Every finding on record at Aria at Mitchell Manor

Based on interview and record review, the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect all 45 residents residing in the facility.Staffing information for Quarter 2 (January 1 - March 31, 2026) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS.Findings include:The CMS Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, indicates: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS .1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate .Report Quarter: staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows: Fiscal Quarter, Date range: (quarter) 1 October 1-December 31, (quarter) 2 January 1-March 31, (quarter) 3 April 1-June 30, (quarter) 4 July 1-September 30 . Surveyor reviewed the PBJ Staffing Data Report, CASPER Report 1705D, for Fiscal year 2026 (run on 6/17/2026) which indicated the Facility had excessively low weekend staffing for the 2nd Quarter (January 1 - March 31, 2026). Surveyor reviewed the Facility's weekend schedules from January 1 through March 31, 2026. Surveyor noted licensed nurses and certified nursing assistants present on each shift, for each unit. Surveyor noted these schedules consistently had five or six nurses, one medication technician and 11 or 12 Certified Nursing Assistants (CNA) per 24 hours.Surveyor reviewed the Facility Assessment, not dated, for position licensed nurses providing direct care total number of staff on duty each day (on average based on census) is listed as 6. Nurse aides is listed as 13. On 06/29/2026, at 2:20 PM, Surveyor interviewed CNA Scheduler-J regarding the scheduling of shifts. CNA Scheduler-J stated ideally on 1st shift they schedule five CNA, two nurses and a Medication Technician. On 2nd shift there is a PM supervisor, five CNA and two nurses. On the night shift the full time Registered Nurse (RN) works with three CNA. On the RN's days off two nurses are scheduled. Surveyor asked how to determine needs on the floor and CNA Scheduler-J stated it depends on the acuity of the residents. Surveyor asked how to fill open shifts or call ins and CNA Scheduler-J stated that the Nursing Home Administrator (NHA)-A or the scheduler will cover. For nurses there is an order for call in coverage that is followed. They do not use agency. On the weekends they try to schedule five CNA, but working with four per shift (AM/PM) would not be considered short. Surveyor asked about low weekend staffing from January through March. CNA Scheduler-J stated there was nothing out of the ordinary going on. CNA Scheduler-J or NHA-A could work or pick up (hours), the system must not be adding scheduler or NHA-A's hours when they pick up.On 06/30/2026, at 10:47 AM, Surveyor interviewed Director of Nursing (DON)-B and NHA-A regarding the January through March staffing and that the facility triggered for low weekend staff. NHA-A stated that we do not work short, either CNA Scheduler-J or NHA-A are available to work. DON-B stated that the Assistant DON, nurse supervisor, or DON-B will work if there is a need. NHA-A stated they will talk to payroll and corporate to determine why they triggered for low weekend staffing in the 2nd quarter. On 06/30/2026, at 11:37 AM, Surveyor interviewed NHA-A who stated they spoke with the Regional Director of Operations and was told there is no way to fix the low weekend staffing because on weekends all of the administration staff are not here. Surveyor noted administration staff should be coded differently. NHA-A stated they will continue to review. On 06/30/2026, at 2:03 PM, NHA-A stated they have no new information on why facility triggered for low weekend staffing, NHA-A assured Surveyor that they do not leave staff to work short on the weekends. They have a call in system and the floor is always covered.On 07/01/2026, at 8:01 AM, Surveyor interviewed CNA-O who stated that staffing is ok, there are no issues or differences on the weekends. CNA-O stated there are a few of us who like to pick up extra shifts for extra money so coverage is good.On 07/01/2026, at 8:02 AM, Surveyor interviewed CNA-F who is a Medication Technician. CNA-F stated staffing is good, as a medication technician, if staffing is short they pull me to work the floor and that rarely happens. On weekends staffing is not an issue, it is the same as during the week.On 07/01/2026, at 8:05 AM, Surveyor interviewed CNA-K who stated that staffing is wonderful at the facility, weekends are the same as during the week and there are no issues.On 07/01/2026, at 8:08 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who stated that the staffing is good here, LPN-D really likes it here. Weekends are great because residents aren't going out for appointments so no rush to get them out the door. It's a more relaxed time to spend with the residents.

Based on observation, interview and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety for two kitchen refrigerators this has the potential to affect all 45 Residents residing in the facility. *Temperature logs were not up to date for two refrigerators in the kitchen.Findings include:The Facility Policy and Procedure Manual titled Food Storage, dated 2019, documents in part:Procedure.12. Refrigerated food storage.b. TCS (Time and Temperature Control for Safety) foods must be maintained at or below 41 degrees F (Fahrenheit) unless otherwise specified by law. Periodically take temperatures of refrigerated foods to assure temperatures are maintained at or below 41 degrees F.A sample Temp (temperature) Log - Cooler is included with the Policy and Procedure Manual. The instructions are: Record temperatures for each cooler in the department (walk-in and reach-in units). Record time and temperature, and provide initials, twice per day (AM and PM). Notify supervisor immediately if cooler temperature is not within acceptable range of 41 degree F - 33 degrees F.On 06/28/2026, at 8:10 AM, Surveyor observed the temperature log on the walk in refrigerator. Surveyor noted it was last filled out on 6/26/26 for the AM shift. On 06/28/2026, at 8:15 AM, Surveyor interviewed Lead Cook-G regarding the temperature log. Lead Cook-G looked at the temperature log and stated yes it was not completed yesterday. Lead Cook-G stated that they are the person who should have completed it.On 06/28/2026, at 8:20 AM, Surveyor observed the temperature log for the refrigerator in the kitchen cooking area. Surveyor noted the 26th and 27th PM readings were not completed. Lead Cook-G confirmed these two reading were not done.On 06/29/2026, at 1:11 PM, Surveyor interviewed Dietary Manager-H regarding the temperature logs for the two refrigerators not being up to date. Dietary Manager-H stated they are aware Surveyor observed the two refrigerators with temperature logs not completed to date. Dietary Manager-H has already spoken with the staff member on PM shift that missed those temperature readings.

Based on observation, interview, and record review, the facility did not ensure that drugs and biologicals used in the facility were labeled and include the expiration date, when applicable, for 5 (R34, R2, R36, R44, & R5) of 9's resident's insulin.*R34 & R2 insulin pens were together in the bottom of the medication cart and not in bags.*R36 & R44's insulin bottles were together in the bottom of the medication cart and not in a medication container.R5's lispro insulin was not dated when open & used.Findings include:The facility's policy titled, Storage of Medications and revised January 2018 under policy documents Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Under procedures for the section Expiration Dating (Beyond-use dating) D. documents When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1) The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (NOTE: the best stickers to affix contain both a date opened and expiration notation line). The expiration date of the vial or container will be [30] days unless manufacturer recommends another date or regulations/guidelines require different dating.1.) On 6/29/26, at 1:16 p.m., surveyor observed in the 3rd floor medication cart in the bottom drawer a compartment type container. On the right side of the container, the first compartment contained a Lantus Solostar insulin pen for R34 and a second insulin pen, NovoLog mix 70/30 for R2. These two pens were not in a bag or any other medication container.2.) On 6/29/26, at 1:21 p.m., surveyor observed in another compartment of the container was a Lispro insulin bottle for R36 and a Humulin R insulin bottle for R44. These two insulin bottles were not in a medication container.On 6/29/26, at 1:23 p.m., surveyor asked Licensed Practical Nurse (LPN)-D if insulin pens are usually kept in a bag. LPN-D replied yes, but some don't have a bag.3.) On 6/29/26, at 1:24 p.m., surveyor observed in the bottom drawer, all the way to the right a bottle of Lantus insulin for R5 that was open, used and not dated.On 6/29/26, at 1:27 p.m., surveyor asked LPN-D if insulin bottles should be dated when they are opened. LPN-D informed surveyor they should be dated for 28 days.On 6/29/26, at 3:51 p.m., surveyor asked Assistant Director of Nursing/Infection Preventionist (ADON/IP)-C if insulin bottles should be dated when opened. ADON/IP-C replied yes absolutely. Surveyor asked ADON/IP-C if insulin pens are placed in bag. ADON/IP-C informed surveyor each resident has a bag with their name. Surveyor informed ADON/IP-C of the observation of insulin pens and bottles not in a bag or container and R5's insulin not dated when opened.

Based on interview and record review, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property affecting residents residing on the third floor. The facility did not ensure their abuse policy was implemented when Registered Nurse (RN)-M and Housekeeper-N did not have Background Information Disclosure (BID), Department of Justice (DOJ), and Integrated Background Information System (IBIS) background checks updated within four years of working at the facility. Certified Nursing Assistant (CNA)-I did not have Department of Justice (DOJ), and Integrated Background Information System (IBIS) background checks updated within four years of working at the facility. Certified Nursing Assistant (CNA)-E's Background Information Disclosure (BID) was not dated, it could not be determined if the form was completed within the last four years.Findings include:The facility policy and procedure titled Abuse Prevention Program Facility Procedures Training Program and Staff Materials, not dated, documents in part: This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or other individuals.The facility will not knowingly employ individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property or mistreatment by a court of law; or have disciplinary action against their license by a state licensing body as the result of a finding of abuse, neglect, exploitation, misappropriation of property, or mistreatment.On 6/28/2026, Surveyor requested from Nursing Home Administrator (NHA)-A the personnel files for eight sampled employees to review for the required background checks.1.) Registered Nurse (RN)-M was hired on 12/06/2021. The Background Information Disclosure (BID) form was completed 11/01/2021, and the Department of Justice (DOJ) letter and the Integrated Background Information System (IBIS) forms were completed 11/3/2021. Four years have lapsed since the background check information has been submitted. 2.) Housekeeper-N was hired 12/1/2020. The BID form was completed 6/29/2026, and the DOJ letter and IBIS form were completed 6/29/2026. Housekeeper-N's BID form, DOJ letter, and IBIS form were completed 6/29/2026 after Surveyor requested paperwork.3.) Certified Nursing Assistant (CNA)-I was hired 12/1/2020. The BID form was completed 6/28/2026, and the DOJ letter and IBIS form were completed 6/29/2026. CNA-I's DOJ letter and IBIS form were completed 6/29/2026 after Surveyor requested paperwork.4.) Certified Nursing Assistant (CNA)-E was hired 12/1/2020. CNA-E's BID form was not dated; it could not be determined if the form was completed within the last four years.On 06/29/2026, at 9:00 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding the BID, DOJ and IBIS forms that were provided. Surveyor explained that RN-M, Housekeeper-N and CNA-I had outdated forms. NHA-A stated that NHA-A saw the outdated forms and has requested new forms to update the employee records. NHA-A is doing a sweep of all employee files to make sure no other employee records are outdated.On 6/30/2026, at 8:41 AM, Surveyor interviewed NHA-A regarding CNA-E's BID not having a date completed documented. NHA-A was unable to locate the page with the date. NHA-A stated the forms are outdated because these were long time employees. An audit was started yesterday to make sure everyone is in compliance.

Based on interview and record review, the facility did not ensure acceptable parameters of nutritional status were maintained or fluid intake was monitored for 4 (R7, R40, and R5) of 5 sampled residents reviewed for nutrition and hydration. *R7 had significant weight loss three times in 6 months that were not identified or acted on. R7 had a weight loss of 14 percent in 6 months and 9 percent in one month. *R40 had a significant weight loss of 7.9 percent in one month that was not identified or acted on. *R5 was on a daily fluid restriction. The facility did not monitor R5's daily fluid intake. Findings include: The facility policy and procedure titled Weight Management dated 3/1/2021 last revised 4/1/2025 documents: PROCEDURE: 1. All residents admitted to the facility will be weighed according to the following schedule: upon admission and weekly times four weeks. 2. All residents will be weighed every month unless otherwise ordered by the physician or deemed necessary by the dietician or the interdisciplinary team. 3. Monthly weights should be obtained by the 7th of each month. 4. The Dietician should evaluate weights, notify appropriate disciplines of significant changes, and initiate corrective measures. 5. A re-weight will be obtained for any weight change identified as a significant change from previous weight unless the physician has ordered other parameters. 6. All weights will be documented in the resident's electronic medical record. 7. If possible, the weights should be obtained at the same time of day, preferably in the morning and with the same scale to ensure consistency. 8. The scale will be zeroed out before weighing the resident by the staff member obtaining the weight. 9. For residents being weighed in a wheelchair, be sure to obtain the wheelchair weight first, including any cushions/devices in use, and subtract weight from the total weight each time the resident is weighed. 10. The resident's nurse will notify the physician and the resident or resident representative of any significant unexpected or unplanned weight changes. The facility policy and procedure titled Nutrition/Hydration Status Maintenance dated 1/1/2021 last revised 10/17/2025 documents: PROCEDURE: . 2. Monitoring and Documentation: a. Residents will be weighed per facility protocol and as clinically indicated. Weight variances exceeding +/- 5% in 30 days or +/- 10% in 180 days will prompt evaluation and documentation of potential causes and interventions. b. Nursing, dietary, and therapy staff will coordinate to identify and address any barriers to adequate nutrition or hydration, such as swallowing difficulties, poor dentition, mood disorders, fluid restrictions, other medical conditions affecting intake, or functional decline. c. All nutrition- and hydration-related interventions, refusals, and changes in condition will be documented in the medical record, including any education provided and resident or family preferences. 1.) R7 was admitted to the facility on [DATE] with diagnoses of Type 2 diabetes, cancer of the left ovary, and major depressive disorder. R7's Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented R7 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12 and required set up or clean up assistance with eating and maximal to total assistance for all other activities of daily living. R7 was on a therapeutic diet and did not trigger the Nutritional Care Area Assessment for further evaluation. R7's Nutritional Care Plan was initiated on 2/5/2021 and last revised on 9/4/2025 with the potential for nutritional problems related to diet restrictions, risk of malnutrition, insulin dependent diabetes, congestive heart failure, diuretics, chronic kidney disease, anemia, and no teeth with R7 preferring to eat without dentures. On 12/5/2025, R7 weighed 180.5 pounds. On 1/1/2026, R7 weighed 185.6 pounds. On 1/8/2026, Registered Dietician (RD)-Q completed and documented a Quarterly Nutrition Assessment in R7's medical record. RD-Q documented R7 remained on a no added salt/low sodium diet with supplementation of 4 ounces of Glucerna twice daily. R7 was able to feed self independently after tray was set up and intakes were 76%-100% with some 51%-75%. The plan was to continue the supplement as R7's weights have remained stable over the past year. R7 had not had a significant weight gain since starting the supplement in 2022. RD-Q documented they would continue to monitor intakes and trends. On 2/3/2026, R7 weighed 176.5 pounds, a loss of 9.1 pounds, or 4.9 percent in one month. No reweight was documented and no documentation was found indicating the physician or RD-Q were notified by nursing staff of the significant weight loss. On 3/5/2026, R7 weighed 180.1 pounds. On 4/6/2026, R7 weighed 169.9 pounds, a loss of 10.2 pounds, or 5.7 percent in one month. On 4/6/2026, RD-Q completed and documented a Quarterly Nutrition Assessment in R7's medical record. RD-Q documented R7 remained on a no added salt/low sodium diet with supplementation of 4 ounces of Glucerna twice daily. R7 was able to eat independently after the tray was set up. Intakes appeared slightly decreased from the last Quarterly Nutrition Assessment ranging from 26%-100% completion. R7 had been working with Speech Therapy since 2/2026 due to coughing with intake. R7 was discharged from services on 4/8/2026 after meeting their goals. RD-Q documented R7 showed a significant weight loss of 5.7 % (10 pounds) in one month and 8.5% (15.7 pounds in three months. Weight is out of usual body weight and intakes do appear decreased. RD-Q documented a reweight would be requested to confirm the loss. Surveyor noted no reweight was documented and the physician was not notified of the significant weight loss. On 5/7/2026, R7 weighed 170.5 pounds. On 6/8/2026, R7 weighed 155.1 pounds, a loss of 15.4 pounds, or 9 percent in one month. On 6/12/2026 at 8:30 AM in the progress notes, the Nurse Practitioner (NP) documented in their monthly follow-up note R7's vital signs and chart were reviewed. R7's weight on 6/8/2026 was 155.1 pounds, significantly down from 170.5 pounds on 5/7/2026 representing a notable weight loss of approximately 15 pounds. Blood sugars were reviewed and were running mostly in the low to mid 100s; no changes were warranted at that time. The NP documented R7 had wounds at that time. Surveyor noted increased nutrition is necessary when healing wounds and weight loss is not desirable. R7 lost 30.5 pounds in 5 months, or 16.43 percent, from 1/1/2026 to 6/8/2026. No reweights were obtained after the weight losses on 2/3/2026, 4/6/2026, or 6/8/2026. No documentation was found indicating the physician or Registered Dietician (RD)-Q were notified by nursing staff of the significant weight losses at the time the weights were obtained. In an interview on 6/28/2026 at 10:21 AM, Surveyor asked R7 if they had been losing weight recently. R7 stated yes, they were not hungry and did not have much of an appetite except for spaghetti and they only have that once a week. R7 was not upset about the weight loss but did not know why it was occurring. In a phone interview on 6/30/2026 at 1:05 PM, Surveyor asked RD-Q and RD Manager-R how they are notified or become aware of significant weight loss. RD-Q stated they go through the monthly weights independently and are occasionally notified of weight changes, but mostly it is through RD-Q's own review. RD-Q stated the nutrition assessment for each resident is completed with the MDS cycle and RD-Q will complete the nutrition and hydration Care Area Assessments with the comprehensive MDS assessments. Surveyor asked RD-Q and RD Manager-R if they would expect the facility to call and notify them of a significant weight loss. RD Manager-R stated they were the dietician at the facility prior to RD-Q, and they would discuss weight concerns during morning meetings. Surveyor asked RD Manager-R how often they were at the facility in a week. RD Manager-R stated once a week the dietician is at the facility. Surveyor asked RD-Q if they were aware of R7's significant weight loss in February, April, and June of 2026. RD-Q stated they attended the morning meetings and did not hear about R7's weight loss. RD-Q reviewed their notes and stated a reweight was requested in April 2026 as well as this month, June 2026. RD-Q stated R7's weight did not seem to be R7's ordinary weight and that is why there was a request for a reweight. Surveyor asked if RD-Q was contacted about the weight loss. RD-Q stated, no, RD-Q found the weight loss on their own when reviewing the chart. RD-Q stated when looking at R7's record, a reweight was not documented. RD-Q stated R7 did not have a change in eating habits and how much is being eaten. Surveyor asked RD-Q if they would expect nursing staff to call them. RD-Q stated a lot of times they will just bring it up in morning meetings or they will ask if it seems out of the ordinary to anyone else. Surveyor asked RD-Q what the facility protocol was for getting reweights. RD-Q stated at a sister facility the weight policy says if there is a 5- or 10-pound weight change, they are to get a reweight. RD-Q confirmed they were not notified by the facility of R7's significant weight changes. In an interview on 6/30/2026 at 1:41 PM, Surveyor asked Licensed Practical Nurse (LPN)-X what the policy was for getting resident weights. LPN-X stated a weight is gotten when the resident is a new admission, weekly times four weeks, and then monthly unless the weights are ordered differently. LPN-X stated the nurse on the floor enters the weight into the resident's electronic medical record. Surveyor asked LPN-X if the nurse can view the previous weight to see if the weight is similar or if there is a variance. LPN-X stated yes, the previous weight is visible. Surveyor asked LPN-X if the weight is significantly higher or lower, is there a pop-up to alert the nurse to that weight change. LPN-X stated yes. Surveyor asked LPN-X what is done when there is a significant weight change. LPN-X stated they would get a reweight, maybe that day or the next day; it depended on what was going on at the time on the unit. Surveyor asked LPN-X if R7 has had a lot of weight loss. LPN-X reviewed R7's record and read off the last few months of weights. LPN-X stated R7 tended to have water weight here and there and was put on a diuretic. Surveyor asked LPN-X when that diuretic was started. LPN-X stated R7 had been on a diuretic since 2021. Surveyor asked LPN-X what they would have done if they had been the nurse to put the weight in with the significant weight loss. LPN-X stated they would have gotten a reweight and would let the Director of Nursing (DON) know. Surveyor asked if the dietician would be involved in the conversation. LPN-X stated the dietician would bring in magic cup or another supplement and the DON would be the one that would notify the dietician or physician. In an interview on 6/30/2026 at 1:58 PM, Surveyor asked DON-B how RD-Q becomes aware of significant weight loss. DON-B stated RD-Q looks at the monthly weights. Surveyor shared with DON-B the concern R7 had weight loss every other month for the last six months and there was no documentation that the dietician or physician was notified of the significant weight loss. DON-B stated RD-Q emailed a report on 6/22/2026 with residents listed that had a weight concern and R7 was not on that list. DON-B stated RD-Q sent an email on 6/25/2026 stating R7 lost 15 pounds in 1 month and 25 pounds in 3 months so was requesting a reweight. DON-B stated no reweights were gotten on Friday (6/26/2026) and DON-B would have gotten the reweight yesterday (6/29/2026) but there were other pressing matters. DON-B texted LPN-D on 6/25/2026 to get a reweight and either LPN-D did not get the weight or did not document the weight. Assistant DON (ADON)-C called LPN-D during the interview to have LPN-D send their notes from 6/26/2026 with R7's reweight on it. DON-B stated R7 was not on RD-Q's email report on 4/2026 for a weight concern and RD-Q's report on 5/29/2026 requested reweights on two residents but not for R7. DON-B stated R7 does have a diagnosis of cancer that could contribute to the weight loss. On 6/30/2026 at 2:49 PM, ADON-C stated LPN-D sent a text back with the notes from 6/25/2026 and R7's reweight was 157.2. (The weight on 6/8/2026 was 155.1.) Surveyor noted the reweight was similar to the original weight on 6/8/2026. In an interview on 7/1/2026 at 9:55 AM, DON-B stated R7's June 2026 weight was wrong, and they got a reweight last night. Surveyor reviewed the weights that were entered into R7's medical record after the interview on 6/30/2026. R7's weights were entered into the medical record documented R7 weighed 157.2 pounds on 6/25/2026 and 170.6 pounds on 6/30/2026. Surveyor asked DON-B how and if the physician is notified of significant weight loss. DON-B stated the physician is notified by RD-Q in an email and RD-Q will make a note in the resident's record. DON-B stated there was no note in R7's record by RD-Q so RD-Q did not catch the weight loss, and the physician was not notified. 2.) R40 was admitted to the facility on [DATE] with a diagnoses of Parkinson's disease, Type 2 diabetes, protein calorie malnutrition, dysphagia, and gastroesophageal reflux disease. R40's admission MDS dated [DATE] documented R40 as having severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 6 and needed set-up assistance for eating. R40 was receiving physical and occupational therapy. R40 had an order for a mechanical soft diet on admission. R40's Activities of Daily Living (ADL) Care Plan initiated on 5/29/2026 documented R40 was able to eat independently. On 5/29/2026, R40 weighed 131.4 pounds. On 6/1/2026, R40 weighed 131.4 pounds. On 6/4/2026 at 12:36 PM in the progress notes, Registered Dietician (RD)-Q documented the Nutrition Admit Assessment. RD-Q documented (R40) transferred to the facility from an assisted living due to a decline in mobility, significant weight loss, and overall decline in nutritional status. (R40) had refused the majority of meals with some meal intake 0-25%. RD-Q documented (R40) had a limited weight history available with the last primary care physician visit on 6/5/2025 with a weight of 175.2. RD-Q documented the weight history shows a significant weight loss of 25.2% (44 pounds) in one year. RD-Q documented concern for further decline in nutrition status and weight loss due to meal refusals and poor intakes. RD-Q documented current supplementation remains appropriate and recommended consideration of an appetite stimulant if appropriate and within goals of care. On 6/10/2026, R40 weighed 118.8 pounds, a loss of 12.6 pounds or 9.6 percent in one week. R40 was admitted to hospice services on 6/12/2026 with the primary diagnosis of Parkinson's disease. No Significant Change MDS was initiated or completed to comprehensively assess the decline in ADLs or weight loss to coordinate care for R40 with the facility and hospice. Cross reference F637. On 6/17/2026, R40 weighed 116.7 pounds. On 6/21/2026, R40 weighed 118.6 pounds. On 6/26/2026, R40 weighed 121.0 pounds. R40 lost 10.4 pounds from admission on [DATE] to 6/26/2026, or 7.9 percent in one month. No documentation was found that RD-Q or a physician was notified of the significant weight loss. In an interview on 6/28/2026 at 1:15 PM, Surveyor asked R40 if they had recently lost weight. R40 stated probably but was not sure because they only weighed R40 a couple of times. Surveyor observed R40 lying flat on the back with jerking, tremor-type movements of the arms. R40 stated they only liked breakfast and would eat lunch and dinner if they served breakfast three times a day. In a phone interview on 6/30/2026 at 1:05 PM, Surveyor asked RD-Q and RD Manager-R how they are notified or become aware of significant weight loss. RD-Q stated they go through the monthly weights independently and are occasionally notified of weight changes, but mostly it is through RD-Q's own review. RD-Q stated the nutrition assessment for each resident is completed with the MDS cycle and RD-Q will complete the nutrition and hydration Care Area Assessments with the comprehensive MDS assessments. Surveyor asked RD-Q and RD Manager-R if they would expect the facility to call and notify them of a significant weight loss. RD Manager-R stated they were the dietician at the facility prior to RD-Q, and they would discuss weight concerns during morning meetings. Surveyor asked RD Manager-R how often they were at the facility in a week. RD Manager-R stated once a week the dietician is at the facility. Surveyor asked RD-Q if they were familiar with R40. RD-Q stated they last saw R40's weight for the admission MDS and have not had a chance to look at R40's weights. RD-Q stated they talked to Director of Nursing (DON)-B about R40's nutrition status and about the significant weight loss prior to admission. Surveyor shared with RD-Q and RD Manager-R the concern R40 has lost over 10 pounds in the first month of admission. RD-Q stated they attended morning meetings and did not hear about R40's weight loss. Surveyor shared that R40 had been placed on hospice on 6/12/2026. RD-Q stated with R40 refusing meals and the low intake, RD-Q anticipated weight loss. RD-Q stated they attempted to meet with R40 but R40 refused to speak to RD-Q. RD-Q stated the speech therapy notes said the same thing about refusing to speak to them. Surveyor shared with RD-Q the conversation with R40 about liking the breakfast meal and would eat breakfast three times a day. RD Manager-R stated they were not sure if the kitchen gets the resident preferences but would bring it up to the kitchen staff to talk to R40. RD-Q stated they were not notified by nursing staff that R40 had a weight loss. In an interview on 6/30/2026 at 1:41 PM, Surveyor asked Licensed Practical Nurse (LPN)-X what the policy was for getting resident weights. LPN-X stated a weight is gotten when the resident is a new admission, weekly times four weeks, and then monthly unless the weights are ordered differently. LPN-X stated the nurse on the floor enters the weight into the resident's electronic medical record. Surveyor asked LPN-X if the nurse can view the previous weight to see if the weight is similar or if there is a variance. LPN-X stated yes, the previous weight is visible. Surveyor asked LPN-X if the weight is significantly higher or lower, is there a pop-up to alert the nurse to that weight change. LPN-X stated yes. Surveyor asked LPN-X what is done when there is a significant weight change. LPN-X stated they would get a reweight, maybe that day or the next day; it depended on what was going on at the time on the unit. Surveyor asked LPN-X if they were aware of R40's weight loss. LPN-X stated R40 is good about drinking the Ensure supplement but has to be fed because R40 shakes. Surveyor asked LPN-X if staff were aware that R40 needs to be fed. LPN-X stated yes, because otherwise the food would go everywhere and R40 would not get any of it in their mouth. Surveyor shared with LPN-X R40's Care Card which documented R40 was independent with eating. LPN-x stated that was not right; there was no way R40 could feed themselves. Surveyor asked LPN-X what they would have done if they had been the nurse to put the weight in with the significant weight loss. LPN-X stated they would have gotten a reweight and would let the Director of Nursing (DON) know. Surveyor asked if the dietician would be involved in the conversation. LPN-X stated the dietician would bring in magic cup or another supplement and the DON would be the one that would notify the dietician or physician. In an interview on 6/30/2026 at 1:58 PM, Surveyor asked DON-B how RD-Q becomes aware of significant weight loss. DON-B stated RD-Q looks at the monthly weights. Surveyor shared with DON-B the concern R40 had lost 10 pounds in the first month of admission. DON-B stated the initial weight may have been a hospital weight. Surveyor shared with DON-B the admission weight on 5/29/2026 of 131.4 pounds was the same weight on 6/1/2026. DON-B stated the second weight is suspicious being exactly the same as the previous weight. Surveyor shared with DON-B the concern R40's Care Plan does not match R40's ability to eat independently. Surveyor shared LPN-X's interview stating R40 needs to be fed due to the jerking motion of the arms. DON-B stated if staff notice a decline, they should let management know. Surveyor shared with DON-B if R40's Significant Change MDS had been initiated with the election of hospice, these changes and deficits may have been caught and addressed. Surveyor shared with DON-B the concern R40 had a significant weight loss that RD-Q was not aware of and it is the policy of the facility to have RD-Q notify the physician. No documentation was found that the physician was notified and RD-Q stated they were not aware of R40's weight loss. 3.) The facility's policy titled, Nutrition/Hydration Status Maintenance and revised 10/17/25 under Procedure #3. documents Fluid Restrictions: Residents with a physician-ordered fluid restriction shall have the restriction implemented and monitored in accordance with the physician's order and individualized plan of care. a. For residents on a fluid restriction: i. The total daily fluid allowance will be clearly communicated to nursing, dietary, and other applicable staff. ii. Fluids shall be distributed throughout the day to promote comfort, compliance, and adequate symptom management while adhering to the prescribed restriction. Iii. Nursing staff will accurately document fluid intake in accordance with the residents' care plan and facility policy. R5's diagnoses include end stage renal disease and dependence on renal dialysis. R5's potential for fluid volume deficit (dehydration) r/t (related to) fluid restriction initiated & revised 6/3/25 document the following interventions: *Fluid restriction of 2000 ml(milliliters)/24 hours, 360 nursing, 1640 dietary. Initiated & revised 6/3/25. *Monitor fluid intake. Initiated 6/3/25. *Monitor/report S & S (signs and symptoms) dehydration: dry mouth, poor skin turgor, dark/concentrated urine or decreased urinary output, sunken eyes, constipation, confusion/altered mental status, warm/dry skin. Initiated 6/3/25. *Notify physician when indicated. Initiated 6/3/25. R5's physician orders include an order dated 1/6/26 which documents Dietary: Fluid restrictions 2000 ml/24 hours - 120 ml every shift for nursing & 540 every shift with dietary. R5's nutrition note dated 4/28/26 written by RD (Registered Dietitian)-Q documents CBW (current body weight): 4/28- 140.6#. Significant loss of 6.6% (10#) x 1 month. Resident has frequent weight changes d/t fluid status. Resident also noted to have decreased intake throughout hospital stay. 2 meals charted since readmission at 0-50%. Resident does have an order for Glucerna QD (every day) to support intakes. Have not received labs from dialysis RD this month r/t (related to) resident's hospital admission. Hosp (hospital) Labs: 4/27- Ca (calcium): 10.6H, alb (albumin): 3.4L. 4/17- A1C (glycated hemoglobin): 6.6% improved from 6.9% on 1/2026. Notified NP & facility re: significant weight change via email on 4/28. R5's significant change MDS (minimum data set) with an assessment reference date of 5/20/26 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R5 is assessed as requiring set up for eating. R5's nutritional CAA (care area assessment) dated 5/21/26 under analysis of findings for nature of problem/condition documents BMI (body mass index): 25.7 – overweight. Significant loss x (times) 1 month r/t (related to) fluid changes/decreased intake. Therapeutic diet appropriate for dx (diagnosis) management. Under care plan considerations for describe impact of this problem/need on the resident and your rationale for care plan decision documents see clinical notes. R5's nutrition note dated 6/23/26 written by RD-Q documents 140.6#. Current weight shows no significant weight changes at 1/3/6 months. Ongoing communication with resident's HD (hemodialysis) RD. Estimated dry weight: 140.8#. Labs: 6/18 Hgb (hemoglobin) 9.2L (low), glucose 54L, the rest were WDL (within desired limits). Facility glucose trends over the past week: mid 100s to low 200s. PO (by mouth) intakes continue to be variable ranging from 0-100%. Receives Glucerna QD (every day) to support intakes – accepts daily per MAR (medication administration record). R5's physician progress note dated 6/26/26 written by Nurse Practitioner (NP)-AA under assessment and plan includes documentation of Continue low-dose metoprolol tartrate 25 mg (milligrams) every 12 hours. Monitor for symptoms of volume overload. Fluid removal managed via hemodialysis three times weekly. R5's Certified Nursing Assistant (CNA) Kardex as of 6/29/26 under the eating/nutrition section documents *EATING: The resident is independent with eating with staff to provide set up assistance. *MONITOR-MEAL PERFORMANCE. Surveyor noted R5's Kardex does not include R5's fluid restriction. Surveyor reviewed R5's June TAR (treatment administration record) which includes Dietary: Fluid restriction 2000 ml/24 hours – 120 ml every shift for nursing & 540 every shift with dietary -every shift – Start date 1/6/26. Surveyor noted there is a check mark with initials daily for each shift. The TAR does not indicate the number of fluids R5 actually consumed each shift. On 6/30/26, at 7:18 a.m., surveyor observed R5's breakfast tray on R5's over bed table. Surveyor observed that there is a cup of coffee, glass of juice and R5's breakfast plate is covered. On 6/30/26, at 10:31 a.m., surveyor asked CNA-S if R5 has any type of food or fluid restriction. CNA-S replied no not that I know of. On 6/30/26, at 10:32 a.m., surveyor asked CNA-K if R5 has any type of food or fluid restriction. CNA-K replied not that I know of, but you can check the Kardex. On 6/30/26, at 10:36 a.m., CNA-K informed surveyor R5 is still on fluid restriction. Surveyor asked CNA-K how he found out R5 is on a fluid restriction. CNA-K informed surveyor he spoke with the nurse. On 6/30/26, at 10:37 a.m., surveyor observed there are three water glasses in R5's room. There is a water glass dated 6/29 AM (morning) partially filled on R5's over bed table. There are two water glasses on the dresser next to R5's recliner. One water glass is dated 6/29 with initials documented approximately half filled, and another water glass not dated which is full. On 6/30/26, at 10:42 a.m., surveyor asked Licensed Practical Nurse (LPN)-X if R5 is under a fluid restriction. LPN-X replied, let me look. LPN-X then informed surveyor R5 is on a 2000 fluid restriction in a 24-hour period and is non-compliant. Surveyor asked LPN-X if residents on fluid restrictions can have water glasses in their room. LPN-X informed surveyor they should get water in their room. Surveyor asked LPN-X if the amount of fluid R5 actually consumes is documented anywhere to ensure R5 is staying within their fluid restrictions. LPN-X replied no. On 6/30/26, at 11:44 a.m., surveyor asked Director of Nursing (DON)-B how the facility monitors a resident's fluid restriction. DON-B explained she keeps on the board who is on fluid restriction. DON-B informed surveyor when there is an order for fluid restriction, she contacts the dietitian for specific breakdown for staff to follow. There is a sign inside the resident's room and at the nurse's station with the breakdown per shift of how much nursing and dietary are allowed. This information is transferred into the care plan. Surveyor asked if a resident is on fluid restriction, are water glasses allowed in the room. DON-B replied only if it's figured in what they receive. Surveyor informed DON-B surveyor has observed water glasses in R5's room. Surveyor informed DON-B surveyor noted R5 is on a 2000 ml fluid restriction and asked if R5's actual fluid consumption is monitored & documented to ensure R5 stays within the fluid restriction. DON-B replied other than the care plan and order, no. On 6/30/26, at 1:22 p.m., surveyor spoke with RD-Q and WI (Wisconsin) area manager-R on the telephone to inquire about resident's fluid restrictions. RD-Q informed surveyor they have a sheet with breakdown for fluid that she references. Surveyor informed RD-Q surveyor noted R5 is on a 2000 ml fluid restriction and asked if anyone is monitoring R5's actual fluid intake. RD-Q informed surveyor she doesn't believe it's tallied up. WI area manager-R informed surveyor usually nursing does, its nursing observing so they can see if a resident is compliant and can notify the physician. RD-Q informed surveyor she hasn't seen any documentation that R5 is non-compliant with the fluid restriction. On 6/30/26, at 1:47 p.m., surveyor asked Activity Assistant-CC if she was aware of any resident on a fluid restriction. Activity Assistant-CC informed surveyor she was not aware of any.

Based on interview and record review the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 1 (R54) of 5 Residents reviewed for pressure injuries.On 4/1/26 Wound Nurse Practitioner (NP)-Z changed treatment orders for R54's left hip pressure injury. The facility did not implement this order.Findings include:The facility's policy titled, Wound Management - Wound Prevention and Treatment and revised 10/11/2025 under policy documents The purpose of this program is to assist the facility in the care, services, and documentation related to the occurrence, treatment, and prevention of pressure as well as non-pressure-related wounds. Under provision and procedure #10 documents The pressure ulcer(s) will be evaluated weekly, and the nurse or physician will document the size, location, appearance, odor (if any), drainage (if any), and current treatment ordered.R54's diagnoses include adult failure to thrive, dementia, and cerebrovascular disease. R54's admission assessment dated [DATE] under the skin condition section documents for site 26) Left trochanter (hip). Under description documents Unstageable: 5 x (by) 3.5 x 0.1. 80% necrotic tissue, 10% slough, 10% gran. (granulation).R54's Braden scale assessment dated [DATE], 1/14/26, 1/21/26, 1/28/26, & 2/4/26 all have a score of 12 which indicates high risk for pressure injury development.R54's initial wound evaluation and management summary dated 1/14/26 by Wound Nurse Practitioner (NP)-Z documents unstageable (due to necrosis) of the left, lateral hip full thickness. Under wound size (L x W x D) (length times width times depth) documents 4.45 x 4.3 x 0.1 cm (centimeter). Thick adherent black necrotic tissue (eschar) is 80% and slough is 20%.R54's wound evaluation and management summary dated 1/21/26 by Wound NP-Z documents Stage 4 pressure wound of the left, lateral hip full thickness. Wound size is 3.3 x 3.8 x 1.0 cm. Thick adherent devitalized necrotic tissue is 80% and slough is 20%. Under additional note documents Post-debridement assessment of this previously unstageable necrotic wound has revealed the underlying deep tissue at the muscle/fascia level, which had been obscured by necrosis prior to this point. This wound has now revealed itself to be a Stage 4 pressure injury. This is not a wound deterioration.From 1/28/26 through 3/25/26 surveyor noted weekly assessments of R54's left hip pressure injury with treatments being completed according to physician's orders.R54's wound evaluation and management summary dated 4/1/26 by Wound NP-Z documents Stage 4 pressure wound of the left, lateral hip full thickness. Wound size is 2 x 1.5 x 0.3 cm. Undermining is 4.2 cm at 7 o'clock. Slough is 10% and granulation is 90%. Under dressing treatment plan for primary dressing documents add Iodosorb Gel once daily and as needed if saturated, soiled or dislodged. Cleanse with wound cleanser once daily and as needed if saturated, soiled or dislodged. Irrigate wound and allow to penetrate for 3-5 minutes. Continue Alginate Calcium w/ (with) silver once daily and as needed if saturated, soiled or dislodged. Discontinue Leptospermum Honey. Secondary dressing continue Foam with border once daily and as needed if saturated, soiled, or dislodged. Under peri wound documents continue skin prep once daily and as needed if saturated, soiled, or dislodged.R54's wound evaluation and management summary dated 4/8/26 by Wound NP-Z documents Stage 4 pressure wound of the left, lateral hip full thickness. Wound size is 1.9 x 1.5 x 0.4 cm. Undermining is 4.0 cm at 7 o'clock. Slough is 10% and granulation is 90%. Wound NP-Z continued the same treatment ordered on 4/1/26.R54's wound evaluation and management summary dated 4/15/26 by Wound NP-Z documents Stage 4 pressure wound of the left, lateral hip full thickness. Wound size is 1.7 x 1.4 x 0.4 cm. Undermining is 4.0 cm at 7 o'clock. Slough is 10% and granulation is 90%. Wound NP-Z continued the same treatment ordered on 4/1/26.R54 was discharged from the facility on 4/17/26.Surveyor reviewed R54's April TAR (treatment administration record) and noted from 4/1/26 to 4/15/26 the facility was completing the following treatment for R54's left lateral hip: Cleanse with NS (normal saline), pat dry; Apply manuka honey to wound bed, pack wound with calcium alginate silver and cover with border foam dressing; MWF (Monday, Wednesday, Friday) and PRN (as needed). The start date of this treatment is 3/20/26 and discontinued on 4/15/26. The facility did not implement the new daily treatment Wound NP-Z ordered on 4/1/26. From 4/1/26 to date of discharge the facility did not follow treatment orders for R54 left lateral hip pressure injury.On 7/1/26, at 8:20 a.m., surveyor met with Assistant Director of Nursing/Infection Preventionist (ADON/IP)-C, who is also the wound nurse and Director of Nursing (DON)-B to discuss R54's left hip pressure injury. At 8:38 a.m. Surveyor informed ADON/IP-C and DON-B surveyor did not see where the facility picked up the new order for R54's left hip pressure injury which Wound NP-Z ordered on 4/1/26. Surveyor informed ADON/IP-C and DON-B the facility was doing the incorrect treatment from 4/1/26 until R54's discharge on [DATE]. ADON/IP-C reviewed Wound NP-Z's wound assessment dated [DATE]. ADON/IP-C informed surveyor she wasn't sure why the treatment wasn't changed and stated to surveyor I messed up.

Based on interview and record review, the facility did not ensure the COVID-19 immunization education was provided and the refusal was documented for 1 (R40) of 5 sampled residents reviewed for immunizations.*R40 did not have documentation of education with the benefits of the COVID-19 vaccine and the refusal or acceptance of the vaccine in the medical record.Findings include:The facility policy and procedure titled Infection Control - Influenza, Covid and Pneumococcal Immunizations for Residents documents: PROCEDURE: . Covid Immunization: 1. Before offering the covid immunization, each resident and or the resident representative will receive education regarding the benefits and potential side effects of the vaccine; 2. Each resident is offered covid immunization unless the immunization is medically contraindicated or the resident has already been immunized. 3. The resident and or the resident representative has the opportunity to refuse immunization; and 4. The resident's medical record includes documentation that indicates, as a minimum, the following: a. That the resident or resident representative was provided education regarding the benefits and potential side effects of covid immunization, and b. That the resident either received the covid vaccination or did not receive the covid vaccination due to medical contraindications or refusal. 5. Covid immunization will be offered in accordance with CDC.R40 was admitted to the facility on [DATE].Review of R40's immunization record showed R40 was due to receive the COVID-19 vaccination. No documentation was found in R40's medical record that R40 was provided education on the COVID-19 immunization or R40's refusal to receive the immunization.In an interview on 6/30/2026 at 11:01 AM, Surveyor asked Assistant Director of Nursing (ADON)-C and Director of Nursing (DON)-B what the facility process was for offering immunizations to newly admitted residents. DON-B stated DON-B or ADON-C will approach the new resident with the immunization information and document the education was given along with either the acceptance or refusal of the immunization. ADON-C stated the second shift nursing supervisor will also ask new residents about the immunizations as well. Surveyor shared with ADON-C and DON-B the concern R40 did not have any documentation that education was provided or the response of R40 to the question of getting or refusing the COVID-19 immunization. DON-B reviewed R40's medical record and agreed there was no documentation. DON-B shared R40's hospital discharge paperwork that documented R40 had declined the immunization at the hospital. Surveyor shared the facility still had the obligation to present the same information to R40 upon admission to the facility. DON-B agreed.

Based on interview and record review, the facility did not ensure the pneumococcal immunization education was provided and the refusal was documented for 1 (R40) of 5 sampled residents reviewed for immunizations.*R40 did not have documentation of education with the benefits of the pneumococcal vaccine and the refusal or acceptance of the vaccine in the medical record.Findings include:The facility policy and procedure titled Infection Control - Influenza, Covid and Pneumococcal Immunizations for Residents documents: PROCEDURE: . Pneumococcal Immunization: 1. Before offering the pneumococcal immunization, each resident and or resident representative receives education regarding the benefits and potential side effects of the vaccine; 2. Each resident is offered pneumococcal immunization unless the immunization is medically contraindicated or the resident has already been immunized; 3. The resident and or resident representative has the opportunity to refuse immunization; and 4. The resident's medical record includes documentation that indicates; as a minimum, the following: a. That the resident or resident representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and b. That the resident received the pneumococcal vaccination or did not receive the pneumococcal vaccination due to medical contraindication or refusal. 5. Pneumococcal immunization will be offered in accordance with CDC.R40 was admitted to the facility on [DATE].Review of R40's immunization record showed R40 was due to receive the Prevnar 20 vaccination. No documentation was found in R40's medical record that R40 was provided education on the pneumococcal immunization or R40's refusal to receive the immunization.In an interview on 6/30/2026 at 11:01 AM, Surveyor asked Assistant Director of Nursing (ADON)-C and Director of Nursing (DON)-B what the facility process was for offering immunizations to newly admitted residents. DON-B stated DON-B or ADON-C will approach the new resident with the immunization information and document the education was given along with either the acceptance or refusal of the immunization. ADON-C stated the second shift nursing supervisor will also ask new residents about the immunizations as well. Surveyor shared with ADON-C and DON-B the concern R40 did not have any documentation that education was provided or the response of R40 to the question of getting or refusing the pneumococcal immunization. DON-B reviewed R40's medical record and agreed there was no documentation. DON-B shared R40's hospital discharge paperwork that documented R40 had declined the immunization at the hospital. Surveyor shared the facility still had the obligation to present the same information to R40 upon admission to the facility. DON-B agreed.

Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R44) of 2 Residents during medication administration.* Appropriate hand hygiene was not observed during R44's medication administration.Findings include:The facility's policy titled, Infection Control - Hand Hygiene, and last revised 4/1/25 under policy statement documents The facility's policy is to perform hand hygiene per national standards from the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO).On 6/29/26, at 8:28 a.m., surveyor observed Licensed Practical Nurse (LPN)-D prepare R44's medication. LPN-D poured 5 ml (milliliter) of Amantadine Hydrochloride 50 mg (milligrams)/5 ml into a medication cup and 5 ml of Valproic acid 250 mg/5 ml into another medication cup. From a blister pack, LPN-D punched one tablet cefuroxime axetile 250 mg and one tablet Amlodipine 5 mg into a medication cup. LPN-D then poured 30 cc (cubic centimeters) of critical care protein. At 8:37 a.m., after pouring R44's critical care protein, LPN-D cleaned off the top of the medication cart with a disinfectant wipe. Surveyor observed LPN-D did not perform any hand hygiene after disinfecting the top of the medication cart. LPN-D then continued with preparing R44's medication including folic acid 400 mcg (micrograms) which LPN-D placed gloves on as the physician orders required 2.5 tablets. LPN-D broke one tablet of folic acid in half. LPN-D continued to wear her gloves until she completed preparing R44's medication. At 9:04 a.m., LPN-D crushed R44's medication together except for Clonazepam 0.5 mg which was crushed separately. At 9:10 a.m., LPN-D removed her gloves and threw the gloves away in the garbage container on the medication cart. LPN-D then placed gloves & a gown on and entered R44's room. Surveyor observed LPN-D did not perform any hand hygiene after removing her gloves.At 9:12 a.m., LPN-D entered R44's room with R44's medication. LPN-D placed paper towels on a chair and filled a graduate with 360 cc of water. LPN-D informed surveyor she was going to check R44's blood sugar. After LPN-D checked R44's blood sugar, LPN-D removed her gloves, went to the room door and asked for gloves. LPN-D placed a new pair of gloves on. Surveyor observed LPN-D did not perform any hand hygiene after removing her gloves. LPN-D flushed R44's G (gastrostomy) tube, administered R44's medications, flushing in between and upon completion. At 9:38 a.m., LPN-D rinsed the syringe used to administer R44's medication, removed her gloves stating now we can leave and come back to give insulin. LPN-D removed her gown and cleansed her hands at the medication cart.On 6/30/26, at 9:01 a.m., surveyor asked Director of Nursing (DON)-B what the expectation regarding hand hygiene during medication pass is. DON-B informed surveyor at least an alcohol-based hand sanitizer between patients, if known contamination then soap & water at a minimum. Surveyor asked DON-B after removing gloves, should a nurse perform hand hygiene. DON-B replied yes, the same. Surveyor informed DON-B of the observations of LPN-D not performing hand hygiene while preparing and administering R44's medication.

Based on observation, interview, and record review the Facility did not ensure there was a medication error rate below 5 percent. There were 4 medication errors in 30 opportunities which resulted in a medication error rate of 13.33%. Medication errors were identified for 1 (R44) of 2 residents observed.R44 did not receive the correct dose of Amantadine HCI & Valproic Acid, did not receive Multivitamins Plus Iron child oral tablet chewable 18 mg (milligrams) and Clear lax was not initially administered enterally according to physician orders.Findings include:1.) On 6/29/26, at 8:28 a.m., surveyor observed Licensed Practical Nurse (LPN)-D prepare R44's medication. LPN-D poured 5 ml (milliliter) of Amantadine Hydrochloride 50 mg (milligrams)/5 ml into a medication cup. LPN-D then poured 5 ml of Valproic acid 250 mg/5 ml into another medication cup.On 6/29/26, at 9:19 a.m., surveyor observed LPN-D cleaned the end of R44's G (gastrostomy) tube with an alcohol wipe stating he has feeding & meds and then flushed R44's feeding tube with 30 cc (cubic centimeters) of water. LPN-D administered 5 ml of Valproic Acid, flushed R44's tube with 30 cc of water and then administered 5 ml of Amantadine HCI.On 6/29/26, starting at 7:24 p.m., surveyor reviewed R44's physician orders and noted an order dated 4/30/26 which documents Amantadine HCI Oral Solution 50 mg/5ml (Amantadine HCI) Give 15 ml enterally two times a day for treat Dyskensia. LPN-D administered 5 ml not 15 ml according to physician orders. This resulted in a medication error for R44.Surveyor reviewed R44's physician orders and noted an order dated 6/16/26 which documents Valproic Acid Oral Solution 250mg/5ml. (Valproate Sodium) Give 24 ml enterally three times a day for Epilepsy. LPN-D administered 5 ml not 24 ml according to physician orders. This resulted in a medication error for R44.This observation resulted in two medication errors for R44.2.) On 6/29/26, at approximately 8:50 a.m., surveyor observed LPN-D remove one tablet Multivitamin with Minerals from a bottle into a medication cup with other medication tablets. At 8:59 a.m. surveyor observed LPN-D remove a second tablet of Multivitamin with Minerals from the bottle into a medication cup with other medication tablets including the previous multivitamins with minerals tablet. At 9:04 a.m., LPN-D poured all the medication tablets into an envelope and crushed R44's medication. At 9:31 a.m., LPN-D stated she's going to add 20 ml to get them (referring to the crushed tablets) mushy and will keep putting water in there. LPN-D flushed R44's G-tube with 30 cc of water, administered a portion of the crushed medication, added additional water and repeated this process multiple times.On 6/29/26, starting at 7:24 p.m., surveyor reviewed R44's physician orders and noted an order dated 4/30/26 which documents Multivitamins Plus Iron Child Oral Tablet Chewable 18 Mg (Pediatric Multiple Vitamins w/ (with) Iron. Give 1 tablet enterally one time a day for supplement. Another order dated 4/30/26 which documents Thera M Plus Oral Tablet (Multivitamins w/Minerals) Give 1 tablet enterally one time a day for supplement. LPN-D did not administer Multivitamins Plus Iron Child Oral Tablet Chewable 18 Mg (Pediatric Multiple Vitamins w/ Iron. This resulted in a medication error for R44.This observation resulted in the third medication error for R44.3.) On 6/29/26, at approximately 8:50 a.m., Surveyor observed LPN-D pour a packet of Potassium Chloride 20 meq (milliequivalent) into a cup & add water. LPN-D then poured 17 grams of Clear Lax into the cup containing Potassium Chloride 20 meq and added additional water for 240 ml. LPN-D then mixed the two medications together.On 6/29/26, at 9:25 a.m., LPN-D flushed R44's G tube with 30 cc of water and asked R44 if he wanted to drink or put in the tube. R44 asked LPN-D what it was. LPN-D informed R44 potassium and Miralax. LPN-D put a straw in the mixture and R44 drank a small amount. LPN-D raised the head of the bed, R44 drank a little more and then stopped drinking. LPN-D then administered the potassium chloride & clear lax via R44's G-tube. Upon completion, LPN-D flushed R44's G tube with 30 cc of water.On 6/29/26, starting at 7:24 p.m., Surveyor reviewed R44's physician orders and noted an order dated 4/30/26 Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350 (Bulk)), Give 17 gram enterally one time a day for constipation. LPN-D initially administered this medication orally which was the incorrect route. This resulted in a medication error for R44.This observation resulted in R44's fourth medication error.On 6/30/26, at 9:01 a.m., Surveyor asked Director of Nursing (DON)-B should nurses follow physician orders during medication pass. DON-B replied yes. Surveyor then informed DON-B of the four medications observed for R44 with LPN-D.

Based on observation, interview, and record review the facility did not ensure 1 (R2) of 1 residents reviewed for Post-traumatic stress disorder (PTSD) receive culturally competent, trauma informed care in accordance with professional stands of practice and accounting or resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of R2.R2 has a diagnosis of PTSD. There is not a PTSD assessment to identify R2's past history of trauma nor is there a person-centered PTSD care plan which includes what triggers R2's PTSD and interventions.Findings include:The facility's policy titled, Trauma Informed Care and dated 10/24/22 under policy documents The facility will ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice, as well as residents' preferences and experiences. Residents will be screened and assessed upon admission in order to identify any history of trauma and/or post-traumatic stress disorder (PTSD). Residents who display or are diagnosed with a mental disorder, psychosocial adjustment difficulty, and/or PTSD will be provided with appropriate treatment and services to attain the highest practicable level of mental and psychosocial wellbeing. Under procedures #8 documents The IDT (interdisciplinary team) Team will ensure that an individualized resident centered care plan is developed for resident that has experienced a traumatic event. The care plan will include but is not limited to the following: *Identification of the stressor/past life trauma. *Identification of interventions that mitigate against re-traumatization. *Identify triggers that could cause re-traumatization. *Clinical manifestations experience by the resident. *Resident-specific goals for preventing re-traumatization. *Interventions including referral for Psychological and Psychiatry services as indicated. *Appropriate recreational activities and or therapeutic relaxing interventions. *The need to obtain assistance from outside agencies and support groups in the community. *The specific cultural, spiritual and professional interventions that would be beneficial for the resident. 12. Residents will be assessed for any history of trauma on each annual assessment and with a significant change in condition. Identified Traumatic events will be care planned for as listed in #8.R2's diagnosis includes post-traumatic stress disorder. R2 has a behavior problem depressed mood r/t (related to) depression, anxiety, bipolar, PTSD, ADHD (Attention-Deficit/Hyperactivity Disorder) care plan initiated & revised 11/22/22 that documents the following interventions:*Administer medications as ordered. Monitor/document for side effects and effectiveness. Initiated 11/18/22.*Anticipate and meet the resident's needs. Initiated 11/18/22.*Behavior monitoring. 1. Depressed Mood. Interventions: 1. Visit 1:1. 2. Visiting with spouse/family. 3. Inform nurse of behavior change. 4. Sees psych services. Initiated 11/18/22 & revised 10/25/23.*Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Initiated 11/18/22.*Monitor prn (as needed) behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Initiated 11/18/22 and revised 3/29/24.*Provide a program of activities that is of interest and accommodates residents' status. Initiated 11/18/22.Surveyor noted that this behavior care plan does not identify R2's past history of trauma, does not include what triggers may cause R2's re-traumatization and does not include person centered interventions to address R2's PTSD.R2's behavior note dated 3/23/26 at 1559 (3:59 p.m.) written by Social Services Director (SSD)-DD documents Resident reviewed during March Behavior meeting. Resident has diagnosis of anxiety, depression, insomnia, ADHD (Attention-Deficit/Hyperactivity Disorder), PTSD. Resident is taking Buspar 15mg (milligrams) TID (three times daily), Wellbutrin 100mg TID, Trazodone 50mg daily, Adderall 20mg BID (twice daily), Prozac 40mg daily and prochlorperazine5mg TID. Resident is followed by psych services at facility, psych to try a dose reduction but resident hesitant psych will continue to follow up with resident. Resident to be reviewed quarterly or as needed.R2's quarterly social service reassessment dated [DATE] does not address R2's PTSD.R2's quarterly MDS (minimum data set) with an assessment reference date of 3/31/26 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R2 is assessed as having a mood score of 00 and is assessed as not having any behavior. For active diagnosis under psychiatric/mood disorder PTSD is marked yes.R2's psychiatry note dated 4/27/26 by Advance Practice Nurse Prescriber (APNP)-BB under chief complaint documents Follow up psychiatric evaluation and medication management. Under history of present illness includes documentation of 04/27/2026 At today's visit he was seen in his room lying in bed watching videos on his phone. He remains at his baseline. He denied any concerns related to depression or anxiety and stated, I'm good. He continues to decline medication changes and prefers to stick to his routine. Staff deny any concerns regarding mood, behavior, or cognition. Sleep is restful with trazodone, and he denies daytime drowsiness. Cognition appears to be at baseline with a BIMS score of 11. Under post medical/surgical history includes Post-traumatic Stress Disorder, Unspecified. PTSD is not included under assessment/plan.R2's behavior note dated 6/22/26 at 1558 (3:58 p.m.) written by SSD-DD documents Resident reviewed during June behavior meeting. Resident has diagnosis of depression, anxiety, ADHD, and insomnia. Resident is taking Buspar 15mg TID, Wellbutrin 100mg TID, Trazodone 50mg daily, Adderall 20mg BID, Prozac 20mg daily and Compazine 5mg TID. Resident has hx (history) of depressed mood, self-isolation. Resident is followed by psych services at facility. Resident to be reviewed quarterly or as needed.On 6/28/26, at 3:31 p.m., surveyor observed R2 sitting in a Broda chair in R2's room. Surveyor asked R2 about their PTSD. R2 stated it may be from ADHD but didn't want to discuss this further with surveyor. Surveyor asked R2 if there is anything that gets them upset. R2 informed surveyor if someone is in their face or when there is loud talking, they go off.R2's Certified Nursing Assistant (CNA) Kardex as of 6/29/26 under the behavior/mood section documents *Behavior monitoring. 1. Depressed Mood. Interventions 1. Visit 1:1; 2. Visiting with spouse/family (Surveyor noted R2 was never married); 3. Inform nurse of behavior change; 4. Sees psych services. *If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. *Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Under the section monitoring includes documentation of *Monitor prn (as needed) behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. R2's CNA Kardex does not address R2's PTSD and any triggers which may re-traumatize R2.On 6/29/26, at 11:56 a.m., surveyor asked Certified Nursing Assistant (CNA)-S to inquire about R2. CNA-S informed surveyor R2 does really good with her and she talks to R2 about what she is going to do for them. Surveyor asked CNA-S if she has ever been told what topics she shouldn't speak with R2 about or anything she shouldn't do which may trigger R2's PTSD. CNA-S replied no.On 6/29/26, at 12:03 p.m., surveyor asked CNA-EE if anyone has spoken to her about what may trigger R2's PTSD. CNA-EE replied no.On 6/29/26, at 12:04 p.m., surveyor asked Social Services Director (SSD)-DD what she can tell surveyor about R2's PTSD. SSD-DD replied I don't know too much about it, an outside psych provider diagnosed R2 with it. SSD-DD explained R2 doesn't really go into details about R2's PTSD with her and R2 has not had a moment of PTSD either. Surveyor asked SSD-DD if she does PTSD (trauma informed care) assessments. SSD-DD replied I've never done one before, no. Surveyor asked SSD-DD if PTSD is something she would care plan for. SSD-DD replied I think I do have it in my behavior care plan, would have to double check. Surveyor informed SSD-DD surveyor had reviewed R2's care plan and did note a behavior care plan but this care plan does not include what triggers R2's PTSD and person-centered interventions for R2's PTSD. SSD-DD stated to surveyor R2 has never spoken to her about their PTSD so how could she care plan. Surveyor shared with SSD-DD surveyor had asked R2 about their PTSD. R2 informed surveyor it may be from their ADHD and really didn't want to speak with surveyor about it but did tell surveyor R2 doesn't like when someone is too close or speaks loudly.On 6/29/26, at 12:30 p.m., surveyor spoke with APNP Psychiatry-BB on the telephone. Surveyor asked APNP Psychiatry-BB what she could tell surveyor about R2's PTSD. APNP Psychiatry-BB replied you know I have to be honest it's a historical diagnosis. APNP Psychiatry-BB explained she doesn't have a lot of data and a lot of times a resident comes in with their diagnoses. APNP Psychiatry-BB informed surveyor R2 doesn't engage deeply with her. PTSD is on R2's diagnoses list but can't tell surveyor much about it. APNP Psychiatry-BB informed surveyor R2's diagnosis of PTSD is dated 11/7/22 which was well before she started his care explaining she's been with the company as a psych np for a year. On 6/29/26, at 1:00 p.m., surveyor asked Director of Nursing (DON)-B who is responsible for PTSD (trauma informed care) assessments. DON-B replied that would be [name], the Social Service Director. Surveyor asked DON-B if SSD-DD would create a PTSD care plan. DON-B replied yes.

Based on observation, interview, and record review the facility did not ensure each resident is treated with dignity and respect that promotes maintenance or enhancement of quality of life for 1 (R39) of 13 residents.*On 6/28/26 Certified Nursing Assistant (CNA)-S stood while feeding R39.Findings include:The facility's policy titled, Resident Rights - Exercise of Rights and revised 4/20/25 under policy statement documents All residents have rights guaranteed to them under Federal and State laws and regulations. This policy is intended to lay the foundation for the resident rights requirements in long-term care facilities. Each resident has the right to be treated with dignity and respect. All activities and interactions with residents by any staff, temporary agency staff, or volunteers must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's goals, preferences, and choices. When providing care and services, staff will respect individuality and honor and value their input. Under procedure #2 documents The facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. 9. Each resident will be treated with dignity and respect.R39's diagnoses includes Parkinson's Disease and Dementia.R39's quarterly minimum data set (MDS) with an assessment reference date of 3/31/26 has a BIMS (brief interview mental status) score of 3 which indicates severe cognitive impairment. R39 is assessed as requiring set up or clean up assistance.On 6/28/26, starting at 12:12 p.m., surveyor observed the lunch meal in the 3rd floor dining room. During this observation, at 12:27 p.m., surveyor observed CNA-S walk over to R39, pick up a spoon and start to feed R39 their lunch. Surveyor observed CNA-S stood the entire time she was feeding R39. At 12:33 p.m., surveyor observed CNA-S finish feeding R39 and removed the clothing protector from R39. On 6/30/26, at 8:58 a.m., surveyor asked Director of Nursing (DON)-B what the expectation is when staff are assisting resident to eat. DON-B replied they are sitting next to the resident not standing over them. Surveyor informed DON-B of the observation during the lunch meal of CNA-S standing and not sitting when feeding R39. DON-B informed surveyor she can't say why CNA-S stood and did not sit.

Based on observation and interview the Facility did not ensure 1 (R45) of 12 residents were provided privacy during personal cares.*R45 was not ensured privacy during wound care when R45's door was left open during the care.Findings include:The Facility Policy and Procedure titled Resident Rights - Exercise of Rights last revised 4/20/25, documents (in part): Procedure.2. The facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.3. The facility will protect and promote the rights of the resident.On 06/30/2026, at 7:48 AM, Surveyor observed wound care for R45. R45 was turned toward the wall with R45's bare, back side exposed to the door. During wound care Assistant Director of Nursing (ADON)-C dropped the clean border foam dressing on the ground. Licensed Practical Nurse (LPN)-L opened the door to leave the room to get a new dressing. LPN-L left the door open while looking for a new dressing. Another Surveyor approached and asked LPN-L a question and the doorremained open with R45's buttock exposed to the hallway.On 06/30/2026, at 7:49 AM, ADON-C used their foot to kick the door shut. ADON-C was supporting R45 on R45's side with R45's bare backside to the door.On 06/30/2026, at 9:06 AM, Surveyor interviewed ADON-C regarding how they felt about LPN-L leaving the door open when LPN-L left the room. ADON-C stated did you see me kick it shut, I had my back to the door and felt a breeze and realized it was open. ADON-C was concerned R45 was exposed to the hallway.On 06/30/2026, at 10:42 AM, Surveyor interviewed DON-B regarding privacy while cares were being performed. DON-B stated oh no, that should not happen.On 7/01/2026, at 8:16 AM, Surveyor interviewed R45 regarding the door being left open while wound care was being done. R45 replied that they did not notice as they were facing towards the window. R45 stated they would prefer the door shut so they are not exposed.

Based on interview and record review the facility did not ensure a resident who uses an as needed (PRN) psychotropic has an order limited for 14 days for 1 (R5) of 5 residents reviewed for unnecessary medication.R5 has an order for PRN lorazepam (Ativan) with an order date of 5/14/26. There is no end date for R5's PRN lorazepam and no documented rationale for continued use.Findings include:The facility's policy titled, Psychotropic Drug Use and revised 4/1/25 under policy F. documents PRN (as needed) orders for psychotropic are limited to 14 days, except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond the 14 days, her/she should document their rationale in the resident's medical record and indicate the duration of the PRN order.R5's diagnosis includes anxiety disorder.R5's psych note dated 5/7/26 by Advanced Practice Nurse Prescriber (APNP) Psychiatry-BB under history present illness includes documentation of She continues to utilize Lorazepam for anxiety and a panicked feeling. She gets 0.25 mg every eight hours as needed for anxietyand 0.5 mg QHS (every hour sleep) scheduled. Under assessment/plans includes documentation of F41.0 Panic Disorder (Episodic Paroxysmal Anxiety) - Stable and managed with lorazepam. She continues to experience intermittent anxiety and restlessness but remains at her behavioral baseline. She was able to discuss concerns appropriately and responded well to reassurance regarding her room change. She continues dialysis three times weekly and acknowledged concerns regarding vaping during treatments after discussion. No acute anxiety symptoms or panic episodes were observed during today's visit. Staff will continue to monitor for changes in anxiety, behaviors, and coping abilities.R5's physician orders include with an order date of 5/14/26 Lorazepam oral tablet 0.5 mg (milligrams) (Lorazepam) Controlled Drug. Give 0.25 mg by mouth every 8 hours as needed for anxiety. Surveyor noted R5's physician orders does not have an end date for PRN Lorazepam.R5's NP note dated 6/5/26 by NP-AA under assessment and plan documents *F41.9- Anxiety Disorder, Unspecified *: Patient having lots of anxiety; does see behavioral health. Patient is a high fall risk. Continue current anxiolytics; do not increase dosage due to fall risk. Continue sertraline 25 mg PO at bedtime. Continue lorazepam 0.5 mg PO at bedtime and lorazepam 0.25 mg PO every 8 hours PRN anxiety per facility orders. Behavioral health follow-up as arranged by facility.Surveyor noted R5's NP-AA's notes dated 6/12/26, 6/19/26, & 6/24/26 under assessment and plan for anxiety disorder has the same verbiage of NP-AA's note dated 6/5/26.Surveyor was unable to locate an end date for R6's PRN Lorazepam and documented rationale for its continued use.On 6/30/26, at 11:40 a.m., surveyor asked Director of Nursing (DON)-B if PRN psychotropic medications have end dates. DON-B explained that the pharmacist will send their recommendations with stop dates. DON-B informed APNP Psychiatry-BB has not been in since the pharmacy recommendation which is dated 5/31/26. Surveyor informed DON-B R5's PRN Lorazepam did not have a stop date when R5's PRN Lorazepam was ordered on 5/14/26 and there is no documented rationale for continued use of the PRN Lorazepam.On 7/1/26 DON-B provided surveyor with pharmacy recommendation dated 5/31/26 signed by APNP Psychiatry-BB on 6/29/26 which has a prn duration of 90 days and clinical rationale of necessary for psychosocial comfort. Surveyor noted this was not reflected in R5's medical record or current orders.

Based on interview and record review, the facility did not initiate or complete a comprehensive Significant Change Minimum Data Set (MDS) assessment within 14 days after a significant change was identified for 1 (R40) of 12 sampled residents reviewed.R40 started hospice services on 6/12/2026. On 6/30/2026, 18 days after the election of hospice, a Significant Change MDS assessment had not been scheduled or completed.Findings include:The Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual dated 10/2025 documents: An SCSA (Significant Change in Status Assessment) is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD (Assessment Reference Date) must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since then nursing home remains responsible for providing necessary care and services to assist the resident in achieving their highest practicable well-being at whatever stage of the disease process the resident is experiencing.R40 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease. R40's admission MDS dated [DATE] documented R40 as having severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 6 and needing set up assistance for eating, moderate assistance with oral hygiene and bed mobility, and dependent with toileting. R40 was receiving physical and occupational therapy.On 6/12/2026, R40 was admitted to hospice. On 6/30/2026, Surveyor noted a Significant Change MDS had not been scheduled to capture the onset of hospice to coordinate R40's care.In an interview on 6/30/2026 at 9:08 AM, Surveyor asked MDS Licensed Practical Nurse (LPN)-Y what the facility process was for scheduling, completing, and signing MDS assessments. LPN-Y stated they schedule the MDS assessments and complete the assessments, and then a Registered Nurse (RN) or the Regional RN signs the assessments. Surveyor asked LPN-Y what would constitute the need for a Significant Change MDS assessment. LPN-Y stated that any time a resident goes out to the hospital, they are looked at for the potential of having a significant change and if they return with a fracture, have intravenous antibiotics, or have any skilled nursing needs on readmission, a Significant Change MDS assessment would be started. LPN-Y stated if the resident has a fall in the facility or if they are completing a Quarterly MDS and notice a decline in activities of daily living (ADLs), then they will change it to a Significant Change MDS assessment. Surveyor asked LPN-Y about a resident that elects hospice. LPN-Y stated a Significant Change MDS assessment is done for a resident that either starts hospice or stops hospice with an ARD seven days after signing onto hospice and then they have 14 days to complete the assessment. Surveyor asked LPN-Y if they were aware R40 signed onto hospice services on 6/12/2026. LPN-Y was not aware R40 had elected hospice. LPN-Y stated they usually find out about hospice at morning meetings and the facility did not have all the meetings they normally do because things kept coming up that needed to be done. LPN-Y stated they had never missed a Significant Change MDS assessment before and would schedule one at that time. Survyoer noted a Significant Change MDS assessment was entered into the computer charting system with an ARD of 7/3/2026.On 6/30/2026 at 3:30 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern R40 did not have a Significant Change MDS assessment with the start of hospice services to coordinate care with the hospice agency and the facility as well as capture the declines R40 was showing with ADLs and weight loss.

Based on record review and staff interviews, the facility did not ensure that they reported allegations of possible abuse or mistreatment to the State Survey Agency for 1 (R1) of 3 sampled residents.On 12/22/25, R1 was repositioned in bed by a facility Certified Nursing Assistant (CNA-D) when R1 experienced severe pain in her left ribs. R1 was sent to the emergency room and diagnosed with a fracture to the 7th and 8th anterior left ribs. The facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to other officials including to the State Survey Agency in accordance with State law through established procedures.Findings include:Policy Review: (Company name) Healthcare Abuse Prevention Program (undated)This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property , and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents.IV. Internal reporting Requirements and Identification of Allegations:Any allegation of abuse or any incident that results in serious bodily injury will be reported to the required regulatory agencies immediately, but not more than two hours of the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. On 2/3/26, Surveyor conducted a medical record review for R1. R1 was originally admitted to the facility on [DATE] with diagnoses of left pelvic fracture, chronic respiratory failure, severe protein-calorie malnutrition, muscle weakness, dysphagia, pressure ulcer of sacral region, gastroesophageal reflux disease (GERD) and repeated falls. R1 needed the assistance of 1 staff for activities of daily living, toileting and bed mobility.A review of R1's plan of care noted the following:The resident (R1) has an activities of daily living (ADL) self-care performance deficit r/t (related to) multiple fractures (pelvic, sternal and vertebral), rheumatoid arthritis, acute respiratory failure with O2 (oxygen) dependence. Interventions include:Provide Adaptive equipment necessary during transferBED MOBILITY: The resident requires assistance by 1 staff to turn and reposition in bed every 2-3 hours and as necessary. Bilateral bed rails to help promote bed mobility.TRANSFER: The resident requires assistance by 1 staff member using 2WW to transferEncourage the resident to participate to the fullest extent possible with each interaction.Encourage the resident to use bell to call for assistance.Monitor/document/report PRN (as needed) any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function.Praise all efforts at self care.PT/OT (physical therapy/occupational therapy) evaluation and treatment as per MD (physician) orders.A review of R1's Physician orders document the following: Q2-3hr (every 2 to 3 hours) repositioning with wedge from right side to back. every 2 hours for Prophylaxis related to NONDISPLACED FRACTURE OF ANTERIOR WALL OF LEFT ACETABULUM, SUBSEQUENT ENCOUNTER FOR FRACTURE WITH ROUTINE HEALING (S32.415D) Order date is 11/17/2025. Nursing Note dated 12/22/2025 at 9:15 PM eINTERACT SBAR (Situation Background Assessment Recommendation) Summary for Providers Situation: The Change In Condition/s reported on this CIC (change in condition) Evaluation are/were: Pain (uncontrolled). Nursing observations, evaluation, and recommendations are: While being repositioned by CNA, resident started c/o (complaints of) severe pain in her Left Ribs. Pain is sharp and stabbing and hurts upon palpation. R1 has a Hx (history) of rib fractures. Writer observed no redness, swelling or bruising at site. R1 repositioned to her right side and given PRN (as needed) Tramadol, which was ineffective. Sent to (name of hospital) ER (emergency room) at R1's request for further eval and treatment. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Dr. updated. Ok with sending the resident to ER.Physician Progress Note dated 12/23/2025 at 10:34 AM; Patient (R1) currently admitted to (name of hospital). Chart reviewed in EPIC (name of hospital electronic medical record) Care Everywhere and updated. Pain in ribs noted last night in patient with known osteoporosis and multiple other pathologic rib fractures.X-ray report below from 12/22/25:1.Suspected left eighth and possibly seventh anterior rib fractures. (anterior rib fracture is a break in the rib bone near the front of the chest, usually caused by direct impact like car accidents, falls, or less commonly, severe coughing) Old bilateral rib fractures are also noted.2. Several thoracic compression fractures are identified and can be seen previously. There is slight apparent increase in the degree of compression of the T7 superior endplate.3. No acute cardiopulmonary findings.Will follow and assume care after hospitalization with pain control and continued management of osteoporosis and myelodysplastic syndrome.On 2/3/2026, Surveyor conducted a review of the hospital Discharge summary, dated [DATE], and noted the following: History of present illness: (R1) Was brought in from rehab facility when she while turning developed severe pain involving chest and hip and was found to have rib fractures and had been admitted for pain control . Plan: admitted as inpatient. Placed on telemetry. Evidence of sacral and coccyx pressure decubitus wound care. Severe pain due to rib fractures and history of pelvic. Added Dilaudid and oxycodone for pain control.On 12/23/25, R1's representative contacted Director of Care Transitions- C reporting on 12/22/25, a CNA came into R1's room extremely agitated and aggressive that R1 had pushed her call light. R1's representative said that the CNA took her anger out on R1 and came behind her, grabbed her around her torso and yanked her backwards in the bed resulting in fractures to R1's left 7th and 8th ribs. The representative for R1 reported to the State Survey agency that they were not aware of any action taken for the first incident and that R1 was transported to the hospital the next day for the 2nd incident. (Cross-reference F585). On 2/4/26 at 8:30 AM, Surveyor interviewed DON (Director of Nursing)- B regarding R1's broken ribs and the allegation that this injury occurred while CNA (Certified Nursing Assistant)- D was repositioning R1 in bed. DON- B stated they made a conclusion that an investigation into the incident was not needed because they spoke with the Physician and based on all of R1's comorbidities and risk factors and previous fractures that there was not concern for abuse or mistreatment. R1 is very fragile so things like this can happen. DON- B stated she spoke with CNA- D who stated that while repositioning R1 in bed, she heard a crack. CNA-D immediately went and got the nurse who completed an assessment on R1. R1 initially did not want to go to the hospital for further evaluation. Surveyor asked DON- B if this incident was reported to the State Survey agency as potentially being an incident of abuse or neglect. DON- B stated again that with R1's history of fractures and comorbidities the facility did not feel they had to report the incident.On 2/4/26 at 10:15 AM, Surveyor interviewed Administrator- A and DON- B regarding the concerns from R1's representative for the cares she received on 11/13/25 and 12/22/25. DON- B acknowledged that she had spoken with R1's Representative because the Representative had questions about the 12/22/25 incident. DON- B stated that she had answered all of the questions and reviewed R1's medical chart with R1's Representative. Surveyor asked DON- B what the questions were that R1's Representative had. DON- B stated that she just wanted to know how this could have happened; referring to R1's diagnosis rib fractures upon admission to the hospital on [DATE] . DON- B stated that she never questioned whether the staff did something to R1 and that R1 had a history of fractures and was very fragile. DON- B again stated that she did not consider the representatives' questions as an allegation of abuse or neglect. Surveyor stated that the concern was that R1 had been repositioned several times prior to 12/22/25 without incident and the allegation is that the CNA was in a hurry and angry and grabbed R1 from the torso, resulting in injuries. This is why the Representative wanted to know how this could have happened, when it was done so many times prior without incident. As of the time of exit, the facility was unable to provide additional information as to why they did not report to the State Survey Agency the potential mistreatment of R1 during repositioning in bed on 12/22/25.

Based on interview and record review, the facility did not address grievances by ensuring documentation of the concern, conducting a thorough investigation of the issues identified or provide resolution of the concerns brought to the attention of facility staff, for 1 (R1) of 3 residents reviewed for grievances.On 11/14/25 and 12/23/25, a representative for R1 expressed concerns to facility staff regarding the care R1 was receiving. The facility did not investigate and ensure a follow-up to the concerns expressed or provide details of a resolution regarding the grievance. Findings include:Policy Review: Grievance Policy, revised 2/12/25.Policy Statement: [NAME] Healthcare's policy is to provide a system whereby residents and/or representatives can voice concerns about the quality of services received at the facility.Procedure: 1. When a grievance is noted (either verbal or written), the resident or their representative may speak to any member of the facility staff and report the nature of the grievance or submit a written grievance form. 2. At the time of the grievance, the staff member will attempt to resolve the issue or direct the resident/representative to the appropriate department head or staff member for further action and/or notify the Grievance Officer.3. Upon notification of a resident grievance, information sufficient to identify the individual registering the concern, the resident's name (if not the individual submitting the report), date of receipt, nature of the matter, and location of the resident will be recorded.4.The Grievance Officer will route the grievance to the appropriate department head related to the grievance filed, and an investigation of the grievance will be conducted.5. After thorough research has been conducted, the Department Heads and/or Grievance Officer will work with staff identified as key individuals critical to problem resolution for the specifically identified concern. All efforts will be made to efficiently and expeditiously resolve the grievance. 6. All grievances receive immediate priority and must be investigated with efforts made toward resolution within 7 days.7. The resident will be provided with a verbal follow-up to their grievance. A representative for R1 alleged they had reported care concerns to Director of Care Transitions - C regarding care issues that occurred on 11/13/25 and 12/22/25. On 11/14/25 the representative shared facility staff were providing cares to R1 (on 11/13/25) when they became very frustrated when R1 needed frequent adjustments in bed. It was reported that staff had called R1 names and yelled at R1 for using the call light and wasting staffs time by having them come in so oftenOn 12/23/25, R1's representative again contacted Director of Care Transitions- C reporting on 12/22/25, a CNA came into R1's room extremely agitated and aggressive that R1 had pushed her call light. R1's representative said that the CNA took her anger out on R1 and came behind her, grabbed her around her torso and yanked her backwards in the bed resulting in fractures to R1's left 7th and 8th ribs. The representative for R1 reported to the State Survey agency that they were not aware of any action taken for the first incident and that R1 was transported to the hospital the next day for the 2nd incident.On 2/3/26, Surveyor conducted a review of the facility's grievance log and noted that there were no documented concerns from R1 or any Representative of R1.On 2/4/26 at 9:58 AM, Surveyor interviewed Director of Care Transitions- C regarding grievances that had been reported to them by R1's representative. Director of Care Transitions- C stated that although he remembers talking with R1's representative, he does not recall exactly what it was all about. Director of Care Transitions- C stated that he recalls there were a few questions and concerns mentioned by R1's representative but he did not take any notes about the concerns. Director of Care Transitions- C stated that he does not work inside the buildings and is not aware of the process for handling grievances. Director of Care Transitions- C stated that he would just forward and email to the Director of Nursing (DON)-B or the Administrator-A. Surveyor asked if there is any documented evidence that he communicated the concerns to DON- B or Administrator- A. Director of Care Transitions- C stated that he had nothing documented in his phone or email.On 2/4/26 at 10:15 AM, Surveyor interviewed Administrator- A and DON- B regarding the representative's concerns for R1 from 11/13/25 and 12/22/25. DON- B acknowledged that she had spoken with R1's representative because the representative had questions about the 12/22/25 incident. DON- B stated that she had answered all of the questions and reviewed R1's medical chart with R1's representative. Surveyor asked DON- B what the questions were that R1's representative had. DON- B stated she just wanted to know how this could have happened. (referring to R1's diagnosis of 7th and 8th rib fractures upon admission to the hospital on [DATE]). DON- B stated that she never questioned whether the staff did something to R1 and that R1 had a history of fractures and was very fragile. Surveyor stated to DON- B that R1's representative was asking for an explanation/investigation into how the CNA repositioned R1 wondering if that was how R1 suffered the rib fractures. R1's representative was aware of R1's medical history. DON- B again stated that she did not consider the representatives' questions as an allegation of abuse or a grievance to address. Surveyor stated that the concern was that R1 had been repositioned several times prior to 12/22/25 without incident and the allegation is that the CNA was in a hurry and angry and grabbed R1 from the torso, resulting in injuries. This is why the Representative wanted to know how this could have happened, when it was done so many times prior without incident. Administrator- A then stated that the concerns brought forth by R1's representative should have neem handled as formal grievance and investigated as such.

Based on record review and staff interview, the facility did not ensure that they thoroughly investigated allegations of possible abuse or mistreatment/ neglect for 1 (R1) of 3 sampled residents.R1 was repositioned in bed by CNA (Certified Nursing Assistant)-D on 12/22/25. While R1 was being repositioned with the assistance from CNA-D, R1 complained of severe pain to her ribs. R1 was sent to the emergency room on [DATE] where R1 was diagnosed with a fracture to the 7th and 8th anterior ribs. On 12/23/25 a representative for R1 raised concerns regarding possible mistreatment to R1 leading to t he sustained rib fractures. The facility did not thoroughly investigate the incident.Findings include:Policy Review: (Name of Company) Healthcare Abuse Prevention Program (undated)This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property , and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents.VI. Internal Investigation1. All incidents will be documented, whether or not abuse, neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. 3. For resident injuries not involving an allegation of abuse or neglect, the Administrator will appoint a person to gather further facts to make a determination as to whether the injury should be classified as an injury of unknown source. An injury should be classified as an injury of unknown source when both of the following conditions are met:* the source of the injury was not observed by any person pr the source of the injury could not be explained by resident; and* The injury is suspicious because of the extent of the injury or the location of the injury ( e.g. the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time of the incidence of injuries over time.4. Investigation Procedures: The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Residents to whom the accused had regularly provided care, and employees with whom the accused had regularly worked, will be interviewed. On 2/3/26, Surveyor conducted a medical record review for R1. R1 was originally admitted to the facility on [DATE] with diagnoses of left pelvic fracture, chronic respiratory failure, severe protein-calorie malnutrition, muscle weakness, dysphagia, pressure ulcer of sacral region, gastroesophageal reflux disease (GERD) and repeated falls. R1 needed the assistance of 1 staff for activities of daily living, toileting and bed mobility.A review of R1's plan of care noted the following:The resident (R1) has an activities of daily living (ADL) self-care performance deficit r/t (related to) multiple fractures (pelvic, sternal and vertebral), rheumatoid arthritis, acute respiratory failure with O2 (oxygen) dependence. Interventions include:Provide Adaptive equipment necessary during transferBED MOBILITY: The resident requires assistance by 1 staff to turn and reposition in bed every 2-3 hours and as necessary. Bilateral bed rails to help promote bed mobility.TRANSFER: The resident requires assistance by 1 staff member using 2WW (wheeled walker) to transferEncourage the resident to participate to the fullest extent possible with each interaction.Encourage the resident to use bell to call for assistance.Monitor/document/report PRN (as needed) any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function.Praise all efforts at self care.PT/OT (physical therapy/occupational therapy) evaluation and treatment as per MD (physician) orders.A review of R1's Physician orders document the following: Q2-3hr (every 2 to 3 hours) repositioning with wedge from right side to back. every 2 hours for Prophylaxis related to NONDISPLACED FRACTURE OF ANTERIOR WALL OF LEFT ACETABULUM, SUBSEQUENT ENCOUNTER FOR FRACTURE WITH ROUTINE HEALING (S32.415D) Order date is 11/17/2025. Nursing Note dated 12/22/2025 at 9:15 PM eINTERACT SBAR (Situation Background Assessment Recommendation) Summary for Providers Situation: The Change In Condition/s reported on this CIC (change in condition) Evaluation are/were: Pain (uncontrolled). Nursing observations, evaluation, and recommendations are: While being repositioned by CNA, resident started c/o (complaints of) severe pain in her Left Ribs. Pain is sharp and stabbing and hurts upon palpation. R1 has a Hx (history) of rib fractures. Writer observed no redness, swelling or bruising at site. R1 repositioned to her right side and given PRN (as needed) Tramadol, which was ineffective. Sent to (name of hospital) ER (emergency room) at R1's request for further eval and treatment. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Dr. updated. Ok with sending the resident to ER.Physician Progress Note dated 12/23/2025 at 10:34 AM; Patient (R1) currently admitted to (name of hospital). Chart reviewed in EPIC (name of hospital electronic medical record) Care Everywhere and updated. Pain in ribs noted last night in patient with known osteoporosis and multiple other pathologic rib fractures.X-ray report below from 12/22/25:1.Suspected left eighth and possibly seventh anterior rib fractures (anterior rib fracture is a break in the rib bone near the front of the chest, usually caused by direct impact like car accidents, falls, or less commonly, severe coughing). Old bilateral rib fractures are also noted.2. Several thoracic compression fractures are identified and can be seen.previously. There is slight apparent increase in the degree of compression of the T7 superior endplate.3. No acute cardiopulmonary findings.Will follow and assume care after hospitalization with pain control and continued management of osteoporosis and myelodysplastic syndrome.On 2/3/2026, Surveyor conducted a review of the hospital Discharge summary, dated [DATE], and noted the following: History of present illness: (R1) Was brought in from rehab facility when she while turning developed severe pain involving chest and hip and was found to have rib fractures and had been admitted for pain control . Plan: admitted as inpatient. Placed on telemetry. Evidence of sacral and coccyx pressure decubitus wound care. Severe pain due to rib fractures and history of pelvic. Added Dilaudid and oxycodone for pain control.On 12/23/25, R1's representative contacted Director of Care Transitions- C reporting on 12/22/25, a CNA came into R1's room extremely agitated and aggressive that R1 had pushed her call light. R1's representative said that the CNA took her anger out on R1 and came behind her, grabbed her around her torso and yanked her backwards in the bed resulting in fractures to R1's left 7th and 8th ribs. The representative for R1 reported to the State Survey agency that they were not aware of any action taken for the first incident and that R1 was transported to the hospital the next day for the 2nd incident. (Cross-reference F585). On 2/4/26 at 8:30 AM, Surveyor interviewed DON (Director of Nursing)- B regarding R1's broken ribs and the documentation that this injury occurred while CNA (Certified Nursing Assistant)- D was repositioning R1 in bed. DON- B stated they made a conclusion that an investigation into the incident was not needed because they spoke with the Physician and based on all of R1's comorbidities and risk factors and previous fractures that there was not concern for abuse or mistreatment. R1 is very fragile so things like this can happen. DON- B stated she spoke with CNA- D who stated that while repositioning R1 in bed, she heard a crack. CNA-D immediately went and got the nurse who completed an assessment on R1. R1 initially did not want to go to the hospital for further evaluation. DON- B stated that CNA- D was following the plan of care because R1 can be repositioned in bed with the assist of 1. Surveyor asked DON- B if the facility looked into the allegation CNA- D repositioned R1 in a hurry, or was upset with R1 or even intentionally grabbed R1 with force. DON- B stated that CNA- D followed the plan of care and would not have hurt R1 on purpose. Surveyor asked DON- B if she had interviewed any other staff who worked on the evening of 12/22/25 who may have knowledge of CNA-D's demeanor that night or if there were concerns between R1 and CNA- D. DON- B stated that she did not speak with other staff or other residents; she did not see the need to further investigate this. DON- B stated again, R1's primary doctor said the injury is of known source and that is because of R1's comorbidities and being fragile.On 2/4/26 at 10:15 AM, Surveyor interviewed Administrator- A and DON- B regarding the representative for R1's concerns for the cares she received on 12/22/25. DON- B acknowledged that she had spoken with R1's representative because the representative had questions about the 12/22/25 incident. DON- B stated that she had answered all of the questions and reviewed R1's medical chart with R1's representative. Surveyor asked DON- B what questions were that R1's representative had. DON- B stated that she just wanted to know how this could have happened; referring to R1's diagnosis of rib fractures upon admission to the hospital on [DATE] . DON- B stated that she never questioned whether the staff did something to R1 and that R1 had a history of fractures and was very fragile. DON- B again stated that she did not consider the Representatives' questions as an allegation of abuse or neglect. Surveyor stated that the concern was that R1 had been repositioned several times prior to 12/22/25 without incident and the allegation is that CNA-D was in a hurry and angry and grabbed R1 from the torso, resulting in injuries. This is why the Representative wanted to know how this could have happened, when it was done so many times prior without incident. As of the time of exit, the facility was unable to provide additional information as to why they did not thoroughly investigate the potential mistreatment of R1 during repositioning in bed on 12/22/25.

Based on observation and interview, the facility did not ensure the residents environment was clean, comfortable and homelike for 25 of 25 residents on the 3rd floor. During the Survey the 3rd floor was noted to have dirty stained carpeting in the resident hallway. Urine smell in 3rd floor resident hallway. Debris and dead insects in the light covers on the 3rd floor resident hallway. 2 fans used on the 3rd floor resident dining area were dirty and unclean. The floor transition on the back elevator was covered in food particles and debris. * The 3rd floor community hallway carpeting, light fixtures, back elevator and dining room fans were not maintained in a clean and sanitary manner. Findings include: On 4/8/25, at 08:15 AM, Surveyor observed the carpet on the 3rd floor as stained and appeared dirty. Surveyor noted a strong odor of urine when Surveyor stepped off the elevator on the 3rd floor and at the midway point of the hallway. Surveyor did not note any residents around the urine smell. Surveyor noted what looked like dead insects and debris in most of the 3rd floor resident hallway ceiling light fixtures. On 4/8/25, at 01:20 PM, Surveyor observed a window box fan in the dining area. The fan blades and screen guards were covered in dirt, dust and debris. On 4/8/25, at 02:20 PM, Surveyor observed food particles, dirt and a wrapper in the transition grooves of the back elevator. The debris appeared to the Surveyor to interfere with the elevators ability to close and allow the elevator to function. Surveyor moved some of the dirt and wrapper away with the Surveyor's foot and the door closed and the elevator operated. On 4/8/25, at 02:37 PM, Surveyor informed the Nursing Home Administrator (NHA)-A that the elevator was not closing appropriately, and that the Surveyor cleared an obstruction with the Surveyor's foot that seemed to allow the elevator door to close. The NHA-A informed the Surveyor the facility would have the elevator looked at. On 4/9/25, at 08:00 AM, Surveyor observed the resident hallway on 3rd floor. Surveyor noted urine smell at the midway point of the hallway. Surveyor observed the same dirt and staining on the carpets and the same dirt and dead insects in the light fixtures as observed on 4/8/25. The elevator still had the same wrapper and food particles in the elevator door slides from the prior day. On 4/9/25, at 08:11 AM, Surveyor observed the dining area. Surveyor observed a large standing fan facing the resident's eating area. Surveyor observed the fan was very dirty and full of dust and debris. The fan blades had debris, dust and dirt caked on them. The wire guards around the fan were full of debris, dust and dirt. Surveyor noted the window fan observed on 4/8/25 in the dining room remained caked with debris, dust and dirt. On 4/9/25, at 09:26 AM, Surveyor observed 3rd floor resident hallway. Urine smell remained in the midway point of the hallway with no residents around the immediate area. The carpet along with the staining had scraps from breakfast, paper lids, and condiment package pieces. On 4/9/25, at 09:37, Surveyor interviewed Environmental Services Director (EVS)-C about the cleaning responsibilities and cleaning schedules. Surveyor was starting an interview with Housekeeper-E and EVS-C came down the hall and introduced EVS-C as the Environmental Services Director. EVS-C informed Surveyor that EVS-C could answer any questions the Surveyor had. Housekeeper-E informed Surveyor that Housekeeper-E had only been employed for a week. Surveyor asked EVS-C what the facility cleaning schedules were for the carpeting, light fixtures and transition areas like the elevator floor and closure areas. EVS-C informed Surveyor that maintenance cleaned the light fixtures and contracted out for carpet cleaning. EVS-C informed Surveyor that housekeepers would run a duster over the outside of the light if it was noticed to been dirty, but there was no schedule for housekeeping to clean the lights. EVS-C informed Surveyor that all floors are mopped daily and as needed by housekeeping. EVS-C informed Surveyor that housekeeping did not do full carpet cleaning but would spot clean right away if there were accidents or spillage. EVS-C asked Surveyor if there was something specific about the carpet the Surveyor wanted to know. Surveyor informed EVS-C that the carpet was stained and looked dirty. Surveyor informed EVS-C that there was frequently an odor of urine on the 3rd floor when no residents were in the area. EVS-C informed Surveyor that it depends on the time of the day before and after cares. EVS-C informed Surveyor that the staff and residents sometimes dispose of used depends in the garbage in the rooms. EVS-C informed Surveyor that they ask staff not to leave depends in the rooms when staff are finished with the cares. EVS-C informed Surveyor our staff will clean up any accidents right away and would never try to mask odors. EVS-C informed Surveyor that the residents often leave their depends in the garbage themselves. Surveyor asked EVS-C if EVS-C could provide the Surveyor with cleaning schedules for light fixtures and other equipment like the fans in the resident dining room area. Surveyor requested documentation and or logs verifying when these areas are cleaned. EVS-C informed Surveyor the Maintenance Supervisor would oversee that. Surveyor asked EVS-C who would have the carpet cleaning schedules and documentation. EVS-C informed Surveyor that the Maintenance Supervisor would oversee that also. On 4/9/25, at 09:45 AM Surveyor interviewed Maintenance Supervisor (MS)-D about cleaning and inspection schedules including documentation, invoices, contracts that verify when the carpet cleaning is completed. Surveyor asked MS-D how often the carpets are cleaned in the resident areas on the 3rd floor. MS-D informed Surveyor the facility contracts out carpet cleaning services. MS-D informed Surveyor carpet cleaning was done maybe 1 to 2 times a year. MS-D then informed Surveyor maybe every 6 months. Surveyor asked MS-D when the last time the carpet was cleaned by their contractor. MS-D informed Surveyor after consulting with EVS-C maybe 3 months ago. Surveyor asked MS-D for the invoice, contract or any documentation on the cleaning of the carpets 3 months ago. MS-D informed Surveyor that there wasn't any documentation kept for the carpet cleaning 3 months ago. MS-D informed Surveyor that MS-D did not keep that information. Surveyor asked for any invoices or contracts from the last year with the company the facility contracted with for carpet cleaning. MS-D informed the Surveyor that MS-D had no invoices or contracts. Surveyor asked MS-D who is responsible for inspecting and cleaning the fans in the dining area on 3rd floor. MS-D informed Surveyor that maintenance supplies the fans in the dining room and some of the residents' room fans if a resident did not have a fan. Surveyor asked MS-D who was responsible for inspecting and cleaning the ceiling light fixtures in the resident's hallway on 3rd floor. MS-D informed Surveyor that maintenance was responsible for the ceiling lights. Surveyor asked MS-D for any invoices, contracts, logs and or schedules/policies for cleaning the fans and the ceiling lights. MS-D informed Surveyor that MS-D did not have any documentation or schedules for the Surveyor. MS-D informed Surveyor that MS-D did not keep records like that. Surveyor asked MS-D how the facility knew to clean the lights and fans or other equipment in the residents' areas that maintenance may be responsible to inspect and have cleaned. MS-D informed Surveyor when the fans or lights looked dirty, or if someone reports that something in the resident areas needed repair or cleaning. Surveyor asked MS-D to confirm there is no documentation, logs, records kept that the Surveyor could verify cleaning of the carpet, light fixtures or fans on 3rd floor. MS-D informed Surveyor that MS-D doesn't have anything to show the Surveyor. On 4/9/25, at 10:04 AM, Surveyor informed Nursing Home Administrator (NHA)-A about Surveyor's observations and concerns over cleanliness and sanitary conditions in the facility. Surveyor informed NHA-A about urine odors frequently noted on 3rd floor. Surveyor informed NHA-A of the observation the carpet on 3rd floor was dirty and stained. Surveyor informed NHA-A of observations of the dead insects and debris in the ceiling lights on the 3rd floor resident hallway. Surveyor informed NHA-A of observations of the dining room fans being caked with dirt and debris especially in a resident food service area. Surveyor informed NHA-A of the back elevator still had food and dirt particles in the transition area of the door. Surveyor informed NHA-A that EVS-C and MS-D could not provide any records, documentation, logs, schedules, invoices or contracts to verify the cleaning of the fans, carpet or ceiling lights in the resident areas on 3rd floor. NHA-A informed Surveyor NHA-A shared Surveyors concerns. NHA-A informed Surveyor NHA-A was currently working with the Assisted Living Administrator on implementing a maintenance and environmental services process for scheduling these types of building maintenance and cleaning tasks. NHA-A informed Surveyor NHA-A was aware there was no regular scheduled cleaning of the light fixtures, fans, and carpets. NHA-A informed Surveyor NHA-A agrees there should be a set schedule for cleaning lights and fans. NHA-A informed Surveyor the facility contracts out the facility carpet cleaning when its needed. NHA-A informed Surveyor the 3 facilities did have access to a shared carpet cleaner that will be utilized more with a scheduled cleaning program. NHA-A informed Surveyor a discussion was already had with the maintenance and housekeeping staff about expectations for building cleanliness. NHA-A informed Surveyor these issues would be fixed immediately. No further information on the facility cleaning procedures were provided to Surveyors prior to exiting the facility.

Based on observations, interviews, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. * The facility does not have a current comprehensive water management plan that includes flow charts specific to the facility to determine areas of concern or interventions implemented on closed units to prevent the spread of opportunistic pathogens (Legionella) in the facility's water systems, and the water management plan was not included in the facility assessment. * R27 was on droplet precautions. Staff did not utilize proper PPE (Personal Protective Equipment) when entering his room. This deficient practice has the potential to affect all 43 residents residing in the facility. Findings include: The facility policy titled Legionella Prevention (not dated) documents (in part) . . The facility will prevent outbreak of Legionella and other opportunistic pathogens by properly maintaining water systems. 1. The infection preventions or designee shall identify if the facility is in need of a water management program. This will be determined by using he worksheet in the CDC (Centers of Disease Control) Legionella toolkit. 2. The facility will take steps to prevent Legionella including but not limited to: a. Looking at internal and external factors that can lead to Legionella growth. b. Identify areas where Legionella could grow and spread. c. Implementing and monitoring control measures by visual inspection, checking disinfection levels, and temperatures. d. Following steps outlined in the CDC Legionella toolkit. The facility policy titled Infection Control - Standard and Transmission Precautions revised 7/7/23 documents (in part) . .It is the facility's policy to ensure that appropriate infection prevention and control measures are taken to prevent the spread of communicable diseases and infections in accordance with state and federal regulations and national guidelines. 14. Droplet precautions are implemented most often for residents who have a respiratory illness. a. Staff are to put on a mask upon room entry and removed upon room exit of a resident placed on droplet precautions 1.) On 1/28/25 at 10:46 AM, EVS (Environmental Service Director)-E provided Surveyor the facility water management binder. EVS-E stated, We've been doing it, but we haven't been keeping up on the documentation. Surveyor initial review of the water management binder revealed no documentation of what was being done in the facility, with the exception of documentation from EMSL Analytical Incorporated which documented Legionella detection testing by culture method last collected 3/15/24 and 9/11/24. There was no map or flow charts identifying specific areas of concern and no documentation a plan was developed regarding the 2nd floor closed unit. On 1/28/25 at 1:11 PM, after reviewing the facility water management plan, Surveyor spoke with DON (Director of Nursing)-B. Surveyor asked how long the 2nd floor has been a closed unit. DON-B reported the 2nd floor has been closed since before she became employed at the facility, at least 3.5 years ago. DON-B confirmed there have been no Legionella cases in the facility since the last recertification survey. DON-B reported she and IP (Infection Preventionist)-D are not really involved in the water management plan, but it is discussed in QAPI (Quality Improvement). Surveyor confirmed the binder provided was the entirety of the facility water management plan. Surveyor advised DON-B the water management plan includes no maps or flow charts identifying water flow, risk assessment by map or narrative, for example; risk areas where Legionella can develop. DON-B reported she would have EVS-E speak with Surveyor. On 1/28/25 at 3:00 PM, NHA (Nursing Home Administrator)-A asked to look at the water management binder provided to Surveyor, stating I'm not sure that is the right binder. Surveyor advised NHA-A that EVS-E informed Surveyor this is the water management binder and stated, We've been doing it, but we haven't been keeping up on the documentation. Surveyor advised NHA-A of concern there is no documentation indicating the facility is following any type of water management plan, for example routine flushing of the 2nd floor, which is closed. NHA-A advised he will have EVS-E speak with Surveyor tomorrow. On 1/29/25 at 07:59 AM Surveyor made the following observations of the 2nd floor closed unit by room: The hallway was dirty with garbage including mask, gloves, paper towel, tissues and a plastic bag. Utility room - Hopper was dry/no water in the bowl. Sink has an eye was station. Dirty mop head on the floor. Shower room - the toilet had water in the bowl. The shower head was attached to the wall by the hose only, no shower head. EVS-E reported she removed the shower head because she uses the shower to clean wheelchairs. 201 - the toilet tank lid was off. The toilet bowl contained water with wads of hair and debris. The sink had brown debris. There was debris, dirty linen and garbage on the floor. 202 - the toilet bowl had no water, there was toilet paper containing a brown substance, resembling BM (bowel movement/stool). The floor was dirty with visible garbage and equipment. 203 - the toilet bowl had no water and there was linen and garbage on the floor. 204 - the toilet had no water in the bowl or tank. The toilet bowl contained toilet paper. Dirty linen on the floor. 205 - the toilet bowl had water with debris. Equipment on the floor of the room. 206 - the toilet bowl had no water, rust stains, visible rust pieces in the bottom of the bowl and toilet paper inside the bowl. The room contained a garbage bag and garbage on the floor. 207 - the toilet bowl had water with a rust stain ring and brown substance resembling BM on the inside of the bowl. There was a large brown dried spill/stain on the bathroom floor. 208 - the toilet bowl had no water, visible rust and contained toilet paper with a brown substance resembling BM and BM smeared on the toilet seat. 209 - the toilet bowl had no water and visible rust stain. Garbage, debris, equipment and O2 tubing was on the floor. 210 - the toilet bowl had no water, visible rust, toilet paper with brown substance resembling BM. Garbage, mask and paper towel on floor of room. 211 - did not visualize toilet. Noted garbage and equipment on floor of room. 212 - the toilet bowl had water, toilet paper and a brown substance. Dirty linen on the floor. 213 - did not visualize toilet. Garbage on the floor of room. 214 - the toilet had no water and visible rust. Dirty linen and garbage on the floor. On 1/29/25 at 8:33 AM, EVS-E provided Surveyor a paper titled, Water Management Plan Education dated 1/28/25, which documented: Administrator reviewed facility water management plan and procedure with EVS Director and Maintenance Supervisor to ensure plan is being followed and all water temperatures and testing are being routinely conducted according to policy. Surveyor asked what this was for. EVS-E stated, We went over it to make sure we're following the plan. Surveyor asked what plan the facility implemented regarding the 2nd floor closed unit. EVS reported she flushes all sinks and toilets on the 2nd floor weekly. Surveyor noted there is no evidence. On 1/29/25 at 8:35 AM, while Surveyor was on the 2nd floor conducting observations, Surveyor heard EVS-E entering rooms and flushing toilets. Surveyor heard EVS-E on the phone say, Did someone turn off the water in 204? Surveyor spoke with EVS and asked again what is the plan implemented on the 2nd floor, as it looks as if it was shut down and has not been cleaned since. EVS-E stated, Oh no, we come up here weekly and flush all the toilets and sinks. We identified the inlets and outlets of water and go over them again and again and the company comes and tests the water every few months. Surveyor asked where is evidence a plan was implemented and is being followed, as there is no documentation in the binder. EVS stated, We just know we have to flush everything weekly, we try to do it Wednesday or Thursday. Surveyor asked if there was a schedule or plan implemented and if it recorded anywhere. EVS-E stated, No, we just do it. Surveyor confirmed EVS-E reported she flushed all the toilets on the 2nd floor last week. Surveyor showed EVS-E several toilets on the 2nd floor which did not contain water, had visible rust, debris and those that contained toilet paper and brown substance resembling BM. EVS-E stated, Staff do come up here and use the toilets, which is why there might be toilet paper in the bowl. On 1/29/25 at 8:59 AM, Surveyor advised Chief Innovation Officer-C of concern there is no evidence the facility has implemented and is following a water management plan. Surveyor advised there is no evidence a risk assessment and plan was implemented for the 2nd floor closed unit. Surveyor advised although EVS-E reported the toilets are flushed weekly, there is no evidence to support this statement, and there is nothing in the water management binder regarding the closed unit. Surveyor advised of observations of the 2nd floor including the toilets. Chief Innovation Officer-C reported he will talk to NHA-A, adding My understanding is that the company they hired did the assessment. On 1/29/25 at 9:11 AM, NHA-A reported he spoke to the company who did a complete assessment with diagrams and everything, adding we are trying to locate it. Surveyor advised the water management plan provided does not include a risk assessment identifying areas of concern specific to the facility and there is no evidence anything has been done on the 2nd floor closed unit, in addition, the IP is not involved in the facility water management plan. On 1/29/25 at 11:30 AM, NHA-A provided Surveyor a water flow chart. NHA-A reported the company that completed the flow chart sent it today. Surveyor reviewed the flow chart and advised of concern the flow chart is not specific to the facility and does not identify where areas of concern are located. In addition, no evidence was provided indicating the facility identified the 2nd floor closed unit as a risk area and implemented a plan. On 1/29/25 at 12:40 PM, Surveyor met with NHA-A and EVS-E. EVS-E reported the facility filled out the risk assessment form and plan, and created flowchart today. EVS-E reported she was assisted by the assessor and Director of operations of the company they hired, who is basically running our water management plan and does the sample testing for Legionnaires. Surveyor explained the expectation of a water management program according to the regulations. EVS-E reported it was her understanding that as long as testing was performed and is clear, all is good. Surveyor advised the facility of concern high risk areas are not identified, there is no risk assessment or plan for the 2nd floor closed unit and no evidence of implementation of any plan. Surveyor advised the closed unit has standing water in toilets, toilets that are completely dry with no water in the bowl, with water in the tank, the utility room with hopper and eye wash station. Surveyor advised there is no evidence anything has been done regarding the 2nd floor since the unit was closed. Surveyor provided resource information for the CDC (Centers of Disease Control)/LTC (Long Term Care website). NHA-A thanked Surveyors and no additional information was provided. 2.) R27 was admitted to the facility on [DATE] with diagnoses that include Chronic Obstructive Pulmonary Disease, Chronic Congestive Heart Failure, Chronic Kidney Disease, Atherosclerotic Heart Disease, Peripheral Vascular Disease, Atrial Fibrillation, and urine retention. R27's medical progress notes documented: 1/22/25 10:41 AM, CXR (chest xray) ordered as reported by Hospice nurse that resident has abnormal lung sounds and SOB (shortness of breath). Hospice nurse verbalized she will update residents Wife. 1/22/25 9:15 AM APNP (Advance Practice Nurse Practitioner) note: Patient seen up in recliner, patient was having sob, wheezing and cough, chest xray showing left lower lobe infiltrate, levaquin ordered x 10 days, receiving nebulizers, no wheezing on visit, sats 93% on NC (nasal cannula) oxygen. Afebrile. R27's Physician's Orders documented: Levaquin Oral Tablet 750 MG (milligrams) Give 1 tablet by mouth one time a day for LLL (left lower lobe) pneumonia for 10 Days. Droplet isolation r/t (related to) pneumonia x 10 days every shift - dated 1/23/25. On 1/28/25 at 8:03 AM, Surveyor observed 2 separate signs on R27's room door which documented: Droplet precautions. Everyone must clean their hands including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. 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 toileting. Device care or use: Central line, urinary catheter, feeding tube, tracheostomy. Wound care: Any skin opening requiring a dressing. Surveyor noted a cart outside of R27's room which contained masks, gloves and gowns. There was no eye protection or face shields in the cart. On 1/28/25 at 8:13 AM, Surveyor observed LPN (Licensed Practical Nurse)-F standing at the medication cart outside of R27's room. LPN-F entered R27's room, not wearing any PPE (no gloves, gown, mask or eye protection) and Surveyor heard her say, Hi, are you getting ready for breakfast? Can I have a finger? LPN-F then said aloud 82 and exited the room. LPN-F sanitized her hands, applied gloves and removed an insulin pen from the medication cart. LPN-F then walked back into R27's room, wearing only gloves (no mask, gown or eye protection). Surveyor observed LPN-F standing next to R27 who was sitting in his recliner. LPN-F was wearing only gloves, no mask or eye protection. LPN-F exited the room, discarded the gloves in the medication cart garbage and sanitized her hands. Surveyor asked LPN-F what PPE should I wear if I want to go into the room and speak with R27. LPN-F looked at the signage on the door and stated, Oh, you should be wearing a mask, I screwed up. Surveyor advised the sign for droplet precautions indicates eye protection as well. LPN-F stated, Yes, you should wear that too. Surveyor advised LPN-F the cart outside of R27's room does not contain eye protection. LPN-F stated, Maybe it's in the other cart. Surveyor and LPN-F looked in the other cart 2 rooms away, which did not contain eye protection. Surveyor confirmed R27 is on both Droplet precautions and Enhanced Barrier precautions. LPN-F stated, Yes, he's just finishing up his antibiotic for pneumonia. R27's January, 2025 Medication Administration Record documents an order for Levaquin 750 MG Give 1 tablet by mouth one time a day for LLL pneumonia for 10 Days with a start date of 1/24/25. Surveyor noted R27 has only been on the antibiotic for pneumonia for 4 days. On 1/28/25 at 9:14 AM, Surveyor observed MT (Medication Technician)-G standing at the medication cart outside of R27's room preparing medications. MT-G entered R27's room wearing a mask, gown and gloves, but no eye protection. On 1/28/25 at 11:13 AM, Surveyor asked DON (Director of Nursing)-B what is the expectation for droplet precautions. DON-B replied, Mask, gown and gloves. Surveyor advised the signage for droplet precautions indicates eye protection. DON-B reported she did not think eye protection was needed for droplet precautions, and looked at the signage. DON-B stated, It does say eye protection, I didn't think you needed eye protection. Surveyor advised DON-B of observation LPN-F entering R27's room not wearing any PPE to include a mask or eye protection and the carts on the unit do not contain eye protection. DON-B reported she was frustrated because she does education all the time. On 1/28/25 at 1:11 PM, DON-B clarified if residents have a productive cough, eye protection would be encouraged. DON-B stated, I reviewed his notes, there was only 2 entries of cough, and it does not indicate it was productive. Surveyor asked what if R27's cough became productive at a moment when staff was in his room, bent over and providing cares. DON-B stated, I see what you're saying. Surveyor advised droplet precautions include eye protection. On 1/29/25 at 3:00 PM, the facility was advised of the above findings. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 1 (R39) of 3 Residents reviewed for pressure injuries. The facility did not routinely assess R39's skin condition, did not implement or update care plans in response to skin changes, and did not evaluate the effectiveness of current care planned interventions and implement effective and timely interventions to prevent R39's pressure injury from becoming an infected stage 4 pressure injury that led to two weeks of hospitalization . * R39 was admitted to the facility on [DATE] with no skin impairment. R39 was assessed to be at risk for the development of pressure injuries. On 05/16/23, R39 developed a Deep Tissue Injury (DTI) to the left ischial tuberosity. The facility indicated on 5/16/23 they ordered/requested a Roho cushion for R39 however it was not immediately available. There is no indication that staff assessed the appropriateness of continuing to use R39's high density foam pommel cushion to ensure it would not be a contributing factor in possible deterioration of the wound until the Roho was obtained. The facility did not get a Roho cushion until 5/30/23. A care plan initiated on 5/16/23 said to encourage R39 to reposition every 2-3 hours. MDS dated [DATE] indicated, however, that R39 needed extensive assist of 2 for transfer and bed mobility and needed partial/moderate assistance to roll left to right. On 05/17/23, a nurse's progress note documents the DTI was opened and the facility updated the physician and received new treatment orders. During the following week, the facility indicated that ongoing assessments of the wound were taking place, as noted on the facility 24-hour boards. However, review of the facility 24 hour boards for the dates of 5/16-5/23/23 do not identify that staff routinely completed the 24-hour board information, and it is noted the 24-hour boards do not contain the information/details that would constitute an assessment of the wound. On 05/23/23 a nurse practitioner (NP) documented that the DTI was an open and unstageable pressure injury due to 80% slough. Review of the facility 24 hour board does not indicate a decline in the wound to an unstageable pressure injury or new treatment details. The 24-hour board entries for this date indicate the dressing is intact. On 5/23/23, the facility implemented new treatment orders but did not update/revise other areas of R39's care plan; R39 continued to sit on a high density foam pommel cushion on the wheelchair, and R39 did not have nutritional, incontinence, nor repositioning care plans updated or revised. On 5/23/2023, the Nurse Practitioner discussed the plan of care for diligent offloading and incontinence cares and cushion in wheelchair at all times while up, no longer than 2 hours at a time in wheelchair. The intervention up no longer than 2 hours at a time in wheelchair was not implemented until 06/15/23, after R39 returned from the hospital for treatment, debridement, and IV (intravenous) therapy for an infected pressure injury, returning to the facility with a Stage 4 pressure injury. Some staff indicated that R39 was noncompliant with repositioning. There is no care plan addressing noncompliance or alternatives. On 05/30/23, the pressure injury was assessed as having 70% necrotic tissue, heavy seropurulent drainage with moderate odor and the surrounding peri wound skin was assessed as black/blue/reddened and hot. On 05/30/23 the facility sent R39 to the hospital, and the hospital sent R39 back to the facility the same day with oral antibiotics. At the facility's request, R39 went to the wound clinic on 06/01/23. The wound clinic had R39 admitted to inpatient for Intravenous (IV) Antibiotics and surgical debridement of the ischial pressure injury. R39 was in the hospital from 06/01/23 to 06/14/23. R39 returned to the facility on [DATE], the left ischial pressure injury was a stage four and R39 had a wound vac. Since re-admission to the facility, R39 continues with the pressure injury. R39 developed a facility acquired, unstageable pressure injury requiring hospitalization , debridement, and IV antibiotic for infection. The facility failure to implement interventions to prevent R39's deep tissue injury from becoming an infected stage 4 pressure injury created a finding of Immediate Jeopardy that began on 05/23/23. Surveyor notified the Nursing Home Administrator of the Immediate Jeopardy on 10/05/23 at 3:08 PM. The Immediate Jeopardy was removed on 10/6/23, however, the deficient practice continues at a scope and severity level of D (potential for harm/isolated) as the facility continues to monitor their plan. Findings include: The facility policy, not dated, entitled, Etiology and Risk Factors for Pressure Injury, documented: Definition: Pressure Injury-A pressure injury is localized damage to the skin and/or underlying soft tissue over a bony prominence or related to a medical device or other devices. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense/prolonged pressure in combination with shear .A pressure injury is considered unavoidable if the resident developed a pressure ulcer even though the facility had evaluated the resident's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and revised the approaches as appropriate . Limit time in chairs: All residents at risk for skin breakdown should avoid long periods of sitting in a chair without being repositioned. A teachable resident should, be taught to shift his/her weight approximately every 15 minutes while sitting in a chair. According to AHRQ [sic] guidelines, the resident should be repositioned, shifting the points of pressure at least every hour or be placed back in bed . Resident Choice: When a resident refuses, evaluate the basis for the refusal and identify potential alternatives. On 10/3 through 10/5/23, Surveyor reviewed R39's medical record which included in part, the following; R39 was admitted to the facility on [DATE] and had diagnoses including, Left-sided Hemiparesis related to Cerebral Vascular accident, Peripheral Vascular Disease, and Diabetes Mellitus type 2. R39 smoked tobacco. R39's Braden Scale Assessment score on 01/24/23 was 18, indicating R39 was at risk for pressure injury development. Interventions initiated on 01/24/23 included: Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of injury. Turn and reposition as necessary. On 01/25/23, the care plan was updated to include: Float heels while in bed. R39's care plans also included (in part): R39's fall risk care plan, initiated 01/24/23, documented the following intervention, 1/31/23 pommel cushion for wheelchair. R39's Nutrition care plan, initiated 01/26/23 documented, Resident is at Risk for Maintaining Nutritional Status R/T (related to): S/P (Status Post) CVA (Cerebral Vascular Accident), Insulin .G (Gastrostomy) Tube was pulled on March 17 as no longer needed for Nutrition Support .Has Increased Cal + Protein Needs R/T DTI PI (Pressure Injury). Q [sic] June 2023 Wt Stable at 30 + 90d . Sept Q [sic] Wt stable @ 1,3,6 mo review and had the following intervention in part: Provide 8 oz (ounces) Ensure + 30 mls (mililiters) Prostat SF [sic]+ 8oz Water TID (three times a day). R39's admission Minimum Data Set (MDS) assessment dated , 01/31/23, assessed R39 to have a Brief Interview for Mental Status (BIMs) of 9, indicating R39 had moderate cognitive impairment. R39 had no pressure injuries upon admission but was assessed to be at risk for skin impairment r/t (related to) impaired mobility and incontinence and documented to follow current interventions listed in skin care plan. R39's Braden Scale Assessments scores on 02/1/23 was documented as 15 indicating at risk for the development of pressure injuries. R39's Bladder Incontinence care plan, initiated 02/06/23, documented, The resident has bladder incontinence r/t impaired mobility, and had the following interventions: Check and change every 2-3 hours and prn (as needed). Date Initiated: 01/27/2023 Clean peri-area with each incontinence episode, establish voiding patterns. Date Initiated: 02/06/2023 . R39's Bowel Incontinence care plan documented, The resident (R39) has bowel incontinence r/t impaired mobility. This care plan was initiated on 02/08/23 and had the following interventions, all initiated on 02/08/23: Call light kept within reach. Check and change every 2-3 hours and prn [as needed] Provide loose fitting, easy to remove clothing Provide pericare after each incontinent episode Staff will assist with incontinence care as needed . R39's Nutrition care plan was updated on 3/10/23 to include 3/10/23 .Provide 8 oz (ounces) Ensure + 30 mls (milliliters) Prostat SF [sic]+ 8oz Water TID (three times a day). 3/10/23 .Provide FROZEN NUTRITION TREAT on Lunch Tray. ***Give Shake when substitute needed . R39's Peripheral Vascular Disease care plan, initiated 03/22/23 documented the following intervention, Encourage resident to change position frequently, not sitting in one position for long periods of time. R39's quarterly MDS, dated [DATE], documented R39 had no pressure injuries but was at risk for pressure injury development and R39 should have a pressure reducing cushion and mattress; R39 was assessed as needing extensive assist of two staff for transfers and bed mobility. This MDS also indicates that R39 needed partial to moderate assistance rolling left to right. R39's Braden Scale Assessments score on 05/8/23 was documented as 16 indicating at risk for the development of pressure injuries. On 05/16/2023 at 12:05 PM a nursing progress note documented; It was reported to writer by CNA (Certified Nursing Assistant) that resident had an area of discoloration to left outer buttocks. Writer along with wound NP (nurse practitioner) assessed area. To the left ischial tuberosity there appears to be a DTI (deep tissue injury). CNA states that this morning the resident was sitting on the edge of the bed on mattress and upon grab bar calling out for help as she wanted to get in her w/c (wheelchair). Area may be bruising from sitting on outer edge of the grab bar but will consider to be a DTI. New orders received for site care. Resident will have application of air mattress. [R39's] weight is monitored weekly. Lab values also closely monitored by [NP-Q]. [R39] denies pain to the site and said [R39] did not know it was there. PMD (Primary Medical Doctor) updated as well as call placed to POA (Power of Attorney). Dietician updated. On 05/16/23 R39's Skin and Wound Evaluation form documented R39 had a Deep Tissue Injury that was In-House Acquired and measured 2.7 cm (centimeters) x (by) 1.8 cm. The wound bed was documented as 100% epithelial tissue, with no drainage, peri wound skin blanchable and there was an order for skin prep to the site. A resident Skin Impairment Data Collection sheet was provided to Surveyor that indicated the original date of area being noted was 5/16/23. This document indicated it was unwitnessed, but with a known origin, pressure area of (L) left ischial tuberosity. Pressure area 5/16/23. Location where impairment occurred was room. Skin preventative measures previously in place per plan of care checked is: preventative topical treatments, specialty alternating air mattress, protective boots. No anticoagulants. Immediate intervention put in place indicates: Roho ordered - wound consult - tx (treatment) monitoring. Surveyor noted the alternating mattress was documented as added on this date and had not previously been in place. R39's skin care plan was updated to indicate: The resident has actual impairment to skin integrity: 05/16/23 - Actual skin impairment - facility acquired - DTI to left ischial tuberosity. Encourage resident to turn and reposition every 2-3 hours, initiated: 05/16/2023 Air mattress applied to bed. Check for function every shift, initiated: 05/16/2023 Encourage resident to turn and reposition every 2-3 hours. Resident often refuses to change position. Resident educated on the importance of frequent position change to help prevent wounds and heal wounds. Date Initiated: 05/16/2023, and revised on 05/30/23 The care plan said to encourage resident to turn and reposition every 2-3 hours, yet the MDS assessment on 4/26/23 indicated R39 needed extensive assist of two for bed mobility and partial to moderate assistance rolling left to right. The Resident skin impairment data collection worksheet provided to Surveyor was noted to have added on 5/17/23: per Licensed Practical Nurse (LPN)-H small OA (open area) within DTI (0.6 x 0.4) pink red/surrounding tissue purple - scant drainage. MD aware - new treatment orders. Surveyor noted it is unclear if this area was assessed by an RN at this time as the documentation indicates the OA was conveyed to DON-B by LPN-H. On 5/17/2023 at 9:53 PM, a nurse progress note documented: Called [name of medical office] and updated NP [name of NP] about resident's wound to left outer hip now open and skin around wound is reddened. NP [name of NP] said to go ahead and apply Xeroform and bordered foam dressing to wound daily and PRN. NP said she will let regular NP know about wound change on resident. Surveyor noted R39's nutritional care plan was revised on 05/17/23 to include Give shake when substitute needed (for Frozen Nutritional Supplement with lunch which was added on 3/10/23). R39's nutritional care plan was not revised further until 06/22/23 when R39 received an order for Prostat, which is a protein supplement. R39's Nutrition care plan was revised on 06/22/23 to include the 30 mls of Prostat and 8oz water TID (three times a day) and also revised on 06/22/23 from Glucerna to Ensure. On 05/23/23 R39's Skin and Wound Evaluation form documented R39's DTI was now Unstageable with 20% granulation and 80% slough. It measured 2.6 cm x 2.9 cm x 0.1 cm with moderate serosanguineous drainage. Peri wound skin was documented as having erythema and normal temperature. The wound was documented as deteriorating, but healable. At this time the treatment was changed to medihoney and foam daily. Surveyor reviewed R39's Electronic Medication Administration Record (EMAR) and noted the wound care orders were changed appropriately and per physician's recommendations. Surveyor did not note any gaps in wound care treatments. Surveyor also reviewed R39's nurse's progress notes from 05/17/23 to 05/23/23 and noted the nurses progress notes did not mention any change to R39's wound. Multiple notes during this time document either dressing changed with no concerns, no drainage noted or dressing is clean, dry, and intact. However, the 24 hour boards do not contain any assessment information, nor do they include who completed the documentation on who entered the information on the 24 hour board. Per documentation, the first time the wound appeared with slough and fully opened was on 05/23/23 when the wound NP did a weekly assessment. Surveyor interviewed Assistant Director of Nursing (ADON)-C on 10/5/23 at 8:19 AM. ADON-C informed Surveyor the wound first opened on 5/23/23 when NP-G was assessing the wound. Surveyor read R39's 5/17/23 progress note, which documented the wound being opened and receiving a new treatment. Surveyor asked if measurements and an assessment were done at that time. ADON-C informed Surveyor because it was the same wound as the DTI, there would not have been another risk management, and ADON-C stated she did not believe the staff would get another set of measurements or stage the wound. Surveyor explained the concern there was documentation R39's DTI changed on 05/17/23, but there was not a comprehensive wound assessment documented until 05/23/23. ADON-C reviewed R39's EMR and informed Surveyor, the staff did what they were supposed to do by notifying the doctor and getting a new order. ADON-C did not think another assessment would have been done at that time. Surveyor reviewed NP-G's progress note dated 05/23/23 which documented, .Wound Care Follow up .Patient seen resting in bed. Seen for wound to left ischium of surgery as a deep tissue pressure injury last week and has now developed into an unstageable pressure injury per wound RN (Registered Nurse). Patient denies pain, fever, chills. [R39] is eating and sleeping per her baseline . ***Diagnosis that could affect wound healing*** Cervical cancer Coronary artery disease Diabetes mellitus History of tobacco use Hyperlipidemia Hypertension Iron deficiency anemia Myocardial infarction ***Interventions in Place*** Pressure reduction devices, bed, cushion per facility protocol; nursing and wound care, nutritional support, PT/OT (physical therapy/occupational therapy) if needed. ***Physical Examination*** Left ischium (unstageable pressure injury) Full-thickness wound measuring 2.6 x 2.9 x 0.1 cm. 20% granulation, 80% slough. Moderate serosanguineous drainage. Peri wound denuded, fragile. No signs or symptoms of infection Status? [sic] decline Plan? [sic] Medihoney and bordered foam daily and as needed . Reviewed medical records Discussed plan of care with ADON Diligent offloading and incontinence cares Cushion in wheelchair at all times while up, no longer than 2 hours at a time in wheelchair Air mattress Protein supplementation as necessary per dietary Follow-up 1 week for reassessment . Surveyor noted R39's fall risk care plan was revised on 5/30/23 (7 days after the NP assessment and 14 days after the area developed) the pommel cushion was changed to a Roho for skin issue . R39's skin care plan was updated to include: The resident has actual impairment to skin integrity: 5/23/23 changed to Unstageable, with the following interventions; Encourage resident to turn and reposition every 2-3 hours. Resident often refuses to change position. Resident educated on the importance of frequent position change to help prevent wounds and heal wounds. Date Initiated: 05/16/2023, and revised on 05/30/23 Roho cushion to wheelchair. Date Initiated: 05/30/2023 Surveyor noted R39's plan of care was not updated to include up no longer than 2 hours at a time in wheelchair until 06/15/23 but was recommended by NP-G on 05/23/23. Surveyor also noted there were no incontinence care plan revisions at this time, even though NP-G indicated diligent offloading and incontinence cares. The next assessment of R39's wound occured on 05/30/23 when NP-G came to the facility for her weekly wound rounds. R39's Skin and Wound Evaluation form, dated 05/30/23, documented: R39 had an unstageable wound measuring 4.1 cm x 5.6 cm x N/A (depth) with 30% epithelial tissue and 70% necrotic tissue, there was increased drainage, redness/inflammation and warmth with heavy seropurulent drainage and moderate odor after cleansing; the peri wound tissue had discoloration of black/blue with erythema and was hot. This form documented R39 was educated on the importance of repositioning in bed as much as tolerated and to not spend long amounts of time up in wheelchair. This form also documented R39 would be sent to the emergency room for further evaluation and documented R39 regularly refuses to get out of the wheelchair and spends a long amount of time in the wheelchair. R39 was sent to the hospital on 05/30/23 and the hospital sent R39 back to the facility on the same day with an order for oral antibiotics. Per facility documentation, the hospital did not feel the wound needed debridement. Surveyor reviewed R39's EMR and noted the following documented in nurses' progress notes between 05/23/23 and 05/30/23: On 5/24/2023, resident repos. [sic] as tolerated Q2 (every 2) hours. DTI to Lt. buttock. VS (vital signs) WNL (within defined limits). On 5/24/2023 16:43, Dressing change DTI of left buttock. No noted bleeding/drainage. No c/o (complaints of) of pain/discomfort. On 5/25/2023, repositioned as tolerated Q2 hours. DTI to Lt. buttock. VSS (vital signs stable). slept well. On 5/25/2023, Treatment done this shift to L buttock for DTI. Cleaned with normal saline, medihoney applied to open area and covered with a bordered foam. On 5/25/2023, Dressing changed to left buttock. Scant drainage and soiled with urine on old dressing. States wound hurts when touched. On 5/26/2023, resident repositioned as tolerated Q2 hours d/t (due to) inability to move on own and DTI to Lt. (left) buttock. VSS. On 5/28/2023, Patient had x-large BM (bowel movement) that covered wound dressing on L outer buttocks. Writer cleaned wound and reapplied dressing. No visible S/S (signs/symptoms) of infection. bleeding or C/O pain or discomfort. On 5/29/2023, Dressing changed to left buttock. VSS and BSS [sic]. C/o pain when wound was touched; otherwise, states it does not hurt. On 5/30/2023, resident repositioned as tolerated Q2 hours. DTI to Lt. buttock. drsg. CDI (clean, dry, intact). VS WNL. Surveyor noted there was no mention of a change in R39's wound appearance until 05/30/23 when NP-G did her weekly assessment. Surveyor noted the 05/24/23, 05/25/23, 05/26/23, and 05/30/23 progress notes document the left buttock as a DTI however as of 05/23/23 the area was assessed to be deteriorating and was assessed as unstageable with 80% slough and 20% granulation. On 5/30/2023 there was an Interdisciplinary Team (IDT) progress note in R39's EMR which documented, IDT met to discuss resident's skin issues. Resident currently has a pommel cushion in her wheelchair from a fall in January. It was discussed that a Roho cushion would be more beneficial at this time to help prevent skin breakdown and to promote healing. Cushions changed. Surveyor noted there was reference to changing the cushion to a Roho going back to the 5/16/23 Resident Skin Impairment Data Collection sheet that was provided to Surveyor by DON-B. This was the first mention of a follow up to changing the pommel cushion that Surveyor could locate. R39's care plan was updated to include the Roho cushion on 05/30/23. Surveyor was provided with information regarding the pommel cushion R39 sat on until replaced by the Roho cushion on 05/30/23. The manufacturer's information for the pommel cushion documented, The four 3D Quadra gel compartments allow for even distribution of gel under the ischials and seated areas while dual density foam layer provides a soft layer of comfort and molded foam base for support and pressure redistribution .and a coccyx relief cutout . There was nothing in the manufacturer's information documenting this cushion would be appropriate for someone who has a DTI or an unstageable pressure injury. Surveyor reached out to the company for additional information but has not heard back. Surveyor reviewed an Unavoidable Pressure Injury document completed by the facility and signed by the NP-G on 05/30/23 which documented: (R39) was not at end of life and was not on hospice, did not have a history of healed skin issues; (R39) had the following diagnoses-severe peripheral vascular disease; chronic bowel incontinence; diabetes; hemiplegia/paraplegia/quadriplegia; R39's serum albumin was below 3.9, hemoglobin less than 12 and protein less than 6.4; (R39) had pale and poor skin; and (R39) was non-compliant with recommendations regarding off-loading of pressure areas such as floating heels, cushions, alternating times up in the chair with times in bed; (R39) did not comply with diet or supplements to increase wound healing and (R39) refused to be turned/repositioned. Surveyor is uncertain if this form is for the development of the wound, the decline in the wound or the infection of the wound. Surveyor reviewed R39's lab work and noted lab work completed on 05/15/23 documented R39's albumin was 3.2 (low with a range of 3.8-5); Protein, Total 5.8 (low with a range of 6.1-8.2) and hemoglobin 10.2 (low with a range of 11.3-15.1). R39's lab results form 06/26/23 documented an albumin of 3 (low); Protein, Total of 6.5 (normal) and hemoglobin 9.3 (low). Surveyor reviewed R39's EMAR (Medication Administration Record) from May and noted a physician's order documenting, Encourage resident to reposition in bed and w/c every 2-3 hours, every shift, with a start date of 05/16/23. Surveyor noted this order was documented as completed every shift. There were no refusals documented. Surveyor noted a physician's order documenting, Glucerna every evening shift for [sic] Give 8 oz, with a start date of 5/11/23. Surveyor noted this order was documented as completed every evening shift except 5/02/23 which documented R39 drank 50%. There were no refusals documented. Surveyor reviewed R39's April EMAR and noted the same Glucerna order which documented R39 refused the supplement two times; R39 drank 0% one day; R39 drank 50% one day and R39 drank 100% the remaining days in April. Of note, R39's Skin and Wound evaluation forms had a section entitled Goal of Care with three options to choose from: 1.) Healable, 2.) Slow to heal: wound healing slow or stalled but stable, little/no deterioration, 3.) Monitor/Manage: Wound healing not achievable due to untreatable underlying condition. On 05/16/23, 05/23/23 and 05/30/23 these Skin and Wound evaluation forms document 1.) Healable. On 5/30/23 the facility made an appointment for R39 at the wound clinic. R39 was seen at the wound clinic on 06/01/23. The wound clinic consult form documented large full thickness left ischial eschar with surrounding cellulitis, developed over last 2-3 weeks .admit for IV antibiotics and surgical debridement. R39 was admitted to the hospital until 06/14/23 when R39 returned to the facility. Surveyor reviewed R39's hospital discharge history and physical, dated 6/11/23 (with a discharge date of [DATE]) which documented, Indication for admission: Infected Left ischial pressure wound, unstageable with necrosis and surrounding cellulitis .Hospital Course .underwent debridement on 06/02, repeat debridement on 06/07 and wound vac placement on 06/09 .Seen by infectious disease and was treated with cefepime, metronidazole, and vancomycin from 06/01-06/07. Upon readmission to the facility, R39's skin care plan was updated to include: The resident has actual impairment to skin integrity: 6/20/23 changed to stage 4. Resident not to be up in wheelchair for more than 2 hours per day to promote wound healing. Date Initiated: 06/15/2023. Surveyor noted this was originally recommended by the NP on 5/23/23 and not implemented until 6/15/23. On 6/15/23, R39 had the following active physician's order: Resident is not to be up in wheelchair for more than two hours a day to promote wound healing. Every shift for monitoring. On 9/13/23, R39 had the following active physician's orders: Wound TX: Left ischial tuberosity- Cleanse with NS (Normal Saline), pat dry. Apply Derma (hydrafera) blue from restorix and cover with super silicone dressing. Change three times a week and prn. one time a day every Tue, Thu, Sat for Wound Care AND as needed for wound care. R39's most recent MDS assessment, dated 09/30/23, documented R39 had one stage 4 pressure injury; R39 required extensive assistance of two staff for bed mobility and total staff assistance for transfers and R39's BIMS was a 9, indicating R39 had moderate cognitive impairment. On 10/03/23 at 8:52 AM, Surveyor observed R39 lying in bed with the head of the bed elevated about 45 degrees. Wound Nurse Practitioner (NP)-G and Assistant Director of Nursing (ADON)-C were outside of R39's room preparing for R39's wound care. ADON-C informed Surveyor R39 had the wound since May 16, 2023, and then it was unstageable. Per ADON-C, R39 went to the hospital for surgical debridement and now the wound is healing. ADON-C informed Surveyor, R39 had a lot of non-compliance issues such as sitting in the wheelchair all day. Per ADON-C, R39 has diabetes, smokes and leans to the left side due to a stroke. ADON-C informed Surveyor R39 is more compliant with off-loading and R39's son comes around 5 PM every day and that is when R39 gets up in the wheelchair. NP-G agreed with what ADON-C told Surveyor. On 10/03/23 at 8:54 AM, Surveyor observed NP-G and ADON-C perform wound care treatment on R39's left ischial tuberosity pressure injury. The wound appeared clean with no signs or symptoms of infection. Surveyor did not identify concerns with the observed wound care treatment. On 10/03/23 at 9:30 AM, Surveyor observed R39 lying in bed. R39 informed Surveyor R39's wound is getting better and does not hurt. R39 stated R39 usually gets out of bed in the afternoon when R39's son comes to visit and takes R39 out to smoke. Surveyor asked if staff provide education on repositioning or encourage R39 not to stay in the wheelchair for long periods. R39 could not remember and stated to Surveyor I do not think so. R39 informed Surveyor if staff suggested something like repositioning [R39] would do it. R39 did not think [R39] refused treatments, cares or repositioning. R39 did not have any concerns. At this time, Surveyor noted there was a Roho cushion in R39's wheelchair. On 10/04/23 at 1:25 PM, Surveyor observed R39 sitting upright in wheelchair. Surveyor asked R39 when staff assisted R39 into the wheelchair. Per R39, R39 got up before lunch and that is when R39 likes to get up. Surveyor asked how long R39 stays in the wheelchair. R39 informed Surveyor [R39] was unaware of how long [R39] stays up in the wheelchair because [R39] has never timed it. R39 did not think there was any time limit for [R39] to be up in the wheelchair. Surveyor asked R39 if staff encourage R39 to only stay in the wheelchair for a couple of hours and R39 replied I do not think so. Surveyor asked R39 if staff ask R39 to lay down or to change positions does [R39] ever refuse or not want to. R39 replied no, if staff want me to do something I do it. On 10/04/23 at 1:29 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-I. CNA-I was on R39's unit and per CNA-I, was familiar with R39's care. Per CNA-I, R39 was only getting up in the wheelchair when R39's son was in the building, but now per CNA-I R39 can stay up in the wheelchair longer. CNA-I informed Surveyor prior to R39's DTI, R39 would get up in the wheelchair around 1:30 PM. CNA-I informed Surveyor R39 was incontinent of bowel and bladder and usually would not call for assistance after an incontinence episode. Per CNA-I staff usually had to initiate incontinence cares for R39. CNA-I stated she was the one who found the DTI and informed the nurse of the area. Per CNA-I, R39 did not have any other wounds prior to the DTI. CNA-I stated she thought R39's DTI opened quickly. CNA-I stated R39 was not non-compliant and did not refuse cares or repositioning, but per CNA-I if staff placed R39 on R39's right side with a pillow under R39's left side, R39 would occasionally remove the pillow. CNA-I informed Surveyor R39 could move side to side in bed by self. CNA-I stated this is the first week R39 can get up in the wheelchair and stay up longer than when she was restricted to the 2 hours. On 10/04/23 at 3:47 PM, Surveyor interviewed PM Supervisor Licensed Practical Nurse (LPN)-H. LPN-H informed Surveyor R39's wound started as a DTI and the facility got a treatment. Per LPN-H, day shift noted the wound was opened, LPN-H was not aware of when the DTI opened. LPN-H stated they were unaware of how the DTI formed, but when it was found she, LPN-H, encourage R39 to remain in bed and re-arranged R39's room so the bed was facing the hallway. Per LPN-H,[TRUNCATED]

Based on interview and record review, the facility did not provide necessary treatment and services to promote healing for a pressure injury. This was observed with 1 (R3) of 3 residents reviewed for pressure injuries. * R3 had an unstageable pressure injury to the left heel and left toe as well as a deep tissue injury to the left lateral foot. R3 had a left below the knee amputation on 8/3/21. The facility was not consistently assessing R3's pressure injury on a weekly basis to determine any changes or infections. The comprehensive care plan did not include interventions upon admission to prevent pressure injuries and was not updated per Facility policy. There was no change in treatment or interventions to advance healing prior to amputation. Findings include: The Wound Management - Wound Prevention and Treatment Policy, revision date of 4/9/21, states the following: 1. The facility will ensure that based on the comprehensive assessment of a resident: a) A resident receives care consistent with professional standards of practice to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and b) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. 3. The licensed nurse will conduct weekly skin checks. The skin checks will be documented in the resident's Electronic Medical Record (EMR). 6. Interventions will be implemented in the resident's care plan to prevent pressure ulcer development when the resident has no areas of concern. 8. Interventions will be implemented in the resident's care plan to prevent deterioration and promote the pressure ulcer's healing. 10. The pressure ulcer(s) will be evaluated weekly, and the nurse or physician will document the size, location, odor (if any), drainage (if any), and current treatment ordered. The Comprehensive Resident Centered Care Plan Policy dated 1/11/21 indicates: Updating Care Plans: 1. Care plans are modified between the care plan conference when appropriate to meet the resident's current needs, problems, and goals. 2. The Care plan may be updated and/or revised for the following reasons: a. A significant change in the resident's condition; b. A change in planned interventions; c. Goals are obtained and the new goals established to meet current resident needs and/or goals; d. A new diagnosis, new medications, or abnormal labs. R3's medical record was reviewed by Surveyor. R3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's most current Quarterly MDS (minimum data set) assessment dated [DATE] indicates R3 has a Brief Interview for Mental Status score of 13 which indicates R3 is cognitively intact. R3 had a right below knee amputation on 4/14/21. On 2/16/21, R3 had a Braden score of 15 which indicates at risk for developing a pressure ulcer or injury. R3's Admission Minimum Data Set (MDS) assessments dated 1/21/21 indicates R3 is at risk for developing pressure injuries and had 0 current unhealed pressure injuries and no other ulcers, wounds or skin problems. Skin and Ulcer/Injury treatments included pressure reducing device for chair and bed. R3's Quarterly MDS assessment dated [DATE] reports R3 is at risk for developing pressure ulcers/injuries, has 0 pressure unhealed pressure ulcers, 0 venous and arterial ulcers with a surgical wound. Skin and Ulcer/Injury treatments included pressure reducing device for chair and bed. R3's Quarterly MDS assessment dated [DATE] states R3 is at risk of developing a pressure ulcer and documents one unhealed Stage 2 pressure ulcer not present upon admission/entry or reentry; as well as, 3 unstageable deep tissue injuries not present upon admission/entry or reentry. There were 0 venous and arterial ulcers present with only a surgical wound indicated. Skin and Ulcer/Injury treatments included pressure reducing device for chair and bed, nutrition or hydration intervention and pressure ulcer/injury care. R3's kardex report as of 9/7/21 states Mobility - while in chair foot buddy is to be placed across the calf pads on wheelchair; non weight bearing to right foot. Prevalon boots to be worn to both feet. Podiatry for foot nail care only. Do not put lotion between toes. R3's care plan with revisions printed on 9/7/21 indicates the following: 1) The resident has an ADL (activity of daily living) self-care performance deficit revised on 1/20/21 with an intervention dated 2/22/21 stating: while in chair foot buddy is to be placed across the calf pads on wheelchair, non-weight bearing to right foot. Prevalon boots to be worn on both feet. 2) The resident has impaired circulation r/t (related to) diabetes, heart failure, [CONDITION(S)] heart disease, h/o (history of) gangrene with a date of initiation and revision of 6/1/21. Interventions include: -Assess left lower extremity for warmth and color every shift until discontinued order. Will be having vascular surgery in June 2021 due to non-healing and new diabetic ulcers with infection. Date initiated and revised on 6/2/21. -Ensure proper fitting foot wear. Inspect feet HS (at bedtime) diabetic foot checks for areas of rubbing or injury. Date initiated and revised on 6/1/21. -Monitor pedal pulses every shift until MD D/C (discontinue). Report abnormalities to MD prn (as needed). Date initiated and revised on 6/2/21. -Podiatry for foot nail care only. Date initiated on 6/1/21. Surveyor noted R3 no longer has lower extremities and the care plan has not been revised. 3) The resident has an amputation of Right BKA (below knee amputation) r/t (related to) Diabetes, h/o (history of) gangrene date initiated and revised on 6/2/21. 4) The resident has pain and/or receiving pain medication PRN Diabetic [CONDITION(S)], wounds. Date initiated and revised on 6/2/21. 5) The resident has potential for pressure ulcer development r/t Hx (history) of ulcers, immobility. Date initiated and revised on 6/30/21. 6) (R3) has actual impairment to skin integrity, related to impaired mobility and [CONDITION(S)] and surgical site to the right lower extremity BKA. Date initiated 5/4/21 with revisions on 6/29/21. Interventions include: -APM (alternating pressure mattress), check placement and function Q (every) shift. Date initiated 6/23/21. -Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Date initiated on 5/4/21. -Keep skin clean and dry. Use lotion on dry skin. Do not put lotion between toes. Initiated on 5/4/21 and revised on 6/23/21. -Turn and position every 2 hours in bed, and encourage frequent positioning in the wheelchair. If refuses chart and let nurse know. Date initiated 6/1/21 with revision on 6/2/21. -Use a draw sheet or lifting device to move resident. Date initiated on 6/1/21. -Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Date initiated on 6/1/21 with revision 6/2/21. -WC (wheelchair) cushion. Date initiated 5/4/21 and revised 6/29/21. -Weekly treatment documentation to include measurements of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Date initiated on 5/4/21. Surveyor did not find any care plan for Left BKA. Surveyor did not find any revisions to the care plan post bilateral BKA. On 5/6/21, wound care clinic consultation reports: Findings: evolving pressure ulcers to left heel, lateral foot and great toe 5th toe. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Deep tissue injury - lateral left foot. Recommendations: [MEDICATION(S)] to left heel, left lateral foot and left 5th toe wounds. Cover with dry dressing. Change 3x weekly and PRN. Non-weight bearing to LLE (lower left extremity), prevalon boots at all times. Turn every 2 hours, reposition frequently. Left lower extremity arterial doppler. Follow up in 2 weeks. Review of R3's May 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Continue with wound wash normal saline and monitor left leg/foot daily and PRN one time a day for prophylaxis. Start date 5/7/21 and end date of 7/25/21. -Follow up in 2 weeks with wound clinic. Start date 5/6/21 with end date of 8/6/21. -Left heel treatment: Cleanse with normal saline, apply [MEDICATION(S)] and cover with dry dressing daily 3 x weekly one time a day every Tuesday, Thursday and Saturday. Start date 5/6/21 with end date of 8/6/21. -Left 5th toe treatment: Cleanse with normal saline, apply [MEDICATION(S)] and cover with dry dressing daily 3 x weekly one time a day every Tuesday, Thursday and Saturday. Start date 5/6/21 with end date 8/6/21. -Left lateral foot treatment: Cleanse with normal saline, apply [MEDICATION(S)] and cover with dry dressing 3 x weekly one time a day every Tuesday, Thursday and Saturday. Start date of 5/6/21 and end date of 8/6/21. -Prevalon boots at all times every shift. Start date of 5/6/21 with end date of 6/29/21. Order updated to prevalon boots on when in bed every shift starting 6/29/21 with end date of 8/6/21. Surveyor found no facility measurement or full assessment of wound including causation at first documentation of pressure ulcers to left foot. On 5/12/21, a facility skin impairment/wound form documents: 1) Left heel deep tissue pressure injury. No measurement. 100% non-blanchable [CONDITION(S)]. Well defined edges. No drainage, no odor, periwound within normal limits. No pain. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) Left lateral foot deep tissue injury. No measurement of wound. 100% non-blanchable [CONDITION(S)]. Well defined edges. No drainage, no odor, periwound within normal limits. No wound pain. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 3) Left 5th toe deep tissue injury. No wound measurement. 100% non-blanchable [CONDITION(S)]. Well defined edges. No drainage, no odor, periwound within normal limits. No pain. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatments include pressure reducing device for chair and bed. Applications of dressings. Barriers to wound healing: diabetes, kidney failure, non-compliant diet, behaviors with staff. Wound care integrity interventions: see above, prevalon boots to LLE (left lower extremity). Air mattress. Education provided. Surveyor noted there was no facility assessment of R3's wounds between 5/13/21-5/26/21. On 5/27/21, a facility skin impairment/wound form documents: 1) Top left foot. Stage 3 pressure injury. Measurement 1 x 0.3 x 0.5 x 0. 5% eschar. Light pink tissue. Well-defined, moderate sanguineous drainage, no odor present, periwound induration. Wound team to assess. Treatment: xeroform gauze, border foam dressing, 3 x weekly. 2) Left heel. No measurement, no staging. 100% non-blanchable [CONDITION(S)]. Well-defined, scant drainage, serous drainage, no odor, periwound within normal limits. No pain. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 3) Left lateral foot. Deep tissue injury. No measurement. 100% non-blanchable [CONDITION(S)]. Well-defined edges, no drainage, no odor, periwound within normal limits. Yes, pain. Interventions to pain - repositioning, PRN [MEDICATION(S)]. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional treatments include pressure reducing bed, turning/repositioning program, nutrition or hydration interventions, applications of dressings and ointments. Barriers to wound healing states [MEDICATION(S)], dry dressing, change 3x weekly and PRN. Current interventions are see above, prevalon boot to LLE, air mattress. Wound education provided. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Start date of 6/2/21 and end date of 8/6/21. -Check pedal pulse on left leg. If absent call MD and update every shift for decreased vascular flow. Start date 6/2/21 and end date of 8/6/21. -Diabetic foot check every evening shift. Start date of 6/2/21 with order change to Diabetic foot check every shift starting 7/2/21 ending on 8/6/21. On 6/17/21, a wound clinic consultation note addresses a pressure injury of left heel unstageable. Findings: Left foot wound Recommendations: Please wash LLE with soap and water. Apply [MEDICATION(S)] to left heel and lateral foot. Cover with dry dressing. Change 3 x weekly and PRN. Return to clinic in 4-6 weeks pending plan for LLE amputation. On 6/17/21, a vascular surgery follow up visit note states patient seen during wound care visit today. The left foot wounds continue to progress without healing.Patient underwent peripheral angiogram 6/8/21 at that time left bilateral below knee amputation was recommended. R3 and POA (power of attorney) opted to continue with aggressive wound care to the left foot to see if the angiogram would allow patient to heal his wounds. Patient returned to wound care clinic today for follow up. Unfortunately, the left foot wounds have not healed. Specifically, the left calcaneus wound has progressed. There does not appear to be active infection, but there is more depth to the wound with more dry eschar . Discussed with patient; the left foot wounds are rather painful. On 6/18/21, a vascular surgery note indicates R3's POA was contacted about options on amputation. POA consented to booking surgery in about one month. POA is happy with the time line. This will give the foot additional time for any possible healing; if it fails to heal then move forward with amputation. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/13/21, a facility skin impairment/wound form documents: 1) Left 5th toe unstageable pressure injury measuring 1 x 1. 100% eschar. Edges are well-defined, no drainage, no odor, periwound within normal limits, no pain. Treatment normal saline cleanse, iodosorb/[MEDICATION(S)], cover with bordered foam 3 x weekly and PRN. 2) Left lateral foot unstageable pressure injury measuring 1 x 6. 100% eschar. Edges are well-defined, no drainage, no odor, periwound within normal limits and no pain. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 3) Left heel unstageable pressure injury measuring 6 x 4 x 0.2. 50% slough and 50% eschar. Edges are well-defined, scant serous drainage, no odor, periwound within normal limits and no pain. Comments: wound assessed. Area is 100% eschar with no drainage, periwound intact. Continue with current treatment. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional treatments include pressure reducing device for chair and bed, turning/repositioning program, nutrition or hydration intervention, pressure ulcer/injury care, and application of nonsurgical dressings. Current interventions patient is on an alternative pressure mattress, heels to be floated or off-loading boots to be worn when patient is in bed. Patient to be turned and repositioned every 2 hours. Patient education provided. On 7/20/21, a facility skin assessment/wound form documents: 1) Left 5th toe unstageable pressure injury measuring 2 x 2. 100% eschar. Edges are well-defined, no drainage, no odor, periwound within normal limits. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) Left lateral food unstageable pressure injury measuring 3 x 3. 100% eschar. Edges are well-defined, no drainage, no odor, periwound within normal limits and no pain. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 3) Left heel unstageable pressure injury measuring 5 x 7 x 0.2. 50% slough and 50% eschar. Edges are well-defined, moderate serous drainage, no odor present and periwound within normal limits. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional treatments include pressure reducing device for chair, bed, nutrition or hydration intervention and. pressure ulcer/injury care. Current interventions patient is on an alternative pressure mattress, heels to be floated or off-loading boots to be worn when patient is in bed. Patient to be turned and repositioned every 2-3 hours. Patient education provided. On 7/27/21, a facility skin assessment/wound form documents: 1) Left 5th toe unstageable pressure injury measuring 1 x 1.5. 100% eschar. Edges are well-defined, no drainage, no odor, periwound within normal limits and no pain. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) Left lateral foot unstageable pressure injury measuring 2 x 5. 100% eschar. Edges are well-defined, no drainage, no odor, periwound within normal limits, and no pain. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 3) Left heel unstageable pressure injury measuring 5 x 7 x 0.1. 50% slough and 50% eschar. Edges are well-defined, moderate serous drainage, no odor, no pain. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional treatments include pressure reducing device for chair, bed, turning and repositioning program, nutrition or hydration intervention, and pressure ulcer/injury care. Current interventions patient is on an alternative pressure mattress, heels to be floated or off-loading boots to be worn when patient is in bed. Patient to be turned and repositioned every 2-3 hours. Patient education provided. Surveyor was unable to find any facility assessments or wound documentation from after 5/27/21 to 7/13/21. On 8/3/21 R3 received a BKA of the left leg. On 9/8/21 at 12:25 PM, Surveyor interviewed Doctor of Medicine (MD) - G. MD-G believed R3's wounds were vascular and was unsure why the facility documents indicate pressure injuries. MD-G would look for further information. No further information was provided. On 9/9/21 at 9:17 AM Surveyor spoke with Chief Nursing Officer (CNO)- F. CNO-F stated there is no facility documentation on R3's wounds from after May 27th to July 12, 2021. CNO-F agreed there was a gap in the care plan. The facility believed since R3 was being seen by a wound consultant that there was a lapse in weekly reviews at the facility. CNO-F stated it was vascular wounds, but cannot find any documentation at this time. The facility hired a wound nurse which is why there were weekly assessments started in July, but the wound nurse is no longer employed at the facility. R3 was often noncompliant and was offered a psych consult which R3 refused which is why behavioral monitoring was started at the end of June. On 9/9/21 at 12:10 PM Surveyor spoke with CNO-F. CNO-F was waiting to hear from MD-G to see if could get any further documentation on R3. CNO-F did not understand the inconsistency with vascular and wound notes. No resolution at this time of missing documentation. No further documentation was provided. On 9/9/21 at 2:45 PM Surveyor shared the concerns with R3's assessments with Administrator-A and DON-B. No further information was provided.

Based on observations, record review and staff interviews the facility did not always ensure that they recognized, evaluated and addressed the needs of 5 out of 7 residents (R30, R32, R4, R6 & R2) who were identified to be at risk or already experiencing impaired nutritional statuses. The facility did not always consistently obtained weights on these residents to identify significant weight loss and then develop interventions based on a comprehensive nutritional status - R30 was noted on 1/28/21 to have experienced a 16 pound weight loss over a 5 month period of (-11.7%) change in weight. Weekly weights and monitoring of meal intake were no implemented following the weight loss. On 4/14/21 R30 was reweighed for the first time since 2/24/21 and was noted to be at 110.4 pounds. - On 1/29/21 a quarterly nutritional note was completed for R32 using a weight from 11/23/20 of 120.2 rather than a current weight. The Minimum Data Set, dated dated dated [DATE] identifies a weight of 105 pounds (5% weight loss in last month, 10% over 6 months). On 3/11/21 a nutritional assessment was completed with no new interventions identified despite weight loss, consistency changes and changes in level of alertness. In 2020 R32 was identified to be weighed weekly, this was not implemented. On 4/14/21 R32 was weighed and was noted to weigh 96/1 pounds which is an 8.82% weight loss since 2/28/21. - R4 was assessed to be at risk for malnutrition. R4's plan of care included interventions to have monthly weights obtained. R4 did not have weights completed from 12/11/20 to 4/13/21, when brought up by the surveyor. R4 had experienced a significant weight loss of 13.35% during this time that was not recognized until 4/13/21 when the weight was obtained. R30, R32, and R4 experienced avoidable, severe weight loss and are being cited at the scope/severity of a G (actual harm/isolated. - R6 had no documented weights from 11/11/20-4/5/21 despite having a 5.02% weight loss from 10/2/20-11/11/20. R6 had a 9.16% weight loss from 10/2/20-4/5/21. - On 12/16/20 R2 was noted to weigh 122 pounds which was a greater than 10% weight loss in 6 months. R2 was noted in December to also be pocketing food when eating and a speech evaluation was recommended. On 2/18/21 R2 was noted to weigh 120.2 pounds indicating continued weight loss. Review of the record indicates recommendations for a speech evaluation, snacks twice daily and high calorie/high protein milkshakes were not implemented. Findings include: Policy Review: Subject: Weight Management, dated 3/1/2021 Policy Statement: The facility's policy is to provide care and services to weight management by State and Federal regulations. Procedure: (includes) 1.) All residents admitted to the facility will be weighed according to the following schedule: upon admission and weekly times four weeks. 2.) All residents will be weighted every month unless otherwise ordered by the physician or deemed necessary by the Dietitian or the interdisciplinary team. 3.) Monthly weights should be completed by the fifth of each month. 4.) Dietary should evaluate weights, notify appropriate disciplines or significant changes, and initiate corrective measures. 5.) A re-weight will be obtained for any weight change of +/- (3) pounds from the previous weight unless the physician has ordered other parameters. A significant number of frail elders lose weight as a result of malnourishment, which is estimated to affect between 35% and 85% of nursing home patients. Involuntary weight loss continues to be a pervasive concern in nursing homes because significant weight loss leads to higher morbidity, higher mortality, and decreased quality of life. (Using Evidence-Based Organizational Strategies to Prevent Weight Loss in Frail Elders) 1.) R30 was originally admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R30's Individual Plan of Care was conducted and it was noted that R30 has a potential for inability to maintain my nutrition due to poor appetite secondary to increased sleepiness, significant weight loss, Alzheimer's dementia, hx of Covid ([DATE]) and Hypertension. This plan of care was initiated on 4/8/2019 and last revised on 1/22/2021. Interventions included that R30 will consume greater than 50% of meals through the next review, will have maintained weight in range of 115- 130 pounds, will monitor/record/report to physician as needed signs and symptoms of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3months, >10% in 6 months, monthly weights. Notify MD/POA of changes >5% x 1 month, >7.5% in 3 months, or >10% x 6 months, provide and serve supplements as ordered: Ensure [MEDICATION(S)], 240ml each day, provide my favorite foods as desired: meat and potatoes, BLT's, egg salad sandwiches, sweet potatoes, cheeseburgers, milkshakes, hot dogs, monitor intake and record each meal, Registered Dietitian to evaluate and make diet change recommendations PRN. Nutrition Note dated 12/15/2020 states that R3 ate 50% or less for 3 or more meals in 3 days. However, resident has appeared more alert at lunchtime over past few days. Likely will be able to eat in socially distanced dining room starting this week for additional mealtime supervision. Met with resident (R30) this afternoon and provided high kcal/protein shake to promote intakes. Unsure of % consumed. Continue to facility monitor. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient sitting upright in chair. No acute concerns today, pleasantly confused. Denies any other concerns for poor appetite or difficulty eating, no nausea/vomiting, abd pain. Denies CP, SOB, cough, fevers/chills. No lower extremity pain. Per RN, only concern is patient fatigue and frequent sleepiness which hasn't improved much on [MEDICATION(S)] 50 mg daily. Noted to now have 16 lb wt loss over past 5 months (- 11.7%), per chart review; per discussion w/RN, nutrition notes, pt continues to have difficulty staying awake at meals. Nutrition following. No other concerns per nursing staff for acute confusion/[CONDITION(S)], [CONDITION(S)], respiratory distress or pain. Occasional constipation, tx w/prune juice. Assessment: R30 is a [AGE] year old female with history of dementia, [CONDITION(S)], hypothyroid, [CONDITION(S)], currently stable in the nursing home; being seen in follow-up for continued unintentional weight loss in setting of increased fatigue. Chronic management as below. Plan: 1. Recent weight loss: 16lb weight loss noted from 8/31-1/28/2021 (- 11.7%). Increase to [MEDICATION(S)] 100 mg qday for daytime fatigue- called in to pharmacy. Pt continues to have difficulty awakening for meals, <50% intake with most meals. Nutrition supplementing with high protein shakes as tolerated - pt often falling asleep during meals. Discussed with POA, and will check CMP, CBC, TSH w/reflex; was ordered last visit, not ultimately obtained. Nutrition Note dated 3/4/2021 states nutrition review for weight status and meal intake: 2/24/2021 weight =118.2#. BMI (Body Mass Index) =21.6, which is at lower end of acceptable geriatric wt parameters, consistent with thin appearance. 2/17=118.0#. 12/14=118.2#. 11/24=120.0#. 8/13=134.0#. Note wts have stabilized in past 2 months, which is desirable following significant wt loss compared to 6 months ago (>10% loss). Now considered to be at new baseline weight. On general diet, regular texture, thin liquids, 240 mL Ensure [MEDICATION(S)] daily. Ate 75% B (breakfast) & L (lunch) today per meal rounds; shows good motivation to eat and feed self independently, but nursing reports occasional sleepiness during mealtimes. Meal intake records show refusal/inability to eat 6 meals last week compared to one meal this week. Anticipate meal intake to continue to fluctuate given advanced age (96). MARs (Medication Administration Record) show 50% consumption of Ensure, which is worthwhile continuing. Staff encourages adequate fluid intake; shows no s/s dehydration today. Skin intact. Meds include [MEDICATION(S)], which may have impacted weights in the past, but not likely to any more due to long term usage. Nutrition problem: dx of malnutrition (PCM) r/t dementia and Covid ([DATE]), AEB significant weight loss (>10% in 6 months), MNA score of 5, use of diuretics. Additional nutrition risk factors: [CONDITION(S)], history of dysphagia, history of sleepiness at mealtimes, age 96. Plan to continue diet and supplements per orders as they meet nutritional needs. Case discussed with MD; note dx of PCM along with current new baseline weight. Monitor prn, including weekly weights. A review of R30's plan of care showed that the intervention for staff to take R30's weight weekly was never added. It was noted that the last weight taken for R30 was 2/24/21, the weight used for the above nutritional assessment. It was also noted that no additional interventions were added to the plan of care, even though continued weight loss had been noted. Surveyor conducted a review of R30's weights on 4/13/21. It was noted that most current weight for R30 was taken on 2/24/21 and noted to be 118.2 pounds. 11/23/2020 14:45 110.8 lbs. 11/24/2020 13:23 120.0 lbs. 12/8/2020 14:08 118.4 lbs. 12/11/2020 16:36 113.5 lbs. 12/14/2020 15:32 118.2 lbs. 2/17/2021 09:42 118.0 lbs. A review of the quarterly Minimum Data Set (MDS), dated [DATE] states that R30 needs supervision and the physical assistance of 1 person for eating. R30's weight is documented at 118 pounds and has lost at least 5% or more in the last month or 10% or more in the last 6 months. It is noted that this is not a prescribed weight loss regimen. On 4/13/21 at 9:00 a.m., Surveyor interviewed Registered Dietitian (RD) - D regarding R30's weight loss. RD- D stated that she works for a consulting company and is at the facility 1 time weekly. RD- D stated that she does communicate with facility staff via email and telephone during the week when she is not at the facility. RD- D stated that on a weekly basis she will review everyone on her list. The list is said to be made of new admission residents, re-admission residents and those who are experiencing weight changes. RD- D stated that those residents with pressure ulcers, tube feeding and [CONDITION(S)] are reviewed monthly. RD- D stated that all residents are to get weighed monthly at a minimum. RD- D stated that she is aware that some of the weights have not been done and she created a list of weights needed weekly and gave it to the nurses. RD_ D stated she would leave the list at the nursing station and depended on the nursing staff to obtain the weights. RD- D stated that in Point Click Care (electronic medical record) there will be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RD- D stated that she did bring up the fact that weights were not being done to the previous Director of Nursing- F and current Director of Nursing- B. RD- D was not able to provide any additional information as to why the order for weekly weights had not been added to R30's plan of care and why the last weight taken for R30 was 2/24/21. RD- D stated that she would be re-assessing R30 and will obtain a current weight. The facility obtained a new weight for R30 on 4/14/20 and the weight was noted to be 100.4 pounds. This weight represented a severe weight loss of 15.06% from 2/24/21 (118.2 pounds) to 4/14/21. Further review of R30's medical record showed that staff were not consistent in monitoring R30's meal intake. This information would be needed in determining adequate nutritional intake. Dietary Note dated 4/14/2021 states the following regarding R30: 4/14 wt=100.4#. BMI=18.4, indicating underweight status, consistent with thin appearance. 2/24 wt=118.2#. 2/17=118.0#. 12/14=118.2#. 11/24=120.0#. Note significant weight loss in past month (>5% loss); plan to monitor daily weights to evaluate further. Wt loss most likely r/t inadequate intake from diet and supps (consuming variable amounts of Ensure, ranging 0-50-100% per MAR). On general diet, regular texture, thin liquids, 240 mL Ensure [MEDICATION(S)] daily. Meal intake records show 50-75% intake and no refusals of meals. Anticipate intake to continue to fluctuate given advanced age (96). Staff encourages adequate fluid intake; shows no s/s dehydration today. Skin intact. Meds include [MEDICATION(S)], which may have impacted wts in the past, but not likely to any more due to long term usage. Nutrition problem: dx of malnutrition (PCM) r/t dementia and Covid ([DATE]), AEB significant wt loss (>5% in 1 month and >10% in 6 months), MNA score of 6, use of diuretics. Additional nutrition risk factors: [CONDITION(S)], hx of dysphagia, hx of sleepiness at mealtimes, age 96. New nutritional intervention: change supps to 8 oz Ensure Plus BID for additional 700 cals daily and to provide different flavors from [MEDICATION(S)]. Start Magic Cup every supper. Communicated with MD. Monitor prn, including weekly wts. Dietary Note Addendum, dated 4/14/2021 stated that R30's estimated nutritional needs based on new CBW: 1590 cals (35), 1818 cc fluids (40), 45-50 g pro (1.0-1.2 g/kg). Diet alone would meet needs if intake was adequate; addition of supps will improve probability of meeting needs and improving weight status despite inadequate meal intake. Continue to monitor. On 4/14/21, Surveyor shared the above concerns regarding R30's significant weight loss, lack of weight monitoring and lack of care plan interventions with Administrator A and Director of Nursing- B. No additional information was provided as of the time of exit. 2.) R32 was originally admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Quarterly Nutrition assessment dated [DATE] states that R32's weight was 120.2 and this weight was from 11/23/20. Quarterly nutrition review for 96 female with MNA (mini nutritional assessment) score of 7, identifying probable malnutrition: On pureed diet, nectar TL (thickened liquid) per SLP (speech therapy) screen, reflecting diet downgrade due to choking episode on 1/27. Depends on staff to be fed. Meal intake records showing decreasing intake to average 25-50% intake since starting pureed diet, compared to 75-100% intake on general diet. May benefit from 2 cal supplement to provide additional calories. Staff encourages adequate fluid intake, especially with new order for nectar TL. 11/23 wt=120.2#. BMI=23.5, which is within acceptable geriatric wt parameters. Note insidious wt gain of 4# in past 6 months and 19# gain in past year. Wt gain most likely r/t good intake. At risk of weight loss with diet downgrade and thickened liquids. Skin intact. Labs noted. Meds include [MEDICATION(S)]. Nutrition problem: probable malnutrition r/t dementia and MNA score of 7, AEB decreased intake, decreased mobility. Additional nutrition risk factors: risk of wt loss, [CONDITION(S)], HF, GERD, dysphagia, pureed texture, thickened liquids, aspiration precautions, recent choking episode, [CONDITION(S)], dependency on staff to eat, age 96. New nutritional intervention: start 60 cc 2 cal Med Pass TID for additional calories to compensate for decreased intake; this supplement is appropriate for nectar TL. Hospice eval pending. Monitor prn (as needed). Surveyor reviewed the most recent, quarterly Minimum Data Set (MDS), dated [DATE]. The MDS stated that R32's weight was 105 pounds and showed a weight loss of 5% in the last month or 10% in the last 6 months. It was indicated that this was not a physician prescribed weight loss regimen. The MDS also states that R32 needs extensive 1 person assistance for eating and had no swallowing disorders. Nutritional Assessment Progress Note dated 3/11/2021 states this is a quarterly nutrition review for [AGE] year old female with MNA score of 2 (indicating probable malnutrition): On MS (mechanical soft) diet, nectar TL (thick liquid), 120 cc 2 cal Med Pass TID. SLP (speech therapy) tx finished this week with downgrade to MS texture; SLP tx notes reviewed; 2 cal Med Pass appropriate with nectar TL. Depends on staff to be fed. Meal intake records show variable intake, ranging 25-100% intake. Ate 100% B (breakfast) today except for bacon because it was too difficult to chew, but she likes taste of bacon. Consumption of 2 cal supps variable at 50-100%. 2/28 wt=105.4#. BMI (body mass index) =20.6, which is below acceptable geriatric wt parameters, indicating underweight status, consistent with thin appearance. 11/23 wt=120.2#. 10/14=120.6#. 8/17=117.2#. Note significant wt loss in past 3 months (>10% loss); wt loss is unintentional and r/t need for changes in diet textures 2/2 dysphasia. Staff encourages adequate fluid intake, especially with nectar TL; shows no s/s dehydration today. Skin status: wound care R lateral thigh. Meds include [MEDICATION(S)] Nutrition problem: unintentional weight loss and probable malnutrition r/t dementia and dysphasia AEB significant wt loss in past 3 months (>10% loss), dependency on staff to be fed, inadequate intake, MNA score 2. Additional nutrition risk factors: [CONDITION(S)], HF, GERD, thickened liquids, aspiration precautions, [CONDITION(S)], age 96. Plan to continue diet and supps as they meet nutritional needs. Reviewed SLP notes. Monitor prn. A review of R32's Individual Plan of Care stated that R32 is at risk for inability to maintain my NUTRITION r/t dementia, CHF ([CONDITION(S)]), [CONDITION(S)], MDD, GERD, UTI, pain. Nutrition problem: probable malnutrition r/t dementia and MNA (mini nutritional score) score of 7, decreased intake, decreased mobility. Additional nutrition risk factors: risk of wt loss, [CONDITION(S)], HF, GERD, dysphasia, pureed texture, thickened liquids, aspiration precautions, recent choking episode, [CONDITION(S)], dependency on staff to eat, age 96. The following interventions were included: R32 needs assistance with meals, Pureed diet with nectar thick liquids, RD (Registered Dietitian ) to evaluate and make diet change recommendations as needed, monthly weights and monitor/record/ report to physician and signs/ symptoms of malnutrition. It was noted that after the Nutritional Assessment was conducted on 3/11/21, identifying an unintentional significant weight loss, no additional interventions were added to the nutrition plan of care. The plan was to continue what was in place as it met R32's nutritional needs. Review of R32's medical record showed that there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was not added to the plan of care, as the plan of care stated weights to be obtained monthly. A review of R32's weights in the electronic medical record showed that the most current weight was taken on 2/28/21 when R32's weight was recorded as 105.4. The previous weight was taken on 11/23/20 and 10/13/20. The facility was not following the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor made the following observations of R32: 04/12/21 09:42 AM R32 is asleep in bed. Breakfast tray remains on bedside table. Resident has not eaten yet. 04/12/21 01:26 PM lunch tray served in room, remains covered. Resident asleep, not eating. No assistance provided at this time. 04/12/21 01:51 PM R32 is still asleep in wheelchair, tray covered in room. 04/12/21 01:55 PM staff in room asks you still don't want eat? R32 responds by saying no. Staff ask R32 is she wants something to drink and R32 states yes. Thickened juice was given to R32 and the tray was removed from her room without R32 eating. On 4/13/21 at 9:00 a.m., Surveyor interviewed Registered Dietitian (RD) - D regarding R32's weight loss. RD- D stated that she works for a consulting company and is at the facility 1 time weekly. RD- D stated that she does communicate with facility staff via email and telephone during the week when she is not at the facility. RD- D stated that on a weekly basis she will review everyone on her list. The list is said to be made of new admission residents, re-admission residents and those who are experiencing weight changes. RD- D stated that those residents with pressure ulcers, tube feeding and [CONDITION(S)] are reviewed monthly. RD- D stated that all residents are to get weighed monthly at a minimum. RD- D stated that she is aware that some of the weights have not been done and she created a list of weights needed weekly and gave it to the nurses. RD- D stated she would leave the list at the nursing station and depended on the nursing staff to obtain the weights. RD- D stated that in Point Click Care (electronic medical record) there will be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RD- D stated that she did bring up the fact that weights were not being done to the previous Director of Nursing- F and current Director of Nursing- B. RD- D was not able to provide any additional information as to why the order for weekly weights for R32 had not been conducted by facility staff and why the last weight taken for R32 was 2/28/21. RD- D stated that she would be re-assessing R32 and will obtain a current weight. On 4/14/2021, R32 was weighed at the weight was noted to be 96.1 pounds. This represented a severe weight loss of 8.82% from 2/28/21 (105.4 pounds). Nutrition Note dated 4/14/2021 states the following regarding R32: 4/14 wt=96.1#. BMI=18.8, indicating underweight status, consistent with thin appearance. 2/28 wt=105.4#. 11/23 wt=120.2#. 10/14=120.6#. Note significant wt loss in past month (>5% loss); wt loss may be r/t inadequate intake. On MS diet, nectar TL, 120 cc 2 cal Med Pass TID. Depends on staff to be fed. Meal intake records show 50-100% intake. Consumption of 2 cal supps variable at 0-100%, usually 50%. Staff encourages adequate fluid intake, especially with nectar TL; shows no s/s dehydration today. Skin status: wound care R lateral thigh. Meds include [MEDICATION(S)]. Nutrition problem: unintentional weight loss and probable malnutrition r/t dementia and dysphagia AEB significant wt loss in past month, dependency on staff to be fed, inadequate intake, MNA score 2. Additional nutrition risk factors: [CONDITION(S)], HF, GERD, thickened liquids, aspiration precautions, [CONDITION(S)], age 96. New nutritional intervention: start Magic Cup at supper for additional 290 cals. Monitor weights x 3 days for further evaluation. Communicated with MD. Nutrition Note Addendum dated 4/14/2021 states; estimated nutritional needs based on new CBW: 1527 cals (35), 1745 cc fluids (40), 53 g pro (1.2 g/kg). Diet alone would meet needs if intake was adequate; addition of supps may increase probability of meeting needs and improving weight status despite inadequate meal intake. On 4/14/21, Surveyor shared the above concerns regarding R32's severe weight loss, lack of weight monitoring and lack of care plan interventions with Administrator A and Director of Nursing- B. No additional information was provided as of the time of exit. 3.) R4 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's annual minimum data set assessment, with an assessment reference date of 12/29/20, documents R4 required limited assistance of one person's physical assistance for eating. R4's plan of care includes a focus area for I have a potential for inability to maintain my NUTRITION r/t [related to] Dementia, therapeutic diet secondary to T2DM [type 2 diabetes mellitus, depression, UTI [urinary tract infection], dysphagia. At risk for fluid imbalance d/t [due to] diuretic use. At risk for malnutrition AEB [as evidence by] MNA [mini nutritional assessment] score of 8. 4/8/21 Probable malnutrition AEB MNA score of 5 initiated on 9/25/17 and revised on 4/8/21. Interventions include Monthly weights. Notify MD/POA [power of attorney]/Family Care/RD [registered dietitian] of changes >5% x 1 month, >7.5% x 3 months, >10% x 6 months revised on 9/14/17 and Provide, serve diet as ordered. Monitor intake and record q [each] meal . revised on 1/2/19. A Nutritional Assessment Progress Note on 4/8/21 at 11:32 PM documents 86F [female] with MNA score of 5, indicating probable malnutrition: On general diet, regular texture, thin liquids, encourage fluids. No issues chewing or swallowing even though edentulous. Able to use L [left] hand to feed self. Meal intake records show variable and fair intake, refusal of 5 meals in past 14 days, but intake improved to 50-100% in past few days. Staff encourages adequate fluid intake; shows no s/s [signs/symptoms] dehydration. 12/11/20 wt [weight]=132.6# [pounds]. BMI [body mass index]=25.1, which is within acceptable geriatric wt [weight] parameters, consistent with appearance. No significant wt changes noted in 6 months prior to [DATE]. Est [estimated] nutritional needs based on CBW [current body weight]: 1813 cals (30), 1813-2115 cc fluids (30-35), 60-78 g pro (1.0-1.3 g). Diet meets nutritional needs if intake is adequate. Skin status: wound care ongoing to R 5th toe, redness to L heel. 3/31 K [potassium]=4.6 wnl [within normal limits] (improved compared to previous labs). WNL for BUN [blood urea nitrogen], crea [creatinine], Na [sodium], glu [glucose]. Meds include [MEDICATION(S)] (may impact wt), [MEDICATION(S)] (may impact wt). Dty supps [dietary supplements]: K tab, MVI/min [multivitamin with minerals], CaCO3-Vit D [calcium and vitamin D]. Nutrition problem: probable malnutrition r/t Alzheimer's, AEB variable intake, MNA score 5, decreased mobility. Additional nutrition risk factors: [CONDITION(S)] [hypertension], DM [diabetes mellitus], [CONDITION(S)] [atherosclerotic heart disease], HLD[hyperlipidemia], CHF[chronic heart failure], GERD [gastroesophageal reflux disease], [CONDITION(S)]. PMH [past medical history]=dysphagia, CVA [stroke], Covid ([DATE]). Plan to continue diet per orders as it meets nutritional needs. Monitor prn [as needed]. On 4/13/21 the surveyor reviewed R4's weights and noted R4's last documented weight was 12/11/20 documenting the resident as weighing 132.6 pounds. The surveyor reviewed R4's April Meal intakes. The surveyor noted out of 42 opportunities for meal intakes in April, only 24 were documented on. Of those 3 meals were documented as refused, 1 meal was documented a 0-25% eaten, and 5 were documented as 26-50% eaten. On 4/13/21 at 3:04 PM the surveyor asked NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B if there was anywhere else weights would be documented. DON-B informed the surveyor weights were something she had identified as an area of concern and were working on a four point plan about it. The surveyor informed NHA-A and DON-B of being unable to find a weight for R4 since December of 2020. DON-B stated that is a gap in practice. On 4/13/21 at 4:58 PM R4 is documented as weight 114.9 pounds (a 13.35% weight loss). On 4/14/21 at 10:06 am R4 is documented as weight 115.5 pounds (A 12.9% weight loss). This is considered a severe weight loss. On 4/14/21 at 9:12 AM the surveyor interviewed Consultant Dietitian-D. The surveyor informed Consultant Dietitian-D about R4 not having a documented weight from December through 4/13/21. Consultant Dietitian-D informed the surveyor R4 was on the list for missing weights, and that it would be up to nursing to follow up. Consultant Dietitian-D informed the surveyor she prints a list of weights missing and puts it on the nursing station so they know who needs weights, and updates it weekly. The surveyor asked if Consultant Dietitian-D had brought up to the Director of Nursing about the weights not being done. Consultant Dietitian-D stated she had checked in with the previous director of nursing and she said she would follow-up. Consultant Dietitian-D stated she would follow-up with R4 and get a reweight. 4.) R6 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's quarterly Minimum Data Set Assessment, with an assessment reference date of 4/2/21, documents R6 requires extensive assistance of one person's physical assistance for eating. R6's plan of care includes a focus area for I have a potential risk for inability to maintain my NUTRITION r/t [related to] -MNA [mini nutritional assessment] score of 9, indicating risk of malnutrition -[CONDITION(S)] and contractures -wound care with wound vac -hx [history of] 2nd degree [CONDITION(S)] -anxiety -hx [history] of COVID ([DATE]) 4/5 wt [weight]=155.7# [pounds], indicating insidious wt [weight] loss in past 6 months revised on 4/8/21. Interventions include Monthly weights revised on 12/7/20. On 12/11/2020 at 6:02 PM a Nutrition Note documents Resident ate 50% or less for 3 or more meals in 3 days. Eating 25-50% of meals on average. Resident status discussed at IDT [interdisciplinary team] meeting. Consensus that resident is having a decline d/t [due to] COVID19 infection. Currently with multiple wounds: Stage I PI [pressure injury] to R [right] heel, MASD [moisture associated skin damage] L [left] buttock, Stage III PI L buttock, large venous ulcer L calf. Resident refused high kcal/protein milkshake today. However nurse reports she was able to get resident to drink all of Ensure supplement. Continue order for Ensure [MEDICATION(S)] BID [twice a day] and high protein kcal milkshakes. In light of current status and multiple wounds, recommend adding ProStat AWC BID. Each 30ml serving will provide 100 kcals, 17 g protein, as well as [MEDICATION(S)] and [MEDICATION(S)] to promote wound healing. Order pending physician approval. Will f/u Monday. On 4/8/2021 at 1:48 PM a Nutritional Assessment Progress Note documents 67M [male] with MNA score of 9, indicating risk of malnutrition: On MS [mechanical soft] diet, double breakfast, thin liquids, 8 oz [MEDICATION(S)] BID [twice a day]. MS texture facilitates chewing and swallowing. Resident would prefer whole meat and insists that he could chew regular meats, but he only has 2 or 4 lower molars and no upper teeth at all; already had SLP [speech therapy] tx in [DATE] who determined appropriate diet texture. Meal intake records show 75-100% intake; today CNA [certified nursing assistant] reported that resident ate extra portions at B [breakfast]. Resident loves juices and stated he dislikes Ensure because he thinks it goes right through me, but nursing reported 100% consumption of strawberry Ensure this am without GI [gastrointestinal] issues. Staff encourages adequate fluid intake; shows no s/s [signs/symptoms] dehydration. 4/5 wt [weight]=155.7# [pounds]. BMI [body mass index]=23.0, which is within acceptable geriatric wt parameters, consistent with appearance. 11/2020=162.8#. 10/2/20=171.4#. Note insidious wt loss in past 6 months (9% loss). Showing wt loss despite good intake and oral supps [supplements], but rate of wt loss significantly slowed in past 5 months with most of wt loss in [DATE]. May benefit from increase in oral supps . The surveyor reviewed R6's weights and noted the following documented: 10/2/20- 171.4 11/11/20-162.8 4/5/21-155.7 The surveyor noted R6 had no documented weights from 11/11/20-4/5/21 despite having a 5.02% weight loss from 10/2/20-11/11/20. The surveyor noted R6 had a 9.16% weight loss from 10/2/20-4/5/21. On 4/13/21 at 3:04 PM the surveyor asked NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B if there was anywhere else weights would be documented. DON-B informed the surveyor weights were som

Based on record review and staff interviews the facility did not always ensure that they had a system in place to ensure a residents advance directives were maintained and accurately documented in the resident's medical record for 2 of 13 sampled residents (R94 & R14) R94's wishes were to be a Do Not Resuscitate code status. R94 experienced a significant decline in condition and was being transported by Emergency Medical Staff to the hospital. The EMS staff did not have the necessary advanced directive paper work for R94 and CPR was provided against R94's wishes. This denied R94 the dignified death she wanted, prolonged the dying process, and subjected her body to unwanted procedures. R14 had paperwork in her medical record that stated that R14 was both Do Not Resuscitate and also that she wanted CPR if medically necessary at the time. The facility would not be able to determine exactly what R14 wishes were based on the documentation in the medical record. Findings include: Policy Review: Subject: Code Status Policy, dated [DATE] Policy statement: It is the facility's policy to honor code status orders in accordance with State and Federal regulations. Procedure: 1.) All residents will have a code status form signed on admission or as soon as the resident or resident representative can consent. 2.) If no choice is made, the resident will be considered a full code. 3.) Code status orders should be obtained to match the resident's consent form. 4.) The Code status form should be scanned and documented into the resident's electronic medical record. According to a nursing home hearing decision, Decision No. CR4545, [DATE] The Retreat at Brightwater vs. CMS, It is important to not lose sight of the fact than an error in deciding whether or not to resuscitate a resident has dire implications: either someone who had a desire to live faces death without any chance for survival, or a person who desired a natural death is forced to undergo significant interventions, such as chest compressions and defibrillation, in an attempt to extend a life that he or she did not want to be unnaturally extended. 1.) R94 was originally admitted to the facility on [DATE]. The Admission Record, located in the electronic medical record, showed that R94 has an advanced directive of DNR (Do Not Resuscitate). A review of the R94's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R94's Individual Plan of Care stated that R94 has advanced directives for DNR- Do Not Resuscitate. This plan of care was initiated on [DATE]. Interventions included that R94 has signed Do Not Resuscitate. Nursing Event Note dated [DATE] states that R94 was found face down on floor in front of her recliner. Face bloody from scab that fell off prior to fall, also found 1cm diameter abrasion to right cheek bone. Background: hx of multiple falls. Assessment (RN)/Appearance (LPN): VS (vital signs) and assessment WNL, chronic pain, was reporting pain prior to fall and received tylenol shortly before fall, a preexisting wound on bridge of nose reopened and was bleeding, lungs clear, heart sounds regular, BS active x 4, no BLE [CONDITION(S)]. Recommendations: neuro checks as scheduled [DATE]at 09:30 a.m, Interdisciplinary Team ( IDT) Note: IDT team met regarding resident's recent fall on [DATE]. Care planned reviewed and updated as appropriate. [DATE] at 10:47 a.m., Health Status Note: R94 had a fall this morning. Neurocheck completed (see assessments), VSS (vital signs stable), mentation at resident's baseline per AM nurse. Resident appears to be more restless and agitated, in comparison to resident's behavior per AM nurse. Resident endorses hitting her head. R94 obtained a new abrasion of right cheek. Wound is red and moist, left OTA (open to air). Abrasion is 3cm x 3cm. R94 denies pain. NP (Nurse Practitioner) and resident's family made aware. NNO (no new orders) at this time, will continue to monitor. [DATE] at 10:48 a.m., Health Status Note Late Entry; Writer informed NP of right pupil not reacting to light the same way has her left pupil. NP aware of dx of [CONDITION(S)]. Other aspects of neuro check negative. NNO at this time. [DATE] at 11:54 a.m., communication with Family/NOK (next of kin)/PO: Writer spoke with R94's son, son updated on R94's fall and new abrasion. Son verified that resident's cognition/ mentation that writer assessed this morning was resident's baseline, son endorsed. Son also endorses that d/t resident's history of right eye [CONDITION(S)], resident's eye is baseline less reactive to light. [Son] updated on POC (plan od care), [son] agreeable. No other questions or concerns at this time. [DATE] at 3:00 p.m., Health Status Note R94 is a post fall from NOC shift. R94 has an injury to her right cheek bone, abrasion. Also her scab on the bridge of her nose has fallen off. R94 was given wound care this morning by writer at 0645. Resident is confused and forgetful. R94 does have a lot of repetitive requests and she does know she is confused as she states she is. R94 is at her baseline as she is pleasantly confused, and does have poor safety awareness. Resident is encouraged to stay in bed d/t her excoriated buttock cheeks. She does c/o pain and discomfort in that area and generalized pain. APAP given with effectiveness. R94 has no inward outward rotations of extremities. No lengthening of extremities. R94 refuses PERRLA (pupils equal, round and reactive to light and accommodation). Neuros are at her baseline. Wound MD did do rounds and new orders for her injury and bridge of nose. Daughter is aware of her injuries and fall. Will cont. to monitor. [DATE] at 9:37 p.m., Health Status Note: R94 calling out most of shift. Repositioning frequently between wheelchair, bed and recliner. Continue to call out. When staff ask if she needs anything she states I don't know or help me, help me but unable to state what she needs. Meals, snacks, fluids offered. She did not eat supper multiple times staff encouraged/offered. Alternate also offered. She does take sips of water, juice when offered. Glass ice water at table where resident is sitting. She has been sitting up at nurses station most of shift as she attempts of self-transfer multiple times. R94 did take medications without difficulty. [DATE] at 07:22a.m., Health Status Note: R94 was sitting at the nurse's station when writer came in this morning. R94 was dozing off and at times calling for help. Reassurance that writer and staff are with in the vicinity. She states I know. Asked if she needed anything and she states no. This continues on for about 30 min. Resident was then taken to her room and was given AM cares this morning and laid back to bed. Vitals completed and are WNL. NO labored breathing. No SOB. After cares she was resting peacefully with no issues or calling out for a bit then started calling out again continuously. Tries to get to edge of bed and out of bed many times. States that she is in pain. Resident was given her AM meds, but she spit out the APAP given for pain. They were bigger than her other pills. Writer did try to crush the APAP and give to her but she spit them out. Multiple attempts and education provided. Was not successful. Son had called this morning and an update was given that she is more confused, agitated, and multiple attempts to get out of bed, recliner, and WC (wheelchair). Writer stayed by her room for quite some time to offer assistance and reassurance. R94 was repositioned off of her buttock to her right side to alleviate pain to coccyx/buttock area. Continues to call out Help me. Asked her what she needs help with she states I don't know. This continues on for over an hour. Management is made aware of resident condition. [DATE] at 09:08a.m., communication with Physician: R94 had a fall on [DATE], since fall resident has become increasingly confused, agitated, and restless. Vitals stable, resident A&O x2. Perrla at resident's baseline. Background: Assessment (RN)/Appearance (LPN): NP made aware. Agreeable to send resident to [hospital] for evaluation. R94's son, made aware and agreeable. (Name of) ambulance to transport. Surveyor obtained a copy of the (Name of) Ambulance transport summary for R94 on [DATE]. The report provides R94's patient information including date of birth, social security number, and home address and for the patient's advanced directives- this is left blank. The nature of the call is documented altered level of consciousness. The report indicates that the transport arrived to the scene at 9:27 a.m. on [DATE]. The narrative portion of the report stated the following: Arrived at scene to find [AGE] year old female patient lying in her bed and alert and orientated times ¼. W/cc of falling yesterday and slowly becoming more and more altered per staff at (name of facility). Pt.( R94) reportedly fell out of her wheel chair at 5:30 yesterday morning. Pt. (R94) had an abrasion under left eye. Pt. (R94) was initially able to tell EMS (emergency medical services) her name, Pt. then became non-verbal. Pt. had unequal pupils. Pt was normally altered per staff, but it was worse now. No other signs of trauma noted. Pt. (R94) appeared very mottled all over her body. Pt appeared to have agonal breathing (medical term used to describe struggling to breathe or gasping). Very weak carotid pulse was felt while in Pt's room of facility. Pt (R94) became unresponsive during walk down to ambulance. BG (blood glucose) was 109. 4- lead was put on showing a [MEDICATION(S)] [NAME] rhythm at approximately 48 beats per minute. SPO2 was not reading reliably. Oral airway was placed without opposition and pt. (R94) was bagged via BVM (bag valve mask). No pulse was felt and CPR was started. IO (intraosseous cannulation) was inserted in right tibia. 1 milligram of 1:10,000 EPI was administered. 300 milligrams of [MEDICATION(S)] was administered. Pt. (R94) was initially in PEA (pulseless electrical activity) but went into V- tach (ventricular tachycardia- fast abnormal heart rate). Pt. (R94) was defibrillated. Pt. converted back to PEA as EMS was walking into the emergency room at (name of hospital). [DATE] at 11:31 AM, Surveyor interviewed Director of Nursing (DON)- B regarding DNR advanced directives and how this information is communicated to EMS. DON- B stated the facility does not have a specific policy on what to do with DNR bracelet and that many residents don't like to wear the plastic bracelet because it is irritating to the skin. DON- B that that if the DNR bracelet is issued from the physician, the bracelet is to remain on the person or the signed physician paperwork is to be in the medical chart. DON-B stated that the facility staff will discuss DNR status upon admission, and if they are DNR we put that in the chart. DON- B stated that it is her understanding there is a difference in DNR forms and that EMS will only honor the signed physician paperwork/ orders stating DNR. DON- B stated that if being sent out in an emergent situation, this information (code status) is verbally communicated to EMS and it is also indicated on the Resident face sheet. DON- B stated she is not aware if a copy of the DNR paperwork is also included in the transport packet and that often times staff does not have time to make a copy of the paperwork prior to the resident leaving with EMS. On [DATE] at 2:10 p.m., Surveyor interviewed Operations Manager (OM) of (Name of) Ambulance- G regarding R94's transport to the hospital on [DATE]. OM- G stated that when EMS staff arrive at the nursing facilities they will often ask staff what code status the resident is. OM-G stated that usually paperwork is given to the EMS crew which will include a facesheet with pertinent patient information and other necessary paperwork. OM- G stated for an individual that is wearing a state issued DNR bracelet or if the state issued DNR paperwork is included in the paperwork that EMS crew receives, the DNR code status will be honored during transport if the patient should become unresponsive. OM- G stated he would follow-up with the EMS crew who assisted in transporting R94 on [DATE]. On [DATE], Surveyor was provided with additional information from OM- G who stated that the EMS crew verified that R94 was not wearing the state issued DNR bracelet and although they received some paperwork from the facility, No DNR paperwork was included in the packet that was provided. [DATE] at 7:55 a.m., Surveyor interviewed DON- B. DON- B again stated that the facility does not print out any of the DNR paperwork that is provided upon admission. The staff nurse will give verbal report to the EMS crew and will print out the face sheet and last few days of progress notes and plan of care and send that with the EMS crew. EMS will also get one last face to face with the nurse before they leave. DON- B again stated that the CPR, signed paperwork is not included in discharge packet. DON- B then stated that there was discussion about a purple bracelet that R94 had worn. DON- B stated that she believed it was a hospital bracelet that is used to identify Code status, not the plastic state issued DNR bracelet. DON- B could not give specifics on who stated this during their IDT meeting on [DATE] but does recall staff stating R94 had a purple bracelet that had been cut off. DON-B stated that the facility will often cut off the hospital bracelets, seen as a dignity issue. On [DATE] at 10:42 a.m., Surveyor interviewed Director of Social Services- I regarding obtaining residents advance directives. SW- I stated that advanced directives are obtained upon admission and there are different forms that are used. SW- I stated that many residents don't want to wear the plastic DNR bracelet and she will recommend they order a metal bracelet that is more comfortable to wear. SW- I stated that in the meantime of obtaining a bracelet, indicating DNR, the advanced directive paperwork is to be placed in the medical record. SW- I was unable to recall if R94 had a DNR bracelet and was unsure if the DNR paperwork was obtained upon admission. On [DATE] at 10: 55 a.m., Surveyor interviewed Administrator- A who had confirmed that R94's advanced directive paperwork had not been transferred from the assisted living facility to the skilled nursing facility when R94 was admitted on [DATE]. Administrator- A stated that only the face sheet came with R94 during the transfer. Administrator- A was also able to verify that there was not a scanned copy of the advanced directive paperwork in R94's electronic medical record or hard chart medical record that obtained paper copies. As a result of the facility not having a copy of the advanced directive wishes of R94, they were not able to properly provide R94's wishes to not be resuscitated in an emergency. The EMS crew noted that R94 became unresponsive during transport to the hospital on [DATE] and CPR was initiated to R94 as well as being defibrilated. R94's wished were not honored. R94 was noted to have expired after being admitted to the emergency roiagnom on [DATE]. Using the reasonable person concept, harm occurred because a reasonable person would be angry and feel dehumanized at not having one's last wish respected and having one's body subject to the trauma associated with efforts to prolong life. 2.) The facility's Code Status Policy, dated [DATE], states 1. All residents will have a code status form signed on admission or as soon as the resident or resident can consent .3. Code Status orders should be obtained to match the resident's consent form. 4. The Code status form should be scanned and documented into the resident's electronic medical record. R14's plan of care includes a focus area Resident has Advance Directive CPR [cardio pulmonary resuscitation]- Full Code; HCPOA [healthcare power of attorney] Activated revised on [DATE]. Interventions include Resident has decided to remain a Full Code initiated on [DATE] and Code status will be reviewed on a quarterly basis and PRN [as needed] initiated on [DATE]. A PREFERRED INTESNITY OF MEDICAL CARE AND TREATMENT FORM, signed by R14's power of attorney on [DATE] documented R14 choices as being resuscitated (full code). R14's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor reviewed R14's medical record and did not note any signed form from R14's power of attorney indicating R14's wishes to be a DNR. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .PT [patient] is FULL CODE status. Has a POA [activated power of attorney] .Attempted to call today to discuss code status. Left a voicemail asking for him to call back . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . [patient]. Agree with [physician's] documentation. Pt stable. Will cont [continue] to attempt clarifying code status. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . They discussed code status. POA wants full cares and would want to send to hospital but done agree with DNR status at this time. The surveyor reviewed R14's banner in their electronic health record and noted that it documented both full code and DNR. On [DATE] at 1:35 PM the surveyor interviewed LPN (licensed practical nurse)-J the surveyor asked where LPN-J would look for someone's code status. LPN-J stated in the banner in PCC (Point Click Care, facility electronic health records system). The surveyor asked LPN-J what R14 would be. LPN-J reviewed R14's record and stated she has CPR and DNR listed. LPN-J stated she would look in the scanned files. LPN-J stated there was a scanned in form from October indicating R14 was a full code. LPN-J stated she would call R14's son and look into it. On [DATE] at 1:29 PM the surveyor interviewed Director of Social Services-I. Director of Social Services-I informed the surveyor that code status is generally reviewed upon admission and during care conferences. Director of Social Services-I stated if someone wants to change from a full code to a DNR they would give them the state DNR form to fill out, have the doctor and resident sign, and the nurse would put the actual order in to the electronic health records system to have it changed in the banner. The surveyor informed Director of Social Services-I of R14's record indicating both DNR and Full code. Director of Social Services-I stated she would look into it. A progress note on [DATE] by Director of Social Services-I on [DATE] documents SW [social worker] called and left voicemail for [power of attorney] in regards to resident Code status. Code status to remain full code until DNR paperwork is signed by POA. On [DATE] at 7:58 am the surveyor interviewed DON (Director of Nursing)-B. DON-B informed the surveyor that it appears R14 was originally a full code, and that it looks like it was changed and the paperwork wasn't completed. DON-B stated the banner in PCC was changed to full code until the paperwork can be completed.

Based on interview and record review the facility did not ensure 2 (R2 and R1) of 4 residents had interventions implemented to reduce accidents. -R2's care plan included an intervention to use a buddy system for all cares, and 2 assist for bed mobility. On 10/23/19, R2 was being assisted with dressing in bed with only 1 staff member. The staff member left the bed at knee level when she went to the closet to obtain clothing. R2 sustained a fall with a fracture involving the left femoral trochanteric region with displacement. - According to a facility self report, on 11/3/19, (R1) was found on the floor in her room, suspected of falling out of her bed that was in a high position. As a result of the fall, R1 required 9 sutures to the right side of the forehead, 2 sutures on the right side of the scalp, and sustained a lower end right femur fracture. The facility's investigation indicates through staff & resident interview conflicting information was noted in regards to whether R1's bed was in a high or low position at the time of R1's fall. The facility was unable to verify if R1 was capable of putting her bed in a different position. During the survey staff indicated they would look on the resident's care plan and Kardex to determine what level the bed should be at despite facility practice to have all beds in a low position unless specified otherwise. R1's care plan and Kardex did not contain what level her bed should be at. At the time of survey, R1's toileting care plan was not updated and indicated she used a sit to stand to toilet, despite being non-weight bearing and was to be transferred with a Hoyer. Findings include: 1. R2 has [DIAGNOSES REDACTED]. R2 was admitted to the facility on [DATE]. Progress notes on 10/19/19 document .Resident Slept restless first portion of shift, initiated low bed and mat on floor R2's care plan includes a focus care area for I have increased risks for actual limitation(s) in my ability to perform my ADL's (activities of daily living) revised on 10/18/19. Interventions include; Use buddy system for all cares d/t (due to) behavior initiated and revised on 10/18/19, BED MOBILITY: Requires mod (moderate) assist of (2) staff for repositioning and turning in bed frequently and as necessary initiated 10/18/19, and DRESSING: I require assist of 1 staff to dress me. Mod assist with upper and max assist with lower body initiated on 10/18/19. A facility initial self-report, submitted to the state agency on 10/24/19, documents, (R2) was getting washed up in bed by aide on 10/23/19 at 0745 (7:45 am) when she turned to get his clothes out of the closet. (R2) rolled out of bed and fell on to the fall mat. Full assessment completed, no apparent injuries noted, full ROM (range of motion), no pain, vitals stable, resident at normal baseline. MD notified at 0900 (9:00am) with no new orders given .On 10/24/19 during therapy resident started to complain of pain to the left hip and knee. MD contacted and new orders received at 1020 (10:20 am) to obtain X-rays of hip and knee. Mobilex arrived at 1256 (12:56 pm) to perform X-ray. Results obtained at 1510 (3:10 PM) showed fracture involving the left femoral trochanteric region with displacement. MD contacted immediately where new orders were obtained to send to hospital for further treatment . A Misconduct Incident Report, submitted to the state agency on 10/30/19, documents The day the resident fell [DATE], fall packet was reviewed and it was found that care plan had not been followed. Resident was an assist of 1 with bathing but should have been a buddy system (2 caregivers at all times for cares) due to inappropriate behaviors. This was added to the Nursing department staff meeting agenda to re-educate all staff (nurses, CNA's, and certified med techs) on the process of reviewing care plans/Kardex of every resident on their assignment at the beginning of every shift . An Investigatory Interview Form, dated 10/28/19, documents an interview between CNA (Certified Nursing Assistant)-D and DON (Director of Nursing)-B which states, The fall happened on (MONTH) 23rd. I was in the room doing cares on (R2). I got done washing him up and I had to get him some clothes. The height of the bed was at about me knee level and I turned to get his clothes from his closet. Once I turned, hadn't even gotten clothes out of the closed and he hit the floor and I called (LPN (Licensed Practical Nurse)-E). Do you look at your resident cardex every day before you start? No. Do you know that's a requirement everyday? No. We look at them to see them. No I did not know that. (DON-B): For (R2's) cares, what is your understanding of his cares? 1:1 bath cares and 2:1 for transfer (DON-B): Did (R2) have an intervention for his ADL's that required a certain number of residents (sic) regarding requiring 2 caregivers due to inappropriate behaviors? Everybody is different. I just heard from the West employees that knew him that he say inappropriate things to us, but other than that no. (DON-B): When we talked and I explained during your suspension why we had to do a state reportable because of the care plan violation you indicated that you knew he was a 2 person because of his inappropriate behaviors? No. You said to me that he was a 1 with cares and 2 with something else I kind of vaguely remember. I never said that he was 2 with cares that I can recall. (DON-B): There's an intervention on his care plan that he's a buddy system and that he's a 2 person with all cares at all times due to inappropriate behaviors and so this is why it is a requirement of your jobs to always look at the cardex before every shift because those cares plans can be updated daily. The biggest thing with this injury is because the care plan was not followed, it looks like we could have prevent the fall therefore, we caused the harm. Do you know how to look at the cardex on the computer? Yes. (DON-B): Anything else? I made an honest mistake. It was bad because he got injured, but it wasn't something I didn't intentionally. I knew to lower the bed. I knew to not leave the bed up, but other than that no. Progress notes on 10/23/19 by LPN-D document Resident rolled out from bed to floor matt/witnessed by CNA/no injuries/no bruise at this x (time) . On 11/18/19 at 8:23 AM, the surveyor interviewed CNA-D. CNA-D verified she was with R2 at the time of the incident. CNA-D stated she had went in to do cares, and had put on some clothes, and that she needed a shirt. CNA-D stated she lowered the bed to knee length, and had gone to get the shirt and R2 rolled out of bed. CNA-D stated she was able to provide cares to (R2) with 1 person with no problems. The surveyor asked CNA-D how she is aware of a residents care plan. CNA-D stated in PCC (the electronic medical records charting system), in care plans under the resident's name. On 11/18/19 at 9:02 AM, the surveyor interviewed LPN-E. LPN-E informed the surveyor she was called to the room and observed R2 close to the bed on the floor mat. The surveyor asked LPN-E what level the bed was at. LPN-E stated it was at waist height. LPN-E stated the closet was very close to the bed. On 11/18/19 at 11:15 AM the surveyor interviewed DON-B. DON-B informed the surveyor all beds are low beds here, it is the facility's standard of care. DON-B informed the surveyor usually max assist means 2 staff, so she could see how it is confusing. DON-B confirmed R2 should have had 2 staff in there (with R2) when doing cares. 2. R1's [DIAGNOSES REDACTED]. Per R1's Significant Change Minimum Data Set (MDS) assessment dated [DATE] (after R1 11/3/19 fall), R1 has a Brief Interview for Mental Status (BIMS) score of 9, which indicates a moderate impairment for decision making skills. The quarterly MDS dated [DATE] prior to R1's fall indicates R1 scored a 9 in her BIMS indicating moderate impairment for decision making skills. On 11/14/2019 at 1:40 PM, Surveyor reviewed facility's initial self-report dated 11/04/2019. The Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report form F dated 11/4/19 prepared by Director of Nursing (DON) B indicated the allegation type was: Neglect: Intentionally withholding care, disregard of policy or care plan. In addition, this report indicated (R1) was found laying on the floor after falling from bed, injuries present and sent out for additional treatment. The Facility self-report, Misconduct Incident Report F- dated 11/11/19 and prepared by the DON B indicates under Summary of Incident: Briefly Describe the Incident, On 11/3/2019 at approximately 10:15 pm, (R1) was found on the floor in her room. Suspected of falling out of her bed that was in a high position. Resident was sent out 911 to ER (emergency room ) after sustaining a head injury. After ER visit (R1) was found to have a right femure fracture, 9 sutures to right [MEDICAL CONDITION], and 2 sutures to right scalp laceration. Resident was brought back to facility a few hours later. Included in the Misconduct Incident Report was an Incident Report Form which indicated the following: Date of Incident: 11/3/19. Time of Incident: 10:20 PM. Documented Under Brief Description of Incident: (R1) was found lying on the floor next to bed. Active bleeding noted from head wound, Pressure applied to wound. Call placed to 911. Transported to WAMH ER by paramedics .Responsible party contacted. In addition, the facility's investigation indicated at 10:40 PM, R1 was transported to the emergency room for further evaluation. R1 received 9 sutures to the right side of the forehead and 2 sutures to the right side of scalp during the emergency room visit. R1 returned to the facility on [DATE] at 4:51 AM with a [DIAGNOSES REDACTED]. The hospital provided a leg immobilizer (a leg brace used to promote alignment of a limb) to the right lower extremity that was to be kept on at all times. R1 was given non-weight bearing status at this time until further evaluation by therapy services. Surveyor also noted that the facility's self report Misconduct Incident Report dated 11/11/19 stated under, Summary of Incident: Describe the effect the incident had on the affected person . states in part, .An aide on the unit not assigned to R1 went to answer her call light. she heard her roommate yelling to help her, the aide entered the room and saw R1 laying on the left side of the bed face down in a pool of blood and the bed in the high position. the aide stayed with the resident and yelled for help. Other staff came running in to help and stayed until 911 arrived to take resident to the ER. After the resident returned from the ER a few hours later she was interviewed and she indicated she raised the height of her bed and slid out. She indicated there was no caregiver there or responsible. She also indicated the bed was in the low position when she fell . Interpreter was present during interview since Spanish is her primary language and resident asked question a few times to ensure she understood what was being asked about the height of the bed being adjusted versus the head of the bed. Each time the resident responded the same that she was the one that adjusted the height of the bed and no caregiver was present and the bed was in low position when she fell however there were several witness statements indicating the bed was in high position. The Misconduct Incident Report dated 11/11/19 under Summary of Incident: Explain what steps the entity took upon learning of the incident .includes in part The facility was unable to substantiate whether the caregiver had left R1's bed in a high or low position prior to the incident. It was unclear whether the R1 had the capacity to adjust the height of bed prior to the reported incident. Clinical staff was provided with education regarding: resident rounding, safety rounds, environmental rounds, positioning, care plans and safe resident movement. On 11/14/2019 at 2:20 PM, Surveyor reviewed the facility's Investigatory Interview Form dated 11/4/2019 related to R1's fall was reviewed. Surveyor reviewed an interview held between the DON-B and with R1's Certified Nursing Assistant (CNA)-F, who was assigned to R1 on 11/3/19. DON-B asked CNA-F whether the bed was in the lowest position prior to leaving (R1's) room on 11/3/2019. CNA-F responded, Yes, when I left (R1) was safe and I even gave (R1) the bed remote. DON-B asked CNA-F whether they had looked at R1's care plans. CNA-F responded No, I didn't know we had to, the last time I knew they were in a binder at the desk. DON-B clarified that CNA-F had not looked at any residents care plans in the last few months. CNA-F confirmed this. Per DON-B, CNA-F no longer works for facility and was not available for interview. Surveyor reviewed a facility Investigatory Interview Form related to R1's fall on 11/3/2019 which was conducted on 11/4/19 between Social Worker-G and R1. When questioned by Social Worker-G, R1 stated, The bed was not raised at all when I fell from it. I was just trying to sit up and fell out of it myself. When Social Worker-G asked R1 to show how they adjust the height of the bed, R1 was unable to demonstrate how to adjust the height of the bed. Surveyor reviewed a facility Investigatory Interview Form dated 11/4/19 between DON B and CNA K who indicated (R1's) roommate was yelling to help her, I went in the room, turned on the light and she was laying on the left side of the bed face down towards the window with blood everywhere. I stayed with her and yelled for help and Licensed Practical Nurse (LPN) J and LPN L came running down to help. They called the other nurses .and they took over. Surveyor noted CNA K's interview did not address the height of the bed when R1 was found on the floor. Surveyor reviewed a facility Investigatory Interview Form dated 11/4/19 between DON B and LPN N. LPN N indicated, I was called to the room by another staff member. DON B questioned LPN N as to what did she see when she (LPN N) got to the room. LPN N stated, the bed was in the high position with (R1) on the floor and (CNA K) was with her. I think that (R1) may have put her bed up high when she was messing with the remote. When (R1) got back from the hospital this morning she told me she was raising the bed and slid and fell out. Maybe she was reaching for something on her ledge because she had noodles and seasonings there. When DON B questioned if LPN N had ever seen (R1) raise the height of her own bed, LPN stated No. On 11/14/2019 at 3:00 P M, R1's care plan was reviewed. R1's fall care plan was last updated by MDS Coordinator-C on 11/5/2019, after R1's fall on 11/3/19. A new intervention was implemented for bilateral fall mats. Upon review Surveyor noted R1's care plan did not mention whether R1's bed should be in a low position. On 11/18/2019 at 11:50 AM, R1's CNA Kardex (instruction sheet for how to provide care) was reviewed. According to R1's Kardex, it is not indicated whether or not R1's bed should be in a low position. On 11/18/2019 at 10:20 AM, Surveyor interviewed CNA-H. Surveyor asked how CNAs would know how to provide care for their residents. CNA-H stated I would check the Kardex for the resident for directions and if needed, would ask the nurse for information. Surveyor asked CNA-H how often the CNA Kardex is checked for residents. CNA-H stated I would check it daily and if the resident is new, I would ask the nurse about them. Surveyor asked CNA-H how they would know if a resident is to have their bed in a low position. CNA-H stated, That would be on the Kardex. Surveyor noted CNA-H would check the Resident's Kardex to see if a resident is to have their bed in a low position however, R1's Kardex did not include information indicating that R1's bed should be in a low position. On 11/18/2019 at 12:10 PM, surveyor conducted interview with CNA-I. CNA-I was asked how they would know how to provide care for their residents. CNA-I stated, I'd check in the computer. Surveyor asked how CNA-I would know whether a resident's bed should be in a low position. CNA-I stated, It should be on the Kardex. Surveyor asked CNA-I if it is not specified on the Kardex whether or not someone should have a low bed, how they would proceed with providing care. CNA-I responded, I would notify the nurse. Basically we are supposed to automatically put the bed down except for those that are ambulatory. Some people don't want their bed down all the way if they are ambulatory. I would check with the nurse though. On 11/18/2019 at 12:30 PM, a phone interview was conducted with LPN-[NAME] LPN-J was asked how staff would know whether or not a resident should be positioned in a low bed. LPN-J responded, It should be in the CNA Kardex and the resident's care plan. Surveyor noted R1's Kardex did not include instructions to ensure R1's bed is in low position. On 11/18/2019 at 10:30 AM, DON-B was asked how staff should know whether a bed should be in a low position. DON-B responded, All beds should be in a low position. It is a facility expectation that beds should be at their lowest position. On 11/14/2019 at 3:45 PM, R1's Significant Change MDS was reviewed. The Care Area Assessment (CAA) from 11/13/2019 stated R1 is [AGE] years old and has a [DIAGNOSES REDACTED]. Requires staff assist with all ADL's, transfers and mobility. Transfers with 2 assist and Hoyer lift, up in w/c (wheelchair) as tolerated propelled by staff. No improvement expected related to advanced age and cognition. Will continue with current P[NAME] (Plan of Care). On 11/18/2019 at 11:20 AM, Surveyor reviewed R1's ADL care plan last updated on 11/6/2019 by MDS Coordinator-C. R1's Care plan states I have increased actual limitations in my ability to perform my Activities of Daily Living (ADLs). Staff will assist me to maintain my functional status and decrease my risks for functional decline to perform and/or assist with completing my ADLs. Transfer: The resident is totally dependent on (2) staff and Hoyer Lift for transferring. Splint/Brace: R leg immobilizer at all times. Toilet use: Resident is totally dependent on (2) staff and stand lift for toilet use. Surveyor noted under transfers, R1 is to use a Hoyer lift however, under toilet use, R1's care plan states for staff to use the stand lift. Surveyor reviewed R1's Bowel and Bladder care plan initiated on 7/11/2019. The Care plan states, Toilet: Assist upon rising, before meals, at HS and upon request. Per R1's Significant change MDS assessment dated [DATE], R1 is coded as always incontinent of bowel and bladder. On 11/18/2019 at 11:25 AM, R1's CNA Kardex was reviewed by Surveyor. Under Transfer: The resident is totally dependent on (2) Staff and Hoyer lift for transferring. Splint/Brace: R leg immobilizer at all times. Non-weight bearing. Toileting: sit to stand assist of (2). Surveyor noted a discrepancy with R1's CNA Kardex indicating for staff to use the Hoyer lift when transferring R1 however, under toileting, staff are to use the sit to stand. On 11/18/2019, Surveyor reviewed R1's Occupational Therapy Plan of Care dated 11/12/2019. R1's Occupational Therapy Plan of Care indicates that R1 requires total assistance with transfers, utilizing a Hoyer Lift and 2 assist and is currently non weight bearing. On 11/18/2019 at 12:10 PM, Surveyor conducted interview with CNA-I. Surveyor asked CNA-I if they were assigned to R1 this shift. CNA-I responded Yes, R1 is my assigned resident. Surveyor asked CNA-I how they know how to provide care for R1. CNA-I responded I'd check in the computer and basically, I know what she likes. Surveyor asked CNA-I how R1 transfers from bed to wheelchair. CNA-I responded (R1) didn't get out of bed today yet. (R1) hasn't been getting up much lately. But right now if we do, a 2 assist for repositioning and a sit to stand for transfers. Surveyor noted that R1's care plan and Kardex requires the staff to use the Hoyer lift for transfers and the sit to stand for toileting. According to the Occupational Therapy Plan of Care, R1 requires total assistance with transfers, utilizing a Hoyer Lift and 2 assist and is currently non weight bearing. Surveyor asked how R1 uses the toilet. CNA-I responded R1 has been a check and change every 2 hours when they are repositioned. Surveyor asked CNA-I how they would know what type of equipment to use to care for R1. CNA-I responded From her Kardex, you would know the safety equipment to use. On 11/18/2019 at 12:45 PM, Surveyor conducted interview with MDS Coordinator-C. Surveyor asked MDS Coordinator-C about the process for implementing a significant change. MDS Coordinator-C stated At morning report, we discuss residents and changes and if they are permanent changes or not. I would talk to nursing staff and CNAs also to determine if there is a change. Surveyor asked MDS Coordinator-C when there is a significant change, when would the resident's care plan be updated. MDS Coordinator-C responded I try to get done within 7 days, sometimes it takes longer. Surveyor asked MDS Coordinator-C who makes immediate changes to care plans or the CNA Kardex as they are needed. MDS Coordinator-C responded I do. Surveyor asked how changes with residents are communicated to staff when MDS Coordinator-C is not in the building. MDS Coordinator-C responded Therapy would give a paper copy so they would know how to care for residents until the care plan and Kardex are updated. Per facility's policy titled, Care Plan Development and Communication dated: 9/1/18: .The overall plan of care (P[NAME]) is oriented towards Person-Centered that honor the resident's preferences, Managing risk factors to the extent possible or indicating the limits of such interventions .The community develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment .A comprehensive care plan (Admission, Annual, Significant Change Assessments or Significant Change prior to Comprehensive Assessment) is completed within 21 days of MDS/CAA Completion + 7 days. The nurse updates the P[NAME] as the resident's needs change. On 11/18/2019 at 12:52 PM, Administrator-A, DON-B and MDS Coordinator-C were made aware of discrepancies on R1's Care plan and CNA kardex related to R1's transfer and toileting status, with the use of the Hoyer lift versus the sit to stand. In addition, CNA- I who was assigned to R1 on 11/18/19 indicated she would use the sit to stand for transferring R1 when R1's care plan and Kardex indicated to use the Hoyer lift for transferring.

Based on interview, observation and record review the facility did not ensure 2 (R1 and R2) of 3 residents reviewed for pressure injuries received the necessary services to prevent pressure injuries. R1 was admitted to the facility on [DATE] without any pressure injuries and on 5/10/19 developed two unstageable pressure injuries. The initial pressure injury assessment was not completed on 5/10/19. The care plan did not reflect preventative measures put into place prior to the pressure injuries occurring and the care plan was not updated after the pressure injuries occurred. R1's pressure injuries required debridement by a wound care physician and progressed to a stage 4 pressure injury. On 5/28/19 R1 was prescribed [MEDICATION NAME] by the wound care physician. R1 was discharged from the facility on 6/11/19. The facility's failure to prevent a stage 4 pressure injury for R1 created a finding of immediate jeopardy that began on 5/10/19. Surveyor notified DON B of the immediate jeopardy on 7/10/19 at 5:06 p.m. The immediate jeopardy was removed on 7/11/19. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan and as evidenced by the following example. R2 was admitted to the facility on [DATE] and had continuous oxygen via nasal cannula. R2 developed a Stage 1 pressure injury behind the right ear. R2 received padding on the nasal cannula but the care plan was not updated. Findings include: 1.) R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital discharge summary dated 4/25/19 indicates R1 has normal strength in upper extremity, decreased strength and sensation in lower extremities. The admission MDS (minimum data set) dated 5/2/19 indicates R1 is alert and oriented and able to make needs known. R1 needs extensive assistance with two staff for bed mobility, transfers and toileting. R1 needs extensive assistance with one staff for dressing and personal hygiene. R1 has impaired range of motion to the lower extremities and is occasionally incontinent of bowel. R1 has a foley catheter due to loss of bladder sensation from the spinal cord infarction. The MDS also indicates R1 is at risk for developing pressure injuries. The CAA (care area assessment) dated 5/3/19 indicates R1 was admitted for short term rehab w/[DIAGNOSES REDACTED]. She is alert and oriented and makes needs known to staff, she requires staff assist with ADL's, transfers and mobility, she transfers with 2 assist and hoyer lift, w/c (wheelchair) utilized for mobility per staff. Her skin is intact, but she is at risk for pressure/ skin breakdown r/t (related to) impaired mobility and occasional incontinence r/t chronic loose stools r/t [MEDICAL CONDITION]. She is working with therapy to improve her functional status and preventative measures put in place to prevent pressure, will continue to monitor and work with therapy. Care plan: The resident has actual impairment to skin integrity as evidenced by pressure areas to sacrum and right buttock. Date initiated: 4/26/19 Revision on 5/14/19 Goal: The resident will maintain or develop clean and intact skin by the review date Date initiated: 4/26/19 Revision on 5/7/19 Target date: 7/25/19 Interventions: -Vohra wound MD to eval and tx (treat) Date initiated: 5/14/19 -Pressure relieving bed mattress Date initiated: 4/26/19 -Wheelchair cushion Date initiated: 4/26/19 -Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Date initiated: 4/26/19 -Encourage good nutrition and hydration in order to promote healthier skin Date initiated: 4/26/19 -Keep skin clean and dry. Use lotion on dry skin. Date initiated: 4/26/19 Revision on 4/26/19 -Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Date initiated: 4/26/19 The care plan does not address repositioning or how frequently R1 should be repositioned. Throughout the nurses notes at times the nurses document R1's refusal to be repositioned. This refusal is not on the care plan and there is no information for staff directing them what to do when R1 refused. The nurse's note dated 5/10/19 indicate three new wounds on sacrum found, wound nurse notified and pictures taken, MD notified, Wound MD requested for evaluation and treatment. Xeroform and dressing applied to wound site. The Skin and Wound evaluation dated 5/10/19 indicates R1 has a pressure injury on the sacrum that is unstageable measuring 0.5 cm by 0.5 cm by 0.1 cm (centimeter). The evaluation is not complete;descriptions of the wound bed, exudate, periwound, wound pain, orders and any notes about the wound were left blank. The Skin and Wound evaluation dated 5/10/19 does not indicate how many pressure injuries R1 has on the sacrum area. There is no assessment or root cause evaluation as to why the wounds might have developed and no changes to the care plan. The MAR (medication administration record) indicates Xeroform oil [MEDICATION NAME] apply to sacrum 3 areas topically one time a day for pressure wounds cut xeroform to size of the wound bed and apply then cover with a gentle foam border. The Vohra Wound Physician's initial wound evaluation and management summary dated 5/16/19 indicate there was a wound on the left buttock. Measurements 3 cm by 3 cm by 0.1 cm with moderate serous exudate, partial thickness MASD (moisture associated skin damage). Dressing treatment plan: [REDACTED]. The evaluation also indicates an unstageable (due to necrosis) sacrum. Measuring 6 cm by 6 cm by 0.1 cm, moderate serous, 50% slough, 20% granulation tissue and 30% skin. Dressing treatment plan: [REDACTED]. The note also indicates debridement was done at bedside. The MAR indicated [REDACTED]. Frequently is not defined. The wound MD notes dated 5/23/19 indicate left buttock wound measures 0.8 cm by 1 cm by 0.1 cm and no change with the treatment orders. The sacrum wound is identified as Stage 4 pressure injury measuring 6 cm by 6 cm by 0.1 cm with moderate serous exudate, 40% slough, 30% granulation tissue and 30% skin. No change in the treatment orders and again the wound was debrided at bedside. The wound MD note dated 5/28/19 indicates left buttock pressure injury resolved. The stage 4 pressure injury on the sacrum is 6.5 cm by 7 cm by 2 cm with 80% slough and 20% granulation tissue, moderate serous exudate and wound progress: deteriorated. The treatment plan changed to recommend [MEDICATION NAME] 100 mg BID for 14 days, Dakins solution apply twice daily for 30 days 1/2 strength Dakins, foam with border apply once daily for 18 days and periwound treatment is stoma paste apply for 30 days. Again the wound was debrided at bedside. On 5/28/19 the Wound MD also ordered [MEDICATION NAME] 250 mg daily for 14 days for the wound infection. The wound MD notes dated 5/30/19 indicates R1's sacrum pressure injury is unstageable measuring 6.5 cm by 7 cm by 2 cm with undermining at 9 o'clock, moderate serous exudate, 75% slough and 25% granulation tissue, wound progress: improved. No change to the wound treatment. The wound MD note dated 6/6/19 indicates R1 pressure injury sacrum is stage 4 measuring 6.5 cm by 7 cm by 1.8 cm with undermining of 4.5 cm at 9 o'clock, moderate serous exudate, 60% slough and 40% granulation tissue, wound progress: improved. No change to the wound treatment. R1 was being followed by the wound physician at least weekly and on 6/11/19 the nurses notes indicate R1 family and R1 requested to be sent to the hospital due to the family's concern the wound was not healing. On 7/2/19 at 8:35 a.m. Surveyor interviewed LPN (licensed practical nurse) C regarding R1's sacrum pressure injury. LPN C stated R1 would often refuse repositioning or offloading. LPN C stated R1 would at times refuse a dressing change if she didn't want to lay back down or if she had family visiting. LPN C stated she would document this in the nurses notes. On 7/2/19 at 8:57 a.m. Surveyor interviewed RN (registered nurse) D regarding R1's sacrum pressure injury. RN D stated R1 had chronic loose stooling and R1's pressure injury would be cleaned many times a day because the loose stool would get near and in the wound. RN D stated R1 would often want to stay up in her wheelchair and would refuse to lay down. RN D stated R1 did not refuse dressing changes for RN D. RN D stated she would document the refusals in the nurses notes. On 7/2/19 at 9: 20 a.m. Surveyor interviewed RN [NAME] regarding R1's sacrum pressure injury. RN [NAME] stated R1 had frequent chronic loose stooling and the dressing and wound would have to be cleaned multiple times a day. RN [NAME] stated R1 did not like being repositioned. On 7/2/19 at 10:06 a.m. Surveyor interviewed LPN Wound nurse F regarding R1's sacrum pressure injury. LPN Wound nurse F stated she not sure why the 5/10/19 skin and wound evaluation form was not completed. Surveyor explained to LPN wound nurse F the concern there is not a comprehensive assessment of the wound (s) on 5/10/19 when the wound was discovered. Surveyor asked LPN Wound nurse F who is responsible for updating the skin care plan and LPN wound nurse F stated she is responsible. Surveyor stated the care plan was not updated to reflect R1 was refusing repositioning and at times dressing changes, the stage 4 mattress and other interventions to prevent and/or heal the pressure injury. LPN Wound nurse F stated she was aware R1 would refuse treatment and repositioning. LPN Wound nurse F stated when she became aware the wound worsened on 5/28/19 she called Wound MD G. On 7/2/19 DON (director of nursing) B provided Surveyor with pictures of the wound (s) dated 5/10/19. The picture reveals there is 1 small area on a buttock area and appears have slough (yellow and dark brown) in the wound. The sacrum area reveals 2 wounds one appears to have slough (yellow and dark brown) and one appears to have granulation tissue no slough noted from the picture. DON B stated on 5/10/19 LPN wound nurse F was having difficulty with the electronic medical record and placed in an IT work request. DON B provided Surveyor with a copy of the email dated 5/11/19 indicating LPN wound nurse F had problems completing the skin/wound evaluation in PCC (point click care). On 7/2/19 at 11:11 a.m. Surveyor interviewed DON B. DON B stated on 6/11/19 she spoke with R1 family because the family was concerned R1 wound was not improving. DON B stated she educated the family on R1 pressure injury, wound debridement and the course of treatment. DON B stated she also educated the family that if R1 refuses to comply with repositioning, offloading and dressing changes, the facility would encourage and educate but would have to respect R1 rights. DON B stated she explained to R1 family they can get a second opinion on R1 pressure injury. DON B stated R1 family insisted on sending R1 to the hospital. DON B stated R1 did not have a concern and was adamant on wanting to return back to the facility. On 7/2/19 Surveyor explained to DON B and NHA A the concern R1 developed an unstageable wounds which worsened and a comprehensive pressure injury assessment was not completed. Surveyor also explained R1's care plan was not updated with intervention to prevent the pressure injury and after a pressure injury occurred the care plan was not updated with interventions. On 7/16/19 at 9:45 a.m. Surveyor interviewed Wound MD G. Wound MD G stated on 5/16/19 he noticed R1 with some slough in the wound and debrided the area. Wound MD G states at times when debridement is done the wound becomes a Stage 4 pressure injury. Wound MD G stated he was informed by nursing staff that R1 would refuse repositioning, offloading and at times dressing changes. Wound MD G stated he verbally educated R1 and R1 daughter on the importance of these things being done to promote healing of the wound. Wound MD G stated he doesn't recall documenting this education. Wound MD G stated on 5/28/19 he was notified R1 had worsenend so he came in and changed the treatment order and added the antibiotic. Wound MD G stated he made an additional assessment on 5/30/19. Wound MD G stated on 6/6/19 R1 wound had improved significantly. Wound MD G stated R1 had constant loose stooling and the dressing was constantly being changed to keep the wound clean. Wound MD G stated he was notified on 6/11/19 that R1 and R1 family wanted R1 to go to the hospital because they felt the wound wasn't improving. Wound MD G was not notified that wound had worsened on 6/11/19. The hospital record dated 6/11/19 indicates R1's vital signs were stable and not febrile. It also indicates R1's lactic acid was elevated and a CT scan of the sacrum was completed. The CT results reveal sacral decubitus ulcer, with subcutaneous [MEDICAL CONDITION] extending to the coccyx tip. There is subtle cortical loss at this level, which is suspicious for osteo[DIAGNOSES REDACTED]. The hospital record indicates R1 had surgical debridement of the sacral pressure injury. The hospital record indicates R1 was discharged to a different facility. The failure for R1 to receive the necessary treatment and services to prevent and heal an avoidable, facility aquired pressure injury, created a finding of Immediate Jeopardy. The facility removed the jeopardy on 7/11/19, when it had completed the following: 1. Completed a house wide skin sweep/assessments 2. An Adhoc QAPI meeting regarding skin assessments 3. Education to all nurses and CNAs regarding the facility's Skin and Wound Management Program The deficient practice continues at a D (potential for harm/isolated) as the facility continues to implememt its plan and based upon the following example: 2.) R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] indicates R2 is alert and oriented and able to make her needs known. It also indicates R2 is on continuous oxygen at 2 liters. The nurses note dated 6/20/19 indicates R2 was discovered to have a 2 cm reddened pressure area behind the right ear where the nasal cannula tubing rest. It also indicates a protective gauze was placed on the tubing to prevent further pressure. The skin and wound evaluation dated 6/21/19 indicate R2 had a Stage 1 pressure injury to the right ear measuring 0.7 cm by 0.2 cm. Treatment ordered for skin prep daily and to apply oxygen tubing foam to prevent pressure to area. On 7/1/19 at 1:50 p.m. Surveyor spoke with R2. R2 stated she was having some discomfort to the back of her right ear and notified the nurses. R2 stated the foam tubing helps to keep the nasal cannula tubing from hurting her. R2 stated she has no pain now. Surveyor observed R2 to have the foam on the nasal cannula tubing. Surveyor asked R2 if Surveyor could observe the right ear and R2 agreed. Surveyor observed the skin intact and no redness. The skin and wound evaluation dated 7/1/19 indicates area now resolved, does have some pinkness to area that is blanchable. Continue treatment with skin prep to protect area as well as foam to oxygen tubing for protection as well. R2's care plan was not updated regarding the right ear stage 1 pressure injury until 7/1/19 when the area is now resolved. On 7/1/19 Surveyor asked NHA A if the facility had a policy regarding resident using continuous oxygen via nasal cannula, specifically the care and treatment of [REDACTED]. On 7/1/19 NHA A stated the facility did not have a specific policy regarding the care and treatment of [REDACTED]. On 7/2/19 at 10:06 a.m. Surveyor interviewed LPN wound nurse F. Surveyor asked LPN wound nurse F why R2's stage 1 pressure injury to the right ear was not updated on the care plan. LPN wound nurse stated she was not sure why it wasn't updated. On 7/2/19 at 11:11 a.m. Surveyor interviewed DON B. Surveyor explained the concern R2 was on continuous oxygen via nasal cannula and the facility did not place intervention to prevent a pressure injury from occurring and that when a pressure injury did occur the care plan was not updated. DON B stated she understood the concern but had no additional information.

Based on interview and record review, the facility did not ensure 1 (R1) of 3 residents reviewed at risk for falls received the necessary services/ interventions and supervision to prevent an injury from a fall. The facility did not implement the care-planned interventions on 6/23/18 of wear a helmet at all times and to be 1:1 by staff at all times. R1 fell sustaining a head injury as a result of the fall. R1 was admitted into the hospital for this unwitnessed fall; R1's hematoma was drained and R1 received staples to his head (occipital) as a result of this fall. Findings Include: R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1 has an activated Health Care Power of Attorney (HCPOA). R1's Admission Minimum Data Set ((MDS) dated [DATE] documents R1 has a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired skills for daily decision making. The MDS indicates R1 had a fall prior to admission to the facility. The MDS also documents that R1 requires extensive assistance with 1 person assistance for transfers, ambulation, dressing, and personal hygiene. Surveyor reviewed the Care Area Assessment (CAA) dated 2/19/18 which documents R1 has a history of falls and gait disturbance. R1 is at high risk for falls and preventive measures are in place to prevent falls. Surveyor reviewed R1's History and Physical (H&P) from the hospital dated 1/30/18. The H&P documents R1 was transferred from assisted living facility to the emergency room because of multiple falls and confusion. R1 had at least 3 falls at the assisted living facility. The hospital course states R1 is impulsive and tries to get out from R1's bed or chair by himself because of which R1 will need constant supervision. Surveyor reviewed R1's Fall Risk Evaluation dated 6/15/18. R1 received a score of 80 which indicates that R1 is at high risk for falls. Surveyor reviewed R1's physician orders [REDACTED]. The following orders are pertinent to R1's risk of falls: 1. (MONTH) use low bed for fall prevention every shift-start date of 4/20/18 2. Soft helmet on at all times except when 1:1 check skin integrity every shift-start date of 4/24/18 Surveyor reviewed R1's care plan and notes the following determined problems: 1. At risk for falls-initiated 2/7/18 with the designated interventions as follows: 1. Be sure call light is within reach and encourage R1 to use it for assistance as needed-initiated 2/9/18 2. Follow facility fall protocol-initiated 2/9/18, revised 2/19/18 3. Keep bed in lowest position-initiated 2/19/18, revised 6/30/18 Hipsters on daily, may remove for cares Wheelchair antitippers on back and autolock brakes No footrests on wheelchairs Play music for relaxation when in room Headboard and footboard removed, head of bed and side wall padded Helmet on at all times 4. My caregivers will provide a safe environment free of clutter-initiated 2/9/18, revised 2/19/18 5. R1 will be 1:1 by staff at all times-initiated 5/13/18 6. Use non-skid floor mat at bedside-initiated 4/21/18 2. Potential for decline/increase in behavior, functional decline, skin breakdown, dehydration, and/or injury-initiated 6/26/18 with the designated interventions as follows: 1. Bed placed against wall 2. Helmet 3. High/low bed 4. Mats on floor when in bed Surveyor reviewed R1's care card and notes the following: 1. Safety: Bed placed against wall, follow facility fall protocol, helmet on at all times, keep bed in lowest position, [MEDICAL CONDITION] Precautions: Do not leave alone during [MEDICAL CONDITION], protect from injury 2. Transfer: Able to transfer with 1 assistance 3. Toilet Use: Requires 1 assistance of staff for toileting Surveyor reviewed the nurse's notes from 4/16/18 - 5/11/18 and noted the following pertinent documentation: 1. On 4/16/18 at 15:21AM, R1 is combative, resistive, confused, and non-compliant. Has frequent falls. Needs continuous cares and redirection. Checked often during awake hours. 2. On 4/16/18 at 11:52PM, R1 has unsteady gait. Uncooperative. Needs 1:1. Has glued scalp laceration 3. On 4/27/18 at 7:03AM, R1 has poor safety awareness. Wears hipster. R1 remains a high fall risk: room environment free from clutter, bed in low position, soft-touch call light within reach. Continues to take off helmet, while staff constantly reapplies. Remains under close supervision per night staff. 4. On 5/4/18 at 2:37AM, R1 remains on 1:1 care, safety helmet in place. 5. On 5/4/18 at 12:31 PM, R1 is very impulsive. Continues to require close supervision. 6. On 5/11/18 at 9:38PM, R1 remains very impulsive. Staff continues to provide 1:1 supervision at all times. On 7/24/18, Surveyor reviewed a facility self report submitted to Division of Quality Assurance(DQA) on 6/26/18. The report alleges that on 6/23/18 at 3:44PM, R1 sustained a head injury from a fall. R1 had been to the emergency room at 9:00AM on 6/23/18 for [MEDICAL CONDITION] and had returned to the facility in the afternoon. The Registered Nurse (RN)-F assessed R1 to be lethargic and sleepy upon readmission. R1 was reported to be comfortable in a low bed with a floor mat. Increased observation and monitoring were established by RN-F with the team to monitor safety and neurological status. R1 was then noted to be on the floor with a head injury. Per hospital report dated 6/23/18, the hospital drained a hematoma and placed staples in the occipital. The hospital record documents R1 had unwitnessed fall from a bed about 1 foot off the ground. R1 returned to the facility on [DATE]. Surveyor reviewed the nurse's notes from 6/23/18 - 6/25/18, concerning the 6/23/18 fall. Surveyor notes the following pertinent documentation: 1. On 6/23/18 at 9:00AM, R1 was transported to the hospital due to R1 unable to stop seizing 2. On 6/23/18 at 3:23PM, R1 was readmitted to the facility. R1 was very lethargic and fell asleep immediately. R1 appears wiped out. Head to toe assessment done. 3. On 6/23/18 at 3:44PM, R1 was found crawling in the hall. A 50 cent size open area in the occipital area of the back of his forehead was swelling and bleeding down R1's neck. When touched, it squirts and remains in flow. 4. On 6/23/18 at 4:45PM, bleeding has not stopped and still squirting when touched. On 6/23/18, at 4:50PM, physician is notified and order received to send R1 back out to hospital. 5. On 6/23/18 at 7:27PM, Spoke to emergency room and was informed R1 has a hematoma which was drained and stapled. 6. On 6/25/18 at 12:45PM, R1 arrived back to the facility. On 7/24/18 at 11:00AM, Surveyor interviewed Licensed Practical Nurse (LPN)-C concerning R1. LPN-C stated (R1) can be anxious and compulsive at times. (R1) is unaware of safety issues and wants to be independent. (R1) is unsteady on R1's feet. LPN-C states no one is assigned 1:1 solely to (R1). The staff tag team to provide 1:1 supervision. (R1) frequently takes (R1's) helmet off, and (R1) wears hipsters. (R1) needs supervision while in (R1's) room. On 7/24/18 at 12:35PM, Surveyor interviewed Certified Nursing Assistant(CNA)-H about R1. CNA-H stated she (CNA-H) has seen (R1) with the helmet on most of the time. Has not seen (R1) fall, but has been listed as a witness. Has seen (R1) bang (R1's) head on the wall 1 time. On 7/24/18 at 12:45PM, Surveyor interviewed CNA-D who stated that she (CNA-D) was not present for the falls or the injuries. CNA-D stated R1 frequently takes off (R1's) helmet. Has never witnessed (R1) to bang (R1's) head on the wall. Stated (R1) needs constant supervision. On 7/24/18 at 12:46PM, Surveyor interviewed Social Services Director (SSD)-E about R1. SSD-E stated (R1) needs constant supervision. (R1) is very impulsive. SSD-E adjusts care plan as (R1) displays new behaviors. SSD-E will sit with (R1) 1:1. All staff take turns to provide supervision. (R1) will get up out of bed and do things not in (R1's) best interest. SSD-E stated if you turn your back for 1 second, (R1) is already getting up displaying unsafe behaviors. SSD-E stated (R1) has poor safety awareness. On 7/24/18 at 2:25PM, Surveyor left a message for RN-F, the nurse who was documented in the self report. Surveyor was unable to reach CNA-G, the CNA who was mentioned in the facility's self report. On 7/24/18 at 3:15PM, Surveyor interviewed DON-B in regards to R1. DON-B stated (R1) will bang (R1's) head on the wall or table purposely. (R1) is impulsive. DON-B stated the management staff rotates taking turns to supervise (R1) to give staff a break. DON-B stated that as each new behavior comes up, the facility develops a new intervention. DON-B stated the facility is trying to keep (R1) from falling and the facility is trying to watch (R1) at all times. Surveyor interviewed DON-B about the fall on 6/23/18. DON-B stated that CNA-G had toileted (R1) upon return from the hospital. CNA-G went downstairs to get linen. (R1) was sleeping and then all of a sudden, (R1) was on the floor with the head injury. On 7/24/18 at 3:34 PM, Surveyor again interviewed DON-B in regards to the details of the day of the fall. DON-B stated (R1) did not have 1:1 supervision when (R1) returned from the hospital because (R1) was so lethargic. DON-B stated staff was doing 15 minute checks. Surveyor noted there was no record of the 15 minute checks. Surveyor asked DON-B what the facility's definition of 1:1 is. DON-B stated that everyone takes turns to constantly monitor/provide supervision, that there is not an actual 1:1 assigned. DON-B stated (R1) is to have the helmet on at all times per physician's orders [REDACTED]. DON-B confirmed to Surveyor that the physician's orders [REDACTED]. DON-B stated to Surveyor, that DON-B would have made the decision to put the helmet on. DON-B also informed Surveyor that there is an extra helmet for (R1) just in case. DON-B stated the expectation is that (R1) is to have the helmet on at all times. On 7/24/18 at 4:29PM, DON-B informed Surveyor that the facility does not have a policy/procedure regarding 1:1 supervision for fall risk. On 7/24/18 at 4:35PM, Surveyor shared with Administrator (ADM)-A and DON-B the concern with R1 and the history of falls. Surveyor shared the concern that preventive measures/interventions were put into place as documented on the care plan and not followed, resulting in a head injury when R1 fell . No further information was provided at this time. On 7/26/18, at 11:31AM, Surveyor received a phone call back from RN-F, the RN working at the time of R1's fall on 6/23/18. RN-F stated that (R1) was so out of it, like a wet noodle. RN-F instructed CNA-G to wash (R1) up. RN-F noticed that (R1) was not wearing R1's helmet. RN-F looked for the helmet and called the hospital to try and locate the helmet. RN-F stated she (RN-F) was going to check R1's vital signs. RN-F stated that CNA-G assumed since (R1) was so lethargic, that (R1) would not be getting up. RN-F reported she (RN-F) could not believe that (R1) was then found crawling in the hallway. RN-F did not think that (R1) would be getting up because the hospital had given (R1) a lot of [MEDICATION NAME] to deal with the [MEDICAL CONDITION]. RN-F was unaware that (R1) had a back-up helmet to use.

Based on observation, interview, and record review the facility failed to ensure that Residents did not develop avoidable pressure injuries, or promote the prevention of pressure injury development for 4 (Residents #1, #2, #3, and #4) of 4 Residents reviewed who were at risk for the development of pressure injuries. Resident #1 was admitted to the facility without a pressure injury or [MEDICAL CONDITION]. On 7/14/16 Resident #1 was noted to have an avoidable pressure injury to his left heel following the facility's failure to: · Provide interventions starting on 7/2/16 when the weekly skin check indicates that Resident #1 had an abnormal finding to his left heel. · Include interventions in the plan of care starting 7/8/16 to off-load Resident #1's heels of pressure or reposition Resident #1 in bed, despite the fact that Resident #1 was considered at risk for the development of pressure injuries, required extensive assistance of 2+ staff for bed mobility, and has [DIAGNOSES REDACTED]. Resident #1 was not provided with diabetic foot checks. · Assess Resident #1's foot on 7/12/16 when Resident #1 complained of left foot pain, and received [MEDICATION NAME] for the pain. The pressure injury to Resident #1's left heel deteriorated to the point that he was hospitalized and required a [MEDICAL CONDITION]. The facility's failure to provide necessary treatment and care to prevent Resident #1's pressure injury, created a finding of Immediate Jeopardy for Resident #1 beginning on 7/8/16. Nursing Home Administrator (NHA)-A and DON (Director of Nursing)-B were informed of the Immediate Jeopardy and substandard quality of care on 10/19/16 at 3:50 p.m. The Immediate Jeopardy was removed on 10/20/16; however, the deficient practice continues at a scope and severity level of G (actual harm that is not immediate jeopardy/isolated) for Resident #2, as evidenced below. Resident #2 on 8/25/16 had a documented pressure injury measuring 4.5 cm x 4.7 cm to the right gluteal containing slough and eschar. The area is documented as red, warm, and swollen. When DON-B was asked why the area was not identified prior to the area measuring that size and containing slough and eschar, DON-B informed Surveyor # that a nurse had just been putting a treatment that was not ordered by the physician on the area without notifying the proper individuals, including the physician. Resident #2 also had a pressure injury to the coccyx that was inaccurately being identified as a stage II pressure injury. Other examples of continuing noncompliance include: Resident #3 was observed in bed with her air mattress pump not plugged in. Resident #4 was observed in bed with the bottom part of her foot beneath her toes pressed against the top part of the footboard base. Findings include: 1.) Resident #1 was admitted to the facility on [DATE] following a hospitalization where Resident #1 had a left hip hemiarthroplasty (a procedure where one half of the hip joint is replaced). Resident #1 had [DIAGNOSES REDACTED]. Resident #1's Admission/Readmission Skin Review dated 6/20/16 documents Resident Skin Intact. Surgical site to (left) hip Drsg (dressing) intact .Multiple Bruises + scratches see skin sheet. The document does not circle the left heel, or document any skin impairment to the left heel. Resident #1's initial Care plan dated 7/1/16 includes the care plan for at risk for alteration in skin integrity ulcers related to pressure/arterial. Interventions include Lift my heels off the bed and or keep pressure off my heels at all times. Resident #1's MDS (Minimum Data Set) Assessment with an Assessment Reference Date of 7/6/16 documents that Resident #1 is cognitively intact, at risk for the development of pressure ulcers, and has no unhealed pressure ulcers or [MEDICAL CONDITION]. Resident #1's Pressure Ulcer Care Area Analysis dated 7/8/16 documents (Resident #1) was admitted for short term rehab s/p (status [REDACTED]. His cognitive status is intact, he informs staff of needs. He currently requires extensive assist with all ADL's (activities of daily living) and is able to transfer with 2 assist, w/c (wheelchair) mobility. He currently has surgical incision, remainder of skin is intact, TX (treatment) done per MD order. Preventative measures in place to prevent pressure and skin breakdown and he is working with therapy to improve his functional status. He is at risk for falls, functional decline, skin breakdown, infection in incision, depression and self isolation. Following the initial care plan, a matrix care plan was developed. The new pressure ulcer care plan with approaches dated 7/8/16 has the following approaches: · Diet as ordered · Labs as ordered · Monitor effectiveness of treatments & make changes as needed · Monitor for s/s (signs and symptoms) of infection (redness, drainage, odor, pain, fever, etc.) · Monitor for timely healing · Notify doctor as needed · Treatment as ordered. On 7/8/16 the care plan no longer included interventions to offload Resident #1's heels of pressure. The care plan does not include interventions to reposition Resident #1 in bed. During a meeting with DON-B, NHA-A, and Nurse Consultant-C Surveyor on 10/17/16 at 3:30 p.m. # asked what care plan staff would be expected to follow. Nurse Consultant-C informed Surveyor # that on admission there is the initial care plan, then when the matrix care plan is developed the facility would pull the initial care plan and follow the matrix care plan. On 10/17/16 at 12:28 p.m. Surveyor # spoke with Resident #1. Surveyor # asked Resident #1 if prior to staff becoming aware of the pressure injury to his left heel if there had been any interventions in place to take pressure off of his heels such as elevating them off the mattress with a pillow or wear a special boot. Resident #1 informed Surveyor # that prior to the area developing nothing was done (to offload his heels of pressure). On 10/19/16 at 2:07 p.m. Surveyor # interviewed MDS Coordinator-G. Surveyor # asked MDS Coordinator-G why no intervention to off-load heels of pressure was transferred to the matrix care plan. MDS Coordinator-G informed Surveyor # that the Matrix Care Plan includes the intervention of treatments as ordered which includes physician orders. Surveyor # stated that offloading heels of pressure was not a physician order [REDACTED]. MDS Coordinator-G stated I see your point. According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance's Prevention and treatment of [REDACTED].), Cambridge Media: Perth Australia; 2014 the section REPOSITIONING TO PREVENT AND TREAT HEEL PRESSURE ULCERS states The reduction of pressure and shear at the heel is an important point of interest in clinical practice. The posterior prominence of the heel sustains intense pressure, even when a pressure redistribution surface is used. It continues to state under the section Repositioning for Preventing Heel Pressure Ulcers 1. Ensure that the heels are free of the surface of the bed. The Weekly Skin Checks on 7/2/16, 7/6/16, 7/9/16, and 7/13/16 all circle the left heel on the diagram. The Weekly Skin Checks are all signed by Licensed Practical Nurse (LPN)-F and CNA-E. On 10/19/16 at 11:45 a.m. Surveyor # interviewed LPN-F. LPN-F confirmed that she had completed the Weekly Skin Checks on 7/2/16, 7/6/16, 7/9/16, and 7/13/16. Surveyor # asked LPN-F what a body part circled on the Weekly Skin Check meant. LPN-F informed Surveyor # that it means that something is going on, is abnormal, and needs to be watched; like redness. Surveyor # asked LPN-F if she notices something abnormal (during the weekly skin check) would she document it anywhere else. LPN-F informed Surveyor # that she would usually refer to her supervisor. Surveyor # asked LPN-F if she recalled anything about Resident #1's left heel. LPN-F informed Surveyor # that at first the heel was fine, then he had a fluid filled blister, then it opened, and was kind of sloughy with black necrotic edges. Surveyor # asked if LPN-F would have told anyone on 7/2/16 about Resident #1's left heel having an abnormal finding. LPN-F stated that she would have told DON-B. On 10/19/16 at 2:20 p.m. Surveyor # asked DON-B if she was informed on 7/2/16 or prior to 7/14/16 by LPN-F of abnormal findings to the left heel. DON-B stated (incorrectly) that she was not the DON at that time, that it would have been the previous DON,that she was not involved with wounds at that time, and did not recall being notified. On 10/19/16 at 12:10 p.m. Surveyor # interviewed CNA-E. CNA-E confirmed that she had completed the Weekly Skin Checks on 7/2/16, 7/6/16, 7/9/16, and 7/13/16. Surveyor # asked CNA-E what a body part circled on the Weekly Skin Check meant. CNA-E informed Surveyor # that it means something is different to that area; it might be red, a bruise, or a skin tear. Surveyor # asked CNA-E if she recalled anything regarding Resident #1's heel. CNA-E informed Surveyor # that Resident #1 had an intact blister to the left heel. Surveyor # asked if nurses were aware the blister. CNA-E informed Surveyor # that nurses were aware. CNA-E was unable to recall the exact rationale as to why the left heel was circled on the weekly skin check sheets, but confirmed that it meant there was an abnormal finding. On 7/12/16, Resident #1's Daily skilled Nursing Note documents c/o (complains of) pain L (left) foot relieved (with)prn (as needed) pain med. Resident #1's MAR (medication administration record) documents that Resident #1 received [MEDICATION NAME] 5 mg/325 mg for left foot pain with a pain rating of 6. There is no documentation that an assessment was completed of the left foot when Resident #1 complained of left foot pain. On 10/17/16 at 12:28 p.m. Surveyor # spoke with Resident #1. Resident #1 informed Surveyor # that he had complained to staff about pain in his left foot, but nobody took the time to take his sock off and look at his foot, until by the time they looked at the foot it was black. Resident #1's 14-day MDS assessment with an assessment reference date of 7/13/16 documents that Resident #1 required extensive assistance of 2+ staff for bed mobility and transfers. The MDS assessment also documents that Resident #1 has a BIMS (Brief Interview for Mental Status) score of 15 (indicating that Resident #1 is cognitively intact), that rejection of care behavior was not exhibited, is at risk for the development of pressure ulcers, has no unhealed pressure ulcers and has no [MEDICAL CONDITION]. On 7/14/16 the Initial Wound Review documents a 5 cm x 5 cm with a dark 1.5 cm peri-wound area. The wound is described as a red heel draining open blister with surrounding darkness. The sounding skin tissue is documented as very dark to black. The pressure injury is staged as a stage 2. An Initial Wound Evaluation dated 7/12/16 and not signed, but whom DON-B confirmed should be dated 7/14/16 and was completed by her, documents the wound as a stage 2 despite the wound bed description of BL indicating Black (eschar) and B indicating Brown (Eschar) according to the key provided on the document. On 10/19/16 at 11:34 a.m. Surveyor # interviewed DON-B. DON-B confirmed that she had completed the document and that it was wrongly dated 7/12/16 and should be 7/14/16. Surveyor # asked why the wound was staged as a stage 2 when the tissue is documented as very black to dark. DON-B stated that the initial wound was like blister that popped. It didn't have eschar at first, it had slough and the edge of the wound bed was black and brown. DON-B stated that she had someone else help her stage it. DON-B stated that there wasn't a lot of slough, just a little in the inner part ( of the wound) had slough. According to the National Pressure Ulcer Advisory Panel, with information found at <http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/>, under the Section Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis .Granulation tissue, slough, and eschar are not present. On 7/14/16 Resident #1's care plan was updated to include the approaches of air mattress, heelz up in place, off-loading boot in place. On 10/17/16 at 12:28 p.m. Surveyor # spoke with Resident #1, who is cognitively intact, over the phone who stated that he is 6 feet and 2 inches tall (74 inches). Resident #1 informed Surveyor # that the bed he was given was too small, that the facility could tell is was too small for him, that they could see his feet rubbing against the end (the foot of the bed), and that he had told multiple people about the bed being too small, but nothing was done. On 10/19/16 at 2:41p.m. Surveyor # confirmed with Nurse Consultant-C, NHA-A, and DON-B that prior to 7/14/16 Resident #1 was on a Proactive Air Mattress that measures 35 x 75 inches. Per Resident #1's MDS assessment with an assessment reference date of 7/13/16 Resident #1 is 72 inches tall. Surveyor # asked Nurse Consultant-C, NHA-A, and DON-B if they have any taller beds for taller Residents. Nurse Consultant-C stated, That's a good question. On 7/18/16 a podiatry note documents Left Dorsalis Pedis nonpalpable. Left Posterior Tibial palpable. Right Dorsalis Pedis nonpalpable. Right Posterior Tibial diminished. On 7/19/16 the weekly wound progress note documents a 5.0 x 6.0 x<0.1 wound, now staged as unstageable. The document states Heel now has black cap. No s/s (signs or symptoms) of infections. No pain noted. Peri-wound pink. MD updated. New orders received. Santyl f/b (followed by) [MEDICATION NAME]. On 7/25/16 a physician's telephone orders an x-ray to the left heel, and to start [MEDICATION NAME] (an antibiotic). On 7/26/16 the weekly wound progress review form documents 5 x 6<0.1 black eschar cap remains. Seen by MD continue Santyl, redness to periwound start abx (antibiotic) x-ray to r/o (rule out) osteo (osteo[DIAGNOSES REDACTED]) family updated. On 8/2/16 the weekly wound progress review form documents that the wound declined. The form states 6.7 x 6.9 larger in size, black cap remains continues ABX (antibiotic) pressure relief shoe ordered by therapy family aware. On 8/2/16 a physician's telephone order is documented to -D/C (discontinue) Santyl tx (treatment -Apply skin prep to L (left) heel 3 x 1 day -Make sure prevelon (sic) boot properly placed -float heels @ (at) all times - no sock on when in bed. On 8/2/16 the TAR (treatment administration record) includes Float heels at all times and Make sure prevalon boot properly placed. 8/2/16 is the first date that signatures in the TAR document these as being completed. On 8/8/16 the weekly wound progress review form documents that the wound declined. The form states 7.2 x 7.9 Black Cap remains. Resident has wound APT (appointment) on 8/12 Family MD updated. On 8/12/16 the outpatient wound care consult diagnosed the wound as a diabetic ulcer of left heel (unstageable.) The document states, We will obtain an xray to the left heel to assess for osteo[DIAGNOSES REDACTED] (an infection in the bone), and also an arterial ultrasound of the left leg to assess the patient's healing potential. The left heel eschar will be treated with [MEDICATION NAME] daily for now. (Resident #1) will be seeing (Physician-D) in the office on 8/18. The patient may require surgical debridement of his left heel wound. I advised him to avoid any pressure to the area. F/U (follow up) here in 2 weeks. On 10/19/16 at 2:20 p.m. Surveyor # interviewed NHA-A, DON-B and Nurse Consultant-C. Surveyor # asked if the facility did diabetic foot checks. Nurse Consultant-C stated that she did not think we (the facility) did those, and they would be on the TAR (treatment administration record) if they were. Surveyor # reviewed Resident #1's TAR and was unable to find documentation of diabetic foot checks being completed. Surveyor # asked if the facility had a diabetic foot care policy and procedure. Nurse Consultant-C stated that all they had was a general skin care policy. On 8/15/16 the weekly wound progress review form documents 6.8 x 7.5 Black Cap remains Continue to keep dry & offload. MD updated. On 8/18/16 the weekly wound progress review form documents that the wound was unchanged. The form states Continue [MEDICATION NAME] tx ordered from wound clinic f/u (follow up) 1-2 wks (weeks after) angiogram. On 8/23/16 Resident #1 was started on [MEDICATION NAME] (an antibiotic) for a [DIAGNOSES REDACTED]. On 8/23/16 at 8:30 p.m. Resident #1's Nursing Note documents Resting in bed. Slow verbally to respond .T 101.3 - denies pain - mild confusion BP (blood pressure) 104/60 P (pulse, no pulse documented) R (respiration) 18. Call out to MD. On 8/23/16 Resident #1 was sent to the emergency room for evaluation. Resident #1's MDS discharge assessment documents that Resident #1 had 1 unstageable pressure injury measuring 6.8 x 7.5 x 0.1, and does not indicate that Resident #1 had a [MEDICAL CONDITION]. Resident #1 was admitted to the hospital in guarded condition with a [DIAGNOSES REDACTED]. Consult notes dated 8/24/16 include assessment notes that document that resident #1 was hospitalized with [MEDICAL CONDITION], left heel, [MEDICAL CONDITION] of the left foot and the leg, and abnormal x-ray suggestive of osteo[DIAGNOSES REDACTED]. The plan was to continue on intravenous [MEDICATION NAME], and start [MEDICATION NAME] (all antibiotics). Orthopedic Surgery Transcribed Documents with a service date of 8/27/16 document postoperative [DIAGNOSES REDACTED]. On 8/31/16 Resident #1 required a [MEDICAL CONDITION] with a pre and postoperative [DIAGNOSES REDACTED]. The procedure transcribed documents state that He (Resident #1) previously underwent surgical debridement of the ulcer. This extended to bone and due to the large size of the ulcer and [MEDICAL CONDITION]-resistant Staphylococcus Aureus infection we discussed treatment options with the patient include wound care and possible calcaneus removal and flap coverage versus amputation. Due to the prolonged course of reconstruction and uncertain results, he wished to proceed directly to transtibial amputation. The facility's failure to provide necessary treatment and care to prevent Resident #1 from developing an avoidable pressure injury, created a finding of Immediate Jeopardy for Resident #1 beginning on 7/8/16. The Immediate Jeopardy was removed on 10/20/16 when: · A house wide resident skin check was completed by licensed nurses. A plan was developed to update assessments, physician orders [REDACTED]. · A house wide skin management intervention / prevention audit will be completed and reconciled by licensed nurses on 10-20-2016. · An audit of current in house pressure ulcers will be conducted by a wound care certified nurse for correct documentation, correct treatment, preventative equipment in place and functioning. · A house wide resident proper positioning audit while in bed (for width and height) was conducted by licensed nurses during resident skin check. · Weekly skin check sheets will be audited weekly for completion by Regional Director of Health Services/ designee, results of the audits will be forwarded to QAPI for further review and evaluation. · Nursing staff were educated by WCC RN/ designee. Staff will be educated prior to working their next shift on: Prevention of pressure ulcers and interventions. Identification and notification of skin issues. Documentation and follow up of skin issues. · The administrator will ensure compliance. Results of the audits will be reviewed and evaluated at QAPI for any further plans and implementation. The deficient practice continues at scope/severity of a G (actual harm/isolated) based upon the following example regarding Resident #2. 2.) Resident #2 has [DIAGNOSES REDACTED]. Resident #2's BRADEN SCALE - For Predicting Pressure Sore Risk on 5/4/16 and 8/2/16 scores Resident #2 as high risk. On 6/2/16 the Initial Wound Review documents that Resident #2 had an abrasion to the Right buttock cheek measuring 1.5 cm x 0.5 cm. On 6/4/16 a physician's orders [REDACTED]. On 6/8/16, 6/15/16, 6/22/16, 6/29/16, and 7/6/16 the weekly nursing summary documents under skin condition skin abrasion R (right) glut (gluteal). The July TAR (treatment administration record) documents that treatment to the right buttock abrasion to clean with soap and water followed by the [MEDICATION NAME] until healed was documented as completed until July 12th, and then on the TAR is written healed. On 7/20/16 the weekly nursing summary documents under skin condition R (right) Glut-duoderm tx (treatment). On 7/27/16 the weekly nursing summary documents under skin condition R (right) Glut (gluteal) duoderm tx (treatment). On 8/3/16 the weekly nursing summary documents under skin condition R (right) Glut (gluteal) duoderm tx (treatment). Surveyor # reviewed Resident #2's medical record including progress notes and was unable to find documentation of a description of the wound to Resident #2's right gluteal after 6/2/16 through when the July TAR documents the area as healed on 7/12/16, and despite the fact that the weekly nursing summary continues to document a treatment to the right gluteal area until 8/3/16. On 10/20/16 Surveyor # interviewed Director of Nursing (DON)-B. Surveyor # asked if there was any documentation or measurements regarding the right gluteal abrasion after 6/2/16. DON-B informed Surveyor # that she did not know if there were measurements, and that they would be in the medical record if they were. DON-B informed Surveyor # that the previous DON would have been following wounds at that time. Surveyor # asked if a resident has an open area if nurses should document a description in the progress note. DON-B stated they should. On 8/25/16 the weekly skin check documents a 4.5 x 4.6 open area on the right gluteal. A Communication Form dated 8/25/16 documents a 4.5 x 4.7 area to the right gluteal containing slough and eschar, the area is documented as red, warm, and swollen. On 10/20/16 at 10:30 a.m. Surveyor # interviewed DON-B. Surveyor # asked why the wound on Resident #2's right gluteal was not identified until the area was measuring 4.5 x 4.6, unstageable, and contained slough and eschar. DON-B informed Surveyor # that a nurse was putting a treatment on the area and just didn't say anything. DON-B informed Surveyor # that the issue in the building is that skin issues are not getting communicated to the appropriate people, including the physician. DON-B informed Surveyor # that a nurse had just been putting a duoderm on the right gluteal without a physician's orders [REDACTED].>On 8/29/16 the pressure injury to the right gluteal was unstageable and measured 3.5 x 3.5 x 0.1. On 9/6/16 the pressure injury to the right gluteal was unstageable and measured 2.5 x 2.9 x 0.1, a culture was obtained, and the wound bed had yellow/green slough. On 9/13/16 the pressure injury to the right gluteal was unstageable and measured 3.1 x 3.0 x 0.2. The wound bed is documented to be brown, green, and yellow with a slight odor noted. On 9/19/16 the pressure injury to the right gluteal measured 3.0 x 2.4 x 0.8. The wound is documented to have slough and a slight odor. On 9/26/16 the pressure injury to the right gluteal measured 1.9 x 2.9 x 1.0. The area is documented to be deeper as slough clears and odor still present. On 10/3/16 the pressure injury to the right gluteal was unstageable and measured 2.0 x 2.5 x 1.3. The area is documented to be slightly deeper and remains to have slight odor. On 10/12/16 the pressure injury to the right gluteal was unstageable and measured 1.2 x 2 x 1.3. The area is documented to contain slough and the wound bed is documented as green and yellow with a slight odor noted. Coccyx- On 9/26/16 Resident #2 was observed to have 1.6 x 3.2 < (less than) 0.1 stage 2 pressure injury to her coccyx with 25% slough noted. Surveyor # noted that the wound was staged as a stage 2 despite the presence of slough. According to the National Pressure Ulcer Advisory Panel, with information found at <http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/>, under the Section Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis .Granulation tissue, slough, and eschar are not present. On 10/3/16 the pressure injury continues to inaccurately be identified as a stage 2 pressure injury despite documentation that it contains a small amount of slough. On 10/12/16 the pressure injury continues to inaccurately be identified as a stage 2 pressure injury despite documentation that it contains a small amount of slough. 3.) Resident #3 has [DIAGNOSES REDACTED]. Resident #3's BRADEN SCALE-For Predicting Pressure Sore Risk dated 10/10/16 documents that Resident #3 is moderate risk. Resident #3's Care plan for the category of pressure ulcer states that Resident is at risk for skin breakdown R/T (related to) impaired mobility & incontinence. Approaches include alternating pressure mattress on bed. On 10/17/16 at 8:45 a.m. Surveyor # observed Resident #3 in her bed on her pack with the air mattress pump observed with the plug noted to be on the floor and not plugged in. At 8:47 a.m. Surveyor # observed CNA (Certified Nursing Assistant)-H enter the room and then inform Resident #3 that she was going to lay the head of her bed down. CNA-H then exited the room with the air mattress pump remaining unplugged. Surveyor # asked CNA-H if the air mattress pump was supposed to be plugged in. CNA-H stated yes and plugged the air mattress pump in. CNA-H states that sometimes it is unplugged when the bed is moved. 4.) Resident #4 has [DIAGNOSES REDACTED]. Resident #4 has a history of pressure injuries. Resident #4's BRADEN SCALE-For Predicting Pressure Sore Risk dated 9/6/16 documented that Resident #4 is moderate risk. On 10/17/16 at 9:25 a.m. Surveyor # observed Resident #4 in bed with the bottom part of her foot beneath her toes pressed against the top part of the footboard base.

Based on observations, interviews and record reviews, the facility did not ensure that each resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the resident's clinical condition demonstrates that they are unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing and prevent infection and prevent new sores from developing. The facility did not ensure this for 4 of 4 residents (Residents #2, #3, #5 and #6) with pressure ulcers that developed in the facility. After assessing the above residents to be at risk for the development of pressure ulcers, the facility did not implement interventions to prevent, to the extent possible, the development of pressure ulcers. Resident #2 was assessed to be at risk for the development of pressure ulcers due to immobility and incontinence. On 2-21-15, when Resident #2 experienced an acute change in her clinical condition that rendered the resident to be at additional risk for the development of pressure ulcers, the facility did not re-evaluate and revise the plan of care in order to account for the resident's decreased mobility and increased time lying in bed. The facility failed to provide interventions to prevent the development of a deep tissue injury (DTI) that progressed to an unstageable pressure ulcer that wound up being infected and required an antibiotic treatment. The facility's failure to assess Resident #2's increased risk for the development of a pressure ulcer as she experienced multiple changes in condition, to revise the care plan and to implement interventions to include consistent repositioning, interventions to prevent shearing, and application of an advanced support surface to assist in pressure ulcer prevention created a situation of immediate jeopardy. The Nursing Home Administrator (NHA)-A and RN Consultant-C were informed of the immediate jeopardy on 5/1/15 at approximately 11:30 am. The immediate jeopardy started on 2/21/15 and was removed on 5/15/15. The deficient practice continues at a scope and severity of a G (actual harm/isolated) based upon the three additional examples. Resident #3 has been diagnosed with [REDACTED]. At the time of admission, Resident #3 was assessed at risk for the development of pressure ulcers, and the facility put in place the intervention of an alternating pressure mattress. Resident #3 left the building for multiple intravenous [MEDICATION NAME] (IVIG) treatments that lasted for upwards of five hours for each treatment. On 4-5-15 the resident was noted to have a right heel blood blister. Prior to and while Resident #3 was receiving the IVIG therapy, the facility did not communicate with the outpatient clinic providing the therapy, to discuss the Resident's need to receive pressure off-loading to the resident's heels during the extended time frame of the IVIG therapy. Resident #5 was admitted to the facility for rehabilitation services on 12-15-14 after a fall requiring hospitalization . Resident #5 experienced increased left knee pain after the fall, due to (soft tissue) injury, such that the resident's physician ordered an immobilizer be placed on Resident #5's left leg to assist in pain management. On 1-14-15, the resident's clinical record notes the discovery of a suspected deep tissue injury (SDTI) on the resident's left heel. The facility updated the resident's plan of care to add a pressure off-loading device and tubi-grips (stockings to aid in the management of swelling of the legs) only after the SDTI developed. Resident #6 currently has an unstageable right heel pressure ulcer. According to Resident #6's plan of care, she is to wear a boot to her right foot while up in the wheelchair. It was noted through interview with facility staff that they were unaware that Resident #6 is to wear the boot while she is up in the wheelchair. The facility also did not update Resident #6's plan of care in a timely manner when they became aware the right heel wound became infected. Findings include: 1.) Resident #2 was admitted to the facility on [DATE], and has diagnoses that include diabetes mellitus, chronic back pain and dementia. The initial Minimum Data Set (MDS) assessment dated [DATE] indicates the resident is cognitively intact, can make her needs known, and requires extensive assistance from two staff members for her transfer and bed mobility. The resident has a urinary catheter and is frequently incontinent of bowel. This same MDS also indicates the resident has no skin issues and that her skin is intact. The Care Area Assessment (CAA) for pressure ulcers dated 12-23-14 notes the resident requires extensive assistance with her ADLs (activities of daily living) . her skin is intact but she is at risk (for the development of) pressure ulcer and skin breakdown due to impaired mobility, general weakness and incontinence. Staff will provide incontinence care after each episode and apply barrier for protection. The ADLs CAA of the same date notes the resident has a history of refusal of cares, however the resident's clinical record also notes the resident is pleasant and cooperative with cares. The clinical record notes Resident #2 experienced an acute change in her condition, where she was diagnosed with [REDACTED]. During this time frame the resident is noted to be more immobile, i.e., not wanting to get out of bed, and has a decreased appetite, both unusual for Resident #2. These developments placed Resident #2 at further risk for pressure ulcer development; however, the facility did not revise the care plan or immediately implement new interventions to address this increased risk. There is no indication that the facility completed a tissue tolerance test for Resident #2 to assess her support surface or skin tissue risk based upon her position on a particular support surface. The facility also did not assess whether a repositioning schedule of every 2 hours was an appropriate schedule for Resident #2's The clinical record indicates Resident #2 was noted to have a Deep Tissue Injury (DTI) on 2-25-15 on the right gluteal (buttock). The clinical record notes the DTI then progressed to an unstageable pressure ulcer on 2-28-15 measuring 3.0 X 4.0 X (less than) 0.1 cm, the area is unstageable because the condition of the wound bed cannot be accurately assessed due to the presence of slough (non-viable tissue). The facility did not revise the resident's plan of care until 2-26-15 when repositioning the resident as she would allow and changing out of the facility's standard pressure reducing mattress to an alternating pressure mattress (APM) were implemented. On 4-28-15 during the daily exit meeting, RN-B indicated the APM are available in storage in the facility, and could have been placed on the resident's bed earlier. The 3-12-14 quarterly update to the MDS assessment indicates Resident #2 remains cognitively intact, still requires two staff members to assist her with her transfer needs and bed mobility, still has a urinary catheter and is incontinent of bowel. The quarterly MDS indicates the resident now has a pressure ulcer. The revised pressure ulcer plan of care dated 3-13-15, that now addresses Resident #2's actual pressure ulcer, directs nursing staff to reposition the resident every two hours and as needed, to keep pressure off of the pressure ulcer as able; the APM was also noted as an intervention. The resident's clinical record notes the appearance of a DTI on 2-25-15 that progressed to an unstageable area on 2-28-15. The resident's clinical record documents the following progress of the pressure ulcer to Resident #2's right gluteal area after 2/25/15: 2-28-15 the area measures 3.0 X 4.0 X (less than) 0.1 cm, the area is unstageable because the condition of the wound bed cannot be accurately assessed due to the presence of slough (non-viable tissue). 3-4-15 - the area measures 3.0 X 4.0 X 0.1 cm, unstageable with greater than 75% slough covering the wound bed, being treated with a wound [MEDICATION NAME] agent. 3-11-5 - the area measures 3.6 X 4.5 X 0.1 cm, unstageable, same treatment. 3-18-15 - the area measures 3.6 X 4.5 X 0.1 cm, unstageable, same treatment. 3-25-15 - the area measures 3.0 X 4.0 X 0.1 cm, unstageable, same treatment. 4-1-15 - the area measures 4.0 X 3.5 X 1.5 cm, unstageable, the treatment now includes packing strips, Dakin ' s solution (a weakened chlorine solution used to treat wounds that show signs of infection), in addition to the [MEDICATION NAME] agent. 4-8-15 - the area measures 3.0 X 3.0 X 2.0 cm with tunneling or undermining of the wound edge; wound with 80% slough; same treatment as 4-1-15. 4-15-15 - the area measures 3.0 X 3.0 X 2.0 cm, the wound is now noted to have drainage and a strong odor with 100 % slough; a culture of the drainage was obtained on 4-14-15, and is now being treated with an antibiotic in addition to the packing strips and Dakin ' s solution. Resident is experiencing a low grade temperature. 4-22-15 - the area measures 1.0 X 1.0 X 4.0 (depth) cm with undermining; same treatment as 4-15-15. 4-29-15 - the area measures 0.5 X 1.5 X 3.4 cm; treatment now changed to normal saline flush, with [MEDICATION NAME] packing. Surveyor # observed Resident #2 on 4-24-15 at 11:35 AM, the resident was positioned on her back. At 1:40 PM and 2:00 PM, Resident #2 was observed in her room in her wheelchair; the resident asked the surveyor to help her get back in bed. The surveyor obtained assistance for the resident. At 3:00 PM and 3:30 PM, the resident was observed in bed positioned on her back. On 4-25-15 at 8:00 AM, 9:30 AM, and 11:30 AM, Resident #2 was observed to be positioned on her back. On 4-27-15 8:30 AM and 9:30 AM, the resident was observed positioned on her back; at 9:30 AM, the resident was served breakfast in bed by CNA-F. At 11:00 AM and 12:00 noon, the resident was again observed in bed on her back. On 4-27-15 at 10:00 AM, Surveyor # interviewed CNA-E, assigned to care for the resident. When the surveyors asked if Resident #2 has a turning or repositioning schedule, CNA-E stated that the resident did have a repositioning schedule and that there is a form that the nursing assistants sign to verify they reposition the residents. At approximately 1:00 PM, LPN-D provided Surveyor # with a copy of the QA (quality assurance) Rounds Tool for turning and repositioning dated 4-26-15 that notes the resident was repositioned every two hours. The document, however, does not address the surveyor's observations on 4-24-15 and 4-25-15. On 4-27-15 at 12:03 PM, Licensed Practical Nurse (LPN)-D entered Resident #2's room in order to complete the treatment to the resident's right buttock. The resident was initially found to be incontinent of bowel. During this observation, CNA-F was observed to squeeze soap and water around the opening to the wound, with some of the soapy water going into the wound. Also during this observation, CNA-F was observed on two occasions to reposition the resident by pulling the resident using the fitted sheet, causing shearing over the resident's right hip and coccyx. At 12:35 PM, LPN-D resumed the process of the dressing change, after the resident had been cleaned up and was now assisted by CNA-E. LPN-D was observed to reposition Resident #2 to her right side by pulling the fitted sheet and causing shearing to her right hip, instead of lifting the resident with a lift sheet. LPN-D conducted the treatment to the resident's pressure ulcer appropriately, with clean technique, and appropriate hand washing and glove changing. Surveyor # observed the wound edges to be macerated (moisture-logged). On 4-27-15 at 4:00 PM, Surveyor # discussed with the facility administrative staff concerns about the development of the pressure ulcer to Resident #2's right gluteal area. On 4-28-15 at 10:50 AM, Surveyor # met with the administrator-A, the director of nursing services-B and RN-C, to discuss the development of the pressure ulcer. The facility brought forward information to explain that the pressure ulcer was unavoidable; including information to indicate the resident is resistive to repositioning. The information provided included hand written statements from nurses and nursing assistants indicating both that the resident will allow herself to be positioned or repositioned, and that she at times will position herself to her back, after she has been positioned to her side. Surveyor # did not, however, observe Resident #2 positioned on her right or left sides, with pillows or other devices in the above observations. On 4-28-15 and 4-29-15, after the discussion with the facility administrative staff, Surveyor # made spot observations of Resident #2 at various times, positioned from side to side with pillows and with a heel pressure off-loading device (heels-up). Surveyor # noted that these were the first observations of the Resident being positioned side to side and with her heels off loaded. On 4/29/15 Surveyor # interviewed Physician (MD)-Q regarding Resident #2 and her changes in condition and pressure ulcer. MD-Q confirmed that Resident #2 experienced multiple changes in condition including a UTI, hypoglycemic episode, influenza and a pressure ulcer. MD-Q indicated that he has known Resident #2 for many years and that this is the first pressure ulcer that Resident #2 has had. MD-Q was asked about his expectations to prevent Resident #2's pressure ulcer given her changes in condition. MD-Q indicated that when all of this was happening to Resident #2 that they were just focused on keeping her alive because she was a very sick individual. The facility's failure to ensure that Resident #2 received preventative pressure ulcer care lead to Resident #2 developing an avoidable, facility acquired deep tissue injury that opened and became an unstageable pressure ulcer. This pressure ulcer ultimately became infected and now has undermining/tunneling and now requires Resident #2 to be seen in a wound clinic. The facility removed the immediate jeopardy on 5/15/15 when they implemented the following: 1. The facility completed assessments on all residents to determine risk for pressure ulcers and to ensure appropriate preventative measures and monitoring is in place for Residents. 2. The facility offered education to all nurses and CNA's regarding pressure ulcer care, orders, updating records, when to contact the physician and pharmacist. CNA's were trained on the use of the CNA care cards and implementation of care measures. 3. A system was established to review all 24 hour boards and audit new orders and care plans for appropriate interventions and completion of Braden scales. 4. A system was established for auditing with changes in conditions by the management team. 5. 3 Daily audit schedules were established by the management team to ensure that intervention are being implemented. The deficient practice continues at a G (actual harm/isolated) due to the following additional examples related to pressure ulcer care. 2.) Resident #3 was admitted to the facility on [DATE], and has diagnoses that include acute idiopathic neurological disorder, chronic pain and post knee joint replacement. The neurological disorder has rendered the resident with increasing weakness and [DIAGNOSES REDACTED] of his legs. The initial Minimum Data Set (MDS) assessment dated [DATE] indicates Resident #3 is cognitively intact, is able to make his needs known and requires extensive assistance from two staff members to complete his ADL's, particularly with bed mobility and transfer needs. This same MDS also indicates the resident's skin is intact; the 1-20-15 Care Area Assessment (CAA) indicates the resident is at risk for the development of pressure ulcers due to occasional incontinence and impaired mobility. The facility devised a plan of care of the same date (1-19-15) to address the resident's risk for the development of pressure ulcers and put in place interventions of an alternating pressure mattress (APM), and pillows to off-load pressure from the resident's feet. The clinical record documents Resident #3 was noted to have a blood-filled blister to his right heel on on 4-5-15; the pressure ulcer's initial measurements are 3.0 X 3.0 cm and is unstageable. Resident #3 was observed on 4-24-15 at 9:55 AM, on 4-25-15 at 8:12 AM and 4-27-15 at 9:10 AM, and at each observation the resident was observed in bed positioned on his back with pressure off-loading boots on both feet and a heels-up device under his feet. Surveyor # interviewed the resident and asked when the above devices were put in place. The resident indicated the devices were implemented after the blood blister appeared to his heel. On 4-27-15 during the daily exit conference, Surveyor # asked the administrative staff for information about the development of the pressure ulcer to Resident #3's right heel, and what interventions were put into place prior to it's development to prevent it, to the extent possible. Surveyor # met with facility staff on 4-28-15 at 11:07 AM to discuss the information brought forward to explain the unavoidable nature of the pressure ulcer to Resident #3's right heel. RN-C indicated while the resident was living on a different floor in the facility, he was doing well, benefiting from rehabilitation services, when the reversal in functional gains were noted. RN-C also indicated the resident also experienced a small weight loss, for which dietary supplements were added to his diet. After consultation with the resident's attending physician, and a neurologist, IVIG (intravenous [MEDICATION NAME]) therapy was decided upon. Resident #3 received five sessions of the IVIG therapy. RN-C indicated in researching the origin of the right heel pressure ulcer, the facility spoke with the outpatient clinic that provided the therapy, and found out after the development of the area, that the resident was placed in a supine position (on his back), for five to six hours while the treatment was administered. RN-C was asked if the facility communicated with the outpatient clinic, or sent along pressure off-loading devices with the resident after the appearance of the blood blister. RN-C indicated the facility did not communicate with the clinic, and pressure off-loading devices were not sent with the resident to the clinic. It was indicated that the Resident went out to the clinic wearing shoes. Resident #3 received a total of five IVIG treatments, two before the appearance of the blood blister and three after. As of 4-22-15 the area to Resident #3's right heel measures 4.0 X 3.4 cm and remains unstageable, and is currently being treated with skin prep, a barrier wipe that serves as a skin protectant. 3.) Resident #5 was admitted to the facility on [DATE], after a hospital stay after falling at home. Resident #5 has diagnoses that includes left knee pain secondary to the fall, and [MEDICAL CONDITION] joint disease with past history of multiple joint replacement surgeries. Resident #5 was discharged to his home on 1-24-15. The initial Minimum Data Set (MDS) assessment dated [DATE] indicates the resident is cognitively intact, able to make his needs known, requires extensive assistance form two staff members in order to carry out his activities of daily living (ADL's), including his bed mobility and transfer needs. This same MDS indicates the resident's skin is intact. The initial MDS also indicates Resident #5 is at risk for the development of pressure ulcers due to limited mobility secondary to pain, and due to a potential problem with friction and shearing of his skin. The pressure ulcer Care Area Assessment (CAA) dated 12-19-14 identifies the resident's moderate risk for the development of pressure ulcers due to the above reasons. The initial plan of care dated 12-23-14 identifies the resident's risk for skin breakdown related to the resident's immobility and pain, but does not include interventions to protect Resident #5's heels, based on his increased immobility. Resident #5's clinical record notes a physician's orders [REDACTED]. The resident's physician wrote to discontinue the use of the immobilizer and to perform rehabilitation services in order to achieve maximum mobility. Resident #5's clinical record documents the discovery of SDTI (suspected deep tissue injury) to the left heel on 1-14-15, measuring 4.6 X 6.2 X less than 0.1 cm. The initial evaluation of the SDTI notes the resident has decreased movement of the left leg related to knee pain. A notation in the nurses notes dated 12-28-14 documents the resident's family is reporting [MEDICAL CONDITION]. On (assessment) . noted 3+ [MEDICAL CONDITION] - pitting (both extremities) to knees. He did not have [MEDICAL CONDITION] on admission, he is not on diuretics, has no orders for TEDS (anti-embolism stockings) and no [DIAGNOSES REDACTED]. in bed. On 4-27-15 at 3:30 PM, during the daily exit conference with the facility administrative staff, the facility was asked for information about the nature of the pressure ulcer, i.e., what the facility did to recognize the resident's risk factors for the development of pressure ulcers and what the facility did to prevent the development of pressure ulcers. On 4-28-15 at 11:07 AM, the administrative staff indicated the resident's bed had an APM, from the time of admission; a heels-up device and tubi-grips (elasticized support bandages used in the management of [MEDICAL CONDITION]) were added to the plan of care on 1-14-15, after the development of the SDTI. Surveyor # interviewed two different members of Resident #5's family on 4-28-15 and 4-29-15. In the interview with the resident's family on 4-28-15, the family member stated they were told the SDTI developed because the resident was spending too much time in bed. This family member indicated that it was because the resident was in pain and that the facility didn't help him to get out of bed until late morning, whereas the resident was always an individual who was an early riser, getting up before 6:30 AM most mornings. In the interview with the family member on 4-29-15 the family member indicated she is still treating the left heel pressure ulcer, and that once a month the resident goes to the wound clinic for evaluations in it's healing. 4.) On 5/11/15, Surveyor # initiated a medical record review of Resident #6. It was noted that Resident #6 was originally admitted to the facility on [DATE]. According to the medical record, Resident #6 developed an open area on the right medial heel. The nursing note, dated 4/18/15 at 7:00 p.m. states that the assessment noted a wound that is 1.5 centimeter round by 0.2 centimeter depth of 75% pale pink/gray and fairly dry with 25% slough. New treatment order obtained. A review of Resident #6's individual plan of care dated 2/2/15, states that Resident #6 is at risk for skin breakdown due to impaired mobility and incontinence. The plan of care was updated on 4/18/15 stating that wound care to right medial heel wound; cleanse with normal saline skin prep, small amount Santyl to wound beds, cover with [MEDICATION NAME] daily, check placement each shift. Alternating pressure mattress and boot on right foot while up in wheelchair. A review of the Certified Nursing Assistant (CNA) Care Card, located on the closet door of Resident #6's room stated 4/18/15: Bilat boots while in bed (crossed out and 'written at all times') and Boot right foot while in chair. On 5/11/15 at 10:30 a.m., Surveyor # observed RN Consultant- C bring a blue, padded boot down to the dining room on the 2nd floor for Resident #6. Surveyor # then made observations of Resident #6 seated in her wheelchair, in the dining room with a blue, padded boot on her right foot. On 5/11/15 at 10:35 a.m., Surveyor # interviewed Licensed Practical Nurse (LPN)- P who stated that RN Consultant- C had just come into the dining room to put on Resident #6's boot on. LPN- P stated she is not sure why she did this and maybe they had ordered a new boot and it came in over the weekend. On 5/11/15 at 10:45 a.m. Surveyor # interviewed CNA- O who was caring for Resident #6. CNA- O stated that she normally takes care of Resident #6 and had not placed a boot on Resident #6 when she got her up this morning into her wheelchair because it must be a new intervention. CNA- O stated that Resident #6 had not previously worn a boot on her right foot when up in the chair; that the boots would be on while Resident #6 was in bed, but she takes them off with morning cares. CNA- O stated that if she is to be wearing the boot when up in the wheelchair, it is a new intervention and that she did not check the CNA care card prior to giving morning cares. CNA- O was unable to state the exact time she got Resident #6 up on 5/11/15, but it was sometime prior to breakfast which was between 7:30 - 8:00 a.m. On 5/11/15 at 10:50 a.m., Surveyor # interviewed Nurse Consultant-C regarding why she placed the blue boot onto Resident #6. RN Consultant-C stated that earlier in the morning she was doing rounds and noticed that Resident #6's boot was dirty so she went to get a new one, but did not immediately get back to Resident #6 because the Surveyor needed information from her. RN Consultant-C then stated that she went a got a new boot and took it down to Resident #6. RN Consultant-C was able to confirm that Resident #6 was not wearing the blue boot prior to her obtaining a new boot and the boot was in Resident #6's room. Surveyor # conducted a review of the weekly wound progress note for Resident #6, the following was noted: 4/22/15, right heel pressure ulcer, facility acquired. 2.0 centimeters by 1.5 centimeter with depth unknown. 70% slough, no pain with treatment or after treatment. Summary states that Resident #6 developed a pressure ulcer to right heel, unstageable due to 70% yellow slough present in wound bed. no signs of infection, no pain noted. 4/29/15, right heel pressure ulcer, unstageable. 1.5 centimeters by 0.5 centimeters by less than 0.1 centimeters depth. Wound bed is pink, no signs of infection, no pain noted. 5/6/15, right outer heel, unstageable, 1.5 centimeters by 0.5 centimeters by less than 0.1 centimeters depth. Wound present with scab, yellow/white thick puss noted under scab. No paint noted. Culture order obtained and sent to lab 5/6/15. ( It was noted that on 5/8/15, Resident #6 was placed on an antibiotic for wound infection). On 5/11/15 at 1: 40 p.m., Surveyor # made observations of Director of Nursing (DON)- B taking measurements and assessing Resident #6's pressure ulcer to her right heel. DON- B assessed the wound to be 1.5 centimeters by 1.5 centimeters by .5 depth. DON- B stated that the wound had grown in size, but looks cleaner now that Resident #6 is on an antibiotic for the wound infection. Resident #6 did report some pain after the assessment of the wound, in which DON- B stated she would be recommending a new treatment as well a Tylenol for pain control. DON- B stated that she still is expecting that Resident #6 will wear a boot to the right heel at all times, as a pillow under Resident #6's heel was not a successful intervention. DON- B stated she expects Resident #6 to wear the boot even when she is up in the wheelchair. Additional review of the medical record showed, that Resident #6's individual plan of care was not updated until 5/11/16 with the new onset of infection of the right heel wound. It was noted that the facility did place Resident #6 on an antibiotic to treat the infected wound on 5/8/15. As of the time of exit on 5/11/15, the facility did not provide additional information as to why Resident #6 did not have on the boot to her right heel, while up in her wheelchair, as per her plan of care. No additional information was provided as to why the plan of care was not updated until 5/11/15 to reflect that Resident #6 has an infection in the right heel wound.

Based on interview and record review, the facility did not ensure that each resident received and the facility provided the necessary care and services to attain or maintain his highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility did not provide necessary care to 3 (Resident #1, #5 and #2) of 5 residents to meet their wound care needs, diabetic care needs, and pain management needs. Resident #1 did not receive proper [DEVICE] care to an amputation site, such that an almost healed surgical site worsened. Resident #5, with long term history of arthritis and joint pain, was not assisted to attain adequate pain control. The nursing staff caring for Resident #2 during a hypoglycemic (low blood sugar) episode, did not have information in a timely manner, hence the resident was administered insulin that lead to the Resident experiencing [DIAGNOSES REDACTED]. Findings include: 1.) Resident #1 has [DIAGNOSES REDACTED]. The 2-23-15 a significant change in condition Minimum Data Set (MDS) assessment indicates Resident #1 is moderately cognitively impaired, but is able to make his needs known. The MDS indicates the resident requires extensive assistance to carry out his activities of daily living (ADL's). The resident's clinical record indicates Resident #1 was receiving hyperbaric oxygen (higher than normal levels of oxygen) for the treatment of [REDACTED]. The treatment was changed to negative pressure wound therapy also known as applying a [DEVICE]. The [DEVICE] dressing was to be changed three times a week. Resident #1's family accompanies the resident to physician and clinic appointments, and was in attendance on 3-13-15, and noted the progress of the healing of the right leg amputation site. The family of Resident #1 provided to the state agency - DQA (Division of Quality Assurance), information from the wound clinic appointment on 3-13-15 including a progressive photograph of the wound, review indicates that the surgical site appeared to be close to healing and noted to be approximately the size of a fifty cent piece. Included in the wound clinic record was information from the next appointment dated 3-24-15. Again included is wound clinic photographic documentation of the surgical site dated 3-24-15 that shows a decline in healing of the surgical site/wound. At this appointment, the wound now appears to cover the entire surface area of the stump rather than just a fifty cent piece area. The documentation from the wound clinic notes the surgical incision measures 7.0 cm x 7.5 cm x 0.5 cm and the non-surgical portion of the entire area measures 10.8 (centimeters) cm x 2.5 cm x 0.1 cm, with the global measurement (diameter) of 10.8 cm. Physician-H, wound clinic physician, noted at the 3-24-15 visit right [MEDICAL CONDITION] wound with a mix of granular and firmly adhered slough tissue. The periwound (skin surrounding the wound) has broken down significantly. Physician-H further documents in his assessment of and plan for further treatment of [REDACTED]. Check a (wound) culture. Periwound skin breakdown appears to be due to the application of the ([DEVICE]) to intact skin. Surveyor # called the wound clinic on 4-27-15 at 10:49 AM and asked to speak with the physician, the physician was not available, but the nurse practitioner, NP-I was. Surveyor # asked for verification that the decline of the surgical wound between 3-13-15 and 3-24-15, was due to the [DEVICE] sponge being applied improperly by the facility staff. NP-I stated the [DEVICE] sponge was applied to the entire distal (away from center) stump, and not to the open wound; NP-I confirmed the [DEVICE] sponge had been applied incorrectly by the facility. Surveyor # observed Licensed Practical Nurse (LPN)-J conduct the treatment to the surgical wound to Resident #1's right [MEDICAL CONDITION] on 4-25-15 at 10:57 AM. The surgical site was observed to be essentially healed, with just a small scab. On 4-25-15 at approximately 4:00 PM, during the daily exit meeting with the facility administrative staff, Surveyor # showed the staff the photographs provided to DQA, and asked what their knowledge of what happened was. On 4-27-15 at approximately 10:00 AM, the administrator and RN-C brought forward information that indicated the facility conducted training to the nurses on the proper application of a [DEVICE]; the training was provided to the nurses by a representative of the [DEVICE] company on 4-1-15 and 4-2-15. On 4-28-15 at approximately 9:00 AM, Surveyor # interviewed LPN-K, and asked if he knew the correct way to apply a [DEVICE] to a wound. Initially, LPN-K stated he would apply a gauze dressing, then the sponge, and then the tubing and tape. LPN-K then corrected himself and stated there should be no gauze, and that the sponge should be applied to the open wound and not the surrounding tissue. On 4-29-15 at approximately 10:00 AM, the facility provided to Surveyor # with a copy of the its [DEVICE] policy and procedure, entitled Negative Pressure Wound Therapy Criteria (NPWT) revised 03/2015; the policy addressed indications for the use of the [DEVICE], but not the actual procedure, i.e., proper application of the wound sponges, operating the equipment, etc. According to the website kci1.com, a supplier of the [DEVICE], Clinical Guidelines A Reference Source for Clinicians states care should be taken to protect the periwound (skin surrounding the wound) noting the foam or sponge should not be allowed to overlap onto intact skin. This same guide also states the foam/sponge should be applied directly to the wound surface to enhance optimal contact of the tissue with the foam/sponge interface. 2.) Resident #5 was admitted to the facility on [DATE] for rehabilitation services after a fall at home where the resident sustained [REDACTED]. The resident was admitted to the facility with a prescription for [MEDICATION NAME] with [MEDICATION NAME] 7.5-325 mg ([MEDICATION NAME]), 1 -2 tablets every six hours as needed (PRN) for moderate to moderately severe pain. Resident #5 was discharged home on 1-24-15. The facility conducted an initial assessment of the resident's pain on 12-15-14, that addressed the acute and chronic nature of the resident's pain. The assessment indicated the resident had acute pain of his left knee/leg related to the fall, the assessment also addresses the chronic nature of the resident's pain of his right knee. At the time of the assessment, Resident #5 rated his pain intensity as 3 - 4, on a scale of 0 - 10. The resident also indicated his acceptable level of pain is between 3 - 4. The assessment indicates movement aggravates his pain. The clinical record documents on 12-17-14 at 8 PM, Resident #5 received one pain pill for pain he rated at 5. On 12-18-14 at 1:30 AM, Resident #5 rated his pain at that time as 8, and received two pain pills. The record also documents on consecutive nights, around bedtime, between 12-17-14 and 12-29-14, and 1-3-15 to 1-15-15, the resident rated his pain between 5 - 9, for which he received one to two tablets of the pain medication. As noted in the initial pain assessment, Resident #5 indicated his acceptable level of pain was between 3 - 4. In addition to the resident receiving PRN doses of the [MEDICATION NAME] at bedtime during December 2014 and January 2015, Resident #5 received PRN doses of pain medications at other times during the day for expressed pain. On 4-28-15 during the daily exit conference with the administrative staff, Surveyor # asked the facility to explain the discrepancy between the resident's expressed pain goal of 3 - 4, and the frequent notations in the resident's clinical record where his pain was between 5 - 9. On 4-29-15 at 10:00 AM, RN-C brought forward documentation from Resident #5's clinical record to refute the allegation that the facility did not assist the resident to optimal pain control. Review of this information indicated the resident experienced frequent times where his pain control was not optimal. RN-C also indicated the facility consulted with the resident's physician, and the bedtime dose of two tablets of the [MEDICATION NAME] was eventually scheduled so that the resident no longer needed to ask for the medication. On 4-29-15 at 11:10 AM, Surveyor # conducted a telephone interview with the family of Resident #5. The family of Resident #5 alleged the facility did not assist the resident to attain optimal pain control, while he was a resident in the facility. The family member indicated the facility administered one pain pill to the resident, and that he had to beg for a second. In this same interview with the resident's family, the family member indicated the resident worked for years on railroads, performing physical labor, additionally the resident has had multiple joint replacement surgeries and had been using the [MEDICATION NAME] for many years. It should be noted the above information from the resident's family was not included in the initial pain assessment. 3.) Resident #2 has been residing in the facility since 12-8-14, and has [DIAGNOSES REDACTED]. The clinical record notes the resident experienced an acute change in her medical condition between 2-21-15 to 2-25-15 where the resident was diagnosed with [REDACTED]. The clinical record notes on 2-24-15 at 9:45 PM, Licensed Practical Nurse (LPN)-L documents she was called to Resident #2's room and noted the resident was exhibiting some confusion, her skin was cool to the touch and clammy or moist. The resident's blood sugar was checked at that time and found to be 39 (normal range 80 to 120) . The clinical record notes LPN-L remained with the resident and administered treatment to the resident in order to raise the the resident's blood sugar, while another member of staff alerted RN-M, the evening supervisor. The clinical record indicates the resident's blood sugar was assessed and re-evaluated every 15 minutes between 9:45 PM and 10:45 PM, until at 10:45 PM, Resident #2's blood sugar was found to be 82. Surveyor # interviewed LPN-L on 4-29-15 at 2:05 PM. LPN-L indicated she followed the facility's emergency diabetic management protocol, which directs the staff to provide edible forms of sugar as long as the resident is symptomatic and alert and able to swallow safely. LPN-L indicated Resident #2 did not lose consciousness. LPN-L indicated she was aware the resident the resident had been experiencing decreased appetite due to the influenza and general malaise, but doesn't recall being told by the nursing assistant that Resident #2 didn't eat supper on the evening of 2-24-15. LPN-L stated she should have been given that information, because then adjustments in her insulin dose would have been made, and that the resident would not have received the 20 U of Humalog insulin prior to the evening meal on 2-24-15; it should be noted Resident #2's blood sugar before the evening meal was 86. Surveyor # interviewed RN-M on 4-29-15 at 2:24 PM. RN-M confirmed the LPN-L's recollection of the events of 2-24-15, also confirming the licensed nursing staff had not been aware Resident #2 did not eat supper, after receiving insulin, this information was not known until the resident experienced [DIAGNOSES REDACTED]. On 4-29-15 the facility's policy and procedure titled [DIAGNOSES REDACTED] (insulin shock) dated 8-1-04. Surveyor # noted upon reading the policy that it was not representative of current standards of practice regarding diabetic care. Surveyor # noted the following in the policy: 3. If the resident is symptomatic, conscious and able to swallow give the resident ONE of the following. ~ 4 ounces of fruit juice (orange non [MEDICAL TREATMENT] residents only, apple etc.) not tomato juice. ~ 1/2 can of soda pop (not diet) or, ~ 1/3 bottle of glucose, or an instant glucose. 4. If the resident rallies immediately and is able to swallow, follow up with one of the following foods if it is more than 30 minutes until the next meal. These are considered additional snacks and are not to be deducted from the next meal. ~ Buttered toast ~ 2 crackers and 1 oz. cheese ~ One serving of ice cream, or ~ One carton (1/2 pint) of milk. 5. Stay with the resident to ensure all the food is eaten and the resident does not fall back to sleep. Feed the resident if he or she is disoriented or lethargic. On 4-29-15 at approximately 2:05 pm and 2:24 pm Surveyor # interviewed LPN-L and RN-M who referenced following a diabetic care sheet located in the Medication Administration Record [REDACTED]. A copy of this one page protocol was provided to Surveyors for review and it was noted that this document was not consistent with the facility's overall policy and also did not reference current standards of diabetic care.

Based on observations, interviews and record review, facility staff did not provide necessary care and services for 2 of 9 sampled Residents (Residents #7 and #8) for them to attain their highest practicable level of mental and psychosocial well-being, in accordance with their comprehensive assessment and plan of care. *Resident #7 has a [DIAGNOSES REDACTED].#7's behavior of screaming and yelling during cares. Resident #7 was heard screaming out loudly and uncontrollably during a shower. Resident #7's reaction during the shower is best described as a catastrophic reaction (defined as disorganized behavior that is the response to a severe shock or threatening situation with which the person cannot cope). Staff were unaware of interventions to address the behavior and stated it happens every time Resident #7 gets a shower. Resident #7's care plan did not address any behavior issues for Resident #7. Resident #7's example led to the finding of Immediate Jeopardy, starting on 8/6/14. Facility administration was informed of the Immediate Jeopardy on 8/8/14 at 9:54 a.m. The Immediate Jeopardy was removed on 8/7/14 when the facility implemented an action plan for Resident #7. The deficient practice continues at a scope and severity (s/s) of a G (actual harm/isolated) based upon the additional example for Resident #8. *Resident #8, who suffers from Dementia, did not have a plan of care in place to address behaviors displayed on this survey since being admitted to the facility. This includes crying, agitation, restlessness, wanting to stand up and walk and angry outbursts. The plan of care instructions for nurse aides only addressed wandering behavior. The individualized needs and preferences of Resident #8 were not used to develop care approaches that may lessen Resident #8's distressful symptoms displayed through behavioral reactions to her environment and unmet needs. The facility did not provide the quantity and quality of staff needed to assist residents with Dementia to reach their highest well-being. Staff were not thoroughly trained in caring for Dementia residents and were not knowledgeable about behaviors, what precipitated behaviors and how to address behaviors of residents with Dementia, including Resident #8. Findings include: CMS (Centers for Medicare/Medicaid Services) issued memo S&C 13-35-NH, dated May 24, 2013 that spoke about the revisions to regulation F309, Dementia Care. Key Principals within this memo speak to: - providing a supportive environment that promotes comfort and recognizes the individualized needs and preferences of Residents with Dementia; -providing staff in both quantity and quality to meet the needs of residents as determined by individual assessments and individualized plans of care; -thorough evaluations of new or worsening behaviors, evaluated by an interdisciplinary team of professional staff and an evaluation of environmental factors that may be contributing to behaviors displayed by Residents with Dementia; -utilizing a consistent process that focuses on individual needs and tries to understand behavior as a form of communication that may help to reduce behavioral expressions of distress in some residents; -involvement of family and resident representatives in potential approaches to address behavioral symptoms. This should be documented in the resident's medical record. -the use of any approach to care must be based on a careful detailed assessment of physical, psychological and behavioral symptoms and underlying causes as well as potential situational or environmental reasons for the behaviors. Caregivers and practitioners are expected to understand or explain the rationale for interventions and approaches to monitor of the effectiveness of these interventions and approaches and to provide ongoing assessment as to whether they are improving or stabilizing the resident's status or causing adverse consequences. -describing the details and possible consequences of resident behaviors helps to distinguish expressions such as restlessness or continuous verbalization from potential harmful actions such as kicking, biting or striking out at others. -identifying the frequency, intensity, duration and impact of behaviors as well as the location surroundings or situation in which they may occur, help staff and practitioners identify individualized interventions or approaches to prevent or address the behaviors. 1. On 8/5/14 at 1:38 p.m., Surveyor # observed Resident #7 crying in bed. CNA (Certified Nursing Assistant)-G said Resident #7 "always yells like that." On 8/6/14 at 9:04 a.m., Surveyor # entered a stairwell on the first floor to go up to the third floor. Once in the stairwell, Surveyor # heard an on-going loud noise, but at first could not make out what it was. The second floor of the facility is undergoing renovations and Surveyor # thought the noise may be related to the construction work. Proceeding up the stairs, it became clear that the noise was someone screaming at the top of their lungs, repeatedly. Arriving on the third floor, Surveyor # opened the door to the interior hallway and looked around to see where the screaming was coming from. The screaming was continuous, sounding like it only stopped for a person to take a breath and start screaming again, and extremely loud. Surveyor # does not know how long the screaming was occurring prior to entering the stairwell. Housekeeper (HSKP)-GG was down towards the end of the hall closer to the dining room. HSKP-GG saw Surveyor # and said "It's OK, they're giving a Resident a shower. That lady always screams like that when she gets a shower." Surveyor # knocked on the shower room door, introduced self and asked permission to enter the shower room. CNA (Certified Nursing Assistant)-G stated "Come in." Surveyor # observed Resident #7 sitting in a shower chair, naked, her feet dangling several inches above the floor, screaming at the top of her lungs, only stopping to take a breath, and then start screaming again. Resident #7 was gripping the arms of the shower chair tightly as she screamed. CNA-G was rinsing soap/shampoo off Resident #7's face, hair and body. When done rinsing, CNA-G turned off the water and the CNA-G and CNA-H began drying off Resident #7 who slowly stopped screaming but started crying. While Resident #7 was screaming, CNA-H stated Resident #7 "screams with a bed bath too, but they want everyone to get a shower. Maybe (Resident #7)'s a little better in bed." Surveyor # asked who "they" were that want all Residents to get a shower, but CNA-H shrugged her shoulders and did not reply. CNA-G stated Resident #7's screaming is worse since Resident #7 came back from the other facility. Surveyors # and # , also hearing the screaming, knocked on the shower door to see what was going on. Seeing Surveyor # in the shower room with staff and Resident #7, they left. At approximately 9:20 a.m., the CNAs activated the call light to summon the nurse to perform a skin/body check for Resident #7. Resident #7 had stopped screaming and was still crying by the time LPN (Licensed Practical Nurse)-JJ entered the room for the body check, but prior to LPN-JJ's entry, the screaming had been clearly audible throughout the whole floor of the facility. By the time CNA-G and CNA-H dried and dressed Resident #7, combed her hair and took Resident #7 to the dining room for breakfast, she had stopped screaming and crying (approximately 9:30 a.m.). Surveyor # interviewed LPN-JJ, asking if Resident #7 could get a bed bath instead of a shower if the shower is so traumatizing for Resident #7. LPN-JJ stated Resident #7 could get a bed bath, "but sometimes she yells with that, too." Surveyor # asked if Resident #7 reacts worse to a shower vs. a bed bath. LPN-JJ stated "maybe a little." Surveyor # reviewed Resident #7's ADL Flow Sheet Log from 5/15/14 to 8/7/14. The documentation shows Resident #7 received 16 showers and 11 bed baths during that time. On 8/7/14 at 7:47 a.m., Surveyor # observed Resident #7 dressed, dozing in a wheel chair in the dining room. Surveyor # asked LPN-D if she was in the room when Resident #7 was assisted with morning cares. LPN-D stated she was not in the room, but did hear Resident #7 yelling out while the CNAs were getting her dressed, adding that it was not unusual for Resident #7 to be yelling out during cares. On 8/7/14 at 10:00 a.m. Surveyor # interviewed CNA-EE who stated she cares for Resident #7 routinely. Surveyor # asked if Resident #7 yelled or cried out during cares that morning. CNA-EE stated, "Yes, she's always like that- yelling and hollering with cares. She seems worse in the morning when you get her up, that's why I only take her to the toilet after lunch when (Resident #7) is calmer. In the morning I wash her and change her in bed." (Note: Resident #7's Care Plan calls for staff to toilet Resident #7 at 7:00 a.m., 10:00 a.m. and 1:00 p.m.). ADMISSION ASSESSMENT/MDS/NURSES' NOTES Staff inaccurately assessed Resident #7, which subsequently hindered staff ' s ability to develop a care plan that addressed Resident #7 ' s specific needs. Surveyor # reviewed Resident #7's medical record from 8/6/14- 8/8/14. Resident #7 had been a Resident at the facility, then was relocated to a sister facility during renovations of this facility. Resident #7 was readmitted to this facility on 5/15/14 with diagnosed including: [DIAGNOSES REDACTED]. Surveyor # reviewed Resident #7's Admission MDS (Minimum Data Set) completed 5/26/14 with an Assessment Reference Date of 5/21/14 (last day of assessment period) which indicates Resident #7 scored "0" of a total score of 15 for the BIMS (Brief Interview for Mental Status) indicating severe cognitive impairment. Staff noted "Behavior not exhibited" for: "Physical behavioral symptoms directed towards others" (includes hitting, kicking, pushing, scratching, grabbing ...); "Verbal behavioral symptoms directed towards others"; "Other behavioral symptoms not directed at others" (includes "verbal/vocal symptoms like screaming, disruptive sounds"); "Rejection of Care" (includes rejection of evaluation or care, e.g. blood work, taking medications, ADL (Activities of Daily Living) assistance...). However, Resident #7's Nurses' Notes contain the following documentation within the Assessment Reference period that indicates some of those behaviors were, in fact, exhibited by Resident #7 during the Assessment Reference Period. These included: 5/17/14 4:00 a.m. ...More cooperative with cares and vitals ... (implies there were times when she was less cooperative) 5/18/14 5:00 a.m. Had brief episode of crying, unable to tell what's wrong, then suddenly stopped. 5/19/14 2:10 p.m. Resident refused a.m. meds and insulin shot. Resident states " No " when writer attempted 5 x's (times). 5/20/14 12:05 p.m. Resident crying constantly, loud and agitating other residents. Resident upset and combative at times with cares. Other Nurses' Notes on 5/20/14 indicate Resident #7 "scooted" out of her wheel chair and fell to the floor. The Notes state Resident #7's physician was called and is "aware of fall with no injuries," but no mention is made of staff informing the physician of Resident #7's behaviors. During the Assessment Reference Period, the following was documented on the 24 Hour Report: 5/17/14 PM Shift- crying episodes x 2 5/17/14 NOC (Night) Shift- No crying or behaviors until 5:00 a.m. 5/18/14 Day Shift- Striking out at lunch 5/18/14 PM Shift- No aggressive behaviors observed until HS (hour of sleep), scratching and biting, resistive with cares. Because Resident #7's behaviors were not identified on the MDS, the CAA (Care Area Assessment) for Behavioral Symptoms was not triggered. The CAA's further assess areas identified on the MDS as being pertinent to that Resident. Under the "Activity Preference" section, Resident #7 noted it is "Very important" to have books, newspapers and magazines to read, to listen to music you like, to be around animals such as pets, to keep up with the news, to do things with groups of people, to do favorite activities, to go outside to get fresh air when the weather is good, and to participate in religious services or practices." The Admission MDS notes Resident #7 needs physical assistance of one person for part of the bathing activity. The Admission MDS also indicates under "Daily Preferences" it is "Very important" for Resident #7 "to choose between a tub bath, shower, bed bath or sponge bath" and "to have family or close friend involved in discussions about your care." Despite knowing that bathing preferences are very important to the resident, no further information was documented. Resident #7's Admission Data Collection Tool dated 5/15/14, under the "ADL Status" section, asks "Bathing Options Preference: __Tub __Shower __Other (nothing is checked); Frequency: __Daily __Every other day __Bi-weekly __ Weekly (nothing checked); Time of Day: __ AM __PM (neither checked). On 8/8/14 at 11:05 a.m., Surveyor # interviewed Activities Director (AD)-Y, who collects the "Preference" information on the MDS. Surveyor # noted Resident #7's Admission MDS noted it was very important to choose between a tub bath, shower, bed bath or sponge bath, and asked if she then asked what Resident #7's preference was, because it is not noted in the care plan or on the CNA Care Card. AD-Y stated she does ask that question and records the information on a worksheet that she then brings to morning report, and then nursing takes over from there. AD-Y stated if a Resident is an exception-meaning they do not want a shower- she passes that information on to nursing. AD-Y stated Resident #7 first moved back onto the second floor, then moved to the third floor when the second floor was closed for renovations, and Resident #7 does have [MEDICAL CONDITION]. Surveyor # asked if she contacted Resident #7's family or their sister facility to get information regarding what bathing preferences and routines Resident #7 previously had. AD-Y stated she had not contacted Resident #7's family or other facility. At 12:10 p.m., AD-Y informed Surveyor # that she did not keep Resident #7's worksheet that may have indicated what Resident #7's bathing preferences are. CARE PLANS Surveyor # reviewed Resident #7's CNA (Certified Nursing Assistant) Care Plan located in Resident #7's room. The "Bathing" section is blank when it asks "Shower Day_____", "AM__ PM___", "Bed Bath__ Tub__ Shower__". No "Targeted Behaviors" are listed. In the "Report to Nurse" section, it states "sweating, increased confusion, no meal intake." Surveyor # reviewed Resident #7's Care Plan located in Resident #7's medical record. None of the Care Plan "Problems" identify or address the behaviors documented elsewhere in Resident #7's record. The Care Plan does include a "Problem" of "Resident is limited in ability to maintain grooming/personal hygiene related to impaired mobility and dementia", with a Start date of 5/23/14 and Goal Target date of 8/23/14. Another Care Plan "Problem" started 5/23/14 is "Resident is at risk for adverse consequences related to receiving antidepressant medication for treatment of [REDACTED]." The Goal Target date is 8/23/14, and the Goal is "Resident will not exhibit signs of drug related side effects or adverse drug reaction." Neither the ADL Care Plan nor the At Risk for Adverse Consequences of receiving antidepressant medication identify Resident #7's behaviors, what seems to trigger the behaviors, what may help during these episodes, and what staff should do at those times. Resident #7's Activities Care Plan dated 5/23/14 notes Resident #7 likes dogs, music of all kinds, (especially '40's and '50's), likes newspapers, books, history, getting nails done and looking good, belongs to Unitarian faith, watches TV, likes to tell stories. Staff are to monitor for frustration when having difficulty communicating. Surveyor # reviewed Resident #7's undated Psychosocial Review indicates Resident #7 loves taking care of children, was a childcare provider and real estate landlord, is married, has children, grandchildren and a great grandchild, and belongs to a church. A Healthy Generation Resident Recreation Program Review completed on 5/16/14 indicates Resident #7 loves to read, likes listening to classical music, likes dogs and cats, likes to read newspapers and watch TV for current events, likes to sew, crochet, play cards and bingo, garden, getting fresh air outside, and practices Jewish and Unitarian faiths. The Review indicates Resident #7 has [MEDICAL CONDITION], but indicates she likes activities, though has limited participation. Used to like creative activities -singing, story-telling. Despite having identified the types of activities that Resident #7 likes, these were not incorporated into a behavioral care plan. On 8/8/14 at 10:05 a.m., Surveyor # interviewed DSS-II. Surveyor # noted Resident #7's care plan did not include what Resident #7's behaviors were or what interventions staff should attempt when Resident #7 had those behaviors, and asked DSS-II what staff are to do at those times. DSS-II stated they have worked with psych and adjusted medications, and thought staff should re-approach the Resident and involve the resident in groups. Surveyor # asked if staff had looked closely at what events cause Resident #7 to yell out in an effort to avoid those events, possibly get information from family or their sister facility to help develop a behavioral plan of care. DSS-II stated he has not contacted Resident #7's family or previous facility, and did not know if anyone else had. Surveyor # asked DSS-II who initiates a Behavioral Care Plan. DSS-II stated it is a combination of Social Services and Activities staff. Surveyor # noted the Activities staff identified several things that are important to Resident #7 that could be used as interventions to prevent or de-escalate a behavior episode, but it does not appear those things (music, religion, babies, newspapers, TV, going outside, dogs, etc.) have been incorporated into a behavioral plan of care for Resident #7. Surveyor # asked if DSS-II had additional notes, including notes from Family Conferences or IDT meetings, other than what is in Resident #7's chart, since Surveyor # did not see any Social Service documentation regarding Resident #7's behaviors or planned intervention to address the behaviors. DSS-II stated perhaps nursing documented in the Nurses' Notes. Surveyor # stated the Nursing documentation of the meetings only referred to more physical conditions, not behavioral. RN-C, who was present, stated they have looked and there are no Social Service notes. RN-C also added they recently discovered that the Targeted Behaviors on the MAR indicated [REDACTED]. At 10:26 a.m., RN-C confirmed DSS-II has no additional information regarding Resident #7. (Cross Reference F250). BEHAVIOR DOCUMENTATION As noted earlier, documentation that identifies the frequency, intensity, duration and impact of behaviors as well as the location surroundings or situation in which they may occur is important in helping staff and practitioners identify individualized interventions or approaches to prevent or address the behaviors. Documentation by staff was incomplete and inconsistent between disciplines, as evidenced below. CNA documentation. Surveyor # reviewed CNA (Certified Nursing Assistant) behavior documentation (CareTracker Behavior Detailed Entry Report) for Resident #7. The records included documentation dated 5/20/14 stating Resident #7 exhibited inappropriate behavior, but it did not specify what the behavior was. On 5/21/14 (within the MDS Assessment Reference period), staff documented Resident #7 exhibited socially inappropriate behaviors of screaming and excessive noise at 9:30 a.m. On 6/12/14 at 1:00 a.m., Resident #7 was screaming, making excessive noise and disruptive sounds. On 6/13/14-through 6/15/14, and 7/1/14 through 7/20/14 and other dates, the CNA documentation indicates "none of these behaviors apply", while the nurses' behavior monitoring indicates behaviors were present (shown below). The CNA documentation shows Resident #7 hit staff on 7/16/14 at 7:00 a.m. On 7/21/14 at 10:30 p.m. Resident #7 made excessive noise that impacted Resident #7 by interfering with cares, and impacted other residents by privacy intrusion and disruption of environment. On 7/22/14 at 12:00 a.m., Resident #7 screamed at staff, caused disruption of the environment of other residents, privacy intrusion and interfered with cares. On 7/22/14 at 12:15 a.m., Resident #7 exhibited socially inappropriate behaviors of excessive noise, disruptive sounds that interfered with cares and disrupted the environment of other residents. On 7/25/14 at 11:30 p.m. Resident #7 was noted to exhibit the socially inappropriate behaviors of screaming, excessive noise, and disruptive sounds that interfered with cares and impacted other residents by disrupting their environment and privacy intrusions. On 8/6/14 day shift, the day Surveyor # heard Resident #7 screaming from two floors below while getting a shower from CNA-G, CNA-G entered "None of these behaviors apply" for that shift. Evening/PM shift made no entry for 8/6/14. On 8/7/14, when both LPN (Licensed Practical Nurse)-D and CNA-EE informed Surveyor # that Resident #7 yelled out during morning cares, CNA-EE entered "None of these behaviors apply." On 8/4/14, only PM shift made an entry, stating "None of these behaviors apply", but that was at 4:14 p.m., with over 6 hours left in the shift. Numerous dates only have two shifts documenting on Resident #7's behaviors, and there is no CNA behavior documentation for the first five days after Resident #7's readmission to the facility. (A subsequent interview with DON (Director of Nursing)-B revealed the CNAs have a standard list of pre-set behaviors to choose from; the behaviors for the CNA behavior documentation are not individualized for each resident). Nursing behavior documentation. Surveyor # reviewed Behavior /Intervention Monthly Flow Records for Resident #7 for May-August 2014. These records are kept in the MARs (Medication Administration Records) binder the nurses use to administer medications and are completed by the nurses. Resident #7's May Behavior record identified "Continuous crying" and "Consuming less than 50% of meal" as the behaviors to monitor for Resident #7. This behavior log in the MAR indicated [REDACTED]. Day Shift-5/20 four episodes, interventions-activity, improved outcomes; 5/21 greater than 10 episodes of crying, interventions of redirection, 1:1, and activity, improved outcome (but not [MEDICATION NAME] if greater than 10 episodes in one 8 hour shift); 5/25- greater than 10 episodes, 5/26- one episode. Evening Shift: one episode on 5/23, 5/27, 5/28. The June Behavior /Intervention Monthly Flow Record indicates for Night Shift, on 6/3 and 6/17 Resident #7 had one episode of crying, and the other days are there were no episodes of crying, while the CNA documentation recorded Resident #7 screaming, making excessive noises and disruptive sounds at 1:00 a.m. on 6/12. For Day Shift, 17 of the 30 days are left blank and the other 13 are "0"- no behaviors. For PM/Evening Shift, Resident #7 had 4 episodes of crying on 6/12, one on 6/13, 3 episodes on 6/14. The July Behavior Flow Record monitors "Crying/Yelling" and "Consumes less than 50% of meals." It shows 10 episodes of crying on Night shift 7/22 and 7/25, 2 episodes on 7/24, with interventions of redirection, 1:1, ambulation, activity, return to room, toileting. The Outcome is indicated as (-) meaning "worsened." Day shift had 15 of 31 days blank, all but 4 were "0's" for no behaviors; the 4 were "occasional." Evening shift, however, documented 19 of 21 shifts that Resident #7 had 3-4 episodes of "Crying-yelling" per shift, with 10 shifts/days left blank. Only two evening shifts were marked "0" for no "crying/yelling." The August Behavior Flow Record identifies behaviors of "Yelling out/crying." As of 8/7/14, Night Shift reports no behaviors; Day Shift recorded no behaviors 8/1 through 8/3, left blank 8/4-6, (8/6 is the day Resident #7 was yelling and crying in the shower). LPN-D recorded no behaviors on 8/7, despite CNA-EE stating Resident #7 did cry and yell with morning cares and LPN-D stated she heard Resident #7 yell during morning cares. On 8/7/14 at approximately 2:30 p.m. when Surveyor # asked LPN-D why she marked "0" for no behaviors for day shift 8/7, after telling Surveyor # earlier that day that she heard Resident #7 yelling during morning cares even though she was no in the room, LPN-D stated she marked no behaviors because Resident #7 was now calmly sitting in a group activity and no longer yelling. LPN-D pointed to Resident #7 in the group activity, and Resident #7 was sitting quietly, but that does not change the fact that Resident #7 was yelling out at the beginning of the shift. Evening Shift nurses had not documented at all on the August 2014 Behavior /Intervention Monthly Flow Record as of 8/7/14 at 4:00 p.m.; each day was left blank. The last day Evening shift nurses documented on the Behavior Monitoring Monthly Record was 7/26/14, and that was following multiple episodes of yelling/crying each evening for 19 of 21 documented shifts in July. PSYCHIATRIC NOTES/BEHAVIOR MANAGEMENT Surveyor # reviewed a "Request for Psychiatric Services" completed by DSS (Director of Social Services) -II for Resident #7 dated 6/9/14. The form asks staff to "Check Problem Type(s) and Circle Applicable Symptoms." DSS-II checked "Cognitive Impairment" and circled "confusion" and "memory loss." DSS-II did not check "Depression" and circle "crying" nor did DSS-II circle "Behavior Disorder" and circle "striking out", "yelling" or "refusing care", though all were already documented in Resident #7's medical record. The 6/9/14 Geropsychiatric visit note indicates Resident #7 cries frequently, good appetite, "not as much" depression, restlessness, calling out at times, and physically aggressive with cares. Resident #7 makes needs known at times, requires extensive assistance with ADLS. Frequent crying, usually consolable. No recent illness ... Speech: Unintelligible with crying with exam ...Language- not always sensical. Mood-labile. Diagnoses-[MEDICAL CONDITION]; Severity-Severe with depression, anxiety, physically aggressive/impulsive behavior; Other status [REDACTED]. Treatment recommendations- add [MEDICATION NAME] sprinkles 250 mg. twice a day, A.M. and HS. (Resident #7 was also receiving [MEDICATION NAME] and [MEDICATION NAME]). Resident #7 was seen on 7/14/14 for a Gero-psychiatric follow-up visit. The Narrative states: Episodes of agitation several times a week [MEDICATION NAME] about an hour and becomes difficult to redirect. Increasing language difficulties. All needs anticipated and met by staff. The Review of Systems includes crying at times, anxiety, restlessness, calling out frequently, physically aggressive occasionally with cares. Diagnoses-[MEDICAL CONDITION]; Severity-Profound. The recommendation was to increase the [MEDICATION NAME] to three times a day (8:00 a.m., 2:00 p.m. and HS) and check [MEDICATION NAME] acid levels. Surveyor # reviewed Behavior Intervention Team Summaries for Resident #7. The first one, dated 6/9/14 notes Resident #7 receives [MEDICATION NAME] for anxiety and depression, [MEDICATION NAME] for depression and appetite, and [MEDICATION NAME] (no diagnosis listed). Targeted Behavior -crying- occurred 32 times. "Interventions/Effectiveness" was left blank. Targeted Behavior-decreased appetite happened twice. Interventions/Effectiveness left blank. Behavior intervention Team Recommendations- trial D/C (discontinue) [MEDICATION NAME]. No discussion of interventions was noted, or what may increase or decreased the number of episodes, or duration of episodes. Surveyor # reviewed the Behavioral Intervention Team Summary dated 7/14/14. It lists the medications Resident #7 was receiving ([MEDICATION NAME] for depression, [MEDICATION NAME] ([MEDICATION NAME]) for appetite, [MEDICATION NAME] (no diagnosis listed), and [MEDICATION NAME] for impulsive mood disorder. Targeted Behavior -Crying was noted to occur 16 times that month. (Note: just counting up the number of episodes of crying/yelling in the nurses' MAR Behavioral/Intervention Monthly Flow Record from 6/10/14 to 7/13/14 totals 36 episodes plus several noted to be "occasional" during some shifts, not including the CNA CareTracker Behavior Monitoring). "Interventions/Effectiveness" was again left blank. Staff wrote "Episodic agitation and calls out, can be difficult to redirect. Psych follow-up today. Increased [MEDICATION NAME]." Again, there was no documentation of assessing what may trigger an episode, times of day the episodes happen, successful strategies to minimize the frequency or duration of episodes, etc. On the morning of 8/7/14, after checking Resident #7's medical record for documentation from 8/6/14, Surveyor # met with DON (Director of Nursing)-B, asking if staff reported to her Resident #7's catastrophic reaction /prolonged, extremely loud yelling while in the shower on 8/6/14 since there was no documentation in the Nurses' Notes about it, nor did the day shift nurse complete the Behavior Flow sheet in the MAR for 8/6/14, and the CNAs documented "no behaviors" for that shift. DON-B stated she was not aware of this and would look into it. Surveyor # shared the details of the observation with DON-B: Resident #7 could be heard in the stairwell on the first floor; upon Surveyor # arriving on the third floor, housekeeper-GG informed Surveyor # that everything was OK, the yelling is from Resident #7 getting a shower and "she always does that when she's getting a shower;" and Surveyor # also heard the yelling and came to investigate moments after Surveyor # entered the shower to see what was happening. Surveyor # also shared with DON-B Resident #7's Care Plan in the chart and Care Card in the Resident's room do not address any behaviors or interventions nor does it specify Resident #7's preference regarding bathing, there are numerous gaps in Behavior Monitoring documentation by the CNAs and nurses, there appears to be no Social Service documentation regarding Resident #7 other than twice counting up (not accurately) how many crying episodes Resident #7 had and starting and adjusting [MEDICATION NAME], and staff appear to accept Resident #7's catastrophic reaction as routine. Surveyor # noted Activity Director-Y identified numerous facets of daily life important to Resident #7 that do not seem to be incorporated into a care plan to address Resident #7's behaviors. Surveyor # noted Resident #7's Admission MDS was coded incorrectly for Behaviors, with the MDS reflecting no behaviors when Nurses' Notes identified behaviors. Correctly coding the behaviors on the MDS would have triggered a CAA (Care Area Assessment) which is a further assessment of the behaviors. The above example regarding Resident #7 created a situation of Immediate Jeopardy that started on 8/6/14. Immediate jeopardy was identified because Resident #7 demonstrated a catastrophic reaction to bathing that was not addressed by facility staff. Multiple staff heard what was occurring but none intervened and, instead, accepted that this was just normal behavior for Resident #7. This resulted in recurrent debilitating fear/anxiety manifested by extremely loud screaming in response to an identifiable situation. This was likely to continue to occur because an inadequate and incomplete initial assessment led to an incomplete care plan that did not identify for staff how to best care for Resident #7. The immediate jeopardy was removed but

Based on observations, record reviews and staff interviews, the facility did not always ensure that 6 of 9 residents (Residents # 2, #9, #8, #5, #6, & #4 ) who are incontinent of bladder received treatment and services to prevent urinary tract infections and restore as much normal bladder function as possible. -Resident #2 experienced a decline in bladder status according to a current MDS (minimum data set) with no evidence of changes in the plan of care with interventions to restore normal bladder function. This example is being cited at the level of actual harm (severity level 3/isolated). -Resident #9 required assistance to the bathroom per the plan of care and would often call out for that help and assistance and observed not to receive that assistance. This example is being cited at the level of actual harm (severity level 3/isolated). -Resident #8 observed not to receive toileting per plan of care. -Resident #5 was observed to receive improper peri care and did not receive catheter care. -Resident #6 toileting assistance was delayed after numerous requests. -Resident #4 was observed to receive improper peri care. Findings include; 1.) Resident #2 is noted per clinical record to be currently alert and oriented and able to make his own decisions. The resident also experiences a left above the knee amputation and demonstrates some difficulty with ambulation that requires the use of a walker. The admission MDS (minimum data set) 02/14/14 indicated that the resident scored a 9 out of 15 on the BIMS and that Resident # 2 was also occasionally incontinent of his bladder. The resident also scores a 15 out of 15 on the BIMS (brief interview for mental status) completed 05/20/14, meaning that the resident is cognitively alert. The initial bladder incontinent assessment completed on 02/10/14 by RN-O along with the admission MDS indicated that Resident #2 experiences functional incontinence and that the toileting plan developed was that "staff assist/offer urinal at 12 a.m., 3 a.m., 5 a.m., 8 a.m.-toilet 10 a.m., 12 p.m., 3 p.m., 6 p.m., 8 p.m., 10 p.m. and per requests, will provide incontinent care and keep as clean and dry as possible." Another MDS assessment completed 05/20/14 and identified as the quarterly assessment indicated that Resident #2 was now "frequently incontinent of his bladder" indicating a decline in bladder functioning. The bladder incontinent assessment completed on 05/13/14 by RN-O states, "requires limited assist with adls (activities of daily living) and transfers with 1 assist, wheelchair mobility, continues to have daily functional incontinence with some control, will continue with current toileting plan." There was no evidence that the facility had identified the cause of Resident #2's decline from occasionally to frequently incontinent considering the residents incontinence has been identified to be a result of his functional status and there is no evidence that the plan of care had been updated in light of the decline. Per interview Surveyor # conducted with Resident #2 on 08/04/14 at 10:56 a.m., the resident did express concern and stated, "waiting to go to the bathroom takes forever." The facility did not ensure -that Resident #2 received services to maintain bladder function. On 08/06/14 at 3:00 p.m., Surveyor # shared these findings with the NHA, DON and RN-C. On 08/07/14 at 2:00 p.m., RN-C stated that there was "nothing found" to support that Resident #2 received treatment to address the residents bladder decline and restore normal bladder function. 2.) Resident #9 per clinical record, is described as alert and oriented and scored a 9 out of 15 for the BIMS (brief interview for mental status). Resident #9 identified per clinical record to require the assist of two staff for toileting needs. On 08/04/14 at 10:15 a.m., Resident #9 was observed to tell CNA-G (certified nurse aide) that he needed to go to the toilet. At that time, CNA-G responded, "Wait, I have to get this resident up." The nurse aide walked away from Resident #9 who then responded, "They keep saying that. I'm going down there and put myself on the toilet." At 10:18 a.m., Resident #9 was observed to be wheeling himself into the bathroom of his room and stated, "I have asked three people to help me." At this same time, CNA-E and CNA-G approached the resident's room to assist with the resident's toileting needs. Once on the toilet, Surveyor questioned CNA-G if the resident's incontinent product was wet to which CNA-G indicated yes. The resident also experienced a bowel movement at that time. During that time, it was noted that staff were frequently asking the resident if he was "Done yet, are you done?" The resident was assisted off of the toilet and was wheeled back into the hallway. Surveyor continued to observe Resident #9 and at 11:08 a.m. the resident asked the Surveyor to take him to the bathroom. Surveyor approached CNA-E and informed her of the resident's request to which she responded that she needed to get some help. Resident #9 continued to propel himself up and down hallway and at 11:31 a.m. was heard by Surveyor to say, "Oh God this is terrible, the service here is awful." "I want to go to the toilet." At about the same time Staff-I (concierge) stated to Resident #9, "Hang in there" as she walked pass him to which Resident #9 sarcastically stated, "Thanks for your concern but I have to go to the bathroom." Staff-I was observed not to respond in such a way as to notify staff of the residents request either. At 11:40 a.m. CNA-G stated to Resident #9 "I'll be right with you to which the resident stated, "I bet you will tomorrow." At 11:45 a.m. Resident #9 was wheeled into the bathroom by CNA-F with CNA-G following behind and CNA-G stating, "Ok we'll take you to the bathroom again." Surveyor observed that Resident #9 did experience a bowel movement at that time. On 08/05/14 at 8:28 a.m. was observed and heard aloud, "I got to take a crap right now, you going to help me or what, doesn't anybody listen to me?" At 8:30 a.m., the resident was then assisted to the toilet by CNA-G. At 11:20 a.m. Resident #9 was observed to have wheeled self into the room next to his and into the bathroom and pulled the call cord in the bathroom. CNA-F and CNA-H removed Resident #9 from the bathroom but offered no assistance. At 11:23 a.m., Resident #9 asked CNA-H to take him to the bathroom at which time CNA-H stated, "Just a second" and parked the resident in his wheelchair outside of his room. Resident #9 did not remain outside of his room but continued to propel self up and down the hallways. At 11:33 a.m. CNA-G wheeled resident back up the hallway and the resident was now asking a visitor along the way, "Can you take me to the bathroom?" At 11:35 a.m., CNA-G stated to the resident, "Someone will help you" to which the resident responded, "In six hours." At 11:41 a.m. Resident #9 wheeled self to the entrance of his room. At 11:43 a.m. Resident #9 asked DA-M (dietary aide) who was traveling with the food cart, to take him to the bathroom of which DA-M stated, "I can't but someone will be with you." DA-M did not share this formation with direct care staff that the resident wanted to go to the bathroom and just proceeded to the kitchenette area. At 11:45 a.m. Resident #9 was observed to wheel himself in his room and into the bathroom and at 11:49 a.m. was observed to be standing up at his wheelchair in the bathroom alone unattended attempting to toilet self. A review of the clinical record noted that the Medicare daily skilled nursing notes reflected on 07/06/14-"toileted several times." 07/13/14-"it is noted that resident is fixated on going to bathroom he requests going to toilet and notes he is put on the toilet he does not do anything." 07/18/14- "he is fixated with going to the toilet and bathroom." The resident has even made other attempts to self toilet himself. 07/19/14-"in the habit of going to toilet every hour, attempting to toilet himself." 07/22/14-"resident is constantly asking for assistance to the toilet." 07/24/14-"resident continues to request help to go to toilet and half the time he does not move his bowels."07/25/14-"request to go to the bathroom very often." On 07/29/14-"able to make needs known, resident is fixated on toileting and he requests to be assisted almost every 10-15 minutes, a toileting schedule for pm shift was made to make sure he is toileted every 2 hours." "He goes into other residents room looking for toilet." 08/03/14-"resident up to use bathroom, requests toileting every 1/2 hour and at times will attempt to self transfer." On 08/04/14 licensed staff contacted MD-NN (medical doctor) to inform that Resident #9 was voiding frequently but only in small amounts. A new order was given to straight cath after voiding to rule out [MEDICAL CONDITION]. Per the treatment administration record, on 08/05/14 a straight catheterization was done but no evidence as to what the results were. Review of the most recent bladder incontinence assessment that also included a three day voiding and bowel movement patterns dated 06/20/14 identified Resident #9 to experience "functional incontinence." Functional Incontinence refers to loss of urine that occurs in residents whose urinary tract function is sufficiently intact that they should be able to maintain continence but who cannot remain continent because of external factors. The assessment indicated that the resident would be "toileted per schedule, provided with incontinent care and keep as clean as possible." A review of the resident's care card that addresses the cares the nurse aide staff are to provide under the area of elimination directs the nurse aide staff to "assist/offer urinal at 2 a.m., 4 a.m., toilet at 7 a.m., 10 a.m., 1 p.m., 3 p.m., 7 p.m., and 10 p.m. The care plan identifies that the "resident is limited in ability to toilet self related to his spinal stenosis and dementia". The interventions include the above toileting plan and to "remind resident not to transfer without assistance." The facility did not ensure that Resident #9 received the treatment and services to restore normal bladder function in a timely manner. Resident #9 would often request assistance for toileting from both staff including non direct care staff and visitors (See F-241) and would not receive that assistance as observed by Surveyor # . It appears that the care plan established for the resident was not effective and through documentation staff is suggesting that the resident's frequent requests to be toileted is behavioral. These findings and observations were shared with the NHA and DON on 08/05/14. 3.) Resident #8 was observed and medical record was reviewed by Surveyor # . On 8/6/14 at 8:30 AM, Resident #8 was observed to receive morning cares by Nurse Aide (CNA)- G. Resident #8 was observed to be offered to use the toilet by CNA-G. Resident #8 said "no". Resident #8 was observed to wear briefs under her pants. CNA-G told the surveyor that Resident #8 is incontinent at times and will make toileting needs known when she is asked. The nurse aide care card located in the resident's room indicated Resident #8 is to wear briefs and is incontinent at times. The toileting plan listed on the care card is to request and offer toileting and assist on and off the bed pan at 12 AM, 2 AM, 5 AM and to toilet at 7 AM, 10 AM, 1 PM, 3 PM, 6 PM, 9 PM and PRN (as needed). Resident #8 was admitted to the facility on [DATE] with a resolved urinary tract infection. An undated "Bladder Incontinence Assessment" in the medical record indicates blank responses to the onset of resident's incontinence or duration of incontinence with no apparent pattern. A 3 day bowel and bladder diary completed on 4/25/14 indicates 2 episodes of urinary incontinence in 3 days. Times were 5 am and 7 am. The Bladder incontinence assessment indicates no pattern was identifiable. The assessment remains incomplete without any history known of resident's previous incontinence status and duration. An individual service plan, dated 12/6/13, from a previous level of care indicates "will self toilet and no briefs". This information was not used as part of an overall assessment and delivery of care for Resident #8. On 8/6/14 at 6:00 PM to 6:22 PM, Resident #8 was asking to go to her room. The toilet schedule indicated to offer Resident toileting at 6 pm. This was not observed to be done as CNA-N was the only nurse aide in the dining room and other staff were out of the unit. No toileting was offered to Resident #8. It is not known in assessment documentation when or why briefs began to be used, despite knowledge in the chart that in December of 2013, resident did not wear briefs and was able to self- toilet. 4.) On 8/4/14 at 10:42 a.m., PTA (Physical Therapy Assistant)-LL transferred Resident #5 to bed from the wheel chair. Resident #5 has a Foley urinary catheter. The urinary drainage bag was inside a privacy bag that was attached underneath the wheel chair. PTA-LL removed the catheter drainage bag from the covering/privacy bag and left the urinary drainage bag lay on the floor while PTA-LL re-applied Resident #5's hip brace. Once PTA-LL transferred Resident #5 to bed, he attempted to move the wheel chair out of the way with one hand and in doing so, ran over Resident #5's catheter tubing twice. PTA-LL stated a different wheel chair with a higher back may be better for Resident #5 because it may allow her to lean back and hopefully the brace would not ride up as much. PTA-LL left the room and returned with a different wheel chair. In exchanging the wheel chairs, PTA-LL ran over Resident #5's catheter tubing two more times. The drainage/collection bag remained on the floor until Resident #5 was transferred into the new wheel chair at 11:02 a.m. and the privacy bag was transferred from the previous wheel chair to the new wheel chair by CNA-G. On 8/5/14 starting at 9:50 a.m. and on 8/6/14 stating at 8:10 a.m., Surveyor # observed CNA (Certified Nursing Assistant)-G assist Resident #5 with morning cares. Resident #5 was in bed during both observations. CNA-G washed Resident #5's upper body and proceeded to perform peri-care for Resident #5. CNA-G washed Resident #5's perineum with rapid back and forth movements of the wash cloth. Washing and/or wiping of the perineum should be done using a front to back motion to reduce chances of contamination with fecal matter. CNA-G did not perform any catheter care for Resident #5 during either observation. On 8/6/14, Surveyor # observed Resident #5's catheter collection bag lying on the floor in the dining room from 9:30 a.m. to 10:05 a.m. Surveyor # reviewed Resident #5's Care Plan dated 5/20/14 for: Limited ability to maintain grooming/personal hygiene related to hip revision and deconditioning, includes an Approach of "Provide full staff assistance for washing/drying face, hands, perineum." Resident #5 also has a Care Plan dated 5/20/14 stating "Resident requires an indwelling urinary catheter related to [MEDICAL CONDITION]. "Approaches" include: "Do not allow tubing or any part of the drainage system to touch the floor", "Provide catheter care q (every) shift and as needed" and "Manipulate tubing as little as possible during care". Surveyor # reviewed the facility's policy CL-IC-3081, dated 1/1/01 and revised 10/1/09 titled " Urinary Catheter and Drainage Bag Care " . The Purpose states " Appropriate measures for controlling common infections are a critical component of the overall plan of care for residents with a urinary catheter. " Procedures " include: 6. states " Do not allow the catheter bag holder, tubing or spigot to touch the floor. 14. Keep catheter and collection tube free from kinking ... 15. Clean away from the urinary meatus and toward the anus to avoid moving colon bacteria into the peri-urethral area. Surveyor # shared the above observations at the daily exit meeting on 8/6/14. No further information was provided. 5.) On 8/4/14 at 11:15 a.m. Surveyor # observed Resident #6 participating in a group exercise activity in a part of the 3rd floor dining room. At 11:38 a.m., Nursing Supervisor RN (Registered Nurse)-AA took Resident #6 to the hall outside of Resident #6's room after Resident #6 stated he needed to use the bathroom. RN-AA informed Resident #6 that staff were assisting Resident #6's roommate use the bathroom, and when they were done, they would assist Resident #6. Surveyor # observed an isolation cart containing PPE (personal protective equipment- gowns, gloves and masks) outside Resident #6's room on the initial tour that morning. LPN (Licensed Practical Nurse)-D JJ stated Resident #6 had been in contact isolation for a UTI (urinary tract infection), but Resident #6 was done with the antibiotics. Surveyor # had also observed Resident #6's CNA (Certified Nursing Assistant) Care Card in Resident #6's room that states " Toilet at 7:00 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m., 3:00 p.m. ... " At 11:57 a.m., CNA-G told Resident #6 that she was just informed that Resident #6 was moving down to the 1st floor. Resident #6 stated he needed to go to the bathroom first. CNA-G said Resident #6 could use the bathroom in his new room on the 1st floor. At 12:00 p.m., CNA-G took Resident #6 down to the 1st floor via the elevator, and left Resident #6 outside Resident #6's new room. At 12:09 p.m., CNA-MM and C-QQ asked what they were supposed to do with Resident #6. LPN (Licensed Practical Nurse)-D said Resident #6 is just moving down from upstairs and needs to go to the bathroom. LPN-D stated Resident #6 will be using " B " bed (by the window). The CNAs did not know how to transfer Resident #6. CNA-QQ went to the 3rd floor and brought down Resident #6's CNA Care Card from his old room. The CNAs transferred Resident #6 with two staff and a gait belt to the toilet at 12:15 p.m. As Resident #6 stood up, Surveyor # observed Resident #6's slacks and wheel chair cushion were wet with urine. Resident #6 sat on the toilet and voided. The CNAs realized they had no briefs or clean slacks for Resident #6. CNA-QQ went back to the 3rd floor to get briefs and slacks. CNA-MM closed the bathroom door almost all the way, leaving it open a crack, but then stood behind the door, where CNA-MM could not see into the bathroom At 12:20 p.m., Resident #6 attempted to stand up three times, stating he was tired of sitting. Surveyor # alerted CNA-MM that Resident #6 was attempting to stand up (Cross reference F323). At 12:24 p.m., CNA-QQ returned with Resident #6's care items. The CNAs provided peri-care and put on a new brief and slacks, and after several tries, transferred Resident #6 back to his wheel chair and left Resident #6 in the new room unattended. Surveyor # reviewed a Bladder Incontinence Assessment for Resident #6 dated 7/9/14 done in conjunction of a Significant Change in Status MDS (Minimum Data Set). It notes Resident #6 has dementia and diabetes, is alert and oriented to self, confused but can follow directions, is wheel chair bound and needs extensive assistance with toileting, has daily incontinent episodes with some control present. The Summary states: A three-day patterning was completed and staff are to assist/offer urinal to Resident #6 at 12:00 a.m., 2:00 a.m., 4:00 a.m.; and toilet Resident #6 at 7:00 a.m., 9:00 a.m., 11:00 a.m., 2:00 p.m., 5:00 p.m., 7:00 p.m., 9:00 p.m. and per request. Will provide incontinence care with hospice to keep as clean and dry as possible." Surveyor # reviewed Resident #6's Care Plan date 7/9/14 for "Resident is limited in ability to toilet self related to weakness, impaired mobility. The Goal is "Resident will toilet self with minimal/moderate assistance and regain day time continence" by 10/9/14. Approaches include: Establish routine time for toileting; provide minimum/moderate assistance as needed. Surveyor # shared the above observations at the daily exit meeting on 8/6/14. No further information was provided. 6.) Surveyor # reviewed Resident #4's medical record on 8/4/14 to 8/6/14. Resident #4 was [DIAGNOSES REDACTED]. The CNA (Certified Nursing Assistant) care card not dated under the section elimination is checked as being incontinent for bladder. The admission MDS (minimum data set) with an assessment reference date of 7/25/14 documents that Resident #4 is frequently incontinent of bladder and requires extensive assistance with two plus person physical assist for toileting. Under the section infection UTI (urinary tract infection) is checked. On 8/5/14 at 11:38 a.m. Surveyor # observed CNA (Certified Nursing Assistant)-G inform Resident #4 that she was going to check and wash her. CNA-G washed her hands, placed gloves on, and filled a wash basin. CNA-G washed Resident #4's face and then informed Resident #4 that she was going to wash her upper body. CNA-G removed Resident #4's gown and washed her upper body. CNA-G then told Resident #4 that she was going to wash her bottom. CNA-G removed her gloves, cleansed her hands, placed gloves on, and unfastened Resident #4's incontinence product. CNA-G washed Resident #4's inner thighs, told Resident #4 to open her legs as she was going to wash her vagina, and washed Resident #4's frontal perineal area from front to back and then with the same portion of the washcloth washed back to front quickly and repeated this process approximately three to four times. Surveyor # observed that CNA-G then rinsed the area in the same manner. Washing the frontal perineal area from front to back prevents any bacterial organisms from traveling into the urinary system. On 8/6/14 at 12:47 p.m. Surveyor # asked the Director of Nursing when staff are washing a Resident's perineal area should they wash from front to back. The Director of Nursing replied "yes." Surveyor # then asked should staff ever wash from back to front. The Director of Nursing replied "no." Surveyor # informed the Director of Nursing of the observation inappropriate perineal care for Resident #4 on 8/5/14. On 8/7/14 Surveyor # reviewed the Facility's routine perineal care revised 3/5/08. Under procedure for female resident documents the following: ? "Assist resident to supine position (on their back) with legs apart and knees flexed, drape legs for privacy, ? Clean the genitalia (peri area) with a clean washcloth or wipe using a downward motion from the pubis (front) to the anus (back), ? Use a different section of the washcloth with each wipe or discard wipe after each stroke to avoid contamination, ? Separate the folds of the labia with one hand and wash from the front to back of perineum, ? Let the skin air dry, ? Place the resident on her side to cleanse the remaining buttocks area if necessary, ? Using a clean washcloth or wipe, wipe from front to back to avoid contamination, ? Let the skin air dry, ? Change gloves and wash hands before applying ordered cream/ointment."

Based on observations and interviews, the facility did not ensure that it promoted care for 2 of 9 reviewed (Residents #9 and #6) that maintained each resident's dignity and individuality. Resident #9 was observed to make several requests of visitors to assist him to the bathroom after direct care staff did not. The facility failed to maintain Resident #9 dignity and individuality after the resident was forced to clearly make multiple and numerous requests to be assisted with his toileting needs on the days observed. Staff continued to ignore his requests, often putting him off with statements of "Someone will help you, hang in there." The resident even resorted to asking visitors and non-direct care staff for assistance and when finally no response, attempted to toilet himself. Staff ignored the resident request for toileting which resulted in some incontinence as well. Direct care staff were observed to be wearing PPE (personal protective equipment) during the provision of cares for Residents #9 & #6 who were not identified to have any infectious or communicable health issues. Findings include; 1) Resident #9 is identified per the clinical record plan of care to require the assist of two staff for toileting needs. On 08/04/14 at 10:15 a.m., Resident #9 was observed to tell CNA-G (Certified Nurse Assistant) that he needed to go to the toilet. At that time, CNA-G responded, "Wait, I have to get this resident up." The nurse aide walked away from Resident #9 who then responded, "They keep saying that, I'm going down there and put myself on the toilet." At 10:18 a.m., Resident #9 was observed to be wheeling himself into the bathroom of his room and stated, "I have asked three people to help me." At this same time, CNA-E and CNA-G approached the resident's room to assist with the resident's toileting. Outside of the room there was an isolation cart set-up with PPE (personal protective equipment) on it. CNA-G donned a yellow isolation gown, gloves and a protective mask. CNA-E donned double gloves only and entered the room to assist Resident #9. Surveyor requested of the resident if he would allow Surveyor to observe the toileting process and the resident stated, "I wish you would." Once placed on the toilet, CNA-G acknowledged that the resident's incontinent product was "wet" when Surveyor asked. At 10:43 a.m. Surveyor walked along with Resident #9 as he was propelling self in the hallway and asked how he was feeling of which he stated, "A little better, they rush me." When asked to explain that, Resident #9 stated, "You know the bathroom." Surveyor continued to observe Resident #9 and at 11:08 a.m., the resident asked the Surveyor to take him to the bathroom. Surveyor approached CNA-E and informed her of the resident's request to which she responded that she needed to get some help. CNA-E did not return. Resident #9 continued to propel himself up and down the hallway asking to go to the bathroom and at 11:31 a.m. was heard by Surveyor to say, "Oh God this is terrible, the service here is awful." "I want to go to the toilet." At about the same time Staff-I (concierge) stated to Resident #9, "Hang in there" as she walked pass him to which Resident #9 stated, "Thanks for your concern but I have to go to the bathroom." Staff-I was observed not to respond in such a way as to notify staff of the resident's request either. At 11:40 a.m. CNA-G stated to Resident #9 "I'll be right with you to which the resident sarcastically stated, "I bet you will tomorrow." At 11:45 a.m. Resident #9 was wheeled into the bathroom by CNA-F with CNA-G following behind and CNA-G stating, "Ok we'll take you to the bathroom again." Surveyor observed that Resident #9 did experience a bowel movement at that time. On 08/05/14 at 8:28 a.m. Resident #9 was observed and heard aloud saying, "I got to take a crap right now, you going to help me or what, doesn't anybody listen to me?" At 8:30 a.m., the resident was then assisted to the toilet by CNA-G. At 11:20 a.m. Resident #9 was observed to have wheeled self into the room next to his and into the bathroom and pulled the call cord in the bathroom. CNA-F and CNA-H removed Resident #9 from the bathroom but offered no assistance. At 11:23 a.m., Resident #9 asked CNA-H to take him to the bathroom at which time CNA-H stated, "Just a second" and parked the resident in his wheelchair outside of his room. Resident #9 did not remain outside of his room but continued to propel self up and down the hallways asking to go to the bathroom. At 11:33 a.m. CNA-G wheeled resident back up the hallway and the resident was now asking a visitor along the way, "Can you take me to the bathroom?" At 11:35 a.m., CNA-G stated to the resident, "Someone will help you" to which the resident responded, "In six hours." At 11:41 a.m. Resident #9 wheeled himself to the entrance of his room. At 11:43 a.m. Resident #9 asked DA-M (dietary aide), who was traveling with the food cart, to take him to the bathroom of which DA-M stated, "I can't but someone will be with you." DA-M did not share this formation with direct care staff that the resident wanted to go to the bathroom and just proceeded to the kitchenette area. At 11:45 a.m. Resident #9 was observed to wheel himself in his room and into the bathroom and at 11:49 a.m. was observed to be standing up at his wheelchair in the bathroom alone, unattended attempting to toilet self. Surveyor immediately notified the NHA-A who was at the nurses station at that time as Resident #9 requires the assistance of two staff to safely be toileted. (Cross-reference F323). A review of the resident's care card that addresses the cares the nurse aide staff are to provide under the area of elimination directs the nurse aide staff to "assist/offer urinal at 2 a.m., 4 a.m., toilet at 7 a.m., 10 a.m., 1 p.m., 3 p.m., 7 p.m., and 10 p.m. The care plan identifies that the "resident is limited in ability to toilet self related to his spinal stenosis and dementia". The interventions include the above toileting plan and to "remind resident not to transfer without assistance." (Cross-reference F315). The facility failed to maintain Resident #9 dignity and individuality after the resident was forced to clearly make multiple and numerous requests to be assisted with his toileting needs on the days observed. Staff continued to ignore his requests, often putting him off with statements of "Someone will help you, hang in there." The resident resorted to asking visitors and non-direct care staff for assistance and when finally no response, attempted to toilet himself. Staff ignored the resident request for toileting which resulted in some incontinence as well. It was also noted that the use of the PPE that staff donned was not necessary for Resident #9 but for the roommate. 2.) On 8/4/14 at 10:18 a.m., Surveyor # 7 observed Resident #6 being assisted with breakfast in the 3rd floor dining room. Resident #6 was eating off regular china plates and using glass glasses. Resident #6 was eating well after CNA (Certified Nursing Assistant)-F set up the meal. Resident #6 was visiting and laughing and appeared in good spirits. On 8/4/14 at 11:15 a.m. Surveyor # observed Resident #6 participating in a group exercise activity in a part of the 3rd floor dining room. At 11:38 a.m., Nursing Supervisor RN (Registered Nurse)-AA took Resident #6 to the hall outside of Resident #6's room after Resident #6 stated he needed to use the bathroom. RN-AA informed Resident #6 that staff were assisting Resident #6's roommate use the bathroom, and when they were done, they would assist Resident #6. Surveyor # observed an isolation cart containing PPE (personal protective equipment- gowns, gloves and masks) outside Resident #6's room on the initial tour that morning. LPN (Licensed Practical Nurse)-JJ stated Resident #6 had been in contact isolation for a UTI (urinary tract infection), but Resident #6 was done with the antibiotics. Surveyor # had also observed Resident #6's CNA (Certified Nursing Assistant) Care Card in Resident #6's room that states "6/16/14 Do Not Leave In Room Unsupervised" and "Toilet at 7:00 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m., 3:00 p.m. ..." At 11:57 a.m., CNA-G told Resident #6 that she was just informed that Resident #6 was moving down to the 1st floor. Resident #6 stated he needed to go to the bathroom first. CNA-G said Resident #6 could use the bathroom in his new room on the 1st floor. At 12:00 p.m., CNA-G took Resident #6 down to the 1st floor via the elevator, and left Resident #6 outside Resident #6's new room. At 12:09 p.m., CNA-MM and CNA-QQ asked what they were supposed to do with Resident #6. LPN (Licensed Practical Nurse)-D said Resident #6 is just moving down from upstairs and needs to go to the bathroom. LPN-D stated Resident #6 will be using "B" bed (by the window). The CNAs did not know how to transfer Resident #6. CNA-QQ went to the 3rd floor and brought down Resident #6's CNA Care Card from his old room. The CNAs transferred Resident #6 with two staff and a gait belt to the toilet at 12:15 p.m. As Resident #6 stood up, Surveyor # observed Resident #6's slacks and wheel chair cushion were wet with urine. Resident #6 sat on the toilet and voided. The CNAs realized they had no briefs or clean slacks for Resident #6. CNA-QQ went back to the 3rd floor to get briefs and slacks. CNA-MM closed the bathroom door almost all the way, leaving it open a crack, but then stood behind the door, where CNA-MM could not see into the bathroom. At 12:20 p.m., Resident #6 attempted to stand up three times, stating he was tired of sitting. Surveyor # alerted CNA-MM that Resident #6 was attempting to stand up (Cross reference F323). At 12:24 p.m., CNA-QQ returned with Resident #6's care items. The CNAs provided peri-care and put on a new brief and slacks, and after several tries, transferred Resident #6 back to his wheel chair and left Resident #6 in the new room unattended. At 12:37 p.m., LPN-D entered Resident #6's room and gave Resident #6 insulin. LPN-D started to take Resident #6 out of the room in the wheel chair but then brought Resident #6 back in the room stating Resident #6 is in isolation, so Resident #6 would have to stay in his room. LPN-D left Resident #6 unattended in the room. On 8/4/14 at 12:46 p.m., Surveyor # observed Dietary staff-Q deliver lunch (fish) in a Styrofoam container. Dietary staff-Q stated she has been instructed to use Styrofoam containers for any resident in any type of isolation, indicated by the cart outside the resident's room. (Resident #6 was on contact isolation for a urinary tract infection for which he completed the antibiotics several days earlier.) (Cross reference F441.) On 8/5/14 at 8:16 a.m., Surveyor # observed Resident #6's breakfast tray in a Styrofoam container on the over-the-bed table. Resident #6 was asleep in the "A" bed, not the "B" bed as reported on 8/4/14. At 8:35 a.m., Surveyor # observed CNA-E enter Resident #6's room to assist him with his meal, but the frame of the bed was lying on top of the electrical cord, and the bed was not plugged in. Because the bed was not plugged in, the controls would not work and CNA-E could not raise Resident #6's head up to eat. CNA-E had donned a gown, gloves and was putting a mask on when Surveyor # asked why she was putting a mask on. CNA-E said she would check with the nurse, and upon returning, did not wear the mask. LPN-D instructed CNA-E to wait with cares and she would call maintenance to get the controls working. After much discussion causing further delay, with CNA-E trying to explain they should get Resident #6 out of bed first so maintenance could then lift the bed off the cord and plug it in, (then the controls would work), LPN-D decided CNA-E could get Resident #6 up out of bed so he could eat breakfast. There were additional delays in Resident #6 getting morning cares as Resident #6 changed rooms on 8/4/14 but his clothes and other personal items had not been moved, so staff had to go back to the 3rd floor get clothes and other supplies (Cross reference F252). CNA-E could not locate Resident #6's CNA Care Card. Surveyor # remembered staff stating Resident #6 was going in "B" bed the day before and suggested CNA-E look in "B" closet, where the Care Card was found. Staff were donning gowns and gloves every time they entered Resident #6's room, and had to remove them before leaving the room, and don another gown before re-entering Resident #6's room. Resident #6's breakfast remained on the over-the-bed table during this time. At 9:22 a.m., Resident #6 stated "I'm hungry, when do I eat?" At 9:26 a.m. LPN-D gave Resident #6 a drink of milk. Resident #6 had not had anything to eat or drink prior to this. Resident #6 drank 90% of the milk in one long drink, then said the milk was not cold, it was warm. LPN-D stated some people like warm milk. Resident #6 said he does not like warm milk, he likes cold milk, and that the milk was too warm. The milk had been sitting on Resident #6's over-the-bed table for at least an hour and 10 minutes. At 9:35 a.m., CNA-PP left to get a china plate to reheat Resident #6's meal because she cannot put Styrofoam in the microwave. Surveyor # asked what the purpose of serving the meal in Styrofoam is if she was going to put it on china now anyway. CNA-PP stated dietary staff cannot touch dishes of residents in isolation, so they use Styrofoam. At 10:50 a.m., Surveyor # interviewed Assistant Dietary Manger (DM)-R, asking why Resident #6 was served lunch on 8/4/14 and breakfast on 8/5/14 in Styrofoam now that he moved to the first floor, but when he ate breakfast on third floor on 8/4/14, he ate in the main dining room off regular dishes. Resident #6 had been on contact precautions for a urinary tract infection, and the last dose of antibiotics was given on 8/1/14, so it was unclear why Dietary staff would not be able to touch the dishes that Resident #6 used. DM-R stated the Dietary Director-V had just in-serviced staff on isolation and disposable dish and utensil use, and Resident #6 did not need to have his meal served in Styrofoam. On multiple observations on 8/4/14 after Resident #6 was moved to the first floor, and on numerous observations during the morning of 8/5/14, Surveyor # observed Resident #6 in his room with staff sitting in Resident #6's room because Resident #6's Care Card stated Resident #6 could not be left in the room unattended. Surveyor # asked multiple staff why Resident #6 could not come out of his room, and all replied - because Resident #6 is in isolation. Surveyor # noted Resident #6 was in group activities on 3rd floor the morning of 8/4, and Resident #6 ate in the main dining room that day, and contact isolation for a urinary tract infection would not prohibit a Resident from leaving their room, and Resident #6's antibiotics ended several days earlier. Surveyor # shared the above observation at the exit meeting on 8/6/14, noting that the numerous instances of overuse of PPE, isolating Resident #6 in the room when not necessary, delays in providing care, delays in being able to serve breakfast, serving warm milk, serving Resident #6's meals on Styrofoam, and the overall poor execution of Resident #6's room change including not letting Resident #6 use the toilet until after he was very incontinent soaking through to Resident #6's slacks, all contributed to treating Resident #6 in an undignified manner. Surveyor # asked what the urgency was in moving Resident #6 to the 1st floor, so hurriedly that Resident #6 could not use the toilet first, and staff were not prepared to meets his needs, or even have his Care Card for reference. DON (Director of Nursing)-B stated she authorized the move using "an overabundance of caution" because Resident #6 had a MDRO UTI (multiple drug resistant organisms) urinary tract infection, and Resident #6's roommate (Resident #9) also uses the toilet, at times unsupervised, and they did not want Resident #9 to contract a MDRO UTI. Surveyor # noted if that was the concern, why would it be a rush to move Resident #6 on 8/4/14, three days after he took his last dose of antibiotics, and not when the UTI was first identified. DON-B stated Resident #9 had a sudden increase in toileting requests on 8/3/14. No further information was provided.

Based on observation, interview and record review, facility staff did not provide medically necessary social services for 2 (Resident #7 and Resident #8) of 9 sampled Residents. Resident #7 was observed screaming very loudly during a shower. Subsequent investigation indicates Resident #7 exhibits behaviors of crying, yelling, screaming, refusing care and other behaviors, but multiple components of the care process were not conducted. Resident #7's Behavior section of the MDS (Minimum Data Set) was not completed correctly, thereby causing further assessment of behaviors to be missed. No care plan was developed to identify and address Resident #7's behaviors. Staff did not attempt to get additional information from Resident #7's family or the previous facility regarding the behaviors. Such information could assist in developing individualized interventions to manage the behaviors. And even though Resident #7's MDS indicates it is "very important" to choose between a tub bath, shower, bed bath and sponge bath, no documentation was observed in Resident #7's medical record as to what that preference was. Activity Staff who gather that information no longer had the worksheet where the information was documented, and Nursing documentation was blank in that area. These lapses cause Resident #7 to experience multiple, on-going episodes of crying, screaming and other behaviors with staff having no guidance on how to prevent or manage the behaviors. On 8/6/14 Resident #7 experienced what the facility defined as a "catastrophic event" while being bathed where Resident #7 screamed repeatedly throughout the bathing process without staff attempting to calm Resident #7. Resident #8 was observed during the survey crying unexpected and inconsolably, making comments that she wanted to die and pounding tables in frustration. There is no indication that a comprehensive plan of care was developed and reviewed to meet Resident #8's psychosocial needs. Findings include: On 8/6/14 at 9:04 a.m., Resident #7's screams could be heard from the first floor stairway that leads to the third floor of the facility. Resident #7 was on the third floor in the bathing room when screaming. Surveyor # heard the screaming and was told by a facility Housekeeper that "It's ok they're giving a Resident (#7) a shower. That lady always screams like that when she gets a shower." Surveyor # asked to enter the bathing areas where Resident #7 was. Surveyor # observed Resident #7 to be seated in an oversized shower chair, with her feet dangling - not even touching the floor. Resident #7 was observed to only stop screaming long enough to take a breath and she would then resume screaming. Resident #7 was gripping the arms of the shower chair tightly while screaming and two CNA's were rinsing soap and shampoo off of Resident #7's hair and body. When the CNA's were done rinsing Resident #7, they turned off the water and the two CNAs starting drying off Resident #7. Resident #7 only then slowly stopped screaming but then proceeded to cry. Throughout this observation staff made no attempt to comfort or soothe Resident #7. Staff was observed speaking over Resident #7's screaming to tell Surveyor # Resident #7 screams with a bed bath too. (Cross reference F309). On 8/6/14- 8/8/14, Surveyor # reviewed Resident #7's medical record. Resident #7 was readmitted to the facility on [DATE]. Resident #7 resided at the facility previously, then moved to a sister facility while renovations were done at this facility. Interviews on 8/6/14 with CNA (Certified Nursing Assistant)-G and CNA-H, and interviews on 8/7/14 with CNA-EE and LPN (Licensed Practical Nurse)-D indicate Resident #7 frequently cries or yells or screams with cares, and has since shortly after admission. (For specific details, please see F309). The Admission MDS completed 5/26/14 indicates under "Daily Preferences" it is "Very important" for Resident #7 "to choose between a tub bath, shower, bed bath or sponge bath" and "to have family or close friend involved in discussions about your care". Resident #7's Admission Data Collection Tool dated 5/15/14 indicates Resident #7 has dementia and depression, is alert with inconsistent levels of orientation to person, "verbal expression" is left blank, has slow comprehension, impaired short, long and situational memory. The "Behavioral Symptoms" of the "Psychosocial Functioning" section is blank, and it is noted Resident #7 receives antidepressant medication. Under the "ADL Status" section, it notes Resident #7 is dependent on staff for bathing. The form asks "Bathing Options Preference: __Tub __Shower __Other (nothing is checked); Frequency: __Daily __Every other day __Bi-weekly __ Weekly (nothing checked); Time of Day: __ AM __PM (neither checked). Surveyor # reviewed Resident #7's CNA (Certified Nursing Assistant) Care Plan located in Resident #7's room. The "Bathing" section is blank when it asks "Shower Day_____", "AM__ PM___", "Bed Bath__ Tub__ Shower__". No "Targeted Behaviors" are listed. In the "Report to Nurse" section, it states "sweating, increased confusion, no meal intake". On 8/8/14 at 11:05 a.m., Surveyor # interviewed Activities Director (AD)-Y, who collects the "Preference" information on the MDS. Surveyor # noted Resident #7's Admission MDS noted it was very important to choose between a tub bath, shower, bed bath or sponge bath, and asked if she then asked what Resident #7's preference was, because it is not noted in the care plan or on the CNA Care Card. AD-Y stated she does ask that question and records the information on a worksheet that she then brings to morning report, then nursing takes over from there. AD-Y stated if a Resident is an exception-meaning they do not want a shower- she passes that information on to nursing. AD-Y stated Resident #7 first moved back onto the second floor, then moved to the third floor when the second floor was closed for renovations, and Resident #7 does have aphasia. Surveyor # asked if she contacted Resident #7's family or their sister facility to get information regarding what bathing preferences and routines Resident #7 previously had. AD-Y stated she had not contacted Resident #7's family or other facility. At 12:10 p.m., AD-Y informed Surveyor # that she did not keep Resident #7's worksheet that may have indicated what Resident #7's bathing preferences are. Nurses' Notes, 24 Hour Reports, and Behavior Monitoring by CNAs and nurses all document Resident #7 exhibiting behaviors including crying, yelling out, screaming, refusing care and medication, being combative with cares, kicking and scratching during the MDS (Minimum Data Set) Assessment Reference Period. However, Resident #7's Admission MDS, completed on 5/26/14, indicates Resident #7 had no behaviors. (Cross reference F278 for details). The Behavior section of the MDS was completed by DSS (Director of Social Services)-II. When interviewed by Surveyor # on 8/8/14, DSS-II stated he was aware Resident #7 had some episodes of yelling, but Resident #7 didn't yell all the time, and sometimes would yell out when no one was even in the room. DSS-II did not explain why the MDS was coded incorrectly, which then did not trigger further assessment through the Care Area Assessment process. Resident #7's Care Plan did not include identification of specific behaviors exhibited by Resident #7, nor did it include individualized interventions staff could use to try to prevent and/or manage those behaviors, or evidence staff carefully analyzed when Resident #7's behaviors occurred, what may trigger the behaviors, what interventions may be successful in alleviating the behaviors. (During subsequent staff interviews conducted by RN (Registered Nurse)-C after Resident #7's catastrophic reaction in the shower on 8/6/14, they learned one CNA has had success turning the TV on in the morning to distract Resident #7 during cares, making the process go smoother, and another only transfers Resident #7 to the toilet after lunch when Resident #7 is more calm.) When interviewed by Surveyor # on 8/8/14 and asked about the lack of a Behavioral care plan, DSS-II stated they have worked with psychiatric providers and adjusted medications, and staff should re-approach the Resident and involve the resident in groups when Resident #7 exhibits behaviors. Surveyor # asked if staff had looked closely at what events cause Resident #7 to yell out in an effort to avoid those events, possibly get information from family or their sister facility to help develop a behavioral plan of care. DSS-II stated he has not contacted Resident #7's family or previous facility, and did not know if anyone else had. Surveyor # asked DSS-II who initiates a Behavioral Care Plan. DSS-II stated it is a combination of Social Services and Activities staff. Surveyor # noted the Activities staff identified several things that are important to Resident #7 that could be used as interventions to prevent or de-escalate a behavior episode, but it does not appear those things (music, religion, babies, newspapers, TV, going outside, dogs, etc.) have been incorporated into a behavioral plan of care for Resident #7. DSS-II had no explanation regarding the lack of a Behavioral Care Plan for Resident #7 but he would check his records for any additional information. At 10:26 a.m., RN-C confirmed DSS-II has no additional information regarding Resident #7. Surveyor # asked if DSS-II had additional notes or information, including notes from Family Conferences or IDT meetings, other than what is in Resident #7's chart, since Surveyor # did not see any Social Service documentation regarding Resident #7's behaviors or planned intervention to address the behaviors. DSS-II stated perhaps nursing documented in the Nurses' Notes. Surveyor # stated the Nursing documentation of the meetings only referred to more physical conditions, not behavioral. RN-C, who was present during the interview, stated they have looked and there are no Social Service notes. RN-C also added they recently discovered that the Targeted Behaviors on the MAR have been identified during the MAR monthly roll-over (getting the MARs ready for the next month), instead of the during the IDT meeting where the behaviors and interventions should be analyzed and identified. At 10:26 a.m., RN-C confirmed/informed Surveyor # that DSS-II has no additional information regarding Resident #7. 2.) Surveyor reviewed the medical record of Resident #8 and conducted observations of Resident #8. Resident #8 has [DIAGNOSES REDACTED]. Resident #8 has behaviors that include crying, tearfulness, trouble with word finding, anxiety and wandering with no purpose. Resident #8 was observed on several occasions by Surveyor to cry unexpectedly and inconsolably, make statement that she just wanted to die and stand abruptly wanting to walk. Staff were always attempting to respond to Resident #8's sudden standing episodes by placing a gait belt around resident's waist in order to grab her quickly from falling. Resident #8 usually had a very anxious and distressed look on her face during this survey. Resident was observed with loud verbal outbursts and pounding her fist on the table when she was unable to walk or when staff were attempting to redirect her behaviors. Resident's medical orders do indicate mood disorder and depression medications and medication for Dementia are being prescribed and Resident is being seen by a geriatric psychiatric group to assist with behaviors. Surveyor reviewed the plan of care, dated 6/6/14. While certain behaviors, such as wandering, trouble expressing self and inability to find words are addressed on the plan of care, individualized care approaches to lessen residents stress, impulsivity, anger and anxiousness are not part of the plan of care. There is no evidence the facility has comprehensively developed individualized approaches to care based on targeted behaviors, prior life preferences, customary routines, communication styles and resident's overall psychosocial being. Surveyor reviewed the care plan used by the nurse aides to deliver care. The only method listed on the care card to assist resident in management of displayed behaviors was 5/30/14 "ambulate length of hallway after each meal". The only targeted behavior listed on this care card is "wandering". There is no instructions to the staff on what to do if resident starts to cry inconsolably, tries to stand abruptly, starts to pound her fists on the table when unable to walk or what to do with residents anxiousness and agitation. Surveyor reviewed the facility training program titled "Five Star Quality Care, Inc. General Alzheimer's/Dementia guidelines and training program, dated 2013". This program does indicate ways to manage resident behavior that includes steps to develop behavioral management programs. However, the information in the training material does not appear anywhere in Resident #8's records or plan of care. Surveyor interviewed 2 nurse aides who work with Resident #8 on the evening shift. On 8/6/14 at 6:08 PM, Surveyor interviewed Nurse Aide (CNA)-K. CNA-K told the surveyor that it is getting harder and harder to care for Resident #8 after the sun goes down with increased agitation and restlessness. CNA-K indicated Resident #8 has to be totally supervised so she does not fall down. CNA-K indicated they had to keep Resident #8 up in the dining room and could not lie her down after supper as she will crawl out of bed and cause disturbance in her room, which she shares with another resident. CNA-K indicated Resident #8 used to be a marathon runner so they will walk her when they can. Surveyor interviewed CNA-N about Resident #8. CNA-N said if they do not keep a gait belt on her they cannot grab her quickly enough in order to prevent her from falling. CNA-N indicated concerns about caring for Resident #8 and still able to supervise and care for all the other residents on the unit. The plan of care does not address the use of this gait belt to prevent falling. On 8/6/14 at 6:22 PM, Surveyor observed Resident #8 being restless with intermittent crying and agitation (pounding her fists on the table), asking to go to her room. CNA-N told Resident #8 she could not leave the dining room until other staff arrived. CNA-N was observed to sit with Resident #8 and talk to her quietly and attempt to calm her down, which did help momentarily. Resident #8 indicated she wanted to lie down and Surveyor heard Resident #8 say she just wanted to die. The plan of care did not have any instructions for the nurse aide staff to deal with these types of behaviors and reduce distress to Resident #8.

Based on observation, interview and record review, facility staff did not provide a safe environment for 1 of 6 residents (Resident #2) who experienced falls, or for 1 of 5 residents with a Wanderguard device, (Resident #6). * Resident #2 had seven falls since the last survey conducted in August 2010. The first fall after the prior survey was on September 25, 2010 and on September 27, 2010, staff added Dycem to her Broda chair. Resident #2 fell out of her chair on December 9, 2010 (4th fall since last survey). Staff did not indicate if the Dycem was in her chair. The new intervention after the December 9, 2010 fall was to add Dycem, unaware that this was the same intervention following the September 27, 2010 fall. Resident #2 fell on [DATE] (5th fall) sustaining a laceration to her head requiring staples to close the wound in the emergency room . Resident #2's care plan dated 12/14/10 called for two staff to provide care, but on 2/28/11, only one staff was providing care, and Resident #2's toileting schedule was not followed. Resident #2 fell twice the night of June 17, 2011. First at 11:15 p.m. Resident #2 was found on the floor. It was noted Resident #2 was agitated, had been given Ativan at 9:00 p.m., and staff did not place Resident #2's body pillow behind her in bed. Resident #2's care plan dated 3/23/11 indicated the use of the body pillow while in bed. At Midnight, Resident #2 was again found on the floor. Staff then added the intervention that if Resident #2 is agitated, staff should not leave her in bed but get her up in her chair. * Resident #6 was observed on 6/28/11 and 6/29/11 not to be wearing a code alert/ wanderguard device that was ordered 5/25/11. Resident #6's photo was not placed in the code alert picture book, nor did staff initial the treatment record that they were checking placement and functioning of the device as ordered until 6/29/11 when the Surveyor inquired about it. Findings include: 1. Surveyor # reviewed Resident #2's medical record on 6/27/11 and 6/28/11. Resident #2 was admitted to the facility on [DATE] for care following a pelvic fracture suffered in a fall at home. Resident #2 also has a [DIAGNOSES REDACTED]. Surveyor # reviewed Resident #2's medical record which includes Interdisciplinary Rehabilitation Screening Forms. These forms indicate Resident #2 had two falls prior to the last survey conducted on 8/16/10. On 6/29/10, Resident #2 fell out of bed and bolsters were placed on the bed. On 7/1/10, Resident #2 fell while trying to stand up while sitting in a Broda chair. Nursing staff was to complete a sleep assessment and toileting schedule. The Rehabilitation Screening Forms indicate: On 9/27/10 a screen was completed after Resident #2 slid out of her Broda chair. The recommendations were to add Dycem (a non-slip surface) to Resident #2's Broda chair and to ensure chair is reclined when not at a meal. On 10/21/10 a screen was completed after Resident #2 fell from her low bed onto a mat on the floor. It was deemed a "safe fall, continue current POC (plan of Care)." On 11/26/10 a screen was completed after Resident #2 rolled out of bed. It notes, "Pt. (patient) has scoop mattress and mat. Nursing to use soft-touch call light. Safe fall, no injuries." On 12/30/10 a screen was completed "after pt. slid out of w/c (wheel chair) reaching for an object. Dycem added to cushion." (It does not note what happened to the 9/27/10 recommendation to add Dycem at that time.) On 3/2/11 a screen was completed after Resident #2 "fell while attempting to self-transfer for toileting. Nursing to provide staff education on toileting schedule and 2 person assist and not leave pt. unattended." On 3/24/11 a "screen was completed after pt. fell rolling out of bed. Staff to provide body pillow. Pt. has scoop mattress and mat." On 6/22/11, a "screen was completed after pt. rolled out of bed. Body pillow not in place. Staff ed (education) provided." Surveyor # reviewed a Five Star Quality Care, Inc. Fall Risk Review Tool for Resident #2. Resident #2 scored at "moderate risk" for falls (score of 16-24) on 4/21/10, 8/19/10, 11/19/10, 2/17/11 and 5/19/11 due to impaired cognitive status, 1-2 falls within last 3 months, balance/ gait impairments- needs assist of 1-2 people for standing, needs assist of 1-2 people for transfers and/or requires use of lift device, requires 1-2 people assist for toileting, receives antihypertensives, cardiovascular, hypoglycemics and narcotic medications, and has 3 or more diagnoses/ clinical concerns impacting fall risk (hypertension, arthritis, osteoporosis, fractures, infection, diabetes, and dementia). Resident #2 scored 28 on 6/18/11, indicating she is now at high risk for falls (a score of 25 or greater indicates high risk), due to decline in cognitive status- poor safety awareness of physical abilities and limitations, 3 or more falls within one month. Surveyor # reviewed an Allay Hospice Fall Risk assessment dated [DATE] indicating Resident #2 scored 65 points. The form states, "Implement fall precautions for a total score of 15 or greater." Resident #2 scored 15 points for history of falls in last three months, and 5 points each for: sensory deficit, age (over 65), confusion, impaired judgement, increased anxiety, unable to ambulate independently, gait/ balance problems, incontinence/ urgency, cardiovascular/ respiratory disease affecting perfusion and/ or oxygenation, and medications. Surveyor # reviewed a Hospice Admission/ Recertification and Medical Guidelines For Determining Prognosis document dated 4/3/11. The "Summary of decline/ need for hospice" states, "...History of falls with fractures pelvic/sacral, distal radius. Has had a decline in mental/cognitive/behavioral status since previous assessment. She has a history of falls, with recurrent, recent falls, including one with a head injury requiring staples to her scalp laceration 2/28/11. Surveyor # reviewed Resident #2's MDS CAA (Care Area Assessment) dated 5/17/11 which states: (Resident #2) "Has [DIAGNOSES REDACTED]. Receives scheduled antidepressant per order, monitored for adverse reaction to medication, used as appetite stimulant. Alert with confusion and impaired cognition, able to make some needs known. Did have fall this quarter, and has history of falls, attempts unassisted transfers. Has low bed with mat in place and body pillow. Transfer with two assist related to behavior. Resident #2's "Short Portable Mental Status Questionnaire" dated 5/3/10 indicates Resident #2 has "severe intellectual impairment." Surveyor # reviewed Resident #2's current Fall Risk Care Plan dated 5/20/11, implemented upon readmission following surgery for [REDACTED]. The Care Plan states: Resident has history of falling and has fallen R/T (related to) attempts at unassisted transfers/ ambulation, impaired cognition/ dementia. Goal: Resident will remain free from injury. Care Plan Approaches include: fall mat next to bed, keep bed in lowest position with brakes locked, bed bolsters, Dycem in wheelchair, body pillow in bed, keep call light in reach, give verbal reminders not to ambulate/ transfer without assistance, keep personal items within reach, provide proper, well-maintained footwear, provide assistance with toileting as needed. On 6/29/11, staff added: when restless in bed offer to get OOB (out of bed) and offer snack and assess for pain. Surveyor # reviewed a current Care Plan (goal date 8/19/11) originated 5/6/10 for Alteration in Thought Process, short and long term memory loss. On 12/14/10 staff added the following intervention: Use two care givers at all times." At the daily exit meeting on 6/28/11, Surveyor # noted the above documentation indicates on 9/27/10, Resident #2 was to have Dycem in her chair after her fall on 9/25/10, but there is no mention of the Dycem being used with the 12/9/10 fall, and it is added as a new intervention at that time. Surveyor # noted regarding Resident #2's fall from bed on 2/28/11 resulting in a scalp laceration requiring staples, it appears two staff members should have been present during cares and only one was present, and it is noted Resident #2's toileting schedule was not followed. Surveyor # noted Resident #2 fell from bed 6/29/10 and bolsters were added. Then she fell out of bed 10/21/10- considered a safe fall, continue current plan of care; she fell out of bed 11/24/10 - also considered a safe fall without injury, call light was changed to soft-touch call light (no indication Resident #2 used the call light or had problems with activating the previous call light). Not until after Resident #2 fell out of bed again on 3/23/11 did staff recommend a body pillow. However, staff did not utilize the body pillow on 6/17/11 and Resident #2 fell out of bed at 11:45 p.m. Resident #2 was assisted to bed, the body pillow put in place, but was then found on the floor 15 minutes later at midnight, documentation indicates she was agitated. Surveyor # asked if there was any additional information regarding Resident #2's falls. On 6/29/11, upon Surveyor # 's arrival to the facility, Incident Report Forms and Fall Investigation Worksheets were on the table in the conference room for each of Resident #2's falls. Surveyor # reviewed the additional information. Resident #2 had a witnessed fall on 9/25/10 at 8:35 p.m.; she slid out of her Broda chair. The Incident Report Form Final Outcome/ Disposition states: "Dysom added to Broda chair, to keep Broda chair reclined except for meals." An Incident Report Form stated on 10/21/10 at 7:20 a.m., Resident #2 was heard calling out from bedroom. When staff went in they found Resident (#2) sitting on the floor next to her low bed. Resident (#2) said "I wanted to get up by (my)self. Tired of being in bed." An Incident Report Form dated 11/24/10 at 3:15 p.m. states Resident #2 "was calling out for help. When staff entered room resident was sitting next to bed with back up against bed. Bed in low position, no apparent injuries. Resident said "I just slid off the bed. I was sitting." The Incident Report Form for the fall from wheel chair 12/9/10 at 11:00 a.m. indicates Resident #2 was sitting in her wheel chair in the dining room near a table, reaching towards the ground and slid out of her wheel chair, landing on her buttocks. No injuries. Staff were present. The "recommendation to prevent further falls" states "Dycem in wheel chair." It does not mention that the Dycem was recommended after the 9/25/10 fall. Another Incident Report Form indicates Resident #2 fell on [DATE] at 8:40 a.m. during cares. "Was reported by CNA (Certified Nursing Assistant) that she went to get clothes out of closet to wear and the resident was trying to get up and fell on the floor, hitting the top of her head (witnessed). The Report states Resident #2 went to the hospital for treatment of [REDACTED]." Surveyor noted that the Care Plan intervention since 12/14/10 was to have two caregivers in the room during cares; and Resident #2's toileting schedule indicates she should have been assisted to the toilet at 7:00 a.m. A Post-fall witness statement from CNA (Certified Nursing Assistant)-P who was providing care for Resident #2. CNA-P stated she had washed up Resident #2, then was getting her clothes out of the closet when she heard Resident (#2) say she had to go to the bathroom. Resident #2 stood up and fell before CNA-P could get to her. Surveyor # reviewed an emergency room report dated 2/28/11 indicating Resident #2 sustained a 2-3 centimeter scalp laceration which was closed with staples. An Incident Report dated 3/23/11 at 3:15 a.m. states Resident #2 was hollering for help. Staff found Resident #2 on the floor. The CNA on duty stated she was the only one on the floor for the night besides the nurse, and she was assisting another resident in another room. Recommendations to prevent future falls states "body pillow added to POC (plan of care). On 6/30/11, Surveyor # requested the staff schedule for 3/23/11. RN (Registered Nurse) Regional Consultant -D provided Surveyor # with the schedule. Surveyor # interviewed RN-D and NHA (Nursing Home Administrator) -A to clarify what "Call off" noted on the schedule meant. Both stated that meant a CNA called in sick. The CNA was not replaced. There are usually two CNA's on the floor along with a nurse. On the night of 3/23/11, there was only one CNA. The CNA had changed Resident #2 at 2:30 a.m. An Incident Report dated 6/17/11 at 11:15 p.m. indicates Resident #2 was found sitting on the floor with her back against her bed. No injury. Final Outcome/ Disposition: No body pillow in bed that night- staff education. The Fall Investigation Worksheet for the above fall states: Restless prior to fall, was given lorazepam (anti-anxiety medication) at 9:00 p.m. Unwitnessed fall, Resident found sitting on floor next to bed. Root cause- restless; body pillow not in place. Staff education- needs a body pillow in bed at night. The nurse's statements says, "Resident had no gripper socks; body pillow was in closet, put it on after fall...Resident not wet. Put her back to bed with body pillow." An undated CNA Care Card attached to the Incident Report includes interventions of non-skid socks, mat on floor, bed bolster, 11/26/10 soft-touch call light, 9/27/10 and 12/29/10 "Dysom" in chair, keep Broda reclined except during meals, two care givers at all times. Surveyor # did not see the "body pillow" intervention on the CNA Care Card. Surveyor # reviewed Resident #2's At Risk for Falls and Injury Care Plan dated 4/30/10 attached to the Incident Report and the re-admission Risk for Falls Care Plan in Resident #2's chart dated 5/20/11. Both state body pillow in bed. Surveyor # reviewed an Incident Report indicating Resident #2 was again found on the floor 45 minutes later, at midnight 6/18/11. The report states, "Resident found sitting on floor next to bed with back against bed. No injury. The Final Outcome/ Disposition states: "Safe fall, expected outcome, will reassess for pain issues. Will also discuss with staff, when restless, get her up and offer snacks." The Fall Investigation Worksheet dated 6/18/11 at midnight states, "Resident was anxious at time of fall. Given PRN (as needed) ativan prior at 11:00 p.m. approximately." Surveyor # reviewed a staff educational document dated 6/23/11 stating: On 6/17/11 (Resident #2) fell out of bed twice in one night. She did not have her body pillow in place, and it was noted that she had been given Ativan at least twice for agitation. Her body pillow must be behind her back in bed to prevent her from rolling out. It should be put in place EVERY time she is in bed. If a resident is agitated and awake, they need to be taken out of bed and put in a wheel chair so that they can be monitored by staff even in the middle of the night. Eight nurses and CNA's signed that they read and understood the information. On 6/30/11 at 1:30 p.m., Regional Consultant RN-D noted she would be leaving soon and asked Surveyor # if Surveyor # had any outstanding concerns that had not been addressed. Surveyor # stated concerns remain regarding Resident #2's falls, noting the Dycem added to the care plan on 9/27/10, but not noted to be used on 12/9/10 when it was again listed as a new intervention; Only one staff was providing cares on 2/28/11 when there should have been two staff and toileting schedule not followed resulting in a fall requiring scalp staples; multiple falls from bed deemed "safe falls" before the body pillow was added 3/23/11; the body pillow was not in place on 6/17/11 at 11:15 p.m. resulting in a fall from bed; and not getting Resident #2 up that night when she was restless and required at least two administrations of Ativan and already had previous fall, resulting in a second fall that night. RN-D stated they had identified issues with their tracking of falls recently through internal Quality Assurance and will be implementing a new tracking tool to enable staff to quickly see at a glance the dates and times of the fall, brief circumstances surrounding the fall, what interventions were in place, and what new interventions will be added or changed. RN-D stated if that tracking tool was in place, they would have been able to easily tell after the December fall that the Dycem should have been implemented in September, and then they would proceed to investigate why it was not in place (i.e. was it not on the care card, could staff not find it, did they forget it, etc.) Knowing what the issue was would then direct their next interventions. At the daily exit meeting on 6/29/11, Surveyor # noted the additional information from the Incident Reports and Fall Investigation Worksheets did not resolve the issues with Resident #2's falls. No further information was provided. 2. Surveyor # reviewed Resident #6's medical record on 6/27/11 through 6/30/11. Resident #6 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. and Depressive Disorder. Resident #6's medical record indicates a physician's orders [REDACTED]. A "Wandering Elopement Risk Review Tool" was completed on 6/9/11 placing Resident at a score of 9. Additionally, a written note on the "Wandering Elopement Risk Review Tool" states, "No exit seeking behavior." The "Wandering Elopement Risk Review Tool" indicates a score of 7 to 12 places Resident at risk for elopement. A care plan was developed identifying a "Potential for Injury with Potential Elopement" dated 6/9/11. The "Potential for Injury with Potential Elopement" care plan identifies the use of a code alert on wrist or ankle ankle and to place on the wanderlist. The current not dated, care card located behind the door in Resident #6's room and used by the CNA's, does not have documented on it, the use of a code alert on either the wrist or ankles. The June 2011 Treatment Book does not identify the use of the code alert/wanderguard placement. On 6/28/11 at 7:52 a.m., Surveyor # observed Resident #6 in a wheelchair in the large social hall on the 3rd floor. Resident #6's ankles were exposed for viewing as Resident #6 was not wearing any socks or stockings. Surveyor # observed Resident #6 not wearing a code alert/wanderguard on either her wrists or ankles. On 6/29/11 at 7:15 a.m., Surveyor # observed Resident #6 up in a wheelchair coming out of the bathroom and placed in the large social hall on the 3rd floor. Surveyor # did not observe a code alert on either Resident #6's wrists or ankles. Surveyor # asked Registered Nurse (RN)-K if she (RN-K) could check Resident #6 for as to whether Resident #6 was wearing a code alert. RN-K started to check Resident #6 however; Resident started to become a little anxious and RN-K stopped. On 6/29/11 at 8:00 a.m., Surveyor # checked Resident #6 and did not see/or feel a code alert on either the wrists or under her black stockings near the ankles. On 6/29/11 at 9:05 a.m., Surveyor # observed the Bridge to Discovery Director-L updating the Code Alert Bracelet List. Bridge to Discovery Director-L stated she was pretty sure Resident #6's name had already been on the list she had just updated. Surveyor # reviewed the facility's code alert picture book and noted Resident #6's picture was not in the code alert picture book. On 6/29/11 at 9:15 a.m., Surveyor # checked the Treatment book and at this time, the Treatment Book addressed the use of the code alert/wanderguard and to check placement every shift and to check function daily. As of 6/29/11 at 9:15 a.m., there was no initialed documentation as to this being done from 6/1/11 to 6/29/11. On 6/29/11 at 10:35 a.m., Surveyor # interviewed Certified Nursing Assistant (CNA) - J who was assigned to Resident #6. CNA-J stated that the night shift got Resident #6 dressed and did not notice if Resident #6 was wearing a code alert/wanderguard. Surveyor # questioned CNA-J as to whether Resident #6 needs a code alert/wanderguard? CNA-J stated, "No, never seen her try to get on the elevator or door." Surveyor # asked CNA-J if Resident #6 is supposed to wear a code alert/wanderguard, CNA-J stated, "I don't know, I would have to re-look at the care card." On 6/29/11 at 11:04 a.m., Surveyor # interviewed Licensed Practical Nurse (LPN)-H regarding Resident #6's code alert/wanderguard. LPN-H stated she placed the code alert/wanderguard on Resident #6 today before Resident #6 went to the beauty shop (Resident #6 was at the beauty shop at 9:55 a.m.) and the information regarding the code alert/wanderguard information had not been transferred onto the June 2011 medication administration record. On 6/28/11, Resident #6 was not observed wearing the code alert/wanderguard as per MD order and as per assessment and care plan. On 6/29/11, Resident #6 was not observed wearing the code alert/wanderguard as per MD order and as per assessment and care plan until Surveyor # inquired as to whether Resident #6 was wearing the code alert/wanderguard. On 6/29/11 at approximately 3:05 p.m., Surveyor shared with Administrator A and Director of Nursing B the observations of Resident #6 not wearing the code alert/wanderguard.