's nursing note dated 2/7/25, at 11:14 AM, documents: Certified Nursing Assistant (CNA) provided activities of daily living to R1 per usual, stated R1 didn't look like herself. Vital signs were taken by writer Blood pressure 141 / 97, pulse 52. Respirations 20, Temperature 98 axillary. Pulse oxygenation at 98% per nasal cannula at 2 liters. R1 was sitting up in wheelchair at the dining room table. Staff was assisting in giving fluids and writer noticed the fluids were drooling from side of R1's mouth. R1 more lethargic than usual self. Writer updated family/POA at this time. Updated Nurse Practitioner continue to monitor condition and call if needed. R1's nursing note dated 2/7/25, at 11:45 AM, documents: Medications were drooling out of mouth. R1's nursing note dated 2/7/25, at 1:39 PM, documents: Spoke with family. Family given an update on residents, weight loss and change of condition. Staff will continue to monitor. R1's nursing note dated 2/7/25, at 6:55 PM, documents: R1 sent to hospital per family request stated that she (R1) does not look good and that she (R1) is not responding to them as normal. They feel she (R1) was unresponsive, wanted her (R1) to be evaluated. MD updated awaiting response. Family/POA aware and was present with rest of family. R1 sent out via Ambulance with two attendants. Blood pressure 122 / 62, Respirations 18, Pulse 87. Oxygen saturation 99% on 2 liters per nasal cannula. Director of Nursing updated. R1's hospital note titled History of Present Illness dated 2/7/25, at 9:10 PM, documents: R1 is a 78 Y female with a history of HFrEF (EF 11%) R1 has a cardiac ejection fraction of 11% (meaning R1's heart has poor ability to pump blood), LV thrombus on apixaban, schizophrenia, CKD (chronic kidney disease), dementia, stroke, and hypertension who presented to hospital Emergency Department (ED) via Emergency Medical Service (EMS) from R1's assisted living facility for confusion and altered mental status. The patient is minimally responsive & nonverbal without any family at bedside, so History and Physical Information (HPI) is obtained from ED documentation. Family stated that R1 lives in a nursing home and they were called today because R1 seemed less responsive and interactive to them. (R1) Has a history of dementia and stroke. Son states R1 does not talk much at baseline. However, when R1 sees him will always seem excited and alert. Today was lethargic with her mouth open and not talking to anyone. EMS (Emergency Medical Service) reported a fever from R1's nursing home. R1 does not walk around her facility at baseline. Son states R1's mouth is very dry and R1 looked very dehydrated to them. They are not sure the last time the staff checked on R1. In the ED (Emergency Department), multiple laboratory abnormalities were noted & most significant levels were for Na (Sodium) level was 186, normal levels are (136-145), CL (Chloride) level was >140, normal levels are (98-107), BUN (blood urea nitrogen) level was 110, normal levels are (6 to 23), Creatinine level was 2.97, normal levels are (0.50-110). Urinalysis (UA) was consistent with UTI. The patient received 1 Liter Normal Saline; 2 Grams ceftriaxone, & is subsequently being admitted to the intensive care unit (ICU) for further management of R1's hypernatremia & urinary tract infection (UTI) . Assessment and plan: R1 is a 78 Y female with a history of HFrEF (EF 11%) R1 has a cardiac ejection fraction of 11% (meaning heart has poor ability to pump blood), LV thrombus on apixaban, schizophrenia, CKD, dementia, stroke, and hypertension admitted to (hospital) 2/7/25 with hypernatremia, UTI and encephalopathy. Hypernatremia: - 1 Liter NS (normal saline) administered in ED for volume depletion. - 5.8L free water deficit. - Continue hydration with D5W (dextrose 5% water). - Insert Dobbhoff (feeding tube) & initiate free water flushes. - Patient has lost 25 lbs. in 3-6 months time. Nutrition consult in AM. - Monitor I/Os (intake and output). - Serial Sodium. UTI (Urinary Tract Infection): - Not overtly septic appearing, lactic acid reassuring. - Skin warm & well perfused. - We'll avoid bolus fluid resuscitation given significant heart failure history, continue ongoing maintenance fluids. - Continue daily ceftriaxone. Acute kidney injury, CKD (chronic kidney disease): - Baseline creatinine appears to be 0.8 to 1, 2.97 on presentation. - Expect prerenal due to hydration. anticipate resolution with ongoing water repletion. - Hold PTA ACE/ARB. - Avoid potential nephrotoxins. - Avoid radiocontrast if possible. - Avoid NSAIDs. - Avoid Phosphate based enemas and laxatives. - Renally dose adjust medications to GFR (glomerular filtration rate). - Strict Intake and Output. - Could consider phrenology consult. HFrEF, LV thrombus, Stroke: - Hold apixaban initially to account for renal function. - Continue apixaban & clopidogrel. - No PTA diuretics on history - Monitor, could consider repeat echo. Toxic metabolic encephalopathy: - Existing dementia diagnosis noted. - Expect resolution back to baseline with treatment of hypernatremia and UTI. Surveyor reviewed R1's fluid intake for the months of December 2024, January 2025, and February 2025 in the facility's electronic medical record system. Surveyor reviewed all the fluid intake information available in the electronic medical record system for R1, including any fluid recorded for meals and snacks. Surveyor noted R1's December 2024 documented daily fluid intake averaged 680.25 milliliters. Surveyor noted R1 had no documentation of fluid intake on 12/1/24. Surveyor noted no snack time fluid intake documented for R1 from 12/1/24 through 12/11/24, and on 12/14/24, 12/17/24, 12/21/24, 12/22/24, and 12/26/24. Surveyor noted R1's January 2025 documented daily fluid intake averaged 871 milliliters. Surveyor noted R1 had 3 dates documenting lower daily fluid totals: 1/13/25 R1 received 200ML, 1/21/25 R1 received 120 ML, and 1/23/25 R1 received 240 ML. Surveyor noted R1's February 2025 documented daily fluid intakes are as follows: on 2/1/25 R1 received 960 ML, on 2/2/25 R1 received 920 ML, on 2/3/25 R1 received 840 ML, on 2/4/25 R1 received 680 ML, on 2/5/25 R1 received 600 ML. On 2/6/25, R1 had no documentation of receiving fluid for the day. On 2/7/25, R1 had no documentation of receiving fluid for the day. R1 left for the hospital at 06:55 PM on 2/7/25. Surveyor attempted to located how much fluid R1 should receive daily in the facility's electronic medical system. The only daily fluid assessment that documented how much daily fluid R1 should receive was from a dietary assessment completed on 2/7/22. The 2/7/22 dietary assessment documented that R1's daily fluid intake goal was 1525 milliliters (ML). On 3/4/25, at 10:38 AM, Surveyor interviewed Dietician (DT)-F regarding R1's daily fluid intake goals. Surveyor informed DT-F that Surveyor has been unable to locate daily fluid intake recommendations for R1. Surveyor informed DT-F that Surveyor was unable to locate any documentation on what R1's daily fluid intake goals should be before and after R1's 2/7/25 hospitalization for hypernatremia, acute kidney injury, and UTI. DT-F informed Surveyor that based on a 25-30 milliliter (ML) per kilogram (KG) formula, R1 should receive 1100ML to 1400 ML of fluid daily. Surveyor informed DT-F that Surveyor could not locate R1's fluid intake recommendation in R1's medical record. DT-F informed Surveyor DT-F could not locate any recent recommendations for R1's daily fluid intake in R1's medical record. DT-F informed Surveyor the last recommendation in R1's record is from 2/7/22. Surveyor asked DT-F with R1's dehydration diagnosis in December 2024 and R1's identified hydration concerns, why would fluid evaluations and daily fluid recommendations for R1 not be completed since 2/7/22. DT-F informed Surveyor DT-F could not answer that question because DT-F had only been covering this facility for another dietician since 2/20/25. Surveyor asked DT-F that in DT-F's professional opinion what should have been done for R1's specific fluid deficit concerns. DT-F informed Surveyor that high risk residents like R1 should be a weekly review for fluid intake and a monthly interdisciplinary team (IDT) review. DT-F informed Surveyor that it looked like the focus had been on R1's nutrition only and not specifically R1's fluid deficits. DT-F informed Surveyor the team would usually look at fluid intake more closely as part of R1's weight loss but in R1's case that wasn't done. DT-F informed Surveyor that DT-F could not locate any documented fluid specific intakes being reviewed in R1's record. Surveyor asked DT-F if dietary staff were aware of R1's BMP results on 11-25-24 that showed an elevated BUN, Chloride, and Sodium levels for R1 and APNP-G's written concern with dehydration and pushing fluids. DT-F informed Surveyor that DT-F was not informed of R1's dehydration concerns documented by APNP-G. DT-F informed Surveyor that this information was not communicated to the dietary department based on what DT-F could see in R1's dietary notes. DT-F informed Surveyor DT-F wasn't at the facility during that time and could not speak to that information. Surveyor asked DT-F if DT-F felt that APNP-G's fluid concerns should have been communicated to dietary and daily fluid goals provided for R1. DT-F informed Surveyor DT-F could see nothing in R1's dietary notes that R1 was flagged for specific dehydration or fluid deficit concerns. Surveyor asked DT-F how dietary staff would expect communication from the facility about fluid deficits or dehydration concerns for residents. DT-F informed Surveyor that dietary staff would expect to be notified of fluid deficits and dehydration from the facility's care partners, staff, and during the IDT meetings. Surveyor asked DT-F if there was anything in R1's notes or if dietary was informed about APNP-G's recommendation to monitor and push fluids on R1. DT-F informed Surveyor that DT-F assumed fluid concerns for R1 would have been discussed in the IDT meetings, but DT-F could not find information in R1's record confirming dehydration concerns were discussed. Surveyor asked DT-F when DT-F started to cover dietary was the fluid deficit or dehydration concern for R1 mentioned. DT-F informed Surveyor that weight loss and nutritional concerns for R1 has been the focus in the dietary notes and not R1's hydration status. DT-F was not informed about any specific dehydration or fluid concerns for R1. Surveyor asked DT-F if DT-F was aware of the 2/29/25 dehydration assessment placing R1 at risk for dehydration. DT informed Surveyor DT-F was not aware of that assessment. On 3/4/25, at 2:50 PM, Surveyor interviewed APNP (Advanced Practice Nurse Practitioner)-G regarding R1's Dehydration diagnosis and daily fluid intake goals. Surveyor asked APNP-G if APNP-G was aware that no new BMP tests were done on R1 after 12-2-24, and it is documented in APNP-G's plan and assessment that R1 was to have a repeat BMP test. APNP-G informed Surveyor just because APNP-G writes repeat BMP in R1's notes, it was a reminder to APNP-G to watch this issue closely for R1. Surveyors asked APNP-G how the staff would know R1 would not get a repeat BMP, as it was in written in APNP-G's 11/27/24 note to repeat a BMP and a BMP test was done.APNP-G informed Surveyors APNP-G would have put the order in the facility's order system application. Surveyors asked APNP-G if APNP-G wanted the staff to monitor R1's fluid and electrolytes that APNP-G documented as part of R1's plan and assessment. APNP-G informed Surveyor that R1's dehydration diagnosis was a clinical diagnosis of symptoms, and with R1's sodium being elevated APNP-G expected the facility to monitor R1's fluid and electrolytes. Surveyor asked APNP-G how staff would know which interventions APNP-G wrote for R1 in APNP-G's December 2024 notes that included repeat BMP, encourage fluids, and monitor fluid and electrolytes were to be implemented when no orders for any interventions were entered into the system. APNP-G could not speak to that at the time but reiterated to Surveyor R1's sodium was elevated so APNP-G expected the facility to monitor R1's fluid and electrolytes. Surveyor asked APNP-G what APNP-G would expect R1 to receive for a daily fluid goal. APNP-G informed Surveyor that APNP-G could not speak to that, but APNP-G expected that dietary should be involved in establishing the daily fluid goals for R1. Surveyor asked APNP-G if a dietary consultation was ordered for R1's fluid intake concerns. APNP-G informed Surveyor that a dietary consult was not ordered by APNP-G, but if the staff had told APNP-G that R1 wasn't drinking fluids, APNP-G would have repeated the order for R1's BMP test. Surveyor asked APNP-G how the staff would know when to inform APNP-G without fluid goals or parameters set for R1. APNP-G informed Surveyor APNP-G would still expect the staff to push fluids because R1's sodium was high, and it is the facility's responsibility to get dietary involved. Surveyor asked APNP-G if APNP-G was aware that the facility tracked R1's fluid intake during meals and snacks in the electronic medical record. APNP-G informed Surveyor that APNP-G had not seen R1's fluid intake documentation from the electronic medical record. Surveyor asked APNP-G how APNP-G determined R1's dehydration diagnosis noted in APNP-G's note dated 11/27/24. APNP-G informed Surveyor R1's elevated BMP results and elevated Sodium is a specific symptom of dehydration. APNP-G informed Surveyor that a focus on R1's weight loss and nutritional intake concerns was ongoing. Surveyor asked APNP-G when R1 showed up to the hospital with elevated BMP results would APNP-G agree it was not just from R1 occasionally not drinking enough water. APNP-G informed Surveyor APNP-G would agree with the assessment that R1 was in a significant fluid deficit. APNP-G informed Surveyor that R1 was at risk for fluid deficit before the hospitalization on [DATE]. Surveyor asked APNP-G if APNP-G agrees without a current fluid assessment with daily fluid goals set for R1, staff would not have guidelines on how to meet R1's current fluid needs. APNP-G informed Surveyor daily fluid intake goals should be set for R1 but expects the dietician to be the one setting R1's daily fluid goals. APNP-G informed Surveyor that APNP-G can't be at the facility all the time and expects that dietary and the facility take some of the responsibility for R1's hydration status. APNP-G informed Surveyor if the staff did not inform APNP-G that R1 had an issue with hydration, there is nothing that APNP-G could have changed for R1. Surveyor asked APNP-G if daily fluid goals for R1 would help staff in knowing what to communicate to the medical providers. APNP-G informed Surveyor that R1 should have daily fluid goals, but dietary should be setting those fluid goals. On 3/4/25, at 1:21 PM, Surveyor interviewed Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A. Surveyor informed NHA-A of Surveyor's concerns about R1's dehydration diagnosis by APNP-G on 11/27/24 and the lack of communication between R1's care team with no comprehensive system to monitor R1's daily fluid intake. Surveyor informed NHA-A R1 had a lack of a specific hydration care plan before and after R1's hospitalization for hypernatremia, elevated BMP laboratory tests, and acute kidney disease. Surveyor informed NHA-A this failure caused R1 to be hospitalized on [DATE] with a 5.8-liter free water deficit causing R1 to stay in the ICU related to R1's 11% injection fraction requiring the hospital to carefully monitor R1's administered fluid replenishment. Surveyor asked DON-B did the facility review R1's fluid and dehydration issues noted in APNP-G's note documented on 11/27/24. DON-B informed Surveyor that DON-B had reviewed APNP-G's note, the facility felt R1 had a change of condition when R1 had declined in R1's ability to feed herself, and R1 developed a food bolus causing R1's hospitalization just prior to APNP-G's note in November 2024. Surveyors asked DON-B what plan for R1 was implemented after APNP-G diagnosed R1 with dehydration in R1's Nurse Practitioner note dated 11/27/24. DON-B informed Surveyor in the facility's weekly meeting R1 and all at risk residents' nutrition and dehydration concerns and other issues are reviewed. Surveyor asked DON-B if R1's dehydration diagnosis was reviewed in these meetings. DON-B informed Surveyor that DON-B could honestly say the team never discussed R1's specific fluid or dehydration concerns outside of R1's overall meal intakes. DON-B informed Surveyor the team focused on preventing R1's weight loss and overall nutrition and not specifically R1's dehydration. Surveyor asked DON-B if DON-B was aware of the Nurse Practitioner notes written by APNP-G on the dates of 12/4/24, 12/6/24, 12/13/24, and 12/20/24 documenting expectation that staff should encourage fluid and monitor fluid and electrolytes for R1. DOB-B informed Surveyor that the facility was aware of R1's dehydration diagnosis and fluid monitoring written by APNP-G. Surveyor asked DON-B if DON-B was aware that APNP-G also documented repeating a BMP test for R1 in the Nurse Practitioner notes written on 12/4/24, 12/6/24 and 12/13/24. DOB-B informed Surveyor that the facility was aware of R1's repeat BMP documentation in APNP-G's notes, but that APNP-G had not put in an order for the BMP. DON-B informed Surveyor that communication issues with APNP-G have been a problem as well as clarifying what APNP-G's expectations are compared to what APNP-G's writes in R1's notes. DON-B informed Surveyor the facility has requested that APNP-G be more specific with APNP-G's expectations when writing notes, because the notes that APNP-G writes often give direction to staff without orders placed into the system. Surveyor asked DON-B if the nursing and IDT teams looked at the fluid intakes Surveyor noted in the electronic medical record for meals and snacks. DON-B informed Surveyor the nursing or IDT team had not reviewed those intake records, that the weekly team reviews had been focused on the weight loss and R1's overall meal intake. DON-B informed Surveyor that R1's fluid intakes were not looked at specifically. Surveyor asked DON-B if DON-B was aware that there had been no daily fluid goal expectations documented for R1 since a dietary note on 2/7/22. DON-B acknowledged there was no current daily fluid goals in R1's plan of care. DON-B informed Surveyor that there is a communication issue with APNP-G, and the facility is having difficulty getting specific parameters from APNP-G. Surveyor asked DON-B if the IDT team was aware that on 2/19/25 a dehydration risk assessment was done for R1 documenting that R1 is at risk for dehydration. DON-B informed Surveyor that DON-B was aware of R1's 2/19/25 dehydration risk assessment. DON-B informed Surveyor that DON-B was aware no specific fluid intake changes in the hydration part of R1's care plan had been implemented. Surveyor asked DON-B why the daily fluid intake in the electronic medical record documented by the nursing assistants is not reviewed by the licensed nursing staff. DON-B informed Surveyor it was an oversight, but R1's intakes in the electronic medical record would be reviewed going forward. DON-B informed Surveyor that while it is not an excuse, the team focuses hard on R1s nutrition and preventing R1's weight loss. DON-B informed Surveyor that R1's family has been resistant to anything around tube feeding or placing R1 in hospice. DON-B informed Surveyor the medical providers have spoken to family repeatedly about R1's decline. DON-B informed Surveyor the family declined Speech Therapy treatment and doesn't want any permanent interventions for R1. On 3/4/25, at 6:49 PM, Surveyor asked Medical Director-H how facility staff is supposed to distinguish between recommendations made by APNP-G and what APNP-G is writing to remind APNP-G what to monitor for R1. Medical Director-H informed Surveyor that there is a problem with the way APNP-G is writing notes for R1, as nursing staff would have a hard time distinguishing between recommendations that APNP-G is using to remind APNP-G to monitor for R1, and what nursing staff at the facility are supposed to do. Medical Director-H emphasized to Surveyor that if APNP-G had specific orders for R1, APNP-G would put an order in the system so that nursing staff could execute the order. Medical Director-H informed Surveyor that there is problem with the communication between APNP-G and nursing staff at the facility as recommendations written by APNP-G are not being followed and that nursing staff is unable to distinguish between what APNP-G is using to remind APNP-G to monitor for R1 and what APNP-G expects nursing staff at the facility to do. Surveyor informed Medical Director-H that APNP-G was not aware of the daily fluid intake for R1 since R1 had not had a daily fluid intake goal assessment completed since 2/7/22. Medical Director-H informed Surveyor that he could not speak to why APNP-G was not aware of the daily fluid intake for R1 and stated that nursing had failed to do a more recent daily fluid goal assessment on R1. Medical Director-H informed Surveyor that going forward the facility would establish better communication between APNP-G and nursing staff and that the facility would complete a quality assurance review of the incident. On 3/4/25 at 7:09 PM, Surveyor informed NHA-A of the above findings. NHA-A informed Surveyor that the facility would complete a root cause analysis of R1's fluid issues and attempt to find out if there were any other issues involving R1's fluid intake. No additional information was provided as to R1's daily fluid intake needs or why R1 did not receive enough fluids prior to being hospitalized on [DATE]. The facility's repeated and systemic failure to assess and address R1's hydration status and implement pertinent interventions based on such an assessment resulted in R1 being admitted to the Intensive Care Unit (ICU) for Hypernatremia, Acute Kidney Injury and a Urinary Tract Infection created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy The immediate jeopardy was removed on 3/5/25 when the facility completed the following: - All facility nursing staff educated on fluid intake documentation, monitoring, change of condition, hydration assessments and when to update provider. - - Nurse Practitioner educated on monitoring change of condition, making clear orders to nursing staff, and communication process with nursing staff. - Dietician educated on implementation of fluid intake goals, clear communication with nursing staff, and monitoring for residents at risk for dehydration. - All training noted above to be completed by next working shift. Any nurses/CNAs who do not complete the competency will not be scheduled until completed. - Competencies and education will be conducted by nursing management and/or a nurse who has passed the competency education and has been designated to give education. - The facility reviewed and updated plan of care for all residents at risk for dehydration. Monitoring includes tracking system in Point Click Care, weekly dietician meetings, nurse manager/DON audit oversight, daily review of charting and fluid intake for at risk residents in stand up. - Facility reviewed policy and procedure for hydration. Policy updated to include: 1. The dietician or consulting dietician will work together with staff to identify residents at risk for fluid deficit or with specific fluid intake needs. 2. The dietician will determine the optimal fluid intake amount for residents at risk and will communicate that to the nursing staff with a breakdown of recommended fluid amounts per shift, per meal, per med pass, and/or water pass. 3. The dietician and staff will monitor for the subsequent development, progression and/or resolution of fluid deficit or fluid restrictions in all at-risk individuals to ensure appropriate interventions and/or follow up continues. 4. The dietician will participate in weekly Nutritional at Risk meetings and maintain on-going dialogue

Based on observation, interview, and record review, the facility did not ensure 2 (R11 and R34) of 3 residents reviewed for accidents received adequate supervision and assistance devices to prevent residents from sustaining continued falls. * On 8/23/24, R11 slipped out of his wheelchair while emptying his urinal and sustained a left hip fracture. R11 had falls on 6/30/24, 7/6/24, 7/16/24, 7/27/24, 8/13/24, 8/23/24, and 9/12/24. The facility did not complete a comprehensive assessment to determine a root cause for each fall, did not reassess interventions to determine if fall interventions were effective, did not complete accurate fall assessments after each fall. R11 experienced falls potentially related to episodes of orthostatic hypertension. The facility did not assess to determine if there was a pattern to the episodes to increase supervision or safety interventions to prevent falls or decrease the potential for injury from falls. * R34 was observed without floor mats. The plan of care indicated floor mats as a intervention for falls. The example regarding R11 rises to a scope and severity level of G (harm/isolated). Findings include: The facility's policy Fall Prevention and Management Guidelines dated 11/2022 and last revised on 11/17/23 documents: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury. The nurse will initiate interventions to help prevent falls on the residence baseline care plan. Suggested standard interventions may include: a. Implement universal environmental interventions that decrease the risk of resident falling, including, but not limited to: i. A clear pathway to the bathroom and bedrooms. ii. Bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed. iii. Call light and frequently used items are within reach. iv. Adequate lighting. v. Wheelchairs and assistive devices are in good repair. Suggested interventions for residents determined to be higher risk for falls may include: provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. Provide additional interventions as directed by the resident's assessment and based on input from the resident or family members including but not limited to: assistive devices, increased frequency of rounds, increased supervision if indicated, medication regimen review, low bed, alternate caregiver or resident education, therapy services referral, scheduled rest periods, and environmental modifications. When a resident experiences a fall the facility will: a. complete a post fall assessment and review: physical assessment with vital signs, neuro checks for an unwitnessed fall or a witnessed fall where a resident hits their head, check for orthostatic blood pressure changes if postural hypotension suspected, resident and/or witness statements regarding fall, environmental review for possible factors, contributing factors to the fall, medication changes, mental status changes, and any new diagnoses. b. Complete an incident report in risk management. c. Notify physician and family/responsible party. d. Review the resident's care plan and update with any new interventions put in place to try to prevent additional falls. e. Document all assessments and actions. f. Obtain witness statements from other staff with possible knowledge or relevant information. Review each fall/fall investigation during the next morning meeting/clinical meeting with the interdisciplinary team (IDT). Actions of the IDT may include: a. Review of investigation and determination of potential root cause of fall. b. Review of fall risk care plan and any updates to plan of care completed post fall. c. Additional revisions to the plan of care including any physical adaptation to room, furniture, wheelchair, and/or assistive devices. d. Education of staff as to any care plan revisions. e. Scheduling resident/family conferences. f. Verification of timely notification of physician and responsible party of the fall. If after IDT review, it is determined that existing interventions in the care plan are most appropriate, document rationale and describe any additional actions taken. 1.) R11 was admitted to the facility on [DATE] with diagnoses to includes cerebral infarction, weakness, unsteadiness on feet, osteoarthritis, muscle wasting and atrophy, difficulty walking, lack of coordination, need for assistance with personal cares, diabetes, cognitive communication deficit, and history of malignant neoplasm of prostate. R11's Admission MDS (Minimum Data Set) dated 6/13/24 documents R11 had a fall in the last month prior to admission to the facility and had a fall in the last two to six months prior to admission. R11's fall CAA (Care Area Assessment) dated 6/13/24 documents R11 is at risk for falls and has a history of falls prior to admission. The CAA documents that R11 has weakness and decline in function. R11 is monitored for orthostatic hypotension, he is using a walker and is on Lexapro. R11 has risks for falls monitoring and preventive measures in place. R11's Functional Abilities CAA dated 6/13/24 documents R11 has weakness and decline in function from a recent hospitalization . R11 has a diagnosis of acetaminophen overdose and multiple comorbidities. R11 attends skilled therapies with plans to return to prior living arrangements when safe and stable. R11 has weakness requiring assistance with ADLs (Activities of Daily Living) and requires intervention and monitoring. R11's Significant Change MDS dated [DATE] documents that R11 is independent with eating, requires supervision with toileting, is dependent with showering, requires substantial/max assist with dressing and rolling from left to right, requires supervision with toilet transferring, and is frequently incontinent of urine and bowel. R11's Significant Change MDS dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 14 indicating R11 is cognitively intact. R11's Fall CAA dated 9/3/24, documents R11 has significant change related to a fall with fracture and recent hospitalization . R11 has pain, weakness, incontinence, and is on psychotropic medication. R11 is participating in skilled therapies. R11 has a history of orthostatic hypotension and remains at risk for additional falls. R11 is encouraged to ask for assistance as needed. R11 has falls and is at risk for additional falls. R11 requires monitoring, staff assist, and preventative measures. R11's care plan, documents: R11 has an ADL self-care performance deficit related to weakness and impaired balance (date initiated 6/6/24, last revised 9/25/24). Interventions include: provide adaptive equipment necessary during transfer, R11 requires assistance by one staff member for showering, R11 is independent with turning and repositioning in bed as necessary, requires assistance of one staff member to dress, requires assistance by one staff member for toileting, requires assistance by one staff member with lateral scoot transfer and gait belt to move between surfaces as necessary, encourage R11 to use bell to call for assistance, and praise all efforts at self-care. Surveyor reviewed R11's medical records that document: Fall risk assessment completed on 6/6/24 documents R11 is a moderate risk for falls. Sleep assessment completed on 6/6/24 documents R11 wakes up 1-2 times a night to urinate. R11 states when he wakes up to urinate, he has a difficult time falling back to sleep. R11 states it has been this way for [AGE] years. Bowel and bladder assessment completed on 6/6/24 documents R11 requires assistance with ambulation and is continent of bowel and bladder. R11's 6/30/24 fall investigation documents R11 sustained an unwitnessed fall at approximately 00:49. R11 was found lying on the bathroom floor. R11 stated he wanted to try walking with the walker. The fall investigation documents the root cause of the fall as R11 attempted to walk alone with his walker. New fall prevention interventions include a sign being hung up in R11's room to call for help. R11's care plan updates include: educate R11 on the importance to call for assistance when needed and place a sign in resident room to remind resident to call for assistance. Surveyor noted some neurological checks were completed by the facility staff however, all the required neurological checks post fall were not fully completed. Surveyor noted a fall risk assessment for R11 was completed on 6/30/24, which documented R11 is low risk for falls. Surveyor noted that R11's fall risk assessment dated [DATE] to be inaccurate, as it documents that R11 does not have a history of falls. R11's 7/6/24 fall investigation documents R11 sustained an unwitnessed fall on 7/6/24, at 11:27 am. Facility staff overheard R11 calling for help. R11 was found on the side of the bed on the floor. R11 hit his head on the wheel of the wheelchair while trying to pick up the cord off the floor. R11 stated he got dizzy and lost his balance. The fall report indicates R11 was last seen in the hallway approximately 10 minutes prior to the fall. R11 sustained a 1.7 x 0.2 laceration to the occipital area with a small amount of blood present. R11 was sent to the emergency room for evaluation. The fall investigation documents the environmental status at the time of the fall was the call light was within reach and the bed was locked. The root cause was identified as R11 attempting to pick up an object and got dizzy and fell . The identified new immediate intervention was to use cal light when need assistance and education was provided to the resident. Surveyor noted the fall report indicated the call light was within reach and yet this was the object R11 was reaching for at the time of the fall and despite R11 attempting to follow that intervention, a fall occurred and was identified to be the new intervention that R11 was educated about. The documented education also was to encourage R11 to increase activity during waking hours and to call staff when items need to be picked up off the floor. Surveyor notes there is no review or assessment for increased staff awareness of R11's movement around the facility to identify possibly changes in situation that could increase the risk for falls and/or increased need for supervision. R11's 7/16/24 fall investigation documents R11 sustained an unwitnessed fall. On 7/16/24, at 12:59 am, staff responded to R11's call light and R11 was found on his knee next to his bed. Staff observed R11's call light was on the bed hanging from the headboard. R11 stated he was reaching for the call light and rolled out of bed. The fall investigation documents the root cause as R11 reaching for his call light and rolled out of bed. Surveyor notes care plan changes to include: encourage (R11) to use his reacher when attempting to get items out of reach. Surveyor noted the fall investigation document does not include details of why the call light was hanging over the headboard for R11 to reach for over R11's head rather than by R11's side, within reach. Surveyor noted the use of a reacher would still require R11 to reach for something above his head but now having to also coordinate using a reacher. Facility documentation provided to surveyor indicates it was later noticed the cord to R11's call light was short and the cord was lengthened along with providing a reacher. Surveyor noted this is the second fall where R11 is attempting to carry out the safety intervention the facility has instructed R11 to complete and both have lead to a fall while trying to implement. Review of R11's record indicates physicians were documenting R11 was still symptomatic regarding blood pressure issues and medication changes to try to stabilize. Surveyor noted there was no assessment of a pattern of when symptoms occur or a plan for increased supervision/monitoring despite the falls and change in condition for R11. R11's 7/27/24 fall investigation documents R11 sustained an unwitnessed fall. On 7/27/24, at 2:09 am, R11 was heard yelling for help, and was lying on the floor, lying on his back at the foot of the bed. R11 stated he was trying to go to the bathroom. Progress notes indicate R11 sustain swelling to his elbow and required x-rays of his elbow and coccyx. The fall investigation documents the root cause as R11 attempted to toilet himself without calling for assistance. Surveyor notes care plan changes to include: R11 is encouraged to use call light for assistance and offer toileting every two hours during the night. Surveyor noted this is another fall from bed. The intervention addressed looking at a toileting schedule, however the support surface, bed positioning etc. for R11 was not reviewed to determine if they are safe given R11's ongoing falls from bed. R11's 8/13/24 fall investigation documents R11 sustained an unwitnessed fall. On 8/13/24, at 7:49 am, R11 was found on the floor. The fall investigation indicates R11's blood pressure to be 212/112 post fall. The fall investigation indicates R11 was unable to state the reason for the fall. Environmental status at the time of the fall indicates R11's call light was within reach, the bed was locked as was R11's wheelchair. The immediate intervention post fall was to add anti-tip bars for wheelchair. Progress notes indicate R11 stated he was repositioning in his wheelchair and went backward, wheel not locked. The root cause of fall is resident was repositioning himself and did not lock his wheelchair. Surveyor noted the post fall report indicated R11's wheelchair was locked at the time of the fall. R11 was found to be unresponsive with a sternal rub. Staff called 911 and the resident was sent out for evaluation. Surveyor notes care plan changes to include: anti tip bars applied to the back of R11's wheelchair. R11 was transported to the hospital for evaluation and was noted to have a urinary tract infection (UTI). It is not documented if facility staff noted any symptoms of a UTI or change in continence needs/routine prior to fall as a pattern had not been completed. R11's 8/23/24 fall investigation which documents R11 sustained an unwitnessed fall. On 8/23/24, at 2:30 am. The post fall document indicates immediately post fall R11 was unable to explain why they thought they fell . Other is checked with the explanation R11 was going to empty urinal. R11 was found in the bathroom. The physical status of R11 prior to the fall indicates R11 had unsteady gait with confusion some of the time as R11's mental status pre and post fall. The Environmental status at the time of the fall indicates as checked: call light within reach, bed locked, wheelchair locked, nightlight on, incontinent products wet. The immediate intervention post fall was resident is encouraged to use call light for assistance. Surveyor noted this has been a consistent intervention for R11 however, R11 has not demonstrated consistency in being able to carry out this safety intervention. X-rays were completed on R11 and document R11 as having a left hip fracture. No surgical interventions were initiated. The fall investigation documents the root cause as R11 with inappropriate footwear and did not call for assistance. A pain assessment, post fall assessment, completed neuro checks, and a staff witness statements were included in the fall investigation. Surveyor notes care plan changes to include: R11 to wear non-skid socks at night. Surveyor noted the intervention to wear non-skid socks at night does not quite correlate with the fall itself. Surveyor noted it is uncertain if R11 started out in bed during the night and then self transferred to the wheelchair. The evaluation does not include when R11 was last toileted as a previous intervention on 7/27/24 was to toilet R11 every two hours. Was R11 being toileted or just being offered a urinal and when do staff follow up with R11 to empty the urinal to prevent R11 from addressing it himself. Progress notes dated 8/23/24 at 03:34 am document: writer and can (sic) heard yelling coming from residents (sic) room found lying on bathroom floor on L (left) side resident assisted to w/c (wheelchair) with two assist bp 166/78 p62 r18 t97.4 resident initially denied any c/o (complaint of) pain after in bed c/o L hip pain able to move L arm w/o (without) difficulty unable to (sic) L leg with limited rom (range of motion) (name of medical group) notified nor (new order) x-ray of L hip. Surveyor noted this was completed by a licensed practical nurse, there is no indication there was an RN assessment at the time of R11's fall. R11's 9/12/24 fall investigation documents R11 sustained an unwitnessed fall at 15:15 (3:15 pm). The post fall assessment indicates life safety measures in place prior to this current fall as being bed is low to ground. The assessment indicates R11 stated he fell asleep as the reason why R11 believed they fell . The assessment states R11 was last seen by the assistant director of nursing (ADON) and activity director but does not indicate a time last seen and the fall occurred in the dayroom/lounge. R11's mental status pre-fall is noted to be confused some of the time. The listed immediate intervention is resident on 15 minute checks. implemented on 9/12/24 at 15:30 (3:30 pm). The assessment indicates the care plan has not been updated. Further review of R11's post fall information indicates the root cause as R11 fell asleep in his wheelchair. Surveyor notes care plan changes to include: encourage R11 to lay down for a nap when feeling tired. Surveyor noted with the review of R11's falls there is no indication a pattern of the falls was considered to include whether they were related to R11's medical condition, impulsivity/lack of safety awareness. Surveyor noted increased supervision or assistance was not included as possible safety interventions until after R11's seventh fall. Surveyor reviewed R11's medical records which includes a Cardiology progress note dated 9/11/24. The cardiology progress note documents R11 having positive orthostatic hypotension, increase midodrine, wear compression stockings, measure orthostatic hypotension and repeat findings to the cardiology office, behavioral modification, and to follow up in 3 months. Surveyor notes R11 does not have compression stockings on his care plan. Surveyor reviewed R11's medical records which includes a Skilled Nursing Facility (SNF) Progress Note dated 6/17/24 by the facility Nurse Practitioner (NP). The SNF progress note documents R11 as being symptomatic with orthostatic hypotension with therapies. Blood pressure drops from 140s down to 110s/60's. R11 feels dizzy and fatigued after several minutes. R11 reports having difficulty completing therapies due to dizziness/fatigue. Amlodipine is discontinued. R11's SNF progress note dated 6/19/24 documents R11 is symptomatic and persists despite as needed midodrine providing some relief. Midodrine is scheduled twice daily and limiting R11's progress in therapies. R11's SNF progress note dated 6/24/24 documents R11 with a history of hypertension and amlodipine currently discontinued. R11 is symptomatic with a 70-point drop and 1 liter of Intravenous (IV) fluids is ordered. Midodrine is scheduled for three times daily. Abdominal binder and compression stockings are ordered. Consult cardiology next if orthostasis persists. Will allow permissive hypertension with R11's significant blood pressure drops. Continue to monitor blood pressures. Surveyor reviewed R11's Occupation Therapy (OT) note dated 7/29/24 which documents, the therapist placed clothing on the top shelf in the closet to increase R11's ability to problem solve how to retrieve items safely while sitting in his wheelchair with retrieving and placing out clothing for morning routine with decreased caregiver assistance. R11 was able to problem solve to use reacher, R11 did require cues to maneuver reacher in order to retrieve clothing with efficiency and good time management while staying sitting in his wheelchair to reduce fall risk due to fluctuation of blood pressure noted to increase with his ADL's. OT notes dated 7/31/24, document R11 reports having increased confusion lately, OT notified the floor nurse and rehab director. On 10/29/24, at 9:13 am, Surveyor interviewed R11 who reports having frequent falls with his most recent fall being in the bathroom about 6 weeks ago. R11 states he has had both hips replaced about [AGE] years ago and there was no surgical intervention with his most recent hip injury. Surveyor noted to R11 his socks and asked if he wears compression stockings or shoes. R11 states his socks are really slippery and will go across the room to get his shoes when he wants to get up or wheel around the facility. Surveyor observed a sign stating for assistance press call button over R11's bed and in R11's bathroom. Surveyor notes R11's commode being in the bathroom, grab bars on the toilet, a low bed with a grab bar on the left side (up against the wall), urinal out of reach across the room on the heat register, and reacher sticks across the room out of reach on top of his shoes which are under the register. R11 is laying in his bed with his wheelchair locked within reach. Surveyor observed R11's call light on his side table on the opposite side of the table that is out of reach. On 10/29/24, at 1:34 pm, Surveyor interviewed Certified Nursing Assistant (CNA)- M who reports R11 tries to do things himself. CNA- M states he gets woozy if he gets up too fast. CNA- M states staff stay in the room with R11 when performing cares. On 10/29/24, at 1:38 pm, Surveyor interviewed Licensed Practical Nurse (LPN)- N who states R11 is independent with transfers by using his wheelchair. LPN- N states R11 will get up independently with his wheelchair to use the restroom. LPN- N indicates R11 should call for help but most of the time he can do it on his own. LPN- N reports R11's falls are related to his dizziness and takes Midodrine for his blood pressures. LPN- N indicates R11's blood pressures fluctuate, and blood pressures are checked prior to giving medications. LPN- N states R11 gets disoriented early in the mornings and she will let him sleep more and/or have breakfast in his room if he is feeling disoriented in the morning. R11 will then be back to baseline around 7 - 7:30 am. LPN- N states R11's disorientation has improved with Tramadol changes. On 10/30/24, at 7:43 am, Surveyor interviewed Nursing Home Administrator (NHA)- A and Director of Nursing (DON)- B. Surveyor asked for additional information for R11's 8/13/24 fall where he was found unresponsive and required a sternal rub. NHA- A states she would have to pull up his fall investigation to answer the questions related to his falls. DON- B indicates R11 did not want to take anything for pain upon admission and the facility was treating his pain with non-pharmacological interventions. DON- B states R11 had medication changes and Tramadol was started after R11 sustained a hip fracture on 8/23/24 to help with therapies. DON- B states R11 has a lot of falls, and she was contacted by the facility on 8/13/24 after his fall. DON- B indicates R11 was able to identify his name after he came to. DON- B indicates he presents alert and oriented most times; however, in the middle of the night she is unsure what happens. DON- B reports R11's daughter states this happened at night prior to his admission into the facility. DON- B reports R11 having multiple falls prior to coming into the facility and the facility has talked a lot to see what they can do on nights to help prevent further falls. DON- B states every 2-hour toileting at night didn't work because staff would go into R11's room for cares and then he would get up right afterwards. DON- B gave an example of R11 getting up in the middle of the night to empty his urinal and his urinal would have no urine in it. NHA- A then stated she is unsure if R11 is independent with getting his shoes on himself, but states R11 is independent with self-propelling throughout the facility. Surveyor notified NHA- A and DON- B with concerns of the facility not completing a comprehensive assessment to determine a root cause for each fall, reassessment of interventions to determine if they were effective, and completing accurate assessments taking into account R11's individualized patterns and needs. On 10/30/24, at 1:07 pm, NHA- A, DON- B, Director of Therapy (DOT)- O, and Clinical Operations Specialist- C requested to speak with Surveyor. DON- B states therapy helps with monitoring of R11's blood pressures and therapy documentation was not included in R11's root cause for his falls. NHA- A states R11 has had medication changes with Amlodipine and Midodrine and the facility has worked closely with the cardiologist to help manage his medications. NHA- A states each fall R11 has had has been different and R11 is not completing the same task with each fall. DOT- O indicates R11 wears shoes during the day and will self-propel throughout the facility. The facility will encourage gripper socks at night and therapy educates R11 with using his reacher as he has a hard time bending down due to his blood pressure changes. NHA- A states compression stockings were initiated during the daytime hours for blood pressure concerns and gripper socks were initiated for nighttime. The facility provided Surveyor a verbal description of R11's 8/13/24 fall that required a sternal rub. R11 was found laying on his back with his eyes open and verbally responded with his name after a second sternal rub. R11 was unable to state his location but expressed his frustration that he fell at the time of the fall. On 10/30/24, at 1:56 pm, DON- B provided Surveyor a staff statement from R11's fall on 8/13/24. Surveyor asked when this staff statement was obtained and DON- B states it was obtained on 10/30/24 after the DON- B had asked the staff member to provide a statement. Surveyor noted the facility did not complete an individualized assessment of R11's fall risks to develop a comprehensive plan of care to ensure safety and prevent injury. R11 has risk factors that include medical and behavioral/safety components that were not assessed together for an individualized plan for R11. Following the survey, the facility provided additional information to review regarding R11's falls to show R11's falls and the resulting injury did not cause harm to R11. This information was reviewed as part of the investigation. 21855 2.) On 10/28/24, at 8:47 AM, Surveyor observed R34 in their bed. R34 had bilateral body pillows in bed and no fall mats on the floor. On 10/28/24, at 3:37 PM, Surveyor observed R34 in their bed. R34 had bilateral body pillows in bed and no fall mats on the floor. On 10/29/24, at 7:37 AM, Surveyor observed R34 in their bed. R34 had bilateral body pillows in bed and no fall mats on the floor. R34's plan of care for High Risk for Falls initiated 10/19/23 documents an identified fall on 4/5/24 with an intervention implemented for floor mats while in bed. The fall mats were not observed on the floor during the survey for R34. On 10/29/24, at 10:56 AM, Surveyor interviewed (Registered Nurse) RN-G. RN-G is assigned to work on the unit R34 resides on. RN-G stated R34 has not had any floor mats since moving to this unit. RN-G stated Administration revises the plan of care. Surveyor shared R34's plan of care documents the need for floor mats. RN-G stated (R34) was on a different unit and does not get out of bed. RN-G stated they thought the floor mats were discontinued with the bilateral bed bolsters. R34 transferred to the current unit on 8/17/24 and the bed bolsters were implemented on 4/16/24 and revised as appropriate on 8/7/24. RN-G did not have any additional information regarding the floor mats. On 10/29/24, at 3:32 PM, Surveyor interviewed the (Director of Nurses) DON-B. DON-B stated the floor mats were for extra protection. The DON-B was not aware of the floor mats being discontinued. On 10/30/24, at 9:02 AM, DON-B spoke with Surveyor. DON-B stated, when R34 switched units, the floor mats did not go with R34. The DON-B observed R34 last night in bed. The DON-B discontinued the floor mats from the plan of care at this time.

Based on observation, interview and record review the facility did not provide quality of care according to professional standards of practice for 2 (R27 and R19) of 12 residents reviewed for quality of care. *The facility did not implement interventions for R19's toe wounds. R19 did not have a care plan addressing the wounds, nor was the care plan revised when the wounds worsened. The wound to R19's third toe became infected and would not heal. R19 ultimately required an above the knee amputation related to the unhealing wound to the third toe. *R27 was receiving hospice care and did not have a hospice care plan nor a physician's order for hospice. Findings include: 1.) R19 was admitted to the facility on [DATE] with diagnoses including: Peripheral Vascular Disease and Congestive Heart Failure. R19 had current diagnoses including: Hemiplegia and Hemiparesis Following Cerebral Infraction Affecting Left Non-Dominant Side and Acquired Absence of The Left Leg Above the Knee. R19's quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 14, indicating R19 was cognitively intact and R19 required extensive assist for transfers and dressing. R19's quarterly MDS dated ,d+[DATE] documented no venous/arterial ulcers. R19's 12/2022 annual MDS assessment documents no venous/arterial ulcers, but yes to diabetic ulcers. R19's 3/25/23 quarterly MDS assessments documented three venous/arterial ulcers. R19's care plan initiated 07/26/23, documented, The resident has potential/actual impairment to skin integrity r/t (related to) hx (history) of cellulitis, and self-infected areas d/t (due to) picking and scratching own skin, and has interventions including, Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short; Encourage good nutrition and hydration in order to promote healthier skin; Medications as ordered and Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Surveyor did not note any other skin care plan for R19 in R19's EMR (Electronic Medical Record.) On 09/10/23 at 12:05 PM, Surveyor observed R19 sitting upright in their wheelchair in their room. R19 had their right leg resting on a wedge type pillow that was set on the outstretched leg rests of R19's high back wheelchair. Surveyor noted R19 did not have a leg below the left knee. R19 informed Surveyor they had to get their leg amputated after being in a car accident. R19 also told Surveyor they never had any wounds. Surveyor noted through R19's record review that neither of those statements by R19 were accurate. R19 has had multiple wounds in the past and had their leg amputated related to unhealing wounds. Surveyor reviewed R19's EMR and noted on 12/12/22 wound physician (WP)-K documented in a wound evaluation and management form, Non-pressure wound of the left first toe full thickness d/t (due to) trauma/injury-Objective goal: healing, abrasion from patient bumping 5 cm (centimeters) x 5 cm x 0.1 cm moderate serous drainage; 30% granulation/70% skin. WP-K also documented on 12/12/22, Non-pressure wound of the left third toe partial thickness due to trauma/injury; objective: healing, abrasion 1 cm x 0.5 cm x `non-measurable depth, dried fibrinious exudate (scab). Surveyor could not locate documentation prior to 12/12/22 regarding the wounds to R19's left third toe and left great toe. At this time, treatment orders were put in to R19's EMR. However, R19's care plan was not revised to reflect these wounds and Surveyor could not locate documentation explaining what the trauma/injury was that contributed to these wounds, nor what interventions the facility implemented to prevent the trauma/injury from happening again. The facility continued to assess these two wounds on a weekly basis. On 12/21/2022, a wound care note documented, During wound rounds on this date writer noted that the resident LLE (left lower extremity) great toe is fiery red warm to touch wound Dr. (doctor) called writer received new orders 1) start resident on doxycycline 100 mg BID (twice a day) x 14/days and probiotic for 30 days daily. Writer called emergency contact (family member) awaiting return call for update. Writer also called RN (Registered Nurse) case work and awaiting her return call as well for update will continue to monitor. Surveyor noted orders for Doxycycline were added to R19's physician's orders. R19's care plan was not revised to reflect the infection and no new interventions, besides the antibiotics, were added to prevent infection. On 12/26/23 the necrotic tissue to the third toe wound is removed by WP-K. On 12/30/22 the resident had a Doppler of the LLE performed which showed PVD (Peripheral Vascular Disease) with mild to moderate stenosis within the mid and distal femoral artery regions and decreased runoff to the foot; negative for occlusion. The great toe wound improves according to the weekly assessments with the last assessment being on 4/3/23 with measurements of 0.3 x 0.3 x 0.1 100% granulation. Throughout January the third toe measurements remain 1 x 1 x 0.1 with 80% slough and 20% granulation. On 2/2/23 R19 saw Medical Doctor (MD)-M on referral from WP-K related to the Doppler results. MD-M recommended an above the knee amputation due to R19's non-ambulatory status. Per MD-M's note, R19 initially refused the amputation and per MD-M's notes that was okay because R19 did not have an infection in those wounds. On 2/6/22 the third toe wound assessment documents 1 cm x 1 cm x 0.1 cm with 70% slough and 30% granulation-improved. On 2/13/23 the wound assessment documents 1 cm x 1 cm x 0.1 cm with 50% slough, 50% bone. Surveyor noted this is the first documentation of bone being exposed. From 2/13/23 until 3/20/23, R19's left toe measurements remain the same: 1 x 1 x 0.1 with 50% slough and 50% bone. On 3/20 the measurement changed to 2 cm x 1.5 cm x 0.1 cm. WP-K documented: wound to third toe deteriorated due to patient being non-compliant with wound care and worsen secondary to trauma from dragging, slipping down chair. From 2/13/23 to 03/20/23 Surveyor did not notice any missed treatments, per R19's EMAR (electronic medication administration record). Surveyor noted one documented treatment refusal during this time. Surveyor noted a physician's order mentioning refusals of care related to behavior monitoring for psychiatric mediations. This order appeared every shift and between February and March was only documented yes four times. Surveyor could not locate documentation by the facility that R19 was refusing wound care treatments nor education given to R19 related to non-compliance. Surveyor could not locate any documentation by the facility regarding R19's foot dragging or R19 slipping down in their chair or what the facility may have done to prevent the dragging or slipping. On 3/14/2023 an x-ray was done on the left toes which documented no acute osseous finding and to repeat imaging if wounds progress. On 3/20/2023 Surveyor noted the following documented in progress notes, Weekly wound rounds competed by writer and [WP-K] Writer spoke with therapy department regarding the resident getting a w/c (wheel chair) that fits as [R19] has a cast and feet sometimes drag [sic] the floor. Therapy stated [R19's] adaptive equipment is on ordered. a Vascular consult order obtained and endorsed to [NAME] to schedule it. Writer informed resident to please wait for staff to help transport [R19] until is [sic] equipment arrives . Surveyor notes this is the first documentation by the facility staff mentioning R19's feet dragging and what interventions the facility was doing: getting a new wheelchair. Surveyor noted this documentation was in March 2023 and R19 acquired the toe wounds in November 2022. On 03/23/2023, R19 saw MD-M again. MD-M recommended an above the knee amputation related to the wounds not healing. MD-M documented R19 had clinical osteomyelitis and started R19 on Augmentin; however Surveyor noted at this time R19 was already receiving Clindamycin related to a wound culture of the left third toe that was positive for staph on 3/20/23. Surveyor noted the following orders in R19's physician's orders: Clindamycin HCl Oral Capsule 300 MG (Clindamycin HCl); Give 300 mg by mouth every 8 hours for Cellulitis left Foot; start date of 3/16/2023 and discontinued date of 3/22/2023 Clindamycin HCl (Hydrochloride) Oral Capsule 300 MG (milligrams); Give 300 mg by mouth every 8 hours for Cellulitis left Foot for 10 Days: start date of 3/22/2023 and end date of 4/1/2023 Augmentin Oral Tablet 875-125 MG (Amoxicillin & Pot Clavulanate), Give 1 tablet by mouth two times a day for osteomyelitis for 14 Days start date of 3/23/2023 and end date of 4/6/2023. Surveyor could not locate documentation R19 was or was not supposed to be receiving both Clindamycin and Augmentin at the same time. On 4/3/23, the last measurements of R19's left third toe wound were 1.5 cm x 1.5 cm x 0.1 cm with 50% slough and 50% bone. R19 had the above the knee amputation on 4/7/23. On 09/12/23 at 9:07 AM, Surveyor interviewed Occupational Therapist (OT)-O. Per OT-O, the therapy company she works for started in the facility in February 2023. OT-O informed Surveyor she remembered being asked about R19's positioning in their wheelchair. OT-O stated the CNAs needed education to put R19 in their wheelchair straight and not crooked. OT-O thought that happened in May 2023. Surveyor asked about any therapy prior to the amputation in April. Per OT-O she did not think therapy saw R19 prior to the amputation, but she stated the old therapy department might have seen R19, however, she did not have access to those documents. OT-O stated she would ask the physical therapist when he came into work and get back to Surveyor if she had any additional information on R19. On 09/12/23 at 9:16 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-N. Per CNA-N she started after R19 had the amputation and did not know anything prior to the amputation. On 09/12/23 at 10:59 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-F. Per LPN-F she could not recall any information regarding R19's left toe wounds. LPN-F was unaware of R19 dragging their foot and did not have any information on the wounds. On 09/12/23 at 12:03 PM, Surveyor interviewed WP-K via phone. Surveyor asked WP-K how he was informed of R19's wounds to the left foot. Per WP-K he could not remember if he found those wounds during wound rounds (R19 had other wounds WP-K was assessing) or if the facility told him about the wounds. Per WP-K most of R19's wounds were from trauma because R19 would propel self in the wheelchair. WP-K stated he could not remember what the dragging/slipping from the chair entailed. Per WP-K he did not witness that behavior, but staff told him. Per WP-K, R19 would remove the wound dressings and R19's room was not the cleanest and R19 was resistive to cares. WP-K stated due to the bone exposure to the left third toe R19 was referred to vascular surgery for a toe amputation. WP-K was uncertain why they did the whole leg, but informed Surveyor it was most likely related to R19's vascular status. Per WP-K, he could not heal R19's third toe wound due to R19's non-compliance and R19's medical status. WP-K informed Surveyor it was a combination of R19's non-compliance and vascular status, however, per WP-K, R19's non-compliance was a big issue at the beginning of the left toe wounds. WP-K stated he only knew R19 would refuse staff assistance at times, but was unaware of what the facility would did to address the non-compliance. On 09/12/23 1:52 PM, surveyor interviewed wound Licensed Practical Nurse (LPN)-C. Per LPN-C, she thought R19 had the toe wounds prior to 12/12/22. Surveyor asked for documentation regarding when the facility was aware of the wounds to R19's left toes. LPN-C stated R19 would drag the foot on the ground and R19's left foot would fall off of the wheelchair. Surveyor asked what did the facility do to help keep R19's foot on the wheelchair? Per LPN-C, staff would put the foot back on the wheelchair. LPN-C stated R19 would propel self in the wheelchair, but LPN-C stated she was unsure if the wounds occurred from self-propelling. Surveyor informed LPN-C, WP-K was documenting R19's toe wounds were from trauma/slipping/dragging. Surveyor asked LPN-C what was trauma and what did the facility do to address the trauma? Per LPN-C WP-K is always assessing wounds as trauma, for instance a skin tear would be classified as trauma. Surveyor asked LPN-C if a resident received a skin tear from trauma would the facility assess how the skin tear occurred and put interventions in place to prevent it from happening again? LPN-C stated R19's wound were venous and R19 had the amputation due to vascular status. Surveyor asked LPN-C why there was not a care plan addressing R19's toe wounds? Per LPN-C, since R19 had the amputation the wounds were gone and why should there be a care plan if R19 no longer has the wounds? Surveyor informed LPN-C the care plan may have been revised but Surveyor should still be able to see the care plan and what the facility did to address R19's left toe wounds which occurred from trauma. Surveyor asked why R19 was put on Doxycycline twice for left toe infections? Surveyor asked LPN-C what interventions the facility put in place when the toe wound first became infected in December? Per LPN-C she did not prescribe the medication and she was unaware why R19 was on the same antibiotic twice. LPN-C stated we started R19 on the antibiotic, that was the intervention for the infection. Surveyor asked LPN-C if R19 was supposed to be receiving both Augmentin and Clindamycin at the same time when R19 was diagnosed with osteomyelitis? Per LPN-C, one of those antibiotics was discontinued. Surveyor informed LPN-C the Clindamycin was on R19's EMAR from 3/16/23 to 4/1/23 and the Augmentin was on R19's EMAR from 03/23/23 to 04/6/23. Surveyor asked for any additional information regarding R19's two wounds to the left toes: when was the facility aware of the wounds, what did the facility do when they were made aware of the wounds, what additional interventions were put in place as the wounds deteriorated and was R19's non-compliance documented anywhere and what did the facility do related to R19's non-compliance? Per LPN-C the facility did get R19 a new wheelchair, but that therapy company was no longer at the facility. LPN-C stated she would look into Surveyor's concerns. On 09/12/23 at 3:08 PM, during the end of the day meeting with Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A, Surveyor relayed the above concerns regarding R19's wounds to the left toes. Surveyor asked for any documentation relating to those wounds including previous care plans, interventions, and when the facility was made aware of the wounds. Surveyor relayed the concern of a lack of documentation related to the trauma that caused the wounds, R19's non-compliant behavior and what the facility did to address the non-compliance and overall lack of documentation regarding R19's left toe wounds. On 09/13/23 at 8:35 AM, NHA-A informed Surveyor she was trying to get access to their previous wound documentation system and was not able to get access, however; NHA-A stated she was able to get R19's previous care plan. NHA-A gave Surveyor a copy of R19's previous care plan which did not carry over when the facility changed ownership. This care plan, date initiated 04/13/2022, documented, The resident has actual impairment to skin integrity evidenced by actual wound to left (shin) resolved 6/20/22 and reoccurred injury from fragile skin lymphedema. Left shin reopened 7/11/22 .Left forearm resolved; Groin; Left knee; Left great toe; right forth toe; and right fifth toe. Surveyor noted the revised date on this care plan was 12/30/22, however there were no interventions added or revised after 08/26/2022. The two wounds to R19's left toes are first documented on 12/12/2022. On 09/13/23 at 8:54 AM, Surveyor spoke with MD-M via the phone. MD-M stated R19 had the above the knee amputation related to non-healing wounds and non-ambulatory status. Per MD-M, the third toe wound became progressively worse and had an infection. Surveyor asked if the wounds did not heal due to R19's vascular status. Per MD-M it was mutli-factoral: R19's vascular status played a part in the wounds not healing but it was not just vascular. MD-M did not have additional information for Surveyor. On 09/13/23 at 9:45 AM, Surveyor interviewed LPN-C. LPN-C informed Surveyor for a time R19 had a cast to the right leg and she was pretty sure R19 would wear a regular shoe on the left foot. Surveyor asked if R19 was non-compliant with wound care or other aspects of care. Per LPN-C, R19 was non-compliant with going outside to smoke and R19 would propel self. LPN-C did not have any additional information on R19 being non-compliant. Per LPN-C the facility gave R19 a new chair but was uncertain when that was. On 09/13/23, throughout the day, NHA-A provided Surveyor with numerous documents relating to R19 including: Three skin impairment documentation forms dated 03/07/23; 03/20/23 and 4/3/23. On 03/07/23 the wound education included resident encouraged to ask for assistance for repositioning to prevent further trauma. On 03/20/23 the wound documentation included a consult with therapy for a chair that fits and on 04/07/23 the wound education included continue with bilateral Prevalon boots and increased nutrition. Surveyor noted the mention of the Prevalon boots on 4/7/23 was the first time there was any documentation regarding R19 wearing something on their feet. Surveyor could not locate an order for the Prevalon boots nor were the Prevalon boots on the CNA kardex or R19's care plan. Surveyor also received multiple physical therapy notes which document R19 started seeing therapy on 01/09/23 related to hips sliding forward in chair and right lateral trunk lean in current wheelchair; 2/7/23 therapy documentation stated R19 has been trialing a high back wheelchair; and 3/31/23 documentation included new positioning aids applied to wheelchair on this date: lateral trunk supports and foot rest extender. Surveyor noted per documentation the facility was made aware of R19's toe wounds on 12/12/23 and R19 did not start therapy until 01/09/23. Surveyor was not given information on interventions put in place by the facility between 12/12/23 and 01/09/23, besides R19 being seen by WP-K and having treatments in place. On 09/13/23 at 1:00 PM, Surveyor interviewed NHA-A and DON-B. Surveyor relayed still having concerns regarding the wounds to R19's left toes including a lack of documentation related to the trauma that caused the wounds, lack of documented facility initiated interventions upon notification of the wounds, and lack of new/revised interventions when the wounds became infected/deteriorated. Surveyor asked for any additional information the facility may have including information regarding the multiple antibiotics R19 was taking related to the osteomyelitis. No additional information was given prior to Survey exit. 20483 2.) R27 diagnoses includes cerebrovascular disease, congestive heart failure, protein calorie malnutrition, hypertension and depressive disorder. R27's power of attorney was activated on 4/22/20. R27 was admitted to hospice on 4/21/23. The quarterly MDS (minimum data set) with an assessment reference date of 8/2/23 has a BIMS (brief interview mental status score) of 2 which indicates severe cognitive impairment. Yes is check for hospice. On 9/13/23 at 8:57 a.m. Surveyor reviewed R27's current physician orders and was unable to locate an order for hospice care. Surveyor reviewed R27's care plans and noted the following care plans: * Self care deficit. Initiated 4/14/22 & revised 5/20/23. * Activities. Initiated 6/1/22 & revised 12/20/22. * Advanced Directives. Initiated 6/13/22 & revised 6/29/22. * Musculoskeletal. Initiated 9/12/22 & revised 5/20/23. * Behavior problem. Initiated 7/20/2022 & revised 5/20/23. * Diastolic Congestive Heart Failure. Initiated 6/14/22 & revised /20/23. * Hypertension. Initiated 6/14/22 & revised 5/20/23. * Cognitive function/dementia or impaired thought process. Initiated 6/14/22 & revised 5/20/23. * Hypothyroidism. Initiated & revised 8/5/22. * Altered endocrine status. Initiated & revised 8/5/22. * Falls Initiated 4/26/222 & revised 5/20/23. * Bowel incontinence. Initiated 6/14/22 & revised 5/20/23. * GERD (gastroesophageal reflux disease). Initiated & revised 8/5/22. * Constipation. Initiated 8/5/22 & revised 5/20/23. * Anemia. Initiated 6/14/22 & revised 5/20/23. * Alteration in hematological status. Initiated 8/5/22 & revised 5/20/23. * Is on pain medication therapy. Initiated & revised 6/14/22. * Anti-anxiety medications. Initiated & revised 7/10/22. * Osteoporosis. Initiated 8/5/22 & 5/20/23. * Osteoarthritis. Initiated 8/5/22 & revised 5/20/23. * Alteration in musculoskeletal. Initiated 8/5/22 & revised 5/20/23. * Mild depression. Initiated 6/14/22 & revised 5/20/23. * Nutritional problem or potential nutritional problem. Initiated & revised 3/3/22. * At risk for acute/chronic pain. Initiated 4/20/22 & revised 5/20/23. * Potential for pressure ulcer development or pressure wound. Initiated 4/20/22 & revised 5/20/23. * Potential for impairment to skin integrity. Initiated 6/27/22 & revised 5/22/23. * Mixed bladder incontinence. Initiated 6/14/22 & revised 5/20/23. * Asthma. Initiated 6/14/22 & revised 5/20/23. * Diagnosis of COPD (chronic obstructive pulmonary disease). Initiated 8/5/22 & revised 5/20/23. Surveyor noted the Facility did not develop a hospice care plan after R27 was admitted to hospice on 4/21/23. On 9/13/23 at 10:56 a.m. Surveyor asked SSD (Social Service Director)-E if she is involved with hospice program at the Facility. SSD-E informed Surveyor DON (Director of Nursing)-B starts hospice here and the nursing staff gets the hospice orders. SSD-E informed Surveyor she doesn't sign any residents up for hospice and if a family is interested in hospice does have information on [name of hospice] but the facility has been working with [hospice company. SSD-E informed Surveyor at her prior place of employment she was involved with hospice but here it is the nursing staff. On 9/13/23 at 11:00 a.m. Surveyor asked DON-B about hospice at the Facility. DON-B explained they look at Residents to see if they are a hospice candidate, speak with the family, reach out to hospice for them to evaluate the resident and that hospice makes the final decision. DON-B explained a Resident may be placed on hospice if they are losing weight or have a terminal condition. Surveyor inquired who would obtain hospice orders. DON-B explained they would get orders for hospice to evaluate & treat. If hospice picks up a Resident then the doctor will write an order for hospice. Surveyor inquired who develops the hospice care plan. DON-B informed Surveyor they all work together & they call hospice for an admitting diagnosis. Surveyor inquired who coordinates with hospice. DON-B informed Surveyor they work as a team. Surveyor informed DON-B Surveyor was unable to locate hospice orders or a hospice care plan . DON-B informed Surveyor R27 should definitely has a hospice care plan. DON-B then looked at R27's electronic medical record. Surveyor asked DON-B if she saw a hospice care plan. DON-B informed Surveyor she didn't and stated we do those right away.

Based on observation, interview, and record review, the facility did not ensure 3 (R47, R36, R23) of 4 residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease. * R47 was admitted to the facility without functional limitations/extensive contractures. According to the quarterly Minimum Data Set (MDS) dated [DATE] R47 developed functional limitations of bilateral lower extremities within 3 months of admission and on 9/21/21, within 6 months of admission, the quarterly MDS indicates functional limitations to both the upper and lower extremities. R47 did not have a care plan addressing the facility acquired contracures or a program for range of motion to prevent the decline in R47's functional abilities. * R36 had right hand contracture with no interventions. * R23 had a right hand contracture observed without splint/washcloth. Findings include: The facility policy, entitled Active and Passive ROM (Range of Motions), dated 6/2015, revised 8/2021, states ROM is performed on any resident who has a functional limitation or loss of voluntary movement to an extremity as determined by assessment. A functional assessment is completed for all residents upon admission, quarterly, and with significant change. The Restorative Director initiates a program and develops a care plan; will document progress and update the care plan on a quarterly basis. R47 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R47's Annual MDS (Minimum Data Set) assessment dated , 5/17/22 indicated R47 was severely cognitively impaired with extensive assistance with 2 staff for bed mobility, transfer, toileting and total dependence for eating-(GT feedings through artificial opening). R47's functional limitation was indicated for bilateral upper and lower extremities. On 6/13/22, at 9:33 AM, Surveyor observed R47 resting in bed on left side, with an air mattress, respiratory ventilator dependent with bilateral knees bent and contracted with arms bent at the elbows. On 6/14/22, at 7:55 AM, Surveyor observed R47 resting in bed, repositioned & changed by staff with knees bent and contracted, arms straight with crooked fingers. On 6/14/22, at 12:17 PM, Surveyor observed R47 has been repositioned with knees bent and contracted. *Surveyor reviewed R47's MDS functional limitation documentation since admission. R47'S 3/23/21 Admission MDS indicated a severe cognitive impairment with no functional limitation. R47's 6/21/21 Quarterly MDS indicated a functional limitation of bilateral lower extremities. R47's 9/21/21 Quarterly MDS indicated a functional limitation of bilateral upper extremities and bilateral lower extremities. R47's 12/28/21 Quarterly MDS indicated a functional limitation of bilateral upper extremities and bilateral lower extremities. R47's 3/30/22 Quarterly MDS indicated no assessment of functional limitations. *Surveyor noted R47 developed functional limitations in bilateral lower extremities in the first 3 months after admission. *Surveyor noted R47 developed functional limitations in both bilateral lower extremities and bilateral upper extremities in the first 6 months after admission. *Surveyor noted R47 did not have a care plan addressing facility acquired contractures or a program for ROM. On 6/14/22, at 3:30 PM, Survey Team shared concerns during daily exit regarding contractures/restorative/ROM concerns. On 6/15/22, at 7:45 AM, the facility provided R47's updated care plan to the Surveyor dated 6/14/22. R47's care plan indicated R47 has limited physical mobility related to contractures with goal free of complications related to immobility including contractures, thrombus formation, skin breakdown, fall related injury. Interventions: Monitor/document/report as needed any increased signs of immobility, contractures forming or worsening, thrombus formation, skin breakdown, fall related injury. Provide supportive care, assistance with mobility as needed, Document assistance as needed. PT/OT referrals as ordered and needed. 6/14/22. On 6/15/22, at 2:29 PM, the Survey Team requested if facility has anything else regarding R47's facility acquired contractures. On 6/20/22, the Survey Team conducted the facility exit and the facility did not provide any further information regarding R47's facility acquired contractures. On 6/30/22, the facility sent a statement dated 6/23/2022 signed by Medical Director-EE which stated, Regarding the contractures. People who develop spastic [CONDITION(S)] inevitably end up developing contractures overtime. They are an unavoidable result associated with neurologic injury. Surveyor noted while contractures overtime may be inevitable, R47 was not provided with care planned interventions, and restorative services such range of (ROM), splints, etc. to decrease the severity of functional limitations/contractures and to maintain as much function as possible. 2. R36 admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R36's Admission Minimum Data Set (MDS) with an Annual Reference Date (ARD) of 2/2/22 section G0400 documents: Functional Limitation in Range of Motion Upper extremity (shoulder, elbow, wrist, hand) - Impairment on one side. R36's Quarterly MDS with an ARD of 5/18/22 section G0110 documents: Activities of Daily Living (ADL) Assistance Personal hygiene - how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers) as extensive 1 person physical assist. Section G0400 documents: Functional Limitation in Range of Motion - Upper extremity (shoulder, elbow, wrist, hand) as no impairment. R36 did not have a Care Plan for contractures. On 6/13/22 at 9:50 AM during initial interview with R36, Surveyor observed R36's right hand to be contracted. Surveyor noted R36's nails on his right hand to be long, thick and discolored. R36's pinky finger was bent and turned in and Surveyor was unable to see the nail without R36 using his other hand to pull it away from his palm. Surveyor observed a napkin in the palm of his right hand, which appeared to be old as evidenced by a brown area in the center of the napkin near his fingers. R36 reported his fingers are tight and he hasn't been able to move them much anymore for a pretty long time, so he puts a napkin in his hand. R36 reported he does not have, nor has he ever had a palm protector or splint for his right hand. R36 reported no open sores in the palm of his hand. On 6/14/22 at 1:40 PM Surveyor spoke with R36 and asked about his nails. R36 stated: No, they haven't cut 'em yet, but they need to. Surveyor noted the nails on his right hand remained long, thick and discolored. R36 reported he changed the napkin in his palm to a new one today, however Surveyor noted the same napkin as previous day as evidenced by the same brown spot in the center of the napkin. Surveyor asked R36 how long his right hand has been contracted, to which he replied: A pretty long time. Surveyor asked if his hand was contracted before he admitted to the facility, to which R36 stated: Oh yeah, it's been awhile. Surveyor was able to visualize R36's palm under the napkin - no open areas or skin breakdown was observed. On 6/14/22 at 1:45 PM Surveyor spoke with Certified Nursing Assistant (CNA)-Z who reported having worked on R36's unit for about 3 months. CNA-Z reported R36 has never had a palm protector that she knows of. He likes to hold the napkin, so whenever I bathe him, he gets a new one. On 6/15/22 at 9:10 AM Surveyor spoke with Rehab Director-BB who reported the new company (Select Rehab) started in May 2022. Rehab Director-DD stated R36 has not been seen in therapy since the new company started. Rehab Director-BB reported she was not aware of R36's right hand contracture and no one has brought it to therapy's attention for the need for a palm protector or splint. Surveyor was unable to review previous therapy notes. On 6/15/22 at 9:40 AM Surveyor noted R36's nails remained unchanged and the same napkin was in the palm of his right hand. On 6/15/22 at 9:40 AM Surveyor spoke with Licensed Practical Nurse (LPN)-AA. Surveyor advised LPN-AA of R36 using a napkin to protect his palm due to long nails on his contracted right hand. LPN-AA reported she was not aware if R36 ever had a palm protector or splint. On 6/15/22 at 10:35 AM Surveyor advised Director of Nursing (DON)-B of concern regarding R36's contracted right hand. Surveyor advised of R36 long, thick nails and his use of a napkin to protect his palm. DON-B was unable to provide an explanation of why R36's contracture was not care planned or why he was not provided a palm protector or splint to prevent further contracture. DON-B was unable to obtain documentation of previous therapy to determine R36 received therapy to prevent further contracture. DON-B was unable to provide evidence R36's right hand contracture had not worsened since admission or that R36 received treatment and services to increase range of motion and/or to prevent further decrease in range of motion. No additional information was provided. 3. R23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R23's Admission MDS dated [DATE], does not document a BIMS (Brief interview for Mental Status) score for R23. No CAAs (Care Area Assessments) were completed for R23's Admission MDS dated [DATE]. Surveyor reviewed R23's CNA care card. Surveyor noted the following directions: .will require assistance with the use of her right hand using a rolled material in the palm as recommended. On 6/13/22 at 1:25 PM, R23 was observed lying in bed. R23 was noted with a right hand contracture. No splint or positioning device was noted related to R23's right upper extremity. On 6/13/22 at 3:45 PM, R23 was observed lying in bed. R23 was noted with a right hand contracture. No splint or positioning device was noted related to R23's right upper extremity. On 6/14/22 at 10:25 AM, R23 was observed lying in bed. R23 was noted with a right hand contracture. No splint or positioning device was noted related to R23's right upper extremity. On 6/14/22 at 1:35 PM, R23 was observed lying in bed. R23 was noted with a right hand contracture. No splint or positioning device was noted related to R23's right upper extremity. On 6/14/22 at 11:35 AM, Surveyor conducted interview with Medication Technician-D, who is currently working in the role of a CNA (Certified Nursing Assistant). Surveyor asked Medication Technician-D how staff would know what types of interventions are in place for residents with contractures. Medication Technician-D told Surveyor that each resident should have a care card to which informs staff how to provide care for residents. On 6/16/22 at 2:30 PM, Surveyor shared concerns with NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B related to observations of R23's right contracted hand noted without a rolled material applied to their palm on 6/13/22 and 6/14/22. The facility did not provide any additional information to Surveyor at this time.

Based on observation, interview and record review, the facility did not ensure 1 (R8 ) of 4 residents reviewed had an environment free from accident hazards and adequate supervision provided to prevent accidents. R8 sustained a fall from his wheelchair while attempting to return inside from the facility smoking area. R8 was hospitalized from 4/14/22-4/20/22 related to a right [CONDITION(S)] and multiple rib fractures related to the fall. R8 was not assessed for safety prior to the incident.The facility's fall investigation did not identify a root cause of the fall and did not implement interventions to prevent future falls. R8 has a history of unsafe practices when smoking including smoking in his resident room. Findings include: The facility's policy, entitled Facility Smoking Safety Policy, dated April 2020, states: To provide a safe and healthy living environment with respect for the health and well-being needs of each resident, staff member and visitor. In this effort, all residents will be supervised by staff while smoking in the designated smoking areas at designated smoking times. The times will be implemented at the discretion of the facility. It is also the objective of this policy to communicate to each resident their role and responsibility in following the rules outlined in this policy and ongoing compliance with this policy. Guidelines: . #2. Smoking is only allowed in designated areas established by the facility. The organization reserves the right to enforce a policy prohibiting resident from keeping any smoking materials in his/her possession for health, safety, and security reasons. #3. Individuals who are non-compliant, exercise poor judgment and show a lack of concern for the welfare of others will be counseled accordingly. Continued behavior at this level may result in a 30-day discharge. #6. It is against facility policy to carry a lighter (and other smoking materials i.e. cigarettes, tobacco, etc.) we are a lighter free facility. Being caught in possession with a lighter and/or cigarettes/smoking materials will be considered a violation of the policy and consequences will be reviewed on an individual basis. The following behaviors will jeopardize independent smoking privileges and alert for safe smoking re-assessment #1. Smoking in any non-designated area, such as a resident room, bathroom, hallways, elevators, stairways and/or a smoke free courtyard. The facility policy, entitled Fall Prevention and Management, revised on 10/2018, states: This facility is committed to maximizing each resident's physical, mental and psychosocial wellbeing. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for prevention strategies and facilitates as safe environment as possible. Guideline: Upon Admission: #1. A fall risk evaluation will be completed on admission, readmission, quarterly, significant change and after each fall. Facility Guideline following a fall incident: . #4. Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence. R8 was admitted to the facility on [DATE], and has diagnoses that include [CONDITION(S)], chronic pain, [CONDITION(S)], [CONDITION(S)] and acquired absence of right leg above the knee. R8's Minimum Data Set (MDS) assessment, dated 4/7/22 documents: Section C: Cognitive Patterns is left blank, but a previous Quarterly MDS dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 15 indicating R8 is cognitively intact for daily decision making. Section J: Personal Hygiene documents R8 requires extensive assistance for maintaining personal hygiene and one-person physical assist. On 6/14/22, at 11:18 AM, Surveyor reviewed R8's care plan dated 4/27/22. A care plan related to R8's smoking documents: Intervention include that (R8) will be encouraged to be compliant with supervised smoking and be free from injury; To inform [Resident's Name] of scheduled smoking times to encourage compliance; Keep smoking paraphernalia in a safe location away from the resident until scheduled smoking times; [Name of Resident] to be supervised by assigned staff at all times during smoking activity. Surveyor was unable to locate a fall risk assessment prior to the R8's fall on 4/14/22. R8's medical records indicate the last fall risk assessment was completed on 3/30/21. On 4/26/22, R8's fall prevention care plan was updated as R8 was assessed to be at high risk for falls as evidenced by MORSE FALL RISK Score of 60 r/t (related to) Deconditioning, Gait/balance problems, Unaware of safety needs. On 4/26/22, R8's care plan was updated to include information related to R8's fall on 4/14/22 outside while in the smoking area. R8's care plan documents R8 experienced a [CONDITION(S)] r/t (related to) a fall while wheeling self-outside without assistance. Surveyor noted no new fall prevention interventions were documented following R8's fall on 4/14/22. Surveyor reviewed R8's Smoking Evaluation dated 5/10/22. This assessment determines R8 is independent and safe smoker: Capable and independent, requires no supervision to smoke. Surveyor is unable to locate a smoking assessment prior to the 5/10/22 smoking assessment. Surveyor requested any other smoking assessments from the facility for R8 since admission. On 6/20/22 at 9:52 AM DON-B stated she is not able to locate any additional smoking assessments. On 6/13/22, at 10:26 AM, Surveyor observed R8 in bed with a cigarette box on the side table. Surveyor asked R8 if he always has his cigarettes in his bedroom and R8 stated there are no cigarettes. R8 opened the cigarette box and this Surveyor observed only a lighter in the cigarette box. Surveyor asked R8 how he was doing and if he had any concerns with the care he was receiving in the facility. R8 stated he fell over backwards in his wheelchair and stated I should sue this place. There is a drop off in the concrete and it should be level. Surveyor asked how the fall happened. R8 stated, I was going backwards trying move out of the way and went off the concrete and fell backwards in my chair. Surveyor asked R8 if he sustained any injuries and R8 said, I bumped my head, broke 3 ribs and broke my hip. I was sent to the hospital. On 6/14/22, at 10:40 AM, Surveyor reviewed R8's medical record which documents: On 4/14/2022, at 16:00 (4:00 PM), Note Text: The resident was outside in the smoking area, tried to open the door for another resident and his W/C (wheelchair) tipped backwards with him landing on the ground hitting his head. Staff was alerted to the incident. The writer was summoned to the incident area. Assessment obtain, Lg. (large)hematoma noted to the back of his head and Left Hip Pain. 911 was called. A cool pack was applied to the back of the resident head. Resident will be transported to FMH (name of hospital) for Eval (evaluation) & (and) TX (treatment). [Name of Nurse Practitioner] NP (Nurse Practitioner) was notified, Facility DON (Director of Nursing) [Name of DON] RN (registered Nurse) MSN (Master of Science Nursing) is aware. Caseworker [name of case worker] from MCFC (Milwaukee County Family Care) was updated. Resident is self POA (Power of Attorney) and agrees with Transport to [Name of Hospital]. On 6/14/22, at 10:36 AM, Surveyor reviewed the facility completed Caregiver Misconduct Incident Report submitted to the State Agency on 4/15/22. The report documented resident was outside smoking and was opening door to come back into the building, The Resident's wheelchair wheel went off the sidewalk and he fell backwards in his chair hitting the ground. Hospital called today stating resident had received broken ribs and would be in the hospital for a bit. A summary of events was written by the Nursing Home Administrator-A (NHA-A). Summary dated 4/18/22 states: Approximately 12:30pm called to the smoking area [name of resident] had fallen. [Name of resident] was lying on the ground on his wheelchair as if the chair had tipped back. [Name of Resident] was screaming in pain, the EMS (Emergency Medical Services) was called and transferred [name of resident] to ER (emergency room ). Another resident was inside and stated he had just come in and when he turned around, he saw [name of resident] through the window on the ground. That resident summoned help from a Med Tech (Medication Technician) and other staff members arrived to offer assistance and call the ambulance. Background: [Name of resident], . [Name of resident] has a BIMS score of 15, is able to make his needs known. [Name of resident] diagnosis includes but is not limited to: [CONDITION(S)] ([CONDITION(S)]), Chronic pain syndrome, [CONDITION(S)], [CONDITION(S)], anxiety disorder. [Name of resident] has a history of smoking and has been able to take himself outside to smoke. [Name of Resident] was admitted to the hospital with [CONDITION(S)] and rib fractures. Conclusion: No abuse suspected, [Name of resident] is independent in his making his needs known. Care plan updated to have resident on supervised smoking program with smoking times. Surveyor reviewed the Discharge Summary from R8's hospital stay from 4/14/22 - 4/20/22, which documents: [Name of resident] was admitted [DATE] for a fall, rib fractures and right [CONDITION(S)]. He was discharged from the hospital on 4/20/22. Discharge diagnoses: fall with right [CONDITION(S)] and multiple rib fractures, acute hypoxic [CONDITION(S)], and abnormal stress CT (Computed Tomography) scan. R8 was discharged with [MEDICATION(S)] PRN (as needed) for pain control, scheduled Tylenol, and [MEDICATION(S)] patches. Trauma surgery was consulted. No need for surgical intervention and recommended conservative management. Orthopedic service consulted regarding right [CONDITION(S)] and the following is a quote from their recommendations on 4/16/22: I do not believe any surgical intervention is warranted. I think with his fall, he strained his left hip which is arthritic and contracted. That will cause a lot of significant inflammation about the hip with pain. The right femoral neck I think is chronic in nature and fixation of that would not be of benefit for him, as he does not weight-bear. I advise him on icing left hip and soft tissues about the left hip, pain management and giving this time to calm down. I assume that this will take a good 4 to 6 weeks at least to abate. On 6/14/22, at 2:22 PM, Surveyor reviewed R8's medical record which documents: On 4/20/2022, at 14:47 (2:47 PM), Note Text: Re admit: Resident arrived via ambulance, admitted to Rm (Room) [room number documented] Alert & o x4 (oriented to person, place time and situation), able to make needs known. Resp (Respirations) even non labored. LCTA. (Lungs Clear to Auscultation). No s/s (signs/symptoms) of distress. Denies Pain @ (at) this time. DX (diagnoses): S/P (status Post) Fall with Right Hip FX (fracture) and Multiple Rib Fractures. S/P Right AKA (Above Knee Amputation), ROM (Range of Motion) WNL (Within Normal Limits) x 4 extremities, No cyanosis or [CONDITION(S)] noted. Skin W/D (Warm/Dry) to touch, bottom remains reddened with skin intact. Diet Reg (regular) with Thin Liq. (liquids) 1800 cc (cubic centimeters) fld (fluid) restriction daily. LBM (Last Bowel Movement) 4/20/22. Wt. (Weight) 211.5 LBS. (pounds). [Name of Nurse Practitioner] NP updated NNO (no New Orders). All orders faxed to the pharmacy. Vss (Vital Signs Stable). On 06/14/22, at 1:58 PM, Surveyor inspected the designated courtyard smoking area for residents. Upon exiting door, there is a 2-3 inch drop from sidewalk to grass level. All concrete is observed to be intact. On 6/15/22, at 9:41 AM, Surveyor reviewed the facility fall investigation report dated 4/14/22, at 14:00 (2:00 PM) which documents: R8 had a fall on 4/14/22 in the courtyard when R8 was trying to open the door and his wheelchair tipped backwards and he fell . Under Predisposing Environmental Factors, the none box is checked. Under Predisposing Situation factors the none box is checked. The Other Info (information) section is left blank. Surveyor identified the facility did not include staff statements. Surveyor noted the fall investigation report does not identify any environmental concerns as the cause of the fall, nor does it identify a root cause of the fall. On 6/15/22, at 9:45 AM, Surveyor interviewed LPN (Licensed Practical Nurse)-J and asked if she was working on 4/14/22 the day R8 fell in the courtyard. LPN-J stated, I was working and responded. R8 was laying back tipped in wheelchair. R8 was trying to reach the door to open it for another resident to come back in and there is a slight incline in the ground towards the door. His wheelchair must have gone backwards and went down into grass. Surveyor asked LPN-J to describe the position of the wheelchair and the sidewalk and grass. LPN-J stated that the wheelchair was backwards, half on the grass and half on the concrete. 911 was called immediately. On 6/15/22, at 10:45 AM, Surveyor interviewed DON (Director of Nursing)-B and asked if she was working on the day of R8's accident on 4/14/22. DON-B stated she was working but did not go outside to assist. She stated, from my understanding, R8 was trying to get in and when opening the door, he rolled backwards, and he rolled off the sidewalk into grass. Surveyor asked if the facility implements scheduled smoking times and DON-B stated, we currently don't have scheduled smoke times. Surveyor asked DON-B if she was aware of any other residents falling in the courtyard. DON-B stated not that she was aware of. On 6/15/22, at 3:08 PM, Surveyor interviewed Maintenance Staff (MS)-I. Surveyor asked MS-I if he was made aware of the concern related to the concrete outside in the courtyard that is used for residents to smoke, to be at higher level than the grass. MS-I stated, yes, I notice the height difference when I cut the grass. Surveyor asked MS-I if he is aware of any residents falling outside due to the level difference of the concrete and grass. MS-I stated it was brought to his attention when he heard a resident fall backwards trying to get back in. Surveyor asked if anyone assessed the outside environment after that fall. MS-I stated, I'm not sure. MS-I stated we are talking about how to resolve it. The sidewalk is not very wide. Surveyor asked if there are any active plans to correct the level of grass and concrete at this time. Maintenance-I stated no, we might put some dirt down. Surveyor asked if MS-I recalls anyone else being injured outside. He stated that he doesn't recall anyone else being injured outside. Surveyor and MS-I went outside to the courtyard where residents smoke and R8 had fallen. MS-I measured the difference in height of sidewalk with his standard tape measure. MS-I measured from the top of the concrete sidewalk down to grass level. MS-I stated there is a 3-inch difference between the concrete and grass. Surveyor asked MS-I how long the grass and concrete has been like this, MS-I stated the whole time I have worked here. When asked how long he has worked at this facility MS-I stated 8 years. On 6/15/22, at 3:15 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A. Surveyor asked NHA-A if a root cause was identified for R8's fall that occurred on 4/14/22. NHA-A stated, no there was not. NHA-I stated because of the change in ownership, it is hard. We have been thinking about moving the smoking area to a different area where the ground is more level and one that is not by a dining room. NHA-A stated the downside is the potential area has no shade. Surveyor asked if anyone physically investigated the outside smoking area after the incident on 4/14/22. NHA-A stated, I'm not seeing any documentation of that; new owners have hired a landscaping company to look at what we can do to level out the grass and concrete. Surveyor asked if there is any scheduled date for this to be done and NHA-A said not at this time. On 6/14/22, at 9:06 AM, Surveyor observed R8 in bed with a cigarette box on his bed with lighter next to it. Surveyor asked R8 when the last time was he had a cigarette. R8 stated it's been a week since I've been able to go outside and smoke. I have no cigarettes to smoke. Surveyor asked R8 if he was on a smoking schedule. R8 stated, I've never been told of a smoking schedule. Surveyor asked if staff stay outside with him while he smokes and R8 stated only once in a while will staff stay outside. Surveyor asked R8 if he has ever smoked in his room. R8 stated, In the past I have smoked in the room when staff would not take me out. What else am I supposed to do if they don't get me up. Surveyor asked if the facility ever told R8 that he was going to be discharged from the facility due to smoking in his room. R8 stated, yes. They told me I'd have to leave and gave me a 30-day notice. Surveyor asked if this notice was in writing. R8 stated it was verbally told to him. On 6/14/22, at 11:15 AM, Surveyor reviewed R8's medial record which documents R8 has a history of smoking in his room. R8's medical record documents a progress note dated 2/6/22, at 18:30 (6:30 PM) Nurses Note: writer smell smoke in resident room asked resident if he was smoking, resident stuck up middle finger and stated F*** You. writer walked out room and put him on 24-hour report staff will monitor this pm (evening) shift, for smoking. Progress Note dated 3/18/22, at 10:17 AM, documents: Social Services: Writer spoke with CM (Case Manager) about resident smoking in the room and his 30-day notice given to him 3/14. She let writer know that a group home will be coming to evaluate him next week for placement in their facility. Progress Note dated 4/18/2022, at 8:08 AM, documents: Note Text: [Name of Resident] has been found with a strong smell of tobacco smoke in his room, with smoking items, i.e., cigarette(s) and lighters, and had admitted to smoking while he is in his room in bed. [Resident's Name] is alert and oriented with a BIMS score of 15. He stated he receives his smoking paraphernalia from his case manager upon request, explaining he has run out of his cigarettes. It was discussed with his case manager that by choosing to smoke in his room he is putting his ability to stay here in jeopardy and putting the safety of other residents at risk. [Name of Resident] has been on a supervised smoking schedule since admission but voluntarily chooses to disregard this schedule and takes himself outside independently. He is care planned for this behavior. Progress Note dated 4/22/2022, at 4:49 AM, documents: Note Text: resident smoking in bed yelled at staff close the damn door, get out of here. Progress Note dated 6/7/22, at 6:44 AM, Patient room has a strong odor of nicotine. Nurse inquired and resident stated that he smokes, and the smell is from him. On 6/14/22, at 11:02 AM, Surveyor interviewed Activity Director-R. Surveyor asked Activity Director-R if she was aware of R8 having a smoking schedule. Activity Director-R stated that she heard that R8 had fallen in the courtyard after smoking and since then she guessed R8 was on a smoking schedule. Activity Director-R stated she is not aware of what R8's smoking schedule is. Surveyor asked Activities Director-R if she is aware of where R8 keeps his cigarettes and lighter when not using them. Activities Director-R stated that the nurse keeps cigarettes and lighters. On 6/14/22, at 11:26 AM, Surveyor interviewed Certified Nursing Assistant-Y (CNA-Y) and asked if R8 had a smoking schedule. CNA-Y stated no, he does not have a smoking schedule. Surveyor asked where R8 keeps his smoking materials when not in use. CNA-Y stated that the nurse keeps R8's cigarettes and lighter. On 6/14/22, at 11:33 AM, Surveyor interviewed Licensed Practical Nurse-J (LPN-J) and asked where R8 stores his smoking materials when not in use. LPN-J stated they are kept in the narcotic box. Surveyor asked if R8 should have access to his lighter in his bedroom, LPN-J stated no. Surveyor asked LPN-J if R8 is supervised when he goes outside to smoke, and LPN-J stated staff are always present. LPN-J stated R8 will not smoke in his room or in any room of the facility. On 6/15/22, at 9:16 AM, Surveyor interviewed Nursing Home Administrator-A (NHA-A) regarding the 30-discharge notice provided to R8. NHA-A stated that his case manager found R8 a place to live in Oshkosh however there is a contractual thing going on. NHA-A also stated that she spoke with the Ombudsman, and she said that we could not discharge R8 from the facility because there was no proof R8 was actually smoking in his bedroom. NHA-A stated the Ombudsman suggested placing another smoke detector above his bed so that if R8 is smoking it should go off and that would provide the facility proof of R8 smoking in his room. NHA-A confirmed there was an additional smoke detector above R8's bed. Surveyor asked NHA-A about the facility's current smoking policy and storage of resident lighters. NHA-A stated they have been trying to revise the smoking policy. Resident lighters should not be kept in resident rooms. NHA-A stated the Ombudsman told us we cannot take a residents' lighter if they refuse to give it to us. It has been a challenge that we are still working on. On 6/15/22, at 10:45 AM, Surveyor interviewed Director of Nursing-B (DON-B). Surveyor asked if R8 is supposed to be supervised while smoking. DON-B stated no R8 is an independent smoker and R8 can handle materials safely himself. Surveyor asked where R8's smoking materials should be stored, and DON-B stated on the nursing carts. Surveyor asked DON-B if the facility has any scheduled smoking times. DON-B stated no, currently there are no scheduled smoking times for any resident. DON-B stated we would like to eventually go to that in the future. On 6/16/22 at 10:55 AM Surveyor interviewed DON-B and asked her what the plan is going forward to keep R8 safe while outside smoking. DON-B stated that the smoking policy we were trying to implement with schedules times is not happening since Ombudsman says we cannot stop R8 going out on his own. We have been looking into getting the smoking area moved. R8 can smoke when he wants, and we can send someone outside with him. Surveyor asked if they are providing supervision currently for him. DON-B stated we can pull someone to go outside with R8. DON-B stated the facility didn't have any documentation that says someone is going out with him, but he is being escorted outside. It's not supervision of his smoking. He is independent in that, but staff is staying outside for the duration of smoking. On 6/20/22 at 9:52 AM Surveyor spoke with DON-B. DON-B confirmed she cannot locate any smoking assessment prior to the fall on 4/14/22. Also stated she cannot find a fall assessment prior to the fall on 4/14/22.

Based on observation, interview and record review, the facility did not ensure that 1 (R26) of 1 residents reviewed received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. * R26 was admitted to the facility with a wound vac (vacuum) to the left knee. R26 was found to have no wound assessments, monitoring of the wound vac or wound care from 3/29/22 to 4/13/22. During this time, the size of R26's left knee surgical wound grew in size and depth. Findings include: The facility's policy dated January 2022, and titled, Skin Management: Monitoring of Wounds and Documentation documents under the General section, It is important that the facility have a system in place to ensure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility. Under the General Guidelines section it documents, An evaluation of the status of the dressing, if present (whether it is intact and whether drainage if pressing, is or is not leaking); the presence of complications, such as signs of increasing area of ulceration or soft tissue infection (for example: increase redness or swelling around the wound or increased drainage from the wound); The amount of observations possible will depend upon the type of dressing that is used, since some dressings are not meant to remain in place for several days, according to manufacturer's guidelines. Under the General Monitoring Guidelines section it documents, With each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the wound should be documented. At a minimum, documentation should include the date observed and: Location and staging; Size (perpendicular measurements of the greatest extend of the wound), depth, and the presence, location and any extent of any undermining or tunneling/sinus tract; Exudate if present: type (such as purulent/serous), color, odor and approximate amounts; Wound bed: Color any type of tissue/character include evidence of healing (e.g., granular tissue), or necrosis (slough or eschar); and description of wound edgers and surrounding tissue as appropriate. 1.) R26 admitted to the facility 3/23/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R26's Admission MDS (Minimum Data Set) dated 4/5/22, along with the CAA (Care Area Assessment), was not submitted and completed as of 4/18/22. R26's Hospital Discharge summary dated 3/23/22 documents, Infected Left Femur: Pt (patient) is 9-month s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Post op (operation) recovery complicated by poor wound healing and underwent excisional debridement 6 months after initial surgery .Ortho (Orthopedic Physician) deferred surgical treatment with .antibiotic spacer until patient's nutritional status improves to optimize her prior to surgery. Wound vac (vacuum) applied to L (left) knee 3/10 (3/10/22) and changed weekly until more nutritionally optimized. Wound vac last changed on 3/23 (3/23/22). Pt to remain NWB (non-weight bearing) to LLE (left lower extremity). Close f/u (follow up) with ortho pre-op (pre operation) and orthopedic clinic. Septic shock likely 2/2 (secondary to) infected left femur, resolved: Source of infection at this point is likely from L (left) femur and she (R26) clinically improved on broad spectrum abx (antibiotic). R26's Skin Integrity care plan dated 3/23/22 documents under the Focus, The resident has actual impairment to skin integrity of the Left Knee r/t (related to) Post Surgical repair infection. Under the Interventions section, dated 3/23/22, it documents, Monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to MD (Medical Doctor); Follow facility protocols for treatment utilizing wound vac therapy. R26's nursing note dated 3/23/22 documents, Admission Summary Note Text: Admission to room .Dx (diagnosis) .Infection to Surgical site r/t (related to) fx (fracture) femur . A/O (alert and orientated) x 4 able to make needs known verbally, skin warm/dry, Has wound vac dressing to left Knee, Dr (doctor) updated to follow & ordered Wet to Moist dressing, Writer removed dressing to reveal area to left Knee of 4.0 x (by) 5.5 x 0.2 cm (centimeters) with significant slough, moderate exudate, area distal to original location reveals wound that measures 1.2 x 1.0 exudate wound bed pink, no slough, 3rd site medial to second area measures 0.5 x 1.5 with pink wound bed and small amount drainage, no odor, orders confirmed with Dr & sent to pharmacy for delivery. Resident is Full Code & weighs 96.0 lbs. (pounds). R26's admission physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Clean area with S/W, apply Xeroform Gauze to all 3 areas and cover with Border Foam dressing, Change Daily & Prn (as needed). R26's March 2022 TAR (Treatment Administration Record) documents that R26 received the above treatment on 3/24/22 and 3/25/22. R26's nursing note dated 3/25/22 documents, Health Status Note Text: Writer contacting Doctor's office after assessing Left Knee d/t (due to) Bleeding from site, Writer removed dressing & cleaned area, placed Pressure dressing which immediately bled through. Also attempting to update sister with no success, Awaiting call back from Ortho. Resident appears comfortable & denies pain. R26's nursing note dated 3/25/22 documents, Health Status Note Text: Writer received communication while Resident out that she is being admitted thru ER (emergency room ) post ortho (orthopedic) visit for abnormal magnesium, [CONDITION(S)] & low BS (blood sugar) for ABX (antibiotic) therapy. R26's Hospital Discharge summary dated 3/29/22 documents, Left Knee Wounds: She has a wound vac (vacuum) in place to left knee; maintain at 125 mm Hg (millimeters of mercury). NWB (non weight bearing) LLE (left lower extremity); follows with ortho (orthopedic clinic) for potential spacer placement once nutritional status improves. R26's nursing note dated 3/29/22 documents, Admission Summary Note Text: Returned to Facility after brief hospital stay, Alert/Oriented x 4 & able to make needs known, Wound vac to Left Knee functioning well at 125mm/pressure. Order to change weekly, Order verified with Np (nurse practitioner) and faxed to pharmacy. Surveyor was unable to locate any nurse practitioner notes or physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor was also unable to locate any documentation that R26's wound vacuum was being monitored daily for functionality or that R26's surgical wound was being monitored and assessed after R26 was readmitted to the facility on [DATE]. Surveyor was also unable to locate any additional care plan interventions for the monitoring and assessment of R26's surgical wound or wound vacuum. Surveyor was unable to locate any RN (Registered Nurse) assessment in R26's medical record that documented that R26's left knee surgical wound was reassessed upon readmission to the facility on [DATE]. Surveyor was also unable to locate any documentation that documented the condition, including the size and status of R26's wound vacuum, of R26's left knee surgical wound upon readmission to the facility on [DATE]. Surveyor was unable to locate any documentation in R26's medical record, including in R26's MAR (Medication Administration Record), TAR (Treatment Administration Record), nursing notes or physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R26's Abuse/Concerns interview dated 4/13/22 documents, 4. Do you have any other concerns we haven't discussed: No one knows how to change my wound vac (vacuum). On 4/13/22 at approximately 12:52 p.m., Surveyor informed RN (Registered Nurse) Consultant-F of the above findings. Surveyor asked RN Consultant-F if R26 had any physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN Consultant-F informed Surveyor that she had become aware that R26 did not have any care plan interventions, wound treatment orders and wound vacuum monitoring orders in place but that she would add them. On 4/13/22 at approximately 2:50 p.m., Surveyor observed the following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ (at) 125mgHG continuous suction to left knee. Change q (every) 3 days; Change wound vac to left knee mon (Monday) /wed (Wednesday)/ fri (Friday) and prn (as needed). On 4/14/22 at approximately 12:30 p.m., Surveyor noted that R26 had the following interventions added to her Skin Integrity plan of care: Notify Licensed Nurse if wound vac becomes unplugged or vac area is compromised. Notify if there is any question of wound vac integrity; The resident needs a pressure relieving cushion to protect the skin while up IN CHAIR; The resident needs a pressure relieving/reducing mattress, to protect the skin while IN BED; Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Date Initiated: 04/14/2022. On 4/14/22 at 12:57 p.m., Surveyor asked R26 if she had any concerns regarding her surgical left knee wound. R26 informed Surveyor that she was concerns that facility staff did not know how to care for her wound and wound vacuum. R26 informed Surveyor that her wound vacuum had been beeping since Tuesday (4/12/22) and that facility staff had not fixed it until yesterday (4/13/22). R26 informed Surveyor that no one had come in and assessed her wound and that she (R26) had not had a wound treatment done on her left knee surgical wound since she was readmitted to the facility on [DATE]. On 4/14/22 at 1:08 p.m., Surveyor asked Wound LPN (Licensed Practical Nurse)-Q, whom oversaw assessing and monitoring all the wounds in the facility, if she had assessed, treated, or monitored R26's left knee surgical wound or vacuum since 3/29/22, since Surveyor could not locate any documentation in R26's medical record. Wound LPN-Q informed Surveyor that she had not assessed, treated, or monitored R26's wound vacuum until yesterday (4/13/22) where she went in and re-anchored R26's wound vacuum dressing. Wound LPN-Q informed Surveyor that she did not assess or treat R26's left knee surgical wound and that all she did was re-anchor the dressing. Wound LPN-Q informed Surveyor that she had never assessed or treated R26's left knee surgical wound since 3/29/22. On 4/14/22 at 1:29 p.m., Surveyor observed Wound LPN-Q remove R26's left knee wound vacuum dressing and apply a wet to dry bandage to the area. Surveyor noted that R26 did not have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During this time Wound LPN-Q measured and assessed R26's left knee wound with Surveyor. As Wound LPN-Q removed the sponge dressing, she informed Surveyor that this was the first time she had observed R26's left knee surgical wound. During the dressing change, Surveyor observed 3 open areas to R26's left knee with the following measurements: Left Knee- 4.5 cm (centimeters) in length by 5.5 cm wide and 0.9 cm deep. Surveyor observed the wound bed to have exposed muscle, bone, and metal hardware along with a necrotic area in the middle of the wound measuring 0.5 cm by 0.5 cm in size; Left Knee Distal: 1.5 cm in length by 1 cm wide. Surveyor initially observed the presence of slough over the wound bed, however Surveyor observed Wound LPN-Q wipe off and remove all of the slough from the wound bed, exposing bone and metal hardware; Left Knee Inferior to Main Wound: 0.5 cm in length by 0.5 cm wide, with a red granulated wound base. Apart from the necrotic area observed by Surveyor, Surveyor observed no signs of infection to the wounds. On 4/14/22 at 1:50 p.m., during the wound dressing change, Surveyor asked Wound LPN-Q if R26's Left Knee Distal wound was a pressure injury or surgical wound as the wound bed had previously been covered with slough. Wound LPN-Q informed Surveyor that she believed the Left Knee Distal wound was a stage 3 pressure injury as she could see bone at the base of the wound. On 4/14/22 at 2:57 p.m., Surveyor observed Wound LPN-Q remove the wet to dry dressing and apply a sponge for a new vacuum dressing on R26's left knee wound. During this observation, Surveyor observed Wound LPN-Q be unsuccessful in obtaining a functional wound vacuum seal on the dressing for R26's left knee wound. On 4/14/22 at 3:32 p.m., RN (Registered Nurse)-D assisted Wound LPN-Q with troubleshooting R26's wound vacuum. Wound LPN-Q informed Surveyor that due to the wound pump not being charged, she would be re-applying a wet to dry dressing to R26's left knee wound until she could get the wound pump to charge and obtain a successful wound vacuum seal on the dressing for R26's left knee wound. Surveyor noted that based on R26's initial wound measurements as documented on 3/23/22, R26's wound had increased in size and depth since being readmitted to the facility on [DATE]. On 4/14/22 at 3:40 p.m., Surveyor informed NHA (Nursing Home Administrator)-A of the above findings. NHA-A informed Surveyor that she would have R26's left knee wound vacuum looked at, however no additional information was provided. On 4/18/22 at 8:49 a.m., DON (Director of Nursing)-B informed Surveyor that R26 was sent out to the orthopedic clinic on 4/15/22 and that R26 now had wound orders in place. R26's Order Summary Report from the orthopedic clinic dated 4/15/22 documents, If there is any malfunction with the wound vac (vacuum), please send to [name of hospital] ER (emergency room ) after hours for wound vac (vacuum) placement. Monday through Friday however, call Doctor's office and we can arrange an office visit to replace the vac (vacuum). Extra canisters are provided for replacement if needed. Surveyor noted that R26's Order Summary Report from the orthopedic clinic dated 4/15/22 did not include an assessment with measurements of R26's left knee surgical wound. On 4/18/22 at 11:34 a.m., Surveyor unsuccessfully attempted to contact R26's orthopedic clinic via telephone to get additional information and an assessment of R26's left knee surgical wound. On 4/18/22 at 1:41 p.m., Regional RN (Registered Nurse) Consultant- C informed Surveyor that she was unsuccessful in getting additional information and an assessment of R26's left knee surgical wound. No additional information was provided as to why R26 did not receive treatment and care in accordance with professional standards of practice, for her left knee surgical wound. \\

Based on record review, observations and staff interviews, the governing body did not implement policies regarding the management and operation of the facility to ensure residents received care that attained or maintained their highest practicable level of physical, mental, and psychosocial well-being. This resulted in 7 Immediate Jeopardy citations being issued at Resident Neglect (F600), Resident Quality of Life (F675), The prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The governing body was made aware that the facility was experiencing significant staffing shortages, yet the administrator indicated she was directed to continue taking new admissions. Forty-seven (47) residents were admitted in February and March 2022. The governing body did not ensure that the plan set forth in the facility's assessment was followed. The governing body should have been aware, that due to the lack of staff, they could not meet the needs of the 70 residents, who were dependent on the facility staff to provide both care and treatments and an overall good quality of life. The governing body's failure to implement policies to ensure the facility had the resources to meet resident needs created a finding of immediate jeopardy that began on 2/28/22. Administrator A and VP of Operations L were notified of the immediate jeopardy on 4/4/22 at 4:45 p.m. Per this regulation, the governing body is als responsible for the facility's Quality Assurance and Program Improvement (QAPI) plan. On 4/14/22 the facility had their first QAPI meeting. This was the first QAPI meeting conducted after 4/4/22 when the QAPI team met to discuss the IJ citations and plans of abatement. Neither the Vice President of Operations (VPO)-L nor Corporate RN BB were in attendance. On 4/14/22, Administrator A informed Surveyor that earlier this morning on 4/14/22, VPO- L and Corporate Consultant RN BB flew back to North Carolina, and they informed Administrator A there was an issue with the Management contract. Administrator A stated they VPO-L and Corporate Consultant RN BB indicated they would not be back in the building until the issue with the contract is clarified. As of 4/14/22 at the time of the exit of the partial extended survey, the Immediate Jeopardy was not removed. This is evidenced by: The Facility's Assessment reflects the following: Policy Review: Facility Assessment last revised October 2018 Policy statement: A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day- to- day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment. Policy Interpretation and Implementation: 1.) Once a year, and as needed, a designated team conducts a facility- wide assessment to ensure that the resources available meet the specific needs of our residents. 2.) The team responsible for conducting, reviewing and updating the facility assessment includes the following: a. Administrator b. A representative of the governing body c. The medical director d. The director of nursing 3.) The facility assessment includes a detailed review of the resident population. This part of the assessment includes: a. resident census data from the previous 12 months b. resident capacity of the facility and its occupancy rate for the past 12 months c. factors that affect the overall acuity of the residents, such as the number and percentage of residents with: 1. Need for assistance with ADL's 2. Mobility impairments 3. Incontinence (bowel and bladder) 4. Cognitive or behavioral impairments 5. conditions or diseases that require specialized care (e.g. [CONDITION(S)], ventilators, wound care) . 6.) The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps determine budget, staffing, training, equipment and supplies needed. It is separate from the Quality Assurance and Performance Improvement evaluation. The Facility Assessment Tool was last updated 1/24/2022 and reviewed with the Quality Assurance committee in January 2022. The facility is licensed to provide care for 87 residents. The average daily census is 71 residents. Part 2: Services and Care that [NAME] of [NAME] Village offer based on resident's needs includes: activities of daily living, mobility and fall/ fall with injury prevention, bowel and bladder toileting programs, pressure injury prevention and care, manage the medical conditions and medication- related issues causing psychiatric, symptoms and behaviors, awareness of any limitations of administering mediations, assessment of pain, identification and containment of infections, prevention of infections, management of medical conditions, other special care needs such as [CONDITION(S)], hospice ostomy care, tracheotomy care and ventilator care, speech, physical and occupational therapy, nutrition services to address individualized dietary requirements, person- centered/ directed care, and psycho/ social /spiritual support. Part 3: Facility Resources needed to provide competent support and care for our resident population every day and during emergencies. Staff type: 1.1 [NAME] of [NAME] has the following staff members, other health care professionals, consultants, and medical practitioners to provide support and care for residents. This list includes but is not limited to: * Administration (i.e.- Administrator, staff development, environmental services, social services, admission. marketing, business office, finance, human resources, corporate compliance, corporate staff). * Nursing Services (i.e.- Director of nursing, Assistant Director of Nursing, RN, LPN, CNA, Medication Aide, MDS nurse, Wound/ Treatment nurse, Infection Control Coordinator) * Food and Nutrition Services (i.e. Director, cooks, support staff, registered dietician) * Therapy Services (i.e. TO, OTA, PT, PTA, RT, RT tech, speech language pathology) * Medical/ Physician Services (i.e. Medical Director, Attending Physician, Physician assistant, Nurse Practitioner) * Pharmacist * Behavioral and mental health providers * Support staff (i.e.- engineering, plant operations, information technologies, housekeeping, maintenance staff, laundry services) * Other (vocational services worker, clinical laboratory services worker, diagnostic x- ray services worker, blood services worker) psychiatric services and mental health providers. 3.2) Staffing plan: [NAME] of [NAME] provides adequate staffing to meet its residents' daily needs, preferences, and routines in order to help each resident attain or maintain the highest practicable physical, mental, and psychosocial wellbeing. This includes services of a registered nurse for at least eight (8) consecutive hours a day, 7 days a week, a designated licensed nurse to serve as a charge nurse on each tour of duty and adequate staffing on each shift to ensure that our residents' needs are met by registered and licensed nursing staff, certified/ state tested nursing assistants, and other support services that include, but are not limited to, dietary, activities/ recreational, social, therapy and environmental services. Respiratory Therapists will be on staff for the ventilator unit 24 hours a day. During extreme events such as a pandemic if the facility is not able to maintain the minimum number of qualified staff to meet the needs of the residents, all staff will assist with ensuring basic cares are met as the facility is in crisis staffing modes. The non- qualified staff will assist with answering call [NAME], serving meals, making beds, duties which you do not need to be certified to perform. [NAME] of [NAME] consistently reviews adequate staffing based on census, acuity, and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Individual Staff Assignment 3.3. Individual staff assignments are reviewed by the Director of Nursing and Administrative team to ensure the coordination and continuity of care for residents within and across these staff assignments based upon census, acuity, and resident diagnosis. Daily staffing assignments shall be posted in a prominent location and shall be updated daily. Staff training/ education and competencies 3.4 [NAME] of [NAME] provides staff training, education and competencies that is necessary to provide care and support needed for our resident population. The training/ education and competencies/ skill checks are generally provided upon hire, during monthly in- servicing/ training, annual inservicing/ training, whenever an area of concern is identified, or new areas are identified based on resident diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . [NAME] of [NAME] provides the training topics and competencies that include, but are not limited to: * Resident rights and facility responsibilities * Abuse, Neglect, and exploitation including reporting of abuse * Identification of resident changes in condition, including how to identify medical issues appropriately, how to dentine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life. * Medication Administration * Resident Assessment and examinations- admission assessment, skin assessment, pressure injury assessment, neurological check, lung sounds, nutritional check, observations of response to treatment, pain assessment. * Caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/ or [CONDITION(S)], and implementing nonpharmacological interventions. The following concerns show that the governing body and the facility did not have the capacity to meet the needs of, and to competently care for, their residents during day- to -day operations, based on the facility assessment: 1. The Governing body and the facility did not ensure 70 residents residing in the facility were free from neglect when the facility did not ensure sufficient staff were deployed to care for residents. This resulted in a finding of immediate jeopardy and substandard quality of care. (Cross Reference F600) 2. The Governing body and the facility did not promote a quality of life by providing 70 residents with the necessary cares and services for residents to maintain their highest practicable level of physical, mental, and psychosocial well-being. Residents stated that they felt scared and felt neglected and felt as if no one would help them because there was no staff. The governing body did not ensure and the facility did not provide an adequate level of staff to provide cares and services to residents of the facility for an extended period of time. This left residents to go without showers/baths, daily personal hygiene, repositioning in the bed and chairs, proper treatment and assessments of pressure ulcers, prevention of falls and medications administered per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility continued to admit new residents to the facility knowing that they were facing daily staffing shortages and providing necessary cares and services to the current residents proved to be incomplete. This pervasive disregard for residents' quality of life created a finding of Immediate Jeopardy and Substandard Quality of Care. (Cross Reference F675) 3. The Governing body and the facility did not provide sufficient staffing to meet the needs of 70 residents living in the facility. The survey team entered the building on 3/28/22 at 8:00 a.m. Staff interview was conducted, and it was confirmed that there was only 1 Registered Nurse and 5 Certified Nursing Assistants to care for 70 residents. Facility staff stated that the morning medication pass would not be completed and the only Registered Nurse had to stay on the Vent unit, leaving the other 4 units without a licensed nurse. A review of the facility staff schedules for the month of March 2022 showed that the facility was often understaffed causing staff to work on more than one unit and at times working without the assistance of another staff member on their assigned unit. Because there was inadequate staff, residents were left in their rooms and in bed, did not receive showers/ baths, did not receive assistance with daily hygiene, residents were not provided with enough supervision to prevent falls, residents who were at risk for skin breakdown were not turned and repositioned, medications were not administered timely, and treatments were not always provided. The failure to provide adequate staffing created a finding of Immediate Jeopardy. (Cross reference F725) 4. The Governing body and the facility did not ensure 10 residents who are dependent of staff for activities of daily living received weekly skin checks and showers/baths and assistance with personal hygiene. The governing body was aware of the staffing shortages and should have anticipated that all care needs could not be met without sufficient staff. The facility did not have accurate documentation/information to show R10, R5, R11, R8, R3, R7, R2, R4, R13, R14 received showers consistent with R's care plans, in addition skin checks were not always completed as per facility policy for R3, R7, R2, R4, R13, R14. R10 is not receiving weekly showers in accordance with R10's plan of care. R10 was observed on 3/28/22 at 9:20 AM, 12:20 PM, and 2:45 PM and again on 3/29/22 at 7:45 AM and appeared very disheveled with dry, flaky skin and excessive facial hair. R11 was observed in bed on 3/28/22 at 12:39 PM .R11's hair was very disheveled and appeared to be greasy as if not washed in some time. R11 is to have a shower at least weekly however no indication of a set day for the shower. The facility was unable to provide any evidence that R11 had been provided a shower for the months of February and March 2022. R4 was observed on 3/29/22 at 8:10 AM lying in the bed on her back with lips cracked and no moisture noted on dry mucous membranes and long beard hairs on chin. R4 stated liking to have her chin shaved and telling the nurses if they see anything on the face to take it off. Surveyor noted R4 had only one documented shower on 3/9/22 in the last 30 days. (Refer to F677) 5. The Governing body and the facility did not ensure 4 residents (R4, R10, R5, R18) received appropriate treatment and services to prevent/ heal pressure ulcers. On 3/29/22, at 6:53 AM, Surveyor interviewed Director of Nursing (DON)-B who stated that for Pressure Injuries I just document what I see, not Wound Certification so no staging. DON-B stated nurses don't measure, only describe, where, what, approximate size but no measurements but stated an RN could stage. DON-B has not seen MD-N notes for over 2 weeks regarding his assessments, measurements, and treatments. DON-B stated she is trying to get access to his corporate notes. On 3/29/22, at 12:54 PM, Surveyor interviewed DON-B who stated the facility doesn't do their own separate staging and measurements, only MD-N stages and measures wounds. DON-B stated she was doing a little bit of everything and has not seen the Wound Physician notes for 2 weeks therefore unable to address any questions. On 2/14/22, R4 developed three unstageable pressure injuries. These combined into one unstageable wound that is now 56 times larger in area than when first identified (2.02 sq. cm. vs. 160 sq. cm). In addition, during 2 different wound care observations, R4 had developed two additional ischial wounds that were not addressed by the facility. R10 acquired an unstageable pressure injury while residing at the facility and was hospitalized , requiring intravenous antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] R5 acquired a stage 4 pressure injury while residing at the facility and was hospitalized , requiring antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] R18's pressure ulcer to the coccyx was not compressively assessed upon her original admission on 3/1/22 and then upon readmission on 3/22/22 and 3/23/22. R18 did not have a plan of care addressing the pressure ulcer with interventions put into place to aide in the healing of the pressure ulcer. The facility was unable to determine if the treatment they were applying daily to R18's coccyx was effective because they had no means to know if the area was healing or not. Repositioning of residents at risk for skin breakdown could not always occur. On 3/30/22, at 7:00 AM, Surveyor interviewed LPN-P who stated she was the only nurse in the facility when the PM nurse who stayed to help night shift left around 4:00-5:00 AM. LPN-P stated there were only 2 CNAs overnight in the facility so not all care was possible because repositioning requires 2 people. The governing body should have been aware that DON- B was on the schedule to work on the Ventilator Unit, often working 2 shifts a day. With DON- B working on the floor, she was unable to keep up with other tasks that were assigned to her such as being a part of the Wound Team. DON- B stated that she did not feel comfortable with the entire assessment of pressure injuries and the governing body did not ensure, per the facility assessment, they could provide sufficient wound care. This resulted in Immediate Jeopardy and Substandard Quality of Care. (Cross Reference F686) 6. The Governing body and the facility did not ensure 2 residents (R16 and R3) were provided with care in supervision to prevent accidents, resulting in serious injuries. The governing body should have been aware that the lack of sufficient staff, often leaving a unit with only 1 CNA or no CNAs and a shared nurse to provide assessment, would not be able to provide supervision to those residents who were at high risk for falls. This resulted in Immediate Jeopardy and Substandard Quality of Care. R16 has had 12 falls since admission on 2/18/22 to 4/3/22. The fall on 3/27/22 (which was the second fall that day) resulted in stitches above the right eyebrow. The fall on 3/26/22 resulted in staples to the back of the head. The fall on 4/2/22 resulted in a re-opening of the staples. The fall on 4/3/22 led to a laceration on the resident's face that required steri-strips. After review of nursing schedules with each of R16's falls, it is noted that based on census and 15 total Residents residing on the same unit as R16, there was an inadequate number of staff to provide supervision to R16 in order to prevent R16 from frequent falling. On 3/20/22 R3 had a fall with injury and a fall assessment with a thorough root cause analysis, and Neuro checks was not completed. (Cross Reference F689) 7. The Governing body and the facility did not ensure 2 residents (R16 & R9) who experienced significant weight loss received dietician and physician recommendations based on a comprehensive assessment. The Governing Body should have been aware that not all staff had access to the resident medical records in Point Click Care. The Dietician did not have access to vital information that should have been accessible on each resident so she could conduct a thorough assessment of the residents' nutritional needs. This resulted in Immediate Jeopardy and Substandard Quality of Care. On 3/31/22, R16's weight was obtained. RD-D documents R16's weight has declined to 72.6 pounds, an 18.6% weight loss since admission. RD-D describes the weight as severely underweight and life-threatening. RD-D contacted the Nursing Home Administrator and recommended R16 be transferred to the hospital STAT. R16 was sent to the emergency room (ER) and returned to the facility on [DATE]. R9 experienced a significant weight loss of 35.4 pounds (29.8%) from 11/15/21 to 1/31/22 without any compressive assessment or dietary intervention. (Cross Reference F692) 8. The Governing body and the facility did not ensure 12 residents received their morning and noon medications on 3/28/22 when the facility only had 1 nurse in the building and could not complete the medication pass. Of the 12 residents, 6 residents experienced a significant medication error by not being administered their insulin, tube feeding or IV antibiotic. The Governing Body should have been aware the lack of sufficient staff, including nurse, would lead to a delay or even omission of the administration of medications for the residents. Upon entrance to the facility on [DATE], there was only 1 nurse on the schedule for 70 residents. Administration was aware and was not able to rectify the situation. During the first shift on 3/28/22, the facility had only 1 Registered Nurse (RN) on duty with a census of 70 residents. Due to staffing shortages, the 3/28/22 morning and noon medications were not administered to the following residents (R8, R11, R18, R2, R4, R13, R14, R10, R3, R7, R16, and R17). The facility did not follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not ensure that 7 (R2, R4, R13, R14, R10, R11, R18) of 8 residents reviewed were free from significant medication errors. (Cross Reference F755 and F760) On 3/30/22 at 3:30 p.m., Surveyor interviewed Administrator - A regarding the staffing shortage that the facility is experiencing. Administrator - A provides a weekly orientation to new staff and has found that for whatever reason staff don't stay on as employees after orientation. Administrator- A acknowledged that there are many open positions for nursing and certified nursing assistant staff and that Corporate level staff are aware. Administrator- A stated that she reports weekly to VPO L where the facility is at with staffing levels. Administrator- A confirmed that DON- B is wishing to step-down and just work on the Vent Unit and this will leave an opening for a Director of Nursing as well as there is an opening for a MDS Nurse. Administrator - A stated that the facility has a contract with 3 different staffing agencies, and often this can be challenge because the staffing agencies are short on staff. Administrator- A stated that the Corporation was going to send a Regional Nurse to assist, but the nurse fell ill and was unable to travel. On 3/31/22 at 12:10 p.m., Surveyor interviewed Administrator- A regarding the facility's admission during the month of February and March 2022. Administrator- A provided Surveyor with a report that showed the facility accepted 47 new admissions during February and March 2022. Administrator- A stated that she was aware of the staffing shortages and would report this to the Corporation weekly. Administrator- A states she was told the facility should continue to take new admissions during this time. The Failure to ensure the governing body implemented policies and procedures related to the management and operation of the facility contributed to multiple care issues identified during this survey and created a finding of immediate jeopardy. As of 4/14/22, the facility continued to have ongoing staffing issues with obtaining and retaining CNAs and licensed nursing staff. According to Administrator A, the facility owes staffing agencies money which limits their ability to get staff. According to the facility's Immediate jeopardy removal plan approved on 4/7/22, the Governing body composed of the Corporate MDS nurse-RN, Nurse Consultant RN, Human Resource Director, and Vice President of Operations will monitor the facility daily for proper follow up for 4 weeks, then weekly for 4 months, and monthly thereafter in the areas identified but no limited to implementation of the clinical team, abuse, neglect, misappropriation, staffing, quality of care, wound care, falls, and weight loss. The governing body will review the outcome of the monthly QAPI to ensure the areas of the plans of correction are implemented, monitored, and maintained. The results of daily walking rounds, wound care, staffing to meet the acuity of residents, falls, assessment/interventions, comprehensive assessments, care plans, weight loss will be reviewed by the governing body for further follow up and recommendation. The VPO will review the outcome of these audits with the facility and corporate QAPI committee monthly for 6 months. The VPO will further review with the Medical Director the status of and outcomes of the audits monthly for further follow up and recommendations. Additionally, Corporate RN BB is part of the facility's IJ removal plan to assist with the stability, training and to ensure clinical systems are reinstituted, monitored and maintained until the facility shows compliance as determined by the Regional Nurse Consultant and Corporate team. Corporate RN BB is also part of the Monitoring, Audit, and QAPI plan. This plan was not followed as evidenced by: On 4/11/22 from 9:00 PM to 10:00 PM there was only 2 CNAs and 2 nurses for the facility. According to Administrator A, on 4/11/22 Scheduler I informed Administrator A, VPO-L and RN-BB of concerns about the 4/11/22 PM staffing shortage. Administrator A stated they were piecemealing the evening shift with staff and they could not get anyone else. VPO-L and Corporate RN BB were in the building and aware of the staffing shortage. Administrator A stated VPO L and Corporate RN BB are both RNs. Administrator A stated neither VPO L nor RN BB went to assist with Resident care. Administrator A stated VPO L and Corporate RN BB left the building at 9:00 PM. Administrator A stated although she is not a nurse she went to the units to help out where she could. On 4/14/22 the facility had their QAPI meeting. This was the first meeting conducted after 4/4/22 when the QAPI team met to discuss the IJ citations and plans of abatement. Neither VPO-L or Corporate RN BB were in attendance. On 4/14/22, Administrator A informed Surveyor that earlier this morning on 4/14/22, VPO- L and Corporate Consultant RN BB flew back to North Carolina, and that they informed Administrator A there was an issue with the Management contract. Administrator A stated they VPO-L and Corporate Consultant RN BB indicated they would not be back in the building until the issue with the contract is clarified. The Failure to ensure the Governing body implemented policies and procedures related to the management and operation of the facility contributed to multiple care issues identified during this survey and created a finding of Immediate Jeopardy. As of 4/14/22 at the time of the partial extended survey exit the facility had not removed the immediate jeopardy.

Based on observations, interviews and record review, the facility failed to ensure that 70 out of 70 residents were free from neglect. The facility was aware of the needs of each of the 70 residents living in the facility. The facility did not provide sufficient staffing to provide cares to all residents. Due to inadequate staffing levels, residents did not receive personal cares such as showers/ baths, adequate supervision to prevent falls, and care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . One resident admitted herself into a hospital as was in an extreme amount of pain and was not getting assistance. Dietitian and Physician recommendations for residents' weight loss were not followed through on. As a result, there were residents who experienced falls, some of them with injury, worsening pressure injuries, development of new pressure injuries, medication errors, resident weight loss, and residents expressing feelings of being neglected because there is not enough staff to take care of their needs. The facility failure to ensure residents were free from neglect, created a finding of immediate jeopardy that began on 2/28/22. Administrator- A and VP of Operations- L were notified of the immediate jeopardy on 4/4/22 at 4:45 p.m. As of the exit of the partial extended survey on 4/14/22, the Immediate Jeopardy was not removed. This is evidenced by: Neglect, as defined at §483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. 1. Insufficient Staffing Levels to meet the needs of the residents: According to the Facility Assessment Tool, last updated on 1/24/2022, the facility is licensed to provide care for 87 residents. The average daily census is 71 residents. The Facility's Assessment Tool indicates: 3.2) Staffing plan: [NAME] of [NAME] provides adequate staffing to meet its residents' daily needs, preferences, and routines in order to help each resident attain or maintain the highest practicable physical, mental, and psychosocial well -being. This includes services of a registered nurse for at least eight (8) consecutive hours a day, 7 days a week, a designated licensed nurse to serve as a charge nurse on each tour of duty and adequate staffing on each shift to ensure that our residents' needs are met by registered and licensed nursing staff, certified/ state tested nursing assistants, and other support services that include, but are not limited to, dietary, activities/ recreational, social, therapy and environmental services. Respiratory Therapists will be on staff for the ventilator unit 24 hours a day. During extreme events such as a pandemic if the facility is not able to maintain the minimum number of qualified staff to meet the needs of the residents, all staff will assist with ensuring basic cares are met as the facility is in crisis staffing modes. The non- qualified staff will assist with answering call [NAME], serving meals, making beds, duties which you do not need to be certified to perform. [NAME] of [NAME] consistently reviews adequate staffing based on census, acuity, and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The survey team entered the facility on 3/28/22 at 8:00 a.m. Staff interview was conducted, and it was confirmed that there was only 1 Registered Nurse and 5 Certified Nursing Assistants to care for 70 residents. Facility staff stated that the morning medication pass on 3/28/22 would not be completed and the only Registered Nurse had to stay on the Vent unit, leaving the other 4 units without a licensed nurse. The facility is composed of five units (East, West, North, Rehab and the Vent unit). A review of the facility staff schedules for the month of March 2022 showed that the facility was often understaffed causing staff to work on more than one unit and at times working without the assistance of another staff member on their assigned unit. On 3/29/22, at 5:00 AM, Surveyor interviewed LPN-P (Licensed Practical Nurse) who stated she was working overnight on 3 units (North, East, Vent) with 3 CNAs one each on the Vent, Rehab, and West units. LPN-P stated all the care was not provided as they were supposed to split the units, rounds were not done as it is too hard to do it when staffing is horrible. LPN-P stated no rounds done since residents went to bed last night and she planned to look for one of the CNAs to she can help him start. LPN-P stated there are no care plans so the CNAs do not know what care to provide and how to transfer residents. LPN-P stated no charting by CNAs in the electronic medical record so the nurses are unable to check if care was provided or not. LPN-P stated the example of no charting on eating so she is unable to tell families about the residents. LPN-P stated no showers are given by CNAs as there is no staff. Surveyor noted R2's call light was on at 5:00 AM when Surveyor began interviewing LPN-P. When Surveyor called attention to the long period of time that R2's call light was on, LPN-P stated See, I don't even know where to start because there is so much to do. R2's call light remained unanswered as LPN-P distributed paper bags of pharmacy medications to each nursing cart. LPN-P stated she needed to go to the rehab unit and login the agency nurse into the electronic medical record under LPN-P's name. LPN-P stated the agency nurse does not have a login to chart so it has to be done under her name. On 3/29/22, at 5:15 AM, Surveyor interviewed CNA-U working on R2, R4, and R14's unit who stated she has worked here since 2/22 and regrets it as there is terrible care provided in this facility. CNA-U stated she could go on and on about the residents' needs. CNA-U stated one resident needed to be changed when she came in at 10 PM but she had to wait as until 12:30 AM for help to turn and reposition. CNA-U stated the facility does not provide the proper linen to clean and change people. CNA-U stated she is unable to get any assistance to turn residents so no repositioning for some residents and rounds are hard to do, to change residents without help. CNA-U stated she tries her best but there is no staff and sometimes night staff leave and come back at 5:30 AM or just sleep during the night On 3/30/22, at 7:00 AM, Surveyor interviewed LPN-P who stated she was the only nurse in the facility when the PM nurse who stayed to help night shift left around 4:00-5:00 AM. LPN-P stated there were only 2 CNAs overnight in the facility so not all care was possible because repositioning requires 2 people. LPN-P stated there was a fall but she did not have time to document, computer not working, and she was returning to the facility at 3:00 PM. LPN-P stated the PM nurse completed the blood sugars prior to leaving in the early AM. LPN-P indicated concerns about minimum standards for staffing. Interviews with staff provided additional evidence that many staff were feeling frustrated with long hours and were very aware that not all of the care was being provided to residents. Administration was aware of these staffing concerns and continued to admit residents. 47 residents had been admitted to the facility from 2/1/22-3/31/22. With each new admission, comprehensive assessments needed to be completed to assure that all of their care needs were being met. Often times, due to lack of staff, comprehensive assessments were not conducted and care plans were not developed. With each new resident that was being admitted , it would take time for staff to become familiar with resident likes and dislikes and to become familiar with how dependent they were on staff for activities of daily living such as grooming and eating. Often times, the facility used agency staff who were not familiar with the electronic medical record system (access to care plans and nursing notes) and were not familiar with the residents on their assignment because they had not worked at the facility on a consistent basis. (Cross Reference F725) 2. Lack of prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Four residents were reviewed by the survey team (R4, R5, R10, R18) and concerns were that the facility did not ensure they provided comprehensive assessments and care to these residents to prevent pressure injuries from developing and to ensure pressure injuries did not worsen and/or become infected by failure to provide adequate cares and treatments. *Facility has not accessed [NAME] notes since February. This is the weekly skin documentation provided by MD- N (Wound Physican). These notes would indicate the need for new treatments and further interventions that may be needed to assist in the healing of the pressure injuries or prevent the pressure injuries from getting worse. *Facility nurses are not staging or measuring, just describing so the facility is totally reliant on MD-N for staging and measurements. When MD-N is not available, wound care assessments can be delayed with potential for adverse outcomes. Some residents went days without being comprehensively assessed by the wound team. The facility would not have a way to know if the pressure injuries had worsened since they were first observed. *Facility was not following current treatment orders. *Facility did not address repositioning in the resident's care plan or the CNA care card. Agency CNAs stated they did not know they needed to reposition certain residents. Additionally, the facility did not always have the staff needed to reposition the resident assuming they knew she needed repositioning. Observations were made of residents not getting repositioned, often laying on boney prominences and affected areas where a pressure injury had already developed. *R4: The facility did not have the physician's notes for March 2022 and, thus, did not know the status of the resident's wound or the current treatment orders. The facility did not follow current treatment orders. The facility did not address repositioning in the resident's care plan or the CNA care card. Agency CNAs stated they did not know they needed to reposition R4. Additionally, the facility did not always have the staff needed to reposition the resident assuming they knew she needed repositioning. This resident on 2/14/22 developed three unstageable pressure injuries. These combined into one unstageable wound that is now 56 times larger in area than when first identified (2.02 square cm. vs. 160 square cm.). The resident has not been out of bed and, during observations, remained flat on her back in bed. *R10 acquired an unstageable pressure injury while residing at the facility and was hospitalized , requiring intravenous antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . *R5 acquired a stage 4 pressure injury while residing at the facility and was hospitalized , requiring antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . * R18's pressure ulcer to the coccyx was not compressively assessed upon her original admission on 3/1/22 and then upon readmission on 3/22/22 and 3/23/22. R18 did not have a plan of care addressing the pressure ulcer with interventions put into place to aid in the healing of the pressure ulcer. The facility was unable to determine if the treatment they were applying daily to R18's coccyx was effective because they had no means to know if the area was healing or not. The facility neglected these 4 residents by not providing the necessary care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . (Cross reference F686) 3. Lack of Supervision to prevent falls: R16 has had 12 falls since admission on 2/18/22. On 3/26/22, R16 received staples to the back of the head. On 3/27/22, R16 received stitches above the right eyebrow. The facility did not complete an initial fall risk assessment on admission, 2/18/22. Given that R16 fell in the hospital prior to admission to the facility and R16's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R16's electronic medical record (EMR) does not contain documentation that an incident report and fall assessment including root cause analysis was completed for R16's falls. Per documentation, it is unclear what fall interventions were in place at the time of each fall. R16's fall care plan was not initiated until 2/26/22 when R16 had R16's first fall. R16's care plan was only updated on 5 of the 12 falls that R16 had. The facility was unable to provide documentation that neuro checks and vitals, as well as physician notifications were completed with R16's falls. After review of nursing schedules with each of R16's falls, it is noted that based on census and 15 total Residents residing on the same unit as R16, there was inadequate amount of staff to provide supervision to R16 in order to prevent R16 from frequent falling. For example, there were no certified nursing assistants assigned to R16's unit on 2/28/22, 3/26/22, and 3/27/22. On multiple other shifts, there were 2 or 3 CNAs to work five units. R16 is a high risk for falls and based on inadequate staffing, the facility did not provide adequate supervision and services to prevent R16 from frequent falling. The facility neglected to provide adequate supervision to R16 by completing an initial fall risk assessment and developing a fall risk care plan with revisions for each fall, not completing a root cause analysis of each fall, not completing a thorough assessment including neuro checks after each fall, not updating the physician with all falls, and not providing care and treatment based on a comprehensive assessment. (Cross Reference F-689) On 3/31/22 at 9:05 AM, Surveyor interviewed R17 in regard to R17's fall from bed during the night shift of 3/29/22. Surveyor noted there were only 2 CNAs and 2 nurses in the facility at the time of the fall per facility written schedule. R17 stated R17 had been reaching for R17's phone to call 911 in order to get assistance because R17's call light had been on for a long time. In the process of reaching for the phone, R17 slid out of bed and onto the floor. R17 believes R17 laid on the floor approximately 1 hour before a nurse came. R17 also stated that a CNA watched R17 slide out of bed and walked out of R17's room and did nothing to help stop R17 from sliding, provide any assistance, or go get help. R17 stated R17 has been at the facility 2 other times for rehabilitation and this is the worst experience yet. R17 stated R17 feels more sad and hopeless about everything. R17 is angry at the situation. R17 stated R17 is having more anxiety since the 3rd admission and is scared of not getting the help that R17 needs. R17 feels like R17 cannot talk to anyone about it. R17 stated that R17 is a RN and would and never treat anyone as R17 has been treated while at the facility. R 17 stated I am so fearful I will never get the help when I am laying in bed. During the interview, R17 was crying. 4. Significant medication errors: The Survey team requested the daily schedule for 3/28/22 and was provided with a schedule for the AM Shift that showed the facility had only 1 Registered Nurse working on the Vent unit and no other licensed nursing staff for the other 59 residents. On 3/28/22 at 11:40 a.m. Surveyor interviewed Scheduler- M in regard to the staffing for the AM shift for 3/28/22. Scheduler- M stated that there is currently no nurse passing medications to the residents and that the 1 registered nurse on duty is DON- B and she is assigned to work on the Vent Unit which requires its own nurse for each shift. Scheduler- M stated that she is working on getting more staff in and has called all the agencies they have contracts with for staff. Scheduler- M stated she has called every other staff and they either have other jobs or are in school. Scheduler- M stated that there was a Medication Technician that had called in sick, leaving just 1 registered nurse on the shift. Scheduler- M stated that Administrator- A is aware. On 3/28/22, 12 residents (R2, R3, R4, R7, R8, R10, R11, R13, R14, R16, R17 and R18) did not receive their morning and noon medications when the facility only had 1 nurse in the building and could not complete the medication pass. Of the 12 residents, 6 (R2, R4, R10, R11, R13 and R14) residents experienced a significant medication error by not being administered their insulin, tube feeding or IV antibiotic. The facility neglected to provide medications to residents who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Cross Reference F-755 and F-760) 5. Pain Management R18 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor conducted a review of R18's medical record and noted that on 2/15/22, R18's Power of Attorney for Healthcare was activated while being treated at the hospital. On 3/31/22 at 8:40 a.m., Surveyor went to made observations of R18. It was noted that R18 was not in her room, the evening meal tray, with food still present, was on the overbed table as well as 2 pills in a medicine cup. On 3/31/22 at 8:44 a.m., Surveyor interviewed Licensed Practical Nurse (LPN)- F in regard to R18's whereabouts. LPN- F stated that she wasn't exactly sure where R18 was but got a written report that R18 had called 911 emergency services herself the night before on 3/30/22 at approximately 8:20 p.m. Surveyor asked LPN- F if she knew why R18 went to the hospital and LPN- F reviewed the electronic medical record and verified there was no nursing notes regarding the incident. LPN- F stated she was not provided any details, just that R18 had sent herself out. On 3/31/22 at 9:26 a.m., Surveyor interviewed Administrator- A in regard to R18 sending herself out to the hospital by calling 911 Administrator- A stated that she was not aware of this incident and would look into it. Surveyor told Administrator- A that the nurse on the unit did not know any details of the incident and that there was nothing written for communication within the nursing notes. Administrator- A verified that an agency nurse was working on 3/30/22 when R18 called 911 and she would need to contact the nurse for details. On 3/31/22 at 10:40 a.m., Administrator- A stated that she had heard R18 sent herself out to the emergency room after a family visit had concluded. Administrator- A stated she is still unaware what hospital R18 went to or any other details. Surveyor contacted R18's Healthcare Power of Attorney on 3/31/22 at 1:48 p.m. R18's AHCPOA stated that she was made aware that R18 wanted to go to the hospital because she was in an extreme amount of pain and could not get any assistance. R18 had reported to a family member she was just going to call 911 herself. AHCPOA (Activated Health Care Power of Attorney) for R18 stated that they had no idea what hospital R18 had went to and they had to call around to all of the local hospitals to find where R18 had been admitted to. (Cross Reference F580) 6. Activities of Daily Living: The facility did not ensure that 10 (R10, R5, R11, R8, R3, R7, R2, R4, R13, R14) of 10 Residents reviewed who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good hygiene. The facility did not have accurate documentation/information to show R10, R5, R11, R8, R3, R7, R2, R4, R13, R14 received showers consistent with the resident's care plans, in addition skin checks were not always completed as per facility policy for R3, R7, R2, R4, R13, R14. R10 is not receiving weekly showers in accordance with R10's plan of care. R10 appeared very disheveled with dry, flaky skin and excessive facial hair when observed on 3/28/22 at 9:20 AM, 12:20 PM, and 2:45 PM and on 3/29/22 at 7:45 AM R11 was observed in bed on 3/28/22 at 12:39 PM with a sheet draped across his lower body and no clothing to the top half of his body. R11's hair was very disheveled and appeared to be greasy as if not washed in some time. R11 is to have a shower at least weekly however no indication of a set day for the shower. There was no indication that R11 had been refusing a shower or bath. The facility was unable to provide any evidence that R11 had been provided a shower for the months of February and March 2022. R8 has physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/31/22, R8 filed a grievance with the facility for not receiving a shower on 1/31/22. R8 was scheduled to have a shower during the day on Friday but it was said the staff person left early and no shower was given. The resolution to the grievance was that R8 was given a shower later that evening by a different staff member. On 3/30/31, Surveyor requested to review any documentation that would provide evidence that R8 was receiving a shower, at least weekly, or a bath. The facility was unable to provide any evidence that R8 had been provided a shower for the months of February and March 2022. R7 stated on 3/29/22 at 10:06 AM R7 has received 2 showers in 6 weeks. R7 was informed R7's shower day was on Fridays on day shift. R7 informed Surveyor that R7 would prefer a shower 2 times a week. R7 stated that of the 2 showers that R7 received, R7 got R7's hair washed 1 time because R7 asked to get it washed. R7 informed Surveyor that R7's family has come in to give R7 showers. Surveyor also shared that R7 has only received 2 showers since admission. R2 stated on 3/28/22 at 10:06 AM going through hell and supposed to get a shower but since August (2021) have only had a few showers. R2 had only one documented shower on 3/7/22 in the last 30 days. The facility has no completed skin check sheets which are to be done with shower per facility policy for R2. R4 was observed on 3/29/22 at 8:10 AM lying in the bed on her back with lips cracked and no moisture noted on dry mucous membranes and long beard hairs on chin. R4 stated liking to have her chin shaved and telling the nurses if they see anything on the face to take it off. Surveyor noted R4 had only one documented shower on 3/9/22 in the last 30 days. R13 had documented showers on 3/4/22, 3/9/22, 3/10/22 in the last 30 days. Documentation indicated R13 had not had a shower in 20 days. R14 was admitted to the facility on [DATE]. R14 had no documented showers since admission for 12 days. (Cross Reference F677) On 3/22/22, SW-C was informed of an allegation of neglect by R7 being denied assistance of being put on the bedpan and had to wait 2 hours for assistance. R7 is her own person. R7's Admission MDS dated [DATE] documents R7's BIMS score to be 15, indicating R7 is cognitively intact for daily decision making. R7's PHQ-9 score is 1, indicating minimal depression. R7 requires extensive assistance with bed mobility and dressing. R7 requires total assistance for transfers and bathing. On 3/29/22 at 10:06 AM, Surveyor interviewed R7. R7 stated that on 3/17/22, R7 requested the bed pan. The nurse placed the bedpan next to R7's bed on the bedside table and walked out of the room. R7 turned the call light on again and waited 2 hours for assistance. R7 stated R7 had to call family in to assist R7. R7 stated during that time, R7 was cramping, in pain, and crying. R7 stated R7 informed SW-C of the incident. On 3/31/22 at 8:45 AM, Surveyor interviewed R7 in regard to the care that R7 has not been receiving while at the facility. R7 explained that R7 had to call family in several times to come to the facility so R7 could get assistance with cares. R7 explained that R7's call light would be on for a long time and no one would come to assist R7. R7 stated not getting cares is making R7 more sad while at the facility. R7 stated R7 cries when R7 cannot get the help, which is a lot. R7 explained it hurts because R7 has to rely on others for assistance because R7 struggles with the loss of being independent. (Cross Reference F609 & F610) 7. Weight Loss R16 and R9 experienced significant weight loss due to staff neglect. Staff did not alert the physician, did not obtain ordered speech therapy evaluation, and did not follow dietary recommendations based on a comprehensive assessment from the Registered Dietician. This resulted in a finding of immediate jeopardy and substandard quality of care. The dietitian stated R16's weight loss was life-threatening. (Cross Reference F692) The failure to assure that all 70 residents were free from neglect created a finding of Immediate Jeopardy (IJ). As of 4/14/22, the facility continued to have ongoing staffing issues with obtaining and retaining CNAs and licensed nursing staff. The facility owes staffing agencies money which limits their ability to get staff. The facility was not able to retain an MDS nurse. On 4/11/22 from 9:00 PM to 10:00 PM there was only 2 CNAs and 2 nurses for the building. According to Administrator A, on 4/11/22 Scheduler I came in and informed Administrator A, VPO-L and RN-BB expressed concerns with the staffing. Administrator A stated they were piece-[NAME] the evening shift and they couldn't get anyone else. VPO-L and Corporate RN BB were in the building and aware of the staffing shortage. On 4/14/22, Scheduler I provided a written statement to surveryos indicating she shared the 4/11/22 pm staffing concern to both Administrator A and VPO L on 4/11/22. Administrator A stated VPO L and Corporate RN BB are both RNs. Administrator A stated neither VPO L or RN BB went to assist with Resident care. Administrator A stated VPO L and Corporate RN BB left the building at 9:00 PM. According to the facility's removal plan, Corporate RN BB is part of the facility's plan to assist with the stability, training and to ensure clinical systems are reinstituted, monitored and maintained until the facility shows compliance as determined by the Regional Nurse Consultant and Corporate team. Corporate RN BB is also part of the Monitoring, Audit, and QAPI (Quality Assurance Performance Improvement) plan. On 4/14/22 the facility had their QAPI meeting. This was the first meeting conducted after 4/4/22 when the QAPI team met to discuss the IJ citations and plans of abatement. Neither VPO-L or Corporate RN BB were in attendance. On 4/14/22, Administrator A informed Surveyor that earlier this morning on 4/14/22, VPO- L and Corporate Consultant RN BB flew back to North Carolina, and that they informed Administrator A there was an issue with the Management contract. Administrator A stated they VPO-L and Corporate Consultant RN BB indicated they would not be back in the building until the issue with the contract is clarified. As of the exit of the partial extended survey on 4/14/22, the Immediate Jeopardy was not removed.

Based on observation, interview and record review, the facility did not provide sufficient staffing to meet the needs of 70 out of 70 residents living in the facility. The survey team entered the building on 3/28/22 at 8:00 a.m. Staff interview was conducted, and it was confirmed that there was only 1 Registered Nurse and 5 Certified Nursing Assistants to care for 70 residents. Facility staff stated that the morning medication pass would not be completed and the only Registered Nurse had to stay on the Vent unit, leaving the other 4 units without a licensed nurse. A review of the facility staff schedules for the month of March 2022 showed that the facility was often understaffed causing staff to work on more than one unit and at times working without the assistance of another staff member on their assigned unit. Because there was inadequate staff, residents were left in their rooms and in bed, did not receive showers/baths, did not receive assistance with daily hygiene, were not provided with enough supervision to prevent falls, residents who were at risk for skin breakdown were not turned and repositioned to prevent skin breakdown, did not receive medications timely, and did not receive scheduled treatments. Residents stated that they felt scared and felt neglected and felt as if no one would help them because there was no staff. Inadequate staffing was a root cause contributing to the six other immediate jeopardy citations issued following this survey. The failure to provide adequate staffing created a finding of Immediate Jeopardy that began on 2/28/22. Nursing Home Administrator- A, and Chief Operating Officer/Vice President of Operations (VPO) L were notified of the immediate jeopardy on 4/4/22 at 4:45 p.m. As of 4/14/22 at the time of the exit for the partial extended survey, the Immediate Jeopardy had not been removed. Findings include: According to the Facility Assessment Tool, last updated on 1/24/2022, the facility is licensed to provide care for 87 residents. The average daily census is 71 residents. Services and care that [NAME] of [NAME] Village offer based on resident's needs includes: activities of daily living, pressure injury prevention and care, management of medical conditions, administration of medications, pain management, therapy, nutrition, person- centered/directed care, and psycho/ social /spiritual support. The Facility Assessment documents; 3.2) Staffing plan: [NAME] of [NAME] provides adequate staffing to meet its residents' daily needs, preferences, and routines in order to help each resident attain or maintain the highest practicable physical, mental, and psychosocial wellbeing. This includes services of a registered nurse for at least eight (8) consecutive hours a day, 7 days a week, a designated licensed nurse to serve as a charge nurse on each tour of duty and adequate staffing on each shift to ensure that our residents' needs are met by registered and licensed nursing staff, certified/ state tested nursing assistants, and other support services that include, but are not limited to, dietary, activities/ recreational, social, therapy and environmental services. Respiratory Therapists will be on staff for the ventilator unit 24 hours a day. During extreme events such as a pandemic if the facility is not able to maintain the minimum number of qualified staff to meet the needs of the residents, all staff will assist with ensuring basic cares are met as the facility is in crisis staffing modes. The non- qualified staff will assist with answering call [NAME], serving meals, making beds, duties which you do not need to be certified to perform. [NAME] of [NAME] consistently reviews adequate staffing based on census, acuity, and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility is composed of five units (East, West, North, Rehab and the Vent unit). According to the Resident Census and Condition Report (Centers for Medicare and Medicaid- Form 672) for the facility, the facility's 70 residents have the following personal care needs: Bathing: Assist of 1 or 2 staff - 49 residents Dependent (require total assistance) - 21 residents Dressing: Assist of 1 or 2 staff - 54 residents Dependent - 10 resident Transferring: Assist of 1 or 2 staff - 37 residents Dependent - 23 residents Toilet use: Assist of 1 or 2 staff - 47 residents Dependent - 17 residents Eating: Assist of 1 or 6 staff - 22 residents Dependent - 8 residents On 3/29/22, at 10:45 AM, Surveyor interviewed SCH-I (CNA). SCH-I stated she staffs by census and acuity but mostly census. SCH-I stated for a census of 70, the plan is: Days & PMs-3 nurses and a Med Tech or 4 nurses. 6-7 CNAs. Nights-3 nurses and 4 CNAs. Always a nurse in the vent unit. SCH-I stated there is not always an RN on the weekends. On 3/28/22, at 11:36 AM, SCH-I (Scheduler) stated we try to have a CNA on each unit if we have enough, but we are understaffed as we need 2 assist with 2 person transfers. The schedules provided indicated short staffing on multiple days across multiple shifts, as evidenced by: Friday March 4th night shift had 2 CNAs; not 4 CNAs. Saturday March 5th night shift had 1 CNA; not 4 CNAs. Wednesday March 9th PM shift had 4 CNAs; not 6-7 CNAs. Friday March 11th night shift had 2 CNAs; not 4 CNAs. Saturday March 12th night shift had 2 CNAs; not 4 CNAs Sunday March 13th night shift had 2 CNAs; not 4 CNAs. Monday March 14th night shift had 2 nurses; not 3 nurses. Wednesday March 16th night shift had 2 nurses, 2 CNAs; not 3 nurses and 4 CNAs. Saturday March 19th night shift had 1 nurse and 2 CNAs; not 3 nurses and 4 CNAs. Sunday March 20th night shift had 1 nurse and 1 CNA; not 3 nurses and 4 CNAs. Tuesday March 22nd night shift had 2 nurses, 2 CNAs; not 3 nurses and 4 CNAs. Wednesday March 23rd night shift had 2 nurses, 2 CNAs; not 3 nurses and 4 CNAs. Friday March 25th night shift had 2 CNAs, not 4 CNAs. Saturday March 26th night shift had 2 CNAs; not 4 CNAs. Sunday March 27th day shift had 3 CNAs, PM shift had 3 CNAs; not 6-7 CNAs. Monday March 28th day shift had 1 nurse (not 3 nurses), PM shift had 2 nurses (not 3 nurses), night shift had 2 nurses (not 3 nurses), 3 CNAs (not 4 CNAs). Census is now 70. Tuesday March 29th night shift had 1 nurse with the PM nurse remaining over until 4-5 AM and only 2 CNAs; not 3 Nurses and 4 CNAs. As of 4/14/22, the facility continued to have ongoing staffing issues with obtaining and retaining CNAs and licensed nursing staff. According to Administrator A, the facility owes staffing agencies money which limits their ability to get staff. On 3/28/22 at 8:00 a.m., Surveyors entered the facility to conduct complaint investigations. It was noted that the facility census was 70 residents, 11 of these residents resided on the Vent unit. The Survey team requested the daily schedule for 3/28/22 and was provided with a schedule for the AM Shift that showed the facility only had 1 Registered Nurse working on the Vent unit (11 residents) and no other licensed nursing staff for the other 59 residents. It was also noted that there was only 5 Certified Nursing Assistants working for the entire facility. On 3/28/22 at 11:40 a.m. Surveyor interviewed Scheduler- I in regard to the staffing for the AM shift for 3/28/22. Scheduler- I stated that there is currently no nurse passing medications to the residents and that the 1 registered nurse on duty is Director of Nursing (DON)- B and she is assigned to work on the Vent Unit which requires its own nurse for each shift. Scheduler- I stated that she is working on getting more staff in and has called all the agencies they have contracts with for staff. Scheduler- I stated she has called every other staff and they either have other jobs or are in school. Scheduler- I stated that there was a Medication Technician that had called in sick, leaving just 1 registered nurse on the shift. Scheduler- I stated that Administrator- A is aware. 1. The facility failed to ensure that it had adequate staffing to meet the needs of its 70 residents. Due to inadequate staffing levels, residents did not receive personal cares such as showers/baths, adequate supervision to prevent falls, and care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . One resident admitted herself into a hospital as was in an extreme amount of pain and was not getting assistance. Dietitian and Physician or dietitian recommendations for residents' weight loss were not implemented. As a result, there were residents who experienced falls, some of them with injury, worsening pressure injuries, development of new pressure injuries, medication errors, resident weight loss, and residents expressing feelings of being neglected because there is not enough staff to take care of their needs. The facility failure to ensure residents were free from neglect, created a finding of immediate jeopardy and Substandard Quality of Care. (Cross Reference F600) 2. On 3/28/22, 12 residents (R2, R3, R4, R7, R8, R10, R11, R13, R14, R16, R17 and R18) did not receive their morning and noon medications when the facility only had 1 nurse in the building and could not complete the medication pass. Of the 12 residents, 6 (R2, R4, R10, R11, R13 and R14) residents experienced a significant medication error by not being administered their insulin, tube feeding or IV antibiotic. (Cross Reference F755 and F760) 3. The facility failed provide sufficient staff to ensure 10 residents (R2, R3, R4, R5, R7, R8, R10, R11, R13, R14) who are dependent on staff for activities of daily living received weekly skin checks and showers/ baths and assistance with personal hygiene. R10 is not receiving weekly showers in accordance with R10's plan of care. R10 appeared very disheveled with dry, flaky skin and excessive facial hair when observed on 3/28/22 at 9:20 AM, 12:20 PM, and 2:45 PM, and on 3/29/22 at 7:45 AM. R11 was observed in bed on 3/28/22 at 12:30 PM .R11's hair was very disheveled and appeared to be greasy as if not washed in some time. R11 is to have a shower at least weekly however no indication of a set day for the shower. The facility was unable to provide any evidence that R11 had been provided a shower for the months of February and March 2022. R4 was observed on 3/29/22 at 8:10 AM lying in bed on her back with lips cracked and no moisture noted on dry mucous membranes and long beard hairs on chin. R4 stated liking to have her chin shaved and telling the nurses if they see anything on the face to take it off. Surveyor noted R4 had only one documented shower on 3/9/22 in the last 30 days. (Cross Reference F677) 4. The facility failed to provide sufficient staff to ensure that 4 residents (R4, R5, R10 and R18) received the appropriate treatment and services to maintain or promote the healing of their pressure ulcers. These 4 residents were not provided comprehensive assessments of their pressure ulcers, not provided with appropriate wound treatments, and not always provided with additional interventions such as pressure relief and repositioning while in the chair or bed. This resulted in a finding of immediate jeopardy and substandard quality of care R4. On 2/14/22, R4 developed three unstageable pressure injuries. These combined into one unstageable wound that is now 56 times larger in area than when first identified (2.02 sq. cm. vs. 160 sq. cm). In addition, during 2 different wound care observations, R4 had developed two additional ischial wounds that were not addressed by the facility. Staff was not aware R4 needed repositioning. On 3/30/22, at 7:10 AM, Surveyor observed R4 in bed lying flat on back. R4 stated she has not seen any staff all night and her door was closed. R10 acquired an unstageable pressure injury while residing at the facility and was hospitalized , requiring intravenous antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] R5 acquired a stage 4 pressure injury while residing at the facility and was hospitalized , requiring antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] R18's pressure ulcer to the coccyx was not compressively assessed upon her original admission on 3/1/22 and then upon readmission on 3/22/22 and 3/23/22. R18 did not have a plan of care addressing the pressure ulcer with interventions put into place to aide in the healing of the pressure ulcer. The facility was unable to determine if the treatment they were applying daily to R18's coccyx was effective because they had no means to know if the area was healing or not. As documented in F686, there were multiple occasions where staff did not provide ordered treatments. (Cross Reference F686) 5. The facility failed to provide sufficient staff to ensure that 2 residents (R16 and R3), who were at risk for falls and had fallen previously in the facility were provided with enough supervision to prevent accidents, resulting in serious injuries. This resulted in a finding of immediate jeopardy and substandard quality of care. R16 has had 12 falls since admission on 2/18/22 to 4/3/22. The fall on 3/27/22 (which was the second fall that day) resulted in stitches above the right eyebrow. The fall on 3/26/22 resulted in staples to the back of the head. The fall on 4/2/22 resulted in a re-opening of the staples. The fall on 4/3/22 led to a laceration on the resident's face that required steri-strips. After review of nursing schedules with each of R16's falls, it is noted that based on census and 15 total Residents residing on the same unit as R16, there was an inadequate number of staff to provide supervision to R16 in order to prevent R16 from frequent falling. At times there was no CNA assigned to R16's unit. On 3/20/22 R3 had a fall with injury and a fall assessment with a thorough root cause analysis, and Neuro checks was not completed. (Cross Reference F689) 6. The facility failed to provide sufficient staff to ensure that 2 residents (R16 and R9) who experienced significant weight loss were provided with the necessary care and services to maintain their nutritional status. Staff did not alert the physician and follow recommendations based on a comprehensive assessment from the Registered Dietician. This resulted in a finding of immediate jeopardy and substandard quality of care. On 3/31/22, R16's weight was obtained. RD-D documents R16's weight has declined to 72.6 pounds, an 18.6% weight loss since admission. RD-D describes the weight as severely underweight and life-threatening. RD-D contacted the Nursing Home Administrator and recommended R16 be transferred to the hospital STAT. R16 was sent to the emergency room (ER) and returned to the facility on [DATE]. R9 experienced a significant weight loss of 35.4 pounds (29.8%) from 11/15/21 to 1/31/22 without any compressive assessment or dietary intervention. (Cross Reference F692) 7. The facility did not provide necessary cares and services to promote quality of life and assist 70 out of 70 residents with the necessary care and services for Residents to attain or maintain the highest practical physical, mental, and psychosocial well-being. This resulted in a finding of immediate jeopardy and substandard quality of care. R18 had called 911 emergency services herself the night before on 3/30/22 at approximately 8:20 p.m. Administrator- A stated that she had heard R18 sent herself out to the emergency room after a family visit had concluded. Administrator- A stated she is still unaware what hospital R18 went to or any other details. R18's AHCPOA stated that she was made aware that R18 wanted to go to the hospital because she was in an extreme amount of pain and could not get any assistance. R18 had reported to a family member she was just going to call 911 herself. AHCPOA (Activated Health Care Power of Attorney) for R18 stated that they had no idea what hospital R18 had went to and they had to call around to all of the local hospitals to find where R18 had been admitted to. On 3/31/22 at 8:45 AM, R7 informed Surveyor of the cares R7 has not been receiving in the facility. R7 explained that R7 had to call family in several times to come to the facility so R7 could get assistance with cares. R7 explained that R7's call light would be on for a long time, and no one would come to assist R7. R7 stated not getting cares is making R7 more sad while at the facility. R7 stated R7 cries when R7 cannot get the help, which is a lot. R7 explained it hurts because R7 has to rely on others for assistance because R7 struggles with the loss of being independent. On 3/31/22 at 9:05 AM, Surveyor interviewed R17 in regard to R17's fall from bed during the night shift of 3/29/22. Surveyor noted there was only 2 CNAs and 2 nurses in the facility at the time of the fall per facility written schedule. R17 stated R17 had been reaching for R17's phone to call 911 in order to get assistance because R17's call light had been on for a long time. In the process of reaching for the phone, R17 slid out of bed and onto the floor. R17 believes R17 laid on the floor approximately 1 hour before a nurse came. R17 also stated that a CNA watched R17 slide out of bed and walked out of R17's room and did nothing to help stop R17 from sliding, provide any assistance, or go get help. R17 stated R17 has been at the facility 2 other times for rehabilitation and this is the worst experience yet. R17 stated R17 feels more sad and hopeless about everything. R17 is angry at the situation. R17 stated R17 is having more anxiety since the 3rd admission and is scared of not getting the help that R17 needs. R17 feels like R17 cannot talk to anyone about it. R17 stated that R17 is a RN and would and never treat anyone as R17 has been treated while at the facility. I am so fearful I will never get the help when I am laying in bed. During the interview, R17 was crying. (Cross Reference F675) On 3/30/22 at 3:30 p.m., Surveyor interviewed Administrator - A regarding the staffing shortage that the facility is experiencing. Administrator- A stated that the Corporate Human Resources Department is running several ads to hire employees. Administrator- A stated that several interviews are set-up and then people don't show up for the actual appointment. Administrator - A provides a weekly orientation to new staff and has found that for whatever reason staff don't stay on as employees after orientation. Administrator- A acknowledged that there are many open positions for nursing and certified nursing assistant staff and that Corporate level staff are aware. Administrator- A stated that she reports weekly to VPO L where the facility is at with staffing levels. Administrator- A confirmed that DON- B is wishing to step-down and just work on the Vent Unit and this will leave an opening for a Director of Nursing as well as there is an opening for a MDS (Minimum Data Set) Nurse. Administrator - A stated that the facility has a contract with 3 different staffing agencies, and often this can be challenge because the staffing agencies are short on staff. Administrator- A stated that the Corporation was going to send a Regional Nurse to assist, but the nurse fell ill and was unable to travel. On 3/31/22 at 12:10 p.m., Surveyor interviewed Administrator- A regarding the facility's admission during the month of February and March 2022. Administrator- A provided Surveyor with a report that showed the facility accepted 47 new admissions during February and March 2022. Administrator- A stated that she was aware of the staffing shortages and would report this to the Corporation weekly. Administrator- A states she was told the facility should continue to take new admissions during this time. (Cross reference F837) 8. On 3/28/22, at 9:30 AM, Surveyor observed R14 who was sitting up in the bed. R14 stated she was uncomfortable but had no rail to assist with turning and no staff to provide assistance. On 3/29/22, at 8:15 AM, Surveyor interviewed R14 who stated no medications were administered yesterday as R14 was told there was no licensed person to give them. 9. On 3/28/22, at 10:06 AM, Surveyor observed R2 lying in the bed with a Foley. R2 stated she was going through hell as she was supposed to get showers, left in the bed 24 hours/day as no one to get her up, no Foley care. On 3/29/22, at 5:35 AM, Surveyor observed R2's call light remained on and unanswered. On 3/29/22, at 5:49 AM, Surveyor observed R2's call light was answered at change of shift. On 3/29/22, at 8:20 AM, Surveyor interviewed R2 who stated she had a good night but the staff did not get me up as assigned (R2 is a night shift get up-early AM). R2 stated she was waiting. R2 stated she did not know why the staff even believe she refuses as the call light was on. On 3/28/22, at 10:30 AM, Surveyor interviewed DON-B (Director of Nursing) who was the vent unit nurse. DON-B stated she was also the facility Infection Preventionist, Wound Care Nurse, and acting DON on paper. On 3/28/22, at 12:00 PM, DON-B stated she tried to do most of the residents' blood sugars but no insulins or IV medications were given as there was no time. DON-B stated she would try to do her best to get the noon blood sugars done but she did not know if she could as she needed to be in the vent unit. On 3/28/22, at 12:27 PM, NHA-A stated she did a blanket call to physicians to notify them that medications were not given and stated insulins and tube feedings were not done. On 3/28/22, at 12:50 PM, Surveyor interviewed CNA-R (Certified Nurse Assistant) working on R2, R4, and R14's unit who stated she was from agency and the facility just put us here with no guidance, no nurse, no way to chart except through others login, and no care cards. On 3/28/22, at 12:55 PM, Surveyor interviewed CNA-S working on R2, R4, and R14's unit who stated she was from agency and has come here before so we know the residents a little bit but there is no nurse today to check and confirm care. On 3/28/22, at 2:47 PM, Surveyor interviewed MT-O (Med Tech) who stated she was passing medications for 34 residents. MT-O stated she will not give the missing AM medications as it is not in the plan as it is too late and too far out. On 3/29/22, at 5:00 AM, Surveyor interviewed LPN-P (Licensed Practical Nurse) who stated she was working overnight on 3 units (North, East, Vent) with 3 CNAs one each on the Vent, Rehab, and West units. LPN-P stated all the care was not provided as they were supposed to split the units, rounds were not done as it is too hard to do it when staffing is horrible. LPN-P stated no rounds done since residents went to bed last night and she planned to look for one of the CNAs to she can help him start. LPN-P stated there are no care plans so the CNAs know what care to provide and how to transfer residents. LPN-P stated no charting by CNAs in the electronic medical record so the nurses are unable to check if care was provided or not. LPN-P stated the example of no charting on eating so she is unable to tell families about the residents. LPN-P stated no showers are given by CNAs as there is no staff. Surveyor noted R2's call light was on at 5:00 AM when Surveyor began interviewing LPN-P. When Surveyor called attention to the long period of time that R2's call light was on, LPN-P stated See, I don't even know where to start because there is so much to do. R2's call light remained unanswered as LPN-P distributed paper bags of pharmacy medications to each nursing cart. LPN-P stated she needed to go to the rehab unit and login the agency nurse into the electronic medical record under LPN-P's name. LPN-P stated the agency nurse does not have a login to chart so it has to be done under LPN-P's name. On 3/29/22, at 5:15 AM, Surveyor interviewed CNA-U working on R2, R4, and R14's unit who stated she has worked here since 2/22 and regrets it as there is terrible care provided in this facility. CNA-U stated she could go on and on about the residents' needs. CNA-U stated one resident needed to be changed when she came in at 10 PM but she had to wait as until 12:30 AM for help to turn and reposition. CNA-U stated the facility does not provide the proper linen to clean and change people. CNA-U stated she is unable to get any assistance to turn residents so no repositioning for some residents and rounds are hard to do, to change residents without help. CNA-U stated she tries her best but there is no staff and sometimes night staff leave and come back at 5:30 AM or just sleep during the night. On 3/29/22, at 5:24 AM, Surveyor interviewed RT-V (Respiratory Therapist) who stated she works from 6:30 PM until 7:00 AM in the vent unit. RT-V stated there is a CNA assigned to work in the vent unit. RT-V stated the nurse comes to vent unit back and forth during the night. On 3/29/22, at 9:50 AM, Surveyor interviewed LPN-J who stated they were always short-staffed, always what she has to go through every day. LPN-J stated the CNAs were cleaning and changing R4 now for the first time so Surveyor could observe R4's wound treatment. On 3/29/22, at 10:45 AM, Surveyor interviewed SCH-I (CNA). SCH-I stated she started in August but since then the facility shut down a staffing program which made staffing easier. SCH-I stated she needed to find a new way to post the nursing hours. SCH-I stated she does not train the new staff but assigns someone to train them. SCH-I stated the agency staff do not get orientation but a quick [NAME] and electronic medical record access. SCH-I stated LPN-P called her at 9:00 PM last night to state the vent nurse called in and SCH-I requested an agency nurse but did not know who it would be so SCH-I would not be able to assign electronic medical record access. SCH-I stated there were nights with only 1 nurse in the facility including 3/20/22. On 3/30/22, at 7:00 AM, Surveyor interviewed LPN-P who stated she was the only nurse in the facility when the PM nurse who stayed to help night shift left around 4:00-5:00 AM. LPN-P stated there were only 2 CNAs overnight in the facility so not all care was possible because repositioning requires 2 people. LPN-P stated there was a fall but she did not have time to document, computer not working, and she was returning to the facility at 3:00 PM. LPN-P stated the PM nurse completed the blood sugars prior to leaving in the early AM. LPN-P indicated concerns about minimum standards for staffing. Surveyor observed R14's call light was on and LPN-P stated she did not know the time of call light initiation. On 3/30/22, at 8:57 AM, Surveyor interviewed MD-N (Wound Physician) who stated typically if he can find a nurse or use an aide to make rounds with him but sometimes there is no staff to assist so he has to go by himself. MD-N stated repositioning definitely should happen. MD-N stated he touches base with DON-B so he knows which residents to see but DON-B is not always available for follow-up. On 3/30/22, at 3:00 PM, Surveyor observed R14's PICC line which had a 3/18/22 admitted d dressing. Surveyor noted R14 had a 3/25/22 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's MAR (Medication Administration Record) indicated initials and documentation of dressing change on 3/25/22 at 8:00 AM. Surveyor notified DON-B of the dated 3/18/22 dressing and the conflicting documentation in R14's MAR. DON-B stated she will assess and change the dressing, rewrite the order then educate the nurse. Staffing continues to be an issue even after informing the facility of having an Immediate Jeopardy for staffing 4/4/22. On 4/11/22 from 9:00 PM to 10:00 PM there was only 2 CNAs and 2 nurses for the building. According to Administrator A, on 4/11/22 Scheduler I came in and informed Administrator A, VPO (Vice President of Operations) -L and RN (Corporate RN Consultant)-BB of concerns with lack of staffing. Administrator A stated on 4/11/22 they were piece-[NAME] the evening shift and they couldn't get anyone else. VPO-L and Corporate RN BB were in the building and aware of the staffing shortage. (On 4/14/22 Scheduler I provided surveyors with a written statement verifying this information). Administrator A stated VPO L and Corporate RN BB are both RNs. Administrator A stated neither VPO L or RN BB went to assist with Resident care. Administrator A stated VPO L and Corporate RN BB left the building at 9:00 PM. The failure to provide adequate staff to meet the needs of the residents created a reasonable likelihood that serious harm could occur, resulting in a finding of Immediate Jeopardy. As of 4/14/22 at the time of the partial extended survey exit, the facility had not removed the Immediate Jeopardy.

Based on observations, interviews and record reviews, the facility did not provide necessary cares and services to promote quality of life and assist 70 out of 70 residents maintain their highest practicable level of physical, mental, and psychosocial well-being. Residents stated that they felt scared and felt neglected and felt as if no one would help them because there was no staff. The governing body did not ensure and the facility did not provide an adequate level of staff to provide cares and services to residents of the facility for an extended period of time. This left residents to go without showers/ baths, daily personal hygiene, repositioning in the bed and chairs, proper treatment and assessments of pressure ulcers, prevention of falls and medications administered per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility continued to admit new residents to the facility knowing that they were facing daily staffing shortages and providing necessary cares and services to the current residents proved to be incomplete. This pervasive disregard for residents' quality of life created a finding of immediate jeopardy that began on 2/28/22. Administrator- A and VP of Operations- L were notified of the immediate jeopardy on 4/4/22 at 4:45 p.m. As of the time of the partial extended survey exit on 4/14/22, the facility did not remove the Immediate Jeopardy. This is evidenced by: During this complaint investigation the following deficiencies were identified: 1. 70 residents were not free from neglect when the facility and governing body did not ensure that sufficient staff were deployed to care for residents. This resulted in a finding of immediate jeopardy and substandard quality of care. (Cross Reference F600) 2. 10 residents who are dependent of staff for activities of daily living did not receive weekly skin checks and showers/ baths and assistance with personal hygiene. The facility did not have accurate documentation/information to show R10, R5, R11, R8, R3, R7, R2, R4, R13, R14 received showers consistent with R's care plans, in addition skin checks were not always completed as per facility policy for R3, R7, R2, R4, R13, R14. R10 is not receiving weekly showers in accordance with R10's plan of care. R10 appeared very disheveled with dry, flaky skin and excessive facial hair when observed on 3/28/22 at 9:20 AM, 12:20 PM and 2:45 PM and on 3/29/22 at 7:45 AM. R11 was observed in bed on 3/28/22 at 12:30 PM .R11's hair was very disheveled and appeared to be greasy as if not washed in some time. R11 is to have a shower at least weekly however no indication of a set day for the shower. The facility was unable to provide any evidence that R11 had been provided a shower for the months of February and March 2022. R4 was observed lying in the bed on 3/29/22 at 8:10 AM on her back with lips cracked and no moisture noted on dry mucous membranes and long beard hairs on chin. R4 stated liking to have her chin shaved and telling the nurses if they see anything on the face to take it off. Surveyor noted R4 had only one documented shower on 3/9/22 in the last 30 days. (Cross Reference F677) 3. 4 residents (R4, R10, R5, R18) did not receive the appropriate treatment and services to prevent/ heal pressure ulcers. This resulted in a finding of immediate jeopardy and substandard quality of care R4. On 2/14/22, R4 developed three unstageable pressure injuries. These combined into one unstageable wound that is now 56 times larger in area than when first identified (2.02 sq. cm. vs. 160 sq. cm). In addition, during 2 different wound care observations, R4 had developed two additional ischial wounds that were not addressed by the facility. R10 acquired an unstageable pressure injury while residing at the facility and was hospitalized , requiring intravenous antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] R5 acquired a stage 4 pressure injury while residing at the facility and was hospitalized , requiring antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] R18's pressure ulcer to the coccyx was not compressively assessed upon her original admission on 3/1/22 and then upon readmission on 3/22/22 and 3/23/22. R18 did not have a plan of care addressing the pressure ulcer with interventions put into place to aide in the healing of the pressure ulcer. The facility was unable to determine if the treatment they were applying daily to R18's coccyx was effective because they had no means to know if the area was healing or not. Facility nurses do not assess, measure or stage pressure injuries. This is left to the wound MD who makes rounds once a week. (Cross Reference F686) 4. 2 residents (R16 and R3) were not provided with care in supervision to prevent accidents, resulting in serious injuries. This resulted in a finding of immediate jeopardy and substandard quality of care. R16 has had 12 falls since admission on 2/18/22 to 4/3/22. The fall on 3/27/22 (which was the second fall that day) resulted in stitches above the right eyebrow. The fall on 3/26/22 resulted in staples to the back of the head. The fall on 4/2/22 resulted in a re-opening of the staples. The fall on 4/3/22 led to a laceration on the resident's face that required steri-strips. After review of nursing schedules with each of R16's falls, it is noted that based on census and 15 total Residents residing on the same unit as R16, there was an inadequate number of staff to provide supervision to R16 in order to prevent R16 from frequent falling. R16 is a [AGE] year-old who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R16 had been living at a group home prior to hospitalization . The facility was unable to locate any documentation from the hospitalization explaining R16's need for the hospitalization from the group home. The facility was not able to provide Surveyor any information in regard to R16's daily routine while at the group home. R16's Admission Minimum Data Set (MDS) dated [DATE] documents R16's short and long term memory is impaired and R16 demonstrates severely impaired skills for daily decision making. R16's PHQ-9 score done by staff is an 8, indicating mild depression. There are no behaviors documented on R16's MDS. R16 is extensive assistance for bed mobility. R16 requires total dependence of 2 staff for transfers. R16 is total dependence for dressing, toileting, and bathing. R16 has both upper and lower bilateral range of motion impairment. R16 is always incontinent and requires tube feeding. Surveyor notes, based on R16's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the [CONDITION(S)] (HD) Society of America, The movement disorder of HD includes emergence of involuntary movements (chorea) and the impairment of voluntary movements, which result in reduced manual dexterity, slurred speech, swallowing difficulties, problems with balance, and falls. Despite knowing R16's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not provide the supervision needed to prevent falls and did not assess or do a root cause analysis of each of R16's falls. There is documentation that R16's initiation to get out of bed or the broda chair was purposeful and with intent. R16 fell twelve times in six weeks, hitting R16's head a number of times and sustaining injuries that needed sutures or staples. R16 repeatedly hit R16's head and was not wearing a helmet, put R16 at risk of sustaining an [MEDICATION(S)] or subdural hematoma. Subdural hematomas can be serious and can lead to decreased quality of life or death. The facility discovered on 3/31/22 that R16 had worn a soft helmet daily while at the group home. On 3/20/22 R3 had a fall with injury and a fall assessment with a thorough root cause analysis, and Neuro checks was not completed. (Cross Reference F689) 5. 2 residents (R16 and R9) experienced significant weight loss without staff alerting the physician and following recommendations based on a comprehensive assessment from the Registered Dietician. This resulted in a finding of immediate jeopardy and substandard quality of care. On 3/31/22, R16's weight was obtained. RD-D documents R16's weight has declined to 72.6 pounds, an 18.6% weight loss since admission. RD-D describes the weight as severely underweight and life-threatening. RD-D contacted the Nursing Home Administrator and recommended R16 be transferred to the hospital STAT. R16 was sent to the emergency room (ER) and returned to the facility on [DATE]. According to Nutritional management of individuals with [CONDITION(S)]: nutritional guidelines, There is a high risk of rapid weight loss for many individuals [with [CONDITION(S)]] . Rapid weight loss can result in loss of muscle mass, weakness, apathy, depression, susceptibility to infection and compromised chest status . Due to staff failure to maintain acceptable parameters of weight for R16, this resulted in an 18.6% weight loss in 39 days for R16. The facility did not weigh R16 as often as dictated by professional standards of practice, did not immediately increase R16's tube feedings when ordered by the dietitian, and did not get a speech therapy evaluation as ordered by the physician to determine to what extent R16 might be able to eat by mouth. Given R16's vulnerabilities ([CONDITION(S)]) and its manifestations, and the need for immediate action, it was determined that repeated, systemic failure to assess and address R16's nutritional status and to implement pertinent interventions based on such an assessment resulted in continued significant or severe weight loss and functional decline for R16. R9 experienced a significant weight loss of 35.4 pounds (29.8%) from 11/15/21 to 1/31/22 without any compressive assessment or dietary intervention. (Cross Reference F692) 6. The governing body and the facility did not ensure there were sufficient staff to care for 70 residents. This resulted in a finding of immediate jeopardy. On 3/28/22, Surveyor noted only one nurse in facility for 70 residents. R4 did not receive meds, insulins not given, GT (Gastric Tube) feeding was not addressed and treatment was not done. On 3/28/22, at 12:50 PM, Surveyor interviewed CNA-R working on R4's unit who stated she was from agency and the facility just put us here with no guidance, no nurse, no way to chart except through others' login, and no care cards. On 3/28/22, at 12:55 PM, Surveyor interviewed CNA-S working on R4's unit who stated she was from agency and has come here before so we know the residents a little bit but there is no nurse today to check and confirm care. On 3/29/22, at 5:00 AM, Surveyor interviewed LPN-P who stated she is working 3 units (North, East, Vent) with 3 CNAs on Vent, Rehab, West units and care is not provided, rounds are not done, too hard to do it as staffing is horrible. LPN-P stated there are no care plans so the CNAs do not know what to do and how to transfer. LPN-P stated no charting by CNAs in the record so the nurses are unable to check care provided or not. On 3/30/22, at 7:00 AM, Surveyor interviewed LPN-P who stated she was the only nurse in the facility when the PM nurse who stayed to help night shift left around 4:00-5:00 AM. LPN-P stated there were only 2 CNAs overnight in the facility so not all care was possible because repositioning requires 2 people. (Cross Reference F725) 7. 12 residents did not receive their morning and noon medications on 3/28/22 when the facility had only 1 nurse in the building and could not complete the medication pass. Of the 12 residents, 6 residents experienced a significant medication error by not being administered their insulin, tube feeding or IV antibiotic. During the first shift on 3/28/22, the facility had only 1 Registered Nurse (RN) on duty with a census of 70 residents. Due to staffing shortages, the 3/28/22 morning and noon medications were not administered to the following residents (R8, R11, R18, R2, R4, R13, R14, R10, R3, R7, R16, and R17). The facility did not follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not ensure that 7 (R2, R4, R13, R14, R10, R11, R18) of 8 residents reviewed were free from significant medication errors. (Cross Reference F755 and F760) 8. The governing body did not ensure that there was sufficient staff as laid out in the facility assessment- staffing plan. The governing body continued to direct the facility to take new admissions even after the Administration reported weekly about concerns for inadequate staffing levels to meet the needs of all the current residents. On 3/31/22 at 12:10 p.m., Surveyor interviewed Administrator- A regarding the facility's admission during the month of February and March 2022. Administrator- A provided Surveyor with a report that showed the facility accepted 47 new admissions during February and March 2022.This resulted in a finding of immediate jeopardy. (Cross Reference F837) 9. On 3/31/22 at 9:05 AM, Surveyor interviewed R17 in regard to R17's fall from bed during the night shift of 3/29/22. Surveyor noted there was only 2 CNAs and 2 nurses in the facility at the time of the fall per facility written schedule. R17 stated R17 had been reaching for R17's phone to call 911 in order to get assistance because R17's call light had been on for a long time. In the process of reaching for the phone, R17 slid out of bed and onto the floor. R17 believes R17 laid on the floor approximately 1 hour before a nurse came. R17 also stated that a CNA watched R17 slide out of bed and walked out of R17's room and did nothing to help stop R17 from sliding, provide any assistance, or go get help. R17 stated R17 has been at the facility 2 other times for rehabalitation and this is the worst experience yet. R17 stated R17 feels more sad and hopeless about everything. R17 is angry at the situation. R17 stated R17 is having more anxiety since the 3rd admission and is scared of not getting the help that R17 needs. R17 feels like R17 cannot talk to anyone about it. R17 stated that R17 is a RN and would and never treat anyone as R17 has been treated while at the facility. I am so fearful I will never get the help when I am laying in bed. During the interview, R17 was crying. 10. On 3/31/22 at 8:45 AM, R7 informed Surveyor of the cares R7 has not been receiving in the facility. R7 explained that R7 had to call family in several times to come to the facility so R7 could get assistance with cares. R7 explained that R7's call light would be on for a long time, and no one would come to assist R7. R7 stated not getting cares is making R7 more sad while at the facility. R7 stated R7 cries when R7 cannot get the help, which is a lot. R7 explained it hurts because R7 has to rely on others for assistance because R7 struggles with the loss of being independent. 11. R18 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor conducted a review of R18's medical record and noted that on 2/15/22, R18's Power of Attorney for Healthcare was activated while being treated at the hospital. On 3/31/22 at 8:40 a.m., Surveyor went to made observations of R18. It was noted that R18 was not in her room, the evening meal tray, with food still present, was on the overbed table as well as 2 pills in a medicine cup. On 3/31/22 at 8:44 a.m., Surveyor interviewed Licensed Practical Nurse (LPN)- F in regard to R18's whereabouts. LPN- F stated that she wasn't exactly sure where R18 was but got a written report that R18 had called 911 emergency services herself the night before on 3/30/22 at approximately 8:20 p.m. Surveyor asked LPN- F if she knew why R18 went to the hospital and LPN- F reviewed the electronic medical record and verified there was no nursing notes regarding the incident. LPN- F stated she was not provided any details, just that R18 had sent herself out. On 3/31/22 at 9:26 a.m., Surveyor interviewed Administrator- A in regard to R18 sending herself out to the hospital by calling 911 Administrator- A stated that she was not aware of this incident and would look into it. Surveyor told Administrator- A that the nurse on the unit did not know any details of the incident and that there was nothing written for communication within the nursing notes. Administrator- A verified that an agency nurse was working on 3/30/22 when R18 called 911 and she would need to contact the nurse for details. On 3/31/22 at 10:40 a.m., Administrator- A stated that she had heard R18 sent herself out to the emergency room after a family visit had concluded. Administrator- A stated she is still unaware what hospital R18 went to or any other details. Surveyor contacted R18's Healthcare Power of Attorney on 3/31/22 at 1:48 p.m. R18's AHCPOA stated that she was made aware that R18 wanted to go to the hospital because she was in an extreme amount of pain and could not get any assistance. R18 had reported to a family member she was just going to call 911 herself. AHCPOA (Activated Health Care Power of Attorney) for R18 stated that they had no idea what hospital R18 had went to and they had to call around to all of the local hospitals to find where R18 had been admitted . Failure to provide residents with the care and services necessary to promote quality of life and promote each resident's highest practicable physical, mental and psychosocial well-being created a reasonable likelihood for serious harm, thus creating a finding of Immediate Jeopardy. As of 4/14/22 at the time of the partial extended survey exit, the facility did not remove the Immediate Jeopardy.

Based on record review and staff interviews, the facility did not always ensure that 2 of 2 Residents (R16 and R9) reviewed for weight loss and overall general decline in condition received care and treatment based on a comprehensive assessment and in accordance with professional standards of practice, particularly assessment, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R16 was admitted to the facility on [DATE]. No comprehensive assessment was completed regarding R16's tube feeding history, reason for use, or evaluation to determine if R16 was a candidate for oral intake. On admission, the facility obtained a weight of 89.2 pounds. There is no documentation of how the weight was obtained. On 3/20/22 the Registered Dietitian (RD-D) documented R16's weight to be 82.2 pounds, a 7.9% unplanned weight loss in 30 days. There is no documentation of how the weight was obtained. There is no documentation R16's physician (DR-H) was notified of the significant weight loss. RD-D recommended to increase the tube feeding and water flushes. R16's tube feeding was not increased until 3/25/22, 5 days after the recommendation. The facility did not follow up on RD-D's 3/20/22 recommendation to increase water flushes as the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon returning to the facility after an emergency room visit on 4/1/22 the water flushes were increased. On 2/18/22, the physician ordered Speech Therapy (ST) screen, evaluate and treat. The facility did not follow through with this order. On 3/25/22, RD-D recommended a speech therapy evaluation and diet evaluation for R16. There is no documentation the ST referral and evaluation was completed. On 4/3/22, RD-D indicates R16 is requesting to eat orally and again documents ST consult ordered and recommend ST evaluate swallow. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/31/22, in the morning, the dietary manager attempted to weigh R16 in the broda chair, but the scale was broken. In the evening of 3/31/22, R16's weight was obtained. RD-D documents R16's weight has declined to 72.6 pounds, an 18.6% weight loss since admission. There is no documentation of how the weight was obtained. RD-D describes the weight as severely underweight and life-threatening. On 3/31/22, RD-D contacted the Nursing Home Administrator and recommended R16 be transferred to the hospital STAT. R16 was sent to the emergency room (ER) and returned to the facility on [DATE]. RD-D recommended another tube feeding change to increase the amount of calories and water R16 should receive. On 4/2/22, R16 was placed at nurse's station during tube feeding time, stood up, and yelled repeatedly R16 wanted cake after observing other Residents eating meals on the unit. R16 then repeatedly hit R16's face and head on floor, while yelling that R16 wanted cake, obtaining a laceration to left cheek bone. On 4/3/22, RD-D documents R16 is requesting to eat orally and again recommends a ST evaluation for swallowing with diet texture. Per Social Worker (SW-C) R16 was able to obtain 2 cups of water and drank both of them. Social Worker (SW-C) took the water from R16 as R16 stated R16 was thirsty and wanted more water. SW-C documented SW-C would follow-up on a ST evaluation. On 4/3/22, R16 again is observed to bang R16's head onto the ground after being told R16 could not have cake. R16 re-opened the injury above R16's right eye and was transported to the emergency room (ER). The facility's failure to comprehensively assess R16's nutritional status upon admission, failure to complete and obtain a speech therapy evaluation, failure to obtain a swallow study, failure to monitor R16's weights in a consistent manner, and a repeated, systemic failure to assess and address R16's nutritional status and to implement pertinent interventions based on such an assessment resulted in continued and severe weight loss that created a finding of Immediate Jeopardy. The Immediate Jeopardy began on 2/18/22. Surveyor notified Nursing Home Administrator- A of the Immediate Jeopardy on 4/4/22 at 4:45 P.M. At the time of the facility exit on 4/14/22, the Immediate Jeopardy has not yet been removed. Noncompliance was also found at a severity level of potential for more than minimal harm that is not immediate jeopardy, as evidenced by: * R9 experienced a significant weight loss of 35.4 pounds (29.8%) from 11/15/21 to 1/31/22 without any compressive assessment or dietary intervention. R9 continued to lose weight and on 2/3/22, the Dietician requested that a dietary supplement be added to R9's daily oral intake twice a day and that R9 be weighed in a consistent method. The facility did not fill the order for the dietary supplement until 2/22/22 and continued to use various methods to weigh R9, which could cause an inadequate weight to be documented. This is evidenced by: Surveyor reviewed the facility's Enteral Nutrition policy and procedure revised November 2018 and noted the following: Policy Statement Adequate nutritional support through enteral nutrition is provided to Residents as ordered. Policy Interpretation and Implementation 1. The IDT (Interdisciplinary Team), including the dietitian, conducts a full nutritional assessment within current initial assessment timeframes to determine the clinical necessity of enteral feedings. The assessment includes: a. Evaluation of the Resident's current clinical and nutritional status b. Relevant functional and psychosocial factors c. A review of interventions to maintain oral intake prior to the use of a feeding tube and the Resident's response to them . 6. If the Resident has a feeding tube place prior to admission, the provider and the IDT will review the rationale for the placement of the feeding tube, the Resident's current clinical and nutritional status, and the treatment goals and wishes of the Resident . 8. The dietitian monitors Residents who are receiving enteral nutrition, and make appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings. 9. The nursing staff and provider monitor the Resident for signs and symptoms of inadequate nutrition, altered hydration. The nursing staff and provider also monitor the Resident for worsening of conditions that place the Resident at risk for the above. Surveyor reviewed the facility's Nutritional Assessment policy and procedure revised October 2017 and noted the following: Policy Statement As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each Resident. Policy Interpretation and Implementation 1. The dietitian in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each Resident upon admission and as indicated by a change in condition that places the Resident at risk for impaired nutrition. 2. As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the Resident at risk for or with impaired nutrition. Surveyor reviewed the facility's Weight Assessment and Intervention policy and procedure revised September 2008 and noted the following applicable: Policy Statement The IDT will strive to prevent, monitor, and intervene for undesirable weight loss for our Residents. Policy Interpretation and Implementation Weight Assessment 1. The nursing staff will measure Resident weights on admission, the next day, and weekly for 2 weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 2. Weights will be recorded in each unit's Weight Record chart. 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. 4. The Dietitian will respond within 24 hors of receipt of written notification. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month-5% weight loss is significant; greater than 5% is severe b. 3 months-7.5% weight loss is significant; greater than 7.5% is severe c. 6 months-10% weight loss is significant; greater than 10% is severe Care Planning 1. Care planning for weight loss or impaired nutrition will be a IDT effort and will include the physician, nursing staff, dietitian, consultant pharmacist, and the Resident or Resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified causes of weight loss b. Goals and benchmarks for improvement c. Time frames and parameters for monitoring and reassessment 1. R16 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R16 has a legal guardian. According to the Nutritional management of individuals with [CONDITION(S)]; nutritional guidelines, There is a high risk of rapid weight loss for many individuals [with [CONDITION(S)]] .Rapid weight loss can result in loss of muscle mass, weakness, apathy, depression, susceptibility to infection and compromised chest status .The risks may change during the progression of the condition but both unmanaged weight loss or weight gain will be problematic. For this reason weight should be carefully managed . https://www.futuremedicine.com/doi/10.2217/nmt.11.69 R16's Admission MDS (Minimum Data Set) dated 2/25/22 documents R16's short and long term memory is impaired and R16 demonstrates severely impaired skills for daily decision making. R16's PHQ-9 score done by staff is an 8, indicating mild depression. There are no behaviors documented on R16's MDS. R16 is extensive assistance for bed mobility. R16 requires total dependence of 2 staff for transfers. R16 is total dependence for dressing, toileting, and bathing. R16 has both upper and lower bilateral range of motion impairment. R16 is always incontinent and requires tube feeding. Surveyor requested R16's hospital discharge summary and history and physical that the facility would have reviewed prior to R16's admission to the facility. The facility was unable to provide this documentation. Surveyor notes there is no documentation of the history of R16's G-tube placement and reason for use. Surveyor was not able to locate an admission tube feeding or nutritional assessment in R16's EMR, and the facility was not able to provide documentation of both assessments. Surveyor reviewed R16's comprehensive care plan and notes R16 requires tube feeding due to Dysphagia, chewing problems, [CONDITION(S)], Dementia, Severe protein-calorie malnutrition, very low BMI, skin impairment, weight loss since admission.-initiated 2/20/22 and revised 3/20/22 On 2/18/22, R16's admission summary refers to R16 tube feeding being [MEDICATION(S)] 1.5 300 ml 4 times a day via gravity with NPO (nothing by mouth) status. Water flush 100 ml 4 times a day (400 ml per day). Surveyor notes that the facility obtained R16's admission weight on 2/18/22 of 89.2 pounds and 3/18/22 of 82.2 pounds and recorded those weights in R16's EMR. On 3/24/22, the dietary manager weighed R16 and R16's weight was 84.2 pounds There is no documentation of how R16's weights were obtained. Surveyor notes that the facility did not obtain R16's weights weekly 1 time a week for 4 weeks after admission based on standards of practice. Surveyor notes that R16's physician has an order dated 2/18/22 (day of admission) for R16 to have a ST screen, evaluate, and treat on admission and as indicated. On 3/20/22 the Registered Dietitian (RD-D) documented R16's weight to be 82.2 pounds, a 7.9% unplanned weight loss in 30 days. There is no documentation of how the weight was obtained. There is no documentation R16's physician (DR-H) was notified of the significant weight loss. RD-D recommended to increase the tube feeding and water flushes is warranted to prevent any further weight loss and support weight gain. RD-D recommendations: [MEDICATION(S)] 1.5-360 ml-5 times a day. Provides 2700 calories, 1772 ml water, and 113 g protein. Recommend additional water flushes per physician. Recommend check CBC, complete metabolic profile, phosphorous, and magnesium as soon as possible. R16's tube feeding was not increased until 3/25/22, 5 days after the recommendation. On 3/21/22, SW-C documented SW-C received email from RD-D requesting tube feeding change. SW-C presented this to the Interdisciplinary team (IDT). On 3/22/22, SW-C documented SW-C received email from RD-D stating RD-D did not see updates and orders per recommendations. SW-C presented this to the IDT. On 3/23/22, SW-C documented SW-C received email from RD-D stating R16's orders and recommendations has not been done. SW-C presented this issue in clinical. On 3/23/22 at 6:23 PM, RD-D documents that nursing was notified of R16's weight loss and new tube feed recommendations/lab requests. No changes in tube feeding order yet. No labs scanned in EMR to assess. RD-D informed, SW-C, and NHA-A regarding R16's significant weight loss and new tube feeding recommendations. On 3/24/22, SW-C documents that R16's tube feeding orders were still not completed. On 3/25/22 at 10:35 AM, RD-D documents that tube feeding has not yet been increased and contacted SW-C. RD-D requested a weight check. Per SW-C, goal is to introduce oral feeding with R16. RD-D recommended ST evaluation and diet per ST recommendations. At 2:48 PM, RD-D documents that R16's weight is 84.2 pounds, but there is no documentation of how that weight was obtained and was not documented in R16's EMR. RD-D again documents that ST is consulted to assess swallow and diet. Surveyor reviewed R16's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Water flush as of 2/18/22 was for 100 ml four times a day. Surveyor notes this is a discrepancy from RD-D recommendation to increase water flushes on 3/20/22. Surveyor reviewed R16's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/27/22 at 9:53 PM, it is documented that R16 was observed in the hallway on R16's knees and started to roll around and R16's face on the floor yelling that R16 wanted some cake. On 3/30/22 at 8:21 AM, RD-D documents that RD-D is unable to review labs due to not being scanned into R16's EMR. RD-D requested weight check today and 2 times weekly is recommended. Requested labs be scanned into R16's EMR. On 3/31/22 at 12:22 PM, RD-D requested R16's weight be obtained. On 3/31/22 at 3:30 PM, it is documented that R16's weight was 72.6 pounds via standing independently with 2 staff assist. On 3/31/22 at 8:43, RD-D documents that R16's weight has declined to 72.6 pounds, 18.6% (or 16.6 pound) weight loss since admission on 2/18/22 (in 42 days) and R16 is severely underweight and life-threatening. RD-D contacted NHA-A and recommended R16 be transferred to the hospital STAT. On 4/1/22 at 7:44 AM, RD-D noted R16 returned from the hospital. RD-D recommended tube feeding be changed to 2 CAL HN-360 mL-5 times daily. Increase water flushes to 180 mL-4 times a day. Provides 3600 calories, 150 g protein and 1980 mL water. On 4/1/22 at 1:13 PM, nursing documents the new order for enteral feeding and flush for R16. On 4/2/22 at 8:15 AM, RD-D documents NHA-A informed RD-D of R16's weight on 4/1/22 was 85 pounds which has not been entered into R16's EMR. Surveyor notes there is no documentation of where or how R16's weight was obtained. RD-D emailed recommendations to SW-C, NHA-A, and Director of Nursing (DON-B) for weights to be obtained on Monday and Friday and to administer medications with scheduled 180 mL water flush. RD-D had attempted to reach the nurse's station 3 times to communicate the recommendations On 4/2/22 at 2:15 PM, it is documented that R16's weight was 81.0 pounds. Surveyor notes there is no documentation of how R16's weight was obtained. On 4/2/22 at 7:00 PM, it is documented that R16 was at nurses station during tube feeding sitting in broda chair. R16 stood up from broda chair yelling I want cake, I want cake, I want to eat like them as evening supper was brought to the unit, and R16 fell to floor hitting R16's head, re-opening 4 staples located to back of head. R16 began to have [CONDITION(S)] activity. 911 was called and transported to ER. On 4/3/22 at 6:58 AM, it is documented that R16 was refusing to sit down or lay in bed and got out bed and chair several times, hard to redirect, asking for cake. On 4/3/22 at 9:02 AM, R16 got up from broda chair down to floor on hands and knees repeatedly hitting R16's face/head on the floor yelling, Give me cake, I want some cake. R16 obtained a laceration on R16's left cheek bone, 3cm x 1cm. Bleeding controlled and applied steri strips. On 4/3/22 at 9:23 AM, RD-D documents that R16 is requesting to eat orally. ST consult has been ordered (was originally ordered on 2/18/22 day of admission and not followed through on) and recommend ST evaluate swallow. Recommend diet texture and liquid consistency according to ST recommendations. On 4/3/22 at 11:44 AM, SW-C documents R16 was able to obtain 2 cups of water and drank both of them. SW-C took the water from R16 as R16 stated R16 was thirsty and wanted more water. SW-C documented SW-C would follow-up on a ST evaluation. On 4/3/22 at 12:35 PM, R16 is observed by staff banging head onto ground after being told R16 could not have cake. R16 then took helmet off and repeatedly banged head onto ground re-opening an injury above R16's right eye. R16 sent out to ER. (Note: There has been no ST evaluation to determine if R16 could eat orally.) On 4/3/22 at 1:18, RD-D notes that R16 drank water and is thirsty despite increase in water provided in both the tube feeding formula and water flushes. On 3/30/22 at 2:20 PM, Surveyor spoke to RD-D via telephone interview in regard to R16. RD-D stated RD-D communicated R16's significant weight loss on 3/20/22 to NHA-A, SW-C, and DON-B. RD-D stated RD-D was so upset that the recommendation to increase tube feeding and water flushes had not been followed through with. RD-D stated RD-D had to beg every day to get the change made for R16. RD-D stated RD-D sent high alerts to NHA-A and calling daily to get the change made. RD-D stated RD-D checked on R16 daily and R16 was RD-D's number one priority. RD-D stated RD-D cannot review labs because they are not scanned in, which is a big issue for RD-D's comprehensive review. RD-D confirmed it took 5 days (from 3/20 until 3/25/22) for R16's tube feeding to be increased. RD-D stated the method that the facility obtains weights should be consistent. RD-D stated RD-D has been very worried about R16's nutritional status and weight. RD-D stated the weight that was obtained on 3/24/22 and not recorded was by the dietary manager (DM-E) who offered to help RD-D out. On 3/31/22 at 7:05 AM, Surveyor spoke to Dietary Manager (DM-E) who confirmed DM-E obtained R16's weight by self. DM-E stated RD-D needed the weight and DM-E was not going to leave until it got done. DM-E stated DM-first weighed R16 in the broda chair, and then weighed the broda chair separately. DM-D recalls having concerns of how frail R16 appeared to be and notified RD-D on 3/19/22 who planned on sending an email to NHA-A. On 3/31/22 at 8:21 AM, Surveyor observed DM-E attempt to weigh R16 in the broda chair. Once DM-E got R16 on the scale, the weight was not able to be obtained because the scale did not work, and DM-E was going to inform maintenance. On 3/31/22 at 2:05 PM, SW-C confirmed that it took 5 days for R16's tube feeding increase to start. SW-C stated SW-C was in on the weekend and had noticed how thin R16 was and requested DM-E give RD-D's contact information. SW-C stated, If I hadn't come in, I truly believe nothing would have been done in regard to R16's nutritional status. On 4/4/22 at 9:40 AM, Surveyor left a message for R16's physician (DR-H). On 4/5/22 at 12:11 PM, DR-H confirmed that DR-H had not been updated on R16's significant weight loss on 3/20/22. On 4/4/22 at 4:45 PM, NHA-A was informed that facility failed to comprehensively assess R16's nutritional status upon admission, failed to complete and obtain a speech therapy evaluation, failed to obtain a swallow study, failed to monitor R16's weights in a consistent method, failed to follow facility policies ad procedures, failed to notify R16's physician of R16's severe weight loss, and failed in a repeated, systemic manner to assess and address R16's nutritional status and to implement pertinent interventions based on such assessment. These failures resulted in continued and severe weight loss, which RD-D stated was life threatening. These failures created a reasonable likelihood for serious harm, and thus created a finding of Immediate Jeopardy. Noncompliance was also found at a severity level of potential for more than minimal harm that is not immediate jeopardy, as evidenced by: 2. R9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS), dated [DATE], documented that R9 has a BIMS (brief interview for mental status) of 3- severely impaired cognitive skills. The MDS also stated that R9 needs extensive assistance with activities of daily living and needs supervision/ 1-person physical assistance with eating. R9's weight is documented at 148 pounds and there is no noted weight loss or gain at the time of this assessment. On 11/1/21, the facility developed a plan of care for R9 stating that R9 is at risk for complications with weight and nutrition due to dementia, dysphasia, texture modified diet, GERD, [CONDITION(S)], weight fluctuations and variable meal intakes. The quarterly MDS, dated [DATE] indicates R9's weight is at 150 pounds and there has been no weight loss or gain. It is also documented that R9 does not have any swallowing concerns. Nutrition review dated 11/15/21 states that R9 weights are: 10/25 150# 11/1 173.2# and 11/15 173#'s. 15% - or 23-pound weight gain in 1 month. Snacks between meals. Intake on admission 26-50%, now improved 76-100%. Receives 120 cc Med Plus three times daily, recommendation made to discontinue. Monitor weight. Quarterly MDS, dated [DATE], documents that R9's weight is at 138 pounds and incorrectly states there has been no weight loss or gain notes. R9 remains needing extensive assist of 1 person/ physical assistance for eating. The following weights were noted in R9's medical record and method of weight taken: 10/25/21 150 pounds- wheelchair 11/01/21 173.2 pounds- wheelchair 11/15/21 173 pounds - wheelchair 11/29/21 166.8 pounds- wheelchair 12/01/21 162 pounds- method not identified 12/13/21 161.7 pounds - wheelchair 12/10/21 163.2- wheelchair 12/20/21 163.2 pounds- wheelchair 01/16/22 144.8 pounds- method not identified 01/31/22 137.6 pounds- mechanical lift 02/14/22 137 pounds- wheelchair 02/28/22 137.9 pounds- Hoyer 03/07/22 139 pounds- wheelchair- (This weight represents a 23-pound weight loss or 14.2% weight loss since 12/10/21) Dietary progress note dated 2/3/22 stated, will notify nursing regarding large discrepancy in weights and weighing methods. Recommend consistent weight method be utilized to accurately track weight trends. Recommended Med Pass 2.0- 120 mL two times daily due to some variability in meal intakes. Will need to monitor weights utilizing consistent weighing method to determine if additional nutritional interventions are warranted. It was noted that the next 3 weights (2/14/22, 2/28/22 and 3/7/22) obtained by the facility were not consistent in method. The nutrition plan of care was revised on 2/3/22 to add the interventions of monitoring weights and labs and to utilize consistent weighing method. In addition, Med Pass 2.0- 120 mL two times daily was added. Dietary note dated 2/18/22; R9's weight is 137 pounds, weight has decreased 5.7 % in 30 days and decreased 8.3% in 180 days. R9 does have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Meal intake- 51-75%. Med Pass 2.0- 120 mL twice daily had not been ordered. Will notify nursing regarding significant weight loss and will request initiation of Med Pass 2.0- 120 mL twice daily again. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The dietician had originally requested this to be ordered on 2/3/22. Dietary note dated 3/5/22 states that R9's weight has slightly increased to 137.9 pounds. Recommend continue with current nutritional plan of care. Goals include weight maintenance or weight gain to reach 145 pounds. Will tolerate diet and R9 will accept 75% average at meals. The nutrition plan of care was updated on 3/5/22 stating R9 has a nutritional problem or potential nutritional problem due to dementia, dysphasia, texture modified diet, GERD, [CONDITION(S)], weight loss and history of variable meal intakes. Interventions included the addition of the Med Pass supplement, and Dietician to evaluate and make diet change recommendations. R9's family requested that R9 be sent to the hospital for evaluation on 3/18/22. R9 did not return to the facility after this hospitalization . On 3/29/22 at 3:07 p.m., Surveyor interviewed Administrator- A in regard to R9 not being evaluated by a dietician from 11/15/21 to 2/3/22 even though R9 was documented to have experienced a 35.4 pound or 20.5% weight loss from 11/15/21 to 1/31/22. Administrator- A stated that the facility was without a dietician from the end of November 2021 until 1/22/22 when the facility was able to hire an interim dietician on contract. On 3/30/22 at 2:20 p.m., Surveyor interviewed Dietician- D in regards R9's significant weight loss. Dietician - D stated that the nursing staff is to update her on any weight changes. When Dietician- D first started she re-assessed each resident over a period of 14 days. Dietician- D noted a huge weight discrepancy with R9 but despite the weight discrepancies she could see a downward trend. Dietician- D stated she recommended the Med Pass supplement to be given twice daily and then upon her assessment on 2/18/22, she noted the Med Pass was never ordered by the nursing staff. Dietician- D stated that she stressed the importance of using the same method to weigh residents each time so that an accurate picture can be given of any weight loss/ gain. Dietician- D stated that she often communicated via email and telephone to the nursing staff anytime she had concerns, need a weight to be taken or any orders to be given to the physician. Dietician- D stated that often she would have to ask multiple times and felt the issue came down to not enough staff or consistent staff to follow through on recommendations.

Based on observations, record review and staff interviews, the facility did not ensure that 3 of 5 Residents (R16, R3, & R17) reviewed who were at risk for falls received the necessary services/interventions and supervision to prevent an injury from a fall. *R16 was admitted on [DATE] with a diagnosis of [CONDITION(S)] (exhibited with involuntary movements and impairment of voluntary movements, which can result in reduced manual dexterity, slurred speech, swallowing difficulties, problems with balance, and falls). R16's diagnosis (Interdisciplinary team noted R16 is very restless and is in constant state of movement) and R16's fall while hospitalized prior to admission put R16 at risk for falls. There was no fall assessment upon R16's admission into the facility on [DATE] and no falls care plan until after R16's first fall. R16 has had 12 falls since admission on 2/18/22 to 4/3/22. The fall on 3/27/22 (which was the second fall that day) resulted in stitches above the right eyebrow. The fall on 3/26/22 resulted in staples to the back of the head. The fall on 4/2/22 resulted in a re-opening of the staples. The fall on 4/3/22 led to a laceration on the resident's face that required steri-strips. R16's electronic medical record (EMR) does not contain documentation that an incident report and fall assessment including root cause analysis was completed for R16's falls. Per documentation, it is unclear what fall interventions were in place at the time of each fall. R16's care plan was updated after only 5 of the 12 falls that R16 had, and then it is not clear that new care plan interventions were always implemented. The facility was unable to provide documentation that Neuro checks and vitals, as well as physician notifications were completed with R16's falls. The facility did not contact R16's group home where R16 had previously lived to discuss R16's safety needs, until after Surveyor questioned the facility regarding R16's falls. The facility did not know R16 wore a soft helmet at the group home until the group home brought it to the facility. After review of nursing schedules with each of R16's falls, it is noted that based on census and 15 total Residents residing on the same unit as R16, there was an inadequate number of staff to provide supervision to R16 in order to prevent R16 from frequent falling. R16 is a high risk for falls and based on inadequate staffing, the facility did not provide adequate supervision and services to prevent R16 from frequent falling. The facility's failure to identify R16's risk factors for falls, its failure to comprehensively assess R16 by completing an initial fall risk assessment and developing a fall risk care plan with revisions for each fall, its failure to complete a root cause analysis of each fall, to complete a thorough assessment including Neuro checks after each fall, and its failure to update the physician with all falls, and to provide care, treatment, and supervision necessary to prevent accidents created a finding of Immediate Jeopardy. The Immediate Jeopardy began on 2/18/22. Surveyor notified Nursing Home Administrator-(NHA-A) of the immediate jeopardy on 4/4/22 at 4:45 P.M. At the conclusion of the partial extended survey on 04/14/22, the immediate jeopardy had not yet been removed. Noncompliance that created a potential for more than minimal harm that is not immediate jeopardy was identified with R3 and R17. *On 3/20/22 R3 had a fall with injury and a fall assessment with a thorough root cause analysis, and Neuro checks was not completed. *On 3/29/22 R17 slid from the bed to the floor and no fall assessment with any root cause analysis was completed, including no documented vitals and Neuro checks being initiated, and no care plan update. Findings include: Surveyor reviewed the facility's Fall and Fall Risk, Managing policy and procedure revised March 2018 and noted the following: Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the Resident's specific risks and causes to try to prevent the Resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation: Resident-Centered Approaches to Managing Falls and Fall Risk 1. The staff, with input of the attending physician, will implement a Resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each Resident at risk or with a history of falls. 2. If a systematic evaluation of a Resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions. 3. In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with increased risk of falling, or indicate why those medications could not be tapered or stopped, even for a trial period. 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. Monitoring Subsequent Falls and Fall Risk: 1. The staff will monitor and document each Resident's response to interventions intended to reduce falling or the risks of falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed. 3. If the Resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue to change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. 4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. 1. R16 was admitted on [DATE] with diagnoses of [CONDITION(S)], Unspecified Dementia, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] with Delusions, Unspecified Intellectual Disabilities, and Dysphagia. R16 has a legal guardian. According to the [CONDITION(S)] (HD) Society of America, The movement disorder of HD includes emergence of involuntary movements and the impairment of voluntary movements, which result in reduced manual dexterity, slurred speech, swallowing difficulties, problems with balance, and falls. R16's Admission Minimum Data Set (MDS) dated [DATE] documents R16's short and long term memory is impaired and R16 demonstrates severely impaired skills for daily decision making. R16's PHQ-9 score done by staff is a 8, indicating mild depression. There are no behaviors documented on R16's MDS. R16 requires extensive assistance for bed mobility, and is total dependence of 2 staff for transfers. R16 requires total dependence for dressing, toileting, and bathing. R16 has both upper and lower bilateral range of motion impairment. R16 is always incontinent and requires tube feeding. Surveyor requested R16's hospital discharge summary and history and physical that facility would have reviewed for R16's admission to the facility. The facility was unable to provide this documentation. On 2/18/20 at 9:21 PM, it is documented that R16 was admitted to the facility at 3:00 PM. R16 was a hospital admission from group home. R16 fell at the hospital on 2/15/22 with negative CT scan of head. Bed in low position due to fall risk. Given that R16 fell in the hospital prior to admission on 2/15/22, and with R16's diagnosis of [CONDITION(S)], this would have put R16 at risk for falls. Despite this, there was no fall risk assessment completed upon R16's admission into the facility on [DATE]. Surveyor reviewed R16's progress notes located in R16's EMR and notes the following falls: 2/26/22 1:57 PM CNA found R16 on floor on left side of bed with pillow under R16's head and half of body. Assessed movement of all extremities, obtained vital signs and performed skin check. R16 transferred in bed with assistance of CNA. Bed was placed in lowest position with pillows on both sides of R16 and mat placed on floor on side of bed. No documented injury. Surveyor notes both physician and guardian were updated with the fall. Care Plan updated to place bed in lowest position, mat next to bed. Facility was unable to provide Neuro checks. The Facility unable to provide an incident report with statements, a fall assessment, or a root cause analysis of fall, including noting if bed was in low position at time of fall. Per nursing schedule provided by the facility, 1 nurse and 1 CNA were assigned to unit Surveyor notes R16's bed should have already been in low position based on admission note. 2/27/22 11:46 AM R16 found on floor on right side of bed with head lying against the bed in sitting position. Obtained vital signs, performed skin check, assessed for pain and movement of extremities. R16 transferred in bed with assistance of CNA. Bed was placed in lowest position. No documented injury. Surveyor notes both physician and guardian were updated with the fall. Care Plan updated to provide pillows for boundaries. Facility unable to provide Neuro checks. Facility unable to provide an incident report with statements, a fall assessment, and noting if R16's bed was in low position at time of fall. Root cause documented is that R16 is restless and or involuntary movements in bed with all current diagnoses, immediate intervention is to have therapy screen and social services to check on order from hospital for a hospice referral. Per nursing schedule provided by the facility, 1 nurse and 1 CNA assigned to unit. Surveyor notes R16's bed should have already been in low position based on admission note. Facility was unable to provide the therapy screen. Surveyor notes that social services did not follow up on a hospice referral. On 4/4/22 at 8:47 AM, Surveyor observed R16 in bed. Surveyor notes R16's bed was in low position, mat next to bed, and a mat between the wall and the bed. Bed placed next to wall. Surveyor notes there is no bolster or pillows around R16, as identified in the updated care for the 2/27/22 fall. 2/28/22 8:45 AM R16 noted lying on mat on floor next to low bed, is alert and able to follow writer with eyes. Baseline is non-verbal. No outward signs/symptoms of pain or discomfort, no medial or internal rotation of lower extremity per normal and body check negative for injury and cran check negative. No documented injury. Surveyor notes both physician and guardian were updated with the fall. Care Plan updated with Neuro checks, attempt to relocate R16 to highly populated area for close staff supervision, physical therapy (PT) consult for strength and mobility, vital signs in first 24 hr. Facility unable to provide Neuro checks. Facility unable to provide an incident report with statements, a fall assessment including noting if pillows were in place at time of fall. Root cause documented is R16 is unable to remain comfortable. Immediate intervention was to add pillows and/or bolsters to assist in making comfortable. Surveyor notes this intervention of adding pillows was already documented as the intervention on 2/27/22. Per nursing schedule provided by facility, there was no CNA assigned to R16's unit. Surveyor validated this with Scheduler (SC-I) on 4/4/22 at 8:37 AM. Facility was unable to provide the physical therapy consult. 3/2/22 5:29 PM R16 seen lying on floor next to bed in fetal position. R16 appears to have rolled out of bed. Alert and oriented. Vitals taken. Assisted off of floor, 2 assist via Hoyer lift. Neuro check negative. No obvious injuries. Range of motion (ROM) within normal limits. Denies pain. No documented injury. Surveyor notes both physician and guardian were not updated with the fall. Care Plan updated to relocate R16 to room with roommate to allow increased socialization. Facility unable to provide Neuro checks. Facility unable to provide an incident report with statements, a fall assessment including noting if bed was in low position with pillows in place at time of fall. Root cause was that R16 came from a group home and is in a private room. R16 unable to make needs known. Root cause is R16 is still anxious most likely due to change from group home to private room and med changes via hospital. Will move R16 to semi private room, attempted to have R16 out of bed in Broda chair, however, R16 did not like the chair as evidenced by R16 wiggling to get out chair. Will continue to have therapy evaluation, will continue other interventions. Surveyor notes observations of R16 during the survey process to be in a room by R16's self with no roommate for socialization and R16 was gotten up in Broda chair and would frequently move around in the Broda chair. Per nursing schedule provided by the facility, 1 nurse and 1 CNA assigned to unit. Surveyor was not provided a therapy evaluation by the facility. On 3/4/22, Social Worker (SW-C) documents that R16's guardian has requested R16 to be seen by psychiatric services. Facility was unable to provide documentation this had been done. 3/8/22 10:30 AM Unwitnessed fall. Observed R16 lying on floor left side prone positioned. No skin breakdown, no raised areas on head. Neuro checks negative. Assist with Hoyer and 2 CNAs from floor back into bed. No signs/symptoms internal or external rotation of legs. No documented injury. Surveyor notes physician was updated with the fall, guardian was not updated. Care Plan updated to update MD to follow up medication review and schedule neurology follow-up. Facility unable to provide Neuro checks. Facility unable to provide an incident report with statements, a fall assessment, a root cause analysis of the fall including noting if bed was in low position with pillows in place at time of fall. Per nursing schedule provided by the facility, 1 nurse and 1 CNA assigned to unit Surveyor notes facility was unable to provide a documented medication review or neurology follow-up. 3/21/22 1:00 AM R16 lying on floor, g tube out, called ambulance to transport R16 to emergency room (ER). R16 tried to walk and fell out of bed. R16 is no longer ambulatory due to R16's disease. CT scan negative, abrasion to left side of forehead. Surveyor notes both physician and guardian were not updated with the fall. No Care Plan revision for fall. Neuro checks provided by facility are incomplete. Facility unable to provide an incident report with statements, a fall assessment, a root cause analysis of the fall including noting if bed was in low position with pillows in place at time of fall. Per nursing schedule provided by facility, 1 CNA was assigned to R16's unit and 2 nurses for all Residents residing in facility. 3/22/22 Interdisciplinary Team (IDT) met to review fall. R16 does not communicate well and is very restless and is in constant state of movement. Previous intervention in place, bed in low position, mat on floor, R16 receiving medications as ordered. Tried assisting R16 to chair and R16 immediately began to slide out of chair. Assist bars on bed, will remove to prevent injury. Care Plan updated. Surveyor notes R16's fall care plan was not updated. 3/26/22 8:29 PM R16 found on floor in doorway lying on R16's back with blood on mat. Performed skin check, obtained vital signs and assessed for pain. R16 transferred in bed with assistance of CNA. Laceration to back of head noted, area cleansed and dressing applied. R16 sent to ER and received four staples to occipital area. Surveyor notes both physician and guardian were updated with the fall. No Care Plan revision for fall. Neuro checks provided by facility are incomplete. Facility unable to provide an incident report with statements, a fall assessment, a root cause analysis of the fall including noting if bed was in low position with pillows in place at time of fall. Per nursing schedule provided by facility, there was no CNA assigned to R16's unit, and only 3 CNAs for all Residents residing in facility. 3/27/22 11:30 AM R16 lying on floor next to bed prone position. Denies hitting head. No active bleeding. No skin breakdown present, able to move four extremities well. No internal or external rotation of lower legs. Transferred back to bed via staff. No documented injury. Surveyor notes both physician and guardian were not updated with the fall. No Care Plan revision for fall. Neuro checks provided by facility are incomplete. Facility unable to provide an incident report with statements, a fall assessment, a root cause analysis of the fall including noting if bed was in low position with mat next to bed with pillows in place at time of fall. Per nursing schedule provided by facility, there was no CNA assigned to R16's unit and only 3 CNAs for all Residents residing in facility Per documentation, Nurse Practitioner (NP) was contacted at 1:40 PM concerning R16's being agitated and restless. Order to discontinue [MEDICATION(S)] 10 mg and increased to start [MEDICATION(S)] 20 mg 3 times a day. It is documented at 2:22 PM that [MEDICATION(S)] 20 mg is outside the recommended dose for this drug. The [MEDICATION(S)] also triggered a possible drug interaction with [MEDICATION(S)] HCI 50 mg which increases risk of seizures when co-administered. Surveyor reviewed R16's medication administration record (MAR) for March and notes on 3/27/22 R16 received [MEDICATION(S)] 10 mg at 8AM and 12 PM, and received [MEDICATION(S)] HCI 50 mg. 3/27/22 9:53 PM R16 observed in hallway on knees. Staff tried to help R16 and R16 laid on floor and started to roll around and hit R16's face yelling that R16 wanted cake. Staff tried to calm R16 down as R16's body continued to jerk and roll around on the floor. 911 was called and transported R16 to ER. R16 received stitches to right eyebrow laceration. X-ray of left humerus demonstrated a subtle lucency in the proximal to mid humerus. It is important that R16 follows up with DR regarding this. Surveyor notes both physician and guardian were not updated with the fall. No Care Plan revision for fall. Neuro checks provided by facility are incomplete. Facility unable to provide an incident report with statements, a fall assessment, a root cause analysis of fall. Per nursing schedule provided by facility, there were only 3 CNAs for all Residents residing in facility. Surveyor requested and facility was unable to provide documentation that R16 had follow-up on humerus. 3/29/22 8:25 PM On 3/29/22 at 8:25 AM, Surveyor heard screaming from the conference room. Surveyor went to investigate and observed R16 in the hallway outside R16's door on R16's knees and yelling. Surveyor observed Admissions (AD-G) who is a CNA pick R16 up and place R16 in Broda chair, without first having a nurse assess R16. On 3/29/22 at 10:20 AM, Surveyor observed R16 in Broda chair, alone in room, sleeping. Broda chair was leaned back, footrest fully extended up. Pillow on left side of R16. Pillow behind head. Gripper socks on. On 3/31/22 at 8:15 AM, Surveyor observed R16 in Broda chair by nurse's station. The Nurse was down the hallway administering medication within eyesight of R16. Surveyor notes above R16's right eye is still swollen. The Broda chair is slightly reclined. R16 has black non-skid shoes on. Surveyor was approached by Licensed Practical Nurse (LPN-J) who stated to Surveyor, Thanks for staying with her, I can't watch her, I have med pass. At 8:21 AM, Dietary Manager came to get R16 in order to obtain a weight. On 3/31/22 at 2:05 PM, Surveyor interviewed SW-C in regard to R16. SW-C confirmed that R16 has not been evaluated by psychiatric services. SW-C informed Surveyor that SW-C did not follow-up on a hospice referral. SW-C also informed Surveyor that SW-C did not call R16's group home to obtain information in regard to R16's daily routine including physical set up of environment, R16's behaviors, and R16's safety needs. SW-C stated that SW-C firmly believes R16's falls are related to R16 needing help and R16 has intent when attempting to get out bed. SW-C stated that on 3/29/22 when R16 was in the hallway, R16 was yelling I need help. 4/2/22 7:00 PM On 4/2/22 at 7:00 PM, it is documented that R16 was at nurses station during tube feeding sitting in Broda chair. R16 stood up from Broda chair yelling I want cake, I want cake, I want to eat like them as evening supper was brought to the unit, and R16 fell to floor hitting R16's head, re-opening 4 staples located to back of head. R16 began to have [CONDITION(S)] activity. 911 was called and transported to ER. On 4/3/22 at 6:58 AM, it is documented that R16 was refusing to sit down or lay in bed and got out bed and chair several times, hard to redirect, asking for cake. (Cross reference F692. Dietitian had asked for a speech therapy evaluation to determine if R16 could swallow, but this was never done.) 4/3/22 9:02 AM On 4/3/22 at 9:02 AM, R16 got up from Broda chair went down to floor on hands and knees repeatedly hitting R16's face/head on the floor yelling, Give me cake, I want some cake. R16 obtained a laceration on R16's left cheek bone, 3cm x 1cm. Bleeding controlled and applied steri strips. On 4/3/22 at 12:35 PM, R16 is observed by staff banging head onto ground after being told R16 could not have cake. R16 then took helmet off and repeatedly banged head onto ground re-opening an injury above R16's right eye. R16 sent out to ER. On 4/4/22 at 8:47 AM, Surveyor observed R16 in bed with a pink soft helmet on. Bed is low position, mat next to bed, no pillows around R16 as per the 2/27/22 care plan intervention. No prevalon boots on. Surveyor observed dry smeared blood on the wall next to bed. Certified Nursing Assistant (CNA-K) sitting in chair in R16's room. CNA-K explained that CNA-K is 1:1 to R16. CNA-K explained that R16 has a 1:1 because Surveyors are in the building. Surveyor asked CNA-K about R16's helmet. CNA-K stated CNA-K was informed by SW-C that the helmet came from the group home (after Surveyor interviewed SW-C on 3/31/22) and R16 is to wear it all times. CNA-K stated R16 likes to wear the helmet. On 4/4/22 at 4:45 PM, NHA-A was informed that facility failed to comprehensively assess R16 on admission as being a high fall risk including not completing a root cause analysis of each of R16's falls including interventions in place at the time of each fall. The facility was unable to provide documentation that Neuro checks and vitals, as well as physician notifications were completed with R16's falls. Surveyor requested the facility's neuro check policy and procedure from Administrator (NHA-A) and was not provided the policy. After review of nursing schedules with each of R16's falls, it is noted that based on census and 15 total Residents residing on the same unit as R16, there was inadequate amount of staff to provide supervision to R16 in order to prevent R16 from frequent falling. R16 is a high risk for falls and based on inadequate staffing, the facility did not provide adequate supervision and services to prevent R16 from frequent falling. These facility's failure to identify R16's risk factors for falls and to comprehensively assess R16's fall risk on admission, to contact R16's group home to discuss safety needs and the facility not being aware of R16 wearing a soft helmet at the group home, to complete a root cause analysis and assessments of R16's falls, to not always update R16's care plan with safety interventions, and to provide the staffing supervision necessary to prevent falls from occurring created a reasonable likelihood for serious harm, which resulted in a finding of immediate Jeopardy. The facility's Immediated Jeopardy was not removed at the time of the partial extended survey exit on 4/14/22. Further noncompliance is evidenced by: 2. R3 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, [CONDITION(S)], [CONDITION(S)], Cognitive Communication Deficit, Unspecified Dementia, Major Depressive Disorder, and Transient Cerebral Ischemic Attack. R3 has an activated Health Care Power of Attorney (HCPOA). R3's Quarterly Minimum Data Set (MDS) dated [DATE] documents R3's Brief Interview for Mental Status (BIMS) score to be 5, indicating R3 demonstrates severely impaired skills for daily decision making. R3's Patient Health Questionnaire (PHQ-9) score is 8, indicating R3 has mild depression. R3 requires extensive assistance with bed mobility, locomotion on/off the unit, and transfers. R3 is not steady with balance during transitions and walking. Surveyor reviewed R3's comprehensive care plan and noted the following: 1. R3 is at risk for elopement due to cognitive deficits secondary to dementia and exit seeking behavior-initiated 8/25/20. 2. R3 displays behavioral symptoms related to paranoia and are manifested by feeling people are talking about her and being afraid to sleep at night, paranoid that R3 won't wake up-initiated 10/28/20. 3. R3 is at high risk for falls secondary to functional deficits, dementia and history of falls-initiated 8/25/20 with revision 10/25/21. All interventions are dated 9/25/20 other than 2 revisions: Fall 8/30/21-Encourage R3 to participate as tolerated in activities during day that promote rest at bedtime. 10/4/21-Psych assessment with medication change. Surveyor was unable to locate any fall risk assessment in R3's EMR. Surveyor notes per incident report, R3 had a witnessed fall on 3/12/22 where R3 slipped in the hallway, hitting R3's chin on the floor. Documentation in R3's progress notes located in R3's electronic medical record (EMR) dated 3/14/22 stated the root cause of R3's fall was R3 was combative during redirection and lost balance and fell hitting R3's face. On 3/14/22, the nurse practitioner (NP) evaluated R3. R3's chin is severely bruised, edematous. NP recommended emergency room (ED) evaluation secondary to concerns for fracture if R3 fell directly on R3's chin. On 3/14/22, R3 went to the hospital for a CT scan of the head. The hospital record dated 3/14/22 documents R3 arrived for an unwitnessed fall that happened yesterday, staff unaware of what time. Swelling and bruising noted to jaw area. Emergency Medical Services (EMS) noted abscess to inner lower lip. On 3/30/22 at 10:45 AM, Surveyor interviewed Director of Nursing (DON-B) in regard to the incident. DON-B shared DON-B had worked that weekend and noted R3's left side of R3's jaw/chin area was bruised and swollen. DON-B asked questions of staff, but no one had answers. DON-B stated, DON-B was finally informed that R3 had slipped and fell and the staff member probably went to grab her. R3's bible was found outside of the west doorway. Surveyor notes that R3's fall risk care plan was not updated after the 3/12/22 fall. Surveyor also notes that non-pharmacological interventions were not in place at time of the fall. The 3/12/22 incident report does not document what interventions were in place at the time. On 3/31/22 at 3:05 PM, Surveyor shared with NHA-A the concern that R3's 3/12/22 had not been comprehensively assessed and R3's care plan did not contain any revisions related to the fall. No further information was provided at this time. 3. R17 was admitted on [DATE] with diagnoses of Major Depressive Disorder, Cerebral Infarction, End Stage Renal Disease, Metabolic [CONDITION(S)], Coagulation Defect, Bells Palsy, Type 2 Diabetes Mellitus, and [CONDITION(S)]. R17 is her own person. R17's last documented MDS dated [DATE] documents R17 has a BIMS (Brief Interview for Mental Status) of 15 indicating R17 is cognitively intact for daily decision making. R17's PHQ-9 score is 3, indicating minimal depression. R17 requires extensive assistance with bed mobility, transfers, dressing, and toileting. R17 is not steady with balance during transitions and walking. R17 has range of motion (ROM) impairment on 1 upper extremity and bilateral lower extremities. Surveyor notes there is no completed admission MDS for this recent admission from 3/7/22. Surveyor was unable to locate a fall risk assessment for R17. Surveyor reviewed R17's comprehensive care plan and notes R17 had an actual fall on 3/10/22 with no injury. The following interventions were put into place on 3/10/22: 1. Check range of motion 2. Continue interventions on the at-risk plan 3. For no apparent acute injury, determine and address causative factors for the fall 4. Re-educate on use of call light and safety precautions On 3/30/22 at 10:20 AM, Surveyor spoke with R17 in regard to an allegation that R17 slid from bed to the floor on 3/29/22 at approximately 10:40 AM. R17 stated that R17 did slide off the bed to the floor. R17 stated that R17 had been reaching for R17's cell phone to call 911 to get help when R17 slid off the bed. R17 stated that a nurse was informed by a visitor R17 was on the floor. The nurse placed R17 back into bed and completed vitals. Surveyor noted there is no fall assessment with any root cause analysis completed. There is no documentation of the vitals, Neuro checks, notification to physician, assessment, or incident report in R17's EMR of the incident. On 3/30/22 at 3:05 PM, Surveyor informed NHA-A of the concern that there is no documentation that R17 had slid from bed to the floor, with no comprehensive fall assessment with a root cause analysis completed and care plan update. No further information was provided at this time.

Based on observation, interview, and record review the facility did not ensure that 4 of 5 (R4, R10, R5, R18) residents received the necessary care and treatment to prevent pressure injuries from developing, to prevent the worsening of pressure injuries, and to prevent the development of infection for residents who were at risk for the development of pressure injuries. The facility does not have a designated wound care nurse. No one from the facility measures or stages wounds. The facility, instead, relies on the notes from the wound physician, who does weekly rounds. A new pressure injury could go six days before being assessed, measured, staged and treated. * R4: On 2/14/22, R4 developed three unstageable pressure injuries. These combined into one unstageable wound that is now 56 times larger in area than when first identified (2.02 cm.2 vs. 160 cm.2). In addition, during 2 different wound care observations, R4 had developed two additional ischial wounds that were not addressed by the facility. The facility did not have the wound physician notes for March 2022 and, thus, did not know the status of R4's wound or the current treatment orders. The facility did not follow current treatment orders. The facility did not address repositioning in the resident's care plan or the CNA (Certified Nursing Assistant) care card. Agency CNAs stated they did not know they needed to reposition R4. Additionally, the facility did not always have the staff needed to reposition the resident assuming they knew R4 needed repositioning. The resident has not been out of bed and, during observations, remained flat on her back in bed. * R10 acquired an unstageable pressure injury while residing at the facility and was hospitalized , requiring intravenous antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . *R5 acquired a stage 4 pressure injury while residing at the facility and was hospitalized , requiring antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no indication of dietary involvement. The facility's failure to assess and stage wounds at the time discovered, as evidenced by facility practice to wait for the wound MD's weekly rounds (conceivably delaying assessment and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . NHA-A (Nursing Home Administrator) and VP-L (Vice President of Operations) were informed of the Immediate Jeopardy and substandard quality of care on 3/30/22 at 1:55 PM. Upon the completion of the partial extended survey on 4/14/22, the Immediate Jeopardy was not removed. The survey also identified noncompliance at the level of potential for more than minimal harm that is not immediate jeopardy, as evidenced by the following: * R18's pressure ulcer to the coccyx was not compressively assessed upon her original admission on 3/1/22 and then upon readmission on 3/22/22 and 3/23/22. R18 did not have a plan of care addressing the pressure ulcer with interventions put into place to aide in the healing of the pressure ulcer. The facility was unable to determine if the treatment they were applying daily to R18's coccyx was effective because they had no means to know if the area was healing or not. Findings include: The facility policy, Pressure Ulcers/Skin Breakdown-Clinical Protocol, (dated 2001 Med-Pass, revised April 2018), indicated in part: Assessment and Recognition 1. The nursing staff and practitioner will assess and document an individual's risk factors for developing pressure ulcers; for example immobility, recent weight loss, and a history of pressure ulcers. 2. In addition, the nurse shall describe and document/report the following: full assessment of pressure sore including location, stage, length, width, depth, presence of exudates or necrotic tissue; pain assessment; resident's mobility status; current treatments including support surfaces; and all active diagnoses. 3. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. 4. The physician will assist the staff to identify the type and characteristics of an ulcer. Treatment/Management 1. The physician will order pertinent wound treatments including pressure reduction surfaces, wound cleansing and debridement approaches, dressings and application of topical agents. 2. The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etc. 3. The physician will help staff characterize the likelihood of wound healing, based on a review of pertinent factors; for example: Healing/Prevention Likely, Healing/Prevention Possible, Healing/Prevention Unlikely. Monitoring 1. During resident visits, the Physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds. 2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. 1. R4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Quarterly 3/7/22 MDS (Minimum Data Set) indicated R4 was cognitively intact with BIMS (Brief Interview Mental Status) score of 13 with no behaviors noted. R4 required extensive assistance with 2 staff for bed mobility and transfer with functional impairment of bilateral upper extremities and bilateral lower extremities. R4's last CAA (Care Area Assessment for skin) on 6/10/21 MDS indicated: After review of resident's medical record, and OBS of resident, resident is noted at risk for pressure ulcers, secondary to Inc (Incontinent) of B&B (Bowel & Bladder), Needs assist with transfers, mobility, ADLS (Activities of Daily Living), and a care plan will be in place to reduce risk factors, (at risk for falls, pain, infections, depression, decreased activity with isolation) and continue to monitor with current skin checks in place. R4's current and active 2/15/22 care plan in the current electronic medical record indicated R4 has potential/actual impairment to skin integrity of bilateral buttocks and sacrum due to fragile skin. Active Interventions included Encourage good nutrition and hydration in order to promote healthier skin (2/15/22), Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . *Surveyor noted repositioning of R4 was not addressed in R4's current and active care plan. R4's CNA (Certified Nursing Assistant) care card, dated 3/28/22, indicated: Pericare with each incontinence episode, Report areas of skin breakdown, skin tears, and redness, Treatment as ordered to Coccyx, Use commercial moisture barrier, Check for wetness on rounds during nights. Toileting-rising, before & after meals. *Surveyor noted repositioning of R4 was not addressed/listed in the active CNA care card for bedside caregivers. R4 had facility skin screens on Monday and Thursday in December 2021 with the last one documented 12/27/21 without skin concerns. The next day, on 12/28/21 at 6:18 AM, R4's progress notes indicated CNA reported R4 has an open area on coccyx added to the 24 hour board for wound nurse to look at the area. R4's Progress notes by the wound nurse on 12/28/21 at 10:48 AM indicated: Was asked to see patient regarding a new wound on her coccyx. Patient has developed an unstageable pressure injury to her coccyx. Updated family and MD-N who will manage care for wound. Pictured and measured wound and provided treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Facility 12/28/21 Skin and Wound Evaluation Form indicated R4 developed an in house acquired new wound: Coccyx -1.5 x 1.9 x 1.1 cm which is Unstageable with 100% slough, Moderate drainage. Treatment-Normal Saline cleanse, [MEDICATION(S)] covered by border gauze. The facility provided a paper copy of a care plan initiated by the wound nurse on 12/28/21, which staff no longer had access to view or change, that indicated R4 has actual skin impairment with unstageable coccyx pressure injury. Interventions included: Address cause if possible, Educate R4 on MD orders for wound care, Educate R4 on the risks of infection and poor healing related to non-compliance, Ensure adequate food and fluid intake, Ensure proper body alignment, Monitor for Signs/Symptoms of Infection-odor, drainage, color, size; Observe and assess regularly, Provide skin care after each incontinent episode, Serve diet as ordered, Supplement with small shifts, Therapeutic mattress in bed and cushion in chair as appropriate, Treatment as ordered to coccyx, Use absorbent pads or briefs that wick and hold moisture, Use pressure redistribution surface if bed or chair bound. Consider pressure redistribution surface if: there is intractable pain or severe pain with turning or additional risk factors are present. *Surveyor noted R4's 12/28/21 closed care plan was no longer active in the facility electronic medical record and repositioning was not addressed with timing or a schedule. On 12/28/21, MD-N (Wound Care Physician) indicated R4's coccyx was Unstageable due to necrosis measuring 1.89 x 1.07 x no measurable depth with 100% slough. Treatment orders were [MEDICATION(S)] sterile gauze covered by bordered foam daily. *Surveyor noted there were no documented treatments in R4's TAR (Treatment Administration Record) on Dec. 29, 30, 31 of 2021. R4 was hospitalized from 12/31/21 to 2/3/22. R4's 2/3/22 Hospital discharge records to the facility had orders for wound care of a worsened Coccyx wound measuring 3 x 1.7 x 0.3 cm, and a Left buttock wound measuring 0.7 x 0.4 x 0.1 cm. Treatment orders were Purasyn cleanse and soak 3-5 minutes, apply 3M [MEDICATION(S)], Santyl, Mepiplex border *Surveyor noted the facility did not follow the hospital discharge instructions for wound care upon readmission on 2/3/22. R4's 2/3/22 readmission progress note by DON-B (Director of Nursing) indicated resolving area of MASD (Moisture Associate Skin [CONDITION(S)]) on Left buttock surrounding tissue smooth, slightly pink wound bed with no drainage present, covered with foam dressing for protection. *Surveyor noted R4 did not have treatment orders initiated upon 2/3/22 readmission. On 2/7/22, MD-N indicated R4's coccyx was Unstageable due to necrosis measuring 2 x 1 cm with 100% slough. MD-N debrided the necrotic wound and Treatment orders were [MEDICATION(S)] sterile gauze covered by bordered foam daily. *Surveyor noted R4's coccyx wound treatment was documented as being done only on 2/6, 2/8, 2/12, 2/13, 2/14, 2/16, 2/17, 2/18 in the TAR (Treatment Administration Record). On 2/14/22, MD-N indicated R4's coccyx was Unstageable measuring 3 x 1 x 0.3 cm with 100% slough. MD-N debrided the necrotic wound and Treatment orders were Santyl daily covered by bordered foam daily. *Surveyor noted MD-N's order on 2/14/22 for Santyl treatment was not ordered until 2/19/22 5 days later and documented on 2/19 & 2/21 in the TAR. MD-N also indicated on 2/14/22: Unstageable DTI (Deep Tissue) Pressure Injury on the Right buttock measuring 9 x 4 cm x 0.1 cm with 80% dermis, 20% skin. Unstageable DTI Pressure Injury on the Left buttock measuring 8 x 4 x 0 cm with 80% dermis, 20% skin. MD-N stated Healing, unavoidable secondary of general decline. Treatment ordered was Zinc ointment application every shift. *Surveyor noted MD-N's 2/14/22 order for Zinc ointment was not documented in the TAR. On 2/21/22, MD-N indicated R4's Coccyx was Unstageable measuring 12 x 12 x 0.3 cm with 100% slough. DTIs resolved as now combined with Coccyx Pressure Injury. Treatment ordered: ½ strength Dakin's cleanse then Alginate/CA covered with border foam daily. R4's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Normal Saline wash followed by Calcium Alginate to entire surface, cover with foam dressing. Change daily & prn (as needed) which was inaccurate in the TAR as MD-N had ordered ½ strength Dakin's cleanse not Normal Saline. R4 was hospitalized from 2/21-2/28/22. R4's 2/28/22 Hospital discharge records to the facility had wound care treatment orders for [MEDICATION(S)] to Sacrum 2 times/day & as needed, Offload aggressively. R4's 2/28/22 Facility Progress notes upon readmission indicated R4 has continued Wound to sacrum in improved condition, Measures 11.3 cm x 8.3 cm, no drainage, has 2 islands of dry tissue to either side of sacrum, treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . *No staging was noted. *Surveyor noted no treatments were documented on 2/28 or 3/1/22. *Surveyor noted at this point in MD-N's assessments, staging, measurements, and treatments despite visits by MD-N to R4 were not in R4's medical record or available to the nurses until 3/29/22 when Surveyor requested the documentation. Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A had to obtain access to the corporate MD-N's account. On 2/28/22, MD-N did not see R4 so there was no staging or measurements that week. On 3/7/22, MD-N indicated R4's Coccyx was Unstageable measuring 12 x 10 x 0.3 cm as a cluster wound with 90% slough 10% skin. Treatment ordered was ½ strength Dakin's cleanse, alginate/CA with border foam daily. On 3/14/22, MD-N indicated R4's Coccyx was Unstageable measuring 12 x 10 x 0.3 cm with 90 slough 10% skin. Treatment ordered was ½ strength Dakin's cleanse then alginate/CA covered with border foam daily. Treat surrounding MASD with House Barrier Cream. On 3/21/22, MD-N indicated R4's Coccyx was Unstageable measuring 12 x 10 x 0.3 cm with 80% slough, 10% granulation, 10% skin. Treatment was ½ strength Dakin's cleanse then alginate/CA covered with border foam daily. Treat surrounding MASD with House Barrier Cream. On 3/28/22, MD-N indicated R4's Coccyx was Unstageable measuring 10 X 16 x 0.3 cm with 60% slough 30% granulation tissue. Treatment ordered ½ strength Dakin's cleanse then alginate/CA covered with border foam daily. Treat surrounding MASD with House Barrier Cream. *Surveyor noted the active Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . NS (Normal Saline) wash followed by Calcium Alginate to entire surface, cover with foam dressing. Change daily & prn. The facility was not following MD-N's order for ½ strength Dakin's cleanse for wound care since initial order on 2/21/22 and ongoing order since 3/7/22. Observations/Interviews: On 3/28/22, Surveyor noted only one nurse in facility for 70 residents. R4 did not receive meds, insulin's not given, GT (Gastric Tube) feeding was not addressed and treatment was not done. On 3/28/22 at 10:03 AM, Surveyor observed R4 lying flat on back on the air mattress with bilateral protective boots. On 3/28/22, at 12:50 PM, Surveyor interviewed CNA-R working on R4's unit who stated she was from agency and the facility just put us here with no guidance, no nurse, no way to chart except through others login, and no care cards. On 3/28/22, at 12:55 PM, Surveyor interviewed CNA-S working on R4's unit who stated she was from agency and has come here before so we know the residents a little bit but there is no nurse today to check and confirm care. On 3/28/22, at 1:08 PM, Surveyor observed R4 sitting up in bed with head of bed elevated. On 3/28/22, at 2:47 PM, Surveyor observed R4 remains in bed flat on her back. On 3/28/22, R4's treatment was not completed as no nurse available on R4's unit. On 3/29/22, at 5:00 AM, Surveyor observed R4 lying flat in bed. Surveyor interviewed LPN-P (Licensed Practical Nurse) who stated she was working overnight on 3 units (North, East, Vent) with 3 CNAs one each on the Vent, Rehab, and West units. LPN-P stated all the care was not provided as they were supposed to split the units, rounds were not done as it is too hard to do it when staffing is horrible. LPN-P stated no rounds done since residents went to bed last night and she planned to look for one of the CNAs to she can help him start. LPN-P stated there are no care plans so the CNAs do not know what care to provide and how to transfer residents. LPN-P stated no charting by CNAs in the electronic medical record so the nurses are unable to check if care was provided or not. On 3/29/22, at 5:15 AM, Surveyor interviewed CNA-U working on R4's unit who stated she has worked here since 2/22 and regrets it as there is terrible care provided in this facility. CNA-U stated she could go on and on about the residents' needs. CNA-U stated one resident needed to be changed when she came in at 10 PM but she had to wait as until 12:30 AM for help to turn and reposition. CNA-U stated the facility does not provide the proper linen to clean and change people. CNA-U stated she is unable to get any assistance to turn residents so no repositioning for some residents and rounds are hard to do, to change residents without help. On 3/29/22, at 6:53 AM, Surveyor interviewed DON-B who stated that for Pressure Injuries I just document what I see, not Wound Certification so no staging. DON-B stated nurses don't measure, only describe, where, what, approximate size but no measurements but stated an RN could stage. DON-B has not seen MD-N notes for over 2 weeks regarding his assessments, measurements, and treatments. DON-B stated she is trying to get access to his corporate notes [VOHRA]. On 3/29/22, at 8:10 AM, Surveyor observed R4 lying in the bed on her back. On 3/29/22, at 9:50 AM, Surveyor interviewed LPN-J who stated they were always short-staffed, always what she has to go through every day. LPN-J stated the CNAs were cleaning and changing R4 now for the first time so Surveyor could observe R4's wound treatment. On 3/29/22, at 9:54 AM, Surveyor observed wound care treatment being provided to R4 and noted R4 has no dressing on coccyx wound. Nurse completed a Normal Saline wash, had 2 types Calcium/Alginate available (1 type had Silver impregnation). Surveyor observed a large wound area across coccyx and buttocks with scattered slough 75% and granulation 25%. Surveyor observed 2 small left ischial wounds covered with slough, not addressed by the nurse. LPN-J placed regular Calcium/Alginate across the coccyx/buttocks region. LPN-J placed a dressing that did not cover the entire coccyx/buttocks wound, then folded 4 x 4 in half and taped it over part of the wound in order to cover it as the proper size dressing was not available. *Surveyor noted LPN-J cleansed R4's wound with Normal Saline as R4's orders were not current and updated per MD-N's treatment orders. MD-N's treatment orders were for the ½ strength Dakin's cleanse for wound care. LPN-J did not address R4's 2 observable ischial wounds by staging, measuring, or any treatment to prevent further decline. On 3/29/22, at 12:54 PM, Surveyor interviewed DON-B who stated the facility doesn't do their own separate staging and measurements, only MD-N stages and measures wounds. DON-B stated she was doing a little bit of everything and has not seen the Wound Physician notes for 2 weeks therefore unable to address any questions. On 3/30/22, at 7:00 AM, Surveyor interviewed LPN-P who stated she was the only nurse in the facility when the PM nurse who stayed to help night shift left around 4:00-5:00 AM. LPN-P stated there were only 2 CNAs overnight in the facility so not all care was possible because repositioning requires 2 people. On 3/30/22, at 7:10 AM, Surveyor observed R4 in bed lying flat on back. R4 stated she has not seen any staff all night and her door was closed. On 3/30/22, at 11:43 AM, Surveyor observed R4 being changed and a new dressing placed on sacral/buttocks wound which is loose not adherent to the intact skin and does not cover the wound. Surveyor asked LPN-Q about R4's 2 ischial wounds and LPN-Q stated she will address the ischial wounds. LPN-Q stated this is her 2nd day as the facility wound care nurse and she plans to become wound care certified soon. LPN-Q stated she will get some tape to hold R4's dressing down or find a larger dressing to fit the size of the wound. On 3/30/22, at 8:57 AM, Surveyor interviewed MD-N who stated R4's wound has been there for 86 days & continues to get worse as it is a significant wound. MD-N stated initially with any wound, they get worse to a peak before the wound gets better with treatment. MD-N stated R4's stooling continues to impact the wound. MD-N stated when R4 came back from the hospital, the wound had improved in the hospital. MD-N stated R4's condition improved so the wound should heal easier. MD-N stated he did not see R4's left ischial wounds on Monday 3/28/22 when he made rounds probably because it was outside of the wound he was assessing/measuring. MD-N stated typically if he can find a nurse or utilize an aide to assist with rounds but sometimes there is no one to assist so he has to make rounds by himself. MD-N stated Repositioning definitely should happen. MD-N stated he touches base with DON-B when he comes so he knows what patients to see but DON-B is not always available for follow-up. MD-N confirmed R4's current and accurate treatment ordered per his 3/28/22 note. The facility provided a closed electronic medical record paper copy of R4's 3/24/17 care plan that had been resolved and staff no longer had access to view/change. The facility provided a paper copy of R4's closed care plan which was no longer active (dated 3/24/17, revised 3/19/18) indicated Skin at risk for impairment due to immobility, incontinence which had interventions including: Assist and encourage resident to turn and reposition every one to two hours and PRN (3/24/17), Dietary Supplements as ordered (3/24/17), Educate resident on the risks of infection and poor healing related to non-compliance (3/24/17), Ensure adequate food and fluid intake (3/24/17), Monitor closely for sensory impairment (3/24/17), Monitor for adequate food and fluid intake (3/24/17), Monitor weights and labs (3/24/17), Notify MD of abnormal findings (3/24/17), Protect heels (3/24/17), Provide skin care after each incontinence episode (3/24/17), RD to assess and recommend (3/24/17), Skin Assessment Weekly (3/24/17), Use lift sheet to move patient (3/24/17). Daily diabetic foot check (4/18/19), Use absorbent Pads or briefs that wick and hold moisture (4/26/19), Use commercial moisture barrier (4/26/19) Quarterly Bradens and PRN (5/28/19), *Facility has not accessed [NAME] notes since February 2022. *Facility nurses are not staging or measuring, just describing so the facility is totally reliant on MD-N for staging and measurements. When MD-N is not available, wound care assessments can be delayed with potential for adverse outcomes. *Facility was not following current treatment orders. *Facility did not address repositioning in the resident's care plan or the CNA care card. Agency CNAs stated they did not know they needed to reposition her. Additionally, the facility did not always have the staff needed to reposition the resident assuming they knew she needed repositioning. The resident has not been out of bed and, during observations, remained flat on her back in bed. This resident on 2/14/22 developed three unstageable pressure injuries. These combined into one unstageable wound that is now 56 times larger in area than when first identified (2.02 square cm. vs. 160 square cm.). In addition, during 2 different wound care observations, R4 had developed two additional ischial wounds that were not addressed by the facility. 2. R10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's Minimum Data Set (MDS) assessment dated [DATE] indicates Resident has a BIMS (Brief Interview of Mental Status) score of 00, indicating R10 is unable to participate in daily decision making. Resident requires extensive assistance of 1 staff with bed mobility, dressing, toileting, personal hygiene and bathing. The MDS indicates R10 is at risk for pressure injuries. On 12/4/21, nurse progress notes indicate resident has an open area to the sacrum. No measurements or assessment of the open area to the sacrum were conducted on 12/4/21 or 12/5/21. On 12/6/21, R10 was initially seen by Wound MD-N. Wound is documented as: Unstageable sacrum full thickness, 5 x 2 x 0.2 cm, 30% necrotic tissue, 70% granulation tissue. A treatment was ordered for Xeroform gauze to the wound bed covered with foam dressing daily. On 12/13/21, R10 was seen by Wound MD-N. Wound is documented as: Unstageable sacrum full thickness, 4.5 x 2 x 0.2 cm, 30% slough tissue, 30% granulation tissue and 40% skin. Xeroform gauze dressing daily continued at this time. The wound was surgically debrided by Wound MD-N. On 12/20/21, R10 was seen by Wound MD-N. Wound is documented as: Unstageable sacrum full thickness, 4.5 x 2 x 0.2 cm, 30% slough tissue, 30% granulation tissue and 40% skin. Xeroform gauze dressing daily continued at this time. The wound was surgically debrided by Wound MD-N. On 12/27/21, R10 was seen by Wound MD-N. Wound is documented as: Unstageable sacrum full thickness, 9 x 6 x 0.2 cm, 30% slough tissue, 30% granulation tissue and 40% skin. Orders were initiated for a Calcium Alginate treatment with foam border dressing changed daily. The wound was surgically debrided by Wound MD-N. On 1/3/22, R10 was seen by Wound MD-N. Wound is documented as: Unstageable sacrum full thickness, 9 x 6 x 0.2 cm, 30% slough tissue, 50% granulation tissue and 20% skin. Treatment orders continued for Calcium Alginate treatment with foam border dressing changed daily. The wound was surgically debrided by Wound MD-N. On 1/10/22, R10 was seen by Wound MD-N. Wound is documented as: Unstageable sacrum full thickness, 8 x 4 x 0.2 cm, 30% slough tissue, 50% granulation tissue and 20% skin. Treatment orders continued for Calcium Alginate treatment with foam border dressing changed daily. The wound was surgically debrided by Wound MD-N. From 1/13/22 to 2/1/22, R10 was hospitalized due to Altered Mental status and [CONDITION(S)]. On 2/1/22, R10 was seen by Wound MD-N via telemedicine visit. Wound is documented as: Unstageable sacrum full thickness, 7 x 8.3 x 0.2 cm, 100% slough tissue. Treatment order was initiated for Dakin's solution soaked gauze with foam border dressing changed daily. The sacrum was debrided at this time. Pressure injury to the left heel was documented as: unstageable necrosis, left heel 1 x 2 x 0.1 cm 90% slough tissue, 10% granulation. Treatment order continues for Xeroform gauze and border foam dressing daily. On 2/7/22, R10 was seen by Wound MD-N. Wound is documented as: Unstageable sacrum full thickness, 7 x 9 x 0.2 cm, 30% slough tissue, 50% granulation tissue and 20% skin. Treatment order was initiated for Santyl, a topical [MEDICATION(S)] ointment with foam border dressing changed daily. An additional pressure injury to the left heel was documented as: Stage 2, left heel 2.5 x 1.3 x UTD (unable to determine). Treatment order was initiated for Xeroform gauze and border foam dressing daily. R10 was hospitalized [DATE]-[DATE] due to worsening of sacrum wound which required treatment with intravenous antibiotics due to infection. Surveyor did not identify any wound assessments conducted by facility or Wound MD-N from 3/14/22 to 3/31/22. Surveyor reviewed R10's TAR (Treatment Administration Record) from December 2021-March 2022. Surveyor could not identify any documented wound treatments on December 2021 TAR for 12/15/21, 12/17/21, 12/25/21, 12/25/21, 12/27/21. Surveyor could not identify any documented treatments on January 2022 TAR for 1/2/22, 1/5/22, 1/7/22, 1/10/22, and 1/12/22. Surveyor could not identify any documented treatments on February 2022 TAR for 2/1/22 or 2/2/22 for R10's sacrum. No documented treatments were noted for R10's Left heel pressure injury until 2/6/22. Surveyor could not identify any documented treatments on March 2022 TAR for sacrum or left heel pressure injuries. R10's skin integrity care plan indicates that R10 requires an alternating air mattress, repositioning every 2 hours and weekly skin assessments. On 3/28/22 at 9:20 AM, R10 was observed in bed in a hospital gown laying on back. R10 does not have an alternating air mattress in place on the bed. R10's heels are noted resting directly on the bed. On 3/28/22 at 12:20 PM, R10 was observed in bed in a hospital gown laying on R10's back. R10 does not have an alternating air mattress in place on the bed. R10's heels are noted resting directly on the bed. On 3/28/22 at 2:45 PM, R10 was observed in bed in a hospital gown laying on back. R10 does not have an alternating air mattress in place on their bed. R10's heels are noted resting directly on the bed. On 3/29/22 at 7:45 AM, R10 was observed in bed in a hospital gown laying on R10's back. R10 does not have an alternating air mattress in place on their bed. R10's heels are noted resting directly on the bed. On 4/4/22 at 8:30 AM, Surveyor conducted an interview with Wound MD-N. Wound MD-N recalls treating R10's pressure injury to the sacrum. Wound MD-N remembered seeing R10's sacrum and [MEDICATION(S)] the wound bed on multiple occasions. Wound MD-N reports only seeing R10's left heel pressure injury once or twice. Surveyor asked if Wound MD-N would expect residents who are at risk for pressure injuries to have their heels floated while in bed. Wound MD-N told Surveyor they would expect this as part of nursing care. Surveyor asked if Wound MD-N would expect residents who are at risk for pressure injuries be repositioned at least every 2 hours. Wound MD-N responded Yes. Surveyor asked if Wound MD-N would expect residents with unstageable pressure injuries to have an alternating air mattress in place on their bed. Wound MD-N responded, If the resident can use an air mattress safely and is dependent on staff for repositioning, I think they should have an air mattress. Surveyor asked Wound MD-N if they are not in the facility to conduct wound assessments whether or not the facility should assess wounds independently. Wound MD-N responded he would expect someone at the facility to assess and measure wounds if he is unavailable. On 4/4/22 at 11:00 AM, Surveyor conducted interview with Director of Nursing (DON)-B. Surveyor asked DON-B who is responsible for weekly wound assessments. DON-B said she had been acting as the facility's wound nurse but has gotten behind. Surveyor asked DON-B why the facility does not conduct their own wound assessments. DON-B responded they do not personally feel comfortable staging pressure injuries so Wound MD-N con [TRUNCATED]

Based on observation, interview, and record review the facility did not ensure that 7 (R10, R2, R4, R13, R14, R11, R18) of 8 residents reviewed were free from significant medication errors. According to the State Operations Manual, Appendix PP-Guidance t Surveyors for Long Term Care Facilities, (11/22/17), A Significant medication error means one which causes the resident discomfort or jeopardizes his or her health and safety . * On 3/28/22, R10 did not receive their scheduled tube feeding, gastronomy tube water flush, blood glucose monitoring and insulin. On 3/14/22, R10's after hospital visit summary ordered for R10 to receive scheduled detemir insulin 10 units each morning and regular insulin per sliding scale based off of R10's glood sugar readings. The regular insulin order per sliding scale based off of blood sugar readings was not transcibed into R10's readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R10 did not receive regular insulin based off of blood sugar readings since no blood sugar checks were done since readmission on 3/14/22, with the exception of the 3/30/22 nurses note. On 3/30/22, R10 was admitted into the hospital. According to the nurses notes, R10 had been sent to the emergency room due to altered mental status and a blood sugar reading of 500 mg (milligrams)/dL (deciliter). * On 3/28/22, R2 did not receive their scheduled [CONDITION(S)] medication. * On 3/28/22, R4 did not receive blood pressure medications, a diuretic, 2 antibiotics, blood glucose monitoring and sliding scale insulin. * On 3/28/22, R13 did not receive blood pressure medications, a diuretic, 2 antibiotics, blood glucose monitoring and sliding scale insulin. * On 3/28/22, R14 did not receive blood pressure medications, a diuretic, an anticoagulant, intravenous antibiotic, and inhaled respiratory medications. * On 3/28/22, R11 did not receive their scheduled blood glucose monitoring at 8 AM and 12 PM. R11 did not receive their scheduled insulin. * On 3/28/22, R18 did not receive their scheduled blood glucose monitoring at 8 AM and 12 PM. R18 did not receive their sliding scale insulin. Example 1 involving R10 rises to a scope and severity level of harm/isolated. Findings include: On 3/28/22, Surveyor reviewed the daily staffing schedule provided by the facility and noted Director of Nursing (DON)-B was listed as assigned to the vent unit and the only nurse in the facility. On 3/28/22 at 11:36 AM, Scheduler (SCH)-I stated there was only one nurse in the building and Nursing Home Administrator (NHA)-A was aware of staffing concerns. On 3/28/22 at 11:56 AM, NHA-A stated she was aware of staffing concerns as she had been notified at 6:20 AM and DON-B was the only nurse in the facility despite offering $200 bonuses and calling agencies. NHA-A stated medications were not passed. NHA-A stated the shortage of nurses does not happen often and usually manage to get things passed. On 3/28/22, at 12:00 PM, DON-B stated she tried to do most of the residents' blood sugars but no insulins were given or IV medications given as there was no time. DON-B stated she would try to do her best to get the noon blood sugars done but she did not know if she could as she needed to be in the vent unit. On 3/28/22 at 12:27 PM, NHA-A stated she did a blanket call to physicians to notify them that medications were not given and stated insulins and tube feedings were not done. On 3/28/22 at 2:47 PM, Surveyor interviewed Med Tech (MT)-O who stated she was passing medications for 34 residents. MT-O stated she will not give the missing AM medications as it is not in the plan as it is too late and too far out. 1. R10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's Minimum Data Set (MDS) assessment dated [DATE] indicates R10 has a BIMS (Brief Interview of Mental Status) score of 00, indicating R10 is unable to participate in daily decision making. Surveyor notes that R10 did not receive the following medications per R10's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] 20 mg - did not receive 8 AM dose. 2. Insulin Detemir 10 units subcutaneously- did not receive 8 AM dose. 3. Tube Feeding: [MEDICATION(S)] solution 1.5 cal (calorie) per mL (milliliter) 70 mL per hour-Did not receive tube feeding for AM shift (6-2 PM). 4. Water flush: 100 mL five times daily-missed 12 PM dose. On 3/28/22 at 11:45 AM, Surveyor asked NHA (Nursing Home Administrator)-A about R10 not receiving their medications or tube feeding this morning. NHA-A responded that there was only 1 nurse in the building and that the only residents who received their medications so far were on the ventilator unit. R10 resides on the East Unit. NHA-A confirmed that R10 has not received their medications or tube feeding in accordance with plan of care. On 3/28/22 at 3:30 PM, Surveyor made NHA-A aware of concerns related to R10 not receiving medications or tube feeding in accordance with their care plan on 3/28/22. No additional information was provided by the facility at this time. Surveyor reviewed R10's nurse progress notes from 3/30/22. Surveyor noted that R10 had been sent out to the emergency room due to altered mental status and a blood sugar reading of 500 mg (milligrams)/dL (deciliter). Additionally, Surveyor reviewed R10's hospital after visit summary from 3/14/22. Surveyor notes orders for R10 to receive scheduled detemir insulin 10 units each morning and regular insulin per sliding scale based off of R10's blood sugar readings. Order from 3/14/22 reads: insulin regular 100 unit/mL injection, Blood glucose low dose Correction, blood glucose <70 Assess patient for symptoms. Administer [CONDITION(S)] meds if indicated. Call Physician .blood glucose 70-149 No action, blood glucose 150-200 2 unit, blood glucose 201-250 3 units, blood glucose 251-300 4 units, blood glucose 301-350 6 units, blood glucose 351-400 8 units, blood glucose >400 Obtain STAT blood glucose, give 8 units and call physician. Surveyor reviewed R10's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional blood sugar monitoring was identified in R10's medical record with the exception of R10's 3/30/22 reading. Surveyor attempted to review R10's admission assessment dated [DATE]. No admission assessment was noted in R10's medical record. On 4/4/22, Surveyor conducted interview with DON (Director of Nursing)-B. Surveyor asked DON-B which nurse had readmitted R10 to the facility on [DATE]. DON-B could not identify which nurse had readmitted R10 to the facility on [DATE] but knows that they had been an agency staff member. Surveyor asked DON-B how a nurse would know what medications a resident should receive when they are readmitted from the hospital. DON-B told Surveyor that they would review the resident's discharge paperwork from the hospital and confirm the medications with the resident's attending physician. DON-B showed Surveyor an admission check list that the admitting nurse should be using to make sure all necessary tasks are performed when a resident is readmitted . Surveyor asked why R10's sliding scale insulin order and blood sugar readings had not been transcribed as part of R10's readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/4/22 at 1:15 PM, Surveyor shared concern with NHA-A that R10 had not been receiving regular blood sugar monitoring or sliding scale insulin in accordance with their physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Quarterly 12/29/21 Minimum Data Set (MDS) indicated R2 was cognitively intact. On 3/29/22, Surveyor reviewed the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Capsule 300 mg ([MEDICATION(S)] Extended)-Give 1 tablet by mouth one time a day for seizures/convulsions. *[MEDICATION(S)] is an anticonvulsant which is administered to treat and prevent seizures. [MEDICATION(S)] blood levels are monitored and missing a single dose could alter that level which could precipitate a [CONDITION(S)]. 3. R4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/29/22, Surveyor reviewed the MAR for March 2022 for R4. It was noted that the following medications were not initialed as being administered on 3/28/22 at 8:00 a.m. as scheduled per MAR: [MEDICATION(S)] tablet 5 mg-Give 0.5 tablet via PEG-tube 1 time/day. [MEDICATION(S)] Solution 10 mg/ml-Give 4 ml via PEG-tube 1 time/day. [MEDICATION(S)] tablet 100 mg-Give 1 tablet via PEG-tube every 12 hours. [MEDICATION(S)] Suspension 200 mg/5 ml-Give 10 ml via PEG-tube 2 times/day. [MEDICATION(S)] tablet 800-160 mg-Give 1 tablet via PEG-tube 2 times/day every Mon, Wed, Fri. [MEDICATION(S)] HCL tablet 0.3 mg-Give 1 tablet via PEG-tube every 12 hours. [MEDICATION(S)] Kwik-Pen solution pen injector 100 unit/ml (Insulin [MEDICATION(S)])-Inject as per sliding scale subcutaneously 3 times/day. *Surveyor noted that R4's blood sugars and insulin was not documented for either scheduled times of 0800 and 1200. *R4 missed blood pressure medications, a diuretic, 2 antibiotics, and the blood sugar checks with insulin which had a high potential for R4 to have adverse consequences. 4. R13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/29/22, Surveyor reviewed the MAR for March 2022 for R13. It was noted that the following medications were not initialed as being administered on 3/28/22 at 8:00 a.m. as scheduled per MAR: [MEDICATION(S)] Sodium tablet delayed release 500 mg-Give 1 tablet by mouth every 12 hours. *[MEDICATION(S)] is an anticonvulsant in which blood levels are monitored and missing a single dose could alter that level. 5. R14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's 3/18/22 Admission MDS was in progress. On 3/29/22, Surveyor reviewed the MAR for March 2022 for R14. It was noted that the following medications were not initialed as being administered on 3/28/22 at 8:00 a.m. as scheduled per MAR: [MEDICATION(S)] 125 mcg-Give 1 tablet by mouth 1 time/day. *[MEDICATION(S)] is used to treat certain heart conditions. [MEDICATION(S)] blood levels are monitored and missing a single dose could alter that level which could precipitate heart conditions. [MEDICATION(S)] 5 mg-Give 1 tablet 2 times/day. *[MEDICATION(S)] is used to prevent blood clots and missing a single dose could lead to an adverse consequence. [MEDICATION(S)] tablet 80 mg-Give 1 tablet 2 times/day. *[MEDICATION(S)] is diuretic intended to remove excess fluid and missing a single dose could lead to an adverse consequence including an electrolyte imbalance. [MEDICATION(S)] tablet-Give 12.5 mg by mouth 2 times/day. *[MEDICATION(S)] is a heart rate and blood pressure medication and missing a single dose could lead to an adverse consequence. [MEDICATION(S)] Sodium solution-Use 2 gm intravenously every 8 hours. *R14 was receiving [MEDICATION(S)] IV for aortic valve vegetation and missing a single dose would change the blood concentration could lead to an adverse consequence. [MEDICATION(S)]-[MEDICATION(S)] Solution 0.5-2.5 (3) mg/3 ml-1 vial inhale orally 4 times/day. Surveyor noted the vial (medication) was not documented for either scheduled times of 0800 and 1200. *R14 missed 2 doses of an inhaled medication designed to assist with breathing and could lead to respiratory distress. Monitor PICC (Peripherally Inserted Central Catheter) line to RUE (Right Upper Extremity) site every shift for S/S (Signs/Symptoms) of infection every shift. On 3/29/22, at 8:15 AM, Surveyor interviewed R14 who stated no medications were administered yesterday (3/28/22) as R14 was told there was no licensed person to give them. On 3/30/22, at 3:00 PM, Surveyor observed R14's PICC line which had a 3/18/22 admitted d dressing. Surveyor noted R14 had a 3/25/22 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor notified DON-B of the dated 3/18/22 dressing and the conflicting documentation in R14's MAR. DON-B stated she will assess and change the dressing, rewrite the order then educate the nurse. On 3/29/22, at 1:30 PM, Surveyor shared concerns regarding significant medications not being provided on 3/28/22 with NHA-A. 6. R11 was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R11's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, R11 is to receive [MEDICATION(S)] Kwikpen Solution 100 unit, inject as per sliding scale: if 100-150= 1 unit, 151-200= 2 units, 201-250= 3 units, 251-300= 4 units, 301-400= 5 units, 401-450= 6 units, subcutaneous three times a day (8:00 a.m., Noon and 4:00 p.m.) for Diabetes Mellitus, notify MD if greater than 450. On 3/29/22, Surveyor reviewed the MAR for March 2022 for R11. It was noted that on 3/28/22, R11 did not receive his noon (12:00) dose of [MEDICATION(S)] Kwikpen Solution 100 unit, inject 10 unit subcutaneous and the [MEDICATION(S)] Kwikpen Solution 100 unit, inject as per sliding scale: if 100-150= 1 unit, 151-200= 2 units, 201-250= 3 units, 251-300= 4 units, 301-400= 5 units, 401-450= 6 units, subcutaneous. It was also noted that R11's blood sugars were not checked at noon as well. 7. R18 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of R18's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] =3 units, 150 or less, 0 units, 200-249= 6 units, 250-299= 9 units, 300-349= 12 units and 350 or greater give 15 units and notify MD three times daily (8:00 a.m., Noon and 4:00 p.m.) On 3/29/22, Surveyor reviewed the MAR for March 2022 for R18. It was noted that R18 did not have her blood sugars checked at 8:00 a.m. or Noon (12:00) and was not administered the [MEDICATION(S)] Kwikpen Solution 100 unit, inject as per sliding scale: if 150-199=3 units, 150 or less, 0 units, 200-249= 6 units, 250-299= 9 units, 300-349= 12 units and 350 or greater give 15 units at 8:00 a.m. or Noon on 3/28/22.

Based on record review and interview, the facility did not ensure all staff were fully vaccinated for COVID-19. The facility's current staff vaccination rate is 95.5% and is not at 100%. Findings include: On 3/31/22, the facility's policy titled Employee Inoculation COVID-19 Pandemic dated 11/8/21 was reviewed and read: All employees must be inoculated unless specifically exempted. On 3/31/22, Surveyor reviewed the NHSN (National Health Safety Network)'s most recent data for the facility dated 3/20/22. On 3/20/22, the facility's percentage of fully vaccinated staff for COVID-19 was noted at 90.2%. On 3/31/22, Surveyor was provided with facility's current staff vaccination rates as of 3/31/22. On 3/31/22, the facility's percentage of fully vaccinated staff for COVID-19 was noted at 95.5%. As of 3/31/22, the facility currently has a total of 90 staff members, including direct facility hires and contracted employees. As of 3/31/22, 86 of 90 staff members were fully vaccinated and 4 of the 90 staff members were partially vaccinated without exemption or delay. The staff members who were not fully vaccinated were Staff-CC, Staff-DD, Staff-EE, and Staff-FF. On 3/31/22 at 3:00 PM NHA (Nursing Home Administrator)-A was interviewed and indicated she was aware that 4 staff members who should be fully vaccinated were not, and arrangements had been made to get them fully vaccinated soon but could not provide a date when that was going to be. NHA-A indicated that it was the staffs' responsibility before she was made aware that not everyone was fully vaccinated but now the facility is arranging to get this done. No residents were found to have been Covid positive in the last 4 weeks. The above finding was shared with Administrator-A on 3/31/22 at 3:00 PM, Additional information was requested. None was provided.

Based on observation, interview and record review the Facility did not ensure Residents who require respiratory care are provided with ventilator (Vent) and [CONDITION(S)] ([CONDITION(S)]) care consistent with professional standards of practice, the comprehensive person centered care plan and Resident's goals for the 14 Residents residing on the ventilator unit. Out of the 31 staffing days reviewed for December 2021, the facility was short staffed 1 respiratory therapist on 20 out of 31 days reviewed. On four of these days (12/12, 12/16, 12/23, 12/25) the facility had no respiratory therapist working for at least 24 hours. Surveyor noted that out of the 12 staffing days reviewed for January 2022, the facility was short staffed 1 respiratory therapist on 9 out of the 12 days reviewed, including 1 day (1/1) where no respiratory therapist worked for at least 24 hours. (Cross reference F725) * On 1/7/22, R7 was having shortness of breath and required suctioning. There was no licensed nurse or respiratory therapist (RT) working on the ventilator unit when R7 was experiencing this change of condition. The facility called 911. When the paramedics arrived, R7 was suctioned and a [MEDICATION(S)] plus was removed. *Ventilator/Aerosol Flowsheets which are completed by the RT's were not completed twice a day, once per shift, on 12/8/21, 12/23/21, 12/25/21, 12/26/21, 1/1/22, 1/2/22, 1/6/22, 1/9/22, & 1/11/22. Surveyor noted that on several of the above dates, the Facility was short staffed respiratory therapists. * R8, R17, and R18 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R8 who is ventilator dependent has physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] & 1/6/22. R8 has a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Facility was short staffed respiratory therapists on several of the above dates. R17 who is ventilator dependent has a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R17's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] & 1/12/22. R17 has a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R17's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] & 1/12/22. The Facility was short staffed respiratory therapists on several of the above dates. R18 is ventilator dependent and has a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] & 1/12/22. R18's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] & 1/12/22. The Facility was short staffed respiratory therapists on several of the above dates. * R10 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/29/21 R10 was transferred to the emergency department for coffee ground emesis. R10 returned the same day with instructions for further monitoring and recommended follow up labs with R10's primary physician. R10 was experiencing a significant change in condition. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no MD orders put in place for NP-L's order for [MEDICATION(S)] treatments or to keep saturation above 92%. There were no MD orders put in place for aggressive pulmonary toilet and [CONDITION(S)] care. There were no progress notes monitoring NP-L's observations of R10 or increased heart rate on 12/30/21, 12/31/21, 1/1/22, 1/2/22 or 1/3/22. R10's O2 sats were 88% and were below NP-L's recommended saturation rate of 92%. R10 ended up in the emergency roiagnom on [DATE] and was admitted into the hospital with septic shock and ventilator-associated pneumonia. * On 1/19/22 R7 complained of shortness of breath. There was no RT scheduled and the nurse on the unit did not know how to adjust the setting to the vent. The ambulance was called and R7 was transferred to the hospital. On 1/24/22 Surveyor observed R7 over breathing the ventilator to overcome the secretions with respiration rates of 28-30 per minute. (R7 was set for 20 respiration rates per minute on the ventilator.) R7 was observed with green bubbling secretions seeping out of the stoma and bubbling into the ventilator tubing. The canister for the secretions was full. The surveyor notified the unit nurse R7 needed suction. There was no RT on the unit or in the building at this time. R7's care plan does not match the MD orders for oxygenation. There was no availability of an ambu bag or obturator (which is used in an emergency for [CONDITION(S)] reinsertion). * R8 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . DON-B stated they (Nursing) were not trained on the use of Passy Muir valves (speaking valve-cap over [CONDITION(S)]). * Director of Nursing -B listed emergency equipment with the obturator are taped to the wall and an AMBU bag in the resident's room. Surveyor did not observe R7 have an AMBU bag or an obturator taped to the wall in the resident's room. * Nurses were not trained on administering physician ordered nebulizer treatments in the absence of an RT. R7 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R8 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatments were not provided on 1/14, 1/15, 1/16, only 2 times 1/18, only once at night 1/19, only once at night 1/20, only once at night 1/24/22. * When a respiratory therapist is not on duty, the ventilator unit is supervised by a nurse. None of the nurses who work on the ventilator unit are certified to work with vent residents and none had competency training. The failure to staff the ventilator unit to meet the needs of the 14 Residents residing on this unit, the failure to ensure the nurses working on the ventilator unit are competent to care for Residents on ventilators and with [CONDITION(S)] and the failure to ensure physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/13/22 at 12:34 p.m. Administrator-A and DON (Director of Nursing)-B were informed of the immediate jeopardy. The immediate jeopardy was not removed at the conclusion of the survey. Findings include: Surveyors were investigating staffing on the vent unit as Surveyors became aware of allegations there were no nurses in the Facility on 1/7/22, with multiple alarms sounding on the ventilator unit and there was no Respiratory Therapist to provide cares. Residents required suctioning and 911 had to be called. Surveyors noted that out of the 31 staffing days reviewed for December 2021, the facility was short staffed 1 respiratory therapist on 20 out of 31 days reviewed (12/2, 12/3, 12/4, 12/5, 12/6, 12/7, 12/8, 12/11, 12/12, 12/13, 12/16, 12/17, 12/19, 12/21, 12/22, 12/23, 12/25, 12/26, 12/30, 12/31/21). On 4 of these days (12/12, 12/16, 12/23, 12/25) the facility had no respiratory therapist working for at least 24 hours. Surveyor noted that out of the 12 staffing days reviewed for January 2022, the facility was short staffed 1 respiratory therapist on 9 out of the 12 days reviewed, including 1 day (1/1) where no respiratory therapist worked for at least 24 hours (1/1, 1/2, 1/3, 1/4, 1/5, 1/6, 1/7, 1/8, 1/11/22). (Cross reference F725 for specific shifts) 1. R7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R7 is a full code. On 1/10/22 at 1:07 p.m. Anonymous-X spoke with Surveyor. Anonymous-X informed Surveyor on 1/7/22 there was only a CNA (Certified Nursing Assistant) on the vent unit. Anonymous-X indicated the night nurse stayed over a little & then left and there was no RT (respiratory therapist) on the ventilator unit. R7 became short of breath, no one knew how to suction, and 911 was called. Anonymous-X indicated a [MEDICATION(S)] plug was removed from R7, and while the paramedics were on the unit R44's alarm was going off. The paramedics went into R44's room and discovered R44's vent was disconnected. On 1/13/22 at 7:53 a.m. Surveyor spoke with a representative at the Milwaukee Fire Department Administration to inquire if paramedics were dispatched to the facility on [DATE]. Surveyor was informed they were dispatched at approximately 10:54 a.m. and again at 6:30-6:45 p.m. Surveyor asked if Surveyor provided the name of the Resident could they verify the paramedics were dispatched for this Resident. Surveyor was informed they don't have names only room numbers. Surveyor provided the representative at the Milwaukee Fire Department R7's room number and was informed the paramedics were dispatched at 10:54 a.m. for this room number which is R7's room. The NP (nurse practitioner) note dated 1/7/22 documents Asked to see patient secondary to Respiratory distress. Patient reporting shortness of breath and requesting suctioning however no staff available on vent unit thus 911 called. 911 personnel suctioned a mucous plug and patient denies shortness of breath afterwards. He denies wanting to go to the hospital. He appears to be stable at this time. On 1/10/22 at 3:33 p.m. Surveyor asked RT-N if she worked on 1/7/22. RT-N replied no. RT-N looked at the RT schedule and informed Surveyor RT-QQ worked until 10:00 a.m. and RT-M came in at 6:30 p.m. (No RT worked from 10 a.m. to 6:30 p.m.) RT-N informed Surveyor RT-T & RT-M are the only full time respiratory therapists. There are a couple other respiratory therapist that fill in when they can. RT-N informed Surveyor the Facility used to pay them a bonus to pick up extra shifts but they stopped this. RT-N informed Surveyor she used to pick up a lot of extra shifts but didn't feel appreciated so she's not picking up extra shifts. Surveyor verified with RT-QQ punch card RT-QQ punched out at 10:00 a.m. on 1/7/22. On 1/14/22 at 9:04 a.m. Surveyor spoke with CNA (Certified Nursing Assistant)-OO on the telephone. CNA-OO was the CNA working the vent unit on 1/7/22. CNA-OO informed Surveyor for part of the day on 1/7/22 she was the only one working the vent unit, there wasn't a nurse or RT. CNA-OO informed Surveyor there were nurses on the unit doing Covid testing on 1/7/22. Surveyor asked if she informed anyone R7 was short of breath. CNA-OO replied no. CNA-OO informed Surveyor she heard the fire department was there for R7, that R7 was short of breath, but she couldn't recall who told her. On 1/13/22 at 7:33 a.m. Administrator-A informed Surveyor she was told there were no nurses in the building on 1/7/22. Administrator-A informed Surveyor she found out Former IP (Infection Preventionist)-T was in the building. Administrator-A indicated she told Former IP-T she need to go out on the floor and work. Former IP-T told her no and left. Administrator-A informed Surveyor MDS (Minimum Data Set) Nurse-RR was in her office and she had MDS Nurse-RR go and work the floor. Administrator-A informed Surveyor she called AL DON (Assisted Living) DON (Director of Nursing)/LPN (Licensed Practical Nurse)-PP and asked her to go to the vent unit but she was in the middle of something. Administrator-A informed Surveyor when AL DON/LPN-PP was finished in the Assisted Living area, she came to the vent unit. Administrator-A indicated she also called DON-B even though she knew that DON-B was sick, but was desperate. Surveyor asked what time DON-B came to the Facility. Administrator-A informed Surveyor DON-B was at the Facility from 11:30 a.m. to 1:00 p.m. On 1/12/22 at 10:48 a.m. Surveyor spoke with AL DON (Assisted Living Director of Nursing)/LPN (Licensed Practical Nurse)-PP on the telephone. Surveyor inquired if she worked on the vent unit on 1/7/22. AL DON/LPN-PP explained she got a call from Administrator-A asking her to go to the vent unit in the health center. AL DON/LPN-PP explained she had to finish a call with a doctor & help with a resident so she probably didn't get over to the vent unit until 10:30-11:00 a.m. Surveyor asked how long she worked on the vent unit. AL DON/LPN-PP informed Surveyor until about 3:00 to 3:15 p.m. Surveyor asked if she has worked the vent unit prior. AL DON/LPN-PP replied yes and explained when she was a nurse manager at the nursing home she had to work the vent unit at times. AL DON/LPN-PP also informed Surveyor she did private duty for a ventilator patient and, at one time, had a certification but she didn't keep the certification up. Surveyor asked on 1/7/22 if there was a RT on the vent unit. AL DON/LPN-PP replied no. Surveyor asked if she saw DON-B on the vent unit. AL DON/LPN-PP informed Surveyor DON-B came in after she was there and they both worked the unit for a little while. Surveyor asked if DON-B appeared sick. AL DON/LPN-PP replied yes she was sick. Surveyor asked AL DON/LPN-PP while she was working on 1/7/22 did any residents have to be transferred to the hospital. AL DON/LPN-PP replied no. Surveyor asked what she would do if a Resident had a change in condition. AL DON/LPN-PP informed Surveyor she would call 911. On 1/13/22 at 11:05 a.m. Surveyor spoke with AL DON/LPN-PP and asked when she worked the vent unit on 1/7/22 did anyone make her aware 911 had been called, the paramedics removed a mucous plug and R7 needed to be monitored. AL DON/LPN-PP informed Surveyor no one told her R7 had a mucous plug removed. On 1/12/22 at 1:02 p.m. Surveyor asked DON-B on 1/7/22 when she came into work if she was still sick with Covid and did she have any symptoms. DON-B informed Surveyor she was still sick. Surveyor inquired why she came into the Facility if she was sick. DON-B informed Surveyor she wasn't sure, felt obligated, and didn't want to see her staff struggle. DON-B indicated she told Administrator-A she didn't feel good but would do her best to come in. DON-B explained when she came in the vent unit needed someone so she went to the unit. DON-B informed Surveyor one of the NP's saw her and told her to leave the building. On 1/11/22 at 11:43 a.m. Surveyor asked Administrator-A if the respiratory therapists are employed by the Facility. Administrator-A replied yes. Surveyor inquired if there is a Respiratory Director. Administrator-A replied no and explained they had a Respiratory Director, but they had to let her go because she refused to get vaccinated. Surveyor asked how many respiratory therapists there are. Administrator-A explained there are two respiratory therapists who are full time and PRN (as needed) therapists who pick up when they can. Surveyor asked what happens if there isn't a respiratory therapist scheduled. Administrator-A informed Surveyor they have been offering bonuses to work extra and they have nurses trained in respiratory therapy. Administrator-A informed Surveyor DON (Director of Nursing)-B and RN (Registered Nurse)-E have been trained. Surveyor asked who trained DON-B & RN-E. Administrator-A replied that I don't know and indicated they are working on getting all the nurses trained on vents. Surveyor asked if the training had started. Administrator-A informed Surveyor the Respiratory Director is no longer employed so they haven't started the training. Surveyor asked Administrator-A if Surveyor could be provided with the training RN-E and DON-B received. Administrator-A informed Surveyor she's not going to be able to provide anything on RN-E and doubt she can for DON-B but she came from a vent unit at another facility. Administrator-A informed Surveyor when she came to the Facility there was no HR (human resource) person and the files were a mess. On 1/11/22 at 2:53 p.m. Surveyor asked DON-B what vent training she has received. DON-B explained she managed a [CONDITION(S)] unit at another Facility right before she came to this Facility. DON-B informed Surveyor she doesn't have any formal written out training but did shadow RT-QQ and the prior Respiratory Director. DON-B informed Surveyor she would be really excited if the facility found a vent class she could take. On 1/11/22 at 2:25 p.m. Surveyor observed R7 on an air mattress on his back with the head of the bed elevated with music playing in R7's room. Surveyor observed secretions coming out of R7's [CONDITION(S)]. Surveyor asked R7 if he needed to be suctioned. R7 indicated he did. Surveyor then went and informed RN (Registered Nurse)-E R7 needed to be suctioned. On 1/12/22 at 8:09 a.m. Surveyor asked RT-M how long he is working on the ventilator unit today. RT-M replied 10:00(a.m.). RT-M informed Surveyor RN-E is working along with a CNA (Certified Nursing Assistant). On 1/12/22 at 9:57 a.m. Surveyor asked RT-M how often the Ventilator/Aerosol Flowsheet is completed. RT-M explained the RT completes this form once in the day and once in the evening. Surveyor asked who completes this form when there is no RT on the unit. RT-M replied I don't think it's done. Surveyor noted the Ventilator/Aerosol Flowsheet documents the Resident's ventilator settings including mode, PEEP (positive end expiratory pressure), respiration rate set & respiration rate actual, peak pressure, inspiratory/expiratory ratio, FIO2 (fraction of inspired oxygen), and fixed tidal volume set & actual. The alarm section on the Ventialor/Aerosol Flow sheet documents low pressure, high pressure, low pressure, low minute ventilation & high respiratory rate. The [CONDITION(S)] care section includes if the inner cannula was changed, [CONDITION(S)] care performed, [CONDITION(S)] ties changed, the [CONDITION(S)] integrity, and left & right breath sounds. Under the miscellaneous section includes the total number of respiratory treatment minutes, HME (heat & moisture exchange), ambu bag, O2 (oxygen) tank or source, red outlet & vent alarm connected. There is also a section for Resident's vital signs. On 1/12/22 Surveyor reviewed R7's December 2021 & January 2022 Ventilator/Aerosol Flowsheets and noted on 12/8/21 none were completed, 12/23/21 completed 1 time, 12/25/21 none were completed, 12/26/21 completed one time, 1/1/22 none completed, 1/2/22 completed one time, 1/6/22 completed one time, 1/9/22 completed one time, & 1/11/22 completed one time. Surveyor noted that on several of the above dates the Facility was short staffed respiratory therapists. On 1/12/22 at 1:43 p.m. Surveyor spoke with MD (Medical Doctor)-J, who is also the Facility's medical director on the telephone. Surveyor inquired what MD-J's expectation is for staffing the ventilator unit. MD-J informed Surveyor the vent unit should have a RT (respiratory therapist) at all times and good to have an RN (Registered Nurse) on the unit. MD-J informed Surveyor there should be a nurse in the building at least 12 hours available, ideally an RN. MD-J informed Surveyor NP (Nurse Practitioner)-O knows all the Residents on the vent unit. Surveyor asked MD-J if the Facility should have a RT at all times. MD-J replied correct. Surveyor asked MD-J if he was aware on 1/7/22 there wasn't a RT or unit nurse on the vent unit when 911 had to be called for R7. MD-J informed he was not aware until he found out yesterday (1/11/22) when a colleague informed him. On 1/12/22 at 2:00 p.m. MD-J telephoned Surveyor back and informed Surveyor he wanted to clarify what he said. MD-J informed Surveyor he was thinking about from a regulatory point don't need a RT 24/7 but need one available. MD-J stated I could be wrong. 2. R8, R17, and R18 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2a. R8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's Quarterly MDS (Minimum Data Set) dated 12/27/21 documents a BIMS (Brief Interview for Mental Status) score of 13, indicating that R8 is cognitively intact. Section G (Functional Status) documents that R8 has total dependence on staff and requires a two person physical assist for her bed mobility, transfer and toileting needs. Section O (Special Treatments and Programs) documents that R8 requires oxygen, suctioning, [CONDITION(S)] and respiratory ventilator/respirator care while at the facility. R8's respiratory care plan dated as initiated on 6/25/21 documents under the Focus section, R8 is vent dependent at night due to admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/11/22 at 9:16 a.m., Surveyor interviewed RN (Registered Nurse)-E, who was working on the ventilator unit, if residents were receiving respiratory care when there was not RT present in the facility. RN-E informed Surveyor that when an RT is not working on the ventilator unit, residents being weaned off the ventilator remain on the ventilator and those on a mask remain on a mask despite physician orders. RN-E informed Surveyor that the facility is short staffed respiratory therapists and that some nurses at the facility do not feel comfortable switching ventilator residents from the ventilator to a mask and vice versa. On 1/11/22 at 1:14 p.m., Surveyor interviewed R8 regarding the respiratory care at the facility. R8 informed Surveyor that she was concerned regarding the lack of respiratory therapists working at the facility. R8 informed Surveyor that when there is no respiratory therapist (RT) she is forced to either stay on the ventilator or on her [CONDITION(S)] mask, as no one is available to switch her over from the vent to the mask or vice versa. R8's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . One time a day. Surveyor reviewed R8's December 2021 and January TAR (Treatment Administration Record) which documents that the above order was not completed on 12/13/21, 12/19/21, 12/21/21, 12/23/21, 12/25/21, 12/26/21, 12/27/21, 12/29/21, 12/30/21, 1/1/22, 1/2/22 & 1/6/22. Surveyor noted that on several of the above dates, the facility was short staffed respiratory therapists. R8's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R8's December 2021 and January TAR (Treatment Administration Record) which documents that the above order was not completed on 12/18/21, 12/25/21, 1/1/22 & 1/12/22. Surveyor noted that on several of the above dates, the facility was short staffed respiratory therapists. On 1/12/22 at 8:32 a.m., Surveyor interviewed RT (Respiratory Therapist)-M regarding the amount of respiratory care needed on the ventilator unit. Surveyor asked RT-M if residents on the ventilator unit receive respiratory treatments, such as putting residents on and off the ventilators, when there is not RT working. RT-M informed Surveyor that residents do not get respiratory treatments when there is no RT present as most nurses on the ventilator unit do not feel comfortable taking residents on and off the ventilators. RT-M informed Surveyor that the residents that were ventilator dependent were stable and that he attempted to leave them with all their treatments done until another RT would arrive. On 1/12/22 at 1:30 p.m., Surveyor informed DON (Director of Nursing)-B of the above findings. Surveyor asked DON-B if the facility had a staffing shortages of respiratory therapists on the above dates, as Surveyor found that respiratory care was not being completed on the above dates for R8. DON-B informed Surveyor that she was aware of the staffing shortage of respiratory therapists on the ventilator unit, but that she (DON-B) could not provide any additional information. 2b. R17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R17's Quarterly MDS (Minimum Data Set) dated 11/26/21 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating that R17 is cognitively intact. Section G (Functional Status) documents that R17 requires extensive assistance and a two person physical assist for his bed mobility and transfer needs. Section O (Special Treatments and Programs) documents that R17 requires oxygen, suctioning, [CONDITION(S)] and respiratory ventilator/respirator care while at the facility. R17's respiratory care plan dated as initiated on 9/8/20 documents under the Interventions section, RESPIRATORY: Resident has potential for difficulty in breathing r/t (related to): Vent (ventilator) dependent. Under the Interventions section it documents, Administer medications/treatments as ordered. R17's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R17's December 2021 and January TAR (Treatment Administration Record) which documents that the above order was not completed on 12/8/21, 12/13/21, 12/18/21, 12/19/21, 12/23/21, 12/25/21, 12/26/21, 12/27/21, 12/29/21, 12/30/21, 1/1/22, 1/2/22, 1/6/22, 1/9/22, 1/11/22 & 1/12/22. Surveyor noted that on several of the above dates the facility was short staffed respiratory therapists. R17's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] ? No If not continuous: Time on the Ventilator: 2400 Time off the ventilator: 0800 two times a day. Surveyor reviewed R17's December 2021 and January TAR (Treatment Administration Record) which documents that the above order was not completed on 12/8/21, 12/13/21, 12/18/21, 12/19/21, 12/21/21, 12/25/21, 12/26/21, 12/27/21, 12/29/21, 12/30/21, 1/1/22, 1/2/22, 1/6/22, 1/8/22, 1/11/22 & 1/12/22. Surveyor noted that on several of the above dates the facility was short staffed respiratory therapists. 2c. R18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's Annual MDS (Minimum Data Set) dated 11/1/21 documents a BIMS (Brief Interview for Mental Status) score of 13, indicating that R18 is cognitively intact. Section G (Functional Status) documents that R18 requires extensive assistance and two person physical assist for her bed mobility needs. Section G also documents that R18 requires extensive assistance and a one person physical assist for her transfer needs. Section O (Special Treatments and Programs) documents that R18 requires oxygen, suctioning, [CONDITION(S)] and respiratory ventilator/respirator care while at the facility. R18's respiratory care plan dated as initiated on 2/22/21 documents under the Focus section, R18 is vent dependent due to admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's December 2021 and January 2022 TAR documents that the above orders were not completed on 12/13/21, 12/18/21, 12/19/21, 12/21/21, 12/23/21, 12/25/21, 12/26/21, 12/27/21, 12/29/21, 12/30/21, 1/1/22, 1/2/22, 1/6/22, 1/9/22, 1/11/22 & 1/12/22. Surveyor noted that on several of the above dates the facility was short staffed respiratory therapists. R18's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's December 2021 and January 2022 TAR documents that the above orders were not completed on 12/13/21, 12/18/21, 12/19/21, 12/21/21, 12/23/21, 12/25/21, 12/26/21, 12/27/21, 12/29/21, 12/30/21, 1/1/22, 1/2/22, 1/6/22, 1/11/22 & 1/12/22. Surveyor noted that on several of the above dates the facility was short staffed respiratory therapists. 3. R10 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R10's MDS (Minimum Data Set) Quarterly Assessment with an assessment reference date of 12/7/21. Documented under Cognition was a BIMS (brief interview mental status) score of 08 which indicated moderately impaired for daily decision making skills. R10 was sent to the Emergency Department (ED) on 12/29/21 with coffee ground emesis. Documented in hospital paperwork was .do not feel this patient needs ICU (Intensive Care Unit) management emergently for an overall normal exam. Rather, will discharge back to his facility for further monitoring and recommended follow up labs with his primary care. Can return to the ED for any acute worsening. The patient was readmitted to the facility on [DATE] at 9:20 PM. Surveyor reviewed R10's Progress Notes. Documented on 12/30/21 at 11:07 AM was [MD-J] in Facility. Resident assessed at Nursing request post ER visit. [New order (NOR)] to increase Water Flushes by 20% of volume administered, obtain Sputum Culture today, STAT [chest x-ray (CXR)] 2 View, [complete blood count lab draw (CBC)], [basic metabolic panel lab draw (BMP)] today, So noted & carried out. Surveyo

Based on observation of the ventilator unit, interview, and record review the Facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each ventilator resident. This has the potential to affect 14 Residents residing on the ventilator unit. On 1/24/22 the State agency returned to the Facility to investigate further concerns regarding the ventilator unit and to determine if the Immediate Jeopardy (IJ) at F695 (Respiratory/[CONDITION(S)] Care and Suctioning) had been removed. It was determined that the Facility did not implement components of their F695 IJ removal plan with a facility removal date request of 1/13/22 and approved by the Division of Quality Assurance on 1/18/22. As of 1/25/22 upon completion of the partial extended survey, the immediate jeopardy continues. The Administrator failed to oversee the completion of its IJ removal plan. The Administrator did not ensure that staff working on the vent until had the competencies needed to provide care to the residents on the unit. The Administrator did not ensure there were Respiratory Therapists (RTs) on the ventilator unit at all times on 1/18/22, 1/19/22, 1/21/22 and 1/24/22. On 1/25/22 for the day shift there was no nurse on the ventilator unit. Facility management was not aware of this until the Surveyor notified the DON. The failure of administration to implement its IJ removal plan to ensure the vent unit was staffed with qualified personnel who could provide care and potential emergency care needed by the residents on the vent unit created a finding of immediate jeopardy. On 1/25/22 at 3:43 p.m. Administrator-A, Nurse Consultant-S, RN Consultant-HH and VP of Operations-SS were informed of the IJ. The IJ was not removed at the completion of the extended survey on 1/25/22. Findings include: On 1/13/22 at 12:34 p.m., Administrator-A and DON (Director of Nursing)-B were informed of the immediate jeopardy for F695 (Respiratory/[CONDITION(S)] Care and Suctioning). The Facility submitted an IJ removal plan for F695 with a facility IJ removal date request of 1/13/22. The IJ removal plan was approved by the state agency on 1/18/22. On 1/24/22 the State agency returned to the Facility to investigate further concerns regarding the ventilator unit and to determine if the IJ at F695 was removed. It was determined that the Facility did not implement components of their removal plan and as of 1/25/22 at the conclusion of the partial extended survey the immediate jeopardy at F695 continues. The Facility did not have a respiratory therapist on staff for the ventilator unit 24 hours a day as per the IJ removal plan under the Facility assessment. On 1/18/22 there was no RT for 4 hours in the afternoon. On 1/19/22 there was no RT during the day shift (12 hours). On 1/21/22 there was no RT on the night shift (12 hours). An LPN was in charge of the unit. On 1/24/22 RT-AM, who had worked the 6:00 p.m. to 6:00 a.m. shift stayed on the unit until 10:00 a.m. There was no RT from 10:00 a.m. to 6:00 p.m The IJ removal plan documented, in the extreme event a RT is not available, a nurse trained in ventilator operations will serve on the unit until a RT is made available. The IJ removal plan indicated that all RNs (Registered Nurses), LPNs (Licensed Practical Nurses) and CNAs (Certified Nursing Assistant) would receive education regarding the Facility's ventilator policy and procedures as per the Facility's IJ removal plan. The Administrator or designee did not ensure education was provided. On 1/25/22, at 10:44 AM, Surveyor interviewed DON-B who stated she read the ventilator packet of information for competencies and then went to a room with a ventilator to talk about the components. DON-B stated she was shown to trouble shoot alarms, finding equipment, putting ventilator on a stand, oxygen setups-portable versus concentrator, on/off ventilator, but she is not comfortable with the settings or doing them because more in depth training is needed. DON-B stated the total training was the packet and nothing else. On 1/24/22 at 8:40 a.m. RN-E, who was scheduled to be the nurse on the vent unit after RT-AM left, informed Surveyor there was no time to do the training identified in the Facility's (F695) IJ removal plan; she was not comfortable with tracheostomies and does not touch the vents. RN-E will only suction Residents. RN-E informed Surveyor that she would not be able to put residents on the vent and off the vent as she did not know how to do this. RN-E informed Surveyor she does not know about the ventilator alarms and should the alarms go off she would call 911 as she does not know what to do. Surveyor reviewed RN-E's competencies in the care of tracheostomies and vents indicated NA (not applicable) for various tasks associated with [CONDITION(S)] care. On 1/24/22 there were 12 residents residing on the ventilator unit. On 1/24/22, at 10:06 AM (after RT-AM had left, leaving RN-E in charge of the unit), Surveyor observed R7 in bed with [CONDITION(S)] and tubing full of bubbling green secretions which R7 was unable to clear. R7's suction canister, dated 12/27/21, was almost full (1100 ml) of thick green sludgy secretions. R7 had pulled the bifurcated protective [CONDITION(S)] site gauze out in efforts to breathe. R7 was over breathing the ventilator with a respiratory rate of 27-28 and struggling to pull volumes of air greater than 500-540 cc. Surveyor observed the ventilator alarm was going off in the room and on the computer board in the nurses' station and hallway posting and notified RN-E immediately of R7's need to be suctioned. R7's Ventilator Settings indicated: Mode-AC, Rate 20 Tidal Volume 350 Peep 5 FiO2 28% Continuous-Chronic Respiratory Failure. R7's care plan, dated 1/17/20, indicated Ventilator Settings: Mode: AC rate 20, Tidal Volume 350 ml, Peep +5, FiO2 40 %. R7's Oxygenation orders and Care plan are inconsistent between FiO2 at 28% and 40%. During this time of R7's respiratory needs, Surveyor observed 5 call lights on and CNA-OO was assisting another resident (no call light on). CNA-OO stated trying but hard to get things done but she tries. On 1/24/22 at 11:04 AM, Surveyor conducted rounds on the specialized ventilator unit and noted 3 call lights on as well as residents banging on their bedside tables for attention. Surveyor observed R7 had green secretions pooling around the [CONDITION(S)] site and stoma with huge secretion green bubbles like blowing a bubblegum bubble and no gauze for skin protection. On 1/24/22 at 1:10 p.m. Surveyors spoke with Administrator-A to inquire what the Facility had done to remove the IJ at F695. Administrator-A indicated she had contacted a respiratory therapy company but currently does not have a contract with them yet. Administrator-A informed Surveyors a RT trained all the nurses and competencies were completed with a return demonstration. Surveyor reviewed nurse competencies including those of DON (Director of Nursing)- B and RN-E with Administrator-A and inquired why NA is marked for numerous items including [CONDITION(S)] dislodgement and apnea alarms. Administrator-A informed Surveyor she would have to check with Nurse Consultant-S. Surveyor asked Administrator-A if she reviewed the competencies. Administrator-A replied no and stated she would have to ask Nurse Consultant-S. On 1/25/22 at 7:30 a.m. Surveyor observed there is no nurse on the ventilator unit. On 1/25/22 at 8:35 a.m. Surveyor asked RT-N and CNA-OO if they have seen the nurse. Surveyor was informed they haven't seen the nurse all morning. On 1/25/22 at 8:40 a.m. Surveyor informed DON-B there is no nurse on the vent unit. DON-B stated No one told me. Facility management staff was unaware there was no nurse until Surveyor reported this. Nurses were not trained on administering physician ordered nebulizer treatments in the absence of an RT. R7 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R8 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatments were not provided on 1/14, 1/15, 1/16, only 2 times 1/18, only once at night 1/19, only once at night 1/20, only once at night 1/24/22. On 1/25/22 at 10:44 a.m., DON-B stated they were not trained on the use of Passy Muir valves (speaking valve-cap over [CONDITION(S)]). R8 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (Cross Reference F695) The failure to administration to implement its IJ removal plan to ensure the vent unit was staffed with qualified personnel who could provide care and potential emergency care needed by the residents on the vent unit created a reasonable likelihood that serious harm could occur, and thus created a finding of immediate jeopardy. On 1/26/22, the Facility submitted an IJ removal plan for F835 (Administration) with a facility date of IJ removal request of 02/04/22, and was approved by The Division of Quality Assurance on 1/26/22. The facility's IJ removal plan indicates the following actions: * A QAPI (Quality Assessment Performance Improvement) meeting was held on 1/26/22 with the Medical Director, Pulmonologist, Administrator, DON, VP of Operations, and RN clinical nurse to develop and review a root cause analysis to ensure that the facility is covering all aspects of the [CONDITION(S)]/vent care provided. Previously reviewed policies and procedures were reviewed. The results of the QAPI meeting were to appoint ventilator RT and licensed nursing staffing to the unit only for continuity of care, change the nurse competencies to return demonstration. * The Facility's current respiratory therapy contract was reinitiated on 1/23/22. The schedule through 2/25/22 was reviewed and completed on 1/25/22. An RT on call schedule was developed and implemented to ensure consistent coverage was developed and implemented on 1/25/22. * The Administrator and DON under the direction of the VP of Operations has developed a designated ventilator schedule for RT and licensed nurses for the ventilator unit on 1/25/22. * The Administrator, Director of Nursing, VP of Operations and RN Nurse Consultant will audit and ensure the RT and licensed nurse staffing meet the needs and care of residents on the ventilator unit. * DON/designee will conduct audits M-F x 2 weeks, weekly x 8 weeks, and monthly x 3 months for ventilator care residents to ensure all the required components are in place. * Administrator/designee will review daily staffing sheets to ensure adequate staffing ratios. * The Facility assessment was updated on 1/24/22 by the Administrator and VP of Operations to reflect 24 hours RT coverage and designated licensed nurse staffing to meet the needs of the residents on the ventilator unit. * Ventilator staffing patterns will reflect the needs of the residents on the unit per the QAPI and MD approved policy and procedures. * The Corporate nurse consultant will ensure the daily staffing patterns are proper for the RT and licensed nurses daily for 4 weeks, weekly for 4 weeks and monthly thereafter. * The Corporate nurse consultant will audit the facility 24-hour report/nurses notes to ensure the MD has been notified of changes and orders were processed appropriately daily for 4 weeks, weekly for 4 weeks and monthly thereafter. * The Corporate nurse consultant, Administrator and DON will audit all new hires to the ventilator unit for licensed nurses and RT to ensure their respective competencies are completed during orientation. * Daily morning meeting during the business week to include staffing review for nursing and RT in house, any education completed the day before, review of new admissions and readmissions to the facility, and review of any current audits in place. A stand down will occur during the business week to ensure that follow up is occurring. * Administrator and DON were educated from VP of Operations about daily follow up for all audits that need to be completed, any education that is required of staff, and any other items that need to be addressed in regard to the IJ removal and continued compliance on 1/25/22. Regional oversight of Administrator and DON on a weekly basis to ensure that follow up is occurring. Regional involvement if needed to aid in ensuring that all follow up is completed in a timely manner. This includes management oversight daily, including weekends until IJ is removed then daily for 4 weeks, weekly for 4 weeks and monthly thereafter. * Administrator and/or DON, with other staff as assigned, will ensure that there is a person of management in the facility daily including the weekend (for at least four hours on Saturday and Sunday) to ensure compliance. * VP of Operations/Regional Nurse/Designee to be on onsite daily to assist with compliance of IJ removal. * VP of Operations/Regional Nurse/Designee to conduct onsite visits monthly to ensure compliance and provide oversight. This will be ongoing. * An audit tool was developed to audit all new hires prior to first day on the unit to ensure that all competencies and education are completed. Annual competencies to be completed with all nursing and RT staff in January of each year. * The DON/designee will review completed audits with the Administrator and VP of Operations weekly. The DON and Administrator will review with QAPI committee monthly for further recommendations and follow up as needed. The Facility was informed of the IJ on 1/25/22 and the IJ was not removed at the completion of the extended survey on 1/25/22.

Based on observation, record review and interview, the facility did not ensure that 1 (R42) of 5 Residents reviewed for accidents had adequate assistance devices and interventions in place to prevent accidents. R42 experienced falls on 5/16/21, 6/4/21, 7/27/21, 8/16/21, 8/28/21, and two falls on 1/11/22. The Facility did not thoroughly investigate, did not conduct a root cause analysis to prevent further falls and did not revise or timely revise the care plan. The lack of conducting thorough investigations after each fall, determining whether prior fall interventions were in place at the time of the fall to evaluate the effectiveness of these interventions and not determining a root cause analysis contributed to R42 having ongoing falls with fractures on 7/27/21 (left hip, left radius and left pubic) and on 8/16/21 (spiral fracture to left femur). On 1/24 and 1/25/22, interventions of mat on floor, pillows to outer perimeter of the mattress, and call light within reach were observed not implemented when R42 was in bed. Findings include: The Fall Prevention and Management guideline with a review date of 9/2021 under Facility Guideline following a fall incident documents 1. Evaluate the resident for any injury and notify the physician and emergency contact. 2. Complete a fall incident report in the PCC (pointclickcare) risk management portal. 3. A fall risk evaluation is completed by the Nurse. A score of 10 or greater indicates the resident is at high risk for falls; a score of less than 10 indicates at risk for fall. 4. Care plan to be updated with a new intervention based on root cause analysis after each all occurrence. 5. Complete the follow-up monitoring form every shift for 72 hours. 6. All incident and accident with SEROUS PHYSICAL INJURY will be reported to IDPH (Illinois Department Public Health) within 24 hours. A full written investigative report is required by IDPH within five (5) days of the incident. Please refer to your state specific guidelines. R42 was admitted to the facility on [DATE]. Diagnoses includes fracture of left femur, hypertension, [CONDITION(S)], anxiety disorder, and depressive disorder. The nurses note dated 5/12/21 documents admitted to room [number] female from [name of hospital] after mechanical fall resulting in ORIF (open reduction and internal fixation) left hip. The Fall Interim baseline care plan dated 5/12/21 is checked for the following interventions: * Call light within reach. * Provide clutter-free environment. * Encourage use of assistive device. * Provide proper, well maintained footwear. The admission MDS (minimum data set) with an assessment reference date of 5/19/21 has a BIMS (brief interview mental status) score of 00 which indicates severe impairment. R42 requires extensive assistance with two plus person physical assist for bed mobility, transfers & toilet use. R42 does not ambulate. R42 is occasionally incontinent of urine and frequently incontinent of bowel. Yes is coded as having fallen in the month prior to admission and 2 to 6 months prior to admission. R42 has fallen since admission with one fall & no injury. The fall CAA (care area assessment) dated 5/20/21 under analysis of findings documents [R42] is at high risk for falls r/t (related to) functional deficits & s/p (status post) LLE (left lower extremity) ORIF (open reduction and internal fixation). She is non ambulatory and w/c (wheelchair) bound at this time, requires staff assist with hoyer lift for surface to surface transfers. The Fall care plan created on 6/21/21 & revised on 10/7/21 documents the following interventions: * Document s/sx (signs/symptoms) of adverse effects of medication on resident. Created 6/21/21 & revised 10/7/21. * Educate resident on the importance of complying with safety measures. Document residents understanding of education and instances of non compliance. Created 6/21/21 & revised 10/7/21. * Encourage appropriate use of wheelchair (Broda). Created 6/21/21 & revised 10/7/21. * Evaluate multiple falls to determine commonalities or patterns. Created 6/21/21 & revised 10/7/21. * Fall risk assessment quarterly and as needed. Created 6/21/21 & revised 10/7/21. * Keep bed in lowest position. Created 6/21/21 & revised 10/7/21. * Keep frequently used items within reach. Created 6/21/21 & revised 10/7/21. * Monitor for changes in gait or ability to ambulate. Created 6/21/21 & revised 10/7/21. * Monitor labs/notify MD (medical doctor) of abnormal findings. Created 6/21/21 & revised 10/7/21. * Notify MD and family of any new fall. Created 6/21/21 & revised 10/7/21. * Promote placement of call light within reach and assess residents ability to use. Created 6/21/21 & revised 10/7/21. * Remove items from line of sight that trigger thoughts of leaving/getting up without assist. Created 6/21/21 & revised 10/7/21. * Restorative care as appropriate. Created 6/21/21 & revised 10/7/21. * Skilled therapy as ordered. Created 6/21/21 & revised 10/7/21. * Fall 8/16/21: On return to Facility, Staff will keep all desired and personal items with in reach. Created 8/16/21. * Fall 8/16/21: Provide pillows to outer perimeter of mattress to provide boundaries. Check frequently. Created 8/17/21. * Assisted lowering to floor 8/28/21: Encourage Resident to be up in reclined Broda when she appears restless in bed. Created 8/28/21. * Fall Star Program. Created 10/25/21. The CNA (Certified Nursing Assistant) kardex printed on 1/24/22 under the safety section documents; *Assisted lowering to floor 8/28/21: Encourage Resident to be up in reclined Broda when she appears restless in bed. * Encourage appropriate use of wheelchair (Broda). * Encourage use of prescribed assistive devices. Encourage use of device (bed rails) for bed mobility. * Fall 8/16/21: Provide pillows to outer perimeter of mattress to provide boundaries. Check frequently. * FALL STAR PROGRAM. 5/16/21 Fall The nurses note dated 5/17/21 at 5:15 a.m. documents 2200 (10:00 p.m.) Resident found lying supine on floor next to bed when staff at change of shift yelling out, bed was in low position, call light not on, resident was not incontinent at time of fall, When asked by writer, resident stated I don't know how it happened resident has impaired memory, judgement dx (diagnoses) [CONDITION(S)], [CONDITION(S)], anxiety, and hx (history) of falls, no injury observed, moving all extremities w/o (without) pain, denied hitting head, assisted back to bed w/ (with) Hoyer lift, floor mat placed on right side of bed, NP (nurse practitioner) [name of], notified of fall and guardian [name of] made aware. The incident report dated 5/16/21 at 10:00 p.m. under incident description for Nursing description documents Resident found lying supine on floor next to bed when staff at change of shift yelling out, bed was in low position, call light not on, resident was not incontinent at time of fall. Under Resident description documents When asked by writer, resident stated I don't know how it happened. Under notes documents No notes found. The Facility did not conduct a thorough investigation as there are no staff statements as to who or when R42 was last seen, whether prior interventions were in place at time of fall, and the Facility did not include a root cause of R42's fall. The care plan was not created until 6/21/21. The fall risk evaluation dated 5/16/21 has a score of 26. A score of 10 or higher makes resident a high risk for falls. 6/4/21 Fall The incident report dated 6/4/21 at 12:00 p.m. under incident description for Nursing Description documents Writer called to patient room: patient found on the floor next to bed soiled. Writer assessed movement of all extremities, performed skin check and obtained vial signs, then transferred in be [sic] bed with the assistance of therapy. For Resident description documents I was trying to go to the bathroom. Under notes documents No notes found. Surveyor noted there is no nurses note on 6/4/21 in R42's medical record regarding this fall. The Facility did not conduct a thorough investigation as there are no staff statements as to who or when R42 was last seen, when was R42 last toileted, whether prior interventions were in place at time of fall, and the Facility did not include a root cause of R42's fall. The care plan was not created until 6/21/21. The fall risk evaluation dated 6/4/21 has a score of 19. A score of 10 or higher makes resident a high risk for falls. 7/27/21 Fall resulting in left hip fracture, left radius fracture, and left pubic fracture. The nurses note dated 7/27/21 documents At 0430 (4:30 a.m.) Cna (Certified Nursing Assistant) found resident on floor in room laying on her back next to roommate bed. Resident state she fell from w/c (wheelchair) returning from bathroom. The nurses note dated 7/27/21 documents Writer in with NP (nurse practitioner) to assess resident after fall, some swelling & bruising noted to left wrist & swelling to left knee, Resident was seen ambulating with Therapy on yesterday, receiving praiseful remarks for making such progress. On interview Resident stated she thought she could do it without calling for staff, was able to make it to BR (bathroom), toilet self & on returning to bed, slid off wheelchair seat and in attempt to catch herself injured her left wrist & knee, XR (x-ray) was ordered but due to extensive delay in ETA (estimated time arrival), NOR (new order) was received to transport to ER (emergency room ) for further evaluation & treatment. Guardian updated and stated she would like [name of hospital] but if resident is comfortable & requests [name of hospital], that is agreeable with her. [name of ambulance company] contacted & Resident prepared for transport, VS (vital signs) 134/67 97.9 69 17 POX 98% on RA (room air) Pain level 1/10. The incident report dated 7/27/21 at 4:20 a.m. under incident description for nursing description documents At 0430 (4:30 a.m.) CNA found resident in her room laying on floor on her back next to roommate bed. For Resident description documents Resident stated the following. I took myself to the bathroom. On the way back from bathroom I fell from w/c. Under notes documents 7/27/21 IDT (interdisciplinary team) note: Resident admitted post fall w/ Fx (fracture) right hip. Resident is mobile using wheelchair but recently ambulating successfully with Therapy. Resident states she self transferred to wheelchair to toilet self as she did not want to bother staff. Made it to BR and on return to bed, somehow fell off wheelchair, using left side to balance self, injury left wrist and left knee, Initially XRs ordered but NP saw and chose to send out to ER. On return intervention will be placed on toileting program per restorative. The Facility did not conduct a thorough investigation as there are no staff statements as to who or when R42 was last seen, when was R42 last toileted, whether prior interventions were in place at time of fall, and the Facility did not include a root cause of R42's fall. The care plan was not revised when R42 returned from the hospital on 8/7/21. The Fall risk evaluation dated 7/27/21 has a score of 9. A score of 10 or higher makes resident high risk for falls. Surveyor noted this evaluation is not accurate as none is checked for falls, accident, fractures and R42 fell on [DATE] & 6/4/21. The nurses note dated 7/28/21 documents Resident admitted to [name of hospital] on 7/27/21 2/2 (secondary to) fall. Sustained Left hip fracture, Left radius fracture, and Left pubic fracture. Surgery for left hip scheduled for today. The nurses note dated 8/7/21 documents readmitted to unit post hospital stay for fall w/(with) injury. Surgical incisions dry & intact w/no sx (symptoms) of infection, dressing dry intact. Incontinent of urine. NWB (non weight bearing) status, able to make needs known verbally. Pain level 4/10 at this time, orders verified and prepared for delivery. The quarterly MDS with an assessment reference date of 8/14/21 has a BIMS score of 5 which indicates severe impairment. R42 requires extensive assistance with two plus person physical assist for bed mobility, transfers, & toilet use. R42 ambulates in the room & corridor with extensive assistance and one person physical assist. R42 is always incontinent of bowel and bladder and has not fallen since admission. 8/16/21 Fall resulted in spiral fracture to left femur. The nurses note dated 8/16/21 documents Writer called to residents room by CNA staff at 1845 (6:45 p.m.). Resident had an unwitnessed fall attempting to self transfer. Writer observed staff come from resident room on a check and change 10 minutes prior. Resident was dry. Resident verbalized not needing anything at that time. Resident position post fall is laying supine on the floor next to her bed, feet at footboard head at the headboard. Resident verbalizes, I just tried to get up. Resident's skin was assessed no new skin concerns appear at this time, Resident denies hitting her head; Neuro check is negative, Mentation per norm. Resident does c/o (complain of) pain 10/10 on numerical scale to left leg Resident other VSS (vital signs stable) Facility administrator, Family, and MD (medical doctor) updated; [name of] ambulance called for lift assist and Resident to be taken to ER for evaluation/treat. Bed hold sent with hospital paperwork. The nurses note dated 8/16/21 documents Writer in Facility after report of fall. On arrival to room, noted resident to be lying in supine position head resting on pillow, right LE (lower extremity) flexed at knee & left LE in good alignment. No external or internal rotation noted. Resident was reaching for snacks at bedside, bed was in lowest position, denies pain or striking head, alert orientated to baseline. Staff was already in contact with On Call & NOR (new order received) to send out to ER for XR (x-ray) since recent injury with subsequent surgery 7/27-7/28. Writer then spoke to [name of hospital] Update given & also spoke with Guardian whom staff had already been in contact with as well. Clinical Administrator updated also. Awaiting EMS (emergency medical services). Observation of Surgical site reveals no anomalies. The incident report dated 8/16/21 at 6:50 p.m. under incident description for nursing description documents Unwitnessed fall. For Resident description documents I just tried to get up. Under notes documents 8/17/21 Resident is a [AGE] year old female with past medical history that includes: [CONDITION(S)] ([CONDITION(S)]), Cognitive communication deficit, Osteoathritis, recent hip fracture, [CONDITION(S)], [CONDITION(S)], anxiety, and major depressive disorder. Resident had an unwitnessed fall that resulted in spiral fracture to left femur. Resident was seen 10 minutes prior to fall after cares were provided to resident. Resident was not incontinent when found. She stated that she was trying to get up. Call light was on the bed within her reach. Call light was not on when staff entered the room. Resident does not follow guidance for calling for staff assist with transfer or ambulation. Resident has a history of falls prior to admission. Care plan reviewed and intervention put in place to have items within reach of resident. The fall risk evaluation dated 8/16/21 documents a score of 21. A score of 10 or higher makes resident high risk for falls. The nurses note dated 8/17/21 documents Spoke with [name of] RN (registered nurse), who said that patient was discharged at 0024 (12:24 a.m.) and was on her was [sic] way back. The ER nurse stated that patient has a spiral fracture of her left femur. When asked if patient wanted surgical interventions she told ER staff she was her own person and refused. ER staff then consulted orthopedics whom told them they were comfortable sending her back to the Facility. Patient on her way back. The nurses note dated 8/17/21 documents Writer spoke with Guardian who requests Resident be taken to [name of hospital] for further follow up from ER visit last night post fall, [name of hospital] contacted and update given, also [name of ambulance company] contacted for transport. Resident is resting comfortably, not complaining of pain. No abnormal rotation of LLE (left lower extremity). [name of] NP here and agreeable. The nurses note dated 8/17/21 documents Resident back from Hosp. (hospital) approximately 2015 (8:15 p.m.) with no NNO (no new orders). Can make her needs known to staff. No changes in conditions. No acute distress or discomfort noted. Can make her needs known to staff. Surgical incision to left hip staples removed. Drsg (dressing) remain dry intact. No drainage noted. Left arm cast dry intact elevated on pillow. Floor mat placed on floor for safety precautions. Encourage resident to call for assistance. Call light and items within reach. Will Cont. (continue) to monitor. 8/28/21 Fall The nurses note dated 8/28/21 documents Writer witness Resident scooting to the edge of her bed while writer was coming in to get vitals. Writer assisted resident down to the safety mat by the side of her bed to sit on her bottom. No injury noted. Head to toe assessment with a 2 staff assist via Hoyer lift into her broda chair. Writer contact Guardian [name of] & [name of physician] who is aware of witness fall, no injury. Facility DON (Director of Nursing) [name of] RN (Registered Nurse) is also aware. VSS (vital signs stable). The incident report dated 8/28/21 at 3:42 p.m. under incident description for Nursing Description documents Writer witness Resident scooting to the edge of her bed while writer was coming in to get vitals. Writer assessed resident down to the safety mat by the side of her bed to sit on her bottom. No injury noted. Vss. For Resident Description documents Unable to explain. Under notes documents 8/30/21 IDT Note: Resident was initially admitted in April for STR (short term rehab) post fall at group home with fracture, Resident recovered and eventually weight bearing status was obtained. Resident was recently working with Therapy and ambulating well. Resident then sustained fall after transferring and fractured left wrist & left femur. Shortly after readmission, Staff entered room and noted her to be attempting self transfer again, She was then assisted to floor w/o (without) any further injury. Intervention: Keep resident up in reclining chair during wake hrs (hours) & attempt to engage in activities. Although R42 was assisted to the floor by a staff member, the Facility did not thoroughly investigate this change of plane as the Facility did not obtain staff statements as to when R42 was seen prior to this incident or when cares were provided. The Facility did not determine a root cause. The Facility did revise R42's care plan. The quarterly MDS with an assessment reference date of 11/12/21 has a BIMS score of 3 which indicates severe impairment. R42 requires extensive assistance with one person physical assist for bed mobility & transfers, ambulates in the room & corridor with extensive assistance and one person physical assist, and requires extensive assistance with two plus person physical assist for toilet use. R42 is frequently incontinent of bowel and bladder and has not fallen since prior assessment. 1/11/22 Two Falls The nurses note dated 1/11/22 at 7:30 a.m. documents Resident sustained fall from bed r/t (related to) unassisted transfer, Assisted to bed with Hoyer, VSS (vital signs stable), No apparent injury. The incident report dated 1/12/22 at 7:30 p.m. under incident description for Nursing Description documents CNA alerted nurse that she was walking down hall past [R42] room, she heard [R42] call out. On entering the room, it was noted that [R42] was sitting on the floor next to bed, with bedding entangled around lower body. Nurse & other CNA entered room, Physical assessment completed with no apparent injuries noted, Resident was assisted from floor with Hoyer lift and returned to bed w/o incident. For resident description documents I slid out of bed. Under immediate action taken for description documents Physical assessment, VSS, assisted to bed, boundaries provided using pillows when in bed. Surveyor noted the intervention of pillows to provide boundaries was an intervention implemented 8/16/21. Surveyor noted there are no notes. Per interview with DON-B on 1/25/22 this incident report should of been dated 1/11/22. The Facility did not conduct a thorough investigation of R42's fall as there are no other staff statements as to when R42 was last seen prior to the fall, when she was last provided cares, etc. The Facility did not determine the root cause of R42's fall and did not determine if previous care plan interventions were in place. There were no revisions in R42's fall care plan. The nurses note dated 1/12/22 documents Writer was just notified at 0813 (8:13 a.m.) by CNA staff on duty that [R42] had 2 falls yesterday on evening shift (1/11/22). Facility administrator present for conversation and updated facility DON. Per recommendation DON wants Resident to be sent out to ER immediately. Upon writers assessment, Resident left knee is visibly swollen in comparison to the right knee. It is warm to touch. Resident c/o pain to the area a 5/10 on numerical pain scale. Writer will complete proper paperwork, contact the family and MD/NP and send Resident to [name of hospital] ER. The NP (nurse practitioner) note dated 1/12/22 documents This morning RN notified that patient had 2 falls yesterday on the evening shift (1/11/22). Patient is complaining of pain in the left knee. Unable to x-ray in facility thus facility wants to send resident to ER for evaluation. Patient is sitting in her wheelchair rubbing her left knee She reports tenderness at the 3 o'clock position. She denies chest pain shortness of breath nausea vomiting fever chills. The nurses note dated 1/12/22 documents Writer called [name of hospital] on resident status. ER visit due to fall and possible injury this am (morning). Per [name of] RN ct scan, x-ray, labs was completed with all results negative. Resident await in ER for ambulance to transport back to facility. No new orders prescribed. The nurses note dated 1/13/22 at 2:57 a.m. documents Resident returned to the facility at the above time via [name of] ambulance from [name of hospital]. Alert in no distress. Placed in bed and currently resting. Surveyor noted there is no documentation of R42's second fall on 1/11/22 in the electronic medical record. There is no incident report or investigation for this second fall. On 1/24/22 at 9:06 a.m. Surveyor observed R42 awake in bed on her back with the head of the bed elevated. Surveyor observed R42's call pad on the bed side dresser and not within reach of R42. Surveyor asked R42 if she uses her call light. R42 replied yes. Surveyor observed there is not a floor mat on the right side of R42's bed and there are no pillows to the outer perimeter of the mattress. Surveyor observed the floor mat is propped up against the wall on the left side of R42's bed between the bed and wall. On 1/24/22 at 10:02 a.m. Surveyor observed R42 sitting in a wheelchair in her room. The call pad is on the bed within R42's reach. On 1/25/22 at 7:21 a.m. Surveyor observed R42 in bed with the blanket covering her head. Surveyor observed there isn't a mat on the floor on the right side of the bed and there aren't any pillows along the perimeter of the mattress. On 1/25/22 at 8:02 a.m. Surveyor observed DON (Director of Nursing)-B state is [R42] up, enter R42's room and shut off the water running in the bathroom. DON-B came out of R42's room stating she's knocked out, she is not a morning person. Surveyor then went into R42's room and observed there is still not a mat on right side of R42's bed and there are no pillows along the perimeter of the mattress. On 1/25/22 at 8:14 a.m. Surveyor observed CNA (Certified Nursing Assistant)-F enter R42's room. Surveyor asked CNA-F if R42 is suppose to have a floor mat on the right side of her bed. CNA-F replied I don't know about the mat to be honest. Surveyor then asked if there should be pillows along the perimeter of the mattress. CNA-F informed Surveyor she doesn't know about pillows and to her she's not a fall risk. Surveyor then showed CNA-F the floor mat which was partially standing up between the bed and the wall. CNA-F moved R42's bed and removed the floor mat. On 1/25/22 at 10:55 a.m. Surveyor met with DON (Director of Nursing)-B to discuss R42's falls. Surveyor asked DON-B if R42 is suppose to have a mat on the right side of the bed. DON-B replied yes, because left side is against wall, suppose to have a fall mat. Surveyor informed DON-B of the observations of R42 not having the floor mat or pillows along the perimeter of the mattress according to the plan of care. Surveyor also informed DON-B CNA-F was unaware of these interventions. Surveyor informed DON-B the mat on the right side of the floor is not on R42's care plan and asked if it should be on the care plan. DON-B informed Surveyor she didn't do the fall care plan and updated the care plan for the falls she did. Surveyor asked DON-B what the falling star program is. DON-B informed Surveyor she didn't know what it involves and Restorative Nurse/LPN-D is not working today. Surveyor then showed DON-B the information Surveyor was provided for R42's 5/16/21 fall, informing DON-B this is the same information Surveyor received for R42's other falls, 6/4/21, 7/27/21, & 8/28/21. Surveyor informed DON-B the information provided to Surveyor for R42's falls does not include staff statements as to who last saw R42, what was R42 doing, cares provided prior to fall, were prior interventions in place at time of the fall, and what is the root cause. Surveyor informed DON-B R42's care plan was not revised timely or not revised. DON-B informed Surveyor this is not the process. DON-B informed Surveyor Resident's falls are reviewed in clinical and the IDT (interdisciplinary team) reviews previous interventions to see if they are still appropriate and a root cause analysis is completed. DON-B informed Surveyor R42 is impulsive and has cognitive impairment. Surveyor informed DON-B there is a nurses note dated 1/12/22 which documents R42 had two falls the evening of 1/11/22. Surveyor showed DON-B R42's incident report dated 1/12/22. DON-B informed Surveyor 1/12/22 is the wrong date and should be dated 1/11/22. Surveyor informed DON-B there is no information regarding R42's second fall in the medical record. DON-B informed Surveyor she contacted LPN-GG multiple times to complete the paperwork and she did not respond until 1/13/22. DON-B informed Surveyor she educated LPN-GG on the process with falls and change of condition. DON-B informed Surveyor she did not receive a telephone call regarding R42's fall and found out by Restorative Nurse/LPN-D who was informed by a CNA (Certified Nursing Assistant). DON-B informed Surveyor R42's knees are always swollen, has a history of self transfer with injury and stated with [name of resident] I always want her to go out. DON-B informed Surveyor she is to be notified when a Resident has a fall whether they have had an injury or not as she may have an intervention to prevent further falls.

Based on observations, record review and staff interviews, the facility did not ensure 1 (R270) of 1 residents reviewed, who required respiratory care due to being on a ventilator, had a care plan addressing weaning from the ventilator and was provided services consistent with professional standards of practice. The facility currently has 12 residents residing on the ventilator unit and 1 ventilator and 4 residents with a [MEDICAL CONDITION] residing off the ventilator unit. On [DATE], R270 had been off the ventilator on [MEDICAL CONDITION] since 6:30 AM. R270 did not have physician orders [REDACTED]. There was no care plan to address when R270 would be off the ventilator, how the facility would monitor R270's oxygen saturation levels to ensure they were greater than 92% (as ordered by the pulmonologist), and how often R270 would be assessed by the Respiratory Therapist and the Registered Nurse. On [DATE], there was no documentation from the Certified Nursing Assistants or nursing staff that cares were provided to R270 after 2:00 pm. On [DATE] at 6:45 PM, a Certified Nursing Assistant responded to R270's call light. R270 was found to be unresponsive with [MEDICAL CONDITION] on the floor. R270 was showing signs of anaphaylaxis with swelling of her face and hives on her body. The facility called a Code Blue at 6:48 PM. Two Licensed Practical Nurses (LPNs) responded but neither brought a crash cart and neither knew how to use the AED. An LPN who had just signed into work, also responded and began chest compressions. 911 was called and arrived at 6:56 PM. They gave three doses of [MEDICATION NAME] and continued cardiopulmonary resuscitation, but they were unable to revive R270 who was pronounced dead at 7:14 pm. The facility failed to have policies and procedures addressing how long residents will be removed from ventilator support, what level and types of assessment will be provided during this process, and how frequently such assessments will be made. There was no care plan developed to address R270's respiratory status and interventions developed to support the weaning process of R270 going off the vent and using [MEDICAL CONDITION]. Facility policies and procedures do not address how respiratory therapists and nursing staff will communicate with each other. The facility assessment does not address the amount of staffing required on the unit, the level of staffing, and the competencies required. Staff was unaware of the professional standards they follow when providing care to vent-dependent residents. The facility's failure to provide respiratory care consistent with professional standards of practice and consistent with the resident's care plan created a situation of immediate jeopardy (IJ) that started on [DATE]. Surveyor notified NHA-A (Nursing Home Administrator) and DON-B (Director of Nursing) of the IJ on [DATE] at 3:15 PM. The IJ was removed on [DATE], however; the deficient practice continues at a scope/severity level of E (potential for more than minimal harm/pattern) as the facility continues to implement and monitor their removal plan. Findings include: Policy: The facility Ventilator Weaning Policy, dated ,[DATE], review date ,[DATE], indicated a resident is advanced through stages as the resident tolerance and endurance improve. The goal is individualized regarding the amount of time off the ventilator that is expected based on their physical condition. Stage 1: Done while the resident is at rest. The initial attempt is done with the RT present for the entire time. As the resident tolerance increases, the time off the ventilator is increased and the need or continual monitoring is decreased. Responsible Party-Nursing Services, Ventilator Care Center: Follow up weaning attempts after Initial attempt indicated in part .Place resident [MEDICAL CONDITION], nasal cannula, speaking valve, dial oxygen and humidification per physician orders. Turn off ventilator. Disconnect ventilator from resident. Place pulse oximetry monitor on resident's finger. RT to assess respiratory status, rate, coping mechanisms, and oxygen saturation. If resident is calm and not hyperventilating, and oxygen saturation is at 90% or greater and stable, RT may leave resident with assurance that they will be back soon and someone will answer their call light. Adapt weaning plan of care to doctor's order for specific resident. Document progress in medical record. Weaning is completed when the patient can function fully off the ventilator while maintaining medical stability. Residents may not be able to progress beyond any one stage due to their respiratory status and/or medical status. R270's closed medical record included the following: R270 was admitted [DATE] with [DIAGNOSES REDACTED]. R270 had contracted COVID-19 with pneumonia and respiratory distress complications requiring intubation & ventilation. R270 had a [MEDICAL CONDITION] placed, requiring ventilator support. R270 came to the facility after an LTACH (Long Term Acute Care Hospital) admission with R270 weaned off the ventilator for a few hours every day but requiring ventilator support at night. R270 has a BIMS (Brief Interview for Mental Status) score of 15 of 15, meaning no cognitive impairments. R270 was able to direct own health care. R270's physician's orders [REDACTED]. [DATE] Vent settings: AC ,[DATE]/+8 and .40 during the day,[MEDICAL CONDITION] at night as tol. (tolerated). Surveyor noted AC (Assist-Control) is mechanical ventilation that places a fixed tidal volume of air into the lungs in set intervals and the resident can trigger a breath.[MEDICAL CONDITION] is a device placed over the [MEDICAL CONDITION] (an opening in the neck in which a tube (trach) is inserted to maintain an open airway) for delivering oxygen or aerosols. Surveyor noted the [DATE] physician's orders [REDACTED]. R270's ventilator settings indicated 18 breaths/minute with a 400 ml tidal volume, and +8 is the PEEP (Positive End-Expiratory Pressure) which is positive pressure flow at the end of exhalation measured in centimeters of water. [DATE] May wear PMV (Passy-Muir Valve) as tolerated. Surveyor noted R270 would wear this valve over [MEDICAL CONDITION] allow speaking. On [DATE], MD-C (pulmonary physician consultation) indicated R270 was currently tolerating [MEDICAL CONDITION] during the day and full vent support at night, wean oxygen to keep saturation more than 92%,[MEDICAL CONDITION]. On [DATE], MD-C indicated R270's plan was a trial of pressure support/trach mask during the day as tolerated and full vent support at night, wean oxygen to keep saturation more than 92%,[MEDICAL CONDITION]. On [DATE], MD-C indicated R270's plan [MEDICAL CONDITION] during the day as tolerated and full vent support at night, wean oxygen to keep saturation more than 92%,[MEDICAL CONDITION]. On [DATE], MD-C indicated R270's plan [MEDICAL CONDITION] during the day as tolerated, R270 has been off the vent during the day, PMV during the day as tolerated, and full vent support at night, wean oxygen to keep saturation more than 92%,[MEDICAL CONDITION]. [DATE] Pressure Support of 12 PEEP +8 in the afternoon. Surveyor noted R270 would initiate a breath and the ventilator would deliver support at the preset value of 12. R270 would control her own respiratory rate and the tidal volume. Surveyor noted R270 was being weaned off oxygen and could tolerate being off ventilator support for several hours during the day. There was no care plan addressing how long R270 could be off and what assessments and monitoring of R270 should be made while off the ventilator, and how frequently such assessments should be made. R270 had required mechanical ventilation for a long period of time and required unique strategies/care planning for effective ventilation and daily weaning from the ventilator which was not addressed in the plan of care. Surveyor reviewed R270's progress notes, which stated: [DATE] 1817 (6:17 PM): Per night shift therapist, Resident requested to come off vent at 0630 (6:30 AM). Resident placed on 28% T-mask per night shift therapist. Resident remains off vent during this shift. Resident cuff is deflated and is on and off PMV. Resident requesting to remain off vent at this time. There is no subsequent documentation in the EMR (Electronic Medical Record). The facility presented Surveyor with additional information regarding the events that occurred on [DATE]. According to information provided, Surveyor noted: On [DATE], facility staff disconnected R270 from the ventilator at 6:30 AM. A pulse oxygen level taken at 12:42 PM was 99%. RT-E saw R270 at 6:17 PM. R270 asked to stay off the ventilator for a while longer. RT-E did not take a pulse oxygen reading but thought R270 looked fine. There is nothing in the record to indicate that R270 had ever been off the ventilator for 12 hours. There was no nursing assessment of how R270 was doing on [DATE]. RT-E did not consult with a nurse because there had not been a nurse working on the ventilator unit since 3:30 PM and there was no RN (Registered Nurse) in the building. On [DATE] at 6:45 PM, CNA-L (Certified Nursing Assistant) responded to R270's call light. CNA-L found the resident unresponsive with [MEDICAL CONDITION] on the floor. R270 was showing signs of [MEDICATION NAME] with swelling of her face and throat and hives on her body. The facility called a Code Blue at 6:48 PM. Two LPN's (Licensed Practical Nurses) responded, but neither brought a crash cart with them and neither knew how to use the AED (Automated External Defibrillator). LPN-G, who had just signed in to work early, also responded and began chest compressions. 911 was called and arrived at 6:56 PM. The paramedics gave three doses of [MEDICATION NAME] and continued cardiopulmonary resuscitation, but they were unable to revive the resident. They pronounced R270's death at 7:14 PM. The facility was unable to determine if R270 had [MEDICATION NAME] and what caused it. There were no [MEDICATION NAME]es on R270 (which R was noted to be allergic to) and no discrepancies with the count of [MEDICATION NAME]es for the resident on the unit who used them. And no one had been passing medications on the unit after the day nurse had left at 3:30 PM. According to the Milwaukee Fire Department Conversion Record: Call Rec. 1848 Dispatch 1851 Patient Contact 1856 CPR 1857 IO (Intraosseus-Bone Access for medications) 1904 Nasopharyngeal (Oral Airway) 1905 1907 [MEDICATION NAME] 1909 [MEDICATION NAME] 1912 VS, [MEDICATION NAME] Dead at Scene without Transport-[MEDICAL CONDITION] *911 Notes: Staff reports multiple versions of a series of events involving a last known well time, crew was unable to obtain accurate timeline. Crew presumed that pt (patient)had not been checked on recently as pt was showing severe/extreme signs of [MEDICATION NAME] including severe swelling beneath skin, hives on chest, Staff on scene also [MEDICAL CONDITION] was extubated prior to their arrival. Asystole. CPR difficult due to obesity & swelling. Airway severely restricted, breaths difficult to administer. Staff reported [MEDICATION NAME] daily but no patch present. Witness statement obtained by DON-B indicate that CNA-M had last seen R270 at 4:00 PM and CNA-L had last seen R270 at 4:30 PM. On [DATE], at 9:16 AM, NHA-A stated there is no CNA documentation of care on [DATE] after 2:00 PM, no repositioning or toileting completed. On [DATE], at 12:40 PM, Surveyor interviewed RT-E (RT-E was at R270's code on [DATE]). RT-E stated she works for the facility and respiratory therapists keep notes on a clipboard. RT-E stated the RT's do computer documentation and check orders. RT-E stated there is no policy for weaning. RT-E stated that for weaning [MEDICAL CONDITION] from vent support is now done with continuous pulse oximetry (monitors oxygen saturation). RT-E stated that using the continuous pulse oximetry is new to the vent unit probably within the last 90 days. Surveyor questioned if weaning/removal from ventilator support requires continuous pulse oximetry. RT-E responded not here but as an RT in the hospital. The facility only has 3 continuous pulse oximeters now for weaning which we use unless the resident refuses it. RT-E stated other than a policy, we just follow the wean order for [REDACTED].>Surveyor interviewed RT-F regarding R270. RT-F stated she was not here when R270 coded. RT-F stated R270 came to the facility on a vent, could make all needs known, and R270 did have an order to wean. RT-F stated R270 weaned off the ventilator with no hook up to continuous pulse oximetry because the facility did not have the equipment. RTs just did spot checks of pulse oximetry. RT-F stated she had e-mailed corporate for respiratory requests, and started asking for continuous pulse oximetry equipment probably in September/November of 2020. Surveyor was provided with emails acknowledging NHA indication to order/rent continuous pulse oximetry machine on Monday [DATE] at 2:40 PM. On [DATE], at 1:23 PM, Surveyor conducted a phone interview with RT-D who stated she no longer works at the facility. RT-D stated it was common not to have a nurse on the vent unit. RT-D stated apparently from 3:00 pm onwards there was no nurse, the on call nurse for the facility came at 8:00 pm. On [DATE], at 12:38 PM, Surveyor conducted a phone interview with MD-C (Pulmonologist) who stated that checking oxygen saturations outside the hospital setting would be standard every shift and that if there were no new problems, then there would be no reason to check again. MD-C stated the facility weans without continuous pulse oximetry and if any change in the resident, then we could grab a continuous pulse oximetry for monitoring. MD-C stated we could always check an end tidal CO2 but typically continuous pulse oximetry while weaning but every shift or every 4 hours after several days of successful weaning is OK. MD-C stated the facility is responsible for incorrect orders, the nurse and the RT together need to determine the orders and check for accuracy & assessment. On [DATE], at 8:19 AM, Surveyor requested facility's assessment from NHA-A. On [DATE], at 8:54 AM, NHA-A stated they are working on a facility assessment. On [DATE], at 9:20 AM, Surveyor received the facility assessment, dated [DATE] and reviewed by QAPI (Quality Assurance Performance Improvement) in [DATE]. Surveyor noted the facility assessment did not include a staffing grid for the ventilator unit. The facility ventilator unit staffing grid would indicate the amount of staffing required on the unit, the level of staffing, and the competencies required which would include RNs, LPNs, CNAs and RTs. On [DATE], at 2:16 PM, Surveyor requested the facility's Respiratory Professional Standards of Practice and Ventilator Unit Criteria. NHA-A provided the facility's admission criteria for residents with ventilators. On [DATE], at 2:18 PM, NHA-A stated we do not have the information: 1) Professional Standards of Practice that the facility is following 2) Ventilator Unit Criteria Surveyor noted according to Best Practices: Ventilator Weaning Protocols, published by the American Association for Respiratory Care, best practices in the area of ventilator weaning could include: Daily assessment for liberation potential - An assessment should be conducted at least daily to determine whether the patient meets criteria to move forward in the liberation process. The criteria might include: evidence of reversal of the underlying cause of [MEDICAL CONDITION], adequate oxygenation on PEEP <8 and FiO2 <0.50, hemodynamic stability, and ability to initiate an inspiratory effort. SBT (Spontaneous Breathing Trial)- Once meeting the liberation criteria, a spontaneous breathing trial (SBT) should be conducted before determining whether extubation can occur. Generally, the SBT should last ,[DATE] minutes. Multiple studies have shown that the SBT should be the test to determine whether a patient is ready to assume breathing without assistance. SBT Failure-Generally, if the patient fails the SBT, he should be placed back on previous settings or a comfortable level of pressure support and reassessed the following day for liberation potential. When patients have declared they are not ready to be liberated, pushing them further may impose excessive load on their respiratory system and can delay liberation or extend duration of invasive ventilation. https://www.aarc.org/nn19-ventilator-weaning-protocols The facility failed to provide respiratory care consistent with professional standards of practice as evidenced by its failure to identify the standards they were to follow, its failure to have a respiratory care plan that addressed how R270 would be weaned from ventilator dependence and for how long Resident could be off the ventilator, what monitoring would be done with frequency and what parameters the RT and nurses would assess to determine when the resident should be placed back on the ventilator, and its failure to assess or identify the type and amount of staffing needed on the vent unit. This created a situation of immediate jeopardy that started on [DATE], which was removed on [DATE] when the facility implemented the following action plan; ~ All respiratory staff and nursing staff were educated on ensuring accuracy of order transcription including: verifying ventilator orders, pressure support orders, and weaning orders. Orders to include time range, settings, and monitoring requirements while in process. ~ All respiratory staff and nursing staff were educated on reviewing and updating care plans of all ventilator residents including: development of appropriate respiratory care plans that are patient specific, procedures for weaning with monitoring requirements, assessment of ventilator residents and frequency, and communication process between departments. Education to also include response related to resident choosing not to follow physician orders [REDACTED]. ~ All respiratory staff and nursing staff were educated on facility policy and procedure on weaning protocol. ~ All nursing management and respiratory management were educated on triple check of resident's orders to ensure accuracy of all ventilator orders, pressure support orders, and weaning orders. ~ All education to be completed by the next working shift. Any staff who do not complete the above education will not be scheduled until completed. All education to be completed by nursing management and/or respiratory staff who have been educated and assigned to give an education. ~ Facility reviewed the policy and procedure on the weaning protocol with medical director and pulmonologist to ensure policy meets current standards of practice. ~ All care plans were reviewed and updated for each potentially impacted resident, ensuring that the care plan was resident centered. ~ All vent orders were reviewed with pulmonologist. ~ Facility implemented rounding with nursing and RT at the beginning of each shift. ~ Continuous pulse oximetry to be monitored as ordered on all active weans. ~ Facility developed a staffing grid for vent unit for nursing and respiratory staff. ~ Batch orders were updated to include ventilator orders, pressure support orders, and weaning orders with time frame. Monitoring of respiratory status while weaning or on pressure support were added to batch orders. ~ Respiratory Director or designee with Director of Nursing or designee will audit daily x 7 days, weekly x 4 weeks, and monthly x 2 months all residents that admit for accuracy of orders upon admission and that care plan has addressed the resident's specific respiratory care needs and orders. ~ Respiratory Director or designee with Director of Nursing or designee will audit daily x 7 days, weekly x 4 weeks, and monthly x 2 months that rounding is occurring on all shifts with RT and nurse on unit. ~ Staffing is monitored daily to ensure adequate staffing on the vent unit. ~ New orders are reviewed daily in clinical morning meeting. All ventilator residents that have a change to ventilator settings, change in pressure support or weaning orders will be discussed in clinical meeting as they occur. Weaning residents will be discussed in daily clinical meeting. ~ Results of the audits will be reviewed at the QA meeting for further recommendations. Facility assessment will be updated related to ventilator care requirements.

Based on observation, interview and record review the facility did not ensure 3 (R11, R7 and R2) of 7 residents were provided care and treatment to prevent the development of pressure injuries. -R11 did not have interventions in place to prevent a medical device related pressure injury prior to the area developing. R11 developed two pressure injuries that were not noted until the areas had progressed into unstageable pressure injuries. -On [DATE] R7 is documented as having severe [CONDITION] and several stage 1 pressure sores. The facility did not implement treatments as ordered related to R7's [CONDITION]. There is no documented complete assessment including measurements of the areas or a description of the areas on [DATE] when a skin impairment is first documented. There is no documented change to R7s care plan. On [DATE] R7 is documented as having an open area. There is no documented update to R7's plan of care when first documented as having an open area on [DATE]. On 12/26/19 R7 is documented as having MASD (moisture associated skin damage). R7's plan of care was updated and a new treatment was put into place. On 12/30/19 the MASD is documented as progressing to an unstageable pressure injury to the coccyx that had not healed upon R7's discharge on 2/4/20. -R2 developed an unstageable pressure injury on her coccyx that was first noted after a [MEDICATION NAME] dressing was removed. There is no documentation of the [MEDICATION NAME] dressing being ordered, how often it was changed, or documentation of the dressing being monitored between R2's admission on 1/3/20 and [DATE] when the area was first noted under the dressing as an unstageable pressure injury. Findings include: 1.) R11 has [DIAGNOSES REDACTED]. Progress notes on [DATE] document Wound team note: Checked residents skin prior to admission. Skin was warm, dry, and intact. Capillary refill less than 3 seconds. Skin turgor wnl (within normal limits). No OA (open area), bumps, lesion, [MEDICAL CONDITION], or bruising noted. Will continue to monitor. On 1/24/20 a careplan was put into place for a focus area related to Skin: At risk for skin complications r/t (related to) impaired mobility, incontinence of B&B (bowel and bladder). Dx (diagnosis) of Severe [CONDITION]I ([MEDICAL CONDITION]), paralyzed on mechanical ventilator, [MEDICAL CONDITION] bladder, disorganized [MEDICAL CONDITION], fx (fracture) of zygomatic arch. (R11) was admitted to facility with a mucosa pressure injury to base of promixal penis 2/2 (secondary to) condom cath (catheter) use per hospital records. Interventions documented as put into place on 1/24/20 were: Protect heels: float heels off bed with pillows when in bed, may remove for cares and therapy; Air Mattress, check function Q (every) shift; assess and document of progress of areas weekly; Daily skin assessment to monitor for any skin impairment such as redness or breakdown. Notify MD for any new or changing skin impairment; Elevate HOB (head of bed) no more then (sic) 30 degrees; Ensure proper body alignment; Monitor area for s/s of infection: odor, drainage, color, size; Notify MD of abnormal findings; Protect elbows and heels if being exposed to friction; Provide skin care after each incontinence episode; RD (registered dietitian) to assess and recommend; Re-position resident every one to two hours and PRN (as needed), Reposition every 1 hours when up in chair; Skin assessment weekly on shower days, then document on skin form; Therapeutic mattress in bed and cushion in chair as appropriate; use absorbent pads or briefs that wick and hold moisture; and Zinc Barrier Cream Q shift and prn. The surveyor did not note any interventions related to avoiding pressure from R11's ventilator on R11's plan of care. Progress notes on [DATE] document Coccyx is a light skin issue. On 2/3/20 a Skin & Wound Evaluation note document a new in-house acquired unstageable medical device related pressure injury to R11's neck. The wound bed is documented as being 100% slough, measuring 1 x 1 x 0.1 cm. The surveyor noted the wound was not noted until the wound had progressed to an unstageable pressure injury. On 2/5/20 an intervention was added to R11's plan of care to include Make sure that Resident's head is laid straight at all times to prevent rubbing on medical device that causes wound. On [DATE] a Skin & Wound note documents a new in-house acquired unstageable pressure injury to R11's sacrum. The wound bed is documented as being 70% granulation and 30% slough with the surrounding tissue being documented as Macerated: Wet, white, waterlogged tissue. The wound is documented as measuring 2.5 x 1.5 x 0.1cm. On [DATE] at 11:30 AM the surveyor interviewed LPN (licensed practical nurse)-G, who is part of the facility's wound team. The surveyor informed LPN-G of the concern related to wounds not being noted until they are unstageable. LPN-G stated it is unexplainable. LPN-G stated we educate staff on how to communicate skin concerns and the aids will say they told the nurse, but the nurse may not let us know. LPN-G stated R11's ventilator device is digging into him and we are looking into options and put a superabsorbent patch in place to give it more cushion. The surveyor asked if interventions are put in place by the facility related to preventing pressure injuries from ventilator equipment. LPN-G stated if we notice position-wise concerns we will use neck pillows. LPN-G stated the only way the equipment is not pressing is if R11's head is flat, which he is unable to be positioned in that way related to his tube feeding and ventilator status. On 2/18/20 at 11:19 AM the surveyor observed treatments to R11's pressure injuries. Upon entering the room the surveyor observed R11's head leaning towards his right side, not in a straight position. The surveyor observed R11 had a pressure injury on his right clavicle/neck area that was approximately dime sized with slough noted in the wound. The surveyor observed the area lined up with R11's ventilator equipment. The surveyor observed R11 had a pressure injury to his coccyx area slightly smaller than dime size with slough observed in the wound bed. On [DATE] at 3:40 PM the surveyor interviewed DON (Director of Nursing)-B. The surveyor asked why pressure injuries are not being identified until they are unstageable. DON-B stated when wounds are not noted until unstageable they wonder why not. The talk with the physician related to if there is a reason the wound is progressing very fast. The surveyor informed DON-B of the concern of R11's wounds not being noted until unstageable. On 2/18/20 DON-B provided the surveyor with an Unavoidable Pressure Ulcer form signed by the physician related to R11. The form documents The resident's pressure ulcer(s) are unavoidable because the resident has impaired mobility and two or more of the following clinical conditions: bowel incontinence, continuous urinary incontinence, Hemoglobin less than 12 mg/dl .The resident receives two more of the follow treatments: Head of the bed elevated due to medical necessity .Other clinical conditions issues or risk factors (see additional comments) (R11) is incontinent of blowel (sic) and bladder, impaired mobility and has a Dx of [CONDITION]I, [MEDICAL CONDITION] bladder, [MEDICAL CONDITION], dysphagia on PEG tube feedings, Afib (arterial fibrillation),[MEDICAL CONDITION](hypertension) and has a hx (history) of [MEDICAL CONDITION] disorder. (R11) is vent dependent. On 2/18/20 at 12:33 PM the surveyor informed DON-B of the concern related to R11 not having interventions to prevent a medical device related injury related to his ventilator status prior to the area developing. Following this DON-B provided the surveyor with a copy of R11's plan of care with the interventions highlighted indicating to surveyor that DON-B considered the existing intervention to have been preventative measures in place prior to the area developing. 2.) R7 has [DIAGNOSES REDACTED]. R7's Pressure Ulcer/Injury Care area analysis, signed as completed 12/30/2019, documents At risk for skin impairment due to limited mobility and incontinence. Will proceed with plan of care. Progress notes on 12/12/19 document .no O/A)s (open areas) noted on body check, bilateral heels pink/intact with normal color, coccyx intact w/o (without) excoriation, skin color WNL (within normal limits) . From 12/13/19-[DATE] an intervention for House barrier cream to buttock every shift and prn for wound prevention was in place. NP (Nurse Practitioner)-R's notes on 12/18/2019 document Patient lying in bed, concerned about a rash. Patient with severe [CONDITION] in the front, posteriorly she has several stage 1 pressure sores, discussed with nurse and wound care team .[MEDICATION NAME] powder to groin increased to TID (three times a day). Patient also having diarrhea, she was on [MEDICATION NAME] BID (twice a day) and senna BID, these area discontinued and [MEDICATION NAME] ordered prn. Under Objective NP-R documents Skin: no masses, rash or lesion on exposed skin. [DIAGNOSES REDACTED] to groin, stage 1 pressure sacral pressure ulcers. NP-R documents under Plan Candidiasis- vaginal, worsened by diarrhea. [MEDICATION NAME] increased to TID, wound care following. Pressure ulcers to sacrum- see wound care for details. Discussed with wound team. The surveyor reviewed the wound team's documentation and R7's progress notes and was unable to find documentation from the wound team related to R7's skin impairments noted on [DATE]. The surveyor reviewed R7's December MAR (medication administration record) and TAR (treatment administration record). The surveyor noted an order for [REDACTED]. The surveyor noted there was not documentation in the MAR indicated [REDACTED]. The surveyor reviewed R7's care plan and noted no updates on [DATE] when R7 is first documented as having a skin impairment to their groin and buttocks area. On [DATE] at 12:18 PM NP-R documents Patient seen lying in bed in nad (sic). Per patient her 'rash' is improving, [MEDICATION NAME] powder to groin [CONDITION] increased to TID . Last visit patient was having diarrhea though she states this has resolved (patient was on stool softeners and these were changed to prn). Under objective the note documents Skin: No masses, rash or lesion on exposed skin. [DIAGNOSES REDACTED] to groin-improving, stage 1 pressure sacral pressure ulcers. Under Plan the note documents Candidiasis- vaginal, improved. Continue increased dose of [MEDICATION NAME] at TID .Pressure ulcers to sacrum- see wound care for details. Discussed with wound team. Continue localized wound care. The surveyor noted no documentation from the wound team related to R7's skin impairment to the buttocks area until 12/26/19. Progress notes on [DATE] at 1:42 PM by LPN-O document Patient open area being monitored: wound nurse aware, treatment in place. The surveyor reviewed R7's plan of care. The surveyor noted no new interventions put into place on [DATE] when R7 is first documented as having an open area. Progress notes on 12/22/19 at 11:55 PM by LPN-Q document Resident is being monitor for open areas on buttock, cream applied, no c/o (complaints of) pain, resident resting in room. Progress notes on [DATE] at 4:24 AM by LPN-P document Open area to gluteal. Treatment in place. No s/s of discomfort. Progress notes on 12/25/19 document no c/o pain to open area on bottom. Progress notes on 12/26/19 at 5:48 AM document Res denies pain and discomfort to o/a to coccyx area. Will continue to monitor. A Skin & Wound Evaluation, with an effective date of 12/26/19 at 2:51 PM documents MASD (moisture associated skin damage) to the left buttock, in-house acquired. This skin is documented as being excoriated, the area is documenting as being 3.5 x 1.5 cm. On 12/26/19 R7's plan of care was updated to include: check and change Q2 (every) hours and prn (as needed) as (R7) does not feel when having a BM (bowel movement), elevate HOB (head of bed) no more then (sic) 30 degrees, ensure proper body alignment, observe and assess regularly, provide skin care after each incontinent episode, treatment as ordered to coccyx, left buttock, use absorbent pads or briefs that wick and hold moisture, and use lift sheets to move patient. Orders were put into place with a start date of [DATE] for Coccyx: Cleanse with wound cleanser f/b (followed by) foam dressing daily and prn and Left Buttock: Cleanse with wound cleanser f/b foam dressing daily and prn. On 12/30/19 a Skin & Wound Evaluation documents an in-house acquired unstageable pressure injury due to slough and/or eschar to the coccyx. The wound bed is documented as being 100% slough. The evaluation documents 1 x 0.5 x 0.1cm Area started as a MASD then progressed to pressure as resident verbalized having bouts of loose stools and is unable to feel when having a BM (bowel movement). Treatment order changed, air mattress. Progress notes on 1/7/20 by LPN-G document Wound team note: Resident coccyx wound that started off as a MASD wound is now classified as a unstageable due to slough that is present within the wound bed as of 1/6/2020 . A Skin & Wound Evaluation, with an effective date of 2/3/20 documents the coccyx area as being unstageable with the wound bed 100% slough and documents the wound as being 1 x 0.5 x 0.1cm. R7 discharged to the hospital on [DATE]. On [DATE] at 11:30 AM the surveyor interviewed RN (registered nurse)-F and LPN-G. LPN-G stated she recalled R7 telling NP-R about a skin concern and NP-R asking them to look at the area. LPN-G stated she recalled R7 having some fungal concerns and excoriation at that time, but no open areas. The surveyor asked what the process is if a new area is identified. LPN-G stated when notified a risk form should be completed in PCC (Point Click Care, the electronic health record); the family, wound team, and physician should be notified; should get a treatment in place; and the wound team will evaluate the wound when in the building next. The surveyor informed RN-F and LPN-G of the concern of R7 being noted to have a skin impairment first noted on [DATE] with no documented treatment in place until 12/26/19. RN-G informed the surveyor barrier cream was in place. The surveyor informed RN-G the barrier cream is documented as already being in place prior to the area developing and is documented as being for prevention, not treatment of [REDACTED]. LPN-G stated they will say wound team aware, but we are not always aware. LPN-G stated we tell them they have to get a treatment in place, don't wait for the wound team. LPN-G informed the surveyor the area had started as MASD and had moved towards the coccyx area where it progressed to pressure. On [DATE] at 3:40 PM the surveyor interviewed DON (Director of Nursing)-B. The surveyor asked what the process is when an area becomes an open area. DON-B stated to call the physician, notify the wound nurse, and start the assessment process. The surveyor informed DON-B of the concern of being unable to find physician notification or a change in treatment when R7's wound is first documented as being an open area on [DATE]. On 2/18/20 at approximately 2:05 PM DON-B informed the surveyor NP-R had seen R7 on [DATE] and had documented the skin as improving. The surveyor informed DON-B the skin is documented as having an open area on [DATE] after NP-R is documented as having seen R7. 3.) R2 has [DIAGNOSES REDACTED]. R2 was admitted to the facility on [DATE] following a hospitalization greater than 1 year in length during which R1 had skin impairments and required skin grafts. Progress notes on [DATE] document .no open areas noted on body check, she has multiple skin graft donor sites noted to upper/lower back, both legs/thighs, coccyx has small areas of redness/excoriation which is covered w/ (with) protective dressing, has hx (history) of debridement with reconstruction of sacral pressure sores, BLE (bilateral lower extremity) parathesia . and .Upon assessment, skin is warm and dry, has [MEDICAL CONDITION]. Resident is paralyzed from waist down and needed to be repositioned q2hrs (every 2 hours). Has multiple skin graft and donor site to leg, sacrum and back . On 1/7/2020 progress notes document Wound team note: Examined residents skin, resident was noted to have multiple skin grafts on BLE's, Sacrum and back .Well (sic) continue to monitor. R2's Pressure Ulcer/Injury care area analysis, signed as completed 1/16/20, documents Resident admitted to SNF (skilled nursing facility) for therapy after recent hospitalization . Requires assistance with ADL's (activities of daily living), [MEDICAL CONDITION] to bilateral lower extremities. Frequently incontinent of bladder. At risk for falls due to immobility. At risk for visual impairment due to history of borderline [MEDICAL CONDITIONS], and vitrectomy. admitted with DTI (deep tissue injury) to left heel. At risk for further skin impairment due to immobility, incontinence, and DM (diabetes mellitus). Dx (diagnosis) of [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]) on [MEDICAL TREATMENT]. Progress notes on [DATE]20 document Wound team note: During daily rounds went to remove residents (sic) protectu=ive (sic) patch to apply a new patch. Patch was noted to be very damp. Upon removing patch from residents coccyx area, resident was noted to have and (sic) unstageable pressure injury located underneath patch. (Wound MD) examined area, (Nurse Practitioner (NP-R)) is made aware. (DON-B) is made aware. (Nursing Home Administrator (NHA-A)) is made aware. Resident is her on (sic) self and is made aware. An air mattress is on order, Resident reposition q (every) 1-2 hours if in bed and q 15 minutes while in chair, PT (physical therapy) to eval for different wheel chair cushion, and resident is to take a cushion with her to [MEDICAL TREATMENT] to sit on. Will continue to monitor. The surveyor reviewed R2's physician orders, MAR (medication administration record) and TAR (treatment administration record). The surveyor was unable to find documentation of a [MEDICATION NAME] dressing ordered for R2. The surveyor was unable to find documentation of the dressing being monitored, assessed or changed between R2's admission on 1/3/20 and [DATE]. A Skin & Wound Evaluation on [DATE] documents an in-house acquired pressure ulcer due to slough and or eschar. The wound bed is documented as being 90% granulation tissue and 10% slough. The wound is documented as measuring 3 x 2 x 0.3 cm. On [DATE] Wound MD notes document a surgical excisional debridement procedure was completed to the wound and documents This wound is in an [MEDICAL CONDITION] stage and is unable to progress to a healing phase because of the presence of a biofilm. On 2/5/20 an MD signed a Unavoidable Pressure Ulcer form documenting The resident's pressure ulcer(s) are unavoidable because the resident has impaired mobility and two or more of the following clinical conditions: [MEDICAL CONDITION], Diabetes, Continuous urinary incontinence, Chronic [MEDICAL CONDITION], Hemoglobin less than 12 mg/dl .The resident receives two or more of the following treatments: [MEDICAL TREATMENT] . Other risk factors: The resident has a prior history of pressure ulcers in the same location, Other clinical conditions, issues or risk factors (see additional comments). Additional Comments Prior to admission res. (resident) developed open area to thigh and buttock per hospital records consistent with cacliphylaxis, treatment included A[CONDITION] (antibiotics)/ debridement with progression of LE (lower extremity) weakness and paralysis. She had several debridement and grafts procedures. She is incontinent of bladder, is checked and changed every 2 hours, has a [MEDICAL CONDITION] for bowel. She attends [MEDICAL TREATMENT] Q MWF (every Monday, Wednesday, Friday), after [MEDICAL TREATMENT] visits with family or goes on outings several times a week. Sitting in w/c (wheelchair) for long periods. Pressure redistribution devices has (sic) been in place prior to the development of the PI (pressure injury), including a Mattress, cushion in WC (wheelchair) and heel lift boots. She is aware of the needs for offloading and re-positioning yet chooses not to despite this. She is encouraged to lay down between meals on no-[MEDICAL TREATMENT] days, yet chooses not to due to going out with family or socializing. Based on comprehensive assessment and review of all circumstances her Pressure Injury could not have been prevents due mainly to her choices. Surveyor noted upon review of the documentation regarding R2's pressure injury it is indicated, despite high risk for developing a pressure injury or reopening a previous area, it was not until [DATE] (after the area developed) that an air mattress was noted to be on order, that a resident specific reposition schedule was created indicating to reposition q (every) 1-2 hours if in bed and q 15 minutes while in chair, that PT (physical therapy) was asked to evaluate R2 for a different wheel chair cushion, and an intervention was suggested for the resident to take a cushion with her to [MEDICAL TREATMENT] to sit on. Surveyor noted the avoidable statement provided by the facility does not include the situation that contributed to the current area developing; which was having a [MEDICATION NAME] dressing in place with no order for the dressing or monitoring of the area/dressing once in place leading to a saturated dressing and an unstageable area. On [DATE] at 9:00 AM the surveyor interviewed LPN (licensed practical nurse)-E. The surveyor asked how she would know if a resident had a [MEDICATION NAME] dressing. LPN-E stated it would be on the TAR. On [DATE] at 11:17 AM the surveyor interviewed LPN-G, who is on the wound team. LPN-G stated R2 came in with a [MEDICATION NAME] dressing that was determined to be kept in place. LPN-G stated she changed the dressing weekly. LPN-G informed the surveyor she recalled returning back from the weekend and noted the dressing was saturated, which was not usual. The surveyor asked if that is something that is in the TAR. LPN-G stated yes. Surveyor noted there was no order for the [MEDICATION NAME] dressing or entry on the TAR to address the dressing or monitor the dressing once applied. On [DATE] at 3:40 PM the surveyor interviewed DON-B. The surveyor asked if physician orders [REDACTED]. DON-B stated yes. The surveyor asked if [MEDICATION NAME] dressings were documented as being completed. DON-B stated it would be in the TAR. The surveyor asked how often staff are expected to check dressings. DON-B stated staff are expected to check on the dressing every shift. DON-B stated it would depend on for how often it is ordered - for how often it would be changed. The surveyor informed DON-B of R2 having no documented orders for a [MEDICATION NAME] dressing, and no documentation of the dressing being monitored or changed until [DATE] when an unstageable pressure injury was noted under the dressing.

Based on observation, interview and record review, the facility did not ensure that a resident who enters the facility without a Pressure Injury (PI) does not develop a PI and a resident with a PI receives appropriate care, treatment, and preventative interventions to promote healing for 5 of 8 residents reviewed (R378, R179, R25, R65, and R228) for PIs. In addition the facility did not have a PI management system in place for appropriate prevention, assessment and treatment of PI. Comprehensive PI polices were not in place at the time of the survey that would direct staff as to the proper procedures for prevention and treatment of pressure injuries. * R378 was admitted to the facility without a comprehensive skin assessment and developed a PI with eschar. R378 was not assessed by a Registered Nurse or Physician after development and was hospitalized [MEDICAL CONDITION] related to the PI infections and several debridement procedures which showed the PI to be very large with palpable bone (Stage 4). * R179 developed in house an unstageable pressure injury to his right buttocks and unstageable to sacrum. On 9/1/19 R179 developed 3 open areas to the right buttock. There was no assessment of the wound beds and the pressure injuries were not staged. On 9/2/19 the PIs to the right buttock were measured with 90% slough noted. There was no other description for the remaining 10%. There was no RN assessment. A skin & wound evaluation dated 10/3/19 for the right buttock was not completed in regards to the wound bed, exudate, periwound, wound paint, treatment and progress. On 9/16/19 a skin & wound evaluation documents a pressure injury to the sacrum. On 10/7/19, the skin & wound assessment indicated a decline to the PI on the sacrum. There was no revision to R179's care plan. The facility's policies titled, Pressure Injuries dated 9/17 and Skin Care Prevention dated 9/19/19 did not provide sufficient guidance for wound care. The Facility PI policies did not direct staff regarding current standards of practice related to the prevention and treatment of Pressure Injuries. The facility did not have a system in place for effective assessment and treatment of Pressure injuries. The facility's failure to properly assess PIs and base treatment off those assessments, to have a system in place for pressure injury care and treatment and to have developed policies and procedures to guide the care and treatment of PIs created a finding of Immediate Jeopardy (IJ) that began on 9/2/2019 . The Surveyor notified Nursing Home Administrator (NHA-A) and Director of Nursing (DON-B) of the IJ on 10/17/2019 at 11:36 AM. The IJ was removed on 10/22/19 however the deficient practice continues at a scope/severity of [NAME] (potential for more than minimal harm/pattern) as the facility continues to implement its action plan and as related to the following examples: * R25 was admitted with stage 4 Pressure injuries. The admission screen documented by a Licensed Practical Nurse (LPN) does not include measurements and no Registered Nurse (RN) assessment. R25 was readmitted into the facility on [DATE] and on 8/6/19 and no comprehensive assessment regarding R25's pressure injuries was completed. R25 was observed on 10/15/19 from 7:19 am to 10:55 am with no respositioning observed. On 10/15/19, Surveyor observed R25 to have a black right heel. * R65's hospital discharge summary indicated a wound on the hip. The 9/18/19 Admission observation by the Registered Nurse (RN) does not include documentation of the pressure injury (PI). On 9/18/19, the Licensed Practical Nurse (LPN) documented the PI to be unstageable, with measurements noted and 80% slough, with no RN assessment of the PI. * R228 was at risk for pressure injuries and his heels were observed not to be offloaded. Findings include: On 10/16/19 the facility's policy titled, Pressure Injuries dated 9/17 was reviewed. The policy only defined the different types and stages of pressure injuries. It did not give any procedures on assessment, management and treatment of pressure injuries. On 10/16/19 the facility's policy titled, Skin Care Prevention dated 9/19 was reviewed and read: Dependent residents will be assessed during care for any changes in skin condition including redness and this will be reported to the nurse. The nurse is responsible for alerting the health care provider. Unless contradicted, elevate heels off bed surface. On 10/16/19 at 2:32 PM Director of Nursing (DON)-B was interviewed and indicated there were no more policies related to pressure ulcer prevention and treatment. 1. R378 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R378's Discharge summary from the hospital on [DATE] does not list any skin concerns except the spinal surgical site. R378's admission assessment by the facility by LPN-FF dated 8/27/19 was reviewed and under the area skin condition read: Coccyx 3 areas on right side of buttock. No other assessment of the areas was made in R378's medical record and no evidence of a Registered Nurse (RN) assessment or call to R378's physician was found. LPN-FF was interviewed on 10/15/19 at 02:32 PM and indicated that on admission R378 had open areas to his coccyx. LPN-FF indicated she did not measure. the areas and did not have an RN assess the areas. LPN-FF indicated she did not remember what R378's open areas looked like and only remembers they were open. LPN-FF indicated the procedure when a resident has a new open area is to notify the doctor, family and wound nurse to get treatment in place, which she did not do. R378's Progress note dated 9/1/19 at 4:37 PM written by Licensed Practical Nurse (LPN)-KK read: multiple open areas found on coccyx open areas cleansed and dressing applied on call doctor updated and wife aware. Wound nurse also updated. The corresponding order LPN-KK received from the doctor for R378's coccyx on 9/1/19 was: Coccyx: Cleanse area with normal saline, followed by xeroform (petroleum dressing) followed by foam dressing daily and as needed. R378's treatment administration record was reviewed and indicated he received this treatment daily until his discharge. R378's skin and wound evaluation written by LPN-U on 9/2/19 was reviewed and read: Moisture associated skin damage, in house acquire. 10% granulation tissue, 90% eschar, location: coccyx, 7.9 cm long by 6.0 cm wide. No other measurements or assessments of R378's coccyx were found in his medical record up to his discharge. LPN-U who is the facility's wound nurse (LPN-U had taken a class in wound care management but was not certified) was interviewed on 10/15/19 at 03:39 PM . LPN-U indicated she was told on 9/1/19 R378's open areas were pink in color and on his coccyx. LPN-U indicated that when she saw R378's open area on 9/2/19 it was almost completely black and pink around it. LPN-U indicated she did not think it was a pressure injury but moisture associated skin damage even though it was on a pressure point. LPN-U then indicated she was going to have Wound Doctor-LL look at it but R378 was at [MEDICAL TREATMENT] and Wound Doctor-LL couldn't see him. (It was later verified R378 was in the building all day 9/2/19 and did not go to [MEDICAL TREATMENT].) LPN-U then indicated she did not call R378's primary doctor due to the rapid deterioration in R378's wound from pink to 90 % eschar and felt it was ok to wait for the wound doctor to see him next week (9/9/19). LPN-U indicated she couldn't remember if an RN assessed the area. LPN-U indicated she saw R378's coccyx area the day after his admission and he only had scar tissue visible but she didn't document anything. R378's admission Minimum Data Set ((MDS) dated [DATE] indicated R378 had no pressure injuries at the time of the MDS but was at risk for pressure injury development. Nurse Practitioner-MM was interviewed on 10/16/19 at 10:19 AM and indicated she is at the facility Monday through Friday and saw R378 on 9/6/19. Nurse Practitioner-MM indicated she was not made aware R378 had any new skin issues other than his surgical site and if she had been aware she would have wanted to look at it. R378's progress note written by Nurse Practitioner-MM was reviewed and read: Skin: No masses, no [MEDICAL CONDITION], or no rashes on exposed skin. Lumbar incision not visualized. Surveyor reviewed R378's Situation, Background, Assessment Recommendation form dated 9/7/19 at 11:55 AM which read: Blood pressure 78/41, Pulse 125, Temperature 97.4. Increased confusion, send patient to hospital. R378's hospital record was reviewed and indicated R378 was admitted to the hospital on [DATE] and stayed in hospital until 10/9/19 when he was transferred to select specialty hospital. The admitting emergency room notes indicated on 9/7/19 R378 was admitted with eschar covered decubitis described as a large sacral decubitis which had a very foul odor and thick black eschar that did not allow for assessment of the underlying tissue. Temperature 102 and blood pressure 64/38. R378 was also diagnosed with [REDACTED]. R378's blood culture showed ecoli and bactrolis fragilis on 9/7/19 and 9/8/19 and was negative on 9/10/19. R378's pressure injury culture of the sacrum showed the same two bacteria. R378's hospital record also indicated the sacral pressure injury was surgically debrided on 9/8/19, 9/9/19, 9/11/19 and 9/26/19. The measurements of the sacral pressure injury after the debridement were 21 centimeters (cm) long by 13 cm wide and 2.5 cm deep with undermining of 5 cm at 12 o'clock. R378's sacral pressure injury was assessed at that time as a Stage 4 decubitis (pressure injury) with muscle visualized and bone palpable. R378 also required a diverting [MEDICAL CONDITION] placement on 9/16/19 for wound healing related to the sacral pressure injury. On 10/16/19 at 1:11 PM Wound Doctor-LL was interviewed and indicated he was never able to see R378 and only comes to the facility on ce a week on Mondays. Wound Doctor-LL says he sees Residents with wounds with LPN-U and trusts her opinion. On 10/16/19 at 1:29 PM Medical Doctor-JJ who is also the facility's Medical Director was interviewed. Medical Doctor-JJ was R378's primary doctor. Medical Doctor-JJ indicated if there is a change in a wound a doctor should be called for a possible change of treatment and waiting a week would not be proper procedure. Medical Doctor-JJ indicated the open area should have been assessed by an RN. On 10/16/19 at 9:00 AM Director of Nursing (DON)-B was interviewed and indicated she could not find an RN assessment of R378's pressure injury and there should have been. DON-B also indicated If a nurse finds skin issues there should be measurements, an RN assessment , and call the doctor for treatment. 2. R179 was originally admitted to the facility on [DATE] with a recent readmission date of [DATE]. R179 has multiple pressure injuries including unstageable left knee, unstageable left medial malleolus, unstageable left trochanter and deep tissue injury on sole of right foot which were all present on admission following hospitalization . R179 developed in house an unstageable pressure injury to his right buttocks and unstageable to sacrum. R179's [DIAGNOSES REDACTED]. R179 was placed on hospice on 10/3/19. The at risk for skin complications care plan initiated 10/3/18 and revised on 6/10/19 documents interventions initiated 10/3/18 of; Protect elbows and heels if being exposed to friction, Provide skin care after each incontinent episode, Serve diet as ordered, Skin assessment weekly and Use commercial moisture barrier. Interventions initiated 12/31/18 of; Notify MD (medical doctor) of abnormal findings, Repositioning q 2 hr (every two hours), and Use lift sheet to move patient. Intervention initiated 4/5/19 of Float heel on pillows q (every) shift. Interventions initiated 4/21/19 of Med pass as ordered and Quarterly and prn (as needed) Braden. The annual MDS (Minimum Data Set) with an assessment reference date of 7/15/19 documents a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R179 requires extensive assistance with two plus person physical assist for bed mobility & transfer and extensive assistance with one person physical assist for toilet use. R179 is coded as having an indwelling catheter and is always incontinent of bowel. R179 is coded as being at risk for pressure injuries and is coded as not having any pressure injuries at time of assessment. The Braden assessment dated [DATE] has a score of 14. Interventions initiated 8/8/19 of; Address cause if possible, Assist and encourage resident to turn and reposition every one to two hours and PRN, Ensure adequate food and fluid intake, Use absorbent pads or briefs that wick and hold moisture, and Use pressure redistribution surface if bed or chair bound. Consider pressure redistribution surface if: There is intractable pain or Severe pain with turning or Additional risk factors are present. The nurses note dated 9/1/19 documents, CNA reported 3 open areas to right buttock. House cream applied and repositioned off right side/ pillow used. Physician-RR updated. The nurses note dated 9/1/19 documents, R179 has a new skin condition. Please see skin condition observation for details. The skin condition sheet for right buttocks dated 9/1/19 documents, 3 open areas. 0.8 x 2cm with a scab forming in middle, 0.4 x1cm (centimeters), 1 x2cm. scanty reddish drainage. Under additional comments documents, Left message for social worker to call facility for update. FM (family member)-SS left message to call facility. Physician-RR updated/keep house cream on and update wound nurse. Surveyor noted there is no assessment of the wound beds and the pressure injuries are not staged. The nurses note dated 9/1/19 documents, Resident alert and oriented per usual; can gesture some needs known. Dressing remain CDI (clean dry intact) to buttocks area. No c/o (complaint of) pain or discomfort noted or reported. The nurses note dated 9/2/19 documents, F/u (follow up) open areas to right buttock. House cream applied x (times) 2. Staff positioned every 2hrs /position off right buttock. Nodded head no when ask if experiencing any pain. No drainage noted. R179 updated on open areas/ resident nodded yes when asked if ok to notify son. The nurses note dated 9/2/19 documents, Resident has open area on right gluteal. No active bleeding. No exudate. No pain. Red pink in color. The skin and wound evaluation dated 9/2/19 for type documents pressure, for stage unstageable, location right buttock, and acquired in house acquired. Length is 4.1 cm (centimeters), width 4.7 cm, and depth not applicable. For wound bed percentage slough is 90%. There is no other description for the remaining 10%. This was completed by LPN (Licensed Practical Nurse)-U. There is no RN (Registered Nurse) assessment. Intervention initiated 9/2/19 of Treatment as ordered to right buttocks, sacrum, left hip, left malleolus, sole of right foot, right heel, and left lateral knee. Intervention initiated 9/3/19 of Use positioning wedge to reposition resident q 2 hours. Surveyor noted weekly skin & wound evaluations dated 9/9/19, 9/16/19, and 9/24/19. The skin & wound evaluation dated 10/3/19 for type documents pressure, for stage unstageable, location right buttock, and acquired in house acquired. Length is 3.1 cm (centimeters), width 1.4 cm, and depth 0.1. The rest of this evaluation has not been completed including wound bed, exudate, periwound, wound pain, treatment, and progress. The weekly skin and wound evaluations for the right buttocks dated 10/7/19 & 10/14/19 were completed. The skin & wound evaluation dated 9/16/19 for type documents pressure, stage deep tissue injury, location sacrum and acquired in house acquired. Length is 3.3 cm, width 1.0 cm and depth not applicable. Under notes documents wound consists of 100% intact skin. Skin prep applied to wound site. The skin & wound evaluation dated 10/7/19 for type documents pressure, stage unstageable, location sacrum and acquired in house acquired. Length is 1.1 cm, width 0.3 cm and depth 0.1 cm. Wound bed is 100% slough. Surveyor noted there was no revision to R179's skin care plan after R179's sacrum pressure injury declined. The Braden assessment dated [DATE] has a score of 12 which indicates high risk for pressure injury development. On 10/16/19 at 3:24 p.m. Surveyor informed LPN-U Surveyor had reviewed the weekly wound evaluations for R179's pressure injuries. Surveyor asked LPN-U for R179's left medial malleolus dated 10/3/19. LPN-U staged the pressure injury as a Stage 1 but the wound bed had 10% eschar. Surveyor informed LPN-U a stage 1 pressure injury would not have eschar. LPN-U informed Surveyor she must have documented incorrectly. Surveyor informed LPN-U on 9/2/19 for the right buttocks the wound evaluation documents 90% slough but there is no indication as to what the other 10% of what the wound bed is. LPN-U informed Surveyor she probably moved fast and she will check into it. Surveyor asked LPN-U how R179's developed a deep tissue injury on his sacrum and inquired how this was developed. LPN-U informed Surveyor they were told on wound rounds that they needed to look at R179. LPN-U informed Surveyor R179 had a decline in his condition. LPN-U stated she couldn't say if the wounds were there before staff told her. LPN-U informed Surveyor if no one tells her about an area how is she going to know. LPN-U informed Surveyor their policy is if staff finds a spot they can't go covering it up, they need to tell the nurse. Even if she is in the building the nurse needs to do a risk, call the doctor & family and then let her know. On 10/16/19 at 3:13 p.m. Surveyor asked LPN-U if a pressure injury declines who would revise the care plan. LPN-U replied I'm guessing it would be me. The facility's failure to properly assess PIs and base treatment off those assessments, have a system in place for pressure injury care and treatment and develop policies and procedures to guide the care and treatment of PIs created a finding of Immediate Jeopardy. The facility removed the immediate jeopardy on 10/22/19, when the facility completed the following: - Facility skin sweeps were completed on 10/17/19. All residents had full skin evaluations to identify any pressure injuries. - All residents identified with pressure injuries were assessed by an RN and associated documentation completed on 10/17/19. - All nursing staff was educated on Pressure injury risk, Pressure injury prevention and treatment, skin evaluations and who to report skin conditions, including inspection of skin with cares and weekly by a licnesed nurse. - Upon admission, a skin evaluation will be completed to identify any skin conditions. Braden Scale will be conducted to identify residents at risk for pressure injuries. Appropriate interventions will be put into place and documented in the resident's plan of care based on the identified level of risk. - Residents with pressure injuries will be assessed and documented weekly by a RN, and will have a plan of care to promote healing completed upon identification of skin impairment. - Pressure injury and change of condition policy and procedure will be reviewed and revisions made as applicable. - Director of Nursing/Designee will review admissions for documentation on pressure injuries and pressure injury treatment orders weekly. - Weekly audit will be conducted to ensure weekly documentation of skin alterations and associated plan of care is in place by Director of Nursing/Designee. - Results of skin sweep and audits will be reported monthly to the Quality Assurance Perfomance Improvement committee to determine continuing audit needs. This deficient practice continues at a scope/severity of [NAME] (potential for more than minimal harm/pattern) as the facility continues to implement its removal plan and as evidenced by the following: 3. R25 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Braden assessment dated [DATE] has a score of 9. A score of 9 or below indicates very high risk for pressure injury development. The skin screen dated 7/24/19 documents under sites: 23) coccyx and description o/a (open area), 31) Right buttocks and description o/a, 32) Left buttocks and description o/a, 49) Right heel and description o/a, and 50) Left heel and description o/a. This skin screen was completed by LPN (Licensed Practical Nurse)-TT. The admission observation dated 7/24/19 under the skin condition section documented instructions are Upon inspection are there skin conditions which require monitoring and/or treatment. Answer additional skin questions even if skin is intact. Under the skin section for c. Indicate any bruises, [MEDICAL CONDITION], surgical wounds, scars, open areas, rash. for site is blank and description is blank. This admission observation was completed by RN (Registered Nurse)-QQ. The skin and wound evaluations dated 7/25/19 were completed by LPN-U. Surveyor noted the skin and wound evaluations for the right elbow, left trochanter, sacrum, right & left heel, and right ischial tuberosity's assessments were completed. The skin and wound evaluation dated 7/25/19 for the left buttocks stage 4 is not completed. There are no measurements for width, length, depth and the rest of the assessment is not completed. There were no RN assessments of R25's pressure injuries when she was admitted . The at risk for skin complications care plan initiated 7/25/19 and revised 8/24/19 has interventions dated 7/25/19 of: Assess and document of progress of areas weekly, Assist and encourage resident to turn and reposition every one to two hours and PRN (as needed), Dietary supplements as ordered, Educate resident on the risk of infection and poor healing r/t (related to) non compliance, Ensure proper body alignment, Monitor area for s/s (signs/symptoms) of infection: odor, drainage, color, size, Notify MD (medical doctor) of abnormal findings, Provide skin care after each incontinent episode, Therapeutic mattress in bed and chair in chair as appropriate. Use foam wedges for 30 degree lateral positioning, Use lift sheet to move patient and Use pressure redistribution surface if bed or chair bound. Consider pressure redistribution surface if: There is intractable pain or Severe pain with turning or Additional risk factors are present. Ensure adequate food and fluid intake. Set up help at all meals. (this intervention was also revised on 7/30/19), Treatment as ordered to sacrum, Rt (right) ischium, Lt (left) hip, Lt Butt. (this intervention was revised 8/24/19). An intervention dated 9/23/19 of Administer antibiotic for suppression of osteo as ordered by MD (medical doctor). Report SE of antibiotic to MD. R25 was discharged to the hospital on [DATE] and was readmitted on [DATE]. The skin screen dated 7/31/19 under the skin evaluation section for location and brief description is blank. Under actions taken documents, Right elbow, right heel, right ischium, sacrum, wound. Treatment in place. This was completed by RN-QQ. The admission observation dated 7/31/19 under the skin condition section for c. Indicate any bruises, [MEDICAL CONDITION], surgical wounds, scars, open areas, rash. for site is blank and description is blank. This admission observation was completed RN-QQ. There is no comprehensive assessment of R25's pressure injuries when she was readmitted to the facility on [DATE]. R25 was discharged to the hospital on [DATE] and was readmitted on [DATE]. The admission observation dated 8/6/19 under the skin condition for sites documents; 17) right elbow & description scab, 26) left trochanter (hip) & description open area, 31) Right buttock & description open area, 32) left buttocks & description open area, 49) Right heel & description scab, 50) Left heel & description scab, and 53) Sacrum open area. This admission observation was completed by LPN-K. The skin screen dated 8/7/19 for skin evaluation under sites documents; 49) Right heel & description is blank, 53) Sacrum & description is blank and site documents Other (specify). Under actions taken documents Res (Resident) will have treatment in place. This skin screen was completed by LPN-UU. There is no comprehensive assessment of R25's pressure injuries when she was readmitted to the facility on [DATE]. There were no RN assessments of R25's pressure injuries when she was readmitted . Surveyor noted weekly skin and wound evaluations completed by LPN-U for all pressure injuries. R25's right & left heel and right elbow pressure injuries healed on 8/12/19. Surveyor noted Wound MD-LL initial wound evaluation and management summary is dated 8/12/19. The admission MDS (Minimum Data Set) with an assessment reference date of 8/13/19 documents R25 is at risk for pressure injury development and is coded as having 7 stage 4 pressure injuries. On 10/15/19 at 7:19 a.m. Surveyor observed R25 in bed on R25's back. There is a pillow under each of R25's arms and R25 is on the ventilator. There is a pillow at the end of the bed against the foot board, R25 is wearing pressure relieving boots and is on an air mattress. On 10/15/19 at 10:49 a.m., Surveyor observed R25 continues to be in bed on R25's back. Surveyor noted R25 has not been repositioned since Surveyor saw R25 at 7:19 a.m., 3.5 hours earlier. R25's call light is on. LPN-U answered R25's light informing R25 she and LPN-K are going to be doing R25's treatment. On 10/15/19 from 10:55 a.m. to 11:57 a.m., Surveyor observed treatment for R25's sacrum, left buttocks, left hip and right buttocks with LPN-U and LPN-K. Surveyor observed the treatment was completed according to physician's orders [REDACTED]. At 12:53 p.m. Surveyor entered R25's room with CNA-V. CNA-V washed R25's chest, abdomen, right leg and removed the bilateral pressure relieving boots. Surveyor observed on the back of R25's right heel a dark area with dried skin. At 1:28 p.m. LPN (Licensed Practical Nurse)-U entered R25's room wearing personal protective equipment, looked at the side of R25's right foot near the great toe and stated it's dried blood. LPN-U did not look at R25's right heel. CNA-V placed a socks on R25's feet and LPN-U left R25's room. CNA-V & CNA-W placed a Hoyer sling under R25 by positioning R25 from side to side, the collection bag was emptied, R25 sling was attached to the Hoyer lift and R25 was transferred into her electric wheelchair. On 10/16/19 at 1:32 p.m. Surveyor asked LPN-G if Surveyor could look at R25's right heel with her. Surveyor accompanied LPN-G to R25's room. LPN-G removed R25's pressure relieving boot. Surveyor showed LPN-G the dark area on the back of R25's right heel and informed LPN-G Surveyor observed this area yesterday while observing cares. LPN-G informed R25 they will probably place skin prep on the area and notify her doctor. LPN-G removed the pressure relieving boot, looked at R25's left heel and stated same on here. Surveyor observed a dark area on the back of R25' left heel. Surveyor asked LPN-G if anyone reported the dark areas on R25's heels to her. LPN-G replied no. LPN-G asked R25 if she could put her heels on a pillow, placed the pressure relieving boots back on R25 and placed a pillow under the boots. LPN-G informed Surveyor she was going to call the doctor and document. The nurses note dated 10/16/19 at 2:06 p.m. documents R25 has a new skin condition. Please see Skin Condition observation for details. The skin condition dated 10/16/19 under the skin condition section for sites documents; 49) Right heel & description maroon area flat with thick scale tissue over and 50) Left heel & description maroon area flat with thick scale tissue over. This skin condition was completed by LPN-G. The nurses note dated 10/16/19 at 2:23 p.m. documents,Resident alert and responsive, resident refused AM cares and treatments, refused breakfast stated has not been sleeping well and would like to rest, consumed 50% of lunch, resident asked if she was ready for cares and treatments after lunch resident refused, resident .stated after 2pm, scabbed areas to back of heels noted, heels elevated off bed with pillows, Physician/Medical Director-JJ aware NOR (new order received) for skin prep BID (twice daily), Resident aware of order does not wish family to be notified. On 10/16/19 at 3:17 p.m. Surveyor informed LPN-U when R25 returned from the hospital on [DATE] & 8/6/19 a comprehensive assessment of R25's pressure injuries was not completed and inquired why. LPN-U informed Surveyor she can't answer as when a Resident goes to the hospital for over 24 hours and returns they are supposed to do an assessment. On 10/15/19 at 10:45 a.m., Surveyor inquired about wound rounds and if Wound MD (Medical Doctor)-LL [MEDICATION NAME] all Residents with pressure injuries with LPN-U. LPN-U replied, yes unless they are surgical. LPN-U explained Wound MD-LL debrides the pressure injuries and they both look at the area to see if they are improving or deteriorating. LPN-U informed Surveyor Wound MD-LL usually does the same treatment for two weeks. LPN-U indicated Wound MD-LL measures and describes the wound bed for his notes. Surveyor inquired who documents the pressure injuries in the Resident's medical record. LPN-U informed Surveyor she documents in PCC (point click care) for the nurses. LPN-U informed Surveyor Wound MD-LL measures the pressure injuries with a ruler and she has a camera which measures the area. LPN-U informed Surveyor wound rounds are on Mondays. Surveyor inquired who the members of the wound team are. LPN-U informed Surveyor herself and Wound MD-LL. Surveyor inquired what happens when a Resident develops a pressure injury or comes in with a pressure injury. LPN-U informed Surveyor she usually works Monday 6:00 a.m. to 2:15 or 2:30 and Tuesday to Friday 7:30 a.m. to 3:30 p.m. LPN-U explained if it's after this time the nurse on the unit looks at the area, describes what they see and the next day she reevaluates the area. 4. R65 was admitted to the facility on [DATE]. R65's [DIAGNOSES REDACTED]. The hospital discharge summary with discharge date of [DATE] under brief course of the patient includes Patient has sacral and hip wound and recommendation regarding his treatment, please see recommendation from the wound care nurse. Under hospital wound care recommendations dated 9/19/19 documents R65 currently has an open area on his right trochanter. Premedication for treatment has not been required. The admission observation dated 9/18/19 under the skin section for c. Indicate any bruises, [MEDICAL CONDITION], surgical wounds, scars, open areas, rash for site is blank. Under Description documents, rash to arms, legs, chest. This admission assessment does not document R65's pressure injury and was completed by RN (Registered Nurse)-QQ. Surveyor met with LPN (Licensed Practical Nurse)-U who is the wound nurse at the Facility on 10/15/19 at 3:56 p.m. Surveyor informed LPN-U Surveyor noted her weekly documentation including the initial wound (TRUNCATED)

Based on interview and record review the facility did not ensure that 1 (R3) of 7 residents reviewed received treatment and care in accordance with professional standards of practice. R3 had a fall with head injury on 5/13/19 and was not assessed by a Registered Nurse following the fall, thorough neurological assessments were not completed following the fall and R3's physician was not notified of a change in condition following the fall. The facility's failure to have a Registered Nurse complete an assessment after R3's fall, failure to complete thorough neurological assessments of R3 after a fall and failure to notify the physician of a change in condition following R3's fall with a head injury, created a finding of immediate jeopardy that began on 5/15/19. Administrator-A and Director of Nursing-B were notified of the immediate jeopardy on 7/23/19 at 12:55PM. The immediate jeopardy was removed on 7/23/19 and continues at a D. Findings include: The facility policy, entitled Change in Resident Condition, dated 9/2017, states: It is the policy of the facility, except in a medical emergency, to alert the resident, resident's responsible physician and resident's responsible party of a change in condition. 1 Nursing will notify the resident's physician or nurse practitioner when: a. The resident is involved in an accident or incident b. There is a significant change in the resident's physical, mental and emotional status. c. There is a pattern of refusing treatment or medication. 2. Once the physician has been notified and a plan developed, the nursing or social service staff will alert the resident and family of the issue and any physician orders. 3. The communication with the resident and their responsible party as well as the physician will be documented in the resident's medical record or other appropriate documents. 4. The Care Plan Coordinator will be notified so that changes in the care plan can be made if needed. The facility policy, entitled Neurological Evaluation, dated 9/2017, states: General: To provide information for early detection and treatment of [REDACTED]. Guidelines: 1 Neurological observations are done with an order, when indicated for a change of condition, and with all head injuries. 2. Observe behavior and note any significant change from normal. 3. Determine the location and type of pain. 4. Determine level of consciousness and responsiveness as compared to baseline. 5. Determine orientation to person, place and time as compared to baseline. 6. Determine capability of movement and strength of all extremities as compared to baseline. 7. Check pupil size and reaction to light. 8. Note speech to determine if it is clear, rambling, and incoherent and absent as compared to baseline. 9. Check vital signs. 10. Determination of how often to check above are based on physician or nurse practitioner order or change of resident condition. 11. The neurological assessment should be documented. 12. Any significant change will be reported to the physician. R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3's Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/30/19, documents: A Brief Interview of Mental Status (BIMS) score of 4, indicating R3 has severe cognitive impairment; a Patient Health Questionnaire (PHQ-9) score of 6, indicating R3 has mild depressive symptoms; No behavior symptoms were documented; R3 requires extensive assist of 2 staff for bed mobility, transfers, dressing and toilet use, extensive assist of 1 staff for locomotion on and off the unit, personal hygiene and eating; impaired range of motion of one side of upper and lower extremity; frequently incontinent of bladder and bowel; a weight of 162 lbs. (pounds); mechanically altered diet. R3's Care Plan, dated 4/23/19, with a target date of 8/7/19, states: Resident is at risk for falls secondary to cognitive deficits, functional deficits . Notify MD (Medical Doctor) and family of any new fall, Date initiated: 4/23/19 . On 5/13/19, at 1:57 PM, R3's medical record documents: Writer called to day room at 11:40 AM resident lying on floor head against wall w/c (wheelchair) about 3 feet from resident in locked position, resident alert and responsive, o x1 (oriented to person per norm , ROM (range of motion) WNL (within normal limits), denies pain or dizziness, assisted to sitting position small amount of active bleeding noted to (right) side of head, resident assisted to standing position bearing weight without difficulty, cont (continue) to denies pain or dizziness, assisted to w/c, area to head cleansed with n/s (normal saline), area stopped bleeding with cleansed small laceration noted hematoma cool compress applied, noted dark, dry drng (drainage) to inner rt ear resident refused to allow writer to clean out ADON (Assistant Director of Nursing) notified and notified DON (Director of Nursing) and Nurse Practitioner (NP)-K NOR (New Order Received) for [MEDICATION NAME] ear drops x 5 days BID (twice a day) POA (Power of Attorney) notified. Cont (continue) to monitor with cran checks. R3's Fall Investigation, dated, 5/13/19 at 1:46 PM, documented by Licensed Practical Nurse (LPN)-C, states: Called to day room at 11:40 to see resident lying on rt side head against wall s/c about 3 feet from where resident was lying. No witnesses stated to hear noise. Resident is alert and responsive, O x1, ROM WNL, resident assisted to sitting position noted small amount of bleeding to rt side of head, denies pain or dizziness, PERL (Pupils Equal and Reactive to Light), hand grasps strong an equal, resident assisted to standing position able to bear weight without difficulty assisted to chair cont (continues) to deny pain or dizziness. Immediate Action Taken: Are to head cleansed with n/s and gauze small laceration with hematoma bleeding stopped as cleansed cool compress applied. Resident not taken to the hospital. Laceration was located on the top of scalp People notified: Director of Nursing-B, Nurse Practitioner-K and Family member. Surveyor was unable to locate documentation of R3 being assessed by a Registered Nurse post fall, the physician being notified of R3's head injury related to the fall and no assessment or treatment orders were located for the laceration and hematoma to the right side of R3's head. On 7/22/19, at 1:30 PM, Surveyor interviewed LPN-C, who stated: She assessed R3 following the fall. LPN-C noted a small amount of bleeding from a small laceration and hematoma to the right side of R3's head. Once R3's head was cleaned up the laceration was not visible so no treatment was ordered. LPN-C stated, she contacted Nurse Practitioner (NP)-K via phone, in regards to R3's fall and continued with neurological checks, no orders for treatment to the head injury were obtained and ear drops for old drainage to ear was ordered. LPN-C stated she notified DON-B of the fall but DON-B did not physically assess R3 after the fall and LPN-C stated there was no Registered Nurse assessment of R3 after the fall. On 7/22/19, at 3:59 PM, Surveyor interviewed Nurse Practitioner (NP)-K, who stated: she does not recall facility staff informing her of R3's fall with head injury. NP-K stated, she would have informed facility staff that R3 was covered by an insurance plan and the Nurse Practitioner from the insurance plan would need to be contacted and updated about the fall. Nurse Practitioner-K stated she last saw R3 on 4/30/19 and the assigned physician last saw R3 on 5/7/19 and the doctor's office has no other records on file for R3 past 5/7/19. On 7/22/19, at 3:04 PM, Surveyor interviewed Nurse Practitioner (NP)-[NAME] NP-J stated she does not recall being informed of R3's fall with head injury . R3's Neurological (Neuro) Flow Sheet, undated, documents: Neuro check time schedule of : Q (every) 15 min (minutes) x 1 hour; Q 30 min x 2 hours; Q hour x 2 hours; Q 4 hours x 24 hours and Q shift for 48 hours. Progress along this time schedule is only if results are stable. Notify MD immediately of signs and symptoms of possible increased intracranial pressure: headache, increased blood pressure, decreased mentation, decreased pulse, vomiting and irregular breathing. R3's first neuro check was completed post fall on 5/13/19 at 12:00pm. It documents: R3 is oriented to name, speech is clear, pupils are equal; hand grasps are strong; and vitals of: Temperature of 97.8; no pulse documented, respirations of 20; and blood pressure of 118/78. On 5/13/19, at 12:15 PM, R3's Neuro check documents: R3 is oriented to name, speech is clear, pupils are equal; hand grasps are weak; and vitals of: Temperature of 97.8; no pulse documented, respirations of 20; and blood pressure of 118/78. On 5/15/19, at 9:42 AM, R3's Neuro check documents: R3 is oriented to name touch, speech is aphasic, pupils are sluggish; hand grasps are weak; and vitals of: No temperature was documented; no pulse documented respirations of 20; and blood pressure of 120/64. At this time the facility did not complete 12 neruo checks that should have been completed per Neurological Flow Sheet directions. Surveyor is unable to locate documentation of R3's physician being notified of the change in pupil reaction. On 5/15/19, at 3:00 PM, R3's Neuro check documents: R3 is oriented to name touch, speech is aphasic, pupils are sluggish; hand grasps are none; and vitals of: No temperature was documented; no pulse documented respirations of 18; and blood pressure of 116/80. Surveyor is unable to locate documentation of R3's physician being notified of the change in hand grasps. The facility only completed 2 neurological checks on 5/15/19 when the Neurological Flow Sheet directions stated at least 3 neurological checks should have been completed and that was only if the results of the checks were stable. On 5/16/19 at 9:27 PM, R3's medical record documents: Resident is alert with confusion continues to be monitored for fall. No visible s/s (signs/symptoms) of any pain/discomfort observed at this time. On 5/17/19, at 4:55 PM, (late entry) R3's medical record documents: NP (Nurse Practitioner) in to see resident this AM (morning). NOR (New Order Received) to do CBC (Complete Blood Count) with diff (Differential) BMP (Basic Metabolic Panel) and U/A (Urine Analysis) with C/S (culture and sensitivity) for lethargy. POA (Power of Attorney) is in and is aware. On 5/17/19, at 5:11 PM, (late entry) R3's medical record documents: Pt (patient) experiencing respiratory distress. Sats (oxygen saturation) dropped as low as 50% and heart rate was inconsistent. Pt not responsive. RT (Respiratory Therapist) present to monitor pt. Ambulance called to send pt to hospital. On 5/17/19, at 7:52 PM, R3's medical record documents: Resident sent to St [NAME]'s Ozaukee at 1800 (6:00PM) via bell ambulance due to increased lethargy, [MEDICAL CONDITION] and [MEDICAL CONDITION]. B/P (blood pressure) 80/50, SPO2 (peripheral capillary oxygen saturation) 74%, 15 lpm (liters per minute) via (by) mask. Skin cool to touch, Wife updated Dr (doctor) updated. Writer called ER (emergency room ) spoke with RN (registered nurse). Resident will be admitted . Current SPO2 in ER 88% on 12 lmp. Blood and diagnostic testing pending. On 7/18/19, at 2:28 PM, Surveyor interviewed Director of Nursing (DON)-B, who stated in reviewing R3's Neurological Assessment Form, R3 did have a change in condition on 5/15/19 and the physician should have been notified. DON-B is unable to state why R3's physician wasn't notified. On 7/22/19, at 3:04 PM, Surveyor interviewed Nurse Practitioner (NP)-J stated she was informed via phone of R3's increased lethargy on 5/17/19 and was told by facility staff R3's vitals were stable so NP-J ordered stat labs and the next thing she heard was R3 was sent to the hospital. NP-J stated she did not assess R3 in person at the facility on 5/17/19. On 7/23/19, at 8:45 AM, Surveyor interviewed, Licensed Practical Nurse (LPN)-E, who stated a certified nursing assistant (CNA) informed her of R3 not being himself, not drinking. LPN-E stated she went to assess the resident in the dining room area and he was not responding to his name. R3 was then taken to his room for further evaluation. LPN-E took R3's vitals and noted they were unstable and called for the supervisor (RN-G) and for Respiratory Therapy assistance. LPN-E is uncertain who called for the ambulance but they arrived quickly and R3 was sent to the hospital for further evaluation. Hospital emergency room documentation, dated 5/17/19, documents: Patient appears lethargic, extraocular movement are intact, normal conjunctiva, pupils are quite small, almost pinpoint do not constrict further to light; lungs are clear to auscultation, respirations are non-labored, breath sounds are equal. No wheezes or crackles. No focal neurological deficits observed. Does not speak. Withdraws to noxious stimuli including my cold hands, moves all 4 extremities. When I ask him to open is eyes he raises his eyebrows but does not open his eyes. Otherwise does not seem to follow commands.Resident presenting with lethargy, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Poor recent by mouth intake in the setting of severe dementia with recent stroke, along with institution of [MEDICATION NAME] which can be sedating. Very broad workup instituted including laboratory studies with ABG and drug screen, CT of head, chest x-fay, and EKG. He was found to have detailed duration which was quite apparent clinically, with acute kidney injury and [MEDICAL CONDITION]. Mild leukocytosis but is afebrile with no signs of infection on exam or laboratory workup. His ABG is normal, he is not hypercarbic. No evidence of hemorrhage or infarct on his CT. He was treated with 2 L of normal saline bolus here as he is did have some further episodes of [MEDICAL CONDITION]. I think this is due to profound dehydration. He is very fluid responsive. He is catheterized for urine specimen and had very little urine in the bladder. Impression and Plan, Diagnoses: [REDACTED]. R3's Medication Administration Record [REDACTED]. Surveyor is unable to locate documentation the facility was monitoring R3's fluid intake. (Cross Reference F 692) On 7/23/19, at 8:57 AM, Surveyor informed Administrator-A and Director of Nursing-B of the concern R3 had a fall with head injury on 5/13/19 and was not assessed by a Registered Nurse following the fall, thorough neurological assessments were not completed following the fall and R3's physician was not notified of a change in condition following the fall. No further information was provided. The facility's failure to ensure RN assessment immediately after R3's fall on 5/13/19, its failure to closely monitor R3 after a fall with a head injury and its failure to immediately consult with a physician when R3 showed signs of a significant condition change created a finding of immediate jeopardy. The jeopardy was removed 7/23/2019 when the facility implemented the following: staff education, audits to ensure compliance, thorough fall investigations appropriate notifications with any resident changes.

Based on record review and staff interview, the facility did not thoroughly assess resident falls and implement appropriate interventions to prevent further falls. This was observed with 3(R2, R6 and R3) of 3 residents reviewed with falls. * R2 had 2 falls in the facility shower room that were not thoroughly investigated and assessed with [REDACTED]. This resulted in actual harm to R2. * R6 had 2 falls from the bed that were not thoroughly investigated and assessed with [REDACTED]. * R3 had a fall with head injury on 5/13/19 and facility did not complete a thorough investigation of the fall and implement interventions that would prevent future falls. Findings include: The facility policy, entitled Fall Prevention and Management, dated 10/2018, states: The facility is committed to maximizing each resident's physical, mental and psychological well-being. While preventing all falls isn't possible, the facility will identify and evaluate those residents at risk for falls, plan for preventative strategies, and facilitate as safe and environment as possible. All resident falls shall be reviewed and the resident's existing plan of care shall be evaluated and modified as needed . Upon admission: 1 A fall risk evaluation will be completed on admission, readmission and quarterly, significant change and after each fall. 2. Residents at high risk for fall will have fall risk identified on his interim plan of care and the ISP (Individual Service Plan) with interventions implemented to minimize fall risk. Facility Guideline following a fall incident: 1 Evaluate the resident for any injury and notify the physician and emergency contact. 2. Complete a fall incident report in the PCC (Point Click Care) risk management portal. 3. A fall risk evaluation is completed by nursing. 4. Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence. 5. Complete the follow up monitoring form every shift for 72 hours. 1. R2 was reviewed as a result of a complaint concern regarding falls in the facility. R2 was admitted on [DATE] and discharged home on[DATE]. R2 has no cognitive impairments and was admitted for short-term rehab due to a spinal fusion surgery. The Admission MDS (minimum data set) assessment completed on 5/15/19 indicates no cognitive impairments, requires 1 staff assist with transfers and bathing. The assessment indicates R2 has had no prior falls. FALL RISK ASSESSMENTS/ CARE PLAN * 5/10/19 R2 is scored a 11, and a score above 10 is a high risk for falls. * Care plan for fall risk has a initiated date of 5/31/19 has no dates prior to 5/31/19. * 5/31/19 R2 is scored a 6 which is no longer a high-risk for falls. However this was after R2 fell in the facility on 5/31/19. * 5/31/19 R2 has a another fall risk completed a couple hours later. This has R2 scored as a 3 which is a very low risk of falls. *6/15/19 R2 is scored as a 5 which is a low risk. This was after a second fall with injury on 6/15/19. * Care Plan has an intervention on 6/17/19 to be supervised with showers. FALL INVESTIGATION R2 had a fall on 5/31/19 at 2:15 PM. R2 reported that when he took a shower he lost his balance and fell . The summary of the investigation indicates R2 lost his balance and is independent with activities of daily living. The root cause listed indicates R2 was alone and became lightheaded. It was discussed with R2 that he should ask for assist with showering and R2 wanted privacy. The summary indicates R2 can shower independently. There are no additional statements from staff. There is no information the reason R2 was alone in the shower and on the floor. There is no information if a call system was in the shower stall. Per plan of care for ADL (activity of daily living) initiated 5/31/19. R2 requires a wheelchair for mobility and requires assist related to back brace. Per the plan of care for falls risks dated 5/31/19, the intervention for 5/31/19 indicates to ensure proper footwear; document any side effects from medications. It does not include to shower independently or address the light headedness. R2 had a second fall on 6/15/19 at 2:23 PM. R2 had a laceration to the back of his head and was bleeding. R2 indicated he was in the shower and stood up with soap on him. R2 was sent to the emergency room and received 12 staples to his head, There are no additional statements from staff regarding events leading up to the shower. There is no information if the call system was available in the shower stall. The facility completed a resident education with R2 to establish a set time so staff can assist. There is no additional information related to the shower floor or how the fall actually occurred. Per plan of care for fall risk initiated 5/31/19, the intervention is supervision with showers. On 7/17/19 at 1:25 PM Surveyor spoke with DON-B. DON-B indicated R2 reported to staff that he fell in the shower. DON-B indicated the Fall Evaluation would have any findings on it. R2 uses a wheelchair and had decreased endurance and was always smoking outside, R2 expressed he didn't want any help. DON-B indicated the shower room is not locked. DON-B indicated there is a bench to sit down on in the shower stall. DON-B did not have any additional statements from staff or environment factors. On 7/23/19 at 12:50 PM Surveyor shared the concerns with R2 falls at the facility exit meeting. 2. R6 was reviewed by Surveyor for falls. R6 is dependent on staff for all ADL's (activity of daily living) R6 was initially admitted on [DATE] and has a [DIAGNOSES REDACTED]. FALL RISK ASSESSMENTS * 6/3/19 R6 is scored as a 13; over 10 indicates high-risk for falls. *6/13/19 R6 is scored as an 8, which is no longer a high-risk for falls. * 6/15/19 R6 is scored a 26, which indicates a high-risk for falls. This was after a fall from the bed. * 6/19/19 R6 is scored an 18, which indicates a high-risk for falls. CARE PLAN * Fall Risk care plan initiated 6/15/19. This date correlates with R6's first fall from bed. There is not evidence of a fall risk care plan prior to this time. The interventions include: low bed, bed buddy, and floor mats. FALL INVESTIGATIONS * On 6/15/19 at 5:10 AM R6's vent alarm was sounding. The RT(Respiratory Therapist) observed R6 on the floor. RT could not find the nurse so he picked up R6 to re-connect him to the ventilator. As the day progressed R6 was noted to have mild swelling by the left eye and no other injuries. The Progress Note indicates a neuro check was performed, however there is no documentation of the neuro checks themselves. The investigation root cause indicates R6 moves to the side of the bed and will have an evaluation for [MEDICAL CONDITION] activity. There is one staff statement that indicates R6 was in bed at 4:50 AM. There is no documented occurrences of R6 moving around in bed. There is no statement by the RT who discovered R6 on the floor and re-connected him to the ventilator. The plan of care for falls does not include moving around in bed or [MEDICAL CONDITION] activity. There was a lab drawn for [MEDICATION NAME] after the fall that showed a normal range. * On 6/18/19 at 12:43 PM R6's vent alarm was sounding. R6 was observed face down on the floor. The fall interventions of mats, low bed and bed buddy were in place. R6 was sent out to the hospital. R6 did not have any major injuries and returned to the facility. The root cause indicates R6 was trying to get out of the bed to go to the hospital. The statements indicate that 10 minutes prior to the fall R6 was lying in bed watching television. The RT statement indicated R6 indicated 3 hours prior to the fall that he wanted to go to the hospital. R6 didn't say why and continued to watch television. R6's plan of care for fall risk was not revised with new interventions. The investigation did not contain documentation to support the root cause analysis. On 7/18/19 at 1:30 PM Surveyor spoke with DON-B (Director of Nurses). DON-B indicated R6 has a history of [MEDICAL CONDITION]. DON-B did not know why fall precautions were not implemented prior to the first fall. DON-B indicated with the second fall the primary physician adjusted some medications. DON-B did not know why this was not included with the fall assessments. DON-B did not know why the plan of care was not revised after the second fall. DON-B did not know why there was no statement from the RT from the first fall. DON-B had no further documentation related to R6's falls. On 7/23/19 at 12:50 PM Surveyor shared the concerns with R6 falls at the facility exit meeting. 3. R3 had a fall with head injury on 5/13/19 and facility did not complete a thorough investigation of the fall and implement interventions that would prevent future falls. R3's Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/30/19, documents: A Brief Interview of Mental Status (BIMS) score of 4, indicating R3 has severe cognitive impairment; a Patient Health Questionnaire (PHQ-9) score of 6, indicating R3 has mild depressive symptoms; No behavior symptoms were documented; R3 requires extensive assist of 2 staff for bed mobility, transfers, dressing and toilet use, extensive assist of 1 staff for locomotion on and off the unit, personal hygiene and eating; impaired range of motion of one side of upper and lower extremity; frequently incontinent of bladder and bowel; a weight of 162 lbs. (pounds); mechanically altered diet. R3's Care Plan, dated 4/23/19, with a target date of 8/7/19, states: Resident is at risk for falls secondary to cognitive deficits, functional deficits. Interventions include: Assess pattern for sleeping and encourage rest per pattern/preference, Date initiated: 4/23/19; Document s/sx (signs and symptoms) of adverse effects of medication on resident: Date initiated: 4/23/19; Encourage and offer rest periods when walking long distances, Date initiated: 4/23/19; Encourage appropriate use of wheelchair, Date initiated: 4/23/19; Encourage resident to keep room free from obstacles/clutter, Date initiated: 4/23/19; Encourage resident is wearing eyeglasses, Date initiated: 4/23/19; Evaluate multiple falls to determine commonalities or patterns, Date initiated: 4/23/19; Fall risk assessment quarterly and as needed, Date initiated: 4/23/19; Keep frequently used items within reach, Date initiated: 4/23/19; Monitor for any changes in condition, Date initiated: 4/23/19; Monitor resident for tolerance and endurance. Schedule tasks accordingly, Date initiated: 4/23/19; Notify MD (Medical Doctor) and family of any new fall, Date initiated: 4/23/19; Orient resident to surroundings frequently, including location of bathroom dining room, bedroom and activity location, Date initiated: 4/23/19; Provide proper, well maintained footwear, Date initiated: 4/23/19; Resident to lay down after lunch meal, Date initiated: 5/14/19; Restorative care as appropriate, Date initiated: 4/23/19; Therapy to evaluate and treat as indicated, Date initiated: 4/23/19. On 5/13/19, at 1:57 PM, R3's medical record documents: Writer called to day room at 11:40 AM resident lying on floor head against wall w/C (wheelchair) about 3 feet from resident in locked position, resident alert and responsive, o x1 (oriented) to person per norm , ROM (range of motion) WNL (within normal limits), denies pain or dizziness, assisted to sitting position small amount of active bleeding noted to (right) side of head, resident assisted to standing position bearing weight without difficulty, cont (continue) to denies pain or dizziness, assisted to w/c, area to head cleansed with n/s (normal saline), area stopped bleeding with cleansed small laceration noted hematoma cool compress applied, noted dark, dry drng (drainage) to inner rt ear resident refused to allow writer to clean out ADON (Assistant Director of Nursing) notified and notified DON (Director of Nursing) and Nurse Practitioner (NP)-K NOR (New Order Received) for [MEDICATION NAME] ear drops x 5 days BID (twice a day) POA (Power of Attorney) notified. Cont (continue) to monitor with cran checks. R3's Fall Investigation, dated, 5/13/19 at 1:46 PM, documented by Licensed Practical Nurse (LPN)-C, states: Called to day room at 11:40 to see resident lying on rt side head against wall s/c about 3 feet from where resident was lying. No witnesses stated to hear noise. Resident is alert and responsive, O x1, ROM WNL, resident assisted to sitting position noted small amount of bleeding to rt side of head, denies pain or dizziness, PERL (Pupils Equal and Reactive to Light), hand grasps strong an equal, resident assisted to standing position able to bear weight without difficulty assisted to chair cont (continues) to deny pain or dizziness. Immediate Action Taken: Are to head cleansed with n/s and gauze small laceration with hematoma bleeding stopped as cleansed cool compress applied. Resident not taken to the hospital. Laceration was located on the top of scalp. People notified: Director of Nursing-B, Nurse Practitioner-K and Family member. On 5/14/19, the fall form documents: Resident had a fall while trying to self-transfer to a chair; obtained hematoma and laceration to right posterior head, medical HX (history) cognitive communication deficit, dysphagia, Alzheimer's dementia,[MEDICAL CONDITION](hypertension), gout. Root Cause: Resident was trying to transfer to lounge chair and became too weak to complete the transfer. Intervention: Offer resident to be laid down after lunch. The fall is not thoroughly investigated. The fall investigation does not state when R3 was last seen by staff, last assisted with toileting needs, last provided food, when last repositioned, when last seen by staff or why R3 was attempting to self-transfer to a lounge chair. The intervention of laying R3 down after lunch does not address the reason R3 fell before lunch. On 7/18/19, at 2:28 PM, Surveyor interviewed Director of Nursing (DON)-B, who stated: After review of the fall investigation form, the investigation does thoroughly document the reason for the fall and does not implement an intervention that would prevent future falls. On 7/23/19, at 8:57 AM, Surveyor informed Administrator-A and Director of Nursing-B of the concern R3 had a fall and that a thorough investigation of the fall was not completed and interventions were not put into place to prevent future falls.

Based on interview and record review the facility did not ensure that 1 (R3) of 7 reviewed maintained acceptable parameters of nutritional status, or was offered sufficient fluid intake to maintain proper hydration and health. R3's fluid intake was not monitored after he was assessed to be at nutritional risk. R3 had unplanned weight loss of 23.8 pounds. R3 became unresponsive and was hospitalized with severe dehydration on 5/17/19. Findings include: The facility policy, entitled Hydration, dated 9/2017, states: General: This policy allows for each resident to be provided with sufficient fluid intake to maintain proper hydration and health. This is done through an evaluation to identify risk factors that may lead to dehydration and if present, a preventative care plan is developed. Guidelines: 1 Nursing will routinely monitor each resident for signs of dehydration such as cracked lips, dry oral mucosa, poor skin turgor and dark urine color. If present, they will be recorded in the medial record and the Health Care Provider will be notified. 2 Nursing will routinely observe the resident's consumption of fluids to determine if individual resident have reduced fluid intake. Pertinent observations will be recorded in the resident's medical record. The Intake Record may be used for this purpose. 3 Dietary manager or consultant dietician will estimate each resident's fluid needs on the initial and annual nutritional assessment. 4The facility will identify the resident's beverage preference on their dietary card. 5 Unless restricted by diet or food preference, residents will receive appropriate fluids at each meal. Water will be made available for all residents unless otherwise restricted. 6 Residents who refuse water are provided with alternative fluids that are tolerable to the resident. 7 Residents with swallowing concerns (dysphagia) shall be identified and provided with fluids consistent with their specific needs, for example thickened liquids as ordered. 8 The facility shall monitor the temperature of the resident's environment to prevent abnormal temperature variations. R3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R3's Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/30/19, documents: A Brief Interview of Mental Status (BIMS) score of 4, indicating R3 has severe cognitive impairment; a Patient Health Questionnaire (PHQ-9) score of 6, indicating R3 has mild depressive symptoms; No behavior symptoms were documented; R3 requires extensive assist of 2 staff for bed mobility, transfers, dressing and toilet use, extensive assist of 1 staff for locomotion on and off the unit, personal hygiene and eating; impaired range of motion of one side of upper and lower extremity; frequently incontinent of bladder and bowel; a weight of 162 lbs. (pounds); mechanically altered diet. R3's Hospital Discharge paperwork, dated 4/22/19, documents: R3 was hospitalized due to altered mental status, [MEDICAL CONDITION] (TIA). R3 had a video swallow study and was followed by speech therapy while in the hospital. Speech Therapy recommendations are: one to one, feed patient; feed pt (patient) when alert, and responsive, and may need cues to move bolus, and swallow it; recommended diet of Puree, with extra sauces/gravies, thin liquids; alternate bite/sip, liquids via cup, liquids via spoon, no straw, sit at 90 degrees during meals, small bites of food, small sips of liquid. Surveyor was unable to locate hospital speech therapy recommendation in R3's care plan. On 4/25/19, R3's medical record documents: Speech Therapy notes: SLP (Speech-Language Pathologist) facilitated dysphagia tx (treatment) with morning meal consisting of puree solids, thin liquids via cup and straw. PT (patient) required initial verbal cues for attention to task, however responded appropriately to solid presentation via tsp (teaspoon). Pt with frequent attempts to self-feed without utensil nor actual food items. However, by the end of the session pt with increased attempts to initiate, holding cup/spoon give hand over hand assistance. Max (maximum) cues for task continuation. Pt required cueing for liquid intake however tolerated from both cup and straw. Pt demonstrated increased prolonged mastication time with puree, with mild-mod (moderate) oral residue noted. Pt with incomplete bolus clearance, holding lingual base. Pt unable to complete volitional swallow given prompts and cues. No s/s (signs/symptoms) of aspiration noted. Surveyor unable to locate interventions in R3's care plan to address Speech Therapy observations from this assessment. R3's Care Plan, dated 4/30/19, documents: Swallowing difficulty r/t (related to) advanced dementia dx (diagnoses) AEB (As Evidenced By) need for puree diet. Interventions: Provide diet as ordered with appropriate feeding assistance; .Document percentage eaten at each meal; Monitor for s/s (signs/symptoms) of dehydration; Weights per facility protocol; Review labs as available, Date Initiated 4/30/19. R3's Dietary Evaluation, dated 4/30/19, documents: A weight of 162# (pounds). Goal is weight maintenance at this time .UBW (Usual Body Weight) 170's. Will be monitored on wkly (weekly) wts (weights) for new admit. Est (Estimated) needs at CBW (Current Body Weight): 1850-2220 cals (calories), 74 g (grams) pro (protein), 2220 ml (milliliters) of fluid. Oral intake: Fluids Consumes 1500-2000 cc/day (cubic centimeter); Resident admitted on puree diet, thin liquids.at risk for poor fluid intake r/t (related to) dementia dx (diagnoses). Extensive to total assistance with eating, 1:1 feeding assistance. No open areas noted. Will continue to monitor wts, po/fluid (per oral) intakes. Follow up PRN (As Needed). R3's weights were: Hospital weight: 162.2 lbs. 5/7/19: 144.2 lbs., down 18 lbs. 5/10/19: 138.4 lbs., down an additional 5.8 lbs. On 7/18/19, at 9:23 AM, Surveyor interviewed Director of Nursing (DON)-B, who stated: she would expect facility staff to obtain an admission weight for all residents within 24/48 hours of admission. DON-B stated she isn't certain why R3's admission weight wasn't obtained until 5/7/19. DON-B stated she would expect the facility Registered Dietitian to address any weight loss or eating concerns for residents. DON-B was able to provide Surveyor with a copy of R3's food intake percentage logs but stated that does not include fluids taken. On 7/18/19, at 10:26 AM, RD-I stated she would have expected to see the facility obtain an admission weight within 24/48 hours of admission and that didn't occur. RD-I stated she completed her assessment of R3 on 4/30/19 and would have expected staff to alert her to a concern for weight loss when R3's weight was taken on 5/7/19 at a weight of 144.2 lbs. Surveyor informed RD-I of the 17.8 lbs. weight loss from the hospital weight to first facility admission weight on 5/7/19. RD-I stated the only thing she can think of related to weight loss is that R3 received IV fluids in the hospital increasing his weight. RD-I stated she did not investigate the weight loss further. RD-I stated she would have expected nursing staff to have care planned the hospital recommended feeding assistance guidelines documented on the hospital discharge summary. On 7/22/19, at 3:04 PM, Surveyor interviewed Nurse Practitioner (NP)-J, who stated, she did not recall any reports of facility concerns for weight loss and R3 not eating or drinking well. NP-J stated she would look to the facility to inform her of concerns with R3's weight and intake and she depends on the facility staff to keep her updated with concerns and changes of condition. NP-J stated she would expect speech therapy to look into hospital concerns for R3 swallowing and altered diet. On 5/7/19, at 12:54 PM, R3's medical record documents: physician was in to see resident this am. NOR (New Order Received) to D/C (discontinue) [MEDICATION NAME] and start resident on [MEDICATION NAME] 15 mg (milligrams) @ (at) HS (Hour of Sleep) to stimulate appetite. The facility was unable to locate a physician progress notes [REDACTED]. On 5/17/19, at 5:11 PM, (late entry) R3's medical record documents: Pt (patient) experiencing respiratory distress. Sats (oxygen saturation) dropped as low as 50% and heart rate was inconsistent. Pt not responsive. RT (Respiratory Therapist) present to monitor pt. Ambulance called to send pt to hospital. On 5/17/19, at 7:52 PM, R3's medical record documents: Resident sent to St [NAME]'s Ozaukee at 1800 (6:00PM) via bell ambulance due to increased lethargy, [MEDICAL CONDITION] and [MEDICAL CONDITION]. B/P (blood pressure) 80/50, SPO2 (peripheral capillary oxygen saturation) 74%, 15 lpm (liters per minute) via (by) mask. Skin cool to touch, Wife updated Dr (doctor) updated. Writer called ER (emergency room ) spoke with RN (registered nurse). Resident will be admitted . Current SPO2 in ER 88% on 12 lmp. Blood and diagnostic testing pending. On 7/23/19, at 8:45 AM, Surveyor interviewed, Licensed Practical Nurse (LPN)-E, who stated a certified nursing assistant (CNA) informed her of R3 not being himself, not drinking. LPN-E stated she went to assess the resident in the dining room area and he was not responding to his name. R3 was then taken to his room for further evaluation. LPN-E took R3's vitals and noted they were unstable and called for the supervisor (RN-G) and for Respiratory Therapy assistance. LPN-E is uncertain who called for the ambulance but they arrived quickly and R3 was sent to the hospital for further evaluation. LPN-G stated staff would assist R3 with eating meals as well as his family. LPN-G stated the facility does not monitor fluid intake for residents unless they are ordered a certain amount of a nutritional supplement and that would be recorded in the medication administration record. LPN-G stated, R3 was not ordered a supplement. R3's Medication Administration Record [REDACTED]. Surveyor is unable to locate documentation the facility was monitoring R3's fluid intake. Hospital emergency room documentation, dated 5/17/19, documents: Patient appears lethargic, extraocular movement are intact, normal conjunctiva, pupils are quite small, almost pinpoint do not constrict further to light; lungs are clear to auscultation, respirations are non-labored, breath sounds are equal. No wheezes or crackles. No focal neurological deficits observed. Does not speak. Withdraws to noxious stimuli including my cold hands, moves all 4 extremities. When I ask him to open is eyes he raises his eyebrows but does not open his eyes. Otherwise does not seem to follow commands.Resident presenting with lethargy, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Poor recent by mouth intake in the setting of severe dementia with recent stroke, along with institution of [MEDICATION NAME] which can be sedating. Very broad workup instituted including laboratory studies with ABG (Arterial Blood Gas) and drug screen, CT (Computerized [NAME]ography) of head, chest x-fay, and EKG (Electrocardiogram). He was found to have detailed duration which was quite apparent clinically, with acute kidney injury and [MEDICAL CONDITION]. Mild leukocytosis but is afebrile with no signs of infection on exam or laboratory workup. His ABG is normal, he is not hypercarbic. No evidence of hemorrhage or infarct on his CT. He was treated with 2 L of normal saline bolus here as he is did have some further episodes of [MEDICAL CONDITION]. I think this is due to profound dehydration. He is very fluid responsive. He is catheterized for urine specimen and had very little urine in the bladder. Impression and Plan, Diagnoses: [REDACTED]. 7/23/19, at 8:57 AM, Surveyor informed Administrator-A and Director of Nursing-B of the concern R3's weight loss wasn't addressed, fluid intake wasn't monitored, feeding guidelines were not care planned when R3 was assessed to be at nutritional risk and R3 was hospitalized due to becoming unresponsive and was diagnosed at the hospital with severe dehydration.

Based on record reviews and interviews, the facility did not ensure that 1 of 1 sampled residents (R184) received treatment and care in accordance with professional standards of practice for foot care. The facility did not complete daily foot checks for a Resident (R184) who has the [DIAGNOSES REDACTED]. R184 was observed with scabbed areas to her left shin and dark discolored areas to her feet. These darkened discolored areas were not identified prior to Surveyor's observation and notification to the facility's wound nurse/Licensed Practical Nurse (LPN-I). The facility did not implement R184's Care Plan that identified R184 is diabetic and the facility would Inspect feet during routine care for open areas, pressure areas, blisters, [MEDICAL CONDITION] or redness. The facility did not implement R184's Care Plan that identified R184 is at risk for skin complications related to limited mobility. The facility did not implement the interventions identified in her SKIN care plan. This is evidenced by: The facility policy entitled, Skin Care Prevention, dated 9/2017, states in part: All residents will receive appropriate care to decrease the risk of skin breakdown. Guideline: 1. The Nursing Department will review all new admissions to put a plan in place for prevention based on the resident's activity level, comorbidities, mental status, risk assessment and other pertinent information. 3. All residents will be evaluated for changes in their skin condition. 6. Unless contraindicated, elevate heels off bed surface and avoid skin to skin contact. 9. Clean skin at time of soiling and at routine intervals. 10. If incontinent, use a topical agent as a moisture barrier. R184's hospital discharge report, dated 3/06/19, showed in part: Hospital Course, R184 has past medical history of [REDACTED]. Psychiatry and clinical psychiatry were consulted for concern of cognitive impairment. Resident (R184) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R184's initial Minimum Data Set (MDS) assessment, dated 3/13/19, indicated that R184 is cognitively intact and requires extensive physical assistance of one staff member for bed movement, transfers, toileting, dressing, and personal hygiene. Section H (Bladder and Bowel), of the MDS indicated that R184 is frequently incontinent of both bowels and bladder and she does not have a toileting program. This initial MDS indicates no foot problems were present. R184's Care Plan, dated 3/06/19, written by Licensed Practical Nurse (LPN-I), states: Skin: at risk for skin complications related to limited mobility, R184 was admitted with a coccyx wound. Interventions include: Assess and document of progress of areas weekly. Assist and encourage R184 to turn and reposition every one to two hours and as needed, offload heels on pillows while in bed, provide skin care after each incontinent episode, skin assessments weekly, treatment as ordered to coccyx, use absorbent pads or briefs that wick and hold moisture, use commercial moisture barrier, and use lift sheet to move patient (of note: R184's community acquired pressure injury to the coccyx healed while in facility). R184's Diabetic Care Plan, dated 3/11/19, states: R184 is at risk for hypo/[MEDICAL CONDITION] related to diabetes. Interventions include: Inspect feet during routine care for open areas, pressure areas, blisters, [MEDICAL CONDITION] or redness. R184's [MEDICAL CONDITIONS] Care Plan, dated 3/11/19, states: R184 is at risk for poor circulation related to the [DIAGNOSES REDACTED]. R184's Activity of Daily Needs (ADL) Care Plan, dated 3/11/19, states: R184 requires assistance with daily care needs related to weakness and frequent falls. Goal Identified as Staff will anticipate and meet all of R184's needs on a daily basis (i.e. clean, dry, groomed, turned and positioned). Interventions include: Assist R184 with ADLs, Keep clean and dry after each incontinent episode, Monitor skin integrity during routine care and report abnormal findings and one person assist with transfers. R184's Care Plan, dated 3/11/19, states: R184 is incontinent of bowel and bladder. Goals identified as R184 will be kept clean, dry and odor free through stay in the facility. Interventions include: Staff to check and change and offer toileting every two hours and as needed. R184's Individual Service Plan Report, undated, states: R184 needs to be assisted with ADLs and is a one person assist for transfers, R184 needs to have her heels offloaded on pillows while in bed and for toileting staff are to check and change and offer toileting every two hours and as needed. On 3/26/19 at 6:54 AM, Surveyor observed R184 in her bedroom. The room had a strong smell of urine. R184 was sleeping in bed fully dressed with the clothing from the previous day. R184's heels were resting on the bed. The facility failed to float R184's heels and to keep her clean and dry. R184 was soaked in urine sleeping in the same clothing from the previous day. The facility failed to provide clean bedding, to float R184's heels, and to provide check and change care every two hours and as needed keeping her clean and dry from the time RN-K observed R184 at the start of third shift. R184 was left in bed without assistance from 10-10:30 PM to 6:59 AM. On 3/26/19 at 7:11 AM, Surveyor observed Certified Nursing Assistant (CNA)-Q assist R184 from her room with a wheelchair to the shower room. CNA-Q notes that R184 smells strong of urine and her clothing is completely soiled up to her shoulders. Surveyor observed CNA-Q undress R184 where Surveyor observed R184 had multiple scabbed areas to her left shin, blackened area to the side of the left foot and her great toe was noted to be dark and blackened. On 3/26/19 at 10:28 AM, Surveyor interviewed LPN-I who notes she is the facility's wound nurse. LPN-I notes that R184 was admitted with Moisture Associated Skin Damage (MASD) that resolved on 3/18/19. LPN-I notes that the nurses do diabetic foot checks and that R184 is on the list to see podiatry. I (LPN-I) do not think R184 is aware when she is incontinent, she needs cognitive assistance. At 10:33 AM Surveyor and LPN-I observed R184 to look at the blackened areas noted to her feet. LPN-I notes that R184's CNA informed her that R184 had pus coming from her great toe and she ordered [MEDICATION NAME] to be applied to the toe two times every day. LPN-I observed R184's left outer foot near the heel noting on R184's side of the left foot there is a discolored area that maybe pressure and is unstageable. R184 stated, OW when the area was touched. The left foot inner side by the heel has an open area that is purple. The right foot, second toe is purple with a large toenail. LPN-I noted the nurses are supposed to do foot checks every shift. Surveyor asked if there are any noted descriptions of R184's feet. LPN-I replied, I don't know and I will have to check on that, maybe on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). Surveyor observed the MAR and TAR for 03/2019 and no information related to R184's feet was noted in the MAR or TAR and no orders were noted to complete diabetic foot checks were found. On 3/26/19 at 12:33 PM, Surveyor interviewed DON-B who noted that R184 is at risk for pressure injuries and we should have done diabetic foot checks on her every day. I (DON-B)will have the wound doctor look at her feet today. I (DON-B) looked at R184's feet and I believe R184's heel and toe areas are diabetic injuries. If we had done the diabetic foot checks they would be found in the TAR and I have already looked at R184's TAR and the foot checks are not there. On 3/26/19 at 2:13 PM, Surveyor observed R184 in bed sleeping. R184's heels are resting on the bed, not being floated as identified in her Care Plan. On 3/27/19 at 7:15 AM, Surveyor interviewed LPN-I who stated that she goes with the wound Medical Doctor (MD). The Wound MD came in yesterday to look at R184 and he said the wound to R184's feet are not pressure injuries but they are diabetic wounds. Surveyor asked if LPN-I has any full body checks that were completed for R184. LPN-I noted that on 3/14/19, R184's notes show that R184's skin is intact and no information was documented on the condition of her feet. LPN-I notes that 3/26/19 was the first time the facility had noted the condition of R184's feet. R184 is considered at risk for pressure injuries and breakdown and she is a diabetic also putting her at risk. Surveyor asked LPN-I what is the facility policy related to diabetic foot checks. LPN-I stated she did not know and that she does not have access to the facility's policies. On 3/27/19 at 7:50 AM, Surveyor interviewed DON-B who stated that diabetic foot checks should be done every night and full body skin checks every week. The Wound MD notes two areas of concern on R184's left foot. The Wound MD did not note anything related to R184's right foot. DON-B notes the facility has no policies for diabetic foot checks. Of Note: Surveyor observed three areas on R184's left foot that were purple in color, tender, and with a break in the skin and one area on the second toe of the right foot that was dark in color. On 3/27/19 at 10:47 AM, Surveyor observed DON-B assess R184 to get an accurate assessment of her feet. R184 slowly removed her socks on her own noting her feet hurt. DON-B observes R184 right foot stating, she has a callous across the top of the lateral aspect of the second toe. DON-B stated the Wound MD did not include any information related to R184's right foot and her 2nd toe. R184 notes her toe is painful when touched. DON-B observed R184's left foot stating the Wound MD had to cut back part of the great toe due to an ingrown toenail. R184's left heel medial aspect is very painful to touch with a darkened area. The lateral aspect of the left heel has a darkened area that is not painful. It is approximately 1.5 X 1cm. I (DON-B) did not see any assessment by the wound MD to this area. R184 has multiple small circular scabbed areas with darkened pigmented skin on her left shin. The area to R184's left great toe looks to be a chronic area. Surveyor notes that R184 is in bed and her feet are not floated with a pillow as per her care plan. DON-B stated she will come back down with a pillow to keep her heels off the bed. The facility did not initiate diabetic foot checks for R184 when she admitted to the facility. The facility identified in her care plan that she is diabetic and at risk for skin breakdown. R184 admitted to the facility on [DATE] with no documented diabetic wounds to her feet. On 3/26/19 Surveyor observed four areas on R184's feet that were darkened in color some of them that were painful to the touch. The Wound MD assessed R184's left foot and noted two of the three areas identifying R184 had diabetic wounds to her feet. R184's feet were not floated in bed and she was not assisted in turning and repositioned every one to two hours as per her plan of care.

Based on observation, interview, and record review, the facility did not provide an environment in which residents were free from neglect for 1 of 5 sampled residents (R184). * R184 was observed sleeping in a bed directly on the mattress without sheets or a blanket. The nurse indicated that at the beginning of 3rd shift he instructed a Certified Nursing Assistant (CNA) to provide incontinent cares and to place linen on R184's bed. R184 was fully clothed and saturated in urine. Findings include: R184's hospital discharge report, dated 3/06/19, showed in part: Hospital Course, R184 has past medical history of [REDACTED]. Psychiatry and clinical psychiatry were consulted for concern of cognitive impairment. R184 was prescribed with a neurocognitive disorder. Clinical psychology found R184 to be unable to receive and process information, unable to utilize logic and reasoning, lacking capacity for medical decisions. R184's sister was R184's preferred power of attorney which was activated during this hospitalization . Resident (R184) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R184's initial Minimum Data Set (MDS) assessment, dated 3/13/19, indicated that R184 is cognitively intact and requires extensive physical assistance of one staff member for bed movement, transfers, toileting, dressing, and personal hygiene. Section H, of the MDS indicated that R184 is frequently incontinent of both bowels and bladder and she does not have a toileting program. R184's Care Plan, dated 3/06/19, written by Licensed Practical Nurse (LPN-I), states: Skin: at risk for skin complications related to limited mobility, R184 was admitted with a coccyx wound. Interventions include: . provide skin care after each incontinent episode, use absorbent pads or briefs that wick and hold moisture, use commercial moisture barrier, and use lift sheet to move patient. R184's Care Plan, dated 3/11/19, states: R184 requires assistance with daily care needs related to weakness and frequent falls. Goal Identified as Staff will anticipate and meet all of R184's needs on a daily basis (i.e. clean, dry, groomed, turned and positioned). Interventions include: Assist R184 with Activities of Daily Living (ADLs), Keep clean and dry after each incontinent episode, and assist with transfers. R184's Care Plan, dated 3/11/19, states: R184 is incontinent of bowel and bladder. Goals identified as R184 will be kept clean, dry and odor free through stay in the facility. Interventions include: Staff to check and change and offer toileting every two hours and as needed. On 3/25/19 at 12:05 PM, Surveyor interviewed Resident (R185) who requested to speak with Surveyor. R185 was concerned that her roommate R184 is soiling herself and the staff are not checking on her every two hours. R185 stated R184 did have a fall mat next to her bed but they removed it because it was soaked in urine. I (R185) am living next to a resident that urinates all over. I (R185) am unable to come home to my room and rest due to the smell of urine. R185 requested that Surveyor come to her room early in the morning to see how R184 is being treated. On 3/26/19 at 6:54 AM, Surveyor observed R184 in bed with a strong smell of urine coming from the bed. R184 was lying on a bare mattress. No sheets or blankets were used to cover R184. R184 was still fully clothed from the previous day. R184 awaked and rolled to the side and Surveyor observed that R184's bed was saturated in urine and it was pooling underneath her. At 6:57 AM, Surveyor asked LPN-W to come down to R184's room. In R184's room LPN-W notes that there is a strong smell of urine from the room and that R184 is in bed without any linens. LPN-W notes that she just arrived for her shift and that Registered Nurse (RN-K) was working third shift last night. At 6:59 AM, Surveyor interviewed RN-K in R184's room and RN-K observed that R184 is lying in a pool of urine in a bed without any linens. RN-K notes that he directed Certified Nursing Assistant (CNA-J) at the beginning of third shift sometime between 10-10:30 PM to assist putting clean linen on R184's bed since she had no sheets or blankets. R185 was still in bed and stated that R184 has been in bed fully clothed without linens since dinner. At 7:11 AM, Surveyor observed CNA-Q transfer R184 in a wheelchair down to a shower room. CNA-Q notes that R184's clothing that she is wearing is saturated with urine completely up to her shoulders. R184 smells strong of urine and this was noted as soon as I (CNA-Q) walked into her bedroom. The unit has bed linen, but I (CNA-Q) do not know why CNA-J did not make R184's bed last night. On 3/26/19 at 7:26 AM, Surveyor interviewed Director of Nursing (DON-B) in R184's bedroom. DON-B stated, This is extremely unacceptable. I need to go back at least two days and investigate why R184 was like this. DON-B notes that all beds should be made by 10AM unless they are getting a shower and then we strip the bed of linens. I will have to talk to the nurse and CNA and obviously this is an issue. On 3/26/19 at 10:28 AM, Surveyor interviewed LPN-I who notes that R184 is incontinent and really needs help, she is unaware of being wet and needs cognitive assistance. On 3/26/19 at 10:33 AM, Surveyor observed that R184's bed remains without clean linen. On 3/26/19 at 10:43 AM, Surveyor interviewed R184 who stated, I was cold last night, I knew I needed to go to the bathroom but I fell asleep and I did not go to the bathroom. I did want to have sheet and blankets but I did not have any blankets, sheets, or my personal blanket. I came back to my room after breakfast around 9:45 AM and I am waiting to get sheets on my bed so I can lie down. On 3/27/19 at 6:50 AM, Surveyor observed R184 in bed sleeping. A strong smell of urine odor was noted in room. On 3/27/19 at 6:57 AM, Surveyor interviewed CNA-N who stated that R184 rarely turns on her call light. On 3/27/19 at 7:03 AM, Surveyor interviewed RN-K who notes that R184 was incontinent of urine during the night and that CNA-J did her last rounds around 4 or 5AM. On 3/27/19 at 7:05 AM, Surveyor interviewed CNA-L who noted that R184 does not ask for assistance by using her call light and that he does not know how R184 is this morning because he did not receive report from the 3rd shift staff. CNA-L notes that R184 has not been changed as of yet this morning. On 3/27/19 at 9:19 AM, Surveyor interviewed CNA-T who notes that she assisted R184 up and out of bed this morning and she was heavily soiled. R184 had a brief on that was soaked and her bedding was wet and I had to strip her bed. On 3/27/19 at 9:21 AM, Surveyor interviewed R184 who stated, When I am in my bedroom and need help I would call for them with my telephone. If I was in bed and needed help I don't know how to reach staff I have never done that before. If the staff were walking down the hall I would go and tap them on the shoulder. In an emergency I would scream to get staff's attention. On 3/27/19 at 9:25 AM, Surveyor interviewed LPN-U who stated, R184 is alert and oriented X2. R184 is confused and forgetful at times needing reminders. R184 is not an accurate reporter. On 3/27/19 at 2:12 PM, Surveyor interviewed Nursing Home Administrator (NHA-A) and DON-B related to the investigation into R184 being found in bed on 3/26/19 heavily soiled and without sheets or blankets on the bed. DON-B notes they are waiting on investigations and they need to talk to the 3rd shift CNA. Surveyor informed NHA-A and DON-B that the concern related to R184 being left in bed without clean linen and being heavily soiled that the concern is due to neglect and asked if a self-report investigation was initiated. NHA-A stated he has not initiated a self-report but will now. The Facility schedule shows that on 3/25/19 and 3/26/19 that CNA-J worked in the facility on 3rd shift as one of the four assigned CNAs. The facility did not ensure that all residents (R184) received appropriate quality care when on 3/25/19, RN-K observed that R184 was in bed fully clothed without any sheets or blankets on her bed at the start of third shift between 10-10:30 PM. Surveyor observed on 3/26/19, at 6:54 AM that R184 was still in bed fully clothed, heavily soiled in a pool of urine, without any bedding (sheets or blankets) on her bed. The facility staff identified that R184 does not or rarely would use her call light.

Based upon interview and record review, the Facility did not operationalize its policy and procedure for abuse, mistreatment, neglect, misappropriation of resident property, and informing local law enforcement for 1 of 3 (R7) allegations reviewed. * R12 was found holding R7's penis on 8/20/17. Approximately 10 minutes before this incident, R12 had reported to LPN-H that he had had sex with R7 the night before and was going to do it again. Despite reporting this, LPN-H left R12 in the room alone with R7. Approximately ten minutes later, staff found R12 standing at R7's bed holding R7's penis. Law enforcement was not notified after R12's admission of sexually assaulting R7 or after the witnessed sexual assault of R12 to R7. *R12 was moved to a private room a couple hours later and by 6:00 a.m., the beginning of day shift, R12 was at most on 15 minute checks for supervision, per the LPN attending to him that day. Other residents were not protected from possible sexual assault of R12 with 15 minute checks as the witnessed incident between R12 and R7 happened in less than 10 minutes after R12 had made his planned action known. * The facility self-report was not thorough and did not include a statement from CNA-G who was an eye witness of the actual sexual abuse and who reported the initial admission of sexual abuse by R12 to R7. The self- report investigation contained no information regarding R12's statements of previous sexual activity with R7 or his intention to have more sexual activity with R7. In addition, the Administrator was not aware of R12's statements before the actual witnessed sexual assault until the Surveyor brought it to his attention. The Facility's failure to operationalize its policies and procedures related to abuse prevention by failing to prevent sexual abuse to R7, failing to contact law enforcement, failing to thoroughly investigate an allegation of abuse, and failing to put a plan in place to protect other residents from potential abuse created a finding of Immediate Jeopardy beginning on 8/20/17. Administrator-A and DON (Director of Nursing)-B were informed of the Immediate Jeopardy on 9/14/17 at 3:15 p.m. The Immediate Jeopardy was removed on 9/14/17 when the Facility implemented an action plan related to the prevention and reporting of resident abuse. The deficient practice continues at a scope/severity of E (potential for harm that is not immediate jeopardy/pattern) as the facility continues to implement its action plan. Findings include: On 9/13/17, the facility's policy for Abuse and Neglect prevention was reviewed with a date of 2/7/17 and read: Sexual Abuse includes but is not limited to sexual harassment, sexual coercion, or sexual assault. Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches and placement, considering his or her safety, as well as the safety of other residents. Including, but not limited to separation of the residents. Investigation procedures: The investigator at a minimum will attempt to interview the person who reported the incident and anyone to have direct knowledge of the incident. Informing Local Law Enforcement: The facility shall contact local law enforcement in the following situations: Sexual abuse of a resident by a staff member, another resident, or visitor. Failure to operationalize policies and procedures to keep residents free from abuse R12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R12 was admitted being responsible for himself and able to make his own decisions. R12's most recent Minimum (MDS) data set [DATE] indicated that R12 had a Brief Interview for Mental Status score =9 (moderate impairment). R12's medical record did not indicate any sexual behaviors directed towards others before 8/20/17. R7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R7's most recent Minimum (MDS) data set [DATE] indicated that R7 had long and short term memory impairment and was unable to complete the Brief Interview for Mental Status, meaning he is severely cognitively impaired. On 9/13/17 a facility self- report was reviewed involving R7 and R12. The self-report indicated that R12 was observed holding R7's penis on 8/20/17 at 4:30 a.m. On 9/14/17 at 10:20 a.m. CNA-G was interviewed and indicated on 8/20/17 at about 3:30 a.m. she was doing rounds and went into (R12's) room and (R12) told her he had sex with him and pointed to (R7). CNA-G indicated she reported this to LPN-H right away. CNA-G stated LPN-H went down to talk to (R12) and she continued her rounds. On 9/14/17 at 8:10 a.m., Licensed Practical Nurse (LPN)-H was interviewed via telephone and indicated that on 8/20/17 at about 3:30 a.m. or 4:00 a.m. Certified Nursing Assistant (CNA)- G came to her and told her that (R12) had told her that he had had sex with him and pointed to (R7). LPN-H indicated she then went down to (R12) and (R7's) room and talked to (R12) who told her he had sex with (R7) last night, it was good and he was going to do it again. LPN-H stated she then left the room and went down to another unit to get some paperwork. LPN-H indicated that she told the nurse from the other unit LPN-E about what (R12) had said. LPN-H indicated that he (R12) was left alone with (R7) after the statements from (R12) that he had sex with (R7) the night before and he was going to do it again. On 9/14/17 at 10:30 a.m., LPN-E was interviewed and indicated that on 8/20/17 at about 3:45 a.m. LPN-H came down to her (LPN-E's) unit for some paperwork. LPN-H told her (LPN-E) what (R12) had said regarding (R7). LPN-E indicated she went down to (R12's) room and saw nobody in (R12's) bed or in the bathroom. LPN-E indicated that the privacy curtain was pulled and when she opened it she saw (R12) standing over (R7) with (R7's) penis pulled out of the side of his brief and (R12's) hands on (R7's) penis. LPN-E indicated no other staff was in the room. LPN-E indicated she called for CNA-G who was in the hallway to come into the room. LPN-E then gave instructions to CNA-G that (R12) had to be 1 to 1. CNA-G indicated on 9/14/17 at 10:20 a.m. that LPN-E called for her from (R12's) room about 10 minutes later from when she had last been in the room. CNA-G indicated she went into (R12) and (R7's) room and found (R12) standing over (R7) with (R7's) penis in his hand. LPN-H stated in the telephone interview on 9/14/17 at 8:10 a.m. that after (R12) was found holding (R7's) penis, (R12) was 1 to 1. LPN-H was asked why she thought it was ok to leave (R12) in the room alone with (R7) after (R12's) statements (about previously having sex with (R7)) and LPN-H indicated they were short of staff that night and unable to do 1 to 1 at all times. LPN-H indicated that she called Registered Nurse Manager (RN) - C about 4:30 a.m. LPN-H indicated R12 was moved to a private room on another unit about 5:45 a.m. On 9/12/17, R12's progress notes were reviewed written by LPN-H on 8/20/17 at 4:11 a.m. which read: Called to room by aide approximately 3:45 a.m. (R12) was attempting to get out of bed to go have sex with his roommate. (R12) had taken off his brief and exposed himself to aide. Writer talked to (R12) and explained this is not acceptable behavior. Writer explained the roommate is a married man and has a wife. (R12) stated he was going to do it anyway. (R12) stated he had sex last night with the roommate and it was good. (R12) knows how to turn off his bed alarm. Aide reentered (R12's) room a short while later and found (R12) bedside at his roommate's bed attempting to grab his (R7's) penis. (R12) had turned off his bed alarm. Night shift is attempting to monitor resident one on one until end of shift. R12's progress notes indicated that R12 was sent to the hospital on [DATE] for a change in condition and did not return until 9/18/17. On 9/13/17 at 2:00 p.m. RN-C was interviewed and stated she was on call on 8/20/17 and received a call from night shift. RN-C reported she came to the building at about 5:45 a.m. RN-C indicated she assessed R7 and he had no signs that he had been sexually assaulted. RN-C indicated that she did not have any training in sexual assault assessment/investigation but that she would know if something happened. R7's progress notes written by RN-C at 8:42 a.m. read: Writer noted (R7's) roommate unfasten (R7's) depend and is observed by night shift CNA touching (R7's) penis. (R7) is assessed by night nurse noting no awareness of incident or injuries. Writer updated (R7's) primary care physician, no new orders received and Family Care via voicemail. Interdisciplinary Team will continue to follow progress. No other entries up to 9/12/17 were made in (R7's) medical record regarding continuous assessment and monitoring for possible effects of abuse were made. No care plan was developed for abuse monitoring after 8/20/17. Failure to operationalize policies and procedures to prevent further potential abuse On 9/14/17 at 10:00 a.m., LPN-J was interviewed. LPN-J was the day shift nurse for (R12) on 8/20/17. LPN-J indicated (R12) was 15 minutes checks possibly on 8/20/17 but definitely not on 1 to 1. LPN-J indicated (R12) had no sexual behaviors the rest of her shift but kept asking about going back to his other room. LPN-J indicated she saw (R12) masturbating in his room about 6:00 a.m. Other residents were not protected from possible sexual assault of R12 with 15 minute checks as the witnessed incident between R12 and R7 happened in less than 10 minutes after R12 had made his planned action known. A statement by RN-C in the facility's investigative report read: RN-C notified (R12's) Physician at 7:00 a.m. and told him of the incident. He gave new orders for (R12's) [MEDICAL CONDITION] medications, [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]). He thinks that this is the cause of the behavior. No evidence could be found that the facility put a plan in place to see if the reduction in medication had the desired effect until (R12's) discharge on 8/22/17. On 9/13/17 at 2:00 p.m., RN-C was interviewed. RN-C indicated she did not call the police because she didn't think anything serious happened. Failure to operationalize policies and procedures to contact law enforcement On 9/14/17 at 8:10 a.m., Licensed Practical Nurse (LPN)-H was interviewed via telephone. LPN-H stated she did not call the police as it was not her place and RN-C took over. On 9/14/17 at 10:20 a.m., CNA-G was interviewed. CNA-G indicated she did not call the police and did not feel she would be the one to do that because she is just a CNA. On 9/14/17 at 10:30 a.m., LPN-E was interviewed. LPN-E indicated that she would not call the police and would let someone else do that. Failure to operationalize policies and procedures to thoroughly investigate On 9/12/17, the facility's self -report was reviewed. No statement from CNA- G was included in the investigation. Furthermore, the statement from LPN-H was incomplete and did not describe the time frame before R12 was found holding R7's penis and was telling LPN-H he had sex with R7 the night before and was going to do it again. Nowhere in any of the investigative statements was there information pertaining to R12's statements made before the actual witnessed assault. On 9/13/17 at 1:30 p.m., Administrator-A was interviewed and indicated he had not read the progress note in R12's chart that indicated R12 had told LPN-H he had sex with R7 the night before and he was going to do it again. Administrator-A indicated if he would have known R12 had said he had sex with R7 he would have expected R7 to be sent out for evaluation. No further information was provided as to why the facility did not ensure why its policies and procedures were not operationalized. The facility's failure to operationalize abuse policies and procedures for R7 and other residents created a situation of Immediate Jeopardy that was removed on 9/17/17 when the facility implemented the following action plan; 1. Policies and Procedures related to abuse were reviewed and found to be adequate and will be followed in its entirety. 2. All staff was in serviced on Abuse and Neglect policy, Resident to Resident Altercation Policy, and Elder Justice Act Reporting Requirements. All staff not trained by 9/14/17 will not be allowed to work until trained. 3. The facility Administrator will be responsible for ensuring these incidents are reported and thoroughly investigated. 4. The facility Administrator will be responsible for ensuring that increased supervision via 15 minute checks and 1:1 supervision is enacted when indicated and that the police are notified of a allegations. 5. The facility QA (Quality Assurance) committee will review all incidents in order to identify any noncompliance and ensure policies and procedures are being followed. The facility Administrator will be responsible for reporting this information to the QA committee and for implementing ongoing preventative measures based on input of the committee 6. Resident's identified are being carefully monitored by staff.

Based on interview and record review, the facility did not ensure that 1 (R7) of 15 residents reviewed was free of sexual abuse from other residents. * R12 was found holding R7's penis on 8/20/17. Approximately 10 minutes before this incident occurring, R12 had reported to LPN-H that he had had sex with R7 the night before and was going to do it again. Despite reporting this, R12 was left in the room alone with R7. Approximately 10 minutes later, staff found R12 holding R7's penis. The Facility's failure to prevent R12 from sexually abusing R7 created a finding of Immediate Jeopardy beginning on 8/20/17. Administrator-A and DON (Director of Nursing)-B were informed of the Immediate Jeopardy on 9/14/17 at 3:15 p.m. The Immediate Jeopardy was removed on 9/17/17. The deficient practice continues at a scope/severity of E (potential for harm that is not immediate jeopardy/pattern) as the facility continues to implement its action plan. Findings include: The facility's policy for Abuse and Neglect prevention with a date of 2/7/17 reads: Sexual Abuse includes but is not limited to sexual harassment, sexual coercion, or sexual assault. R12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R12 was admitted being responsible for himself and able to make his own decisions. R12's most recent Minimum (MDS) data set [DATE] indicated that R12 had a Brief Interview for Mental Status score =9 (moderate impairment). R12's medical record did not indicate any sexual behaviors directed towards others before 8/20/17. R7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R7's most recent Minimum (MDS) data set [DATE] indicated that R7 had long and short term memory impairment and was unable to complete the Brief Interview for Mental Status, meaning he is severely cognitively impaired. On 9/13/17 a facility self- report was reviewed involving R7 and R12. The self-report indicated that R12 was observed holding R7's penis on 8/20/17 at 4:30 a.m. On 9/14/17 at 10:20 a.m. CNA-G was interviewed and indicated on 8/20/17 at about 3:30 a.m. she was doing rounds and went into (R12's) room and (R12) told her he had sex with him and pointed to (R7). CNA-G indicated she reported this to LPN-H right away. CNA-G stated LPN-H went down to talk to (R12) and she continued her rounds. On 9/14/17 at 8:10 a.m., Licensed Practical Nurse (LPN)-H was interviewed via telephone and indicated that on 8/20/17 at about 3:30 a.m. or 4:00 a.m. Certified Nursing Assistant (CNA)- G came to her and told her that (R12) had told her that he had had sex with him and pointed to (R7). LPN-H indicated she then went down to (R12) and (R7's) room and talked to (R12) who told her he had sex with (R7) last night, it was good and he was going to do it again. LPN-H stated she then left the room and went down to another unit to get some paperwork. LPN-H indicated that she told the nurse from the other unit LPN-E about what (R12) had said. LPN-H indicated that he (R12) was left alone with (R7) after the statements from (R12) that he had sex with (R7) the night before and he was going to do it again. On 9/14/17 at 10:30 a.m., LPN-E was interviewed and indicated that on 8/20/17 at about 3:45 a.m. LPN-H came down to her (LPN-E's) unit for some paperwork. LPN-H told her (LPN-E) what (R12) had said regarding (R7). LPN-E indicated she went down to (R12's) room and saw nobody in (R12's) bed or in the bathroom. LPN-E indicated that the privacy curtain was pulled and when she opened it she saw (R12) standing over (R7) with (R7's) penis pulled out of the side of his brief and (R12's) hands on (R7's) penis. LPN-E indicated no other staff was in the room. LPN-E indicated she called for CNA-G who was in the hallway to come into the room. LPN-E then gave instructions to CNA-G that (R12) had to be 1 to 1. CNA-G indicated on 9/14/17 at 10:20 a.m. that LPN-E called for her from (R12's) room about 10 minutes later from when she had last been in the room. CNA-G indicated she went into (R12) and (R7's) room and found (R12) standing over (R7) with (R7's) penis in his hand. LPN-H stated in the telephone interview on 9/14/17 at 8:10 a.m., that after (R12) was found holding (R7's) penis, (R12) was 1 to 1. LPN-H was asked why she thought it was ok to leave (R12) in the room alone with (R7) after (R12's) statements (about previously having sex with (R7)) and LPN-H indicated they were short of staff that night and unable to do 1 to 1 at all times. LPN-H indicated that she called Registered Nurse Manager (RN) - C about 4:30 a.m. LPN-H indicated R12 was moved to a private room on another unit about 5:45 a.m. On 9/12/17, R12's progress notes were reviewed written by LPN-H on 8/20/17 at 4:11 a.m. which read: Called to room by aide approximately 3:45 a.m. (R12) was attempting to get out of bed to go have sex with his roommate. (R12) had taken off his brief and exposed himself to aide. Writer talked to (R12) and explained this is not acceptable behavior. Writer explained the roommate is a married man and has a wife. (R12) stated he was going to do it anyway. (R12) stated he had sex last night with the roommate and it was good. (R12) knows how to turn off his bed alarm. Aide reentered (R12's) room a short while later and found (R12) bedside at his roommate's bed attempting to grab his (R7's) penis. (R12) had turned off his bed alarm. Night shift is attempting to monitor resident one on one until end of shift. R12's progress notes indicated that R12 was sent to the hospital on [DATE] for a change in condition and did not return until 9/18/17. On 9/13/17 at 2:00 p.m. RN-C was interviewed and stated she was on call on 8/20/17 and received a call from night shift. RN-C reported she came to the building at about 5:45 a.m. RN-C indicated she did not call the police because she didn't think anything serious happened. RN-C indicated she assessed R7 and he had no signs that he had been sexually assaulted. RN-C indicated that she did not have any training in sexual assault assessment/investigation but that she would know if something happened. R7's progress notes written by RN-C at 8:42 a.m. read: Writer noted (R7's) roommate unfasten (R7's) depend and is observed by night shift CNA touching (R7's) penis. (R7) is assessed by night nurse noting no awareness of incident or injuries. Writer updated (R7's) primary care physician, no new orders received and Family Care via voicemail. Interdisciplinary Team will continue to follow progress. No other entries up to 9/12/17 were made in (R7's) medical record regarding continuous assessment and monitoring for possible effects of abuse were made. No care plan was developed for abuse monitoring after 8/20/17. On 9/14/17 at 10:00 a.m., LPN-J was interviewed. LPN-J was the day shift nurse for (R12) on 8/20/17. LPN-J indicated (R12) was 15 minutes checks possibly on 8/20/17 but definitely not on 1 to 1. LPN-J indicated (R12) had no sexual behaviors the rest of her shift but kept asking about going back to his other room. LPN-J indicated she saw (R12) masturbating in his room about 6:00 a.m. A statement by RN-C in the facility's investigative report read: RN-C notified (R12's) Physician at 7:00 a.m. and told him of the incident. He gave new orders for (R12's) [MEDICAL CONDITION] medications, [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]). He thinks that this is the cause of the behavior. No evidence could be found that the facility put a plan in place to see if the reduction in medication had the desired effect until (R12's) discharge on 8/22/17. On 9/13/17 the information for the drug [MEDICATION NAME] on the website drugs.com was reviewed. Under possible side effects lists: increased interest in sexual ability, desire, drive, or performance. No further information was provided as to why the facility did not ensure that (R7) was free of sexual abuse from (R12). The facility's failure to prevent abuse to (R7) created a situation of Immediate Jeopardy that was removed on 9/17/17 when the facility implemented the following action plan; 1. An abuse and neglect screening tool was completed on all residents. The screening will be completed upon admission, quarterly, upon change of condition and as needed. 2. Any residents identified as vulnerable to abuse will have appropriate care plans as needed in order to address those individual safety needs. 3. R12 and R7 have been assessed or will be assessed prior to readmission 4. The facility QAPI (Quality Assurance Performance Improvement) committee will review all resident screens that trigger vulnerable residents to ensure care plans remain appropriate for those individuals. Cross reference F225 and F226.

Based on record review and staff interview, facility staff did not thoroughly investigate, contact law enforcement, or prevent abuse for one resident (R7) involving sexual abuse, nor prevent the potential for further abuse toward other residents, for 1 out of 3 investigations reviewed. * R12 was found holding R7's penis on 8/20/17. Approximately 10 minutes before this incident, R12 had reported to LPN-H that he had had sex with R7 the night before and was going to do it again. Despite reporting this, LPN-H left R12 in the room alone with R7. Approximately ten minutes later, staff found R12 standing at R7's bed holding R7's penis. Law enforcement was not notified after R12's admission of sexually assaulting R7 or after the witnessed sexual assault of R12 to R7. *R12 was moved to a private room a couple hours later and by 6:00 a.m., the beginning of day shift, R12 was at most on 15 minute checks for supervision, per the LPN attending to him that day. Other residents were not protected from possible sexual assault of R12 with 15 minute checks as the witnessed incident between R12 and R7 happened in less than 10 minutes after R12 had made his planned action known. * The facility self-report was not thorough and did not include a statement from CNA-G who was an eye witness of the actual sexual abuse and who reported the initial admission of sexual abuse by R12 to R7. The self- report investigation contained no information regarding R12's statements of previous sexual activity with R7 or his intention to have more sexual activity with R7. In addition, the Administrator was not aware of R12's statements before the actual witnessed sexual assault until the Surveyor brought it to his attention. The Facility's failure to ensure that all allegations of abuse were adequately investigated in order to prevent sexual abuse to R7, the failure of the facility to ensure law enforcement was notified, and failing to put a plan in place to protect other residents from potential abuse created a finding of Immediate Jeopardy beginning on 8/20/17. Administrator-A and DON (Director of Nursing)-B were informed of the Immediate Jeopardy on 9/14/17 at 3:15 p.m. The Immediate Jeopardy was removed on 9/14/17 when the Facility implemented an action plan related to the prevention and reporting of resident abuse. The deficient practice continues at a scope/severity of E (potential for harm that is not immediate jeopardy/pattern) as the facility continues to implement its action plan. Findings include: On 9/13/17, the facility's policy for Abuse and Neglect prevention was reviewed with a date of 2/7/17 and read: Sexual Abuse includes but is not limited to sexual harassment, sexual coercion, or sexual assault. Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches and placement, considering his or her safety, as well as the safety of other residents. Including, but not limited to separation of the residents. Investigation procedures: The investigator at a minimum will attempt to interview the person who reported the incident and anyone to have direct knowledge of the incident. Informing Local Law Enforcement: The facility shall contact local law enforcement in the following situations: Sexual abuse of a resident by a staff member, another resident, or visitor. R12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R12 was admitted being responsible for himself and able to make his own decisions. R12's most recent Minimum (MDS) data set [DATE] indicated that R12 had a Brief Interview for Mental Status score =9 (moderate impairment). R12's medical record did not indicate any sexual behaviors directed towards others before 8/20/17. R7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R7's most recent Minimum (MDS) data set [DATE] indicated that R7 had long and short term memory impairment and was unable to complete the Brief Interview for Mental Status, meaning he is severely cognitively impaired. On 9/13/17 a facility self- report was reviewed involving R7 and R12. The self-report indicated that R12 was observed holding R7's penis on 8/20/17 at 4:30 a.m. On 9/14/17 at 10:20 a.m. CNA-G was interviewed and indicated on 8/20/17 at about 3:30 a.m. she was doing rounds and went into (R12's) room and (R12) told her he had sex with him and pointed to (R7). CNA-G indicated she reported this to LPN-H right away. CNA-G stated LPN-H went down to talk to (R12) and she continued her rounds. On 9/14/17 at 8:10 a.m., Licensed Practical Nurse (LPN)-H was interviewed via telephone and indicated that on 8/20/17 at about 3:30 a.m. or 4:00 a.m. Certified Nursing Assistant (CNA)- G came to her and told her that (R12) had told her that he had had sex with him and pointed to (R7). LPN-H indicated she then went down to (R12) and (R7's) room and talked to (R12) who told her he had sex with (R7) last night, it was good and he was going to do it again. LPN-H stated she then left the room and went down to another unit to get some paperwork. LPN-H indicated that she told the nurse from the other unit LPN-E about what (R12) had said. LPN-H indicated that he (R12) was left alone with (R7) after the statements from (R12) that he had sex with (R7) the night before and he was going to do it again. On 9/14/17 at 10:30 a.m., LPN-E was interviewed and indicated that on 8/20/17 at about 3:45 a.m. LPN-H came down to her (LPN-E's) unit for some paperwork. LPN-H told her (LPN-E) what (R12) had said regarding (R7). LPN-E indicated she went down to (R12's) room and saw nobody in (R12's) bed or in the bathroom. LPN-E indicated that the privacy curtain was pulled and when she opened it she saw (R12) standing over (R7) with (R7's) penis pulled out of the side of his brief and (R12's) hands on (R7's) penis. LPN-E indicated no other staff was in the room. LPN-E indicated she called for CNA-G who was in the hallway to come into the room. LPN-E then gave instructions to CNA-G that (R12) had to be 1 to 1. CNA-G indicated on 9/14/17 at 10:20 a.m. that LPN-E called for her from (R12's) room about 10 minutes later from when she had last been in the room. CNA-G indicated she went into (R12) and (R7's) room and found (R12) standing over (R7) with (R7's) penis in his hand. LPN-H stated in the telephone interview on 9/14/17 at 8:10 a.m. that after (R12) was found holding (R7's) penis, (R12) was 1 to 1. LPN-H was asked why she thought it was ok to leave (R12) in the room alone with (R7) after (R12's) statements (about previously having sex with (R7)) and LPN-H indicated they were short of staff that night and unable to do 1 to 1 at all times. LPN-H indicated that she called Registered Nurse Manager (RN) - C about 4:30 a.m. LPN-H indicated R12 was moved to a private room on another unit about 5:45 a.m. On 9/12/17, R12's progress notes were reviewed written by LPN-H on 8/20/17 at 4:11 a.m. which read: Called to room by aide approximately 3:45 a.m. (R12) was attempting to get out of bed to go have sex with his roommate. (R12) had taken off his brief and exposed himself to aide. Writer talked to (R12) and explained this is not acceptable behavior. Writer explained the roommate is a married man and has a wife. (R12) stated he was going to do it anyway. (R12) stated he had sex last night with the roommate and it was good. (R12) knows how to turn off his bed alarm. Aide reentered (R12's) room a short while later and found (R12) bedside at his roommate's bed attempting to grab his (R7's) penis. (R12) had turned off his bed alarm. Night shift is attempting to monitor resident one on one until end of shift. R12's progress notes indicated that R12 was sent to the hospital on [DATE] for a change in condition and did not return until 9/18/17. On 9/13/17 at 2:00 p.m. RN-C was interviewed and stated she was on call on 8/20/17 and received a call from night shift. RN-C reported she came to the building at about 5:45 a.m. RN-C indicated she assessed R7 and he had no signs that he had been sexually assaulted. RN-C indicated that she did not have any training in sexual assault assessment/investigation but that she would know if something happened. R7's progress notes written by RN-C at 8:42 a.m. read: Writer noted (R7's) roommate unfasten (R7's) depend and is observed by night shift CNA touching (R7's) penis. (R7) is assessed by night nurse noting no awareness of incident or injuries. Writer updated (R7's) primary care physician, no new orders received and Family Care via voicemail. Interdisciplinary Team will continue to follow progress. No other entries up to 9/12/17 were made in (R7's) medical record regarding continuous assessment and monitoring for possible effects of abuse were made. No care plan was developed for abuse monitoring after 8/20/17. On 9/14/17 at 10:00 a.m., LPN-J was interviewed. LPN-J was the day shift nurse for (R12) on 8/20/17. LPN-J indicated (R12) was 15 minutes checks possibly on 8/20/17 but definitely not on 1 to 1. LPN-J indicated (R12) had no sexual behaviors the rest of her shift but kept asking about going back to his other room. LPN-J indicated she saw (R12) masturbating in his room about 6:00 a.m. Other residents were not protected from possible sexual assault of R12 with 15 minute checks as the witnessed incident between R12 and R7 happened in less than 10 minutes after R12 had made his planned action known. A statement by RN-C in the facility's investigative report read: RN-C notified (R12's) Physician at 7:00 a.m. and told him of the incident. He gave new orders for (R12's) [MEDICAL CONDITION] medications, [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]). He thinks that this is the cause of the behavior. No evidence could be found that the facility put a plan in place to see if the reduction in medication had the desired effect until (R12's) discharge on 8/22/17. On 9/13/17 at 2:00 p.m., RN-C was interviewed. RN-C indicated she did not call the police because she didn't think anything serious happened. On 9/14/17 at 8:10 a.m., Licensed Practical Nurse (LPN)-H was interviewed via telephone. LPN-H stated she did not call the police as it was not her place and RN-C took over. On 9/14/17 at 10:20 a.m., CNA-G was interviewed. CNA-G indicated she did not call the police and did not feel she would be the one to do that because she is just a CNA. On 9/14/17 at 10:30 a.m., LPN-E was interviewed. LPN-E indicated that she would not call the police and would let someone else do that. On 9/12/17, the facility's self -report was reviewed. No statement from CNA- G was included in the investigation. Furthermore, the statement from LPN-H was incomplete and did not describe the time frame before R12 was found holding R7's penis and was telling LPN-H he had sex with R7 the night before and was going to do it again. Nowhere in any of the investigative statements was there information pertaining to R12's statements made before the actual witnessed assault. On 9/13/17 at 1:30 p.m., Administrator-A was interviewed and indicated he had not read the progress note in R12's chart that indicated R12 had told LPN-H he had sex with R7 the night before and he was going to do it again. Administrator-A indicated if he would have known R12 had said he had sex with R7 he would have expected R7 to be sent out for evaluation. No further information was provided as to why the facility did not complete a thorough investigation, protect facility residents and call law enforcement for a crime. The facility's failure report to law enforcement, to thoroughly investigate, and protect R7 from abuse and other residents from potential abuse created a situation of Immediate Jeopardy that was removed on 9/14/17 when the facility implemented the following action plan; 1. Policies and Procedures related to abuse were reviewed and found to be adequate and will be followed in its entirety. 2. All staff was in serviced on Abuse and Neglect policy, Resident to Resident Altercation Policy, and Elder Justice Act Reporting Requirements. All staff not trained by 9/14/17 will not be allowed to work until trained. 3. The facility Administrator will be responsible for ensuring these incidents are reported and thoroughly investigated. 4. The facility Administrator will be responsible for ensuring that increased supervision via 15 minute checks and 1:1 supervision is enacted when indicated and that the police are notified of a allegations. 5. The facility QA (Quality Assurance) committee will review all incidents in order to identify any noncompliance and ensure policies and procedures are being followed. The facility Administrator will be responsible for reporting this information to the QA committee and for implementing ongoing preventative measures based on input of the committee 6. Residents identified are being carefully monitored by staff.

Based on a complaint received at the Southeastern Regional Office, interviews, and record review the Facility did not ensure that 1 (R6) of 3 Residents received and was administered medications to meet his needs as R6 did not receive Humalog insulin per sliding scale and blood sugar checks every six hours as documented on the hospital profile medication orders signed by the physician 12/7/16 and did not receive Phenobarbital Solution 20/mg/5ml with instructions to give 5 ml via [DEVICE] every 12 hours. According to Pharmore Pharmacist-JJ, the pharmacy did not receive the written Phenobarbital script until 12/14/16. On 12/13/16, the nurses note documents R6 had facial twitching and involuntary movement of eyes resembling seizure activity which lasted one minute. According to the Medication Administration Record, [REDACTED]. On 12/14/16, R6's was sent to the hospital emergency room in a comatose state. R6's blood glucose was 1300. The Facility's failure to ensure that the Facility received and administered medications to meet the needs of R6 created an Immediate Jeopardy situation that began on 12/7/16. On 3/9/17 at 10:26 a.m. Administrator-A and Corporate RN (Registered Nurse)-C were informed of the immediate jeopardy. It was determined that the Facility removed the immediate jeopardy on 12/22/16. The deficient practice continued at a scope/severity level of E (potential for harm that is not immediate jeopardy/pattern) until 1/18/17 when the facility corrected the deficiency. Findings include: The medication error prevention policy and procedure dated 6/2015 under guidelines documents; 1. All new residents will have their medication reconciled upon admission. 2. The reconciliation will occur by the staff reviewing the transfer form and comparing that with hospital MAR (medication administration record). 3. Any medications not on the transfer form, that are on the hospital MAR indicated [REDACTED] 4. The admitting nurse will ask the family, if available, for a list of medications the resident took at home. 5. The nursing staff will provide a list of medications to the resident or receiving facility upon discharge. 6. All residents will be identified for medication pass with two identifiers. If these are both not present, the nurse will take a time out and assure they are present before proceeding. Surveyor reviewed R6's medical record on 3/6/17 to 3/9/17. R6 was admitted into the facility on [DATE]. The hospital discharge summary dated 12/7/16 under discharge [DIAGNOSES REDACTED]. Under hospital course documents, Past medical history significant for *diabetes hypertension sleep apnea was admitted to Columbia Saint(NAME)Hospital with seizures. He was subsequently intubated and sedated. Patient could not be weaned off the vent and required tracheotomy. He was also put on phenobarb coma. He was closely followed by Neurology Neurosurgery because he was [DIAGNOSES REDACTED] and has ventricular peritoneal shunt. Patient required vent weaning and management of his other comorbidities and was transferred to select Specialty Hospital Saint Luke's for ongoing care. Under medications document, Please see reconciliation list. The hospital profile medication orders signed by the physician 12/7/16 page: 1 of 5 (which is listed on top right) documents the following medication; Gentamicin sulfate 0.3% Soln (solution). Under continue Ord (order)? No is circled, Metolazone 2.5 mg. Under continue Ord? Yes is circled, Furosemide 40 mg tabs. Under continue Ord? Yes is circled, Florajen3 caps. Under continue Ord? Yes is circled, Phenobarbital 20 mg/5 ml. Under continue Ord? Yes is circled, Humalog Insulin Sliding scale. Under continue Ord? Yes is circled. On page 2 of 5 includes, *Blood Glucose check with Frequency Every 6 hours. Under Continue Ord? Yes is circled. The medication review report under pharmacy documents; Acetaminophen Elixir 160 mg/5 ml Give 650 mg by mouth every 4 hours as needed for pain with an order date of 12/7/16, Acetylcysteine Solution 20% 4 cc via trach every 4 hours as needed for Dyspena with an order date of 12/7/16, Bisacodyl Suppository 10 mg Insert 1 suppository rectally as needed for constipation with an order date of 12/7/16, Doxazosin Mesylate Tablet 1 mg Give 1 tablet via G tube one time a day for BPH (benign prostatic hyperplasia) with an order date of 12/8/16, Flomax Capsule 0.4 mg (Tamsulosin HCI) Give 1 capsule via [DEVICE] one time a day for benign prostatic hyperplasia with an order date of 12/7/16, Floragen 3 capsule (probiotic product) Give 1 capsule via [DEVICE] two times a day for prophylaxis with an order date of 12/7/16, GlucaGen HypoKit Solution Reconstituted 1 mg (Glucagon HCI) (rDNA) Inject 1 mg intramuscularly) as needed for [DIAGNOSES REDACTED] Give 1 mg IM (intramuscular) as needed for [DIAGNOSES REDACTED] with an order date of 12/7/16, Ipratropium Albuterol solution 0.5-2.5 (3) mg/3ml 3 ml via trach every 4 hours as needed for SOB or wheezing via nebulizer with an order date of 12/7/16, Keppra Tablet 500 mg (Levetiracetam) give 1 tablet via [DEVICE] every 12 hours for seizure disorder with an order date of 12/7/16, Lasix tablet 40 mg (furosemide) give 40 mg via G tube twice a day with an order date of 12/7/16, Latanoprost Solution 0.005% Instill 1 drop in bot eyes at bedtime for glaucoma with an order date of 12/7/16, Lidocaine HCI Gel 2% Apply to stoma site topically as needed for pain with an order date of 12/7/16, Lidocaine HCI Solution 1% 2 cc via trach every 4 hours as needed for cough with an order date of 12/7/16, Metolazone tablet 2.5 mg Give 1 tablet via peg tube one time a day with an order date of 12/7/16, Metolazone tablet 5 mg . Give 5 mg via [DEVICE] one time a day with an order date of 12/7/16, Multiple Vitamin tablet Give 1 tablet via [DEVICE] one time a day for supplementation with an order date of 12/7/16, Nystatin suspension 0 unit/ml Give 5 ml by mouth four times a day for prophylaxis for 3 days swish and swallow with an order date of 12/7/16, Phenobarbital Solution 20 mg/5 ml Give 5 ml via [DEVICE] every 12 hours for seizure disorder with an order date of 12/7/16, Pro-Stat liquid (amino acids-protein hydrolys) Give 30 ml via [DEVICE] two times a day for Prophylaxis Pro Stat sugar free 30 ml BID with an order date of 12/7/16, Vancomycin HCI Suspension Give 250 mg via [DEVICE] every 6 hours for infection with an order date of 12/7/16, Vancomycin HCI Suspension Give 250 mg via G tube every 6 hours for infection until 12/15/16 with an order date of 12/12/16. Phenobarbital Review of the December 2016 MAR indicated [REDACTED]& 2100, 12/10/16 at 0900 & 2100, 12/11/16 at 0900 & 2100, 12/13/16 at 2100, and 12/14/16 at 0900. On 3/9/17 at 10:09 a.m., Surveyor spoke with Pharmacore Pharmacist-JJ on the telephone to inquire when the pharmacy received the order for R6's Phenobarbital. Pharmacore Pharmacist-JJ informed Surveyor that they didn't receive the written script for Phenobarbital until 12/14/16. Surveyor inquired if anyone from the Facility contacted them prior about the medication. Pharmacore Pharmacist-JJ informed Surveyor there is nothing in their system from 12/7/16 until 12/14/16. Pharmacore Pharmacist-JJ explained that the Facility orders are electronic but controlled medication cannot be sent electronically and need to be faxed. Pharmacore Pharmacist-JJ informed Surveyor that R6's Phenobarbital script is written on 12/7/16 but they didn't receive it until 12/14/16. Surveyor is unsure how this Phenobarbital was administered on 12/12/16 at 0900 and 2100 and 12/13/16 at 0900 (as documented in the December MAR) as the script was not faxed to the pharmacy until 12/14/16. Humalog Insulin According to the Medication Administration Record, [REDACTED]. On 3/7/17 at 7:20 a.m., Surveyor interviewed RN (Registered Nurse)-W regarding R6's (12/7/16) admission and medication. RN-W explained that RN-V helped him put the medications into the system. RN-W informed Surveyor that he didn't see the insulin orders and that someone left out the first page with the insulin on it. Surveyor asked RN-W how the Facility became aware that R6 was not receiving his insulin. RN-W informed Surveyor that R6 went back to the hospital (12/14/16) because he was very lethargic and when he was at the hospital they discovered he had a high blood sugar and we had not been giving him his insulin. Surveyor asked RN-W if he noted on the hospital records that R6 has a [DIAGNOSES REDACTED]. RN-W stated that he was trying to do the assessments and RN-V was doing the medications. RN-W stated that the computer system is complicated for him. RN-W informed Surveyor that Prior DON (Director of Nursing)-II educated him and that he apologized to the family as he felt so bad. Surveyor asked RN-W who reviews the paperwork that the hospital sends. RN-W replied, We kind of all do and explained that the admitting nurse does and he was the admitting nurse for R6. RN-W informed Surveyor that he's not so good with the computer and that the [DIAGNOSES REDACTED]. RN-W stated, It was an oversight. Surveyor asked RN-W if he reads all the hospital paper work that is sent. RN-W replied, All that I can that time allows. On 3/8/17 at 3:10 p.m., Surveyor interviewed RN-V to inquire how he was involved with R6's (12/7/16) admission. RN-V explained to Surveyor that RN-W asked him to enter R6's orders into the computer. RN-V informed Surveyor that he entered the medication from the papers that RN-W had given him and after he completed entering the medication he gave RN-W the papers back. Surveyor asked RN-V who called the doctor to verify the orders. RN-V informed Surveyor that RN-W did and that he was just asked to enter the orders in the computer. On 3/7/17 at 4:12 p.m., Surveyor interviewed RN (Registered Nurse)-F regarding R6 and to inquire about the Facility's system for when a Resident is admitted . RN-F explained that when a Resident is admitted they receive a discharge summary from the hospital and the unit nurse is supposed to go through the papers. The unit nurse is supposed to compare the medication on the discharge summary with the after summary. Surveyor asked RN-F if she reviews new admissions medical records. RN-F informed Surveyor that sometimes as manager she will review the medical records but doesn't do everyone. Surveyor asked RN-F if she reviewed R6's medical record. RN-F replied, I don't recall and then stated, No I didn't audit R6's chart. RN-F informed Surveyor that RN-V was the nurse that helped RN-W. RN-F stated that she believed that RN-V was the nurse that did the orders and RN-W was the nurse on the unit. Surveyor asked RN-F if she was aware that R6 didn't receive the sliding scale insulin. RN-F informed Surveyor that LPN-GG informed her after LPN-GG had received a call from the hospital. RN-F informed Surveyor that Prior DON-II spoke with RN-V and RN-W. Surveyor asked RN-F if she was aware that R6 didn't receive Phenobarbital. RN-F informed Surveyor that she doesn't know about this. Surveyor asked RN-F what should happen if a medication is not available. RN-F explained that the nurse should call the doctor and then the patient could be on the twenty four hour report board. RN-F explained that the nurse's notes get pulled over to the twenty four hour board. Surveyor asked RN-F again if she was notified about R6's Phenobarbital not being available. RN-F replied, I don't remember this. On 3/7/17 at 3:26 p.m., Surveyor interviewed LPN (Licensed Practical Nurse)-GG regarding R6's medication. LPN-GG informed Surveyor that she called Physician-Y on 12/14/16 because R6 didn't have the Phenobarbital. Surveyor asked LPN-GG how staff missed the sliding scale insulin. LPN-GG replied, to be honest he was already here and explained that she had been off for three days. LPN-GG informed Surveyor that there are a lot of distractions when they have to enter a Resident's orders explaining that the phone rings or a Resident or their family wants something. Surveyor asked LPN-GG to explain the process at the Facility after a Resident is admitted regarding their medication. LPN-GG explained that they get the hospital discharge, call the doctor to verify the orders and enter the medications into the computer. LPN-GG informed Surveyor that you can enter the orders and have them sitting & waiting and then after the orders are verified can ok them or not depending on the doctor. Surveyor asked LPN-GG who reviews the hospital paper work? LPN-GG informed Surveyor that RTD (Respiratory Therapy Director)-HH looks at the vent information and we kind of look through them. LPN-GG informed Surveyor that RN (Registered Nurse)-F or Interim DON (Director of Nursing)-B will review the information that day or the next day. On 3/8/17 at 10:09 a.m., Surveyor reviewed Prior DON-II investigation including the plan of correction. This plan of correction documents R6 was admitted to the facility on 12.07.16 with a three-page Discharge Summary and a separate loose paged Medication Reconciliation List. When R6 discharged to the hospital a chart review was conducted for return to hospital prevention. A loose five page Medication Reconciliation List was found. Pages two thru five had whole punches, page one did not. Page one list had a total of six medication one being Insulin. Two RN's participated in the admission process and verified the medication. Unknows (sic) to the RN's page one of the Medication Reconciliation List was missing and therefore not involved in the verified medications. On Bria of Trinity Village paper there is a handwritten note of the following, First page missing all first page meds missing Gentamicin Sulfate Metolazone 2.5 mg Furosemide 40 mg Florajen 3 caps Phenobarbital Insulin Humalog Solution. Surveyor is unable to interview Prior DON-II as she is no longer employed by the Facility to inquire how, if page 1 was missed, five of the medications were on the order sheet and December 2016 MAR but Humalog insulin was not. Subsequent to missing these two medications, R6 experienced changes of condition on 12/13/16 and 12/14/16. 1. The nurse's note dated 12/13/16 documents, Reported to writer pt. (patient) had facial twitching and involuntary movement of eyes resembling seizure activity, lasting about 1. Stat phenobarb level ordered. The nurse's note dated 12/14/16 documents, Res (Resident) alert and responsive non-verbal. No seizure activity noted. Res. Phenobarbital level 9.4 L (low) call placed to pharmacy for medication review and Phenobarbital signed script re-faxed . 2. The nurse's note dated 12/14/16 documents, Non arouse during contact, comatose state, no seizure like activity noted. The nurses note dated 12/14/16 documents, Reported to writer by respiratory therapist that pt's (patients) RR (respiration rate) 40's-50's and decreased O2 (oxygen) sats (saturation) 88-90% on 35% FIO2 (fraction of inspired oxygen). call placed to NP for Physician-Y awaiting call from NP to report change of condition. The respiratory note dated 12/14/16 documents, Pt. send St. Mary's Hospital per Bell Ambulance at 1535 (3:35 p.m.) for eval (evaluation) and tx (treatment). His SPO2 97% on 40% aerosol per TM (trach mask) HR (heart rate) 97bpm (beats per minute) and RR (respiratory rate) 40 bmp which were short and shallow and clear. Pts mentation was unresponsive. The hospital discharge summary for admission date of [DATE] and discharged date of 12/29/16 under discharge [DIAGNOSES REDACTED].>Delirium HTN (hypertension) urgency, HHS (hyperosmolor hyperglycemic state) beta hydroxybutyric acid/BHB negative, DM (diabetes mellitus) 2, Acute Kidney Injury on CKD (chronic kidney disease), Hx (history) of Seizures, Hydocephalus and SHD (structural heart disease) Hypoxemic and Hypercapnic Resp (respiratory) failure. Under hospital discharge summary (12/29/16) under course documents, 77 yo (year old) M (male) with a complex PMH (past medical history) notable for obstructive [DIAGNOSES REDACTED] due to a colloid cyst of the third ventricle post VP (ventriculoperitoneal) shunt, SDH post evacuation, trach and peg tube dependence, seizure disorder, HTN, DM2, and CKD who present to the ED on 12/14/2016 initially for eval and management of a trach tube malfunction, but was found to have HHS with a glucose of 1300 with hypernatremia and acute renal failure. The patient was admitted to the ICU (intensive care unit) for further evaluation and management. Etiology unclear. Unclear if patient was actually receiving insulin at his LTACH facility, some reports suggest he was, other suggest he was not. On 3/9/17 at 7:49 a.m., Surveyor spoke with Physician-Y on the telephone. During this conversation, Physician-Y informed Surveyor that he was not aware that R6 was not receiving Phenobarbital until R6 had a seizure (12/13/16) and ordered the level (12/14/16). Surveyor asked about R6's insulin. Physician-Y informed Surveyor that R6 was on a sliding scale insulin. Surveyor informed Physician-Y that R6 was not receiving the sliding scale at the Facility and that his blood sugar was very high at the hospital. Physician-Y informed Surveyor that EMS gave R6 dextrose in the ambulance. On 3/20/17 at 10:29 a.m., Surveyor received the patient care report from Bell Ambulance with a service date of 12/14/16 under the narrative section documents, Bell 462 dispatched with lights and sirens to Trinity Village for [AGE] year old male trach patient. Upon EMS (emergency medical services) arrival to room [ROOM NUMBER], EMS found client lying unresponsive on a trach mask. Pt. airway patent, he was breathing at adequate rate and depth, and circulation was sufficient (cap refill< (less than) 2 seconds, strong radial pulse, normal skin color, temp (temperature), moisture). Clients unresponsive mental status is normal per facility. According to staff, client has not been a ventilator dependant patient. Pt was seen earlier with rapid, shallow respirations at a rate of 40 breaths per minute. Pt O2 (oxygen) saturation was high 80's and was apparently bradycardic with heart rate of 40. Prior to our arrival, staff changed clients tracheostomy and symptoms seemed to have subsided. Facility requested transport to emergency room for further evaluation. Pt was transferred to cot via bed sheet and he was secured to cot x (times) 5. Pt O2 was transferred via trach mask that was provided PTA (prior to arrival). O2 was set at 10 LPM (liters per minute) in our care. Pt placed on cardiac monitor to show sinus rhythm with no ST changes or ectopy. Blood sugar and axillary temp were taken. Pt had Foley catheter in with 300 ml (milliliter) yellow urine in bag. Full pt. assessment, hx (history) vitals obtained. Vitals wnl (within normal limit). Pt heart rate remained 90-100 BPM (beats per minute) throughout our care and client was satting at 99%. Respirations remained between 18-24 breaths per minute. Pt condition stable and unchanged throughout our care. Pt transported to St Mary's by request and brought to ED (emergency department) in care of RN. Signatures obtained. Surveyor noted there is no evidence in the patient care report that R6 received dextrose. Surveyor noted and as stated above, according to the Hospital discharge summary dated 12/29/16, .on 12/14/16 .was found to have HHS with a glucose of 1300 .patient was admitted to the ICU (intensive care unit) for further evaluation and management. Etiology unclear. Unclear if patient was actually receiving insulin at his LTACH facility, some reports suggest he was, other suggest he was not. Facility failure to provide pharmaceutical services ton ensure accurate acquiring, receiving, and administration of medications created a finding of immediate jeopardy. The Facility removed the immediate jeopardy on 12/22/16 when: * The facility ensured that R6 is currently receiving all medication as ordered. * All nurses were in-serviced prior to the start of their next shift on the facility policy and procedure to obtain medications and proper processing of medication orders including controlled substances, administration of medication and what to do if a medication is not available. * All nurses were in-serviced prior to the start of their next shift on the procedure for processing medication order entry and delivery and what to do in the event medications are not delivered in a timely manner including physician and family notification and back up pharmacy usage. * All MEDICATION ORDERS FOR [REDACTED]. * A nurse manager will conduct chart reviews on all new admissions the following business day. * All nurses were in-serviced prior to the start of their next shift on discharge summaries, medication reconciliation, medication errors, and medication error prevention. * All audit results will be reviewed by the facility Quality Assurance Committee to determine if any further staff education or facility policy changes are needed. Any deficiencies will be corrected immediately and reviewed again by the Quality Assurance Committee monthly. The deficient practice was corrected when the facility did their first Quality Assurance Review on 1/18/17.

Based on a complaint received at the Southeastern Regional Office, interviews, and record review the Facility did not ensure that 1 (R6) of 3 Residents was free of significant medication errors as R6 did not receive the Humalog insulin per sliding scale and blood sugar checks every six hours as documented on the hospital profile medication orders signed by the physician 12/7/16 and did not receive [MEDICATION NAME] Solution 20/mg/5ml with instructions to give 5 ml via [DEVICE] every 12 hours. On 12/13/16 the nurses note documents R6 had facial twitching and involuntary movement of eyes resembling [MEDICAL CONDITION] activity which lasted one minute. On 12/14/16 R6 became comatose with a respiratory rate in the 40s-50s. He was admitted to the hospital in a hyperosmolar hyperglycemic state. The Facility's failure to ensure that R6 was free of significant medication errors created an Immediate Jeopardy situation which began on 12/7/16. On 3/9/17 at 10:26 a.m., Administrator-A and Corporate RN (Registered Nurse)-C were informed of the immediate jeopardy. It was determined that the Facility removed the immediate jeopardy on 12/22/16. The deficient practice continued at a scope/severity level of E (potential for harm that is not immediate jeopardy/pattern) until 1/18/17 when the facility corrected the deficiency. Findings include: Surveyor reviewed R6's medical record on 3/6/17 to 3/9/17. R6 was admitted into the facility from the hospital on [DATE]. While in the hospital, lab values for glucose were: 11/18/16 - 136 11/19/16 - 99 11/20/16 - 124 11/21/16 - 113 Glucose range is 70 to 110. [MEDICATION NAME] - 11. [MEDICATION NAME] range is 10-30 mcg (microgram) per ml (milliliter). Under assessment documents, [MEDICAL CONDITION] disorder and Diabetes type 2. The hospital discharge summary dated 12/7/16 under discharge [DIAGNOSES REDACTED]. Under hospital course documents, Past medical history significant for *diabetes hypertension sleep apnea was admitted to Columbia Saint Mary Hospital with [MEDICAL CONDITION]. He was subsequently intubated and sedated. Patient could not be weaned off the vent and required tracheotomy. He was also put on [MEDICATION NAME] coma. He was closely followed by Neurology Neurosurgery because he was [DIAGNOSES REDACTED] and has ventricular peritoneal shunt. Patient required vent weaning and management of his other comorbidities and was transferred to select Specialty Hospital Saint Luke's for ongoing care. Under medications document, Please see reconciliation list. The hospital profile medication orders signed by the physician 12/7/16 page: 1 of 5 (which is listed on top right) documents the following medications; [MEDICATION NAME] sulfate 0.3% Soln (solution). Under continue Ord (order)? No is circled. [MEDICATION NAME] 2.5 mg. Under continue Ord? Yes is circled. [MEDICATION NAME] 40 mg tabs. Under continue Ord? Yes is circled. Florajen3 caps. Under continue Ord? Yes is circled. [MEDICATION NAME] 20 mg/5 ml. Under continue Ord? Yes is circled. Humalog Insulin Sliding scale Under continue Ord? Yes is circled. On page 2 of 5 includes, *Blood Glucose check with Frequency Every 6 hours. Under Continue Ord? Yes is circled. The medication review report under pharmacy documents; [MEDICATION NAME] 160 mg/5 ml Give 650 mg by mouth every 4 hours as needed for pain with an order date of 12/7/16, [MEDICATION NAME] Solution 20% 4 cc [MEDICAL CONDITION] 4 hours as needed for Dyspena with an order date of 12/7/16, [MEDICATION NAME] Suppository 10 mg Insert 1 suppository rectally as needed for constipation with an order date of 12/7/16, [MEDICATION NAME] Tablet 1 mg Give 1 tablet via G tube one time a day for [MEDICAL CONDITIONS] with an order date of 12/8/16, [MEDICATION NAME] Capsule 0.4 mg (Tamsulosin HCI) Give 1 capsule via [DEVICE] one time a day for [MEDICAL CONDITION] with an order date of 12/7/16, Floragen 3 capsule ([MEDICATION NAME] product) Give 1 capsule via [DEVICE] two times a day for [MEDICATION NAME] with an order date of 12/7/16, [MEDICATION NAME] HypoKit Solution Reconstituted 1 mg ([MEDICATION NAME] HCI) (rDNA) Inject 1 mg intramuscularly) as needed for [DIAGNOSES REDACTED] Give 1 mg IM (intramuscular) as needed for [DIAGNOSES REDACTED] with an order date of 12/7/16, [MEDICATION NAME] solution 0.5-2.5 (3) mg/3ml 3 ml [MEDICAL CONDITION] 4 hours as needed for SOB or wheezing via nebulizer with an order date of 12/7/16, [MEDICATION NAME] Tablet 500 mg (Levetiracetam) give 1 tablet via [DEVICE] every 12 hours for [MEDICAL CONDITION] disorder with an order date of 12/7/16, [MEDICATION NAME] tablet 40 mg ([MEDICATION NAME]) give 40 mg via G tube twice a day with an order date of 12/7/16, Latanoprost Solution 0.005% Instill 1 drop in both eyes at bedtime for [MEDICAL CONDITION] with an order date of 12/7/16, [MEDICATION NAME] HCI Gel 2% Apply to stoma site topically as needed for pain with an order date of 12/7/16, [MEDICATION NAME] HCI Solution 1% 2 cc [MEDICAL CONDITION] 4 hours as needed for cough with an order date of 12/7/16, [MEDICATION NAME] tablet 2.5 mg Give 1 tablet via peg tube one time a day with an order date of 12/7/16, [MEDICATION NAME] tablet 5 mg. Give 5 mg via [DEVICE] one time a day with an order date of 12/7/16, Multiple Vitamin tablet Give 1 tablet via [DEVICE] one time a day for supplementation with an order date of 12/7/16, [MEDICATION NAME] suspension 0 unit/ml Give 5 ml by mouth four times a day for [MEDICATION NAME] for 3 days swish and swallow with an order date of 12/7/16, [MEDICATION NAME] Solution 20 mg/5 ml Give 5 ml via [DEVICE] every 12 hours for [MEDICAL CONDITION] disorder with an order date of 12/7/16, Pro-Stat liquid (amino acids-protein hydrolys) Give 30 ml via [DEVICE] two times a day for [MEDICATION NAME] Pro Stat sugar free 30 ml BID with an order date of 12/7/16, [MEDICATION NAME] HCI Suspension Give 250 mg via [DEVICE] every 6 hours for infection with an order date of 12/7/16, [MEDICATION NAME] HCI Suspension Give 250 mg via G tube every 6 hours for infection until 12/15/16 with an order date of 12/12/16. The nurse's note dated 12/7/16 documents, Res. (Resident) arrived from the hosp (hospital) per ambulance on a stretcher in stable condition. Res. oriented to facility staff and the call light. Orders per Physician-Y will alert pharmacy. [MEDICATION NAME] The eMAR (Medication Administration Record) note dated 12/7/16 documents, [MEDICATION NAME] Solution 20 mg (milligram)/5 ml (milliliter) Give 5 ml via G (gastrostomy) Tube every 12 hours for [MEDICAL CONDITION] Disorder med not here. The eMAR note dated 12/8/16 documents, [MEDICATION NAME] Solution 20/mg/5ml Give 5 ml via [DEVICE] every 12 hours for [MEDICAL CONDITION] Disorder on order. The eMAR note dated 12/9/16 documents, [MEDICATION NAME] Solution 20 mg/5 ml Give 5 ml via [DEVICE] every 12 hours for [MEDICAL CONDITION] Disorder med (medication) not given not available, not on cart. Under [DIAGNOSES REDACTED]. Under plan documents, [MEDICAL CONDITION]. On [MEDICATION NAME] and [MEDICATION NAME]. Goal: Resident will remain [MEDICAL CONDITION] free for the next 3 months. Plan: Continue current medications. Lab levels as needed. In collaboration with Physician-Y and his NP's (nurse practitioner). The eMAR note dated 12/11/16 documents, [MEDICATION NAME] Solution 20mg/5 ml Give 5 ml via [DEVICE] every 12 hours for [MEDICAL CONDITION] Disorder. reorder. The eMAR note dated 12/11/16 documents, [MEDICATION NAME] Solution 20mg/5 ml Give 5 ml via [DEVICE] every 12 hours for [MEDICAL CONDITION] Disorder. on order. Surveyor spoke with Pharmacore Pharmacist-JJ on the telephone on 3/9/17 at 10:09 a.m. to inquire when the pharmacy received the order for R6's [MEDICATION NAME]. Pharmacore Pharmacist-JJ informed Surveyor that they didn't' receive the written script until 12/14/16. Surveyor inquired if anyone from the Facility contacted them prior about the medication. Pharmacore Pharmacist-JJ informed Surveyor there is nothing in their system from 12/7/16 until 12/14/16. The nurse's note dated 12/13/16 documents, Reported to writer pt. (patient) had facial twitching and involuntary movement of eyes resembling [MEDICAL CONDITION] activity, [MEDICATION NAME] about 1. Stat [MEDICATION NAME] level ordered. The eMAR note dated 12/13/16 documents, [MEDICATION NAME] Solution 20mg/5 ml Give 5 ml via [DEVICE] every 12 hours for [MEDICAL CONDITION] Disorder. med not available. The nurse's note dated 12/14/16 documents, Res (Resident) alert and responsive non-verbal. No [MEDICAL CONDITION] activity noted. Res. [MEDICATION NAME] level 9.4 L (low) call placed to pharmacy for medication review and [MEDICATION NAME] signed script re-faxed. Signed script needs to be clarified per MD as it states [MEDICATION NAME] po (by mouth) BID (twice daily) and liquid via peg instructions res. is NPO (nothing by mouth). Pharmacy to contact MD. Skin w/d (warm dry) to touch. ABT (antibiotic) therapy continue for [DIAGNOSES REDACTED]. ([MEDICAL CONDITION]) no adverse reactions noted. No loose stools. Contact isolation maintained. O2 (oxygen) 8L/M (liters per minute) [MEDICAL CONDITION] SpO2 95% no SOB or respiratory distress. HOB (head of bed) elevated 30 degrees tolerating TF (tube feeding) and H2O (water) flush without difficulty. No s/sx (signs symptoms) of hypo/[MEDICAL CONDITION]. Foley catheter patent draining clear yellow urine. T (temperature) 99.8 P (pulse) 92 R (respirations) 20 130/58. The nurse's note dated 12/14/16 documents, Call placed to Physician-Y NP (nurse practitioner) to update on [MEDICATION NAME] order needing clarification. Awaiting return call. The nurse's note dated 12/14/16 documents, Received call from NP-EE for Physician-Y. NP updated on [MEDICATION NAME] level of 9.4. Also informed of [MEDICATION NAME]. needing clarification. NP will clarify order and fax to pharmacy. NOR (new order received) to re check [MEDICATION NAME]. level in 1 week. Writer informed NP of [MEDICATION NAME] level of > (greater than) 0.8 not receiving [MEDICATION NAME] therapy. The eMAR note dated 12/14/16 documents, [MEDICATION NAME] Solution 20mg/5 ml Give 5 ml via [DEVICE] every 12 hours for [MEDICAL CONDITION] Disorder. reordered. Review of the December 2016 MAR indicated [REDACTED]& 2100, 12/10/16 at 0900 & 2100, 12/11/16 at 0900 & 2100, 12/13/16 at 2100, and 12/14/16 at 0900. On 12/12/16 at 0900 & 2100 and 12/13/16 at 0900 the MAR indicated [REDACTED]. Surveyor is unsure how this medication was administered as the script was not faxed to the pharmacy until 12/14/16. On 3/9/17 at 7:49 a.m., Surveyor spoke with Physician-Y on the telephone. During this conversation, Physician-Y informed Surveyor that he was not aware that R6 was not receiving [MEDICATION NAME] until R6 had a [MEDICAL CONDITION] (12/13/16) and ordered the level (12/14/16). Humalog Insulin The nurse who entered R6's medications into the computer system failed to enter the Humalog sliding scale insulin and blood glucose checks. Surveyor noted R6's medication review report and December 2016 MAR (Medication Administration Record) for the time period 12/7/16 to 12/14/16 does not include the Humalog sliding scale and the blood sugar checks. The Optum progress note dated 12/9/16 under Patient History documents, CC/Reason for Admission: [MEDICAL CONDITION], trach. History of Present Illness (HPI): R6 is a 77 y.o. (year old) male who arrived at Trinity with tach to vent unit on 12/7/16. He was hospitalized initially after having a [MEDICAL CONDITION] that did not resolve and was admitted to St. Mary's Milwaukee Hospital. While there he was placed on a vent and was unable to be weaned. He was transferred to Select Specialty hospital on [DATE] where he remained until coming here. His hospital stay is complicated by pneumonia and acute on chronic CKD ([MEDICAL CONDITION]). He has been at Trinity for rehab with last discharge from Trinity on 8/30/16. Before being hospitalized he was living with his son. Staff interviewed and chart reviewed. Under the section assessment and plan for [DIAGNOSES REDACTED]. Under plan documents, Type DM (diabetes mellitus) with CKD. Not currently on antidiabetic agent, previously on various insulins. Goal: Resident will demonstrate stable glycemic control as evidenced by A1C within goal of at or <(less) 80% within the next 6 months. Resident will demonstrate no decrease in GFR in next 3 months. Plan: Renal dose medications as needed. Continue BID (twice daily) BG (blood glucose) checks. Add [MEDICATION NAME] first if BG is elevated. Surveyor noted the 12/9/16 Optum progress note referenced the continuation of BG checks twice daily, yet these were not being done. R6 had a change of condition later in the day on 12/14/16. The nurse's note dated 12/14/16 documents, Non arouse during contact, comatose state, no [MEDICAL CONDITION] activity noted. The nurse's note dated 12/14/16 documents, Reported to writer by respiratory therapist that pt's (patients) RR (respiration rate) 40's-50's and decreased O2 (oxygen) sats (saturation) 88-90% on 35% FIO2 (fraction of inspired oxygen). Call placed to NP for Physician-Y awaiting call from NP to report change of condition. The nurse's note dated 12/14/16 documents NP-FF, Omni NP who is assigned to pt. on unit made aware of change of condition, will page NP-EE to update Physician-Y and get orders to send pt to ER (emergency room ). Orders received, will update all. The respiratory note dated 12/14/16 documents, Pt. send St. Mary's Hospital per Bell Ambulance at 1535 (3:35 p.m.) for eval (evaluation) and tx (treatment). His SPO2 97% on 40% aerosol per TM (trach mask) HR (heart rate) 97bpm (beats per minute) and RR (respiratory rate) 40 bmp which were short and shallow and clear. Pts mentation was unresponsive. The hospital discharge summary for admission date of [DATE] and discharged date of 12/29/16 under discharge [DIAGNOSES REDACTED].>[MEDICAL CONDITIONS](hypertension) urgency, HHS (hyperosmolor hyperglycemic state)(beta [MEDICATION NAME] acid/BHB negative), DM (diabetes mellitus) 2, Acute Kidney Injury on CKD ([MEDICAL CONDITION]), Hx (history) of [MEDICAL CONDITION], [DIAGNOSES REDACTED], SHD (structural [MEDICAL CONDITION]) Hypoxemic and Hypercapnic Resp (respiratory) failure. Under hospital course the hospital discharge summary (12/29/16) documents, 77 yo (year old) M (male) with a complex PMH (past medical history) .was found to have HHS with a glucose of 1300 with [MEDICAL CONDITION] and acute [MEDICAL CONDITION]. The patient was admitted to the ICU (intensive care unit) for further evaluation and management. Etiology unclear. Unclear if patient was actually receiving insulin at his LTACH facility, some reports suggest he was, other suggest he was not. On 3/7/17 at 7:20 a.m., Surveyor interviewed RN (Registered Nurse)-W regarding R6's (12/7/16) admission and medication. RN-W explained that RN-V helped him put the medications into the system. RN-W informed Surveyor that he didn't see the insulin orders and that someone left out the first page with the insulin on it. Surveyor asked RN-W how the Facility became aware that R6 was not receiving his insulin. RN-W informed Surveyor that R6 went back to the hospital (12/14/16) because he was very lethargic and when he was at the hospital they discovered he had a high blood sugar and we had not been giving him his insulin. Surveyor asked RN-W if he noted on the hospital records that R6 has a [DIAGNOSES REDACTED]. RN-W stated that he was trying to do the assessments and RN-V was doing the medications. RN-W stated that the computer system is complicated for him. RN-W informed Surveyor that Prior DON (Director of Nursing)-II educated him and that he apologized to the family as he felt so bad. Surveyor asked RN-W who reviews the paperwork that the hospital sends? RN-W replied, We kind of all do and explained that the admitting nurse does and he was the admitting nurse for R6. RN-W informed Surveyor that he's not so good with the computer and that the [DIAGNOSES REDACTED]. RN-W stated, It was an oversight. Surveyor asked RN-W if he reads all the hospital paper work that is sent. RN-W replied, All that I can that time allows. On 3/8/17 at 3:10 p.m., Surveyor interviewed RN-V to inquire how he was involved with R6's admission. RN-V explained to Surveyor that RN-W asked him to enter R6's orders into the computer. RN-V informed Surveyor that he entered the medication from the papers that RN-W had given him and after he completed entering the medications he gave RN-W the papers back. Surveyor asked RN-V who called the doctor to verify the orders. RN-V informed Surveyor that RN-W did and that he was just asked to enter the orders in the computer. On 3/7/17 at 3:26 p.m., Surveyor interviewed LPN (Licensed Practical Nurse)-GG regarding R6's medications. (LPN-GG informed Surveyor that she was the nurse who called Physician-Y on 12/14/16 because R6 didn't have the [MEDICATION NAME].) Surveyor asked LPN-GG how staff missed the sliding scale insulin. LPN-GG replied, To be honest he was already here and explained that she had been off for three days. LPN-GG informed Surveyor that there are a lot of distractions when they have to enter a Resident's orders explaining that the phone rings or a Resident or their family wants something. Surveyor asked LPN-GG to explain the process at the Facility after a Resident is admitted regarding their medications. LPN-GG explained that they get the hospital discharge, call the doctor to verify the orders and enter the medications into the computer. LPN-GG informed Surveyor that you can enter the orders and have them sitting & waiting and then after the orders are verified can ok them or not depending on the doctor. Surveyor asked LPN-GG who reviews the hospital paper work? LPN-GG informed Surveyor that RTD (Respiratory Therapy Director)-HH looks at the vent information and we kind of look through them. LPN-GG informed Surveyor that RN (Registered Nurse)-F or Interim DON (Director of Nursing)-B will review the information that day or the next day. On 3/8/17 at 10:09 a.m., Surveyor reviewed Prior DON-II's investigation including the plan of correction. This plan of correction documents, R6 was admitted to the facility on 12.07.16 with a three-page Discharge Summary and a separate loose paged Medication Reconciliation List. When R6 discharged to the hospital a chart review was conducted for return to hospital prevention. A loose five page Medication Reconciliation List was found. Pages two thru five had whole punches, page one did not. Page one list had a total of six medication one being Insulin. Two RN's participated in the admission process and verified the medication. Unknows (sic) to the RN's page one of the Medication Reconciliation List was missing and therefore not involved in the verified medications. On Bria of Trinity Village paper there is a handwritten note of the following First page missing all first page meds missing [MEDICATION NAME] [MEDICATION NAME] 2.5 mg [MEDICATION NAME] 40 mg Florajen 3 caps [MEDICATION NAME] Insulin Humalog Solution. Surveyor is unable to interview Prior DON-II as she is no longer employed by the Facility to inquire how all the page 1medications, which were allegedly missed, were on the order sheet and December 2016 MAR indicated [REDACTED] On 3/9/17 at 7:49 a.m., Surveyor spoke with Physician-Y on the telephone. Surveyor asked about R6's insulin. Physician-Y informed Surveyor that R6 was on a sliding scale insulin. Surveyor informed Physician-Y that R6 was not receiving the sliding scale at the Facility and that his blood sugar was very high at the hospital. Physician-Y informed Surveyor that EMS gave R6 [MEDICATION NAME] in the ambulance. On 3/20/17 at 10:29 a.m., Surveyor received the patient care report from Bell Ambulance with a service date of 12/14/16 under the narrative section documents, Bell 462 dispatched with lights and sirens to Trinity Village for [AGE] year old [MEDICAL CONDITION]. Upon EMS (emergency medical services) arrival to room [ROOM NUMBER], EMS found client lying unresponsive on [MEDICAL CONDITION]. Pt. airway patent, he was breathing at adequate rate and depth, and circulation was sufficient (cap refill< (less than) 2 seconds, strong radial pulse, normal skin color, temp (temperature), moisture. Client's unresponsive mental status is normal per facility. According to staff, client has not been a ventilator dependent patient. Pt was seen earlier with rapid, shallow respirations at a rate of 40 breaths per minute. Pt O2 (oxygen) saturation was high 80's and was apparently bradycardic with heart rate of 40. Prior to our arrival, staff changed clients [MEDICAL CONDITION] and symptoms seemed to have subsided. Facility requested transport to emergency room for further evaluation. Pt was transferred to cot via bed sheet and he was secured to cot x (times) 5. Pt O2 was transferred [MEDICAL CONDITION] that was provided PTA (prior to arrival). O2 was set at 10 LPM (liters per minute) in our care. Pt placed on cardiac monitor to show sinus rhythm with no ST changes or ectopy. Blood sugar and axillary temp were taken. Pt had Foley catheter in with 300 ml (milliliter) yellow urine in bag. Full pt. assessment, hx (history) vitals obtained. Vitals wnl (within normal limit). Pt heart rate remained 90-100 BPM (beats per minute) throughout our care and client was satting at 99%. Respirations remained between 18-24 breaths per minute. Pt condition stable and unchanged throughout our care. Pt transported to St Mary's by request and brought to ED (emergency department) in care of RN. Signatures obtained. Surveyor noted there is no evidence in the patient care report that R6 received [MEDICATION NAME]. Surveyor noted and as stated above, according to the Hospital discharge summary dated 12/29/16, .on 12/14/16 .was found to have HHS with a glucose of 1300 .patient was admitted to the ICU (intensive care unit) for further evaluation and management. Etiology unclear. Unclear if patient was actually receiving insulin at his LTACH facility, some reports suggest he was, other suggest he was not. The failure to give [MEDICATION NAME] and sliding scale Humalog insulin were significant medication errors that created a finding of immediate jeopardy. The Facility removed the immediate jeopardy on 12/22/16 when they: * Ensured that R6 is currently receiving all medication as ordered including insulin and blood sugar monitoring. * All residents with a diabetes [DIAGNOSES REDACTED]. * All MEDICATION ORDERS FOR [REDACTED]. * A nurse manager will conduct chart reviews on all new admissions the following business day. This will include hospital record review and will be documented on the audit tool. * All nurses were in-serviced prior to the start of their next shift on discharge summaries, medication reconciliation, medication errors and medication error prevention. * All new admissions with insulin orders will be audited by the next business day by a nurse manager to ensure accuracy of insulin orders and blood sugar monitoring. * All audits results will be reviewed by the facility Quality Assurance Committee to determine if any further staff education or facility policy changes are needed. Any deficiencies will be corrected immediately and reviewed again by the Quality Assurance Committee monthly. The deficient practice was corrected when the facility did their first Quality Assurance Review on 1/18/17.

Based on observation, interview, and record review the Facility did not ensure that 1 (R7) of 5 Residents at risk for development of pressure injuries received the necessary treatment and services. R7 who is at high risk for the development of pressure injuries did not have a care plan intervention addressing the need to offload R7's heels. On 3/6/17, Surveyor observed R7 in bed with heels resting directly on a pillow and are not offloaded. On 3/7/17, Surveyor observed a pressure injury to R7's right heel the approximate size of a quarter with necrotic tissue. The Facility was not aware that R7 had a pressure injury to her right heel until 3/9/17 when the Surveyor made Facility staff aware. Findings include: Surveyor reviewed R7's medical record on 3/6/17 to 3/9/17. R7's [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED] is a rare skin condition that causes large fluid filled blisters. These blisters develop on areas of skin that often flex such as the lower abdomen, upper thighs or armpits. R7 has a history of pressure ulcers and was started receiving hospice services on 12/21/16. The skin care plan initiated & revised on 12/17/15 includes interventions of: Initiated 12/17/15 - Assist and encourage resident to turn and reposition every one to two hours and PRN (as needed), Monitor for adequate food and fluid intake, Monitor for adequate urine output, Monitor weights and labs, Notify MD of abnormal findings, Observe and assess with cares, Protect elbows and heels if being exposed to friction, Provide skin care after each incontinent episode, RD (registered dietitian) to assess and recommend, Serve diet as ordered, skin assessment weekly. Initiated 12/15/15 and revised 3/10/16: Observe and assess with cares, Therapeutic mattress (refuses) in bed and cushion in chair as appropriate. 3/10/16 - down for naps after meals. Surveyor did not note any care plan intervention to offload R7's heels. The Braden assessment dated [DATE] has a score of 12 which is high risk. The quarterly MDS (Minimum Data Set) with an assessment reference date of 1/14/17 and signed as complete on 1/24/17 documents a BIMS (brief interview mental status) score of 12 which indicates moderately impaired. R7 does not ambulate, is totally dependent with two plus person physical assist for transfers, extensive assistance with two plus person physical assist for bed mobility & toileting and is frequently incontinent of bowel & bladder. R7 is at risk for developing pressure ulcers and is coded as having three Stage 2 pressure injuries. Pressure reducing device for chair, pressure reducing device for bed, turning/repositioning program, nutrition or hydration intervention to manage skin problems, pressure ulcer care, application of nonsurgical dressings (with or without topical medications) other than to feet, & applications of ointments/medications other than to feet are checked for skin and ulcer treatments. The dermatology consult dated 2/13/17 under [DIAGNOSES REDACTED]. Under recommendation documents, Call Dr. if new blister forms that is not (not is circled) in a pressure/friction area. Under patient instructions document, 3 blisters 2 in potential pressure areas Buttocks and toe tip treatment with antibiotics ointment as doing is the best for these. Left wrist one not in a pressure area and may be from possible [DIAGNOSES REDACTED] (not [DIAGNOSES REDACTED]). To late for a biopsy to confirm [DIAGNOSES REDACTED]. If another blister forms that is NOT in a pressure area, then call and I will try to see patient within a few days to consider a biopsy to confirm diagnosis. The skin screen dated 2/25/17 is checked for per facility protocol as the reason for skin check. Under site documents,Right Heel and description split to r (right) heel c (see) no drainage. house it applied. Surveyor did not note any further documentation regarding R7's right heel. The individual service plan report, which is utilized by the CNA's (Certified Nursing Assistant) dated 3/6/17 for R7 has categories of Bathing/Showering, Transferring, Eating/Nutrition, Resident Care, Toileting, ROM (range of motion) and transferring. Surveyor noted transferring is listed twice. Under Resident Care documents, Assist with turning and repositioning every two hours and as needed. roll to left x (times) 3, roll to right x 3. Under toileting documents, Monitor skin daily for sign of redness or breakdown. On 3/6/17 at 3:42 p.m., Surveyor observed R7 in bed on her back with the head of the bed elevated. Surveyor observed R7's heels are resting directly on a pillow and are not being offloaded. On 3/7/17 at 1:26 p.m., Surveyor observed CNA-N wheel R7 out of the North-West dining room and into her room. CNA-N removed the pillows from R7's bed, told R7 that she was going for help and left R7's room. On 3/7/17 at 1:30 p.m., Surveyor , CNA-N, and CNA-Q enter R7's room. CNA-N and CNA-Q transferred R7 into bed using a Hoyer lift. At 1:35 p.m., CNA-N left R7's room for towels and returned with towels at 1:36 p.m. CNA-N filled a wash basin. R7 was positioned from side to side to remove the sling, and CNA-N unfastened R7's incontinence product which was saturated with urine. CNA-N then washed R7's frontal perineal area. R7 was positioned on her side and CNA-N washed R7's buttocks. Surveyor did not observe any pressure injuries. CNA-N placed an incontinence product under R7 and then R7 was positioned side to side to straighten out & fasten the incontinence product and remove the soiled incontinence product. R7 was then positioned on her back. Surveyor informed CNA-N and CNA-Q that Surveyor would like to look at R7's feet. CNA-N and CNA-Q removed the long red gripper socks and pulled up R7's tubi grips. Surveyor observed on the back of R7's right heel a pressure injury the approximate size of a quarter with necrotic tissue. Surveyor observed R7 left heel does not have any pressure injuries. Surveyor asked CNA-N and CNA-Q if R7 has anything on her heels. CNA-N and CNA-Q replied, no. CNA-N and CNA-Q pulled down R7's tubi grips and placed the long red gripper socks on. A pillow was placed under R7's feet so her heels were being offloaded and covered R7 with a blanket. On 3/8/17 at approximately 4:00 p.m., Surveyor asked Interim DON (Director of Nursing)-B if tomorrow Surveyor and Interim DON-B could look at R7's skin together. Interim DON-B informed Surveyor that she would ask night shift to leave R7 in bed and that she usually comes in around 7:45 a.m. On 3/9/17 at 10:34 a.m., Surveyor asked Interim DON-B if she could accompany Surveyor to see R7's skin. Interim DON-B informed Surveyor that it may be easier after lunch when R7 is in bed. Surveyor informed Interim DON-B that Surveyor only wanted to look at R7's feet with her. Surveyor then accompanied Interim DON-B and CNA-N to R7's room. R7 was sitting in her wheelchair in her room. Surveyor informed Interim DON-B that Surveyor only wanted to look at R7's right foot. CNA-N removed R7's long red gripper sock and tubi grip. Surveyor then showed Interim DON-B the pressure injury on R7's posterior heel. Interim DON-B stated, looks like 25 % granulation and 75% necrotic tissue. Interim DON-B asked CNA-N to put R7's tubi grip back on and informed Surveyor that she will put a treatment in place. Interim DON-B informed Surveyor that it looks like there was a DTI (deep tissue injury) there. Surveyor asked Interim DON-B if she had been aware of this pressure injury. Interim DON-B informed Surveyor that she was not made aware and that she isn't the wound nurse anymore. Surveyor inquired who is the wound nurse. Interim DON-B replied RN (Registered Nurse)-U. On 3/9/17 at 10:44 a.m. Interim DON-B informed Surveyor that she is going to get boots for R7 and is going to have to check to see why no one knew about R7. On 3/9/17 at 10:53 a.m., Surveyor asked RN-U if she was the wound nurse. RN-U informed Surveyor that she is going to take over the wounds and that they have to get someone to replace her on the floor. RN-U stated that last week she went with the wound doctor for rounds. Surveyor asked RN-U if she was aware that R7 had a pressure injury on her right heel? RN-U replied, not that I was told. RN-U explained that there was an issues with blisters and had gone to see a dermatologist. RN-U informed Surveyor that none of the CNAs came to her. Surveyor asked RN-U if she would expect the CNAs to inform her. RN-U replied, yes and explained that they tell her if someone's bottom is red and they need more than barrier cream or if they have a skin tear. RN-U stated that no one came to her and they would have done a treatment. RN-U then thanked Surveyor for letting her know and will look at it. On 3/9/17 at approximately 2:45 p.m., Interim DON-B informed Surveyor that Physician-T had examined R7's feet yesterday (3/8/17) and did not see any pressure ulcers on R7's right heel. Surveyor informed Interim DON-B that Surveyor had observed the pressure injury on 3/7/17 and that's why Surveyor had asked her to look at R7's skin on 3/8/17. Surveyor informed Interim DON-B that after they entered R7's room Surveyor asked for only the right sock & tubi grip to be removed. The nurses note dated 3/9/17 documents, Wound Evaluation right posterior Heel: suspected DTI (deep tissue injury) 0.9 x (times) 1.0 UTD (unable to determine) peri area of wound callouses 50% red viable 50% necrotic minimal serosanginous drainage treatment: daily [MEDICATION NAME] f/b (followed by) kerlix f/b (foam boot). On 3/9/17 at 3:48 p.m., during the daily exit conference Administrator-A, Interim DON-B and Corporate RN-C were informed of the above. On 3/14/17, the Facility emailed Surveyor the nurses note dated 3/9/17 which documents, right heel discoloration noted; area [MEDICATION NAME] and wrapped with kerlix foam boots to be utilized. Wound MD to evaluate area on on next visit. On 3/14/17, the Facility also emailed Surveyor Wound Physician-S initial evaluation dated 3/10/17. The Wound Physician S's initial evaluation consists of the following information: For HPI (history present illness) statement documents, At the request of Physician-T, this [AGE] year old female was seen and evaluated today. She presents with an unstageable (due to necrosis) of the right heel of at least 1 days duration. There is no exudate. There is no indication of pain associated with this condition. For the unstageable (due to necrosis) of the right heel under etiology (quality) documents, Pressure. MDS 3.0 Stage: unstageable Necrosis, Duration: > (greater) 1 days, Objective: Palliation, Wound size (L X W X D) (length times width times depth): 3 x 3 x not measurable cm (centimeters), Surface area: 9.00 cm2 (centimeters squared),, Periwound radius: Surrounding DTI (deep tissue injury) (purple/maroon), Exudate: none, and thick adherent black necrotic tissue (eschar) 100%. Under additional information documents: 3/10/17: Pt. (patient) has a history of recent blistering skin condition for which she saw dermatology. The consult note is not in the paper chart nor uploaded as far as I can see. Interim DON (Director of Nursing)-B RN (Registered Nurse) will get the note for completeness sake. Reportedly she recently was afflicted with [DIAGNOSES REDACTED] and completed steroids for this. I do not see any fluid-filled blisters today. Additionally, there is documentation that on 2/25/17 she had a skin tear on her right heel. This, in combination with her underlying documented [MEDICAL CONDITION], diabetes, and clinical bilateral lower extremity near paralysis (unclear if this is due to her spinal stenosis?) makes her high risk for extremity wounds and poor at wound healing overall. She has a limited prognosis and has has qualified for hospice. This wound is multi-factorial, as many wounds are, but given the small areas of periwound discoloration consistent with DTI pressure is a factor. I found her with attempts at off-loading the heel including calves on pillow and foam booties, but given all her underlying pathology I would like to be more aggressive and use an off-loading boot like a Prevalon boot. I discussed this with RN-U as well as Administrator-A. On 3/14/17, the Facility also emailed Surveyor Wound Physician-S progress note dated 3/10/17 which documents, NOTE: This afternoon I was able to speak with Physician-T who clarified R7's history. Given her poor overall health with the the last hospitalization and her terminal status, the wound on her right heel would be considered unavoidable. To clarify my previous notes, the skin screen from 2/25 refers to the right heel as having a split not a tear as I wrote earlier.

Based on observation, record review and interviews, the facility did not ensure residents who enter the facility do not develop pressure injuries for 2 of 2 residents (Residents #5 and #6) reviewed with pressure injuries and did not provide the necessary treatment and services to promote the prevention of pressure injury development for 1 (#11) of 13 residents at risk for pressure injuries. * Resident #6 was identified to be at risk for the development of pressure injuries. Resident #6 developed multiple pressure injuries while at the facility. On 9/13/2016, Resident was noted to have fluid filled blisters to bilateral heels and on 9/14 both the right and left heel was described as boggy with treatment to the area. There is no indication of physician/practitioner notification from 9/13/2016 through 9/21/2016 of Resident having pressure injuries to his heels. The nurse practitioner saw resident on 9/22/16. According to the September Treatment Administration Record (TAR), treatment did not begin for the heels until 9/22/16. On 9/19/16 Resident is noted to have an open area to both the right and left buttock areas and fluid filled blisters to both the right and left heel. Actions taken: Right and left heels -Ulna boots applied. Buttock left and right - area cleansed barrier applied. Wound nurse to assess. The wound nurse did not assess these areas until 9/26/16. The September 2016 Treatment Administration record indicates no treatment to the buttock areas on the September TAR. * Resident #5 was assessed as high risk for the development of pressure injury. On 4/8/16, Resident developed an abrasion to left buttock. The MD was updated who gave orders for Normal Saline wash followed by TAO (Triple Antibiotic Ointment) f/b (followed by) allevyn dressing to left buttock. On 4/14/16 the area is identified as pressure stage 2. On 4/18/16 and on 4/29/16 the area is described as having necrotic tissue/slough and is considered nonstagable. There is no physician notification of the change in the pressure injury to discuss further guidance for the care and treatment of [REDACTED]. According to the MD, Normal Saline would not have been appropriate treatment for [REDACTED]. The area remained unstagable until 9/26/16 when the pressure injury was assessed to be a stage 3. * Resident #3 is identified at risk for pressure injuries. Resident #3's plan of care indicates to float/off load heels while in bed and bilateral heel boots while in bed and encourage pillow under lower extremities to float heels. On 10/5/16 and on 10/6/16, Surveyor observed Resident in bed. Resident's heels were not off-loaded. Findings include: 1.) On 10/3 through 10/6/16, Surveyor # reviewed Resident #6's medical record. The Minimum Data Set ((MDS) dated [DATE] indicates Resident #6 was admitted on [DATE]. The Nurse Practitioners Note dated 8/22/16 indicates Resident #6's [DIAGNOSES REDACTED]. According to Resident #6's 8/25/16 Minimum Data Set (MDS), Resident #6 is at risk for pressure injury development and did not have any pressure injuries. A Skin Screen dated 8/18/16 16:53 (4:53p.m.), is documented with, no O/As (open areas) present, heels firm and intact, coccyx intact . Resident #6's Care Plan initiated on 8/23/16, with a revision on 9/19/16 indicates, Skin - At risk for skin complications, Will maintain adequate skin integrity throughout next review, Notify MD of abnormal findings. Nurses Note dated 8/18/16, 18:11 state; skin W/D (warm and dry) and intact, no O/A Nurses Note dated 8/19/16, 20:42 state; skin W/D and intact Nurses Note dated 8/20/16, 21:34 state; skin W/D and intact A Skin Screen dated 9/9/16, 21:50 state; No new skin issue noted Nurses Note dated 9/13/16, 20:57 states: patient son update about fluid filled blisters to bilateral heels A Skin Screen dated 9/14/16, 14:16, Skin Evaluation - Right heel/Boggy, Left heel/Boggy, Actions Taken: Resident has treatment to the area. Nurses Note dated 9/14/16, 00:15, Res (resident) has blisters on bilateral heels. Blisters are currently intact. Nurses Note dated 9/14/16, 14:19, .both heals (sic) to be boggy, skin very dark and dry. Nurses Note dated 9/15/16, 00:32, Blisters noted bilaterally heels. Blisters boggy and intact. A Skin Screen dated 9/19/16, 02:32, Skin Evaluation - Right buttock/open area, Left buttock/open area, Right heel/fluid filled blister, Left heel/fluid filled blister, Actions taken: Right and left heels - socks removed. Ulna boots applied. Unit manager informed - wound care nurse to assess. Buttock left and right - area cleansed barrier applied. Unit manager informed-wound care nurse to assess. Nurses Notes dated 9/19/16, 05:58 indicates, VM (voicemail) left for wound nurse to assess patient on day shift. (Surveyor # noted the wound nurse did not assess until 9/26/16) Nurses Notes dated 9/20/16, 05:40 indicates, Resident being monitor for blisters on bilateral heels and o/a to buttocks. (Surveyor noted this is the first documentation in the nurses note of open area to buttocks-wound nurse did not assess until 9/26/16. The faclity did not inform the physician or obtain treatment orders. No treatments to the resident's buttocks were documented as being given the remainder of September.) A Dietary Note dated 9/20/16, 11:04 indicates, .notified of new pressure areas - Right and Left heel - fluid filled blisters, Right and Left buttock open areas. Nurses Note dated 9/21/16, 01:13 indicates, Being monitored for open area to buttocks. Blister to left heel opened .Blister to right heel remains intact. Nurse Practitioner (NP) Note dated 9/22/16, 04:21 states, Staff noticed blisters to bilateral heels about 3-4 days ago and opened about 2 days ago. Skin Observations: Pressure Ulcer Notes: Bilateral heels with open, draining blisters. No surrounding [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. (Surveyor # noted this is the first notification to physician/NP made regarding pressure injuries of heels. There is no documentation regarding open areas on buttocks.) A Skin Screen dated 9/23/16, 22:40, indicates, Right buttock/open area, Left buttock/open area, Right heel/fluid filled blister, Left heel/fluid filled blister, Actions taken: Right and left heels - socks removed. Ulna boots applied. Unit manager informed - wound care nurse to assess. Buttock left and right - area cleansed barrier applied. Unit manager informed-wound care nurse to assess. The Treatment Administration Record (TAR) for September 2016 was reviewed. The September 2016 TAR indicates no treatment noted for open areas on buttocks. The September 2016 TAR indicates treatment for [REDACTED]. Wound Assessment (Surveyor # noted this is the first time wound assessments are completed for open areas on heels and buttocks) - measured in cm (centimeter) L x W x D = Length x Width x Depth · 9/26/16, 6:48 AM, Registered Nurse Manager - D, Left Heel, unstageable, 3.00 x 2.50 x Unknown · 9/26/16, 6:52 AM, Registered Nurse Manager - D, Right Heel, unstageable, 3.5 x 2.5 x Unknown · 9/26/16, 6:59 AM, Registered Nurse Manager - D, Left ischial tuberosity - a weight bearing point in a sitting position - Stage 2 - 1.00 x 1.00 x 0.00 · 9/26/16, 7:03 AM, Registered Nurse Manager - D, Right ischial tuberosity, unstageable - 2.00 x 1.00 x Unknown Wound Assessment · 10/3/16, 6:22 AM, Registered Nurse Manager - D, Left Heel, unstageable, 7.00 x 7.50 x Unknown · 10/3/16, 6:20 AM, Registered Nurse Manager - D, Right Heel, unstageable, 6.00 x 8.00 x Unknown · 10/3/16, 6:29 AM, Registered Nurse Manager - D, Left ischial tuberosity, Stage 2, 2.00 x 1.50 x 0.00 · 10/3/16, 6:29 AM, Registered Nurse Manager - D, Right ischial tuberosity, Unstageable, 4.00 x 2.50 x 0.00 Wound Physician Initial Evaluation and surgical debridement onsite and treatment orders dated 10/3/16 which indicates: Left Heel - Unstageable due to necrosis - [MEDICATION NAME] - Once daily and PRN (as needed), Dry Protective Dressing - Once Daily and PRN Right Heel - Unstageable due to necrosis - Dry Protective Dressing - Once Daily and PRN, Calcium Alginate - Once Daily and PRN Left Ischium - Unstageable due to necrosis - Dry Protective Dressing - Once Daily and PRN, Collagen Dressing - Once Daily and PRN Right Ischium - Unstageable due to necrosis - Dry Protective Dressing - Once Daily and PRN, Santyl - Once Daily and PRN On 10/6/16 at 1:05 PM, Surveyor # interviewed the Director of Nursing - B (DON-B) and Registered Nurse Manager-D (RNM-D). RNM-D stated Resident #6's open areas were definitely facility acquired. DON-B searched the computerized medical record for Resident #6 and could not find any physician notification regarding Resident #6's open areas. DON-B checked the treatment record and did not find any treatment orders for the open areas on the heels until 9/22/16. DON-B could not find any treatment record for open areas on Resident #6's buttocks for September 2016, but found treatment orders for the buttocks pressure injuries on 10/01/16, 17:00 (5:00 pm). On 10/6/16 at 2:40 PM, Surveyor # observed the open areas on Resident #6's buttocks and heels and Surveyor # observed the open areas on the heels. On 10/6/16, 2:50 PM, Surveyor # spoke with Assistant Director of Nursing - C (ADON-C) who supervises the unit Resident #6 resides on. Asked if anyone notified Resident #6's physician of open areas, ADON-C replied, whatever is in computer is what is there. 2.) On 10/3/16 - 10/6/16, Surveyor # reviewed Resident #5's medical record. The record indicates Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's care plan, at risk for complications with skin integrity related to decreased mobility, weakness, decreased appetite and incontinence: was initiated on 12/16/15. The goal initiated 12/16/15 indicates Resident #5 will maintain adequate skin integrity throughout next review. Interventions initiated 12/16/15 include: provide skin care after each incontinence episode, therapeutic mattress in bed and cushion in chair, assist and encourage resident to turn and reposition every one to two hours and PRN (as needed), ensure proper body alignment, monitor closely for sensory impairment, monitor for adequate food fluid intake, monitor urine output, monitor weights and labs, notify MD of abnormal findings, observe and assess regularly, and protect elbows and heels if being exposed. Surveyor # noted the care plan was not updated to reflect any interventions for the facility acquired stage 3 pressure injury. Progress note dated 4/9/16 at 10:18am indicates: POA (Power of Attorney) updated on area to left buttock and welcome call. Progress notes dated 4/9/16 at 4:00 p.m. written by Licensed Practical Nurse (LPN-F) indicate: Late entry: from 4/8/16. Abrasion to left buttock, 4 x 3 x 0.1 purplish in color no drainage noted. Wound bed pink in color, surrounding tissue intact. No indication of pain. Physician updated and writer informed to follow protocol. DON (Director of Nursing) updated. Surveyor # noted there is no additional progress notes from 4/12/16-6/8/16. Review of Resident #5's physician's orders [REDACTED]. One time a day. This order was discontinued on 6/23/16. Review of Resident #5's wound assessment detail report dated 4/14/16 at 5:45pm indicates the following: Wound: left ischial tuberosity Status: active Type: Pressure Classification: Ulceration Source: Facility acquired Date identified: 4/12/16 Identified by: (RN Manager-D) Assessment date: 4/14/16 5:45pm Performed by: (RN Manager-D) Clinical stage: stage 2 Tissue Types: Pale pink non-granulating = 100% Has been debrided: No Outcome: Probable improvement Measurement Size (cm): 7.50 x 3.50 x 0.0 (LxWxD) (length by width by depth) Area: 26.25 cm Volume: 0.00 cm Current plan & comments: Resident is noted with stage two wound with abrasion. Current treatment is effective pain is managed. Resident has a low air loss, pressure relieving mattress. Resident diet intake is fair, supplement added to assist with wound healing. Staff will reposition resident q 2 hrs (every 2 hours) while in bed and up in chair. In addition chair pad added. Review of Resident #5's wound assessment detail report dated 4/18/16 at 7:58am indicates the following: Wound: left ischial tuberosity Status: active Type: Pressure Classification: Ulceration Source: Facility acquired Date identified: 4/12/16 Identified by: (RN Manager-D) Assessment date: 4/18/16 7:58 am Performed by: (RN Manager-D) Clinical stage: stage 2 Tissue Types: Necrotic soft, adherent= 100% Has been debrided: No Outcome: Probable improvement Measurement Size (cm): 3.00x1.00x0.0 (LxWxD) Area: 3.0 cm Volume: 0.00 cm Current plan & comments: This wound assessment was not electronically annotated in the wound round system. Surveyor # noted based on the picture of the wound and the tissue type description the wound would be classified as an unstageable pressure injury and not a stage 2 as documented on the wound assessment. The wound classification as being an unstagable pressure injury and not a stage 2 was confirmed by Director of Nursing (DON) -B on 10/6/16 at 11:48 a.m. Surveyor # noted there is no documentation that the physician was notified of the pressure injury tissue type changing from pale pink non-granulating tissue as indicated on the 4/14/16 wound assessment detail report to having necrotic soft, adherent tissue type on the 4/18/16 wound assessment detail report, nor was there an updated treatment implemented. On 10/10/16 at 8:42am, Surveyor # spoke with Physician-O by phone. Physician-O indicated, normal saline would have not been an appropriate treatment for [REDACTED]. Review of Resident #5's wound assessment detail report dated 4/29/16 at 12:11pm indicates the following: Wound: left ischial tuberosity Status: active Type: Pressure Classification: Ulceration Source: Facility acquired Date identified: 4/12/16 Identified by: (RN Manager-D) Assessment date: 4/29/16 12:11pm Performed by: (RN Manager-D) Clinical stage: stage 2 Tissue Types: slough loosely adherent=35%, Necrotic soft, Adherent=65% Has been debrided: No Outcome: Probable improvement Measurement Size (cm): 3.00 x 1.0 x 0.0 (LxWxD) Area: 3.0 cm Volume: 0.00 cm Current plan & comments: Resident wound continues to heal no signs or symptoms of infection noted. Resident has Roho cushion in chair, low air mattress. Staff are repositioning q2hrs (every 2 hours). Pain is managed; resident diet is fair, often refused to lay down between meals. Surveyor # noted the facility stages this pressure injury at a stage 2 even though slough and necrotic tissue is identified in the assessment. Surveyor # noted that the presence of slough and necrotic tissue is usually identified as an unstageable pressure injury or a stage 3 or 4. Surveyor # noted there is no documentation that the physician was notified of the pressure injury tissue type changing from pale pink non-granulating tissue as indicated on the 4/14/16 wound assessment detail report to having slough loosely adherent = 35%, necrotic soft adherent =65% tissue type on the 4/29/16 wound assessment detail report, nor was there an updated treatment implemented. The facility continued to use normal saline until this was discontinued on 6/23/16. Physician orders [REDACTED]. Two times a day related to pressure ulcer left hip, stage 2. This order was discontinued on 6/27/16. Physician orders [REDACTED].¼ sol wet to dry dressing to wound daily. One time a day related to pressure ulcer of left hip, stage 2. This order was discontinued on 7/13/16. Physician orders [REDACTED]. One time a day related to pressure ulcer of left hip, stage 2 apply Dakin's ¼ sol wet to dry dressing to wound daily. On 10/10/16 at 8:42am, Surveyor # spoke with Physician-O by phone regarding Resident #5's facility acquired stage 3 pressure injury. Surveyor # asked Physician-O when did the facility notify him of the change in the pressure injury. Physician-O indicated, usually when the facility contacts him he would write it down. Physician-O reviewed the facility notes and indicated, he thought his notification was in June when the area got worse. Physician-O indicated that he goes through the facility notes carefully and would have put notification in my progress notes or the facility would have documented it in their notes. Physician-O stated I don't see it. Surveyor # noted that wound assessment detail report dated 5/2/16 documents Resident #5's wound as unstageable and the comments indicate: Resident is followed by wound team, the following intervention remain cushion in chair, low air mattress, encourage to lay down between meal times reposition q 2 hrs (every 2 hours) while up in chair. Resident intake is inadequate PCP (primary care physician) is aware will continue to monitor. Surveyor # noted Resident #5 had a change in status on 4/18/16 related to the facility acquired pressure injury and there was no update in treatment update until 6/23/16. Further review of Resident #5's ongoing wound assessment detail report from 4/12/16-9/26/16 indicate that Resident #5's pressure injury continued to deteriorate. The Pressure injury continued to increase in size and PUSH score (the sum of length x width, exudate amount and tissue type). The pressure injury was documented as a stage 2 on 4/14/16 and based on tissue type and image was an unstageable pressure injury from 4/18/16-8/29/16. The pressure injury was not identified to be a stage 3 until 9/26/16. Resident #5's treatment was not updated until 6/23/16. 3. Surveyor # reviewed Resident #11's medical record. Resident #11 experiences total dependence on staff for all activities of daily living (ADLs). Resident #11's medical record indicates Resident #11 has been identified by the facility to be at risk for skin complications including pressure injuries based on her [DIAGNOSES REDACTED]. The plan of care interventions initiated 10/05/16 indicates to Float/off load heels while in bed. This intervention is documented as created by RN-C (registered nurse). It is also noted that this intervention is addressed on the nurse aide care card as well to Float/off load heels while in bed. The nurse aide care card also states, bilateral heel boots while in bed and encourage pillow under lower extremities to float heels. On 10/05/16, Surveyor # observed Resident #11 in bed from 8:10 a.m. throughout the shift without evidence of off-loading of her feet. The resident was wearing yellow footie socks and bilateral heel boots. After the administration of morning cares on 10/06/16, Surveyor # observed Resident #11's feet were still not off-loaded by either CNA-H (nurse aide) or CNA-I.

Based on observation, record review and interviews, the facility did not ensure residents with pressure ulcers received the necessary care and treatment to promote healing. This was observed with 2 (Resident #8 and #7) of 5 residents reviewed with pressure ulcers. Resident #7 developed a fluid filled blister on her left lower leg from an immobilizer brace following a fracture. The facility did not immediately consult with the physician regarding the blister. The facility did not update Resident #7's care plan to include the left lower leg wound. The facility did not ensure the assessment wound included all characteristics including the stage of the wound. The Resident did not receive daily dressing changes for a facility acquired pressure ulcer on the left leg. Resident #7 was admitted to hospital from the facility where the hospital documented the left lower leg wound was 100% covered with eschar. Resident #8 was observed to have received the wrong pressure ulcer treatment for [REDACTED]. Example 1 involving Resident #7 rises to a scope and severity level of a G (harm/isolated). Findings include: 1.) Resident #7's medical record was reviewed by Surveyor # . Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #7 no longer resides in the facility. The Admission MDS (minimum data set) completed on 9/3/15 does not indicate Resident #7 has any pressure ulcers. Resident #7 requires staff assistance with activities of daily living. The MDS indicates Resident #7 is at risk for pressure ulcers. Resident #7 went for a scheduled Orthopedic follow-up appointment on 9/8/15 related to her left femur fracture. The 9/8/15 Orthopedic consult indicates a new brace was applied, continue immobilizer and follow-up in 2 weeks. Review of Resident #7's Skin Assessment Forms indicate: on 9/12/15 there was a 9 centimeter by 7 centimeter, fluid filled blister on the left calf, this was attributed to a immobilizer brace rubbing on the area. This form does not include details related to any application of treatment to the area or that the physician or Legal Representative were notified of the skin concern. The facility does not indicate what the stage is of this wound and instead indicates inapplicable related to stage. Resident #7's Interdisciplinary Note dated 9/12/15 indicates the following: therapy noted a leaky blister on the left calf, this blister correlated with the leg brace, the blister was cleansed with normal saline and a ABD pad was applied for active drainage, nursing order to do this daily until healed. The note does not indicate a physician was consulted with regarding this wound. The next Orthopedic consult is dated 9/22/15 and indicates the brace is causing rubbing and the immobilizer will be discontinued. Resident #7 medical record does not indicate the facility assessed the immobilizer and consulted with the physician on 9/12/15 when the blister first developed to determine if the immobilizer should continue to be used and if still needed what could be implemented to prevent further skin issues from pressure. The next Skin Assessment Form for Resident #7's left lower calf is dated 9/28/15 (Surveyor # noted this was 12 days from the previous skin assessment). This assessment indicates the blister area is now opened, measuring 11 centimeters by 2 centimeters with 0.4 centimeters depth. The treatment listed is normal saline wash, followed by Iodosorb, followed by Vaseline gauze, then dry gauze, and wrap with Kerlix every day. The form indicates the family and physician are aware of this wound. The facility does not indicate what the stage is of this wound and instead indicates inapplicable related to stage. The Interdisciplinary notes on 9/30/15 indicate a new treatment is recommended and the physician was updated. The new left leg treatment is normal saline wash, followed by Santyl (enzymatic [MEDICATION NAME] agent), followed by Vaseline gauze and Kerlix wrap every day. No stage is indicated of the wound. The last Skin Assessment for the left calf wound was completed on 10/19/15. The treatment listed on the assessment is normal saline wash followed by Vaseline gauze, followed by dry gauze wrap with Kerlix QD (each day). Surveyor # noted this is not consistent with the ordered treatment of [REDACTED]. The description indicates: Acute, irregular shaped wound, with maceration, 90% necrotic wound bed tissue with no signs or symptoms of infection. The measurements are 10.5 centimeters by 2.0 centimeters and no depth. For stage, the assessment indicates inapplicable. A Nurse's note on the skin assessment form indicates: .(Physician name) consult reports left fracture wound healed, x-ray looks ok, doing better and brace causing rubbing and to discontinue brace . The last Interdisciplinary Note addressing the left leg wound was on 9/30/15 with the change in treatment. Resident #7's plan of care for pressure ulcers dated 8/27/15. This indicates Resident #7 has skin breakdown due to impaired mobility secondary to surgical wound on the left hip from surgery and a hairline open area to the gluteal crease. Interventions include to monitor skin daily with cares, during baths, and weekly. MD update if indicated, apply lotion to arms and legs every am and hs (bed time), assess for presence of risk factors: treat, reduce, eliminate risk factors to extent possible, encourage physical activity, mobility, and Range of Motion to maximum potential, Orthopedic follow up per MD order, L (left) hip fx (fracture) NWB (non weight bearing), hairline open area to gluteal crease. House barrier cream. Surveyor # noted there is no indication the care plan was revised to include the pressure ulcer on Resident #7's left lower calf. A orthopedic care plan started 9/9/15 indicates to monitor for skin breakdown this also was not revised following the issues from Resident #7's immobilizer brace. Resident #7's Treatment Administration Record for 10/2015 was reviewed. The treatment for [REDACTED]. There is missing signatures from 10/16/15 - 10/19/15 and 10/21/15 - 10/25/15. Resident #7 was transferred to the hospital in the evening on 10/25/15. On 2/8/16 at 7:48 a.m. Surveyor # spoke with HSW-O (Hospital Social Worker). HSW-O indicated that when Resident #7's hospital skin assessment was done there was a dressing on the left lower leg that was dated 10/20/15. Resident #7's hospital records were reviewed by Surveyor # . The Wound/Skin assessment dated [DATE] includes a left lower leg area measuring 11 centimeters by 2 centimeters with 100% eschar base. On 2/8/16 at 10:30 a.m. Surveyor # spoke with DON-B (Director of Nurses) and CC-C (Clinical Coordinator) regarding Resident #7's skin conditions. DON-B did not know off hand about the left lower leg dressing not being completed, and indicated she would look into it. On 2/8/16 at 12:40 p.m. DON-B spoke with Surveyor # . DON-B showed Surveyor # a staff disciplinary form regarding Resident #7's treatments not being completed. The dates on the disciplinary were 10/16/15 - 10/19/15. It did not include the dates after 10/20/15; however DON-B indicated they received a call from the hospital regarding the treatment not being done. DON-B does not recall who called from the hospital or who was contacted at the facility. DON-B did not have any information regarding the dressing changes on Resident #7's left lower calf. On 2/9/16 at 3:00 p.m. the concerns with Resident #7's skin condition was shared at the exit meeting. No additional information was provided. 2.) On 2/2/16 at 7:50 a.m. Surveyor # observed cares and the pressure ulcer treatment for [REDACTED]. This treatment was performed by LPN-D (Licensed Practical Nurse). Resident #8 received morning hygiene cares by CNA-J (Certified Nursing Assistant) and CNA-K. During this observation Resident #8's incontinence brief was removed and it was observed there was no dressing on the right buttock pressure ulcer. CNA-J and CNA-K performed perineal care. LPN-D then applied Butt Paste to Resident #8 buttocks with their gloved hand. Resident #8 has an irregular, red open area on the right buttock, which was also covered with the Butt Paste. Resident #8 was positioned in bed with pillows and blankets. LPN-D then completed the treatments to Resident #8 heels. Resident #8's medical record was reviewed by Surveyor # . The most current treatment order is dated 12/25/15. This physician order [REDACTED]. Resident #8's most current pressure ulcer assessment is date 2/1/16 and indicates a stage 2 pressure ulcer on the right buttock, and the current treatment correlates with the physician order [REDACTED]. On 2/3/16 at 2:50 p.m. Surveyor # spoke with DON-B (Director of Nurses) and CC-C (Clinical Coordinator) regarding Resident #8's treatment to the right buttock. Resident #8's Treatment Administration Record was reviewed on the computer at this time. Surveyor # shared the observation of Resident #8 not having a [MEDICATION NAME] border dressing on the right buttock during the observation of cares. DON-B indicated that it typically is an evening shift dressing and the computer system does not show it for the day shift. The computer system just display what needs to be done on your shift, so it did not show a [MEDICATION NAME] dressing even exists for Resident #8's buttocks. The other shifts would not be aware that Resident #8 should have a [MEDICATION NAME] border dressing on the right buttock. On 2/9/16 at 3:00 p.m. the concerns regarding Resident #8's pressure ulcer dressing. No additional information was provided.

Based on record review and interviews, the facility did not ensure that each resident received and the facility provided the necessary care and services to attain the highest practicable physical well-being for 1 (Resident #1) of 2 sampled residents identified by the facility with vascular wounds. Resident #1 had been hospitalized in March 2015 and readmitted to the facility on [DATE]. He was assessed upon readmission and had no pressure ulcers or arterial/venous ulcers. Staff nurses obtained an order on 4/10/15, to cleanse Resident #1's left heel with normal saline, followed by Vaseline gauze, an ABD (absorbent dressing) and kerlix wrap. Resident #1 was assessed by the facility wound team on 4/13/15, and noted to have bilateral blackened heels with an established wound etiology of mixed arterial/venous, diabetic. The area on the left heel measured 5.5cm x 3.2cm. The facility policy regarding arterial and venous ulcers indicates a vascular consult should be obtained to determine the etiology of the compromised circulation. There was no evidence that a vascular consult had been considered. Resident #1's weekly skin assessments revealed evidence of lower extremity [MEDICAL CONDITION]. When asked if Resident #1 had been evaluated to determine if compression would help with his vascular insufficiency, the Director of Nursing (DON) stated she thought he wore [MEDICATION NAME] for compression. The use of [MEDICATION NAME] stockinettes was not on the care plan and an interview with Certified Nursing Assistant (CNA)-E revealed Resident #1 did not wear [MEDICATION NAME] while at the facility. By 4/27/15, the weekly wound assessments revealed the left heel measured 8.0cm x 7.0cm. The physician was not notified of the significant increase in the size of the left heel wound. On 5/4/15, the weekly wound assessment revealed the left heel wound measured 8.0cm x 12.0cm, and had a moderate amount of exudate (drainage) with odor. The wound team recommended a wound clinic consultation due to concerns about possible gangrene. The physician was not immediately notified of the wound team recommendation. The DON was not aware that the physician had not been notified of the change in wound size on 4/27/15, or about the delay in notifying the physician about the need for a wound clinic referral. The order to refer Resident #1 to the wound clinic was not obtained until 5/8/15. Resident #1 was sent to his primary physician at the Veterans Administration (VA) on 5/12/15, (a VA requirement prior to a wound clinic appointment) and was admitted to the hospital, where he required an above the knee amputation on 5/19/15. The physician stated the resident may not have needed an amputation had he been seen sooner. A review of the care plan revealed no update to the care plan to acknowledge actual skin breakdown, rather than the potential for skin breakdown. There were no approaches developed related to the ineffective tissue perfusion identified in the skin risk care plan. Treatment approaches were not updated on the care plan as the heel ulcers deteriorated. The failure to refer Resident #1 to a vascular specialist as directed by the facility policy, the failure to change the care plan with changes in treatment as the ulcer on the left foot worsened, and the failure to promptly get an order for [REDACTED]. The immediate jeopardy was removed 5/22/15, however, the deficient practice continues at a scope and severity level of D (potential for harm that is not immediate jeopardy/isolated). The facility still needs to complete staff (nurse) training regarding physician notification with changing wound status, the process for follow-up on recommendations, required documentation, and complete internal monitoring of specified approaches to achieve substantial compliance. Findings include: On 5/21/15, Surveyor # reviewed the facility Skin Care Protocol effective 11/06, with a revision date of 11/14. In the section of the policy titled, Vascular Wounds, the procedure for arterial wounds includes obtain a vascular consult to determine the etiology of compromise and for potential surgical intervention to increase circulation. In the section of the policy titled, Vascular Wounds, the procedure for venous wounds includes obtain a vascular consult to determine the etiology of compromise. Resident will be considered on an individual basis for compression wraps. Surveyor # reviewed Resident #1's record 5/19-5/21/15, as part of a complaint investigation. Resident #1 was readmitted to the facility on [DATE], after a brief hospitalization . Resident #1's [DIAGNOSES REDACTED]. Resident #1's admission Minimum Data Set (MDS) completed on 11/21/14 indicated Resident #1 had no venous or arterial ulcers. Resident #1 was determined to be at risk for pressure ulcer development. The pressure ulcer Care Area Assessment (CAA) indicates a pressure relief cushion is used in the wheelchair, and staff are to observe/monitor skin daily with cares. A review of Resident #1's mobility care plan initiated upon return from the hospital on [DATE] indicated that initially Resident #1 required a Hoyer mechanical lift for transfers, but by 4/22/15, had progressed to a pivot transfer with 2 staff. The at risk for skin breakdown care plan initiated on 3/17/15, included the approaches of skin prep to bilateral heels every shift and bilateral heel boots when in bed. The Resident Care Guide (care sheet for Certified Nursing Assistants (CNAs) dated 3/17/15, indicated under the heading of skin precautions; turn every 2 hours, float heels, skin prep to bilateral heels every shift and bilateral heels boots when in bed. Resident #1 has a nursing order dated 3/18/15, to apply skin prep to bilateral heels every shift. On 5/20/15 at 10:00am, the DON, who also is the facility wound nurse, told Surveyor # that the skin on Resident #1's heels was intact upon readmission on 3/17/15, and the skin prep was used [MEDICATION NAME] to toughen the skin on his heels. On 4/10/15, there is a physician's orders [REDACTED].#1's left heel with normal saline, followed by Vaseline gauze, followed by an ABD and kerlix wrap. There is no documentation in the progress notes regarding the status of the left heel on 4/10/15 to indicate why this order was given. Beginning on 4/13/15, Resident #1 was assessed during weekly skin rounds by the facility wound team. The following information was found on the Wound Assessment forms provided to Surveyor # on 5/20/15, by the DON. RIGHT HEEL: 4/13/15: Black area measuring 2.0cm (centimeter) x 3.5cm. Skin prep was continued. The etiology of the ulcer was noted with this assessment and documented as mixed arterial/venous/diabetic. 4/20/15: Black area measuring 2.0cm x 4.0cm. Continue skin prep. 4/27/15: Black area measuring 2.0cm x 4.0cm. Treatment changed to [MEDICATION NAME] wash followed by ABD pad, followed by kerlix wrap every day. ABD pad added for protection. 5/4/15: Black area measuring 2.0cm x 4.0cm with moderate serosanguineous (blood and serous fluid) exudate with odor. The wound team recommended Resident #1 be sent for a wound clinic evaluation. The physician was not contacted until 5/8/15, when a physician's orders [REDACTED]. 5/11/15: Black area measuring 2.0cm x 4.0cm with moderate serosanguineous exudate with odor. LEFT HEEL: 4/13/15: Black area measuring 5.5cm x 3.2cm. Continue treatment ordered 4/10/15. The etiology of the ulcer was noted with this assessment and documented as mixed arterial/venous/diabetic. 4/20/14: Black area measuring 5.5cm x 3.0cm. Black necrotic area soft. Treatment changed to 0.25% Dakins wash followed by normal saline wash, followed by Santyl (topical [MEDICATION NAME] agent), followed by Vaseline gauze, followed by ABD and kerlix wrap daily. 4/27/15: Black, soft necrotic area measuring 8.0cm x 7.0cm. There was no exudate present. The Wound Assessment form indicated the status of the wound as unchanged, even though the area had increased in size from 5.5cm x 3.0cm on 4/20/15. The physician was not notified of the change in the left heel ulcer. 5/4/15: Black, soft area measuring 8.0cm x 12.0cm with moderate serosanguineous exudate with odor. Recommendation was for appointment with wound clinic due to possible gangrene. The physician was not contacted until 5/8/15, when a physician's orders [REDACTED].#1 to the wound clinic. 5/11/15: Black, soft area measuring 9.0cm x 12.0cm, with moderate serosanguineous exudate with odor. The surrounding skin is described as [DIAGNOSES REDACTED]tous (reddened). The recommendation section of the form indicates wound clinic appointment set, NP (Nurse Practitioner) aware 4/21/15. Each of the weekly skin assessments for the right and left heel ulcers described the surrounding skin as [MEDICAL CONDITION]. A review of Resident #1's care plan on 5/20/15 revealed a problem of at risk for skin breakdown due to impaired mobility, with a goal that Resident #1 will have no skin breakdown, skin will remain intact. This plan was initiated on 3/17/15. The care plan was not updated to reflect the actual skin impairment. In the approaches section of the skin risk care plan is the statement, Ineffective tissue perfusion r/t (related to) cardiopulmonary disease and diabetes a. m. b. (as measured by) skin temperature changes, altered sensation, weak pulse, skin discoloration and prolonged capillary refill time. There were no approaches listed that addressed ineffective tissue perfusion. The approach section of the skin risk care plan also listed the use of skin prep to bilateral heels every shift, which had been discontinued for the left heel on 4/10/15, and the right heel on 4/27/15. The approach section of the skin risk care plan stated, May follow wound team/MD (physician) recommendations for treatment, heels deteriorating. On 5/12/15, Resident #1 was sent to the Veterans Administration (VA) clinic to see his primary physician prior to going to the wound clinic. Progress notes from Primary VA MD-D dated 5/12/15, state facility nurse called in on 5/8/15 with concerns about heel breakdown. Physical examination reveals left foot swollen with gangrene great and first toes. Sloughing lateral foot. [DIAGNOSES REDACTED] top of foot. Resident #1 was admitted to the VA hospital for gangrene of the left foot. Surveyor # reviewed hospital progress notes on 5/21/15. Inpatient Wound Nurse-C assessed Resident #1 on 5/12/15, and noted the following: Left heel to lateral side incorporating left lateral malleolus (ankle) is with eschar, moist at edges with surrounding loose skin, measures approximately 10cm x 15cm, a strong foul odor, surrounding ecchymosis and mild [DIAGNOSES REDACTED] (bruising and redness), left dorsal ankle with 4.5cm x 10cm area of deep tissue injury. Left great and second toes with eschar. Left medial heel with 1.0cm eschar, right lateral heel with 1.4cm x 1.2cm eschar, no surrounding [DIAGNOSES REDACTED], no drainage. Right dorsal foot with 2cm x 2cm area of ecchymosis, darker in areas, no surrounding [DIAGNOSES REDACTED]. A comprehensive physical assessment was completed when Resident #1 was admitted to the hospital. A review of the musculoskeletal assessment reveals diminished left post tibial pulses, and absent left pedal pulse, as well as, absent right post tibial pulse and diminished right pedal pulse. These findings are consistent with decreased circulation to Resident #1's feet. According to information received from the VA hospital, on 5/19/15, Resident #1's left leg was amputated above the knee. When interviewed on 5/19/15 at 3:15pm, Primary VA MD-D stated that Resident #1 obviously had gangrene of his foot. Primary VA MD-D stated the foot had to have been getting worse for some time and may not have needed amputation if seen sooner. On 5/20/15 at 2:00pm, Surveyor # spoke with the DON concerning facility protocols for follow-up on recommendations made during facility weekly wound rounds. The DON stated she participates in rounds as the facility wound nurse, and relies on the clinical coordinators and staff nurses to follow through on recommendations made during the weekly wound rounds. When asked specifically about physician notification of the change in size of the left heel ulcer on 4/27/15, the DON stated the unit nurse or clinical coordinator should have notified the physician of the change. When asked about the delay in notifying the physician about the need for referral to the wound clinic, the DON stated she had not been aware of the delay, so did not know why the recommendation to send Resident #1 to wound clinic had not been initiated on 5/4/15. The DON stated that recommendations from the wound team are shared after the rounds are completed. Surveyor # spoke with the Director of Nursing and Clinical Coordinator-B on 5/20/15 at 12:45pm. Clinical Coordinator-B states she rounds with the wound team. Neither the DON or Clinical Coordinator-B remembered seeing Resident #1 with blackened toes. When asked about the ongoing [MEDICAL CONDITION] noted in the weekly assessments, in relationship to the need for compression to improve venous return, the DON stated she thought Resident #1 wore [MEDICATION NAME] (a compression stockinet). A review of the care plan and CNA care sheet reveal no instructions regarding the use of [MEDICATION NAME]. On 5/20/15 at 2:35pm, Surveyor # spoke with CNA-E who had been one of Resident #1's CNA caregivers. CNA-E stated Resident #1 did not wear [MEDICATION NAME]. Resident #1 was already at high risk given his [DIAGNOSES REDACTED]. The vast majority of diabetic foot complications resulting in amputation begin with the formation of skin ulcers. <http://www.aafp.org/afp/1998/0315/p1325.html>. This risk, combined with care that was not timely, led to the left lower leg amputation. According to Amputations - Complications, Complications associated with having an amputation include: · heart complications - such as [MEDICAL CONDITION] · blood clots (venous [MEDICAL CONDITION]) · slow wound healing and wound infection · pneumonia (infection of the lungs) · stump and phantom limb pain · psychological problems The loss of a limb can have a considerable psychological impact. Many people who have had an amputation report feeling emotions such as grief and bereavement, similar to experiencing the death of a loved one. Coming to terms with the psychological impact of an amputation is therefore often as important as coping with the physical demands. <http://www.nhs.uk/Conditions/Amputation/Pages/Complications.aspx> The facility's failure to immediately notify the physician of the changes in Resident #1's ulcer, seek a vascular consultation to evaluate the possibility of improving circulation to the lower extremities, and update treatments and the care plan created a situation of immediate jeopardy. The facility removed the immediate jeopardy on 5/22/15 when: * All current residents with impaired skin integrity were assessed by a Registered Nurse (RN), to ensure physician notification, treatments, interventions and care plans are appropriate and clinical recommendations are followed. * Weekly Wound Assessments will be distributed to Clinical Coordinators after wound rounds. The Clinical Coordinators will submit a daily status review to the Director of Nursing of follow-up on any changes of conditions that have occurred, wound care team recommendations and required physician notification. * Recommendations made during wound rounds will be placed on 24 hour report board. If the team determines the wound to be vascular/venous, the physician will be contacted within one business day to determine if a vascular consult is warranted. * Licensed Nurses will be in-serviced by the Director of Nursing and Clinical Managers on the Skin Care policy and procedure, required physician notification for impaired skin integrity, process for follow-up on recommendations and to the required documentation, by 5/22/15. Licensed staff will participate in wound rounds through a scheduled rotation on an on-going basis to assure competency with facility Policy and Procedure. * To monitor effectiveness of this process the Director of Nursing or designee will audit three residents on wound rounds weekly to ensure that physician notification, treatments and recommendations have occurred. Results of the audits will be reported to the Quality Assessment Process Improvement Committee for review and follow up.

Based on record review and interviews, the facility did not notify the physician when a significant change in wound status occurred for 1 (Resident #1) of 2 sampled residents identified by the facility with vascular wounds. Resident #1 had been hospitalized in March 2015 and readmitted to the facility on [DATE]. He was assessed upon readmission and had no pressure ulcers or arterial/venous wounds. Staff nurses obtained an order on 4/10/15, to cleanse Resident #1's left heel with normal saline, followed by Vaseline gauze, an ABD (absorbent dressing) and kerlix wrap. Resident #1 was assessed by the facility wound team on 4/13/15, and noted to have bilateral blackened heels with an established wound etiology of mixed arterial/venous, diabetic. The area on the left heel measured 5.5cm x 3.2cm. Weekly wound assessments were completed and by 4/27/15, the left heel measured 8.0cm x 7.0cm. The physician was not notified of the significant increase in the size of the left heel wound. On 5/4/15, the weekly wound assessment revealed the left heel wound measured 8.0cm x 12.0cm, and had a moderate amount of exudate (drainage) with odor. The wound team recommended a wound clinic consultation due to concerns about possible gangrene. The physician was not immediately notified of the wound team recommendation. The order to refer the resident to wound clinic was not obtained until 5/8/15. Resident #1 was sent to his primary physician at the Veterans Administration (VA) on 5/12/15 (a VA requirement prior to being sent to the wound clinic), and was subsequently admitted to the hospital where he required an above the knee amputation on 5/19/15. The physician stated the resident may not have needed an amputation had he been seen sooner. The Director of Nursing (DON) was not aware that the physician had not been notified of the change in wound size on 4/27/15, or about the delay in notifying the physician about the need for a wound clinic referral. The lack of physician notification about Resident #1's deteriorating wound and need for prompt referral to the wound clinic, with a subsequent above the knee amputation of Resident #1's left leg, resulted in a finding of immediate jeopardy, which began on 4/27/15. The facility Administrator was notified of this finding on 5/21/15 at 4:15pm. The immediate jeopardy was removed 5/22/15, however, the deficient practice continues at a scope and severity level of D (potential for harm that is not immediate jeopardy/isolated). The facility still needs to complete staff (nurse) training regarding physician notification with changing wound status, and complete internal monitoring of specified approaches to achieve substantial compliance. Findings include: Surveyor # reviewed Resident #1's record 5/19-5/21/15 as part of a complaint investigation. Resident #1 was readmitted to the facility on [DATE] after a brief hospitalization . Resident #1's [DIAGNOSES REDACTED]. Resident #1's admission Minimum Data Set (MDS) completed on 11/21/14 indicated Resident #1 had no venous or arterial ulcers. Resident #1 was determined to be at risk for pressure ulcer development. The pressure ulcer Care Area Assessment (CAA) indicates a pressure relief cushion is used in the wheelchair, and staff are to observe/monitor skin daily with cares. A review of Resident #1's mobility care plan, initiated upon return from the hospital on [DATE], indicated that initially he required a Hoyer mechanical lift for transfers, but by 4/22/15, had progressed to a pivot transfer with 2 staff. The at-risk for skin breakdown care plan initiated on 3/17/15, included the approaches of skin prep to bilateral heels every shift and bilateral heel boots when in bed. The Resident Care Guide (care sheet for Certified Nursing Assistants (CNAs) dated 3/17/15 indicated under the heading of skin precautions: turn every 2 hours, float heels, skin prep to bilateral heels every shift and bilateral heels boots when in bed. Resident #1 has a nursing order dated 3/18/15 to apply skin prep to bilateral heels every shift. On 5/20/15 at 10:00am, the DON, who also is the facility wound nurse, told Surveyor # that the skin on Resident #1's heels was intact upon readmission on 3/17/15, and the skin prep was used [MEDICATION NAME] to toughen the skin on his heels. On 4/10/15, there is a physician's orders [REDACTED].#1's left heel with normal saline, followed by a Vaseline gauze, followed by an ABD and kerlix wrap. There is no documentation in the progress notes regarding the status of the left heel on 4/10/15. Beginning on 4/13/15, Resident #1 was assessed during weekly skin rounds by the facility wound team. The following information was found on the Wound Assessment forms provided to Surveyor # on 5/20/15, by the DON. RIGHT HEEL: 4/13/15: Black area measuring 2.0cm (centimeter) x 3.5cm. Skin prep was continued. 4/20/15: Black area measuring 2.0cm x 4.0cm. Continue skin prep. 4/27/15: Black area measuring 2.0cm x 4.0cm. Treatment changed to [MEDICATION NAME] wash followed by ABD pad, followed by kerlix wrap every day. ABD pad added for protection. 5/4/15: Black area measuring 2.0cm x 4.0cm with moderate serosanguineous (blood and serous fluid) exudate with odor. The wound team recommended Resident #1 be sent for a wound clinic evaluation. The physician was not contacted until 5/8/15, when a physician's orders [REDACTED]. 5/11/15: Black area measuring 2.0cm x 4.0cm with moderate serosanguineous exudate with odor. LEFT HEEL: 4/13/15: Black area measuring 5.5cm x 3.2cm. Continue treatment ordered 4/10/15. 4/20/14: Black area measuring 5.5cm x 3.0cm. Black necrotic area soft. Treatment changed to 0.25% Dakins wash followed by normal saline wash, followed by Santyl (topical [MEDICATION NAME] agent), followed by Vaseline gauze, followed by ABD and kerlix wrap daily. 4/27/15: Black, soft necrotic area measuring 8.0cm x 7.0cm. There was no exudate present. The Wound Assessment form indicated the status of the wound as unchanged, even though the area had increased in size from 5.5cm x 3.0cm on 4/20/15. The physician was not notified of the change in the left heel ulcer. 5/4/15: Black, soft area measuring 8.0cm x 12.0cm with moderate serosanguineous exudate with odor. Recommendation was for appointment with wound clinic due to possible gangrene. The physician was not contacted until 5/8/15, when a physician's orders [REDACTED].#1 to the wound clinic. 5/11/15: Black, soft area measuring 9.0cm x 12.0cm, with moderate serosanguineous exudate with odor. The surrounding skin is described as [DIAGNOSES REDACTED]tous (reddened). The recommendation section of the form indicates wound clinic appointment set, NP (Nurse Practitioner) aware 4/21/15. On 5/12/15, Resident #1 was sent to the Veterans Administration (VA) clinic to see his primary physician prior to going to the wound clinic. Progress notes from Primary VA MD-D dated 5/12/15, state facility nurse called in on 5/8/15 with concerns about heel breakdown. Physical examination reveals left foot swollen with gangrene great and first toes. Sloughing lateral foot. [DIAGNOSES REDACTED] top of foot. Resident #1 was admitted to the VA hospital for gangrene of the left foot. Surveyor # reviewed hospital progress notes on 5/21/15. Inpatient Wound Nurse-C assessed Resident #1 on 5/12/15 and noted the following: Left heel to lateral side incorporating left lateral malleolus (ankle) is with eschar, moist at edges with surrounding loose skin, measures approximately 10cm x 15cm, a strong foul odor, surrounding ecchymosis and mild [DIAGNOSES REDACTED] (bruising and redness), left dorsal ankle with 4.5cm x 10cm area of deep tissue injury. Left great and second toes with eschar. Left medial heel with 1.0cm eschar, right lateral heel with 1.4cm x 1.2cm eschar, no surrounding [DIAGNOSES REDACTED], no drainage. Right dorsal foot with 2cm x 2cm area of ecchymosis, darker in areas, no surrounding [DIAGNOSES REDACTED]. According to hospital progress notes, on 5/19/15, Resident #1's left leg was amputated above the knee. When interviewed on 5/19/15 at 3:15pm, Primary VA MD-D stated that Resident #1 obviously had gangrene of his foot. Primary VA MD-D stated the foot had to have been getting worse for some time and may not have needed amputation if seen sooner. On 5/20/15 at 2:00pm, Surveyor # spoke with the DON concerning facility protocols for follow-up on recommendations made during facility weekly wound rounds. The DON stated she participates in rounds as the facility wound nurse, and relies on the clinical managers and staff nurses to follow through on recommendations made during the weekly wound rounds. When asked specifically about physician notification of the change in size of the left heel ulcer on 4/27/15, the DON stated the unit nurse or clinical manager should have notified the physician of the change. When asked about the delay in notifying the physician about the need for referral to the wound clinic, the DON stated she had not been aware of the delay, so did not know why the recommendation to send to wound clinic had not been initiated on 5/4/15. The DON stated that recommendations from the wound team are shared after the rounds are completed. Resident #1 was already at high risk given his [DIAGNOSES REDACTED]. The vast majority of diabetic foot complications resulting in amputation begin with the formation of skin ulcers. <http://www.aafp.org/afp/1998/0315/p1325.html>. This risk, combined with care that was not timely, led to the left lower leg amputation. According to Amputations - Complications, Complications associated with having an amputation include: · heart complications - such as [MEDICAL CONDITION] · blood clots (venous [MEDICAL CONDITION]) · slow wound healing and wound infection · pneumonia (infection of the lungs) · stump and phantom limb pain · psychological problems The loss of a limb can have a considerable psychological impact. Many people who have had an amputation report feeling emotions such as grief and bereavement, similar to experiencing the death of a loved one. Coming to terms with the psychological impact of an amputation is therefore often as important as coping with the physical demands. <http://www.nhs.uk/Conditions/Amputation/Pages/Complications.aspx> The facility's failure to immediately notify the physician of the changes in Resident #1's ulcer created a situation of immediate jeopardy. The facility removed the immediate jeopardy on 5/22/15 when: * All current residents with impaired skin integrity were assessed by a Registered Nurse (RN), to ensure physician notification, treatments, interventions and care plans are appropriate and clinical recommendations are followed. * Weekly Wound Assessments will be distributed to Clinical Coordinators after wound rounds. The Clinical Coordinators will submit a daily status review to the Director of Nursing of follow-up on any changes of conditions that have occurred, wound care team recommendations and required physician notification. * Recommendations made during wound rounds will be placed on 24 hour report board. If the team determines the wound to be vascular/venous, the physician will be contacted within one business day to determine if a vascular consult is warranted. * Licensed Nurses will be in-serviced by the Director of Nursing and Clinical Managers on the Skin Care policy and procedure, required physician notification for impaired skin integrity, process for follow-up on recommendations and to the required documentation by 5/22/15. Licensed staff will participate in wound rounds through a scheduled rotation on an on-going basis to assure competency with facility Policy and Procedure. * To monitor effectiveness of this process the Director of Nursing or designee will audit three residents on wound rounds weekly to ensure that physician notification, treatments and recommendations have occurred. Results of the audits will be reported to the Quality Assessment Process Improvement Committee for review and follow up.

Based on resident and staff interviews and record reviews the facility did not ensure that 1 of 1 residents (Resident #13) reviewed with a condom catheter received the necessary care and services for Resident #13 to maintain his highest practicable physical, mental, and psychosocial well being. On 4/18/14, Resident #13 was admitted into the facility with orders to continue the use of an external (condom) catheter. The facility did not ensure Resident #13 was fitted with the correct sized condom catheter. The facility secured a condom catheter with the use of paper tape. The facility did not change Resident #13's condom catheter daily. On 5/19/14, Resident #13 was diagnosed with [REDACTED]. Resident #13 stated the doctor told him that this condition (penile ulcer) was caused by the lack of care related to the catheter and the inappropriate application of the device, (referring to the paper tape that was used to secure the catheter to the penis.) Resident #13 experienced a Penile Ulcer, pain, and discomfort and is now without the use of the a catheter due to the condom catheter being discontinued on 5/19/14. Resident #13 reported this has caused him a lot of stress and anguish because he now feels degraded as his only option is to urinate in a brief as if he is an infant. Findings include: On 6/11/14 at 11:00 a.m., Surveyor # conducted a resident group interview with the attendance of 8 residents. Resident #13 was present during this group interview and reported that he was very upset with some of the things going on at the facility since he arrived on 4/18/14. Resident #13 stated that he was admitted with orders to continue condom catheter use to assist with incontinence related to various medical conditions. Resident #13 then stated that the facility did not have the correct size condom catheter so they began using one that was too large and wrapped paper tape around it to keep it in place. Resident #13 also stated staff was to come in and clean the catheter daily to prevent infection but they would leave it on for a week at a time without cleaning and this later caused a "sore on his penis." On 6/12/14 at 9:25 a.m., Surveyor# conducted an individual interview with Resident #13. Resident #13 repeated the concerns stated earlier in the group and also gave more information regarding the sore on his penis from the catheter. Resident #13 stated he went into the emergency room the previous month for another condition but while there, doctors diagnosed him with a "penis ulcer." Resident #13 stated the doctor told him that this condition was caused by the lack of care related to the catheter and the inappropriate application of the device, referring to the paper tape that was used to secure the catheter to the penis. Resident #13 stated that the sore was very painful and caused him a lot of discomfort so the catheter was removed and he is now left with using a urinal and briefs to assist with his incontinence. On 6/12/14 at 10:03 a.m., Surveyor# reviewed Resident #13's medical record. Resident #13's admission Minimum Data Set (MDS) with a reference date of 4/25/14 indicates Resident #13 scored a 13 on the Brief Interview for Mental Status (BIMS) which indicates Resident #13 is cognitively intact. This initial MDS also indicates Resident #13 has an external catheter, no trial of a toileting program has been attempted and that Resident #13's urinary continence has not been rated, resident has a catheter (indwelling, condom)... Resident #13's medical record indicates Resident #13 was admitted to the emergency room (ER) on 5/19/14 for rectal bleeding. Surveyor # reviewed the ER discharge paperwork dated 5/19/14 and Resident #13 was diagnosed with [REDACTED]." The ER discharge paperwork also stated, "please do not use paper tape on the penis, as the skin is very sensitive and the hair is also ripped out with tape removal." On 6/12/14, Surveyor # spoke with Director of Nursing (DON)-B and Administrator-A to request additional information regarding Resident#13 and the catheter that was in place prior to 5/19/14. Surveyor # was provided with copies of the manufacturer's information for the Extended Wear condom catheter that the facility was using at the time, a [MEDICATION NAME] Diagram that listed the measurements of each catheter ranging from 25-41mm, the directions for application of the catheter, and the facility's catheter care policy. Surveyor# interviewed DON-B at this time and asked what size catheter Resident #13 was using at the time it was in place. DON-B stated that the resident was using a medium 26-30mm and provided a copy of this information. Surveyor # asked if the facility had taken the measurements of Resident #13's penis to ensure that the medium was the proper fit and if so what was his actual measurement. DON-B stated that she was unsure of his actual measurement and was unable to locate any supporting documentation that could verify that a measurement had been completed for Resident #13. At this time, Surveyor # informed DON-B of Resident #13's concerns related to the catheter being too large and one of the staff using tape to secure it. DON-B stated she was unaware of who would apply the catheter that way because no tape is necessary for the application of a condom catheter. Surveyor # also informed DON-B that Resident #13 also reported that the catheter was sometimes left on for a week at a time without being removed for cleaning or even evaluated at all. Surveyor # and DON-B reviewed Resident #13's Treatment Records for the months of April and May 2014 up until the catheter was discontinued on 5/19/14. The Treatment Records indicate that Resident #13 received no catheter treatment during the dates of April 18 through April 30, 2014, and treatment dates were also missed May 11 through May 13, 2014. Surveyor# then referred to the facility's policy dated April 2013 related to condom catheter care. Per the facility's policy, facility staff is to "change external catheter daily and PRN." The facility's condom catheter care policy also stated that the device should be applied "per package directions." Due to lack of appropriate catheter care of changing Resident #13's catheter care daily, and inadequate sizing of the condom catheter with the use of tape to secure the condom catheter in place, Resident #13 experienced a Penile Ulcer, pain and discomfort and is now without the use of the a catheter due to the condom catheter being discontinued on 5/19/14. Resident #13 reported that this has caused him a lot of stress and anguish because he now feels degraded as his only option is to urinate in a brief as if he is an infant. Resident #13 also voiced concerns that the staff take too long to respond to his call light when he requests to be changed so he is now forced to lay in bed soaked with urine for 1-2 hours. As of 6/16/14, Resident #13 was still awaiting a new medical evaluation to resume the use of a catheter.

Based on observation, interview and record review, facility staff did not ensure 3 of 10 residents who were assessed as at risk for falls received adequate supervision, assistance and assistive devices to prevent accidents. - Resident #4's care plan states two staff assist are needed with cares. On 2/21/13, CNA-P was assisting Resident #4; while her attention was diverted, Resident #4 fell out of bed and sustained a fractured clavicle and a subarachnoid hemorrhage. - Resident #10's care plan states a bed alarm is to be used when he is in bed. Staff assisted Resident #10 to bed but did not turn on the bed alarm. - Resident #8's care plan calls for Resident #8 to be in common areas when not in bed. Resident #8 was left in her room in her wheelchair on multiple observations, including after staff came in Resident #8's room in response to her chair alarm. Findings include: 1. From 5/2/13 to 5/8/13, Surveyor # reviewed Resident #4's medical record and a facility self-report. The medical record indicates she has [DIAGNOSES REDACTED]. Resident #4's Care Plan dated 9/14/12 and CNA Care card state Resident #4 is totally dependent on staff for all ADLs (Activities of Daily Living), and she requires assist of two staff for bed mobility, turning and positioning. The facility self-report indicates that on 2/21/13, CNA (Certified Nursing Assistant)-P was assisting Resident #4 with cares while Resident #4 lay in bed. CNA-P rolled Resident #4 onto her right side, facing the door. At the same time, Resident #4's roommate was attempting an unsafe transfer to an unlocked wheelchair. CNA-P turned to speak to the roommate and when she turned back to Resident #4, Resident #4's shoulders were off the bed, CNA-P lost her hold on Resident #4 and the momentum carried Resident #4 to the floor. CNA-P immediately summoned help. A LPN (Licensed Practical Nurse) and DON (Director of Nursing)-B responded and provided physical assessment and assistance. Resident #4 complained of head and side pain. Resident #4 was sent to the Emergency Department where she was diagnosed with [REDACTED]. Resident #4 was admitted to the hospital and after consultation with the neurosurgeon, the Resident/Family decided against surgery for [REDACTED]. Resident was readmitted to the facility on [DATE]. Following the incident, facility staff notified NHA (Nursing Home Administrator)-A and an investigation was conducted. CNA-P, who admitted to providing care without a second staff member present, was suspended pending the outcome of the investigation. Numerous staff were interviewed. This incident was reported to the State Office of Caregiver Quality. Surveyor # reviewed training conducted with staff before and after Resident #4's fall, which includes: 1/9/13 Safe Transfers and Restorative Care 2/15/13 Patient Care 3/17/13 Re: F282 Services Provided in Accordance with plan of care and F323 Preventing accidents; 3/19/13 Fall preventions, resident care cards. 2. Surveyor # reviewed Resident #10's medical record on 5/2/13 & 5/6/13. Resident #10 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The fall risk data collection dated 4/3/13 has a total score of "18." A score of 18 or higher is considered "at high risk." The quarterly MDS (minimum data set) signed as completed on 4/9/13 documents that Resident #10 has a BIMS (brief interview for mental status) total score of "7" which indicates severe impairment. Resident #10 has not fallen since the previous assessment. The monthly physician orders [REDACTED]." The CNA assignment sheet provided to Surveyor # on 5/2/13 for Resident #10 under the section bed alarms documents "yes." The March 2013 treatment record documents "FYI (for your information)" "Bed alarm check function and placement q (every) shift." On 5/2/13 at 1:46 p.m. Surveyor # observed LPN (Licensed Practical Nurse)-C ask Resident #10 if he wanted to lay down. Resident #10 replied "yes" and then requested an enema. LPN-C informed Resident #10 that he had an order for [REDACTED]. At 1:49 p.m. LPN-C wheeled Resident #10 into his room and informed Resident #10 that she would need to find CNA (Certified Nursing Assistant)-J. At 1:52 p.m. LPN-C and CNA-J entered Resident #10's room, washed their hands, and placed gloves on. CNA-J placed a gait belt around Resident #10 and then CNA-J with LPN-C transferred Resident #10 from the wheelchair into bed. Resident #10 was positioned on his left side and LPN-C administered a suppository. Resident #10's incontinence product was fastened and his pants pulled up. CNA-J placed a body pillow along Resident #10's right side, lowered the bed, and placed a mat on the floor along the right side of the bed. Surveyor # observed an alarm box resting on the bedside table to the right of Resident #10's bed. At 2:00 p.m. CNA-J and LPN-C washed their hands and left Resident #10's room. On 5/2/13 at 2:06 p.m. Surveyor # checked the alarm box. Surveyor # observed there was no green light flashing on the alarm box and also noted that the switch on the alarm box was in the off position. Resident #10 is in bed on his back. On 5/2/13 at 2:40 p.m. Surveyor # observed Resident #10 continues to be in bed and the switch on the alarm box continues to be in the off position. On 5/7/13 at 2:19 p.m. Surveyor # informed RN (Registered Nurse)-G of Surveyor # observation of Resident #10 in bed without the bed alarm on. On 5/7/13 at 3:10 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above. 3. Surveyor # reviewed Resident #8's medical record on 5/7/13. Resident #8 was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The falls plan of care with a start date of 5/1/12 includes an approach start date of 12/20/12 of "Unwitnessed Fall: Q (every) 20 minute checks x (times) 24 hour, keep in common area when not in bed, Pt (patient)/Staff education Cran. check (cranial checks)." The Fall Evaluation/Assessment/Physician Notification form dated 12/20/12 has the following checked as new interventions following the fall "resident checks q 30 x q shift," "pt education/staff education/family education" and "keep in common area when out of bed." The quarterly MDS (minimum data set) signed as completed on 1/17/13 documents that Resident #8 has a BIMS (brief interview for mental status) total score of "6" which indicates severe impairment. Resident #8 has fallen since prior assessment with 1 major injury. The fall risk data collection dated 4/9/13 has a total score of "36." A score of 18 or higher is considered "at high risk." Resident #8's last fall was 1/25/13. The annual MDS signed as completed on 4/19/13 documents that Resident #8 has a total BIMS score of "5" which indicates severe impairment. Resident #8 is checked as having no falls which is inaccurate as Resident #8 had a fall on 1/25/13 which is after the prior assessment. The fall CAA (care area assessment) dated 4/19/13 documents, "Resident #8 is a long term care resident. She has dementia with delusions, anxiety, & depression, is impulsive has chair & bed alarm & hx. (history) of falls. Does not ask for assistance with toileting. She attempts to self transfer to toilet & nursing responds to alarm. Continue to offer toilet assistance upon rising, after meals, & before bed, not always receptive can be defensive and argumentative with staff." On 5/2/13 at 11:21 a.m. Surveyor # observed CNA (Certified Nursing Assistant)-J leave Resident #8's room. Surveyor # observed Resident #8 is in her room alone. Surveyor # then heard Resident #8's alarm sound and observed Resident #8 standing by the closet. CNA-J entered Resident #8's room asking Resident #8 what she was trying to get out of the wardrobe. CNA-J then left Resident #8's room. Resident #8 was left in her room and not placed in a common area. On 5/2/13 at 11:24 a.m. Surveyor # observed Resident #8 along in her room. Surveyor # observed Resident #8 stand up from her chair, the alarm sounded and then Resident #8 sat back in her chair. LPN (Licensed Practical Nurse)-C then entered Resident #8's room. Prior to LPN-C entering Resident #8's room, Resident #8 was alone in her room and not in a common area according to her plan of care. On 5/2/13 at 11:43 a.m. Surveyor # observed Resident #8 sitting in her wheelchair in her room along side the bed. There is no staff in the room with Resident #8 and is not in a common area according to her plan of care. On 5/2/13 at 12:09 p.m. Surveyor # observed CNA-J wheel Resident #8 out of her room into the dining room for lunch. On 5/2/13 at 1:10 p.m. Surveyor # observed Resident #8 sitting in the wheelchair by the window in her room. There is no staff in the room with Resident #8 and is not in a common area according to her plan of care. On 5/2/13 at 1:44 p.m. Surveyor # observed Resident #8 sitting in her wheelchair looking into the wardrobe in her room. There is no staff in the room with Resident #8 and is not in a common area according to her plan of care. On 5/6/13 at 9:59 a.m. Surveyor # observed Resident #8 propelling herself in her wheelchair in her room. There is no staff in the room with Resident #8 and is not in a common area according to her plan of care. On 5/6/13 at 11:11 a.m. Surveyor # observed Resident #8 leaning forward in her wheelchair her room activating her alarm. There is no staff in the room with Resident #8. At 11:12 a.m. Surveyor # heard Resident #8's alarm sounding. The alarm continued to sound until 11:13 a.m. when RN (Registered Nurse)-G entered Resident #8 room. Resident #8 had transferred her self onto the toilet and was observed sitting on the toilet. On 5/6/13 at 11:48 a.m. Surveyor # heard Resident #8's alarm sounding from her room. RN-D entered Resident #8's room to respond to the alarm. Prior to RN-D entering Resident #8's room there were no staff in the room with Resident #8. On 5/8/13 at 8:54 a.m. Surveyor # heard Resident #8's alarm sounding. At 8:55 a.m. CNA-E entered Resident #8's room. Resident #8 had transferred her self onto the toilet and was observed sitting on the toilet. Resident #8 had been in her room alone and not in a common area according to her plan of care. At 9:01 a.m. Surveyor # observed CNA-E leave Resident #8's room. At 9:02 a.m. Surveyor # observed Resident #8 looking in her closet. Resident #8 was alone in her room and not in a common area according to her plan of care. On 5/8/13 at 11:09 a.m. Surveyor # asked LPN (Licensed Practical Nurse)-C if Resident #8 is suppose to be in her room alone. LPN-C replied "no, we try to keep her in the common area." On 5/8/13 at 11:25 a.m. Surveyor # observed CNA-E enter Resident #8's room to respond to Resident #8's alarm sounding. Surveyor # observed prior to CNA-E entering Resident #8's room, Resident #8 was in her room alone and not in a common area. On 5/8/13 at 2:35 p.m. Surveyor # informed the Director of Nursing of Surveyor # observations of Resident #8 being in her room alone and that there is an intervention that Resident#8 should be in a common area.

Based on observation, staff interviews and record review, the Facility did not have an effective infection control program to prevent the development and transmission of infections. Staff did not disinfect the glucometer after checking blood sugars for Residents #20 and #21. The glucometer is used for multiple residents. After record review on 5/15/12, it was discovered Resident #20 has Hepatitis C, a blood borne pathogen and the glucometer used for Resident #20 is also used for other Residents. Additionally, the nurse put the non-disinfected glucometer into her pocket, potentially contaminating her clothing and creating another means for spreading a potential infection. The facility failed to follow standards of practice with relation to glucometer use created a finding of Immediate Jeopardy starting on 5/15/12. On 5/15/12 at 1:30 p.m. the Administrator, Director of Nursing, and Corporate RN (Registered Nurse)-C were notified of the Immediate Jeopardy. The Immediate Jeopardy (IJ) was removed on 5/17/12, however; the deficient practice continues at a scope and severity of an E (potential for harm that is not immediate jeopardy/pattern) as the facility must continue to follow through on aspects of their IJ removal plan (e.g., ensuring all nurses have received training on properly disinfecting the glucometers between resident use) to ensure the safety of the six residents whose blood sugars are taken with a common glucometer. Findings include: Division of Quality Assurance (DQA) memos state: DQA Memo 08-013 dated May 6, 2008, Glucose Meters and Infection Control: "...Patient-to-patient transmission of bloodborne pathogens is a well known risk when lancets, needles, and syringes are reused between patients. However, patient-to-patient transmission of pathogens facilitated through the use of devices such as glucose meters may not be as well known. The Centers for Disease Control and Prevention (CDC) has published recommendations for infection control and safe injection practices to prevent patient-to-patient transmission of bloodborne pathogens. Facility staff should evaluate practices related to glucose meter, lancet, and needle use,...Following are specific infection control recommendations published by the CDC that focus on diabetes-care procedures in healthcare and group residence settings...Glucose meters should be assigned to individual patients. If glucose meters are shared between patients, the devices should be cleaned and disinfected between each patient use..." DQA memo 11-031 dated November 29, 2011, Glucose Meters and Infection Control "...Facilities continue to be cited for failing to clean and disinfect meters between residents when the meter is used by multiple residents. One new issue that has arisen is not ensuring the cleaning and disinfecting process is effective. Observations have included staff using cleaning agents that do not kill bloodborne pathogens or staff not adhering to the manufacturers' instructions for the cleaning agents to ensure effectiveness. For example, for a given disinfecting wipe, the manufacture's instructions direct the disinfecting wipe to have contact time on the surface for 2 minutes to be effective. For this particular wipe, an observation of a violation would be staff using a wipe with a contact time of 30 seconds. Facilities should evaluate the products that are being used to clean and disinfect the glucose meters to ensure they are effective against bloodborne pathogens. Facilities should also complete surveillance to ensure staff is following the appropriate instructions for the cleaning agent being used." On 5/15/12 at 7:53 a.m. Surveyor # observed LPN (Licensed Practical Nurse)-G remove a glucometer from the drawer of the medication cart. At 7:57 a.m. Surveyor # entered Resident #20's room with LPN-G. LPN-G placed gloves on, cleansed Resident #20's right middle finger with an alcohol pad, poked the finger, squeezed and placed blood on the testing strip. Resident #20's blood sugar was 168. LPN-G placed the glucometer in her pocket, removed her gloves and washed her hands. At 8:00 a.m. Surveyor # observed LPN-G remove the glucometer from her left pocket of her uniform top. LPN-G placed the glucometer on top of the medication cart and charted the results. LPN-G did not disinfect the glucometer. LPN-G gathered her supplies, picked up the glucometer from on top of the medication cart and at 8:03 a.m. entered Resident #21's room. LPN-G placed gloves on, cleansed Resident #21's right index finger with an alcohol pad, poked her finger, squeezed and placed blood on the testing strip. Resident #21's blood sugar was 181. LPN-G removed her gloves and washed her hands. LPN-G left Resident #21's room and placed the glucometer on top of the medication cart. LPN-G charted the blood sugar results. At 8:07 a.m. LPN-G placed the glucometer inside the medication cart. LPN-G did not disinfect the glucometer prior to placing the glucometer in the medication cart. On 5/15/12 at 8:18 a.m. Surveyor # reviewed Resident #20's medical record. Resident #20 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. On 5/15/12 at 8:20 a.m. Surveyor # reviewed Resident #21's medical record. Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Surveyor # did not note any [DIAGNOSES REDACTED]. On 5/15/12 at 9:47 a.m. Surveyor # asked LPN-G to see the drawer in the medication cart with the glucometers. Surveyor # observed there was one glucometer in the drawer. Surveyor # asked LPN-G if this was the glucometer she used this morning. LPN-G replied, "Yes." Surveyor # asked just this one. LPN-G replied, "Yes." Surveyor # asked LPN-G if there was a procedure for disinfecting the glucometers. LPN-G informed Surveyor # it ' s the purple wipe. Surveyor # informed LPN-G that Surveyor # did not see LPN-G disinfect the glucometers this morning while Surveyor # was observing her with blood sugars. LPN-G replied, "Forgot to do that." At 9:50 a.m., Surveyor # looked at the purple top canister. Surveyor # noted the Super Sani cloth germicidal disposable wipes are the 2 minute germicidal wipe. Surveyor # noted directions on the canister stating that treated surfaces must remain visibly wet for a full 2 minutes. On 5/15/12 at 10:05 a.m. the survey team met with the Administrator, Director of Nursing, and Corporate RN-C. Surveyor # informed the Facility of the observation of LPN-G checking blood sugars and not disinfecting the glucometers in between Residents. Surveyor # informed the Facility that during Resident #20's record review it was noted that Resident #20 was diagnosed in 2009 with Hepatitis C. Surveyor # asked if there is a procedure for Residents with bloodborne diseases. Corporate RN-C stated they should have their own glucometers. On 5/15/12 at 11:25 a.m. Surveyor # reviewed the Facility policy and procedure for Glucose Meter: Sure Compliance revised 1/10. Under general information documents "The meter must be wiped with disinfectant wipe before and after resident use." The failure of facility staff to properly disinfect glucometers used on multiple residents, including a resident with a [DIAGNOSES REDACTED]. On 5/15/12 at 1:30 p.m., the Administrator, Director of Nursing, and Corporate RN-C were informed of the immediate jeopardy, beginning on 5/15/12. The Immediate Jeopardy was removed on 5/17/12 when: * The attending physician, medical director, resident and family were notified of the bloodborne pathogen exposure as identified in the above deficiency. * The facility reviewed and revised the Nursing Policy & Procedure for "Glucose Meter: Sure Compliance." * 50 percent of all licensed staff were re-educated on policy and procedure, proper disinfection protocol for glucometers between resident use, proper glucometer storage. Employees who were not able to be in-serviced will be in-serviced prior to their next scheduled work day. * Professional staff were re-educated on the facility's policy to issue a personal glucometer to residents in isolation and/or history of Hepatitis, HIV, MRSA, VRE., etc. * To monitor the effectiveness of these interventions, the facility will perform random weekly audits of at least 6 residents per week continuing for the ninety days. * Director of Nursing/designee will review audits on a weekly basis and report variances to the QI Committee. QI will determine the need for future monitoring. The deficient practice continues at a scope/severity level of an E (No actual harm that is not immediate jeopardy/pattern) as the facility must continue to follow through on all aspects of their removal plan to ensure the safety of the six residents whose blood sugar levels are taken via a common glucometer. The facility needs to complete their re-inservicing of approximately 20 licensed staff. The facility needs to continue with monitoring the effectiveness of these interventions with random weekly audits for the next 80 days. The Director of Nursing/designee needs to continue reviewing weekly audits and report any variances to the QI Committee.

Based on record review and staff interviews, the facility did not ensure that each resident is offered the pneumococcal vaccine unless contraindicated or evidence that the resident has already been immunized for 1 of 1 residents and that the risk and benefits are offered before the immunization is administered. There was no evidence that Resident #5 was offered the pneumococcal vaccine since her admission and no evidence that she has had the immunization since the age of [AGE] years. On 03/24/12 Resident was diagnosed with [REDACTED]. Findings include; Per clinical record, Resident #5 had a previous admission to the facility from 09/25/10-10/25/10 and returned back to her assisted living residence. On 12/29/11 Resident #5 was admitted again to the facility. Resident #5 is identified per clinical record to be alert, oriented with some confusion and anxiety. A review of the resident's clinical record by Surveyor # on 05/15/12, noted that the resident had received antibiotics 03/24/12 for a [DIAGNOSES REDACTED]. The resident's influenza immunization history was well documented. On 05/16/12, Surveyor # requested from the Nursing Home Administrator (NHA) and Director of Nursing (DON) information that can provide evidence of a history of Resident #5 either having received the pneumococcal vaccine in the past five years or evidence that the vaccine was offered with risk and benefits explained and the resident refused. On 05/17/12 at 9:50 a.m., Surveyor again requested the immunization information for Resident #5. At 10:00 a.m., RN-F informed Surveyor that "there was no documentation of Resident #5 having had or been offered the pneumococcal vaccine....we checked with the clinic to see if they had anything, including the State Immunization website." It was at this time that RN-F stated that the resident "received the pneumococcal vaccine today 05/17/12." On 05/18/12, the facility faxed to Surveyor # documentation from Resident #5 clinic visit of 10/27/10 that documents, "per her immunization history, she had a [MEDICATION NAME] since the age of 65 and is due for a flu shot." This information does not give indication as to when the resident received her last [MEDICATION NAME]. Surveyor noted Resident #5 is [AGE] years of age, therefore; the facility had no information of the resident's pnumococcal vaccination status or pnumococcal vaccination history for the past twenty-eight years. In addition, there was no evidence of attempts to obtain information from the resident or her identified legal representative.