Every finding on record at Aria of Brookfield

Based on observation, interview, record review, and review of facility policies, the facility failed to ensure food was served at a palatable temperature for three residents (Residents (R)16, R27, R28 ) of three residents reviewed for food palatability. This failure poses the risks of weight loss, reduced quality of life, and foodborne illness for Findings include: 1. Review of R16's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 05/15/26, located in the electronic medical record (EMR) under the MDS tab, revealed an admission date of 03/14/25 and diagnoses of urinary tract infection (UTI), malnutrition, and heart failure. Review of R16's Brief Interview for Mental Status (BIMS) revealed a score of 15 out of 15, indicating R16's cognition was intact. Review of R16's care plan, revised 05/27/26, located in the EMR under the Care Plan tab revealed Resident is at risk for malnutrition r/t [related to]: a PMHx [past medical history] of hypertension, hypothyroidism, CHF [chronic heart failure], GERD [gastroesophageal reflux disease], and hx [history] multiple Pls [pressure injuries]. Review of R16's order, dated 07/13/26, located in the EMR under the Order tab revealed NAS (No Added Salt) diet, Regular texture, Regular (Thin Liquids) consistency. On 07/20/26 at 11:55 AM, R16 was in bed awake with her Family Member (FM)5 at her bedside. R16 and FM5 stated, the food is cold because the trays come out and sit on the cart too long. On 07/22/26 at 8:35 AM, the breakfast cart on the hall was in progress. At 8:55 AM, R16's breakfast tray was delivered to her room. R16 was served scrambled eggs, pancakes, syrup, oatmeal, and milk. R16 commented that her eggs and pancakes are not warm. R16's plate did not contain an insulated base, just the insulated cover. During an interview on 07/22/26 at 9:06 AM, the Registered Dietitian (RD) stated the kitchen did not have a manager at this time and she was just filling in for the other RD. RD was unaware of who monitored food temperatures for food palatability. 2. Review of R28's significant MDS with an ARD date of 11/11/26, located in the EMR under the MDS tab, revealed an admission date of 06/18/24 and diagnoses of Alzheimer's disease, presbyopia, and renal insufficiency. Review of R28's BIMS revealed a score of four out of 15, indicating R28's cognition was severely impaired. Review of R28's care plan, revised 02/10/26, located in the EMR under the Care Plan tab revealed, Resident with alteration in nutritional status r/t recent hospitalization and PMHx of acute osteomyelitis, dementia Alzheimer's disease severe protein-calorie malnutrition sepsis cellulitis of left lower limb and chronic kidney disease. Resident has hx of skin breakdown including PUs [pressure ulcers] (resolved 8/9/24). Unstageable PU (resolved 10/1/24. Presently with stage 2-L [left] heel. Review of R28's order, revised 07/10/26, located in the EMR under the Order tab revealed General diet, Pureed texture, Nectar thick liquids consistency. 3. Review of R27's admission MDS with an ARD date of 04/27/26, located in the EMR under the MDS tab, revealed an admission date of 04/21/26 and diagnoses of cancer, malnutrition, and epilepsy. Review of R27's BIMS revealed no score and cognition was severely impaired. Review of R27's care plan, revised 04/22/26, located in the EMR under the Care Plan tab revealed Resident at risk for malnutrition r/t a PMHx which includes malignant neoplasm of brain cerebral edema epilepsy tremor delusional disorders type 2 diabetes mellitus and depression. Review of R27's order, dated 05/05/26, located in the EMR under the Order revealed General diet, Pureed texture, Regular (Thin Liquids) consistency. 4. On 07/22/26 at 11:48 AM, the tray line food temperatures were checked by Dietary Aide (DA)1 as Dietary Manager (DM)1 supervised and DM2 were present. Two resident meals were observed to already be plated with three pureed items, broccoli, mashed potatoes, and turkey and wrapped in plastic sitting on top of the hot lid of the tilt skillet. The temperature of the first resident meal was 117 degrees Fahrenheit (F), and the temperature of the second resident meal was 125 degrees F. DM1 acknowledged the temperatures were not at 135 degrees F. The trays belonged to R28 and R27. During an interview on 07/22/26 at 1:18 PM, DM1 was asked about cold food and the plate on the test tray and other plates didn't have an insulated base. DM1 stated they are short the bases for the plates. During an interview on 07/22/26 at 4:46 PM, the Administrator stated regarding complaints about cold food and food palatability, Just here and there and residents wanting their tray reheated. The Administrator stated she was aware of the shortage of insulated bases for food plates. The Administrator confirmed the two pureed meals belonged to R27 and R28. Review of the food temperature logs for March 2026, provided by the facility revealed on 03/04/26 the temperature for mostaccioli was documented at 110 degrees F and on 03/06/26 the temperature for the buttered noodles was documented at 110 degrees F. Review of the facility grievance file, provided by the facility, revealed on 07/06/26 resident reported concerns with temperature of the food. No details were provided of which meal it was or what day. The resolution included the Assist Administrator spoke with resident who stated she did not eat the meal immediately after it was delivered. Review of the Resident Council Minutes, provided by the facility, revealed on 04/05/26 a resident complained about the toast and sometimes it is hard and sometimes soggy. [name] said they are working on getting it right. One resident asked about plate warmers and he said they are looking into that or another solution. On 06/17/26 Residents brought up heated trays and Administration is working on that. Review of the facility policy titled The Dining Experience, undated, provided by the facility, revealed Individuals will be provided with nourishing, palatable, attractive meals that meet daily nutritional, and/or special dietary needs and food preferences and are served at a safe and appetizing temperature. Review of the facility policy titled Food Temperature, undated, provided by the facility, revealed 1. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees F.

Based on observations, record review, interviews, and review of facility policies, the facility failed to ensure nurses who administered a narcotic, confirmed the dosage administered matched the prescription order on the narcotic sign out sheet and the physician's order on the Medication Administration Record (MAR), for one of four residents (Resident (R) 7) reviewed for administered narcotics. This deficient practice had the potential for resident overdosing. Findings include: Review of R7's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 06/25/26 with medical diagnoses that included right leg below the knee amputation and left foot amputation. Review of R7's admission Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 07/02/26, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R5 was cognitively intact. During an observation on 07/20/26 at 2:09 PM, R7 was noted in her room alert, oriented, and moving around in bed. Review of R7's MAR for July 2026 documented a physician's order dated 07/09/26 for Oxycontin Oral Tablet extended release (ER) 12-hour Abuse Deterrent 10 milligram (mg) (Oxycodone HCL). Give 10 mg by mouth three times a day for pain. Times of administration were set for AM, PM, and HS (bedtime) Review of R7's narcotic sign out sheet from the pharmacy, provided by the facility, documented the prescription Oxycodone 10mg one tablet twice a day. The actual times the medication was administered were documented on the narcotic sheet and revealed the following days and times the oxycodone 10mg was administered: 1. 07/12/26 PM dose administered at 6:30 PM, HS dose administered at 9:09 PM, 2 hours 40 min after PM dose was administered 2. 07/13/26 AM dose administered at 7:24AM, PM dose administered at 6:15PM, 11 hours 45 minutes after AM dose, and HS dose administered at 9:38 PM, 3 hours 18 minutes after PM dose was administered. 3. 07/14/26 AM dose not administered, PM dose administered at 7:33PM, and HS dose administered at 9:31PM, 2 hours 1 minute after PM dose was administered. 4. 07/15/26 AM dose administered at 7:35 AM, PM dose administered at 4:46 PM, 9 hours 11 minutes after AM dose, and HS dose administered at 8:56 PM, 4 hours 10 minutes after PM dose was administered. 5. 07/16/26 AM dose administered at 7:34 AM, PM dose administered at 5:07PM, 9 hours 33 minutes after AM dose, and HS dose administered at 8:39 PM, 3 hours 28 minutes after PM dose was administered. 6. 07/17/26 AM dose administered at 8:11 AM, PM dose administered at 5:30 PM, 9 hours 19 minutes after AM dose, and HS dose administered at 9:04 PM, 3 hours 34 minutes after PM dose was administered. 7. 07/18/28 AM dose administered at 8:04 AM, PM dose administered at 3:04 PM, 7 hours after AM dose, and HS dose administered at 7:54 PM, 4 hours 50 minutes after PM dose was administered. 8. 0719/26 AM dose administered at 6:46 AM, PM dose administered at 5:39 PM, 10 hours 8 minutes after AM dose, and HS dose administered at 10:03 PM, 4 hours 24 minutes after PM dose was administered. 9. 07/20/26 AM dose administered at 7:20 AM, PM dose administered at 3:30 PM, 8 hours 45 minutes after AM dose. Review R7's Misc tab in the EMR handwritten physician's order dated 07/09/26 revealed Oxycodone 10mg twice a day (BID). The handwritten order had no date or time, the person noting the order was initialed as noted and lacked a date and time the order was noted. During an interview on 07/20/26 at 4:00 PM, the Director of Nursing (DON) was informed about the concerns with the oxycodone 10mg order being administered three times a day when the order was for two times a day. The DON confirmed the order in the EMR was not correctly transcribed and the order was for two times a day (BID) not three times a day (TID), which was what was entered into the EMR. The DON verbalized the need to change the order in the EMR, so doses were given based on a correct order going forward. The DON confirmed these doses were not 12 hours apart and should have been. Review of R7's narcotic sign out record for 07/20/26 revealed the HS dose of oxycodone 10 mg was administered at 7:35 PM, 4 hours and 4 minutes after the PM dose was administered. During an interview on 07/21/26 at 1:49 PM, the DON and the Administrator explained the actions taken following the information about the oxycodone 10mg order being entered into the EMR system incorrectly. They stated the physician was called, but the notification was not documented in the progress notes, and the DON confirmed not changing the order on 07/20/26 after the 4:00 PM interview. This resulted in R7 in receiving the HS dose of oxycodone 10 mg at 7:35 PM, 4 hours and 4 minutes after the PM dose was administered. During a phone interview on 07/22/26 at 10:04 AM, the Pharmacist confirmed the process for the facility to obtain the narcotics for the residents involved the prescription being sent from the physician to the pharmacy to fill. They compare the prescription with the narcotic being distributed to the facility as their internal check and do not verify narcotics with the EMR system. Review of the facility policy titled Controlled Substance Prescriptions, reviewed 01/2018, revealed Documentation of the Controlled Substance Prescription. l) Each controlled substance prescription is documented in the resident's medical record with the date, time, and signature of the person receiving the prescription. The prescription is recorded on (the physician order sheet . or the telephone order sheet . or posted elsewhere in the record, and recorded on the Medication Administration Record (MAR)/electronic medical record . 2) New orders for controlled substances communicated to the nurse verbally or orally by the prescriber via telephone were entered onto the [physician order sheet telephone order sheet/electronic medical record] and noted as follows: [T.O., noted 3:00 p.m.5/1712011, M. [NAME], R.N.] or as determined by an electronic health record system. Review of the facility policy titled Medication Administration-General Guidelines, revised 12/2019, revealed Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. FIVE RIGHTS - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (l) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away.

Based on interviews, record review, and review of facility policies, the facility failed to provide the resident and/or representative with written transfer and bed-hold notices that included where and why the resident was transferred for three residents (Resident (R6), R16, R3) of three residents reviewed for hospitalization. The failure had the potential to affect the residents and/or their representative concerning the residents' appeal rights. Findings include: 1. Review of R6's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 08/30/24 and readmission on [DATE] with medical diagnoses that included end-stage renal failure. Review of R6's Prog Notes tab in the EMR dated 05/13/26 at 6:18 PM, revealed R6 was admitted to the hospital due to gastrointestinal (GI) bleed. Review of R6's Prog Notes tab in the EMR dated 05/14/26 at 9:51 AM, revealed SW (Social Worker) left resident a voicemail in regard to a behold due to resident being in the hospital. During a phone interview on 07/20/26 at 12:08 AM with Family Member (FM) 1, she stated no paperwork was received when transferred to the hospital in May. Review of R6's Misc tab in the EMR revealed the document titled Healthcare Bed Hold Notice dated 05/14/26, the signature line written verbal consent; R6 [name], and the document titled Notice of Transfer dated 05/14/26 with the reason for notice of transfer documented hospitalization. 2. Review of R16's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 05/15/26, located in the EMR under the MDS tab, revealed an admission date of 03/14/25 and diagnoses including urinary tract infection (UTI), malnutrition, and heart failure. Review of R16's Brief Interview for Mental Status (BIMS) revealed a score of 15 out of 15, indicating R16's cognition was intact. Review of R16's Health Status Note, dated 07/10/26, located in the EMR under the Progress Note, revealed Writer was alerted by CNA [Certified Nurse Aide] that resident had 3x [three times] emesis last night and that she wasn't looking good. Writer went in and obtained vital signs, temp [temperature]102. Writer updated MD [physician] and stated that the resident wanted to go out to the hospital, MD agreed. Resident was sent to Waukesha memorial hospital. ADON [Assistant Director of Nursing] was also notified. Review of R16's NRSG [nursing]: admission Data Collection Progress Notes, dated 07/13/26, located in the EMR under the Progress Note, revealed Resident arrived via ambulance to facility after hospitalization following UTI [Urinary Tract infection]. Resident with history of multidrug resistant UTI. Resident was treated to meropenem in the hospital and transitioned to oral antibiotics prior to discharge and readmission to facility. Review of R16's Bed-Hold and Transfer Notices, dated 07/13/26, located in the EMR under the Miscellaneous tab revealed the notices provided verbally and not written. The Notice of Transfer did not include the reason R16 was being transferred or the location in which R16 was being transferred to. During an interview on 07/22/26 at 9:33 AM, the Administrator confirmed R16 was sent to the hospital 07/10/26The Administrator wasn't aware R16 nor Family Member (FM) 5 did not receive a written copy of the bed-hold notice or the transfer notice. She stated she thought R16 did receive a written copy. During an interview on 07/22/26 at 10:45 AM, the Administrator confirmed the location and reason for the transfer was not on R16's transfer notice. During a follow-up interview on 07/22/26 at 12:30 PM, the Administrator confirmed the 07/13/26 notices for bed-hold and transfers were documented as verbal. The Administrator stated the notices are sent with the ambulance along with the other transfer information for the hospital staff to give to R16 and FM5. The Administrator stated she could not prove the notices were provided in writing. 3. Review of R3's non-federal MDS with an ARD date of 03/10/26, located in the EMR under the MDS tab, revealed an admission date of 03/03/26, received hemodialysis and diagnoses including displaced fracture of base of neck of left femur, subsequent encounter for closed fracture with routine healing, type 2 diabetes mellitus with diabetic chronic kidney disease, and hypotension of hemodialysis. Review of R3's Brief Interview for Mental Status (BIMS) revealed a score of 15 out of 15, indicating R3's cognition was intact. Review of R3's Health Status Note, dated 03/11/26 at 16:47, located in the EMR under the Progress Note, tab revealed Resident admitted at [name] Hospital for Hypoglycemia, acute encephalopathy, increased troponin and syncope. Review of R3's Bed-Hold and Transfer Notices, dated 03/11/26, located in the EMR under the Miscellaneous tab revealed the notices were provided verbally and not written. The Notice of Transfer included a handwritten note hospitalization but did not include the reason for the hospitalization or the location in which R3 was being transferred. During an interview on 07/21/26 at 4:00 PM, the Administrator stated R3's representative could not come to the facility and that was why the representative was telephoned. The Administrator stated the social worker sent the notices in the mail but there was no documentation to prove it. During an interview on 07/22/26 at 9:30 AM, the Administrator stated the facility does not have a process to confirm that the notices are mailed and they have no way to prove it. The Administrator stated they send the notices with the residents via EMS but again there was no way to confirm whether the hospital staff are giving it to the residents or their representative. The Administrator stated the social worker will call, verbally informing the representative, and then it is mailed but they cannot provide confirmation this was done. During a follow-up interview on 07/22/26 at 10:45 AM, the Administrator confirmed R3 was admitted to [name] hospital and that the progress notes were correct. The Administrator acknowledged location and reason for transfer were missing. Review of the facility policy titled Transfer and Discharge Policy, revised 05/22/25, provided by the facility revealed 2. Before the facility transfers or discharges a resident, the facility will:. b. Notify the resident and, if known. a family member or the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. c. Include in the notice the following items: i. The reason for transfer or discharge; ii. The effective date of transfer or discharge; iii. The location to which the resident is transferred or discharged ;. l. The notice will be in writing and will contain all information required by state and federal law, rules, or regulations applicable to Medicaid or Medicare cases. Review of the facility policy titled Bed Hold Policy Notification, dated 06/26/26, located in the admission packet provided by the facility revealed 1. Provide written notice according to the Notice of Bed Hold Policy.

Based on interview, record review, and facility policy review, the facility failed to properly prepare for the arrival of a resident who had been pre-screened and approved for placement, resulting in a resident being returned to the hospital for one resident (Resident (R)2) of three residents reviewed for admissions. This failure caused a disruption of the resident's continuum of care and could have triggered negative consequences. Findings include: Review of the Email thread from the admission Director (ADD,) revealed on the first thread dated Friday, 06/05/26, provided by the facility, revealed Sunday 6/7 [R2's name], [hospital abbreviations], Time: Leaving at 2pm, Payer: [name of insurance provider], RM [room number], 5'[feet]2[inches], 253 lbs [pounds], Presented for SOB [short of breath] and leg swelling, Full Code, Diet: Cardiac, *2L[liters] 02[oxygen]*, STR [short-term rehabilitation], Own person. Second thread dated Sunday, 06/7/26 at 1:51 PM, revealed admission announcement Sunday 6/7 – [R2's name] [facility name]. She is coming today at 2pm!!! Review of the hospital records/Referral, dated 06/01/26, provided by the hospital revealed Patient will continue to benefit from skilled therapy while in the hospital to address above impairments and further increase independence with functional mobility to facilitate a safe and appropriate discharge, Placement Needs: SNF [skilled nursing facility]/SAR [subacute rehabilitation], Discharge Location Recommendation: post acute rehab [rehabilitation]. During a telephone interview on 07/21/26 at 4:22 PM, the Facility Liaison (FL) stated the reason R2 wasn't admitted to the facility on Sunday 06/07/26 was because it was the Nurse's issue as she didn't know R2 was being admitted . The FL stated everyone was supposed to be aware as he sent an email admission announcement. During an interview on 07/21/26 at 4:58 PM, the Regional Director of Operations (RDO) stated, Yes, the facility knew R2 was supposed to be admitted on [DATE] at 2:00 PM. The RDO stated Licensed Practical Nurse (LPN)10 didn't think they took weekend admissions. The RDO stated, the admitting nurses were not on the email that announced admissions, the admitting nurse received word by the management staff. During a telephone interview on 07/21/26 at 6:56 PM, LPN10 stated it was a Sunday and she saw the ambulance at the end of unit and she had no idea there was an admission. LPN10 stated she was told R2 was admitted but she had no report from the hospital. LPN10 stated, Normally the hospital nurse calls them, but she didn't receive a call. LPN10 stated R2's room wasn't ready, as the floor was dirty and the bed wasn't made. LPN10 stated she had not looked at R2's medications and so she told R2's son she had not received report for R2. LPN10 informed the ambulance personnel and R2's son she could not accept R2. R2 was still on the stretcher and the ambulance personnel returned R2 to the hospital. LPN10 stated she is made aware of admissions by the hospital's customer relations person [name] who will text, call, or tell them in person about new admissions, but LPN10 stated she did not get that. LPN10 stated normally they don't have admissions on weekends. LPN10 stated the Hospital's Case Manager, called the facility, and told the receptionist they were getting an admission. LPN10 stated the Case Manager said, you guys are accepting this admission, but the receptionist did not tell her. When LPN10 talked to the Case Manager, she kept saying Name of a person said R2 can come but LPN didn't know of anyone that worked at the facility by that name. LPN10 went on to say later she found out it was the admission Director (ADD), who was one of the admissions persons. During a telephone interview on 07/22/26 at 11:24 AM, ADD stated R2 was accepted as an admission to their facility and R2 was supposed to be admitted on a Sunday, 06/07/26 for shortness of breath and leg swelling. The ADD stated, We could have cared for her. ADD stated she told the hospital social worker about R2's weekend admissions. An email was sent on Friday, 06/05/26 and a follow up email on Sunday, 06/07/26. ADD stated all management were informed via the same email that was sent to the hospital SSW. ADD stated the facility's nurse manager, or the nurse-on-call should have informed the facility's admitting nurse. Review of the facility policy titled Admission/readmission Procedure, revised 11/10/25, provided by the facility revealed Pre-admission: . 5. Room readiness completed by IDT [interdisciplinary team]. 6. admission notifications sent to nursing staff and leadership prior to admission. Notifications include, isolation needs, special equipment needs, following physician, admitting location, discharge summaries and orders needed. Process: 1. The receiving unit is notified by the admissions office as soon as possible regarding the upcoming admission. 2. A qualified staff member conducts the admission process involving the resident and family. 7. Information about resident admission is communicated in a timely manner to the appropriate departments. Procedure: 1. The admission office, nursing department, guest relations, and housekeeping make preparation before the arrival of a new patient. 2. The admissions office obtains information regarding the resident and forwards that to the appropriate nursing personnel for report.

Based on interview, record review, and policy review the facility failed to ensure physician narcotic orders were accurately transcribed to the Medication Administration Record (MAR) in the electronic medical record (EMR) for 2 of 5 residents (Resident (R) 5 and R7). As a result of this deficient practice, residents have the potential for both over medication and under medication. Findings include: 1. Review of R5s admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 05/17/24 and readmission on [DATE] with medical diagnoses that included type II diabetes and major depressive order. Review of R5's annual Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 05/06/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R5 was cognitively intact.Review of R5's Prog Note tab in the EMR revealed on 04/08/26 at 13:06 PM, revealed an interdisciplinary team (lDT) meeting was convened to review and address a medication discrepancy involving Suboxone for resident R5. However, the facility failed to investigate. Review of R5's MAR in the EMR for December 2025, revealed the following orders: Buprenorphine HCl-Naloxone HCl Sublingual Film 4-1 milligram (mg). [Suboxone] Give 1 film sublingually in the morning for opioid use / pain -Start Date- 07/17/2025 and a second order on the December MAR documented Buprenorphine HCl-Naloxone HCl Sublingual Film 2-0.5 mg [Suboxone] Give 1 film sublingually one time a day for opioid dependence -Start Date- 12/18/2025.Review of R5's narcotic sign out sheets, provided by the facility, for December 2025 to March 2026 revealed Drug Bupren/Nalox [Suboxone] 4-1mg sublingual film. 1 film inside the cheek once daily, Summary: Suboxone 4mg sublingual once a dayReview of R5's MAR from January 2026 to March 2026 revealed the physician's order Buprenorphine HCl-Naloxone HCl Sublingual Film 2-0.5 mg. Give 1 film sublingually one time a day for opioid dependence -Start Date- 12/18/2025 -D/C Date- 04/08/2026. Summary: Suboxone 2mg sublingual once a dayReview of R5's MAR for April 2026, revealed a physician's order for Buprenorphine HCl-Naloxone HCl Sublingual Film 2-0.5 mg [Suboxone]. Give 1 film sublingually one time a day for opioid dependence -Start Date-12/18/2025. 04/01/26 and 04/02/26 doses were documented as not administered.During an interview on 07/22/26 at 11:26 the Director of Nursing (DON) confirmed the medication for R5 ran out at the end of March 2026 and R5 went two days without the Suboxone and the Nurse Practitioner (NP) was asked to write the renewal since the renewal process had not been initiated timely. The NP used the MAR information prescribed the Suboxone 0.2mg sublingual once a day. The DON stated R5 then received Suboxone 0.2mg dosing for the next six days as documented on the MAR. R5 complained about the dose not being correct, the facility then identified the issue since 12/17/25 which the MAR documented Suboxone 2mg and the narcotic sign out sheet documented Suboxone 4mg. Also, the refill order from the NP was for Suboxone 2mg and the dose R5 had been receiving was 4mg.During an interview on 07/22/26 at 11:15 AM, the Staff Development/Infection Preventionist explained in December 2025, the Pharmacist recommended a gradual dose reduction (GDR) for R5 Suboxone from 4mg to 2mg. The pharmacy recommendation was not approved by the physician and the previous DON decided to reduce the dose and put the order into the EMR for Suboxone 2mg. However, the narcotic prescription from the physician was never changed from Suboxone 4mg. Review of R5's EMR lacked documentation of the pharmacy recommendation for December 2025. During an interview on 07/22/26 at 12:25 PM. LPN8 confirmed working at the facility for four years on the same unit as R5 and was unaware there was an error with the Suboxone for over three months. LPN8 explained that the pharmacy would call if there was a discrepancy between the physician orders and the MAR and depended on the pharmacy for any discrepancies. During an interview on 07/22/26 at 11:16 AM the DON and the Regional Director of Operations (RDO) confirmed the medication error identified 04/08/26 involving R5 was not fully investigated by the facility resulting in staff over the first four months of the year were not checking the narcotic being administered with the physician order documented in the MAR. 2. Review of R7's admission Record located in the EMR under the Profile tab, revealed an admission date of 06/25/26 with medical diagnoses that included right leg below the knee amputation and left foot amputation. Review of R7's admission MDS located in the EMR under the MDS tab with an ARD of 07/02/26, revealed a BIMS score of 14 out of 15, indicating R7 was cognitively intact.During an observation on 07/20/26 at 2:09 PM, R7 was noted in her room alert, oriented, and moving around in bed.Review of R7's MAR for July 2026 documented a physician's order dated 07/09/26 for Oxycontin Oral Tablet extended release (ER) 12-hour Abuse Deterrent 10 mg (Oxycodone HCL). Give 10 mg by mouth three times a day for pain. Review of R7's narcotic sign out sheet, provided by the facility, for Oxycodone 10mg documented the prescription Oxycodone 10mg one tablet twice a day.Review R7's Misc tab in the EMR handwritten physician's order dated 07/09/26 revealed Oxycodone 10mg twice a day (BID). The handwritten order had no date or time, the person noting the order was initialed as noted and lacked a date and time the order was noted. Review R7's Misc tab in the EMR two other narcotic orders, for Percocet and Tramadol were handwritten by the physician, lacked dates and times, and lacked a notation that the order had been noted.During an interview on 07/20/26 at 4:00 PM, the DON reviewed the order on the MAR and confirmed the handwritten order was incorrectly transcribed resulting in R7 receiving three doses of oxycodone during the regularly scheduled times for an administration of three times a day in the morning, afternoon and at night. The DON confirmed these doses were not 12 hours apart.During a phone interview on 07/22/26 at 10:04 AM, the Pharmacist confirmed the process for the facility to obtain the narcotics for the residents involved the prescription being sent from the physician to the pharmacy to fill. They compare the prescription with the narcotic being distributed to the facility as their internal check and do not verify narcotics with the EMR system. The Pharmacist also explained that the 12 ER oxycodone has properties to prevent a potential overdose of oxycodone for R7 as well as her long history of narcotic use and high tolerance. Review of the facility policy titled Controlled Substance Prescriptions, reviewed 01/2018, revealed Documentation of the Controlled Substance Prescription. l) Each controlled substance prescription is documented in the resident's medical record with the date, time, and signature of the person receiving the prescription. The prescription is recorded on (the physician order sheet . or the telephone order sheet . or posted elsewhere in the record, and recorded on the Medication Administration Record (MAR)/electronic medical record . 2) New orders for controlled substances communicated to the nurse verbally or orally by the prescriber via telephone were entered onto the [physician order sheet telephone order sheet/electronic medical record] and noted as follows: [T.O., noted 3:00 p.m.5/1712011, M. [NAME], R.N.] or as determined by an electronic health record system. Review of the facility policy titled Medication Administration-General Guidelines, revised 12/2019, revealed Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration ofmedications without unnecessary interruptions. FIVE RIGHTS - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (l) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away.

Based on interview and record review, the facility failed to appropriately pre-screen a resident before admission to determine whether the facility could meet the resident's needs and subsequently discharged the resident, because they were unable to provide the required care for one resident (Resident (R1) of one resident reviewed for the Facility Assessment. This failure had the potential to result in undue hardship for residents and disrupt the continuity of care. Findings include: Review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 02/24/26, located in the electronic medical record (EMR) under the MDS tab, revealed an admission date of 02/24/26 and diagnoses including cerebral infarction due to thrombosis of precerebral arteries, hemiplegia following a cerebral infarction on the right dominant side, and encephalitis and encephalomyelitis, unspecified and had a feeding tube. Review of R1's Brief Interview for Mental Status (BIMS) revealed a score of 99, indicating R1's cognition was severely impaired. Review of R1's referral packet, dated 02/10/26, provided by the facility, revealed Secondary Diagnosis: acute ischemic left MCA [Middle Cerebral Artery] stroke s/p [status post] decompressive hemicraniectomy [an emergency life-saving surgery where a neurosurgeon removes a large flap of the skull, leaving an opening]. Radiology: Soft Tissues and Skull: Left craniectomy noted. Mild left-sided scalp soft tissue swelling noted overlying the craniectomy. No skull fracture. Impression: 1. Status post left craniectomy with chronic-appearing left MCA territory encephalomalacia. There is associated expansion of the left cerebral hemisphere through the craniectomy defect . Review of R1's hospital Discharge summary, dated [DATE], located in the EMR under the Miscellaneous tab revealed Final diagnosis: 1. Acute ischemic MCA stroke, s/p hemicraniectomy. 7. S/p left hemicraniectomy. aspirin 81 MG [milligram] chewable tablet Administer 1 tablet (81 mg total) per tube in the morning. Indications: Stroke Due To Limited Blood Flow, Acute ischemic left MCA stroke status post hemicraniectomy 11/18/25. Review of R1's Health status Note, dated 02/24/26 at 13:47, located in the EMR under the Progress Note, revealed VS [vital signs] rechecked 1 hour post midodrine administration and are as follows: BP [blood pressure] 72/52, HR [heart rate] 106 BPM [beats per minute], Oxygen Sat [saturation]. 95% MD [physician] notified. Review of R1's skin/wound note, dated 02/24/26 at 14:02, located in the EMR under the Progress Note, revealed Writer completed head to toe skin assessment. No skin impairments noted. Healed surgical incision to left head present. Skin is clean, dry and intact upon admission to the facility. Review of R1's Health Status Note, dated 02/24/26 at 14:16, located in the EMR under the Progress Note, revealed MD stated to send resident out to ER for eval [evaluation] and treat. Review of R1's Hospital Records, dated 02/24/26, provided by the hospital, revealed [DON- Director of Nursing] from [facility name] calling to inform staff that, due to patient's hx [history] of a craniotomy, patient cannot return to facility due to patient acuity. Writer informing DON that patient will be admitted overnight for observation and will inform admission RN of this information. Review of R1's Health Status Note, dated 02/26/26, located in the EMR under the Progress Note, revealed Facility Regional Director of Sales and Marketing spoke with guardian- [name]. Guardian stated resident will not be returning to facility and requested resident's belongings to be brought to hospital. Regional Director packed belongings and brought them to hospital. During a telephone interview on 07/20/26 at 1:28 PM, FM6 stated the facility had admitted R1 and then a few hours later sent R1 to the hospital for a possible fall out of the bed and for being hypotensive. FM6 stated the facility wouldn't readmit R1 because she had a craniotomy but had a helmet. During an interview on 07/21/26 at 10:16 AM, the Administrator stated R1 was sent to hospital due to low blood pressure. The Administrator stated R1 wasn't readmitted because R1 had clinical conditions the family did not tell them about. The Administrator stated therefore, R1was denied coming back due to safety concerns. During an interview on 07/21/26 at 10:23 AM, the DON stated the family wanted R1 to be physically restrained and that R1 had a history of falls. After reviewing the hospital paperwork, the DON stated she realized R1 had a bone flap and wore a helmet for protection. The DON stated, We don't accept residents with helmets for that purpose. The DON stated the POA [power of attorney] was informed that the facility does not use physical restraints and that R1's bone flap was also a condition for which they could not care. The DON stated the facility recognized it should not have accepted R1. The DON stated, It was in the hospital paperwork, but since the Facility Liaison (FL) isn't clinical, he didn't pick up on it. The DON further stated the FL was onsite at the hospital when screening R1, but R1 was not wearing the helmet, and the FL did not recognize the condition. The DON stated residents with bone flaps or helmets are not accepted due to fall risks and safety concerns. The DON reviewed the Facility Assessment and confirmed it did not identify or indicate if residents who wore helmets were appropriate for the facility. During a telephone interview on 07/21/26 at 4:27 PM, the FL stated he visited R1 at the hospital, spoke with hospital staff, and reviewed R1's paperwork. The FL stated the paperwork did not indicate R1 had a bone flap and he was unaware the facility could not provide care for R1's condition. However, because the condition was not identified during his hospital visit, he accepted R1 for admission. During a telephone interview on 07/22/26 at 11:30 AM, the Admissions Director (ADD) stated R1 was not appropriate for placement at the facility and was denied readmission. The ADD stated she had a referral for R1 but missed the diagnosis and condition. Review of the facility assessment, dated 6/18/26, provided by the facility revealed under Common Diagnoses and Specific Care or Practices, hemicraniectomy was not listed as a condition the facility provided care and services for. Review of the facility's Admissions Education, dated 02/26/26, provided by the facility as the practice used at the time of R1's admission, revealed The purpose of this education is to ensure the Admissions Team completes a thorough, consistent, and clinically sound review of every referral. Each referral must go beyond the admitting diagnosis to identify the underlying cause of the acute hospitalization and confirm that the facility can safely and appropriately meet the prospective resident's needs.

Based on observation, interview, record review, and review of facility policies, the facility failed to follow Enhanced Barrier Precautions, use proper hand hygiene, and keep soiled linens off the floor for one resident (Resident (R)15) of three residents reviewed for infection control. These breaches in infection control have the potential to cause a spread in disease and affect all the residents. Findings include: Review of R15's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 07/15/26, located in the electronic medical record (EMR) under the MDS tab, revealed an admission date of 07/08/26 and diagnoses including multidrug-resistant organism (MDRO), bacteremia, and cellulitis of right and left lower limbs and wounds. Review of R15's Brief Interview for Mental Status (BIMS) revealed a score of 15 out of 15, indicating R15's cognition was intact. Review of R15's order, 07/08/26, located in the EMR under the Order tab revealed Isolation: Enhanced Barrier Precautions; Resident is in isolation with Enhanced Barrier Precautions for protection every shift. Review of R15's care plan, dated 07/17/26, located in the EMR under the Care Plan tab revealed The resident requires enhanced barrier precautions related to wounds. An intervention included Implement Enhanced Barrier Precaution. Review of R15's skilled daily note, dated 07/17/26, located in the EMR under the Progress Note tab, revealed Due to recent history of MRSA bacteremia, resident remains under skilled observation for signs and symptoms of recurrent infection. During an observation on 07/20/26 at 10:03 AM, an Enhanced Barrier Precaution (EBP) sign was noted on R15's open door and a bin containing personal protective equipment (PPE) was located outside of R15's door. R15 was in bed, and soiled laundry and bed sheets were noted directly on the floor rather than bagged. Certified Nurse Aide (CNA) 1 was in the room and was wearing gloves but no other PPE. CNA1 gathered the soiled items from the floor and placed them in a hallway bin. CNA1 was unable to provide knowledge of why R15 had an EBP sign on his door. During an observation on 07/20/26 at 10:07 AM, CNA1 was in R15's room wearing only gloves (no other PPE) and positioned the resident's right leg. At 10:08 AM, CNA1 removed her gloves, exited the room, and discarded the gloves in a trash bin. CNA1 entered room [ROOM NUMBER] without performing hand hygiene. During an observation on 07/20/26 at 12:28 PM, R15 was sitting in a wheelchair in his room and lower legs were noted to be very scaly. R15 appeared to be very sleepy. During an interview on 07/20/26 at 2:28 PM, CNA1 confirmed she did not wear a gown when changing R15's brief and bed sheets. CNA1 stated it was acceptable to place soiled linens directly on the floor, because she would place the linens in the bins. During an interview on 07/22/26 at 9:08 AM, the Infection Preventionist (IP stated, CNAs are to gown-up when they touch bodily fluids, during patient care, including incontinent care and changing bed linens. The IP also stated, soiled sheets are to be placed in a bag and into the receptacles. The IP also stated, Nothing should be on the floor. The IP stated once gloves are removed, CNAs are to perform hand hygiene. The IP confirmed R15 had an EBP sign due to wounds. Review of the facility in-service records, dated 04/15/26, provided by the facility, revealed CNA1 received instructions regarding linen and garbage separation. Review of the facility policy titled Hand Hygiene, revised 04/01/25, provided by the facility revealed 2. Alcohol-based hand sanitizer is appropriate for decontaminating the hands:. d. After contact with a resident; e. When moving from a contaminated body site to a clean body site during resident care; f. After contact with body fluids, excretions, mucous membranes, non-intact skin, or wound dressing (if hands aren't visibly soiled); g. After removing gloves;. Review of the facility policy titled Enhanced Barrier Precautions, dated 02/25/25, provided by the facility revealed b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. 4. High-contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting. h. Wound care: any skin opening requiring a dressing. Review of the facility policy titled Linen Management, revised 08/21/25, provided by the facility, revealed 5. Dirty linens are contained in a closed container or bag. 6. Dirty linens are to be handled in a way to prevent aerosolizing infectious agents (i.e.do, not shake linens).

Based on observations, record review, interviews, and review of facility policies, the facility failed to ensure one of one residents (Resident (R) 5) was assessed for self-administration of medication. As a result of this deficient practice the residents had the potential for harm of not receiving physician prescribed medications. Findings include: Review of R5s admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 05/17/24 and readmission on [DATE] with medical diagnoses that included type 2 diabetes and major depressive order. Review of R5's annual Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 05/06/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R5 was cognitively intact. During an observation on 07/20/26 at 1:40 PM, 5 pills and one capsule were noted on a napkin on the lunch tray. R5 stated she was taking them on her own, after lunch. Review of R5's EMR under the Forms tab lacked documentation of an assessment for Self-Administration of Medications. During an interview on 07/20/26 at 1:52 PM, Licensed Practical Nurse (LPN) 9 stated she left the medications in a med cup on the bedside table about 10:00 AM this morning. LPN 9 confirmed that R5 did not have an assessment completed for self-administration of medication and should not have left them with the R5 without confirming administration During an interview on 07/21/26 at 3:10 PM, the Director of Nursing (DON) confirmed an assessment for self-administration of medications had not been completed for R5 and should have been done before medications were left at the bedside. Review of the facility policy titled Self-Administration of Medications, revised 01/2018, revealed If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process. Review of the facility policy titled Medication Administration-General Guidelines, revised 12/19, revealed The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR, and action is taken as appropriate.

Based on interview and record review, the facility did not ensure prompt resolution of all grievances for 1 of 8 residents (R3) reviewed for grievances.R3's POA (Power of Attorney) voiced concerns related to R3's call light being purposefully disconnected by staff. The facility conducted an investigation but failed to provide follow up to the POA regarding the final results of the investigation into the grievance.Findings includeThe facility's grievance policy states, in part, When a grievance is noted (whether 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 .All grievances receive immediate priority and must be investigated with efforts made toward resolution within seven days.The resident will be provided with a verbal follow up to their grievance, including the following information: a) The name of the department head conducting the investigation b) The steps taken to investigate the grievance, c) The final results of the grievance.R3 was admitted to the facility on [DATE]. She has an activated POA.During a state survey on 1/8/26, POA C (R3's POA) indicated to Surveyors that a CNA had purposely unplugged R3's call light and that she (POA C) was concerned for R3's care. POA C indicated to Surveyors at this time that she had told the social worker at the facility when the event occurred, which POA C stated was in October of 2025.The facility submitted a report to the State Agency upon notification from Surveyors on 1/8/26 regarding the complaint. The facility conducted an investigation and submitted its findings to the State Agency.On 2/5/26 at 11:18 AM, Surveyor interviewed NHA A (Nursing Home Administrator) who stated that she was aware that POA C had had a concern regarding R3's care but administration was not aware of the concern until it was brought to their attention on 1/8/26. When asked if the facility had followed up with POA C's concerns, NHA A stated that they had not followed up as they were unable to get a hold of her.On 2/5/26 at 1:35 PM, Surveyor interviewed POA C (via telephone) who stated that she was hoping to get some answers from the facility but had yet to hear from the facility and was unaware of what was going on with R3's care. When asked if the facility had given her any updates throughout the process of the investigation, POA C stated, None.The facility failed to ensure their grievance policy was followed and failed to provide feedback and a resolution promptly to POA C.

Based on observations, record review, and interviews, the facility failed to ensure medications stored in a secure location, and expired medications were discarded appropriately. This had the potential for facility staff to use expired medications and supplies that could potentially not be effective.Findings included:During a review of the facility's crash carts with the Assistant Director of Nursing (ADON) on 01/08/26 at 11:00 AM, the following was observed:On top of the unlocked, unsecured crash cart in 2 South -Three packs of Tiotropium Bromide Monohydrate inhalation powder expiration date 01/2027 labeled with R16's name. One inhaler was used and had a use by expiration of 08/21/25.At the time of the observation, ADON acknowledged the medications should not have been sitting unsecured on the crash cart. The ADON stated there was a medication room for expired medications, and the inhalers should have been placed there for pharmacy to retrieve and dispose.Review of the facility's policy titled Medication Storage in the Facility dated January 2018 revealed, 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 .All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner.

Based on observations, interviews, record review, and policy review, the facility failed to ensure the call button to activate the call light system was accessible for two (Resident (R) 11 and 6) of 16 residents in the sample. This failure placed the residents at risk for accident, injury, or unmet needs related to an inability to call for staff assistance.Findings include:1. Review of R11's admission Record located in the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] and had diagnoses including hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting left non-dominant side.Review of R8's Care Plan Report located in the Care Plan tab of the EMR revealed a fall intervention, Be sure my call light is within reach and encourage me to use it for assistance as needed, revised 08/01/25.Review of R8's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/23/25 and located in the MDS table of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated moderate cognitive impairment.During an observation on 01/07/26 at 9:14 AM, staff exited R11's room, where he sat up in bed, after setting up his breakfast tray. R11's call button was observed hanging over the edge of the upper left corner of the bedframe, below mattress level, out of reach of the resident.During an observation and interview on 01/07/26 at 10:17 AM, the call button was in the same position, hanging off the upper left corner of the bedframe. R11's breakfast tray was no longer in his room. He reported he was unaware of where his call button was. He stated staff were better recently about clipping it to the blanket, but it might have moved when they sat him up for breakfast.During an interview and observation on 01/07/26 at 10:22 AM, Certified Nursing Assistant (CNA) 4 reported R11 was not assigned to her but confirmed his call button was out of reach, moved it to R11's tray table, and told R11 where it was.During an interview on 01/08/26 at 11:57 AM, the Director of Nursing (DON) reported that she expected staff to clip the call lights, typically to a sheet, within reach of the residents so that residents could not inadvertently knock them off the bed.2. Review of R15's Profile provided by the facility, revealed R15 was admitted to the facility with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.Review of Quarterly MDS with an ARD of 11/17/25 revealed R15 required total assistance with most activities of daily living (ADLs), and extensive assistance of two persons for bed mobility and transfer. R15 also needed physical assist for toileting.During an observation on 01/05/26 at 1:00 PM, R15 was observed in bed talking on her cell phone. The call light was buried under some linen on a chair out of R15's reach. R15 stated she needed to be changed but had no way to call for help. R15 stated this happened quite often and she would call the main facility line, ask for the nursing supervisor, and tell the supervisor she needed to be changed. R15 stated she had made the call about 15 minutes prior.On 01/05/26 at 1:45 PM, when asked, R15 stated no one had come in to assist her yet.On 01/05/26 at 1:46 PM, surveyor informed CNA3 that R15 needed assistance and had been waiting for over 45 minutes. CNA3 stated she did not know that because R15's call light was not on. CNA3 went into R15's room. Surveyor asked CNA3 where R15's call light was. CNA3 confirmed that the call light was not within reach and was in a chair far out of R15's reach and could not be used by R15.During an interview on 01/07/26 at 2:04 PM, the Administrator stated it was her expectation that call lights should be within residents' reach at all times.Review of the facility's procedure titled, Call Lights, revised 04/08/25, revealed, When leaving room, be sure the call light is placed within the resident's reach. Residents that have been identified to move the call light to locations not easily accessible after staff have placed it in a location within reach, should have this behavior included in the resident's plan of care and Kardex. Monitor the call light location during rounds to ensure it is within reach of the resident.

Based on observation, interview, record review, and policy review, the facility failed to answer a call light and respond for one (Resident (R) 8's) request for assistance in a timely manner out of a sample of 16 residents. This failure caused a delay in meeting the resident's care needs.Findings include:Review of R8's admission Record located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] and had diagnoses including reduced mobility and muscle weakness.Review of R8's Care Plan Report located in the Care Plan tab of the EMR revealed a fall intervention, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, revised 08/01/25. In addition, the care plan contained an intervention, revised 12/04/24, for assist of one staff with toileting.Review of R8's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/16/25 and located in the MDS table of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition.During an observation on 01/05/26 at 12:51 PM, R8's call light was observed to be on, indicated by a light above her doorway in the hall.During an interview on 01/05/26 from 12:53 PM to 1:32 PM, R8 laid in her bed in her room, call button near her left hand. R8 reported pushing the call button a while ago because she needed staff to assist her in using the bed pan. R8 felt she may have soiled herself because she had diarrhea, and her bottom was sore. R8 stated she started asking for help around 11:00 AM, and she knew her Certified Nursing Assistant (CNA) was busy because the CNA told her she was serving dinner earlier and then she was assisting residents going to dialysis. During the interview she stated she waited an hour at times for her call light to be answered. When asked how often this happened, she said almost daily. She denied having any adverse effects from waiting.During the interview with R8, a dietary aide came in at 1:15 PM to gather R8's lunch tray without asking if R8 needed anything. At 1:28 PM the Housekeeping Supervisor came into the room to remove garbage without asking R8 why her call light was on.During an observation on 01/05/26 at 1:32 PM, Housekeeper (HSKP) 1 entered R8's room. The call light remained on, with the indicator lit above her door. When HSKP1 left the room at 1:38 PM, she walked across the hall to another resident's room and asked CNA7 if she was R8's nurse. CNA7 responded that she was R8's aide and that she told R8 she would be with her, but she had dialysis people she had to take care of first.During an observation on 01/05/26 at 1:48 PM, 57 minutes after the call light was first observed on, the Assistant Director of Nursing (ADON) went into R8's room, asked R8 what she needed, and turned off the call light. The ADON assisted R8 with the bed pan. R8 was observed to have not been incontinent and was without any skin breakdown.During an interview on 01/05/26 at 1:55 PM, the ADON reported staff were expected to respond to call lights timely and not turn them off until the resident received assistance. Fifty-seven minutes to respond to a resident's needs was unacceptable. When an assigned CNA was busy, other nursing staff were to assist as able.During an interview on 01/07/26 at 12:12 PM, CNA7 reported R8 used her call light to ask for assistance, usually when she needed the bed pan or wanted something from her refrigerator. CNA7 stated R8 was aware that she had to get another resident ready for dialysis on 01/05/26 before she could assist her. Other staff usually answered call lights unless they were really busy.During an interview on 01/08/26 at 11:57 AM, the Director of Nursing (DON) reported the expectation that call lights were responded to within 15 minutes, maybe 20 minutes.Review of the facility's procedure titled, Call Lights, revised 04/08/25, revealed, Respond to resident's call lights in a timely manner . If unable to complete the request, inform the resident/family and notify the appropriate discipline. If this is the case, call light must remain on until the request has been completed.

Based on observations, record review, and interviews, the facility failed to protect one out of one resident (Resident (R)2 from misappropriation of property when Licensed Practical Nurse (LPN) 7 took R2 AirPods without R2's permission. Findings include: Review of the admission Record found under the Profile tab of the electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included multiple sclerosis, spastic hemiplegia affecting left dominant side, and type 2 diabetes mellitus. Review of the resident's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/05/25 found under the MDS tab revealed R 2 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. Review of facility's self-reported incident to the state survey agency originally, dated 10/31/25, revealed R2 reported missing AirPods, believed to be left in her room before hospitalization. Facility staff tracked the AirPods via R2's iPhone link. On 11/04/25, the AirPods were found with a LPN7 who was employed at the facility at the time. The AirPods were returned to R2. LPN7 was terminated by the facility after their investigation. During an interview on 01/05/26 at 3:45 PM, R2 revealed her AirPods went missing, and the facility found the nurse that took them, and returned them. During an interview on 01/08/26 at 4:00 PM, the Administrator was informed that since the facility substantiated the allegation of misappropriation by their staff, the facility was responsible for their employees' actions. Review of the facility's policy titled Review of the policy titled Abuse Prevention Program Facility Procedures revealed: Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent . Additionally, misappropriation of a resident's property means obtaining properly of a client by intentionally deceiving the client with a false representation which is known to be false, made with the intent to defraud, and which does defraud he person to whom it is made and/or intentionally using or attempting to use personal identifying information .

Based on observations, record review, interviews, and policy review, the facility failed to ensure treatments to surgical wounds were documented as completed and were did not ensure that wound treatment was completed when the wound nurse was unavailable for two (Resident (R) 1 and R8) of three residents reviewed for non-pressure skin wounds. This failure had the potential to cause confusion over whether treatments were completed and to cause wounds to decline.Findings include:1. Review of R1's admission Record located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] and had diagnoses which included displaced comminuted fracture of the shaft of right femur (broken right thigh bone).Review of R1's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 11/04/25 and located in the MDS table of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. R1 had a surgical wound which required wound care.Review of an Order Audit Report located in the Orders tab of the EMR revealed orders: Wound care for distal end of right hip incision [right knee], and right shin. Cleanse with normal saline, apply collagen sheet and xeroform, cover with ABD [type of dressing] and Kerlix [gauze wrap] daily and PRN, ordered from 12/11/25 to 01/06/26.Review of R1's Care Plan Report located in the Care Plan tab of the EMR revealed a focus area, Risk for Impaired Skin Integrity . Non-pressure wound right shin, Non-pressure wound right knee . revised 12/23/25. Interventions included, Provide skin care per facility guideline and PRN [as needed], dated 05/16/24.Review of R11's Treatment Administration Records (TARs), dated December 2025 and January 2026 and located in the Orders tab of the EMR, revealed the treatment to the right knee and shin was not signed off as completed (remained without documentation) on 12/17/25, 12/22/25, 12/30/25, 12/31/25, 01/01/26, 01/02/26, and 01/06/26.During an interview on 01/07/25 at 9:25 AM, R1 was in bed, covered, and refused interview or wound observation.There was no documentation provided that the treatments were completed on the above dates. 2. Review of R8's admission Record located in the Profile tab of the EMR revealed she was admitted to the facility on [DATE] and had diagnoses including encounter for orthopedic aftercare following surgical amputation and peripheral vascular disease (reduced blood flow to limbs).Review of R8's Care Plan Report located in the Care Plan tab of the EMR revealed a focus area, revised 03/19/25, [Resident] had a [left below the knee amputation] . related to her non-healing wounds . with interventions including: Encourage compliance with treatment regimen.Review of R8's quarterly MDS assessment, with an ARD of 12/16/25 and located in the MDS table of the EMR, revealed a BIMS score of 15 out of 15, which indicated intact cognition. R8 had a surgical wound which required wound care.Review of R8's Order Summary Report located in the Orders tab of the EMR revealed an order dated 12/23/25 for Wound Care for left BKA [below the knee amputation] surgical wound: Cleanse with normal saline; Pack with Dakins soaked gauze then cover . daily and PRN. Another order, dated 11/18/25, indicated Wound Care for right foot surgical site. Wash daily with soap and water . Apply betadine and dry gauze . MWF [Monday, Wednesday, and Friday] and PRN.Review of R8's TARs, dated December 2025 and January 2026 and located in the Orders tab of the EMR, revealed the treatment to the left BKA was not signed off as completed (remained without documentation) on 12/26/25, 12/30/25, 12/31/25, 01/01/26 and 01/03/26. The treatment order for R8's right foot was not signed off as completed (remained without documentation) on 12/17/25, 12/19/25, 12/22/25, 12/26/25, and 12/31/25.During an observation and interview on 01/05/26 at 12:53 PM, R8 reported her wound care was completed every day to her left leg and every other day to her right foot. The treatments were completed as ordered; if missed, it was infrequent. Both dressings were dated, indicating the treatments were completed earlier in the shift.During an interview on 01/06/26 at 1:44 PM, the Wound Treatment Nurse (WCN) 2 reported she did the facility's wound treatments Monday through Friday with other wound care nurses completing treatments on the weekends. If WCN2 was sick or not working, another nurse filled in, or the floor nurses completed their own treatments.During an interview on 01/07/26 at 12:55 PM, Licensed Practical Nurse (LPN) 2 reported she never signed off wound treatments on the TAR because the wound nurses completed them. The facility sent text notifications to the floor nurses if they needed to complete their own wound treatments. LPN2 had not received any text messages regarding wound care in the last month. LPN2 worked on 01/01/26.During an interview on 01/08/26 at 9:52 AM, LPN5 stated the facility texted the floor nurses when they needed to do wound treatments. She worked 01/01/26 but had not received a text to do wound treatments for at least three weeks, to include 01/01/26.During an interview on 01/08/26 at 11:45 AM, WCN2 reported she was sick on 01/01/26 but otherwise did all the facility's wound treatments from Monday through Friday for the last month. When she was sick, the facility sent out a text message for the floor nurses to complete the treatments. WCN2 was unsure who notified the nurses of the need to do treatments on 01/01/26. WCN2 stated she routinely completed all the treatments; however, she was bad with documenting the treatments on the TAR.During an interview on 01/08/26 at 11:57 AM, the Director of Nursing (DON) stated, in general, that wound care was not completed if it was not documented. The DON expected wound care to be documented as completed. If a wound care nurse was unavailable to do treatments, the floor nurses were expected to do the treatments.Review of the facility's policy titled, Documentation Expectations, dated 07/29/25, revealed, It is the policy of this facility that employees will adhere to current standards of practice when documenting on legal documents up to and including resident medical records. Documentation shall be: a. Timely . Document actual events . Documentation is by exception but is expected regarding the following situations: . Treatments.

Based on observations, record review, interviews, and policy review, the facility failed to ensure treatments to pressure injuries were documented when completed and were completed when a wound treatment nurse was unavailable for two (Resident (R) 1 and R14) of four residents reviewed for pressure ulcers. This failure had the potential to cause confusion over whether pressure injury treatments were completed and to cause wounds to decline.Findings include:1. Review of R1's admission Record located in the Profile tab of the electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE] and had diagnoses which included diabetes and peripheral vascular disease.Review of R1's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 11/04/25 and located in the MDS table of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. R1 had a stage three pressure injury which received pressure injury treatment.Review of an Order Audit Report located in the Orders tab of the EMR revealed orders: Wound care for left 2nd toe: Cleanse with normal saline, apply Silver Sulfadiazine 1% and calcium alginate . Daily and PRN [as needed] from 12/11/25 to 01/07/26.Review of R1's Care Plan Report located in the Care Plan tab of the EMR revealed a focus area, Risk for Impaired Skin Integrity . Stage 3 PU [pressure ulcer] left 2nd toe . revised 12/23/25. Interventions included, Provide skin care per facility guideline and PRN [as needed], dated 05/16/24.Review of R11's Treatment Administration Records (TARs), dated December 2025 and January 2026 and located in the Orders tab of the EMR, revealed the treatment to the left second toe was not signed off as completed (remained without documentation) on 12/17/25, 12/22/25, 12/30/25, 12/31/25, 01/01/26, and 01/02/26.During an interview on 01/05/26 at 2:05 PM, the Wound Care Doctor (MD) 1 stated that he had not yet made wound rounds on R1 for that day's visit. R1 tends to hit her legs and feet and cause micro trauma. She doesn't even realize she's hitting stuff. [R1's] toe wound had reopened, but it sounds like it may be healed now.During an interview on 01/07/25 at 9:25 AM, R1 was in bed, covered, and refused interview or wound observation.There was no documentation provided that the treatments were completed on the above dates. 2. Review of R14's admission Record located in the Profile tab of the EMR revealed he was admitted to the facility on [DATE] and was re-admitted on [DATE] following a hospital stay which began on 12/26/25. R14 had diagnoses which included osteomyelitis and diabetes.Review of R14's admission MDS assessment, with an ARD of 11/26/25 and located in the MDS table of the EMR, revealed R14 was severely impaired according to the Staff Assessment for Mental Status. R14 was admitted to the facility with a stage two pressure ulcer which received treatment.Review of R14's Order Summary Report located in the Orders tab of the EMR revealed an order dated 12/10/25 for Wound Care for pressure injury to sacrum: Cleanse with normal saline; Apply Silver sulfadiazine 1% and calcium alginate . daily and PRN.Review of R14's Care Plan Report located in the Care Plan tab of the EMR revealed a focus area, revised 12/16/25, The resident has unstageable to sacrum. An intervention, dated 12/03/25, was to Administer treatments as ordered and monitor for effectiveness.Review of R14's TARs, dated December 2025 and January 2026 and located in the Orders tab of the EMR, revealed the treatment to the sacrum was not signed off as completed (remained without documentation) on 12/17/25, 12/18/25, 12/22/25, 12/30/25, 12/31/25, 01/01/26 and 01/02/26.During an observation and interview on 01/05/26 at 2:05 PM, the MD1 assessed and treated R14's sacral wound. MD1 reported the wound had improved from the last weekly visit.During an interview on 01/06/26 at 1:44 PM, the Wound Treatment Nurse (WCN) 2 reported she did the facility's wound treatments Monday through Friday with other wound care nurses completing treatments on the weekends. If WCN2 was sick or not working, another nurse filled in, or the floor nurses completed their own treatments.During an interview on 01/07/26 at 12:55 PM, Licensed Practical Nurse (LPN) 2 reported she never signed off wound treatments on the TAR because the wound nurses completed them. The facility sent text notifications to the floor nurses if they needed to complete their own wound treatments. LPN2 had not received any text messages regarding wound care in the last month. LPN2 worked on 01/01/26.During an interview on 01/08/26 at 9:52 AM, LPN5 stated the facility texted the floor nurses when they needed to do wound treatments. She worked 01/01/26 but had not received a text to do wound treatments for at least three weeks, to include 01/01/26.During an interview on 01/08/26 at 11:45 AM, WCN2 reported she was sick on 01/01/26 but otherwise did all the facility's wound treatments from Monday through Friday for the last month. When she was sick, the facility sent out a text message for the floor nurses to complete the treatments. WCN2 was unsure who notified the nurses of the need to do treatments on 01/01/26. WCN2 stated she routinely completed all the treatments; however, she was bad at documenting the treatments on the TAR.During an interview on 01/08/26 at 11:57 AM, the Director of Nursing (DON) stated, in general, that wound care was not completed if it was not documented. The DON expected wound care to be documented as completed. If a wound care nurse was unavailable to do treatments, the floor nurses were expected to do the treatments.Review of the facility's policy titled, Wound Management - Wound Prevention and Treatment, revised 10/11/24, revealed, The facility will ensure that based on the comprehensive assessment of a resident: . A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, . Interventions will be implemented in the resident's care plan to prevent deterioration and promote the pressure ulcer's healing.Review of the facility's policy titled, Documentation Expectations, dated 07/29/25, revealed, It is the policy of this facility that employees will adhere to current standards of practice when documenting on legal documents up to and including resident medical records. Documentation shall be: a. Timely . Document actual events . Documentation is by exception but is expected regarding the following situations: . Treatments.

Based on observations, record review, interviews, and policy review, the facility failed to report changes in eating and supplement consumption and failed to monitor weights and intakes to ensure interventions were in place for three (Residents (R) 1, R12, and R13) out of five residents reviewed for weight loss. This failure had the potential to result in continued weight loss.Findings include:1. Review of R1's admission Record located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] and had diagnoses which included diabetes, dysphagia (difficulty swallowing), and moderate protein-calorie malnutrition.Review of R1's Order Summary Report, located in the Orders tab of the EMR, revealed an order for weekly weights four times, and then monthly weights, dated 11/21/24.Review of R1's Care Plan Report located in the Care Plan tab of the EMR revealed a focus area, revised on 09/03/25, Resident with alternation in nutritional status . Interventions included: Resident to be weighed per facility protocol.Review of the Weight Summary, located in the Wts/Vitals tab of the EMR, revealed R1 had an 11.7 percent (%) weight loss from 09/26/25 (160.5 pounds (lbs)) to 10/13/25 (141.8 lbs). No additional weights were documented until 01/02/26, when R1 lost an additional 10.5 lbs and weighed 131.3 pounds.Review of a Nutrition/Dietary Note, dated 10/14/25 and located in the Progress Notes tab of the EMR, revealed, Significant wt [weight] change follow up: Resident triggered for wt loss of -5.0% change [Comparison Weight 9/26/25, 160.5 lbs [pounds], -11/7%, -18.7 lbs] from prior wt, which had shown a gain of 6% [+9 lbs] in August. Wt loss remains unplanned and unfavorable given the magnitude and timeframe . Reweight requested to confirm accuracy and assess for ongoing wt change.Review of R1's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 11/04/25 and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. R1 was documented as having no, or unknown, weight loss.Review of a Nutrition/Dietary Note, dated 01/05/26 and located in the Progress Notes tab of the EMR, revealed, Resident triggering for wt loss of -10.0% change over 180 day[s] . Etiology of wt loss continues to be multifactorial . Per notes resident continues to state she feels good about herself/her health. Wt loss unplanned/unfavorable given the continuation of loss . Monitor weights per facility protocol . Review of the EMR's Progress Notes tab, Wts/Vitals tab, and Medication Administration Records (MARs) under the Orders tab revealed no documentation that R1 refused weights.During an observation on 01/07/25 at 9:25 AM, R1 was in bed, without a breakfast tray and refused interview.During an interview on 01/07/26 at 2:33 PM, the Registered Dietician (RD) stated that R1 would deem her weight loss as planned and favorable. The RD had reviewed R1's food preferences in detail with R1 and documented them and put interventions in place to prevent further weight loss.2. Review of R12's admission Record located in the Profile tab of the EMR revealed she was admitted to the facility on [DATE] and had diagnoses which included diabetes, morbid (severe) obesity, congestive heart failure (CHF) and glaucoma.Review of R12's Order Summary Report, located in the Orders tab of the EMR, revealed two orders for weekly weights. Weight monitoring for CHF. Notify for weight gain 5 lbs. in one week. One time a day every Tuesday was ordered 11/10/23 and Daily weight before breakfast in the morning every Sunday was ordered 01/07/25.Review of R12's Care Plan Report located in the Care Plan tab of the EMR revealed a focus area, revised on 09/22/25, Resident is at nutritional risk . Hx [history] of wt changes. Interventions included: Monitor and record PO [oral] intake of food . Resident will be weighed as ordered by my physician . R12 had an intervention, Eating: Independent with set-up assist for meals, revised on 02/13/25 under her ADL focus area.Review of the Weight Summary, located in the Wts/Vitals tab of the EMR, revealed R12 had a 8.7 percent weight loss from 10/03/25 (206.8 lbs) to 10/26/25 (188.9 lbs). No further weights were documented.Review of a Nutrition/Dietary Note, dated 10/27/25 and located in the Progress Notes tab of the EMR, revealed, Significant wt change . Resident triggered for wt loss of -5.0% change over 30 day[s] [Comparison Weight 9/24/2025, 212 Lbs, -10/8%, -23 Lbs] . Wt loss if accurate is unplanned/unfavorable given the amount in the period of time . Recommend continuing to monitor intakes, wts . Monitor weights per facility protocol.Review of R12's annual MDS assessment, with an ARD of 12/08/25 and located in the MDS tab of the EMR, revealed a BIMS score of 12 out of 15, which indicated moderately impaired cognition. R12 had no current weight and was documented as having no, or unknown, weight loss.Review of the EMR's Progress Notes, Wts/Vitals, and Tasks tabs, as well as the MARs under the Orders tab, revealed no documentation that R12 refused weights or that meal intakes were recorded.During an observation on 01/06/26 from 8:35 AM to 9:10 AM, R12 sat up in bed in her room with a breakfast tray in front of her with her eyes closed.During an observation and interview on 01/06/26 at 9:10 AM, R12 sat up in bed in her room with her breakfast tray in front of her containing two slices of toast, one slice mostly eaten, and two uneaten hard-boiled eggs. R12 reported she did not need assistance eating but could barely see her tray. R12 reported she had lost a lot of weight and did not always like the food. She reported the facility gave her a supplemental drink and weighed her with the Hoyer (mechanical) lift.During an observation on 01/07/26 at 9:05 AM, R12 was asleep in bed with her breakfast tray untouched in front of her.During an observation and interview on 01/07/26 at 9:27 AM, R12 awoke to a knock on the door and her name called out. R12 stated her appetite had not been good and reported she had not eaten anything. Two hard-boiled eggs, one piece of toast, and a bowl of bran cereal with raisins were on her tray.During an interview on 01/07/25 at 12:55 PM, Licensed Practical Nurse (LPN) 2 reported R12 had ups and downs with eating and depression. LPN2 stated there was no excuse why R12's weight had not been done.During an interview on 01/07/26 at 2:33 PM, the RD reported she needed to look at her notes regarding R12's weight loss and lack of weights. The RD did not return with additional information.During an interview on 01/07/26 at 4:12 PM, the Assistant Director of Nursing (ADON) stated nursing had just obtained R12's weight. R12 weighed 192.3 pounds, which was an increase of three pounds from her previous weight on 10/26/25.3. Review of R13's admission Record located in the Profile tab of the EMR revealed he was admitted to the facility on [DATE] and had diagnoses which included protein-calorie malnutrition and dysphagia.Review of the Weight Summary, located in the Wts/Vitals tab of the EMR, revealed R13 had a 6.0% percent weight loss from 09/26/25 (161.0 lbs) to 10/14/25 (151.4 lbs). No further weights were documented.Review of R13's Order Summary Report, located in the Orders tab of the EMR, revealed an order, dated 10/14/25, for a general diet with mechanical soft texture and nectar thick liquids per speech language pathologist recommendations based on a swallow study. An order for weekly weights four times followed by monthly weights was ordered on 09/08/25.Review of a Nutrition/Dietary Note, dated 10/17/25 and located in the Progress Notes tab of the EMR, revealed, Significant wt [weight] change . Resident is triggering for significant wt loss of -5.0% change [Comparison Weight 9/26/2025, 161.0 Lbs, -6.0%, -9.6 Lbs] . Nursing noted resident is able to feed self but assistance is provided as needed. Supplementation was recently increased to aid in possible wt loss . This is unplanned/unfavorable loss at this time . Recommend increasing Med Pass to TID [three times a day] . Monitor PO [oral] intake: goal 50% of meals . Monitor weights per facility protocol.Review of R13's Care Plan Report located in the Care Plan tab of the EMR revealed a focus area, revised on 10/17/25 that Resident remains at risk for malnutrition . [history] of significant wt change, possible loss. Interventions included: Weigh per facility protocol and Monitor intake and record q [every] meal.Review of an Order Audit Report, located in the Orders tab of the EMR, revealed an order for Med Pass 2.0 calorie [supplemental drink] three times a day . to aid in wt stability, from 10/17/25 to 12/02/25.Review of an Order Audit Report, located in the Orders tab of the EMR, revealed that Proheal (supplemental drink) was ordered twice daily on 12/02/25 to replace Med Pass which was on backorder.Review of R13's annual MDS assessment, with an ARD of 12/16/25 and located in the MDS tab of the EMR, revealed a BIMS score of 15 out of 15, which indicated he was cognitively intact. R13 ate with supervision, had no current weight entered, and was documented as having no, or unknown, weight loss.Review of R13's Medication Administration Record (MAR), dated December 2025 and located under the Orders tab of the EMR, revealed R13 did not consume his Proheal supplement 40 times out of 59 offerings.Review of R13's MAR, dated January 2026 and located under the Orders tab of the EMR, revealed R13 did not consume his Proheal supplement nine times out of 14 offerings.Review of the EMR's Progress Notes, Wts/Vitals, and Tasks tabs, as well as the MARs under the Orders tab, revealed no documentation that R13 refused weights or that meal intakes were recorded. In addition, there was no documentation that the RD or physician were notified of him refusing the Proheal.During an observation and interview on 01/06/26 at 9:24 AM, R13 was in bed with the head of the bed elevated and breakfast tray in front of him containing a covered plate and two full cups of thickened liquids. R13 reported he was unable to see his food because he was legally blind. R13 reached for the tray and stated he was unable to see to remove the lid. When assisted with the lid, the plate contained scrambled eggs and a biscuit and gravy, none of which was eaten. R13 reported he had lost a lot of weight due to no appetite, food not tasting good, and his inability to see. R13 reported he used to weight 165 pounds and up to 175 pounds. R13 reported he had not been weighed and had not refused to be weighed. He stated he was interested to know what he weighed.During observations on 01/07/26 at 9:40 AM, 9:50 AM, 10:00 AM, and 10:14 AM, R13 was in bed with his breakfast tray on the tray table in front of him. R13 was observed not eating, not touching his meal.During an observation and interview on 01/07/26 at 10:20 AM, Dietary Aide (DA) 1 was observed removing breakfast trays from residents' rooms. DA1 reported she did not do anything if a resident had not eaten their meal or had eaten very little, but she would let the nurse know if the nurse asked.During an observation and interview on 01/07/26 at 10:25 AM, DA2 was removing breakfast trays from residents' rooms. DA2 stated he did not record any intakes; he let an aide (Certified Nursing Assistant) know when there were concerns with intakes. DA2 confirmed R13 did not eat anything and stated that R13 told him he was not hungry. DA2 said that R13 not eating or eating very little was normal recently. DA2 had not told anyone because the nursing staff were aware.During an interview on 01/07/26 at 1:14 PM, CNA5 reported R13 was able to feed himself once sat up in bed. CNA5 reported she told the nurse a couple of weeks back that he was not touching his food. He usually liked breakfast but was not eating it. R13 received supplements, and CNA tried to coax him to eat. His weight was obtained using the Hoyer lift each month.During an interview on 01/07/26 at 2:33 PM, the RD said she would have to look up whether she was aware of R13 not eating well or not consuming his supplement. The RD did not return with any information regarding R13.During an interview on 01/07/26 at 2:40 PM, the RD reported she sent emails requesting missed or questionable weights needing re-done to nursing at least weekly. Some residents refused, and staff relayed verbal refusals, which the RD tried to document. The RD stated weights were based on facility protocol, and that nursing could clarify the protocol. When asked how she approached interventions for weight changes without having current weights or recorded intakes, the RD responded, That's a good question.During an interview on 01/07/26 at 3:40 PM, Licensed Practical Nurse (LPN) 3 stated R13 was very particular with his food and refused weights. LPN3 was unsure if the refusals were recorded and stated she needed to check with the Assistant Director of Nursing (ADON). Nurse management usually recorded the monthly weights. R13 was upset with his mechanical soft diet.During an interview on 01/07/26 at 4:12 PM, the ADON stated nursing had just tried to weigh R13, and he refused. Weights were to be done on admission and then according to physician orders. The facility had a standing order for four weekly weights and then monthly weights, but that could be changed by the physician. The orders showed up on the MAR for nurses to document. Nurses were to document in the EMR if residents refused to be weighed and then reattempt. The ADON confirmed there was no prior documentation that R1, R12, or R13 had refused weights. The ADON stated intakes were not documented routinely, but a nurse may put a note in. R13 did not see well and had refused eye surgery. The CNAs should help if he was unable to see or do something.During an interview on 01/08/26 at 11:57 AM, the Director of Nursing (DON) reported she expected nursing to weigh residents according to the physician's orders and document any refusals. The DON was new to the facility and was uncertain about the facility's documentation of meal intakes.Review of the facility's policy titled, Nutrition/Hydration Status Maintenance, revised 10/17/25, revealed, . the facility will ensure that each resident: . Is provided assistance with eating and drinking as needed to support adequate intake and maintain dignity and independence. Is monitored routinely for changes in nutritional and hydration status, which interventions revised as needed based on data such as weights, intake records, . Residents will be weighed per facility protocol and as clinically indicated. Weight variances exceeding [more/less] than 5% in 3- days will prompt evaluation and documentation of potential causes and interventions.Review of the facility's policy titled, Weight Management, dated 03/01/21, revealed, . All residents will be weighed every month unless otherwise ordered by the physician or deemed necessary by the dietician or the interdisciplinary team . 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.

Based on record review, interviews, and policy review, the facility failed to ensure a resident was transported to dialysis for one (Resident (R) 8) of one resident reviewed for dialysis services. This failure caused the resident to miss a dialysis session and had the potential to result in the resident having fluid overload and abnormal lab results.Findings include:Review of R8's admission Record located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] and had diagnoses including end stage renal disease and dependence on renal dialysis. Review of an Order Audit Report, dated 11/16/24 and located in the Orders tab of the EMR, revealed an order, Hemodialysis for Chronic Renal Failure Frequency: Mon-Wed-Fri [Monday-Wednesday-Friday] every day shift . Resident taken to dialysis . If dialysis is missed for any reason for one day, BMP [basic metabolic panel- monitors kidney function] lab to be drawn for the following day and reported to MD [physician] . Review of R8's Care Plan Report located in the Care Plan tab of the EMR revealed a focus area, revised on 05/14/25, The resident needs dialysis . with interventions including, Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis 3x [three times] a week as scheduled.Review of R8's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/16/25 and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. R8 received dialysis.Review of a Health Status Note, dated 01/05/26 at 11:15 AM, located in the Progress Notes tab of the EMR, revealed that Licensed Practical Nurse (LPN) 1 documented, Resident missed dialysis today due to 3rd shift staffing. Resident has dialysis at 0500 [5:00 AM] and per Diaysis [sic] nurse all chairs completely booked for the day. MD aware, DON [Director of Nursing] aware. Stat [immediate] BMP [lab] ordered.During an interview on 01/05/26 at 12:53 PM, R8 was in bed in her room. R8 reported she was supposed to go to dialysis at 5:00 AM that morning instead of her normal 9:00 AM time because she had an appointment scheduled in the afternoon. The on-site dialysis center was full, so residents needed to be switched around to accommodate the earlier time. The Certified Nursing Assistant (CNA) started getting her ready for dialysis and put her on the bed pan, but then she left the room and did not return. When the day shift staff arrived, they assisted her, but dialysis was unable to accommodate her at the later time, and she was concerned about missing the afternoon appointment.During an interview on 01/07/26 at 12:12 PM, CNA7 stated, Whoever worked the night shift was not on their 'A' game. They got her on the bedpan and didn't come back. I got her calmed down and tried to see if we could get her in a spot later. LPN1 assisted R8 prior to CNA7 arriving. During an interview on 01/07/26 at 3:51 PM, LPN1 reported that R8 was supposed to go to dialysis at 5:00 AM, on the shift before LPN1's shift. When LPN1 arrived, night shift reported they were unable to find a dialysis chair for R8, and she missed her dialysis slot. When LPN1 messaged dialysis, they had no availability for R8's dialysis. LPN1 notified the doctor and ensured labs were ordered and the resident was monitored.During an interview on 01/08/26 at 11:57 AM, the Director of Nursing (DON) stated that a night shift CNA had called her on 01/05/26 about not being able to locate a dialysis chair to take R8 to dialysis in. The DON instructed the CNA to search the facility, the dialysis area, and the room, and to get R8 to dialysis. Review of the facility's policy titled, Dialysis Policy, revised 05/01/25, revealed, The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.

Based on observation, interview, and record review, the facility did not ensure residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 2 (R5 and R97) of 5 residents reviewed with pressure injuries. *R5 had a history of pressure injuries and was readmitted to the facility on [DATE]. R5’s skin was not comprehensively assessed by a Registered Nurse (RN) upon readmission. On 9/6/2024, R5 was assessed by the Wound Physician and discovered to have a Stage 3 pressure injury to the right buttock, a Stage 3 pressure injury to the left buttock, and a Stage 3 pressure injury to the coccyx and treatments were initiated to the pressure injuries at that time. Surveyor observed R5 repositioning independently in bed and potentially causing shearing to the skin; R5’s Skin Integrity Care Plan had the intervention to use a draw sheet or lifting device to move R5. *R97 was readmitted to the facility after hospitalization with a Stage 3 pressure injury to the right fifth toe, no treatment was ordered for five days, and no treatment was completed to the pressure injury until one week later. Findings include: The facility policy and procedure titled “Wound Management – Wound Prevention and Treatment” dated 10/11/2024 documents: “PROVISION AND PROCEDURE: … 2. Upon admission, the resident will receive a head-to-toe skin check to identify any skin issues. An RN will assess any noted pressure injuries and complete an initial comprehensive assessment. … 5. Daily, during routine care, the Certified Nursing Assistant (CNA) will observe the resident’s skin. When abnormalities are noted, this will be communicated to the licensed nurse, and the licensed nurse will evaluate and implement a skin event if applicable. An RN will assess any noted pressure injuries and complete an initial comprehensive assessment.” 1.) R5 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, diabetes, morbid obesity, chronic respiratory failure, below the knee amputation of the right leg, above the knee amputation of the left leg, and peripheral vascular disease. R5’s Annual Minimum Data Set (MDS) assessment dated [DATE] documented R5 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. R5’s Skin Integrity Care Plan was initiated on 10/19/2022 on admission. The following interventions were in place on 10/30/2023:-Encourage and assist to reposition every 2-3hrs and upon request.-Use a draw sheet or lifting device to move resident.-Bilateral grab bars to aid with independence and bed mobility. R5 had a history of skin impairment to multiple areas with previous pressure injuries and non-pressure injuries to R5's left and right buttocks and the sacrum or coccyx. R5's Skin Impairment/Wound Evaluation form dated 8/16/2024 documented that R5 had moisture associated skin damage (MASD) to the right thigh and left buttock. R5's progress note dated 8/23/2024 at 12:07 PM documented that R5 had a critical lab that was called in that morning and the Nurse Practitioner (NP) was notified of the lab result. The NP gave an order to send R5 to the hospital for evaluation. At 6:56 PM in the progress notes, nursing documented R5 was admitted to the hospital for cellulitis. On 8/29/2024 on the hospital discharge record, the physician documented R5 had a diagnosis of cellulitis to the pannus (tissue and fat that hangs down from the abdomen). No other skin alterations or wounds were documented. R5 was readmitted to the facility on [DATE]. R5’s hospital record did not document any wounds to the skin. R5's Readmissions Data Collection Tool dated 8/29/2024 and written by Licensed Practical Nurse (LPN)-V documented on the Skin Section of the form R5 had redness to the coccyx, the left buttock, and the right buttock. The areas were not measured, and no characteristics of the areas were documented, such as if the redness was blanchable or had any raised or open areas. No documentation was found of an RN assessing R5’s skin. On 9/6/2024, R5 was seen by the Wound Physician on scheduled weekly rounds. R5 had last seen the Wound Physician on 8/16/2024 prior to R5’s hospitalization. On 9/6/2024 on the Skin Impairment/Wound Evaluation form, nursing documented R5 had a Stage 3 pressure injury to the right buttock that measured 1.6 cm x 1 cm x 0.1 cm with 50% granulation tissue and 50% slough, a Stage 3 pressure injury to the left buttock that measured 1.7 cm x 0.8 cm x 0.1 cm with 100% granulation tissue, and a Stage 3 pressure injury to the coccyx that measured 2.63 cm x 0.9 cm x 0.1 cm with 100% granulation tissue. All three pressure injuries were surgically debrided by the Wound Physician and a treatment of Medihoney was initiated at that time. Surveyor noted no treatments, such as barrier cream, was in place prior to the discovery of the pressure injuries. No documentation was found of the pressure injuries being discovered prior to R5 being assessed by the Wound Physician on scheduled rounds or any notification of any skin impairment. R5’s Skin Integrity Care Plan had been revised on 9/10/2024 with documentation R5’s Stage 3 pressure injuries to the right buttock the left buttock and the coccyx were present on readmission on [DATE]. Surveyor noted R5 was readmitted to the facility on [DATE] and no comprehensive assessment had been completed or documented prior to 9/6/2024 when R5 was seen by the Wound Physician. R5’s left buttock Stage 3 pressure injury healed on 9/13/2024 and reopened on 11/6/2024. On 8/20/2025 on the Skin Impairment/Wound Evaluation form, R5’s left buttock Stage 3 pressure injury measured 2.5 cm x 1.2 cm x 0.1 cm with 40% epithelial tissue and 60% granulation tissue. R5’s right buttock Stage 3 pressure injury healed on 10/30/2024, reopened on 11/13/2024, healed on 1/22/2025, reopened on 4/30/2025 after readmission from the hospital, healed on 6/4/2025, reopened on 6/11/2025, healed on 6/25/2025, and reopened on 7/23/2025. On 8/20/2025 on the Skin Impairment/Wound Evaluation form, R5’s right buttock Stage 3 pressure injury measured 1.5 cm x 1 cm x 0.1 cm with 100% granulation tissue. R5’s coccyx Stage 3 pressure injury healed on 10/2/2024. On 8/24/2025 at 1:04 PM, Surveyor observed R5 lying in bed on R5’s back with the head of the bed elevated at approximately 30 degrees. R5 had a pillow under the head. No other pillows or positioning devices were observed in R5’s bed or room. Surveyor asked R5 if R5 had concerns with open areas to the skin. R5 stated R5 had a pressure injury to the backside for about one year and it was tiny but just would not close up. In an interview on 8/25/2025 at 3:28 PM, Surveyor asked Wound Nurse (WN)-F if WN-F was familiar with R5. WN-F stated yes. Surveyor shared with WN-F the concern R5 was not assessed by an RN when readmitted on [DATE] and on 9/6/2024, when R5 was seen by the Wound Physician, R5 had developed three Stage 3 pressure injuries, and no treatments were in place prior to 9/6/2024 to prevent any skin breakdown. WN-F stated WN-F would see if WN-F could find any information to fill in the gaps with the assessments and treatments. On 8/26/2025 at 9:31 AM, Surveyor observed LPN-AA complete wound care to R5. R5 was lying in bed on the back with the head of the bed elevated approximately 30 degrees. R5 had a pillow under the head. No other pillows or positioning devices were observed in R5’s bed or room. LPN-AA asked R5 to roll to the left side which R5 was able to do independently by using the enabler bar on the side of the bed. R5 had a wound to the coccyx that measured approximately 2 cm x 2 cm x 0.1 cm with clean pink tissue to the wound bed. Surveyor noted documentation was of a wound to the right buttock and not the coccyx. R5 had a wound to the left buttock adjacent to the coccyx wound that measured approximately 2 cm x 2 cm x 0.1 cm with active bleeding and a pink wound base. A smaller area below the left buttock wound, appearing like a puncture wound, had serosanguineous fluid leaking out of the wound. The wound measured less than 0.5 cm x 0.5 cm, and the wound bed was not visible. R5 had excoriation to the lower right and left buttock that appeared to have barrier cream remnants still in place. A single dressing was placed over all three open areas after collagen was applied. After LPN-AA had completed the dressing change, R5 independently rolled back onto the back, lowered the head of the bed with the feet elevated, and grabbed onto the headboard with both hands and pulled so R5 was positioned at the top of the bed. R5 did not ask for assistance and no draw sheet was observed to be in place on the air mattress. Surveyor noted additional shearing may have occurred due to no assistance with positioning. In an interview on 8/26/2025 at 12:57 PM, Surveyor asked Director of Nursing (DON)-B what the facility protocol for assessing skin was when either a new admission comes to the facility or when a resident is readmitted to the facility. DON-B stated the nurse that is assigned to the unit does the initial skin assessment, but within 24 hours WN-F does a skin sweep as well. DON-B stated newly admitted and readmitted residents should have a skin assessment done. Surveyor shared with DON-B the concern an LPN assessed R5 on readmission documenting redness to the right buttock, left buttock, and coccyx and did not have a comprehensive skin assessment until 9/6/2024 when the Wound Physician found R5 to have three Stage 3 pressure injuries. On 8/27/2025 at 8:27 AM, Surveyor observed R5 to be lying on the back with the head of the bed elevated approximately 30 degrees with a pillow under the head. No other pillows or positioning devices were observed in R5’s bed or room. Surveyor asked R5 if staff ever put pillows behind R5’s back or hip to keep pressure off R5’s bottom or encouraged or assisted R5 to move onto the side. R5 stated no. R5 stated no one had ever offered pillows and would not have said no if they had asked. In an interview on 8/27/2025 at 8:33 AM, Surveyor asked CNA-L if R5 needed assistance with bed mobility or positioning and if R5 needed to be turned, how often would that be done. CNA-L stated CNA-L did not know because this was the first time CNA-L had worked with R5. Surveyor asked CNA-L where CNA-L would look to see how much assistance R5 needed. CNA-L stated CNA-L would ask the nurse. CNA-L talked to LPN-Q and CNA-L told Surveyor R5 should get turned every two hours with staff assistance. In an interview on 8/27/2025 at 8:36 AM, Surveyor asked CNA-BB if CNA-BB was familiar with R5. CNA-BB stated CNA-BB has worked with R5. Surveyor asked CNA-BB how much assistance R5 needed to turn in bed. CNA-BB stated R5 is able to turn independently in bed so does not need any help turning. CNA-BB stated R5 grabs onto the side bar and can put the leg over independently. On 8/27/2025 at 11:23 AM, Surveyor met with Director of Quality Assurance (DirQA)-CC and WN-F to discuss the concerns Surveyor had shared with WN-F and DON-B regarding R5’s readmission skin assessment and discovery of the three Stage 3 pressure injuries. DirQA-CC stated WN-F was not the wound care nurse in August 2024, so DirQA-CC was trying to help WN-F figure out what happened at that time. Surveyor shared with DirQA-CC and WN-F R5’s Skin Integrity Care Plan documented R5 came back to the facility with the Stage 3 pressure injuries on 9/2/2024 even though R5 returned on 8/29/2024. DirQA-CC stated DirQA-CC saw the documentation of the redness to the right buttock, the left buttock, and the coccyx and it was not known if the redness was blanchable or not. DirQA-CC stated DirQA-CC would have liked to see more description of the area but stated barrier cream had been ordered at that time and that would have been appropriate for redness. Surveyor noted R5 did not have any orders for barrier cream at the time of readmission. DirQA-CC provided an Unavoidable Pressure Injury Tool form completed by the physician on 11/6/2024 showing comorbidities that were causing the wound to reopen. DirQA-CC stated with modalities in place, the wound should have healed so they met with the physician to discuss what was going on with R5. Surveyor shared the concern that if R5 did have redness on readmission, the Stage 3 pressure injuries would have developed prior to the Wound Physician assessing them on 9/6/2024 and there is no documentation showing anyone reporting open areas or assessing them when found. Surveyor shared with DirQA-CC and WN-F the conversations with CNA-L and CNA-BB about repositioning; CNA-L was not aware R5 needed repositioning and CNA-BB stated R5 repositions independently. Surveyor shared the observation of no pillows or positioning devices in R5’s room and the conversation with R5 of never being positioned on the side. WN-F stated WN-F had seen pillows under R5 at times and knows R5 needs more assistance when ill and then is much more independent with bed mobility when feeling better. Surveyor shared the observation of R5 repositioning independently to boost up in bed and the concern excessive shearing was possible with no assistance of a lift sheet. No additional information was provided. 2.) R97 was readmitted to the facility on [DATE] with diagnoses of paraplegia and a pressure injury. R97 is alert and able to make his needs known.The wound assessment upon readmission on [DATE] documents, Stage 3 pressure injury of right 5th toe measuring 1.5 cm by 0.5 cm by 0.2 cm with 80% granulation and 20% slough. The physician orders do not reflect any treatment orders for the right 5th toe pressure injury. On 6/30/25, the physician orders document, wound care for right 5th toe: cleanse with normal saline, apply medihoney and calcium alginate with silver f/b (followed by) foam border dressing. Daily and PRN (as needed). The TAR (treatment administration record) for June 2025 documents wound care for right 5th toe: cleanse with normal saline, apply medihoney and calcium alginate with silver f/b (followed by) foam border dressing. Daily and PRN (as needed). The TAR has this order under the PRN orders and no daily scheduled treatment orders is documented. The June 2025 TAR indicates no treatment for the right 5th toe is completed. R97’s impaired skin integrity care plan dated 5/6/25 documents provide pressure relieving device (s): APM (alternating pressure mattress); offloading heels boots, turn and position as necessary, follow facility protocols for treatment of injury. The medical record indicates on 7/2/25 Wound MD assessed the right 5th toe pressure injury and debrided the wound and now the area measures 1 cm by 1.3 cm by 0.3 cm with 60% granulation and 30% necrotic tissue and 10% tendon. The treatment for the wound remained the same. The TAR reflects the daily treatment order on 7/2/25. The 8/21/25 wound evaluation documents the right 5th toe pressure injury measures 0.8 cm by 1 cm by 0.1 cm with 100% granulation. The treatment is cleanse with normal saline, apply methylene blue foam f/b gauze border dressing; 3x/week and PRN every day shift every Mon, Wed, Fri AND as needed. On 8/27/25 at 8:34 a.m. Surveyor observed R97's treatment to the right 5th toe. Wound Nurse-F performed the treatment. No concerns were noticed with the treatment. On 8/27/25 at 8:46 a.m. Surveyor interviewed Wound Nurse-F. Surveyor asked Wound Nurse-F who is responsible for putting in treatment orders when a resident is admitted or readmitted to the facility. Wound Nurse-F stated either she or another wound nurse will do it. Wound Nurse-F stated if they are not around then the admitting nurse will do it. Surveyor explained the concern R97 was readmitted to the facility on [DATE] with the right 5th toe pressure injury and there wasn’t an order until 6/30/25 but in the TAR it was documented as PRN and it looks like a treatment wasn’t completed until 7/2/25. Wound Nurse-F stated she would look into it. On 8/27/25 at 11:41 a.m. Surveyor interviewed Wound Nurse-F again. Wound Nurse-F stated she placed the treatment order on 6/30/25. Surveyor explained no treatment was documented as being completed until 7/2/25. Wound Nurse-F stated she understood the concern and the treatment order should have been ordered and placed in the TAR on 6/27/25 and treatment should have been completed.

Based upon interview and record review, the facility did not ensure the mandatory staffing data, submitted for the second quarter of 2025 (January 1- March 31) was accurate, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (Centers for Medicare and Medicaid Services). During review of the payroll-based-journal (PBJ) staffing data for the facility, the facility was triggered for excessively low weekend staffing. This had the potential to affect all 102 residents.Findings include:On 8/25/25 The facility's assessment was reviewed, including staffing hours and acuity levels of care being provided. The facility's assessment documented staffing needs in the facility. The facility's schedules were reviewed for the quarter of 1/1/25 to 3/31/25. No low weekend staffing was identified and call ins were replaced in most cases. On 8/25/2025, at 1:37 PM, Surveyor interviewed Director of Recruitment (DOR)-Z via phone. DOR-Z submits the PBJ staffing reports to CMS for the facility. DOR-Z stated all he does is put in the staffing data, DOR-Z stated that he does not get any alerts for low staffing and has not seen any indications of low staffing at the facility. On 8/25/25, at 2:16 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding any low weekend staffing. NHA-A indicated she was not aware of having low staffing on the weekends.No additional information was provided as to why the facility did not ensure that mandatory staffing data, submitted for the second quarter of 2025 (January 1- March 31) was accurate, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.

Based on record review and interview, the facility did not ensure resident's that were transferred to the hospital received the required notice information. This was observed with 5 (R65, R13, R10, R4 and R58) of 6 residents reviewed that were transferred out of the facility. * R65, R13, R10, R4 and R58, did not receive written notice at the time of transfer that included: A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and [NAME] of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. The facility did not provide a facility policy and procedure related to transfer notice requirements. Findings include: 1.) On 8/24/2025, at 10:37 AM, Surveyor interviewed R65 in their room. R65 stated they could not recall details of why they went out to the hospital and thought maybe there was an infection. R65 has returned to the same room. R65's medical record was reviewed. R65 is their own person and is in the facility for wound care. R65 was transferred to the hospital on 8/2/25 for a change in condition and returned on 8/7/25. R65 was transferred to the hospital on 7/22/25 for a change in condition and returned 7/29/25. R65's medical record did not contain documentation of the required notice information for the 2 hospital transfers. On 8/25/2025, at 11:20 AM, Surveyor requested R65's transfer notice information from Nursing Home Administrator (NHA) –A. NHA-A stated the process is the Social Worker completes the bed-hold, and the floor nurse provides the transfer notice. On 8/26/202, at 9:12 AM, NHA-A spoke with Surveyor. NHA-A did not provide written transfer notices for R65's transfers from the facility. The facility does not have a policy and procedure for transfer notice requirements 2.) R13 is their own person and did not want to be interviewed. R13's medical record was reviewed. R13 was transferred to the hospital on 6/19/25 for a change in condition and returned on 6/23/25. R13 was transferred to the hospital on 4/26/25 for a change in condition and returned on 4/29/25. R13's medical record did not contain documentation of the required notice information for the 2 hospital transfers. On 8/25/2025, at 11:20 AM, Surveyor requested R13 transfer notice information from Nursing Home Administrator (NHA) –A. The NHA-A stated the process is the Social Worker completes the bed-hold, and the floor nurse provides the transfer notice. On 8/26/202, at 9:12 AM, The NHA-A spoke with Surveyor. The NHA-A did not provide written transfer notices for R13's transfers from the facility. The facility does not have a policy and procedure for transfer notice requirements 3.) R10 was admitted to the facility on [DATE] with diagnoses of Anemia (a decrease of iron levels in the blood) and Heart Failure. On 8/24/25, Surveyor reviewed R10's Electronic Medical Record. R10 was transferred to the hospital on 7/21/25 for a change in condition and returned on 7/22/25. On 8/25/2025 at 11:25 AM, Surveyor requested transfer notice information from Nursing Home Administrator (NHA) –A. NHA-A stated the process is the Social Worker completes the bed-hold, and the floor nurse provides the transfer notice. On 8/26/2025 at 9:12 AM, NHA-A spoke with Surveyors. NHA-A did not provide written transfer notices for R10's transfer from the facility. The facility does not have a policy and procedure for transfer notice requirements 4.) R4 was admitted to the facility on [DATE] with diagnoses of Anemia (a decrease of iron levels in the blood), Heart Failure and Coronary Artery Disease (a narrowing or blockage of the arteries to the heart). On 8/24/25, Surveyor reviewed R4's Electronic Medical Record. R4 was transferred to the hospital on 3/12/25 for a change in condition and returned on 3/20/25. On 8/25/2025 at 11:25 AM, Surveyor requested transfer notice information from Nursing Home Administrator (NHA) –A. NHA-A stated the process is the Social Worker completes the bed-hold, and the floor nurse provides the transfer notice. On 8/26/2025 at 9:12 AM, NHA-A spoke with Surveyors. NHA-A did not provide written transfer notices for R4's transfer from the facility. The facility does not have a policy and procedure for transfer notice requirements 5.) R58 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (a brain dysfunction caused by metabolic disruptions possibly from liver or kidney disease), congestive heart failure, sever protein-calorie malnutrition, chronic kidney disease, and anxiety. R58 was transferred to the hospital on 7/23/2025 after a fall and returned on 7/24/2025. R58's medical record did not contain documentation of the required transfer notice information for the hospital transfer. On 8/25/2025 at 11:20 AM, Surveyor requested from Nursing Home Administrator (NHA)-A R58's transfer notice information for R58's transfer to the hospital on 7/23/2025. NHA-A stated when the resident leaves the facility, the Social Worker completes the bed hold and the floor nurse provides the transfer notice to the resident. NHA-A stated the facility keeps the bed hold from and the transfer notice goes with the resident. NHA-A provided R58's form with medical information that is given to the hospital, but did not have a form with the required appeal information. On 8/26/2025 at 9:12 AM, NHA-A stated no written transfer notice was given to R58 when transferred to the hospital. The facility did not have a policy and procedure for transfer notice requirements.

Based on observation, interview, and record review, the facility did not ensure the safety of 4 of 7 residents (R12, R14, R15, R13) reviewed for accidents. * R12 was transferred not according to the care plan and sustained a laceration to the lower left extremity requiring 17 stitches when staff performed a pivot transfer instead of using a Hoyer lift per R12's care plan. * R14 sustained falls on 10/24/2024, 10/25/2024, and 10/29/2024 that were not thoroughly investigated. The intervention for R14's fall on 10/29/2024 was not revised on care plan until 11/7/2024. * R15 sustained falls on 9/11/2024, 9/15/2024, and 9/20204 that were not thoroughly investigated. R15's Wanderguard bracelet was not placed on the wheelchair according to the company manual for the Wanderguard bracelet. * R13 care plan and Kardex indicated the need for assistance with ambulation greater than 50 feet and dependent on staff for up to 150 feet. On 11/8/2024, R13 walked across the street to a restaurant; the facility did not conduct an assessment for R13 to determine if it was safe or not for R13 to do so. R12 is being cited at severity level 3 (actual harm). R14, R15 and R13 are being cited at severity level 2 (potential for more than minimal harm). Findings include: The facility policy titled Resident Transfer Policy revised on 2/1/2024 documents: The Resident Transfer Policy exists to ensure a safe working environment for residents and care giver. Initial screening will be performed on all residents to assess transfer & (and) ambulation status. - Therapy and/or nursing will assess each resident to ascertain transfer needs. - Resident transfer and ambulation status will be reviewed via care-plan time frame and on an as needed basis. - Resident transfer status will be found in PCC (Point Click [NAME]- electronic medical record) to inform the staff of appropriate technique to use. Transfers: The transfers will be designated into one of the following categories: - Independent - 1 (one) person transfer - 2 (two) person transfer - Sit to Stand = 2 caregivers required - Sling Lift (Hoyer) (requires 2 caregivers) Caregivers can always use a device that gives more assistance if required for the safety of the resident but must inform the nursing staff of this change from the care plan . The facility policy titled Fall Policy reviewed on 7/17/2024 documents: POLICY STATEMENT: All residents will receive adequate supervision, assistance, and assistive devices to prevent falls. Each resident will be evaluated for safety risks, including falls and accidents. Care plans will be created and implemented based on the individual's risk factors to aid in preventing falls. All falls are to be investigated and monitored. PROCEDURE: 1. INVESTIGATIVE GUIDELINES: . f. Complete Incident/ Event Report g. Obtain detailed statements from ANY [sic] witnesses. 2. Quality Assurance Guidelines: a. Review Incident report for completeness b. Complete Investigative Report c. Take the incident to Stand up meeting for review and care plan review . e. The care plan is to be updated with any new interventions . h. The Interdisciplinary Plan of Care (IPOC) team will meet within the same period and discuss the causative factors, interventions to prevent another fall, make therapy referral as necessary, and revise the care plan if necessary . 1.) R12 was admitted to the facility on [DATE] with diagnoses that include Dementia and venous insufficiency. R12's quarterly minimum data set (MDS) dated [DATE] indicated R12 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 0. The facility assessed R12 needing total assist for pivot transfers, repositioning with 1 staff member, and used a wheelchair dependent on a staff member for transporting in the facility. Surveyor reviewed a facility self-report submitted on 11/24/2024 regarding an injury of unknown origin for R12 that happened during a transfer. On 11/24/2024 at 21:07 (9:07 PM), in the progress notes, nursing documented that Certified Nursing Assistant (CNA)-Z called Licensed Practical Nurse (LPN)-N to R12's bedroom because R12 had a leg wound that needed to be looked at. LPN-N documented R12 was sitting on the edge of the bed, R12 had no facial grimacing or indication of pain. R12's left lower leg was bleeding and there was a gash noted on the left lower leg. LPN-N asked CNA-Z what happened and CNA-Z replied CNA-Z did not know what happened. LPN-N called for an ambulance to transport R12 to the hospital for further evaluation. On 11/25/2024 at 00:36 (12:36 AM), in the progress notes, nursing documented R12 returned to the facility at 2345 (11/24/2024 at 11:45 PM) and was treated at the hospital for a laceration to the left lower extremity that required 17 stitches. The facility self-report also documents R12 was not transferred according to R12's care plan. Surveyor reviewed R12's ADL (Activities of Daily Living) self-care performance deficit r/t (related to) weakness and advancing dementia care plan that had the following intervention for transfers: -TRANSFER: the resident (R12) requires Mechanical Hoyer Lift with assistance of 2 staff for transfers (initiated/revision 11/15/2024) Surveyor noted a prior resolved intervention for R12's transfer status: -RESOLVED: TRANSFER: the resident (R12) requires assistance by 1 staff to move between surfaces. (initiated 8/2/2023, resolved/ revised on: 11/15/2024) Surveyor reviewed R12's CNA Care Kardex and documented the following for R12's transfer status: -TRANSFER: the resident requires Mechanical Hoyer Lift with assistance of 2 staff for transfers. Surveyor reviewed staff statements collected for the facility self-report: On 11/24/2024, CNA-Z documented in a statement that CNA-Z asked CNA-M to assist with a transfer for R12 to put back into R12's bed. CNA-Z documented CNA-Z was in back of R12 and CNA-M was on the side and assisted R12 into bed. CNA-Z noted blood on the left lower leg. CNA-Z documented CNA-Z went to get the nurse and CNA-M stayed in the room with R12. CNA-Z documented that blood was not observed on R12's bed rail or the wheelchair and that CNA-Z was unsure of what could have happened to cause R12's injury. Surveyor noted that CNA-Z is no longer employed at the facility and was unable to be reached for an interview. On 11/24/2024, CNA-M documented in a statement CNA-M assisted CNA-Z with a pivot transfer for R12 from the wheelchair to the bed. CNA-M stated CNA-M went to put R12's feet into the bed but noted blood on R12's leg. CNA-M checked the wheelchair and bed but did not see anything sharp. On 11/24/2024 at 19:48 (7:48PM), LPN-N documented in a statement that LPN-N was called to the room by CNA-Z regarding R12's leg bleeding. LPN-N asked R12 what happened. LPN-N documented R12 was unable to verbalize what occurred and just pointed to a side table. LPN-N called for transport to the hospital. On 12/9/2024 at 3:56 PM, Surveyor interviewed CNA-M who stated CNA-M was asked to assist with a transfer for R12. Surveyor asked what kind of transfer was performed for R12. CNA-M stated that CNA-M and CNA-Z pivoted R12 from the wheelchair to the bed. Surveyor asked if CNA-M knew what kind of transfer R12 was. CNA-M stated that CNA-M did not know what kind of transfer R12 was but that CNA-Z request help with a pivot transfer for R12. Surveyor asked CNA-M if at any time during the transfer if R12 called out or said something while being transferred. CNA-M stated CNA-M did not recall R12 making a noise during the transfer or indicate R12 had any pain. Surveyor asked CNA-M where staff find information on the residents needs such as how a resident transfers. CNA-M stated that all nursing staff have the CNA care Kardex for each resident, staff can also look in PCC on the resident's chart, and also noted on the care plan for nursing staff. Surveyor asked how staff are notified if a transfer status for a resident has changed. CNA-M stated that staff should always look at the CNA care Kardex before caring for the resident, shift report, and in PCC again for any changes. Surveyor asked CNA-M if CNA-M was aware of what R12's transfer status was. CNA-M stated that R12 was not on her resident list and was only helping CNA-Z with the transfer and that CNA-M did not check to see how R12 transferred before helping CNA-Z. Surveyor asked if CNA-M noted anything that could have cut R12's leg. CNA-M stated that CNA-M looked at the wheelchair and bed and there was not anything sharp that CNA-M could see. On 12/10/2024, at 12:04 PM Surveyor interviewed LPN-N who stated LPN-N was called to the room because R12 was bleeding and LPN-N noted a cut on R12's leg. LPN-N stated LPN-N called for transport to the hospital to get it evaluated. LPN-N could not tell what R12 could have cut R12's leg on, the wheelchair and bed looked fine. Surveyor asked LPN-N if LPN-N knew how R12 was to be transferred at the time of the incident. LPN-N stated that it could be found on R12's care plan, and CNA Kardex. LPN-N could not recall what R12's transfer status was but believed it was a Hoyer lift. LPN-N could not recall if CNA-Z asked LPN-N about R12's transfer status on 11/24/2024. On 12/10/2024, at 12:09 PM, Surveyor interviewed R18 who was R12's roommate on 11/24/2024. Surveyor asked R18 if R18 recalled R12 and the incident on 11/24/2024. R18 remembered R12 and the incident on 11/24/2024. R18 stated that 2 staff members transferred R12 from R12's wheelchair to the bed. Surveyor asked if R12 made any noise during the transfer or indicated that R12 was hurt. R18 remembers R12 yelling out because it startled R18 and when R18 looked over R18 noted R12 mouth open and was making a crying noise. Surveyor asked if staff could see what R12 cut herself on. R18 stated that it may have been something on the wheelchair because R12 called out when the staff member helped R12 stand out of the wheelchair, but no one could tell what could have cut R12. On 12/10/2024, at 12:25PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who stated CNA care Kardex's are available on all units and updated with all changes. ADON-C stated staff can also view the residents PCC for transfer status among other care information and are to look at it before all care with a resident every time staff is on the unit. On 12/20/2024, at 3:08 PM, Surveyor shared concerns with nursing home administrator (NHA)-A, DON-B, Regional Director- H and Director of Quality Assurance-L regarding R12 not being transferred according to R12's care plan. R12 was transferred using a pivot transfer instead of a Mechanical Hoyer lift transfer and sustained an injury to R12's left lower leg requiring 17 stitches. Regional Director- H stated that the facility investigated the incident with R12 on 11/24/2024 and noted that R12 was not transferred according to R12's care plan and the facility completed a 4 (four) point plan and brought it to their Quality Assurance and Performance Improvement (QAPI) Committee. Surveyor stated if offered, Surveyor would look at the plan. On 12/11/2024, at 7:47AM, Surveyor reviewed the facility's 4 point/ QAPI plan for R12's incident on 11/24/2024. On 12/11/2024, at 8:58AM, Surveyor interviewed Maintenance Director-E. Surveyor asked if Maintenance Director-E was asked to look at R12's bed or wheelchair to see if there were concerns of anything on the bed or wheelchair that could have caused the laceration to R12's left lower extremity. Maintenance Director-E could not recall but would check notes and orders. On 12/11/2024, at 9:15AM, NHA-A stated that NHA-A looked at R12's wheelchair and that NHA-A has directed Maintenance Director-E to look at R12's bed and wheelchair. NHA-A stated that there were not areas on the wheelchair that could have cause the type of laceration R12 had, however there were some areas that may have been a little rough so R12's wheelchair was swapped out for another wheelchair. NHA- A stated R12's bed was fine, and no areas of concern were noted. On 12/11/2024, at 9:51AM, Surveyor shared with NHA-A, DON-B, Regional Director- H and Director of Quality Assurance-L that the 4 point QAPI plan was reviewed however there were other concerns that R12 was harmed when transferred not according to R12's plan of care and that R12 required 17 stitches to R12's left lower extremity. On 12/11/2024, at 10:54 AM, Maintenance director-E stated that R12's wheelchair and bed were looked at and there were no concerning areas found, however the facility gave R12 a new wheelchair to avoid any other issues. 2.) R14 was admitted to the facility on [DATE] and has diagnoses that include rhabdomyolysis, type 2 diabetes mellitus, peripheral vascular disease, major depressive disorder, hearing loss, and a history of falling. R14's admission minimum data set (MDS) dated [DATE] indicated R14 has severely impaired cognition with a brief interview for mental status (BIMS) score of 6 and the facility assessed R14 needing moderate assist with 1 staff member using a gait belt and two wheeled walker up to ten feet, toileting hygiene, lower body dressing, and putting on and off footwear. R14's fall risk was assessed as a high risk with a score of 12.0 on 10/14/2024. R14's fall care area assessment dated [DATE] documents that R14 triggered for falls related to a history of falls and other contributing factors including physical deconditioning, rhabdomyolysis, diabetes, hypertension, and impaired mobility. A plan of care was initiated to continue to monitor and prevent falls. Implementation to include fall precautions in place such as: frequent checks, ensure R14's call light is within reach, make sure gripper socks are on, and safety reminders. R14's at risk for falls care plan was initiated on 10/14/2024 with the following interventions: - Be sure the resident's call light is within reach and encourage the resident to use it for assistance and as needed. - Ensure that the resident is wearing appropriate footwear, and that footwear is donned appropriately. (revised on 10/24/2024) - Educate the resident/ family/ caregivers about safety reminders and what to do if a fall occurs. - Follow facility fall protocol. - PT (physical therapy) evaluate and treat as ordered and PRN (as needed). - Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/ remove any potential causes if possible. Educate resident/ family/ caregivers/ IDT (Interdisciplinary Team) as to cause. - The resident needs activities that minimize the potential for falls while providing diversion and distraction. - Fall mat at bedside (initiated 10/25/2024) - Encourage resident to have bed in lowest position while in bed. Resident refuses at times, educate on risks versus benefits of this intervention, continue to provide reminders on the importance of keeping bed in low position. (initiated 10/25/2024, revision on 12/3/2024) - Educate and encourage resident to wait for staff assistance after pressing call light before attempting to ambulate. (initiated 11/7/2024) On 10/24/2024, at 12:14 PM, in the progress notes Assistant Director of Nursing (ADON)-C documented R14's roommate notified nurse roommate heard R14 fall in the bathroom. ADON-C went to R14's room and asked what happened. ADON-C documented R14 stated R14 slipped because R14's gripper socks were on upside down with the grippy part on top of the foot and the cloth part on the bottom of the foot. On 10/25/2024, at 3:24 AM, in the progress notes licensed practical nurse (LPN)-HH documented that LPN-HH walked into R14's room and observed R14 lying on the floor on R14's left side. R14 stated R14 was attempting to get in the wheelchair. On 10/29/2024 at 15:13 (3:13 PM), in the progress notes nursing documented: R14 found sitting on R14's bottom parallel to R14's bed. R14 stated R14 turned on the call light and got up to use the bathroom and when got back from the bathroom was not back against R14's bed enough and slid to the floor. On 12/9/2024, at 12:05 PM, Surveyor observed R14 lying in bed waiting for lunch. Surveyor asked if R14 has had any falls while at the facility. R14 stated when R14 first got to the facility R14 fell a couple of times, but now waits to get help before getting up. R14 did not recall details about the falls on 10/24/2024, 10/25/2024, and 10/29/2024. On 12/10/2024, Surveyor reviewed the fall investigation for R14's falls on 10/24/2024, 10/25/2024, and 10/29/2024 and noted the following concerns. - There are no staff statements documenting the events leading up to R14's falls. - There are staff statements documenting when R14 was last observed and toileted prior to R14's falls. - R14's fall care plan was not revised until 11/7/2024 after R14's fall on 10/29/2024. On 12/10/2024, at 12:22 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C regarding R14's fall on 10/24/2024. ADON-C recalls R14 sitting on R14's bed and was notified of R14's fall right away. ADON-C does not feel it was a long time between when the roommate notified staff of R14's fall and when R14 was assessed. Surveyor asked if ADON-C knew when R14 was last seen, toiled or if anyone was interviewed about R14's falls on 10/24/2024, 10/25/24, and 10/29/2024. ADON-C stated ADON-C did not know when R14 was last seen or toileted by staff and does not recall interviewing anyone regarding R14's falls. Surveyor informed ADON-C that R14's fall care plan was not revised until 11/7/2024 after R14's fall on 10/29/2024. Surveyor asked what the expectation for care plan revision was. ADON-C stated that R14's care plan should have been revised after R14's fall on 10/29/2024 and should not have been done on 11/7/2024. Surveyor informed ADON-C that R14 pushed the call light for help on 10/29/2024 but went to the bathroom without assistance due to having to wait and no staff arriving. Surveyor asked ADON-C if this lack of assistance was investigated, or any staff were interviewed to determine when R14 pushed the call light and how long R14 was waiting before R14 walked to the bathroom alone. ADON-C was not sure how long R14 was waiting after R14 pushed the call light and could provide no additional information. On 12/10/2024, at 2:21 PM, Surveyor interviewed LPN-HH who stated on 11/25/2024 LPN-HH recalled R14 was restless and kept trying to get out of the bed. LPN-HH stated staff kept trying to reorient R14 to the time of day and that it was still nighttime and R14 should sleep. LPN-HH stated it was the first time LPN-HH had R14 and was not sure what R14's baseline was so not sure if the behaviors were new for him but now that LPN-HH has cared for R14 more LPN-HH is aware the restlessness was not R14's baseline. LPN-HH was not sure when the last time staff observed or toileted R14 before the fall on 10/25/2025. LPN-HH stated after the fall, R15 stayed in bed and there were no further issues. Surveyor noted that there was not indication that the facility investigated why R14 was restless or kept wanting to get out of bed. On 12/10/2024, at 3:08 PM Surveyor shared concerns with Nursing Home Administrator (NHA)-A, DON-B, Regional Director-H and Director of Quality Assurance- L that R14's falls on 10/24/2024, 10/25/2024, and 10/29/2024 were not thoroughly investigated and did not include staff statements of when R14 was last observed or toileted, why R15 was restless and trying to get out of bed on 10/25/2024, and R14's care plan was not revised until 11/7/2024 after R14's fall on 10/29/2024. No additional information was provided. 20483 3.) R15's diagnoses include hemiplegia & hemiparesis following unspecified cerebrovascular disease affecting left dominate side, left above knee amputation, diabetes mellitus, seizure disorder, bipolar disorder, and vascular dementia. R15's power of attorney for healthcare was activated on 9/26/22. R15's risk for falls care plan initiated 10/3/22 & revised 8/16/24 documents the following interventions: * Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Initiated 10/4/22. * Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Initiated 10/4/22. * Follow facility fall protocol. Initiated 10/4/22 & revised 1/11/23. * PT (physical therapy) evaluate and treat as ordered or PRN (as needed). Initiated 10/4/22. * Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT (interdisciplinary team) as to causes. Initiated 10/4/22. * Place call don't fall sign in room. Initiated 1/2/23 & revised 5/23/24. * Floor pad next to side of bed, when in bed. Initiated 1/4/23 & revised 8/6/24. * Medication review. Initiated 1/4/23. * Encourage to follow smoking schedule and remind resident of smoking times. Initiated 1/25/23 & revised 8/6/24. * Offer and assist to bed between lunch and dinner as desired. Initiated 3/1/23. * Soft touch call light. Initiated 3/14/23. * Resident remains 1 assist but continues to self-transfer, therapy to evaluate for safety. Initiated 8/10/23. * Hx (history) of self-transferring to and from bed. Requested made for therapy to eval (evaluate) for education and work on self-transfers to reduce falls. Resident is a 1 assist, reviewed fall history and continues to try and self-transfer despite education. Initiated 8/14/23 & revised 5/23/24. * Refer to therapy for eval and treat for transfer safety. Initiated 3/27/24. * Apply anti-roll backs to wheelchair. Initiated 3/28/24. * Therapy recommendations for restorative program including transfer training and AROM (active range of motion) for upper and lower extremities. Initiated 4/1/24. * Evaluate height of bed for safe transfers. Initiated 4/1/24 & revised 5/23/24. * Apply break extenders to bilateral brakes on wheelchair (applied but resident habitually removes these). Initiated 4/17/24 & revised 9/25/24. * Frequent monitoring in between smoking times. Initiated 5/17/24. * Enabler bars to assist with transfers and positioning in bed. Initiated 8/6/24. * Encourage resident to use call light to request staff assistance prior to attempting to self-transfer. Initiated 8/6/24. * Educate family on ETOH (alcohol) usage. Initiated 9/24/24. R15's event note dated 9/11/24, at 17:07 (5:07 p.m.), documents: Situation: CNA (Certified Nursing Assistant) informed writer patient was sitting on his fall mat. It appeared he had slid himself out of bed. Vitals taken and they were stable, pupils equal and reactive, no signs of bleeding MD (medical doctor) called. POA (power of attorney) notified Recommendations: MD informed writer to keep a close eye on patient and call if anything changes. This note was written by LPN (Licensed Practical Nurse)-F. R15's nurses note dated 9/14/24 at 09:52 (9:52 a.m.) documents Resident on board for an unwitnessed fall. Resident stable, VSS (vital signs stable), resident has no complaints of pain or discomfort. This nurses note was written by RN (Registered Nurse)-DD. R15's nurses note dated 9/15/24 at 22:15 (10:15 p.m.) documents found resident on the floor on the mat sitting on his bottom no c/o (complaint of) pain or discomfort no injury seen neuro (neurological) started [Name] and POA notified. This nurses note was written by LPN-EE. R15's late entry nurses note dated 9/20/24 at 1500 (3:00 p.m.) created on 9/23/24 at 1655 (4:55 p.m.) documents Resident was attempting to transfer himself from bed into wheelchair, but the resident did not lock the wheels on his wheelchair, so when attempting to transfer, the chair rolled back and the resident fell on the floor. No injuries noted. Resident denies hitting his head. This nurses note was written by UM (Unit Manager)-FF. R15's fall risk assessment dated [DATE] has a score of 11 which indicates high risk for falls. R15's annual MDS (minimum data set) with an assessment reference date of 10/11/24 has a BIMS (brief interview mental status) score of 14 which indicates cognitively intact. R15 is assessed as not having any behavior. Assessed as being independent for rolling left and right, and requires partial/moderate assistance for chair/bed to chair transfer & toilet transfer. R15 is assessed as always being incontinent of urine and bowel. R15 has not had any falls since prior assessment period which was a medicare 5 day with an assessment reference date of 9/23/24. The fall CAA (care area assessment) was not triggered. The CNA Kardex as of 12/9/24 under safety section documents *Floor pad next to bed, when in bed. *Frequent monitoring in between smoking times. *Monitor exit seeking behavior. *Nurse cart has cigarettes and lighter in locked box. *Requires supervision while smoking. On 12/9/24 at 11:32 a.m., Surveyor observed R15 in bed on the back with the head of the bed elevated. There is a transfer bar on each side of R15's bed and a gray floor mat on the left side of R15's bed. There is green sign on the wall on the right side of the bed which documents Call Don't fall. On 12/9/24 at 12:36 p.m., Surveyor observed R15 in bed eating lunch. On 12/9/24 at 3:05 p.m., during the end of the day meeting with NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B, Surveyor asked for the complete investigation for R15's falls on 9/11/24, 9/15/24, & 9/20/24. On 12/9/24 at 3:41 p.m., Surveyor observed R15 in bed on his back with the head of the bed elevated. Surveyor observed the call pad is hanging down on the right side of the bed and not within reach. The gray floor mat is on the left side of the bed and transfer bars up on R15's bed. On 12/10/24 at 8:16 a.m., Surveyor observed R15 in bed on his back with his eyes closed. Surveyor observed the transfer bars are up, there is a gray mat on floor on the left side of R15's bed, the call pad is hanging down on the right side and is not within reach. On 12/10/24 at 9:09 a.m., Surveyor reviewed the fall information provided for R15's fall on 9/11/24 when R15 slid from the bed onto the floor which included resident fall data dated 9/11/24. This resident fall data includes a question for last time toileted or incontinence cares given & was the call light activated which were not completed. The section for witness statements obtained by all staff working on the unit is not completed nor were there any witness statements provided. An event note dated 9/11/24, an order dated 9/12/24 for PT/OT (physical therapy/occupational therapy) eval/treat for falls and an IDT (interdisciplinary team) note dated 9/13/24 was also provided. Surveyor noted the Facility did not conduct a thorough investigation as there are no staff interviews as to who last saw R15, when incontinence cares were provided to R15, etc. The Facility did not determine a root cause and did not revise R15 care plan until 9/24/24 or did not indicate the fall interventions were appropriate when R15 fell on [DATE]. On 12/10/24 at 9:11 a.m., Surveyor reviewed the fall information provided for R15's fall on 9/15/24 when R15 slid from the bed to the mat on the floor. This information included resident fall data dated 9/15/24 which includes a question for last time toileted or incontinence cares given. The section for witness statements obtained by all staff working on the unit is not completed nor were there any witness statements provided. Also provided was a nurses note dated 9/16/24, [managed care name] note dated 9/16/24, an IDT note dated 9/17/24, [managed care name] note dated 9/17/24, and Basic Metabolic Panel result dated 9/14/24. Surveyor noted the facility did not conduct a thorough investigation as there are no staff interviews as to who last saw R15, when incontinence cares were provided to R15, etc. The facility did not determine a root cause and did not revise R15 care plan until 9/24/24 or did not indicate the fall interventions were appropriate when R15 fell on [DATE]. On 12/10/24 at 9:15 a.m., Surveyor reviewed the fall information provided for R15's fall on 9/20/24 when R15 fell when attempting to transfer into the wheelchair. Surveyor was provided only with an incident report. Under incident description for nursing description documents Resident was attempting to transfer himself from bed into his wheelchair, but the resident did not lock the wheels on his wheelchair, so when attempting to transfer, the chair rolled back and the resident fell on to the floor. No injuries noted. Under resident description documents Resident sated he was trying to get into his wheelchair, and the wheelchair rolled back when he was trying to transfer, so he fell on to his butt on the floor. Surveyor noted the facility did not conduct a thorough investigation as there are no staff interviews as to who last saw R15, when incontinence cares were provided to R15, etc. R15's care plan was not revised until 9/24/24. On 12/10/24 at 11:53 a.m., Surveyor met with ADON (Assistant Director of Nursing)-C with DON (Director of Nursing)-B. Surveyor informed ADON-C of R15's three falls on 9/11/24, 9/15/24, & 9/20/24. Surveyor informed ADON-C there are no staff statements or indications staff were interviewed, the fall information provided to Surveyor does not include who last saw R15, when was incontinence cares provided etc and the care plan was not revised until 9/25/24. Surveyor asked ADON-C for any additional information for R15's three falls. On 12/10/24 at 3:22 p.m. during the end of the day meeting NHA (Nursing Home Administrator)-A, DON-B, Regional Director-H, and Director of Quality Assurance-L were informed R15 had three falls on 9/11/24, 9/15/24, & 9/20/24. There is no evidence of a thorough investigation for these falls as the information provided to Surveyor doesn't include staff statements or indicates staff was spoken to as to who last saw R15, when was R15 provided with incontinence cares etc, what was R15 trying to do etc. There is no root cause and the care plan was not revised until 9/25/24. Surveyor asked to be provided with any additional information regarding R15's falls. On 12/11/24 at 8:37 a.m., Surveyor asked DON-B to explain the process when a resident falls. DON-B explained the nurse will do an assessment, for any skin or injury with the fall, vitals, and getting the resident in a safe position transferring with a hoyer. The MD, POA, Guardian will be contacted. If the resident is their own person will ask if they want the emergency contact contacted. If the resident hits their head they will be sent out to the hospital. The risk management and falls packet will be completed. Surveyor inquired who completes these. DON-B informed Surveyor the floor nurse. DON-B informed Surveyor the floor nurse is responsible for getting staff statements. DON-B informed Surveyor the fall packet is given to her. Surveyor inquired who determines the root cause. DON-B replied that would be me. The WanderGuard departure alert system user & installation manual for the section Component Descriptions-Bracelets under warning includes documentation of Do not place the bracelet on or next to metal, such as wheelchair frames, jewelry, watches,etc., or allow it to come in contact with a metal door or associated hardware such as crash bars, push bars, etc. Metal could interfere with the signal sent from the bracelet to the door antennas and result in an unauthorized departure. The WanderGuard System Operation - Bracelet Activation and Use section on page 17 under Bracelet Placement documents WanderGuard bracelets (model 36000 series) should be placed on the residents dominate wrist. The metal in a wheelchair frame (or any metal items) may interfere with the bracelet's signal to the door modules. Before proceeding with alternate placement, you must contact Technical Service for further instructions. Your bracelet placement protocol needs to define the standard

Based on observations, interviews, and record review, the facility did not ensure that 1 of 1 resident (R5) reviewed for elopement was provided adequate supervision and interventions to prevent elopement and ensure safety. R5 had a Wanderguard placed on admission for exit seeking behaviors. R5 was assessed as a non-smoker on admission. On 10/8/24, R5 cut his Wanderguard off. A new Elopement Risk Assessment was completed and scored a higher risk for elopement than the assessment on admission, but the facility staff determined that R5 did not require the Wanderguard. Additional supervision was not put in place by the facility. On 10/8/24, Psychiatric Nurse Practitioner (NP)-R documented that R5 was an active smoker and that R5 needed to continue taking Seroquel for agitation and start taking Zoloft for anxiety and depression. The facility did not assess R5 for smoking safety/supervision and did not initiate a care plan for smoking. The facility did not enter the Zoloft medication order and start offering R5 the medication until 10/14/24. R5 refused multiple doses of Seroquel and Zoloft. The facility did not document that NP-R was made aware of multiple refusals of Seroquel and Zoloft after the 10/8/24 visit. On 10/18/24, R5 was seen smoking on the facility grounds at 1 PM. Facility staff did not document seeing or assessing R5 after 1PM on 10/18/24. Licensed Practical Nurse (LPN)-P went to R5's room to give R5 medications at 6:00 PM on 10/18/24. R5 was not in his room. LPN-P returned to R5's room at 8:00 PM. R5 was not in his room. The facility staff began to search for R5. The Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A were notified and a larger search began. On 10/18/24 at 10:40 PM, the police were called. On 10/19/24 at 8:24 AM, a silver alert was placed by the local police department. R5 was found by police on 10/19/24 at 11:00 AM in R5's former apartment, which is 17 miles away from the facility. The facility's failure to provide adequate supervision and interventions to prevent elopement and ensure safety for R5 created a finding of immediate jeopardy that began on 10/8/2024. NHA-A was notified of the immediate jeopardy on 10/30/24 at 3:00PM. The facility removed the immediate jeopardy on 10/31/24. The deficient practice continues at a scope and severity of an E (potential for harm/pattern) as the facility continues to implement their action plan. Findings include: The facility policy titled, Elopement prevention and missing resident policy with a date of 1/5/2021 documents in part: Purpose: to create an environment that is as safe as possible for residents at risk for elopement and develop a plan of action that will ensure a prompt, effective and coordinated response when a resident is reported missing . It is the policy of this facility, while continuing to foster the independence of all residents, will provide support for potential elopement of residents; and to ensure that a plan of action is in place to assist any resident who may wander from the facility . Elopement is defined as a situation where a resident with cognitive impairment who cannot recognize normal danger and hazard outside the facility leaves the facility without knowledge . Assessments and Plan of Care: Upon admission or re-admission, all residents will be assessed for elopement risk utilizing the Elopement Risk Assessment form. A comprehensive elopement prevention plan of care will be developed for each resident identified as at risk for elopement. Residents at risk for elopement will be reassessed quarterly and with a significant change of condition . Routine Procedures: .All elopement risk residents will be accompanied by a responsible party when leaving the facility. The responsible party will follow the sign-out procedure before departure. Should an exit alarm sound, staff shall immediately respond and determine the cause of the alarm. If no reason can be found, the Supervisor shall be notified, and an account of all residents identified to be at risk for elopement shall be performed. All staff members are responsible for responding to an exit alarm. Environmental Consideration: Residents who are at risk for elopement shall be provided at least one of the following safety precautions. 1. A WanderGuard device that will notify facility staff when the resident has left the building without supervision. 2. Door alarms on facility exits. 3. Staff supervision either by visual contact or closed-circuit television of facility exits . Elopement Policy: .If any staff member identifies that they cannot find a resident in a place that the resident is anticipated to be, the staff member will alert their supervisor for assistance once affirming that the resident was not signed out of the facility. The Supervisor will assume control of the search and gather all available staff and begin an immediate preliminary search of the area and immediate premises . If the resident is not located in a reasonable amount of time, the Administrator and/or the Director of Nursing, the resident's representative, the Attending Physician, and law enforcement officials will be notified . R5 was admitted to the facility on [DATE] with diagnoses that include Rhabdomyolysis, Metabolic encephalopathy, Dementia, Weakness, Hypertension, Depression, and Anxiety. R5's Admission Minimum Data Set (MDS) Assessment, dated 10/3/24, documents that R5 is understood and usually understands. R5 has a Brief Interview for Mental Status (BIMS) Assessment of 6, indicating that R5 has severely impaired cognition. R5 has a PHQ9 score of 15, indicating R5 has Moderately Severe symptoms of Depression. R5's MDS documents that R5 does not exhibit behaviors of wandering. R5 exhibits rejection of care 4 to 6 days. R5's mobility is independent but when tested for walking 150 feet the MDS documents R5 is dependent. For walking 10 feet on uneven surfaces and doing steps (stairs or curbs) R5 is dependent. R5's Care Area Assessment for Cognition Loss/Dementia and Behavioral Symptoms dated 10/3/24, documents: Resident is alert and oriented with confusion and forgetfulness [related to] Dementia. [R5] verbalizes feeling depressed, difficulty sleeping, feeling tired, poor appetite and difficulty concentrating. [R5] refuses medications and vitals at times [related to] Dementia. [R5] was very weepy during [R5's] interview. Prior to R5's admission to the facility, R5 was hospitalized on [DATE] after being found on the floor of his home. The Hospital's After Visit Summary (AVS) dated 9/26/24, documents, in part: [R5] was diagnosed with Acute toxic metabolic encephalopathy, rhabdomyolysis, heart attack and positive urine drug screen for amphetamines and benzodiazepines. The AVS documents [R5] is unable to explain his urine drug screen and says he only take suboxone . [R5] says [R5] smokes cigarettes but does not do any other recreational drugs. In addition, while hospitalized , R5 was appointed a court-ordered temporary guardian. R5's Elopement Risk Evaluation completed by LPN-P, dated 9/26/24, documents the following: a total score of 2. Category: not at risk. Relevant Diagnosis/Impaired Cognition. No. Communication-Diminished ability to understand others. No. Historical Behavior Pattern-Purposeful exit seeking, frequently searching for home or something familiar. No. Other relevant Behaviors-Grasping at doorknobs or handles without purpose, following visitors closely. No. Mobility status-Independently mobile via ambulation . Yes. New to facility-admitted to facility within 60 days. Yes. Evaluation-Score of 4 or more requires action unless resident is not ambulatory. Is the resident at risk for elopement? Yes. List interventions taken, or reason resident is not at risk if they scored 4 or more. This question was answered with, Wanderguard. On 10/29/23 at 12:33 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-Q who cared for R5 on R5's first day of admission. CNA-Q stated that R5 walks independently without a walker. CNA-Q stated R5 was counting and checking each exit door on the first day R5 was at the facility. CNA-Q stated that R5 would push exit doors to see if they would alarm. CNA-Q stated that R5 was exit seeking from the beginning of R5's stay at the facility and that R5 has continued to exhibit these behaviors. CNA-Q stated that R5 likes to ask everyone if they have a vehicle. On 10/30/24 at 8:25 AM, Surveyor interviewed LPN-P who was the nurse who admitted R5 to the facility. LPN-P stated when R5 arrived at the facility R5 was counting how many doors are in each unit. LPN-P stated that during the nurse-to-nurse report from the hospital staff, LPN-P was told that R5 was an escape seeker. LPN-P indicated that R5 was exit seeking from the beginning of R5's stay at the facility. LPN-P stated that R5's exit seeking behaviors have continued since admission. Because of that, R5 had a Wanderguard put in place on admission. LPN-P indicated that R5 walks independently without a walker. Surveyor noted that R5 has a diagnosis of dementia, R5 had a historical behavior of exit seeking per the hospital staff report, and R5 was counting doors and pushing them to see if they would alarm. These findings were not reflected on the 9/26/24 Elopement Risk Evaluation. R5's limited physical mobility care plan initiated on 9/26/24 documents interventions that include: The resident is NON-weight bearing. The resident is Weight-Bearing. Ambulation: the resident requires extensive assistance with ambulation up to 50 [feet] with the [four-wheeled walker] . Surveyor noted that R5's limited physical mobility care plan does not accurately portray R5. Facility staff stated that R5 is independent and does not use a walker. The care plan has that the resident is both weight-bearing and non-weight bearing. R5's elopement care plan initiated on 9/26/24 documents interventions that include: Monitor exit seeking behavior. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. R5's MD order with a start date of 9/27/24 documents, Wanderguard: Check placement, location, and function [every] shift for elopement risk. Right wrist. Surveyor reviewed R5's Treatment Administration Record (TAR). Surveyor noted that staff documented that R5 was wearing R5's Wanderguard from 9/27/24 through 10/8/24. Surveyor reviewed R5's Medication Administration Record (MAR) and TAR from 9/27/24 through 10/8/24. Surveyor noted nursing staff were not monitoring exit seeking behaviors as outlined in R5's Elopement Care Plan. Surveyor reviewed R5's CNA documentation of wandering and exit seeking behaviors. Surveyor noted that from 9/27/24 through 10/8/24, CNAs documented, None of the above observed. Surveyor noted that CNA-Q informed Surveyor that R5 was exit seeking from the beginning of R5's stay at the facility and that R5 has continued to exhibit these behaviors. Surveyor noted that these behaviors were not documented within R5's medical record. R5's progress note entered by Unit Manager (UM)-M and dated 10/8/2024 at 2:37 PM, documents: Resident has not been exhibiting exit seeking behaviors and has been ambulating with purpose and remaining in the facility without concern. Writer completed an updated elopement assessment and resident is no longer an elopement risk. Wanderguard has been removed and resident remains without a Wanderguard at this time. Resident is no longer exhibiting exit seeking behavior, and no longer needs a Wanderguard in place. R5's Elopement Risk Assessment entered by UM-M and dated 10/8/2024, documents the following: a total score of 4. Category: At risk for elopement. Relevant Diagnosis/Impaired Cognition. Yes. Communication-Diminished ability to understand others. No. Historical Behavior Pattern-Purposeful exit seeking, frequently searching for home or something familiar. No. Other relevant Behaviors-Grasping at doorknobs or handles without purpose, following visitors closely. No. Mobility status-Independently mobile via ambulation . Yes. New to facility-admitted to facility within 60 days. Yes. Evaluation-Score of 4 or more requires action unless resident is not ambulatory. Is the resident at risk for elopement? No. List interventions taken, or reason resident is not at risk if they scored 4 or more. Resident walks around facility but isn't exit seeking. Resident also goes outside in the appropriate courtyard for resident use without exit seeking and returns back inside appropriately. Surveyor noted that R5's Elopement Risk assessment score was higher on 10/8/24 than it was on admission. Despite a higher score, the facility determined that R5's Wanderguard was no longer necessary. Surveyor reviewed R5's Elopement Care Plan and noted no additional supervision intervention was put in place after the Wanderguard was removed. On 10/29/24 at 2:19 PM, Surveyor interviewed UM-M. Surveyor asked when a Wanderguard was typically placed on a resident. UM-M stated that on admission, if a resident scores a 4 or more on the assessment, a Wanderguard is placed. Surveyor asked about R5's behaviors. UM-M stated that R5 can be hostile and become aggressive if R5 is not doing what R5 wants to do. UM-M stated R5 can be stand-offish. Surveyor asked if R5 is exit seeking. UM-M stated that R5 was exit seeking for the first day or two after admission. UM-M stated that R5 was talking or asking about leaving in the beginning but then after that R5 would be wandering the halls but moving throughout the building appropriately. UM-M indicated that R5 cut off R5's Wanderguard on 10/8/24 and R5 would not allow another Wanderguard to be put in place. UM-M stated that after the elopement risk assessment was completed, the facility determined the Wanderguard could remain off R5. On 10/8/24, an initial Psych evaluation was completed on R5 by Nurse Practitioner (NP)-R. This note documented in part: . [R5] with history of dementia, depression, and anxiety is being seen today for initial psychiatric evaluation. Staff reports patient has been very forgetful, impulsive, longing for home and barricading his door . Smoking Tobacco: Cigarettes: Active: Yes . [R5] is quite resistant with medications. Staff reports that he is very forgetful and is physically impulsive. He has been known to barricade the door to his room. He is not always easily redirected . There may be some underlying psychosis. Patient was admitted with Seroquel 25 mg nightly. Plan: Continue Seroquel for now. Add Zoloft to treat anxiety as well as depression . Surveyor noted NP-R documented R5 as longing for home on the same day the Wanderguard was removed, and no additional care plan intervention was put into place. Surveyor noted NP-R's psychiatric note documented R5 as an active smoker. Surveyor reviewed medical record for a smoking assessment and did not locate a completed smoking assessment for R5. Surveyor reviewed R5's care plans and did not locate a smoking care plan. R5's Orders-Administration note dated 10/9/2024 at 1:51 PM documents: Resident upset after speaking with case manager regarding going home. [R5] is refusing skin check and shower. Surveyor noted staff documented R5 as being upset regarding going home one day after Wanderguard was removed and no additional supervision was put into place. On 10/29/23 at 12:33 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-Q about R5's smoking. Surveyor asked when R5 started smoking. CNA-Q stated that CNA-Q thought R5 had been smoking since admission. On 10/30/24 at 8:25 AM, Surveyor interviewed LPN-P who was the nurse who admitted R5 to the facility. LPN-P stated that LPN-P asked R5 if R5 was an active smoker. R5 told LPN-P that R5 did not smoke. LPN-P noted on the hospital record that he smoked years ago but had quit smoking. Surveyor asked when R5 started smoking at the facility. LPN-P stated R5 started smoking 2 to 3 weeks after R5's admission. LPN-P stated that R5 would get cigarettes from other residents. Surveyor asked if LPN-P knew if other staff had seen or were aware that R5 was smoking. LPN-P stated other staff knew R5 was smoking. On 10/29/24 at 2:53 PM, Surveyor interviewed LPN-G. Surveyor asked when R5 started smoking. LPN-G stated that R5 started smoking sometime after admission. Surveyor asked how often R5 smoked. LPN-G stated R5 goes out to smoke every once in a while. On 10/29/24 at 2:19 PM, Surveyor interviewed UM-M about when R5 started smoking. UM-M stated that UM-M was unsure when R5 started smoking. UM-M stated that R5 was supervised when R5 did smoke. Surveyor asked when a smoking assessment and care plan should be implemented. UM-M stated on admission if a resident is a smoker. Surveyor asked if R5 should have had an assessment and care plan entered after staff knew R5 was smoking. UM-M stated, Ideally, yes. On 10/30/24 at 9:17 AM, Surveyor returned to UM-M; UM-M stated that UM-M had not seen R5 smoke. UM-M stated that R5 went to the courtyard (smoking area) to socialize. Surveyor noted that staff were aware that R5 had started smoking. Surveyor noted NP-R's psychiatric plan for R5 was to continue with Seroquel medication and add Zoloft to treat Anxiety and Depression. R5's MD order with a start date of 9/27/24, documents: Seroquel 25mg. Give 1 tablet by mouth at bedtime for agitation. Surveyor reviewed R5's MAR to confirm that R5 was receiving Seroquel as ordered. R5 took the medication as ordered from 9/27/24 through 10/2/24. Resident refused Seroquel on 10/3, 10/6, 10/8, and 10/9. Staff did not document a refusal or administration of the Seroquel in the MAR for the 10/11 dose. R5 refused Seroquel on the 13th and 14th. Staff did not document a refusal or administration of the Seroquel in the MAR for the 15th. R5 refused Seroquel on the 16th and 17th of October. Surveyor noted that NP-R's psychiatric note on 10/8/24 documented, [R5] is quite resistant with medications indicating that NP-R was aware of previous refusals of medications. Surveyor did not locate any other documentation after 10/8/24 that NP-R was made aware of R5's multiple refusals of Seroquel. R5's MD order with a start date of 10/14/24, documents: Zoloft Oral Tablet 50 MG. Give 50 mg by mouth one time a day for depression, anxiety. [half] tab [every day for] 6 days, then 1 tab every day. Surveyor reviewed R5's MAR to confirm R5 was receiving Zoloft as ordered. R5 refused Zoloft on 10/14 and 10/15/24. R5 took Zoloft on the 16th, 17th, and 18th of October. Surveyor noted that the Zoloft was recommended by NP-R to start on 10/8/24 and was not entered as an order until 10/14/24. Surveyor did not locate documentation that NP-R was made aware that R5's medication did not start until 10/14/24 or that R5 refused the medication on 10/14 and 10/15/2024. On 10/15/24, the facility doctor visited R5. The facility doctor's note documents, in part: .Patient continues to be going out and smoking . Nicotine dependence . Smoking cessation counseling was discussed. Currently not interested. R5's progress note, dated 10/18/24, at 11:07 PM documents: Nurse attempted to administer PM medication after [6:00 PM]. Resident was not present. During second attempt to administer medication nurse observed resident not present in room. PM supervisor and staff began searching facility and surrounding areas for resident. Interim DON and Administrator notified of resident's elopement. Administrator and interim DON arrived at the facility to help facilitate search. Staff searched local businesses and restaurants with no evidence of resident. BPD was called, and statements were given to the officer. MD and guardian was notified. On 10/29/24 at 10:35 AM, Surveyor interviewed R5. Surveyor asked how things were going at the facility. R5 stated, I'm not supposed to be here. I don't know why I am here. Surveyor asked R5 to explain more. R5 stated that R5 ran away a few weeks ago. Surveyor asked why R5 left the facility. R5 stated, because I don't like it here. Surveyor asked how long R5 had felt that way. R5 indicated that R5 wanted to go home since admission and stated that R5 still wants to go home. R5 stated that the facility is supposed to be working on getting R5 home. R5 stated that R5 had told the facility that he wanted to go home prior to running way, and they didn't listen. R5 indicated that the day R5 left the facility, R5 went outside for a cigarette at the designated area at the back of the building and then walked off. R5 indicated that R5 left the facility around 1200 (noon). R5 stated that R5 walked, hitchhiked, and got a ride from a cop to get home. Surveyor asked if R5 used a walker. R5 indicated, R5 walks independently. R5 stated that it took R5 an hour and a half to get home. R5 indicated that he made it home safely. Surveyor asked when R5 started smoking. R5 stated that R5 smoked most of his life but did quit smoking years ago. Once R5 arrived at the facility, R5 stated R5 started smoking a few days after that. R5 stated that R5 would buy cigarettes from other residents. Surveyor noted the weather on 10/18/24 was reported as sunny with a high of 66 and a low of 41 (at 6 PM). Surveyor reviewed the facility's self-report timeline which documents in part: At 8:30 PM on 10/18/24, staff noticed R5 was not in his room. Staff began to immediately check building and surrounding areas. At 9:30 PM, DON-B was notified and R5's prior apartment was contacted but voicemail was received . At 10:00 PM, NHA-A and DON-B arrived at the building to assist with building and property checks . At 10:40 PM, 911 was called and [R5] was reported missing. R5's guardian was called, and voicemail was left. At 11:15 PM, a police officer arrived at the facility to being an investigation . On 10/19/24, at 8:00 AM, R5's prior apartment was contacted but voicemail was received . At 8:24 AM, a silver alert was placed for resident . At 11:00 AM, [R5] was located in [R5's] old apartment by the police . At 11:42 AM, [R5] returned to the facility. At 12:09 PM, [R5] was sent out to the emergency room for evaluation . The facility collected statements of staff who worked on 10/18/24. CNA-S, LPN-P, LPN-T, and DON-B were among the statements collected. On 10/29/24 at 3:10 PM, Surveyor interviewed CNA-S. Surveyor asked what R5's personality is like. CNA-S stated that R5 is pretty chill. CNA-S stated that R5 wanders a lot and talks about how he is ready to go home. CNA-S stated that R5 will say things like, I'm ready to get out of this place. Surveyor asked when that started. CNA-S stated it has been more in the last couple of weeks but that is started at the beginning of October. Surveyor asked if CNA-S was working on 10/18/24. CNA-S stated yes. Surveyor asked CNA-S to explain what happened. CNA-S stated that CNA-S did not remember seeing R5 during the day. CNA-S stated that R5 would typically come to the nurse's station by CNA-S later in the evening for a snack but did not come to the desk that night. CNA-S stated that CNA-S was alerted around 8PM that R5's room was empty. CNA-S stated that staff checked the building and surrounding area after that and did not find R5. On 10/30/24 at 8:25 AM, Surveyor interviewed LPN-P. Surveyor asked what R5's personality is like. LPN-P stated R5 is sweet and sarcastic. R5 is laid back, quiet, and sneaky. Surveyor asked LPN-P to explain what happened on 10/18/24 with R5. LPN-P stated that LPN-P worked first shift on the first floor and 2nd shift on the 2nd floor where R5's room is located. LPN-P stated that LPN-P saw R5 at 12 or 12:30 PM. LPN-P stated R5 was taking another resident's sweatshirt that was left outside, back to the resident's room. LPN-P stated that R5 typically walked around the facility in gripper socks and pajamas but on 10/18/24, R5 was wearing clothes, socks, and tennis shoes. LPN-P stated that R5 took the elevator upstairs and that was the last time LPN-P saw R5. LPN-P stated that R5 will typically come out of R5's room and go to the nurse's station between 4 and 6 PM to ask for R5's medications, but otherwise R5 stays in R5's room most of the PM shift. On 10/18/24, R5 did not come to the nurse's station asking about R5's medications. At 6 PM, LPN-P went to R5's room to give medication to R5. R5 was not in R5's room. LPN-P stated that LPN-P asked a coworker if they had seen R5 and the coworker told LPN-P that maybe R5 went downstairs to smoke. LPN-P stated that LPN-P went back to R5's room at 8 and R5 was not in the room. LPN-P stated LPN-P looked downstairs and when LPN-P could not locate R5, LPN-P notified the supervisor and staff began a search. On 10/30/24 at 8:50 AM, Surveyor interviewed LPN-T. Surveyor asked what R5's personality is like. LPN-T stated that R5 refuses a lot of care and most of R5's meds. LPN-T stated R5 can get aggressive toward staff and R5 likes to manipulate situations. Surveyor asked LPN-T to explain what happened on 10/18/24 with R5. LPN-T stated LPN-T and a coworker worked R5's hall during the day on 10/18/24. LPN-T stated that R5 refused the morning medications. LPN-T stated that LPN-T saw R5 at lunch and that was the last time LPN-T saw R5. LPN-T stated R5 was acting normal that day. On 10/30/24 at 9:30 AM, Surveyor interviewed DON-B. Surveyor asked what R5's personality is like. DON-B stated that R5 is a bit intimidating. R5 can be aggressive and has lunged at staff in the past. DON-B stated that DON-B has a great relationship with R5 and R5 will talk to DON-B. R5 has told DON-B that R5 likes that staff are intimidated by R5. Surveyor asked when DON-B saw R5 last on 10/18/24. DON-B stated that DON-B saw R5 smoking a cigarette outside at 1 PM. DON-B indicated that this was the first time DON-B had seen R5 smoke. Surveyor noted R5 was last seen by facility staff at 1 PM on 10/18/24. An initial search for R5 did not start until 8:30 PM, which was 7.5 hours later. On 10/29/24 at 3:10 PM, Surveyor interviewed CNA-S. Surveyor asked how often CNA-S and other staff round on residents. CNA-S stated every two hours. On 10/30/24 at 8:25 AM, Surveyor interviewed LPN-P. Surveyor asked how often LPN-P and other staff round on residents. LPN-P stated every 2 hours. On 10/29/24 at 2:19 PM, Surveyor interviewed UM-M. Surveyor asked how often staff should round on residents. UM-M stated every one to two hours. Surveyor noted that staff did not round on R5 every two hours on 10/18/24. Surveyor reviewed CNA documentation regarding R5's 10/18/24 meals. Surveyor noted that facility staff did not document any meals given to R5 on 10/18/24. On 10/30/24 at 10:30 AM, NHA-A informed Surveyor that R5's dinner meal tray was dropped off by a CNA and collected by a dietary aide. NHA-A indicated that the facility conducted an audit regarding this concern and concluded that this instance was a one-off issue and not a systemic issue. R5's progress note dated 10/19/24 at 2:36 PM, documents: Resident returned to the facility via [local police department name] at 1145. Resident was instructed by staff that he would need to be sent to the hospital for evaluation. Resident refused to comply with nursing and refused to go to the hospital. Resident's guardian arrived at the facility at 1155. Guardian was able to get the resident to be agreeable to going to the hospital. At 1205, resident was transferred to [Local hospital name] . for evaluation. R5's Hospital AVS dated 10/19/2024, documents a discharge diagnosis of: Problem related to social environment. Surveyor reviewed the hospital documentation and noted that no new injuries were found. While in the hospital R5 refused vitals, labs, and an IV. R5 had to be redirected back to his room after trying to go smoke. Hospital staff had to supervise R5 when R5 went out to smoke. R5's progress note dated 10/19/2024 at 11:45 PM documents, in part: Resident was brought to facility via Bell ambulance on stretcher . Resident jumped off gurney as Bell staff was pushing him down the hall. Once finally getting in his room resident cursed and swore at Bell staff and then slammed his room door . Writer attempted to get a set of vitals and resident refused. Writer placed resident on 15-minute check. Writer called MD on call and let them know that resident had made it back to the facility. Resident resting comfortably in his bed. Surveyor reviewed R5's 24-hour board and noted staff started 1 to 1 supervision and 15-minute checks when R5 returned from the hospital. On 10/19/24, R5's elopement care plan was updated with 2 new interventions: Identify pattern of wandering. Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise. Intervene as appropriate. Assess for fall risk. On 10/20/24, R5's elopement care plan was updated with an intervention: [R5]-refuses Wanderguard, guardian aware. Staff will provide 1:1 supervision and supervised smoke breaks. R5's Elopement Risk assessment dated , 10/20/2024, documents a score of 6. Category: At risk for elopement. Relevant Diagnosis/Impaired Cognition. Yes. Communication-Diminished ability to understand others. No. Historical Behavior Pattern-Purposeful exit seeking, frequently searching for home or something familiar. Yes. Other relevant Behaviors-Grasping at doorknobs or handles without purpose, following visitors closely. No. Mobility status-Independently mobile via ambulation . Yes. New to facility-admitted to facility within 60 days. Yes. Evaluation-Score of 4 or more requires action unless resident is not ambulatory. Is the resident at risk for elopement? Yes. List interventions taken, or reason resident is not at risk if they scored 4 or more. Resident refuses Wanderguard, guardian aware. Requires 1:1 supervision including supervised smoke breaks. R5's MD order with a start date of 10/20/24 documents: Behaviors - resident monitored for the following: restless, anxious, agitated, fearful, repetitive physical, repetitive question, sleeplessness, wandering, exit seeking, refusal of care/hygiene. Document Y for NONE or N if BEHAVIORAL .Choose other chart code and document progress note that includes non-pharmacy and any drug interventions and effectiveness. Every shift. Surveyor reviewed the TAR and noted that nursing staff were monitoring the above behaviors since 10/21/24. On 10/21/24, facility staff completed a smoking assessment for R5 and initiated a smoking care plan. R5's MD order with a start date of 10/22/24, documents: Zyprexa Oral Tablet 5 MG (Olanzapine). Give 5 mg by mouth one time a day for psychosis, exit seeking. Surveyor noted when R5 returned to the facility after eloping, the facility started to regularly monitor R5's behaviors, initiated a 1 to 1 intervention, completed a smoking assessment and smoking care plan with supervised smoking, and started R5 on new medication. On 10/30/24 at 7:00 AM, Surveyor observed the facility's courtyard, which is the designated smoking area. This courtyard is located at the back of the building. Outside there are benches and trash receptacles for the smoking materials. Surveyor observed a sidewalk that leads to a large parking lot at the back of the facility. Behind the parking lot, there is a tree line. The tree line is next to a road with a 25-mph speed limit. If you turn left out of the courtyard, there is a road with a 30-mph speed limit. At the front of the facility is 6 lane road with a 45-mph speed limit. On the inside of the building, there is a door leading out to the smoking area. This door has a box located on the left side. A code must be entered before opening the door or the door will alarm until the code is entered. On 10/29/24 at 12:45 PM, Surveyor observed R5 leave his room. R5 walked independently and without a walker. R5 was followed by CNA-U. CNA-U opened the door to the courtyard and R5 sat on a bench and smoked a cigarette. CNA-U remained indoors but observed R5 through a large window. Surveyor asked how long R5 had been smoking. CNA-U stated that R5 has been smoking since admission. Surveyor asked how the door to the smoking area is supervised. CNA-U stated that anyone who smokes[TRUNCATED]

Based on observation, interview, and record review, the facility did not ensure 3 of 3 residents (R) reviewed (R1, R2, and R3) had a comprehensive assessment and care plan to prevent and heal pressure injuries. R1 was admitted to the facility on [DATE]. Upon admission, R1 had no open wounds or pressure injuries. R1 was assessed to be at risk for pressure injuries and to need extensive assistance with bed mobility. On 7/12/24, R1 developed a blister to the right heel. An RN assessment was not completed until 7/17/24. On 7/12/24, R1's right heel blister was inaccurately assessed as Stage 1 pressure injury with 100% granulation. The care plan does not indicate heel offloading was an intervention prior to R1 developing a blister to the right heel. The nurse's notes and weekly wound assessments indicate R1 is not compliant with interventions and treatment of the right heel pressure injury. The facility does not have evidence of any discussion with R1 regarding risk and benefits of noncompliance. The noncompliance was also not addressed in the care plan until 9/25/24. R1's pressure injury deteriorated on 9/18/24, which required hospitalization for osteomyelitis. R1 required IV antibiotics and debridement of the wound while hospitalized . R1 returned to the facility on [DATE] with a Stage 4 pressure injury. On 9/25/24, Wound MD-D assessed R1's heel as a Stage 4 pressure injury. On 9/25/24, the facility wound evaluation inaccurately indicated R1's heel is an unstageable pressure injury. The facility's failure to prevent the development of a facility acquired stage 4 pressure injury with infection by ensuring assessment, prevention, and treatment in accordance with current standards of practice created a finding of immediate jeopardy that began on 9/18/24. Surveyor notified NHA (Nursing Home Administrator)-A of the immediate jeopardy on 10/10/24 at 2:55 p.m. The immediate jeopardy was removed on 10/11/2024, however, the deficient practice continues at a scope/severity of G (actual harm/isolated) based upon additional resident examples involving R2 and as the facility continues to implement its action plan. R2 was found with pressure injuries to the plantar area of both feet on 9/30/2024, the care plan was not updated with the relevant intervention until 10/9/2024, a Physician order for treatment was not started until later the next day, and then only on the right foot. When Surveyor observed wound care, one pressure injury was incorrectly staged. There is an additional example involving R3: *The facility did not stage R3's left and right heel pressure ulcers according to standards of practice as observed during wound treatment care on 10-09-24. Facility did not follow skin monitoring interventions listed in R3's care plans. Findings include: The facility's Wound Management-Wound Prevention and Treatment policy revised 5/9/22 documents: 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. 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. According to the National Pressure Injury Advisory Panel (NPIAP): https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf. NPIAP Pressure Injury Stages - The updated staging system includes the following definitions: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon, or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. 1.) R1 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes with diabetic neuropathy, obesity, pain in right hip, idiopathic gout right ankle and foot, localized edema, and spinal stenosis. R1 has an activate healthcare Power of Attorney (HCPOA). The admitting MDS (Minimum Data Set) dated 5/28/24 indicates R1 has a Brief Interview for Mental Status (BIMs) score of 8 indicating R1 has moderate cognitive impairment and needs extensive assistance with bed mobility. The MDS also indicates R1 is at risk for pressure injuries and is free from pressure injuries, R1 did not demonstrate any rejection of care, and R1's ability to understand others may include missing some part/intent of message but comprehends most conversation - usually understands. R1 is noted to have a care plan indicating for a focus: the resident is functioning at a cognitively moderately impaired level r/t (related to) observable loss of memory initiated 5/29/24 and revised on 5/29/24. Goals initiated 5/29/24 with a revision on 6/5/24 include resident will participate in the following activities through the next review date of 8/20/24. Interventions different activities/strategies to help R1 participate and remember things cognitively. R1 also is identified as having a communication problem related to being understood by others and usually understanding others appropriately related to her moderately impaired cognition. Interventions dated 5/29/24 include anticipate and meet needs . Ri's Activities of Daily Living (ADL) care plan initiated 5/22/24 and revised on 5/29/24 documents, Focus: The resident has an ADL self-care performance deficit related to being physically deconditioned s/p (status post) recent hospitalization for Spondylopathy of the cervical region and spinal stenosis. Goals include: The resident will maintain current level of function through the review date initiated: 5/22/24, revised 6/5/24, target date 8/20/24. The resident will improve current level of function through the review date initiated 5/22/24, revised on 6/5/24. Interventions include: .Bed Mobility: The resident requires extensive assistance initiated 5/22/24, revised on 5/29/24 . Transfer: The resident requires extensive assistance with chair/bed transfers initiated 5/22/24, revised on 5/29/24. R1 also had a care plan related to diabetes with a focus documenting: The resident had Diabetes Mellitus Type 2 with Neuropathy and utilizes po (by mouth) medication management initiated: 5/29/24, revised on: 5/29/24. Goal: The resident will be free from any s/sx (signs/symptoms) of hypoglycemia through the review date. Initiated: 5/29/24, revised on 6/5/24. Interventions include, Check all of body for breaks in skin and treat promptly as ordered by doctor initiated: 5/29/24 . Surveyor noted the care plan does not specify completion of diabetic foot checks or the frequency at which staff are to check all of R1's body for breaks in skin. The care plan with a focus area of limited physical mobility related to the Spondylopathy of the cervical Region, spinal stenosis initiated 5/22/24, revised 9/2/24 to include a right heel unstageable PU (pressure ulcer/injury). Goal is for the resident to demonstrate the appropriate use of adaptive device(s) to increase mobility through the review date. Initiated 5/22/24, revised 6/5/24, target date: 8/20/24. Interventions include: The resident is weight bearing initiated: 5/22/24, Ambulation: The resident requires extensive assistance with ambulation with the FWW (four wheeled walker) up to 10 feet initiated: 5/22/24, revised: 5/29/24. Provide supportive care, assistance with mobility as needed. Document assistance as needed initiated: 5/22/24. PT (physical therapy), OT (occupational therapy) referrals as ordered, PRN (as needed) initiated: 5/22/24. Surveyor noted there is no revised intervention related to the noted unstageable heel pressure injury that is a focus area of the care plan. R1's care plan with a focus on the potential for impairment for skin integrity related to impaired mobility was initiated on 5/22/24 and revised 5/29/24. The goal documents, the resident will maintain or develop clean and intact skin by the review date. This was initiated 5/22/24, revised on 6/5/24 with a goal date of 8/20/24. Interventions dated 5/22/24 include encourage good nutrition and hydration in order to promote healthier skin, follow facility protocols for treatment of injury, turn and reposition as necessary and provide pressure relieving device(s): Pressure relieving mattress initiated 5/22/24. Revised on 10/9/24: refuses apm (alternating pressure mattress). The facility added to this care plan on 7/15/24, elevate heels off surface of bed using pillows, heels up device or heel lift boots. Surveyor noted prior to 7/15/24, the care plan related to R1 being at risk for skin integrity issues did not include preventative interventions for R1's feet despite R1's risk factors for skin integrity concerns. Surveyor also noted the plan of care was not individualized for R1. Additional review of R1's care plans include a focus initiated 5/29/24 related to kidney function and renal insufficiency that included the intervention to elevate feet when sitting up in chair to help prevent dependent edema initiated 5/29/24. A care plan initiated on 5/29/24 related to impaired circulation related to diabetes and hyperlipidemia initiated 5/29/24 includes an intervention to elevate R1's legs when resting initiated 5/29/24. It is noted R1 also had issues related to edema. Surveyor noted the care plans did not address how to individually care for R1's risk factor to allow elevation to prevent edema while decreasing the risk for the development of pressure injuries. A nurses note dated 7/12/24 documents, Rt heel, discolored filled blister, (Wound MD-D) aware, order to (sic) skin prep. Family at bed side, family aware. The skin impairment/wound evaluation dated 7/12/24 documents R1's right heel blister as, Stage 1 measuring 4.0 cm (centimeters) by 3.0 cm and the wound bed is 100% granulation. Surveyor noted a description of a stage 1 blister would not include the presence of granulation according to standards of practice. Both the nurses note and the wound evaluation are documented by an LPN (Licensed Practical Nurse). A skin issues form dated 7/12/24 prepared by DON-B indicates R1 has a right heel ulcer - new skin area with resident unable to give a description. Immediate action taken indicates PCP (primary care physician,) wound nurse, and DON notified. Treatment ordered for skin prep and to off-load heels. The document indicates R1 is oriented to person, place, and time. Predisposing environmental factors indicate none. Predisposing physiological factors indicate none and behavioral factors - resistive/non-compliant. Predisposing situation factors indicate none. Notes document: IDT (interdisciplinary team) meeting s/p status post resident new skin issue. DON and wound care nurse assessed wound - root cause analysis completed, resident frequently up in wheelchair daily, refuses care and assessment at times. Resident is assist (sic) with transfers and repositioning needs, staff will continue to reposition per facility policy. Nursing intervention - foot boots for heel protection and treatment per wound care MD. Care plan reviewed and updated. There is a document dated 7/12/24 with the front and back outline of a body that includes R1's name and is signed by Director of Nursing (DON)-B. The document has a circled area on the back, right heel stating 4 cm (centimeter) x (by) 3 cm, blister. Surveyor noted there is no description of the blister as to whether it is fluid filled or not and what type of fluid it may be if present. There are also no details describing the surrounding skin to the wound. Surveyor noted there were no revisions to R1's skin integrity care plan until 7/15/24 when the facility added the intervention to elevate (R1's) heels off the surface of bed using pillows, heels up device, or heel lift boots. Surveyor also noted the skin issues form indicates behaviors as a factor including resisting cares or noncompliance. Surveyor noted there is no assessment of these behaviors and no care plan interventions to address these behaviors. Surveyor noted R1 has cognitive impairment. The 7/16/24 Wound MD-D assessment indicates the right heel is an unstageable DTI (deep tissue injury) measuring 5 cm by 9 cm, skin intact with purple/maroon discoloration and blood-filled blister. The note also indicates the development of this wound and the context surrounding the development were considered in greater detail today. Counseling offered to optimize wound healing regarding relevant conditions including diabetes, chronic kidney disease. Reviewed off-loading surfaces and discussed surfaces care plan. Recommend upgrading off-loading devices in bed and/or chair. Considered patient behavior as factor is complicating wound healing and discussed it further with staff and/or family. Discussed wound healing trajectory and expectations with patient and/or family. Dressing treatment plan: skin prep apply once daily for 30 days. Recommendations: float heels in bed; elevate leg(s); pressure off-loading boot. Surveyor noted this does not specify whether the counseling was provided to the facility staff, resident, family, etc. The note does not indicate a discussion of risks and benefits. The facility did not initiate a behavior care plan for any behaviors R1 may display that could impact healing. Wound MD-D's wound evaluation dated 7/23/24 indicates unstageable pressure injury of the right heel, full thickness. Measuring 5cm by 9cm by not measurable cm, depth is unmeasurable due to presence of nonviable tissue and necrosis. 100% thick adherent devitalized necrotic tissue. Exacerbated due to patient non-compliant with wound care. The note also indicates: The progress of this wound and the context surrounding the progress were considered in greater detail today. Counseling offered to optimize wound healing regarding relevant conditions (or possible conditions) including diabetes, anemia, noncompliance. Patient not following repositioning or off-loading recommendations and counseling provided. Reviewed off-loading surfaces and discussed surfaces care plan. Recommend upgrading off-loading device in bed and/or chair. Considered patient behavior as factor that is complicating wound healing and discussed it further with staff and/or family. Discussed wound healing trajectory and expectations with patient and/or family. Primary dressing: betadine apply twice daily for 30 days. Secondary dressing: ABD (abdominal) pad apply twice daily for 30 days; gauze roll (kerlix) 3.4 apply twice daily for 30 days. Recommendations: float heels in bed; elevate leg(s); pressure off-loading boot. Surveyor noted this does not specify whether the counseling was provided to the facility staff, resident, family, etc. The note does not indicate a discussion of risks and benefits. The facility did not initiate a behavior care plan for any behaviors R1 may display that could impact healing. The facility's skin impairment/wound evaluation dated 7/23/24 indicates the presence of an unstageable pressure injury: obscured full thickness skin and tissue loss. Measuring 5 cm by 9 cm by UTD (unable to determine) cm. Wound tissue: blister. It also indicates exacerbated due to patient non-compliant with wound care. Surveyor noted there is no indication the facility assessed R1's resistance to wound care interventions and established a plan to address this behavior if it was impacting wound healing. Wound MD-D's wound evaluation dated 7/30/24 indicates unstageable (due to necrosis) of the right heel full thickness. Measuring 5 cm by 6 cm by not measurable cm. Depth is unmeasurable due to presence of nonviable tissue and necrosis 50% thick adherent devitalized necrotic tissue and 50% granulation tissue. Primary dressing: Iodosorb gel apply once daily for 30 days. Secondary dressing: ABD pad apply once daily for 23 days; gauze roll (kerlix) 3.4 apply once daily for 23 days. Recommendations: float heels in bed; elevate leg(s); pressure off-loading boot. The facility's skin impairment/wound evaluation dated 7/30/24 indicates the same evaluation as Wound MD-D's assessment and continues to indicate exacerbated due to patient noncompliant with wound care. Surveyor noted there is no indication the facility assessed R1's resistance to wound care interventions and established a plan to address this behavior if it was impacting wound healing. The facility's skin impairment/wound evaluation dated 8/6/24 indicates unstageable pressure injury: obscured full thickness skin and tissue loss to right heel. Measuring 6 cm by 6.5 cm by 0.2 cm with 50% granulation 50% eschar and continues to indicate exacerbated due to patient noncompliant with wound care. Wound MD-L's wound evaluation dated 8/9/24 indicates unstageable (due to necrosis) of the right heel full thickness. Measuring 4.5 cm by 6 cm by 0.2cm 50% thick adherent devitalized necrotic tissue and 50% granulation tissue. Primary dressing: iodosorb gel apply once daily for 20 days. Secondary dressing: ABD pad apply once daily for 13 days; gauze roll (kerlix) 3.4 apply once daily for 13 days. Recommendations: float heels in bed; elevate leg(s); pressure off-loading boot. Wound MD-L's wound evaluation dated 8/16/24 indicates unstageable (due to necrosis) of the right heel full thickness. Measuring 4.5 cm by 6 cm by 0.2cm 50% thick adherent devitalized necrotic tissue and 50% granulation tissue. Primary dressing: iodosorb gel apply once daily for 13 days. Secondary dressing: ABD pad apply once daily for 30 days; gauze roll (kerlix) 3.4 apply once daily for 30 days. Recommendations: float heels in bed; elevate leg(s); pressure off-loading boot. It also indicates remove necrotic tissue and establish the margins of viable tissue. Treatment options-risk-benefits and the possible need for subsequent additional procedures on this wound were explained on 8/16/24 to the patient who indicated agreement to proceed with the procedure(s). Wound MD-L's wound evaluation dated 8/23/24 indicated unstageable (due to necrosis) of the right heel full thickness. Measuring 4.3 cm by 5.5 cm by 0.2cm 40% thick adherent black necrotic tissue (eschar) and 50% thick adherent devitalized necrotic tissue and 10% granulation tissue. Primary dressing: leptospermum honey apply once daily for 30 days. Xeroform gauze apply once daily for 30 days. Secondary dressing: ABD pad apply once daily for 23 days; gauze roll (kerlix) 3.4 apply once daily for 23 days. Recommendations: float heels in bed; elevate leg(s); pressure off-loading boot; antibiotic choice: doxycycline 100mg BID (twice a day) for 7 days. Wound MD-L's wound evaluation dated 8/30/24 indicated unstageable (due to necrosis) of the right heel full thickness. Measuring 3.2 cm by 6.4 cm by 0.3cm 20% thick adherent black necrotic tissue (eschar) and 50% thick adherent devitalized necrotic tissue and 30% granulation tissue. Primary dressing: Sodium hypochlorite solution (Dakin's) apply twice daily for 30 days: 1/2 strength, soaked gauze to pack the wound. Secondary dressing: ABD pad apply once daily for 16 days; gauze roll (kerlix) 3.4 apply once daily for 16 days. Recommendations: float heels in bed; elevate leg(s); pressure off-loading boot. Wound MD-L's wound evaluation dated 9/6/24 indicated unstageable (due to necrosis) of the right heel full thickness. Measuring 3.2 cm by 5.9 cm by 0.3cm 20% thick adherent black necrotic tissue (eschar) and 50% thick adherent devitalized necrotic tissue and 30% granulation tissue. Primary dressing: Sodium hypochlorite solution (Dakin's) apply twice daily for 23 days: 1/2 strength, soaked gauze to pack the wound. Secondary dressing: ABD pad apply once daily for 9 days; gauze roll (kerlix) 3.4 apply once daily for 9 days. Recommendations: float heels in bed; elevate leg(s); pressure off-loading boot. Wound MD-L's wound evaluation dated 9/13/24 indicated unstageable (due to necrosis) of the right heel full thickness. Measuring 3.8 cm by 4.8 cm by 0.3cm 50% thick adherent devitalized necrotic tissue 30% slough and 20% granulation tissue. Primary dressing: Sodium hypochlorite solution (Dakin's) apply twice daily for 16 days: 1/2 strength, soaked gauze to pack the wound; metronidazole sprinkled apply once daily for 30 days. Secondary dressing: ABD pad apply twice daily for 30 days; gauze roll (kerlix) 3.4 apply twice daily for 30 days. Recommendations: float heels in bed; elevate leg(s); pressure off-loading boot. The facility's skin impairment/wound evaluation dated 8/17/24, 8/23/24, 8/31/24 and 9/7/24 reiterates Wound MD-L's wound assessments. There is no documentation of noncompliance from R1. Wound MD-D's wound evaluation dated 9/18/24 indicates unstageable (due to necrosis) of the right heel full thickness. Measuring 6 cm by 7 cm by not measurable cm 80% thick adherent devitalized necrotic tissue and 20% granulation tissue. Wound progress exacerbated due to patient noncompliant with wound care. It also indicates, Patient recommended for transfer to hospital for further care. The hospital record dated 9/18/24 indicates R1 was admitted with osteomyelitis and surgical debridement of the wound was performed. The hospital record indicates a conversation regarding possible amputation was discussed with R1 and R1 adamantly refused amputation. R1 also received IV antibiotics for the osteomyelitis. The medical record indicates R1 returned to the facility on [DATE]. Wound MD-D assessed the right heel at a Stage 4 pressure injury measuring 4 cm by 6.5 cm with 30% necrotic tissue and 70% granulation tissue. Acting DON-B, who is also the 2nd floor unit manager and Wound nurse, documented on 9/28/24, R1's pressure injury as unstageable instead of Stage 4 as assessed by Wound MD-D. The weekly wound evaluations performed by Acting DON-B continue to indicate R1's pressure injury as unstageable instead of Stage 4. The facility's skin impairment/wound evaluations dated 7/23/24 and 7/30/24 and Wound MD-D's 7/23/24 assessment indicate R1 was noncompliant with treatment and interventions to help heal pressure injury. There is no documentation in the nurse's notes indicating R1 is noncompliant with interventions and treatment to heal the pressure injury. On 10/10/24 at 9:52 a.m., Surveyor interviewed Acting DON-B and NHA-A. Surveyor explained the concern; R1 developed an avoidable, facility acquired unstageable right heel pressure injury which was inaccurately assessed on 7/12/24 and there wasn't a RN assessment until 7/17/24. R1's care plan did not address interventions to prevent the heel wound from developing and R1's pressure injury deteriorated to the point of osteomyelitis and needing surgical debridement along with IV antibiotics in the hospital with discussion of possible amputation. Surveyor also explained the facility continued to assess the wound as unstageable after Wound M-D assessed it as a Stage 4 pressure injury post hospitalization . NHA-A stated R1 would be noncompliant with treatment and interventions. Surveyor explained R1 did not have a care plan addressing this noncompliance until 9/24/24 and there is no documentation that R1 was educated on risk and benefits of her noncompliance. Acting DON-B agreed the 7/12/24 assessment was incorrect and the assessments after R1 returned from the hospital should be assessed as Stage 4 instead of unstageable. On 10/9/24 at 2:27 p.m., Surveyor observed R1's pressure injury treatment. Wound MD-D assessed the wound and stated the wound is improving. The 10/9/24 wound assessment reveals R1 to have a Stage 4 pressure wound to right heel measuring 3.5 cm by 4.5 cm by 0.3 cm with moderate serosanguineous drainage and 100% granulation tissue. On 10/10/24 at 3:00 p.m. during the exit meeting with Acting DON-B and NHA-A, Surveyor explained the deficient practice. NHA-A stated the facility initiated to elevate heels after the discovery of the blister on R1's right heel. Surveyor explained there is no evidence interventions were in place to prevent a pressure injury from developing. On 10/30/24 at 4:20 p.m., Surveyor interviewed R1's son, the HCPOA for R1. R1's son stated he was never notified R1 was non-compliant with the care and treatment of the heel pressure injury. R1's son stated he would ask staff why (R1's) wound was not healing and he was told, Oh, that sometimes it takes a while to heal. R1's son stated Wound MD-D or Wound MD-L did not notify him of anything regarding R1's heel. R1's son stated R1 came to the facility for rehab due to weakness and then was supposed to go home. R1's son stated R1 now can't go back home and has to remain at a skilled nursing facility. The facility's failure to assess R1's risk for the development of pressure injuries and to establish preventative interventions to address R1's risk led to R1 developing a facility acquired, avoidable stage 4 pressure injury with osteomyelitis. R1 was hospitalized because of deterioration in the pressure injury and required surgical debridement and amputation was discussed. The facility consistently stated R1 was noncompliant with wound care and yet did not complete an assessment to show this noncompliance or establish a care plan to work with R1's behaviors. These failures created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The immediate jeopardy was removed as the facility implemented the following action plan: ~Residents at risk for pressure injuries were identified and person-centered care plans were established to ensure preventative measures. ~Education was provided to nursing and IDT prior to the start of their next shift on following the facility's wound management policy including the requirement of a comprehensive RN assessment of any newly identified pressure injuries and updating care plans. ~All nursing and IDT staff will be educated prior to the start of their next shift on the importance of implementing person centered care plans for the prevention of pressure injuries. ~All Nursing staff and IDT will be educated prior to the start of their next shift on documentation of Risk vs Benefit conversation and documentation for any non-compliance. ~The facility policy and procedure on wound management and coordination was reviewed with the medical director. Including RN assessment and care plan updates to ensure policy meets current standard of practice. ~IDT will meet weekly to audit residents at risk for pressure injuries to ensure preventative interventions are in place, care plans are updated, and weekly skin checks are documented. ~IDT will review daily in clinical meeting any new admissions assessments, incidents regarding skin, and document on eagle board to ensure proper assessments have been obtained and notifications have been made. ~Ad hoc QAPI is scheduled for 10.11.2024. The immediate jeopardy was removed on 10/11/24, however, the deficient practice continues at a scope and severity of a G (actual harm/isolated) related to the following example regarding R2. 49011 2.) R2 was admitted to the facility on [DATE] with diagnoses which include encounter for palliative care, vascular dementia, bipolar disorder, depression, anxiety disorder, neurocognitive disorder with Lewy bodies, epilepsy, and adult failure to thrive. R2's Quarterly Minimum Data Set (MDS) with an assessment reference date of 9/24/2024 indicated R2 had a Brief Interview for Mental Status score of 00 (severe cognitive impairment). R2 has an activated power of attorney. Per the MDS, R2 rarely or never makes self-understood or has ability to understand others. The behavior of rejection of care was noted to have occurred on 1-3 days during the 7 day look back period, no other behaviors were noted. R2 is noted to be frequently incontinent of bowel and bladder. R2 is assessed to be at risk for pressure injuries. R2 has a care plan for The resident has actual impairment to his skin integrity related to his impaired mobility, Vascular Dementia with Behavioral Disturbances, and a Neurocognitive Disorder with Lewy Bodies 7/14/24-skin tear buttocks

Based on interview and record review, the facility did not ensure the residents received treatment and care in accordance with professional standards of practice, individual assessment, the comprehensive person-centered care plan, and the resident's choices for 2 (R4 and R6) of 9 residents. * R4 was admitted to the facility on [DATE]. There wasn't a comprehensive assessment or monitoring ordered for R4's midline surgical incision. On 10/10/24 R4 went to the hospital for an infection to the midline surgical incision. On 10/15/24 (R4 was not in the facility at the time) a care plan was initiated for R4's midline incision. R4 was readmitted to the facility on [DATE] with treatment orders for the midline incision. R4's care plan was not revised until 10/21/24 and R4's midline treatment/ monitoring orders for the midline incision were not implemented until 10/21/24. On 10/23/24 R4 was sent to the hospital for possible infection to the midline surgical incision. * R6 had a change in condition, the facility did not act upon ordered labs and results accordingly. R6 was admitted to the hospital. Findings Include: The facility policy entitled Wound Management- Wound Prevention and Treatment revised on 10/11/2024 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 no-pressure-related [sic] wounds. PROVISION AND PROCEDURE: . 2. Upon admission, the resident will receive a head-to-toe skin check to identify any skin issues. 4. All residents will have the following nursing care procedures implemented: a. Skin hygiene- - Daily with cleanser and rinse thoroughly. - As needed to keep local areas of skin clean, dry, and free of body wastes such as urine, feces, perspiration, and wound drainage. - During care, inspect the skin for signs and symptoms of skin breakdown. 5. Daily, during routine care, the certified nursing assistant (CNA) will observe resident's skin. When abnormalities are noted, this will be communicated to the licensed nurse, and the licensed nurse will evaluate and implement a skin event if applicable. The facility policy entitled Change of Condition Process initiated on 3/1/2021 documents: The purpose of this policy is to promptly implement a system for a resident having a change in condition. A change of condition is defined as an improvement or decline in their physical, mental, or psychosocial status. 5. Change of condition documentation will continue until the director of nursing (DON) or IDT (interdisciplinary team) determined there is a resolution of the condition. 1.) R4 was admitted to the facility on [DATE] and has diagnoses that include colon cancer with metastasis to the liver and lung, viral hepatitis C, peritoneal abscess, spinal stenosis, protein-calorie malnutrition, history of cocaine abuse with intoxication, adjustment disorder with anxiety, cognitive communication deficit, and adult failure to thrive. R4's admission minimum data set (MDS) dated [DATE] indicated R4 had intact cognition with a brief interview for mental status (BIMS) score of 15 and the facility assessed R4 requiring moderate assistance with 1 staff member for toileting hygiene and minimal assistance with 1 staff member for personal hygiene. R4 had a right hemicolectomy and was continent of urine. R4 had a right lower back JP drain (drain for excess fluid buildup) and a midline incision above R4's umbilicus where an abdominal abscess was removed while R4 was in the hospital. R4 was admitted to the facility for rehab and wound management. Surveyor reviewed the admission collection and baseline care plan tool dated 10/3/2024 and noted staff documented in the skin condition section: -Abdomen- vertical surgical wound with staples approximated, no S/SX (signs/symptoms) of infection. Surveyor noted there was no care plan initiated or orders initiated to monitor R4's abdominal surgical incision or interventions established. There wasn't a comprehensive assessment documented about how long the incision was, how many staples are present, what surrounding skin looks like. On 10/5/2024, at 7:12 AM, in the progress notes nursing documented follow up abd (abdominal) incision, staples intact, incision open to air. Surveyor noted there are no further assessments or documentation regarding R4's abdominal incision observation or assessments. On 10/10/2024, at 15:30 (3:30 PM), in the progress notes nursing documented writer asked by Certified Nursing Assistant (CNA) to look at resident due to drainage coming from the surgical site. Nursing documented creamy/slightly green drainage coming from incision site above umbilicus site, no drainage noted from JP drain. R4 was sent to emergency room for evaluation. On 10/14/2024, at 13:13 (1:13 PM), in the progress notes nursing documented R4 was admitted to the hospital with abdominal wall abscess and leaking from the abdominal drain. Surveyor noted that a care plan was initiated on 10/15/2024 for actual skin impairment to skin integrity related to abdominal surgical wound, right hemicolectomy, small bowel resection, and end ileostomy and drainage of abdominal abscess on 9/17/2024 and a JP drain site on right lower abdomen area. Abdominal incision, PICC site, ostomy right lower abdomen with the following interventions: - Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. - Document skin observation during ADL (activities of daily living) care- report abnormal findings to the nurse. - Educate resident/family/caregivers of causative factors and measures to prevent skin injury. - Encourage good nutrition and hydration in order to promote healthier skin. - Follow facility protocols for treatment of injury - Identify/document potential causative factors and eliminate/resolve where possible. - Implement pressure reducing devices i.e. w/c (wheelchair) cushion, air-mattress, off-loading heels, etc. - Monitor for side effects of the antibiotics and over-the-counter pain medications: . - Monitor/document location, size, and treatment for skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration, etc. to MD (medical doctor). Surveyor notes that R4 was still in the hospital at time the care plan was initiated on 10/15/2024. Surveyor reviewed R4's initial hospital visit note dated 10/15/2024 that documents the following: - Possible surgical wound infection - CT abdomen and pelvis show no drainable abscess Plan/Recommend: - IR (interventional radiology) repositioning/replacement for perihepatic collection - Gauze dressing to abdominal wound, change twice daily - Monitor for staple removal, after drainage incision improves - IV antibiotics (treated with Micafungin and high dose Augmentin based on cultures growing candid glabrata and coli methicillin -sensitive E faecalis) - Likely high output as drainage from incision appears similar to output of JP drain. IR replaced the drain and adjustment on 10/11/2024. On 10/18/2024, at 1733 (5:33 PM), in the progress notes nursing documented R4 readmitted to the facility . has orders for IV antibiotics including two oral antibiotics. R4's abdominal incision dehisced both above and below the umbilicus. R4 has new wound orders that have been entered into PCC (point click care-healthcare software). A wound evaluation form was completed on 10/21/2024 that stated wound was assessed on 10/19/2024 and documents: Abdominal surgical wound: -Above umbilicus- 4.5 cm x 2.3 cm x 1 cm (length x width x depth), 50% granulation, 50% slough, moderate serosanguineous drainage. - Below umbilicus- 2.3 cm x 1.5 cm x 1 cm, 50% granulation, 50% slough, moderate serosanguineous drainage Surveyor noted that the following wound orders were not implemented on R4's MAR/TAR (medication/treatment administration record) until 10/21/2024: 1. Monitor dressing placement to abdomen to ensure dressing is clean, dry, intact. Replace dressing if soiled or breakthrough drainage noted every shift. 2. Monitor wound to abdomen for signs and symptoms of infections such as pain, swelling, warmth, redness, odor, purulent, and deterioration. Notify MD if s/sx of infection, deterioration noted. 3. Wound care abdomen: Dakin's packing to abdominal wounds (1/2 inch packing strip to superior wound, kerlix to inferior wound). Cover with abdominal pad and secure with tape BID (twice a day) for abdominal incision wound infection. Surveyor noted that R4's abdominal incision care plan was not revised until 10/21/2024 with the following interventions. - Turn and reposition as necessary - Weekly treatment documentation to include measurement of each area of skin breakdown width, length, depth, tissue type and exudate and other notable changes or observations. On 10/23/2024, at 11:44 AM, in the progress notes nursing documented R4 is being transferred out due to post surgical infection. Vital signs: blood pressure 94/57, hear rate 100, temperature 97.8 . Surgical site is purulent drainage and abdominal pad is soaked through. R4 has been complaining of increased abdominal pain. On 10/29/2024, at 2:00 PM, Surveyor interviewed unit manager (UM)-M who stated expectations for wound assessments on admission are that two nursing staff observe the wound and document the measurement, and appearance of the wound, treatments are initiated on the medication/ treatment administration record (MAR/TAR) and a care plan is initiated. Surveyor asked UM-M how often staff should have been monitoring and documenting on R4's abdominal incision wound. UM-M stated nursing should document observation of any warmth, redness, swelling, and other signs/symptoms of infection every shift and as needed or as ordered. UM-M stated that it would have been listed on R4's MAR/TAR. Surveyor asked if monitoring of R4's abdominal incision should have been on the MAR/TAR, UM-M stated that it should have been on R4's MAR/TAR to monitor the abdominal incision each shift and is not sure why it was not. Surveyor asked UM-M when are care plans initiated when there are areas of concern observed. UM-M stated that care plans should be initiated or revised as soon the area of concern is observed to get interventions in place. Surveyor asked why R4's abdominal care plan would have been initiated on 10/15/2024 if R4 was not in the facility at the time. UM-M was not sure why it was initiated at that time. On 10/30/2024, at 9:26 AM, Surveyor interviewed director of nursing (DON)-B who stated initially comprehensive assessments were not done for surgical wounds with staples but recently the facility implemented a RN comprehensive assessment for all wounds. Surveyor asked when that would have happened. DON-B stated that on 10/9/2024 R4's wound was assessed but unfortunately DON-B did not get measurements or description of the wound. DON-B stated that the wound MD assessed R4's abdominal incision on 10/9/2024 but would not follow any longer due to R4 seeing outpatient surgery for R4's abdominal wound management. Surveyor asked about wound monitoring for R4's abdominal incision. DON-B stated that CNA staff did daily observations with activities of daily living (ADL) care and would report abnormalities to nursing staff. DON-B stated usually standard to monitor skin with showers that are 1-2 times a week. Surveyor asked how staff would know to monitor wounds if it was not listed on the MAR/TAR or care plan. DON-B stated that there is a 24 hour board and nursing report. DON-B stated R4's abdominal incision was open to air and that monitoring should have been on the MAR/TAR but must have been missed. Surveyor asked if wound care followed R4 at all for R4's incision. DON-B stated R4 would not have been seen due to R4's wound being a surgical wound, but the wound care nurse did see R4 on 10/9/2024 with the wound MD. Surveyor did not see an assessment for R4's abdominal surgical incision for 10/9/2024. Surveyor requested to speak with the wound care nurse, the wound care nurse did not come talk with Surveyor. Surveyor reviewed CNA charting for skin observation for R4 and noted that there wasn't consistent documentation for skin observations for R4. CNAs did not document each shift or document about the incision for R4. Many days on the skin observation task form were left blank. Surveyor reviewed the 24 hour reports for 10/3/2024 - 10/10/2024 and noted there was inconsistent monitoring/mention of R4's abdominal wound or mention that R4 had areas of concern to monitor. Surveyor reviewed a (name of wound care group) note dated 10/9/2024 that documented: -Signing off on patient who remains in the facility. Surgical wound. Surveyor noted there is no wound MD assessment of R4's abdominal wound. Surveyor noted there was no assessment or recommendations etc. regarding R4's incisions. 10/30/2024, at 10:30 AM, Surveyor interviewed licensed practical nurse (LPN)-N who stated when a resident is admitted , any orders get implemented into the MAR/TAR and two nurses assess the resident for any wounds or skin concerns. LPN-N stated wound care will see the resident the next day if there are any concerns and implement any orders. LPN-N stated that R4 was admitted with a drain and staples but could not recall anything else. LPN-N stated if an incision was to be open to air it should still be put on the MAR/TAR so staff are aware and monitoring of the area, but usually wound care will put in those orders when they see them the next day. Surveyor asked if wound care would see residents if the wounds are surgical. LPN-N stated that a request gets put it when the skin observation sheet gets filled out and there are concerns on it so R4 should have seen wound care, but LPN-N stated LPN-N was not quite sure what that process is. Surveyor asked how LPN-N would know or where staff would look if R4 or any other residents had surgical incisions or other skin concerns that had to be monitored. LPN-N stated that it would be on the residents MAR/TAR and care plan with interventions that needed to be done. Surveyor asked where documentation is located for any observations/ monitoring. LPN-N stated there would be a progress note and initials to the MAR/TAR. On 10/30/2024, 12:33 PM, Surveyor shared concerns with nursing home administrator (NHA)-A and DON-B of lack of documented monitoring/ assessments for R4's abdominal incision and R4 had to go to the hospital twice for wound abdominal wound incision infections. Surveyor shared concerns that R4 did not have a care plan initiated until 10/15/2024, when R4 was in the hospital, and that there were no orders for monitoring of R4's abdominal wound. Surveyor shared concerns that when R4 was readmitted to the facility on [DATE] R4's wound care orders/ monitoring was not imitated until 10/21/2024 and R4's care plan was not revised until 10/21/2024 and R4 was sent out to the hospital a second time on 10/23/2024 for potential abdominal incision infection. 42037 2.) R6 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure, Intestinal Perforation, Urinary Retention, Diabetes Mellitus and Malnutrition. R4's Admission Minimum Data Set (MDS) dated [DATE] indicated R6 had intact cognition with a BIMS score of 13. R6 was discharged from the facility on 10/13/24. Surveyor reviewed R6's closed medical record including progress notes, physician orders, laboratory reports and comprehensive care plan. A progress note by Licensed Practical Nurse (LPN)-Y dated 10/11/24 with a posted time of 11:23 PM documented the following: Resident was c/o (complaining of) emesis x 2 around dinner time, writer checked resident's vitals (stable) and notified NP (Nurse Practitioner). NOR (New Order Received) for CBC (Complete Blood Count) and BMP (Basic Metabolic Panel) and Zofran (An anti-nausea medication) 4 mg every 8 hours as needed. Surveyor requested R6's CBC and BMP lab results from 10/11/24 order. A progress note by LPN-Z dated 10/13/24 at 4:25 PM documented the following: Writer reviewed resident's blood work, writer immediately called on call MD. MD instructed the writer to take a full set of vitals. Vital signs viewed as the patient's baseline besides (sic) low diastolic blood pressure. The writer informed resident that he would be sent out to his hospital of choice for IV fluids and medications . On 10/13/24, R6 was sent to the hospital. R6 has not returned to the facility at this time. Surveyor reviewed R6's laboratory report from 10/12/24. Surveyor noted the WBC (White Blood Cell) reference range to be 4.0-10.8. p/mL (per milliliter), Sodium reference range of 137-146 mEq/L (milliequivalents per liter) and Potassium reference range of 3.6-5.0 mEq/L. On 10/12/24, R6's laboratory report results were documented as follows: WBC 19.24p/mL .sodium 127 mEq/L .potassium 2.7.mEq/L, On 10/29/24 at 12:35 PM, Surveyor conducted interview with LPN-Z. Surveyor asked LPN-Z what the procedure would be for arranging for laboratory blood draws at the facility. LPN-Z responded that the nurse that obtained the order should notify the laboratory company by faxing a requisition form with the resident's demographic information, diagnostic reason for laboratory test and physician's order. LPN-Z told Surveyor that if the Surveyor was interested in speaking about R6 that the only thing LPN-Z knew was that on 10/13/24 on PM shift, LPN-Z found R6's laboratory results and reported the abnormal lab results to the on call physician. Surveyor asked LPN-Z what they had meant by saying they found R6's laboratory results. LPN-Z responded that R6's laboratory results were at the nurse's station desk located by the 24 hour report board. Surveyor asked LPN-Z what the facility's expectation would be for reporting laboratory results to a physician. LPN-Z responded that abnormal laboratory results should either be reported to a physician by phone or their email at the time that the facility receives the laboratory results via fax or phone from the laboratory. Surveyor asked LPN-Z if they knew why there had been a delay in reporting R6's abnormal laboratory reports as the laboratory results were drawn on 10/12/24. LPN-Z remained silent at this time and did not respond to Surveyor's question. Surveyor concluded interview with LPN-Z at this time. On 10/30/24 at 1:09 PM , Surveyor conducted interview with LPN-Y via telephone. Surveyor asked LPN-Y what the procedure would be for arranging for laboratory blood draws at the facility. LPN-Y responded that the nurse that obtained the order should notify the laboratory company by faxing a requisition form with the resident's demographic information, diagnostic reason for laboratory test and physician's order. Surveyor asked LPN-Y if they recalled receiving the order for R6's laboratory tests from an NP on 10/11/24. LPN-Y told Surveyor that they remembered receiving orders for Zofran and lab work for R6. Surveyor asked LPN-Y if they recalled notifying the laboratory company of R6's physician orders for a CBC and BMP. LPN-Y told Surveyor that they did not recall if they had notified the laboratory company of R6's physician orders for a CBC and BMP. Surveyor asked LPN-Y what the facility's expectation would be for reporting laboratory results to a physician. LPN-Y responded that abnormal laboratory results should either be reported to a physician by phone or their email at the time that the facility receives the laboratory results via fax or phone from the laboratory. On 10/30/24 at 11:15 AM, Surveyor contacted the laboratory company's main telephone line. Surveyor conducted interview with Laboratory Assistant-AA via telephone. Surveyor asked Laboratory Assistant-AA to verify when the Laboratory had received the facility's laboratory requisition for R6's CBC and BMP labs. Laboratory Assistant-AA verified facility's laboratory requisition for R6's CBC and BMP labs was received via fax from facility on 10/12/24 at 4:02 PM. It was noted they were a stat order. Laboratory Assistant-AA told Surveyor that a phlebotomist from the laboratory had collected a blood sample from R6 on 10/12/24 at 5:20 PM. Laboratory Assistant-AA told Surveyor that R6's CBC results were faxed to the facility on [DATE] at 6:05 PM and that R6's BMP results were faxed to the facility on [DATE] at 7:34 PM. On 10/29/24 at 1:15 PM, Surveyor conducted interview with Unit Manager-M. Surveyor asked Unit Manager-M what the procedure would be for arranging for laboratory blood draws at the facility. Unit Manager-M responded that the nurse that obtained the order should notify the laboratory company by faxing a requisition form with the resident's demographic information, reason for laboratory test and a physician's order. Surveyor asked Unit Manager-M what the facility's expectation would be for reporting laboratory results to a physician. Unit Manager-M responded that abnormal laboratory results should either be reported to a physician by phone. Surveyor asked Unit Manager-M if they were aware that R6 had laboratory orders for a CBC and BMP with results on 10/12/24 including an elevated WBC (White Blood Cell) level of 19.24 p/mL, low sodium level of 127 mEq/L and low potassium level of 2.7 mEq/L not being reported to R6's physician until 10/13/24 at 4:20 PM, resulting in R6 being discharged to the hospital. Unit Manager-M told Surveyor when they heard that R6's laboratory results from 10/12/24 were not reported to R6's physician until the following day that they were very concerned and that there must have been a miscommunication among nursing staff. On 10/30/24 at 1:25 PM, Surveyor conducted interview with Acting DON-B. Surveyor asked Acting DON-B what the procedure would be for arranging for laboratory blood draws at the facility. Acting DON-B responded that the nurse that obtains the order should notify the laboratory company by faxing a requisition form with the resident's demographic information, reason for laboratory test and a physician's order. Surveyor asked Acting DON-B what the facility's expectation would be for reporting laboratory results to a physician. Acting DON-B responded that abnormal laboratory results should either be reported to a physician by phone or emailed to the physician on call. Surveyor asked Acting DON-B if they were aware that R6 had laboratory orders for a CBC and BMP with results on 10/12/24 including an elevated WBC (White Blood Cell) level of 19.24 p/mL, low sodium level of 127 mEq/L and low potassium level of 2.7 mEq/L not being reported to R6's physician until 10/13/24 at 4:20 PM, resulting in R6 being discharged to the hospital. Acting DON-B told Surveyor that they had spoken to the facility's medical director after they were made aware of R6's abnormal laboratory results and that if the Medical Director had been on call on 10/13/24 that the medical director would have managed R6's condition at the facility and would have not sent R6 to the hospital. On 10/30/24 at 1:30 PM, Surveyor shared concerns with Acting DON-B that R6's abnormal lab results that were received on 10/12/24 at 6:02 PM and 7:34 PM were not reported to R6's physician until 10/13/24 at 4:20 PM, leading to a delay in treatment for R6 which resulted in R6 being admitted to the hospital. Acting DON-B did not have any further information available for Surveyor at this time. On 10/30/24 at 1:45 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A that R6's abnormal lab results that were received on 10/12/24 at 6:02 PM and 7:34 PM were not reported to R6's physician until 10/13/24 at 4:20 PM, leading to a delay in treatment for R6 which resulted in R6 being admitted to the hospital. The facility did not have any further information available for Surveyor at this time.

Based on observation, interview and record review the facility did not ensure 3 (R40, R259 and R77) of 5 residents reviewed with pressure injuries had the necessary care and treatment to prevent and heal the pressure injuries. On 4/15/24 R40 developed a stage 2 pressure injury to the coccyx area and treatment orders were for zinc ointment to the area. On 4/24/24 the pressure injury worsened and was assessed to have 50% slough in the wound bed. The Wound Nurse Practitioner (NP)-L continued to stage the pressure injury as a stage 2 and continued the zinc ointment. R40's pressure injury continued to have slough and no signs of healing were identified. On 5/15/24 the pressure injury worsened to 90% slough and 10% granulation and stage 4. Wound NP-L then prescribed aquacel to the wound. On 5/22/24 Surveyor observed wound treatment with Wound NP-L. Wound NP-L assessed the wound at 60% slough and 40% granulation and stated the aquacel is doing it's job in healing the pressure injury. R40 developed a facility acquired Stage 4 pressure injury; Wound NP-L has been incorrectly staging the pressure injury and prescribing treatment for the wound that is not according to standards of practice causing the wound not to heal. R259 was admitted to the facility on [DATE] with a Foley catheter related to urine retention. R259 had no pressure injuries upon admission. R259 developed erosion to head of penis from the catheter. R259 was hospitalized and a suprapubic catheter placed. R77 developed a pressure injury and did not receive the care and treatment necessary for the healing of pressure injury. Findings include: The facility's Wound Management-Wound prevention and treatment policy dated 2/24/21 indicate: 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. The National Pressure Injury Advisory Panel (NPIAP) definition of staging pressure injury is as follows: Stage 1 pressure injury: non-blanchable erythema of intact skin . Stage 2 pressure injury: Partial thickness skin loss with exposed dermis. Partial thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist and may also present as an intact or ruptured serum filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present . Stage 3 Pressure injury: Full thickness skin loss Full thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury. Stage 4 Pressure injury: Full thickness skin and tissue loss Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon. ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury. Unstageable Pressure injury: Obscured full thickness skin and tissue loss Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance on the heel or eschemic limb should not be softened or removed. The NPIAP indicates for pressure injuries with slough to debride the pressure injury of devitalized tissue and suspected or confirmed biofilm and perform maintenance debridement until the wound bed is free of devitalized tissue and covered with granulation tissue. The significant Minimum Data Set (MDS) dated [DATE] indicates R40 has long and short term memory problems; no behavior concerns including no concerns for rejection of care; range of motion limitations of the upper extremity on one side; maximal assistance required for eating, dependent for toilet use, rolling from left to right, moving from sitting to lying, lying to sitting, sitting to standing and chair to bed transfers, always incontinent of bowel and bladder; at risk for the development of pressure injuries and no unhealed stage 1 or higher pressure injuries. The CNA (Certified Nursing Assistant) documented tasks indicate R40 is dependent for bed mobility. R40's care plan for impaired skin integrity indicates implement pressure reducing devices i.e w/c (wheelchair) cushion, air mattress, off loading heels, etc. dated 10/15/21. Turn and reposition every two hours and as necessary dated 10/6/21 The medical record indicates on 4/15/24, R40 was discovered with a Stage 2 pressure injury to the coccyx area measuring 0.9 cm (centimeters) by 0.7cm. 100% granulation tissue. The skin and wound evaluation dated 4/15/24 indicate New pressure area discovered during routine cares. No signs of pain or infection during assessment. Treatment orders in place per MD (Medical Doctor). The treatment orders dated 4/15/24 indicate for zinc ointment three times a day everyday. Wound (Nurse Practitioner) NP-L note dated 4/17/24 indicates R40's coccyx pressure injury is a stage 2 measuring 1 cm by 0.5cm by 0.1cm with 100% granulation tissue. The treatment orders indicate to continue with Zinc ointment three times daily. Wound NP-L note dated 4/24/24 indicates R40's coccyx pressure injury is a Stage 2 measuring 4.5cm by 1.5 cm by >0.1cm with 50% granulation tissue and 50% slough. The treatment orders indicate to continue with Zinc ointment three times daily. The TAR (treatment administration record) indicates on 4/24/24 the Zinc ointment was changed to three times a day every other day, instead of the prescribed daily order. Wound NP-L note dated 5/1/24 indicates R40's coccyx pressure injury is a Stage 2 measuring 4 cm by 1 cm by 0.4 cm with 80% granulation tissue and 20% slough. The treatment orders indicate to continue with Zinc ointment three times daily despite the TAR indicating the Zinc is being applied three times a day every other day. Wound NP-L note dated 5/8/24 indicates R40's coccyx pressure injury is now assessed as a Stage 4 measuring 2 cm by 4 cm by 0.4 cm with 50% granulation tissue and 50% slough. The treatment orders indicate to continue with Zinc ointment three times daily. Surveyor notes the TAR still indicates Zinc is being applied three times a day every other day. Wound NP-L note dated 5/15/24 indicates R40's coccyx pressure injury is a Stage 4 measuring 1.4 cm by 1.8 cm by 0.6 cm with 10% granulation tissue and 90% slough. The treatment orders have changed to Aquacel and a bordered dressing change daily. On 5/21/24, at 1:07 p.m., Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of QA (Quality Assurance)-D. Surveyor asked if any facility staff review Wound NP-L assessments and documentation. Director of QA-D stated the floor nurses and at times she will accompany the Wound NP-L on her rounds. Surveyor explained the concern Wound NP-L is not assessing the pressure injury correctly and is not providing treatment that is needed for slough in the wound according to current standards of practice. NHA-A and Director of QA-D had no additional information. On 5/22/24, at 12:04 p.m., Surveyor observed wound treatment provided to R40. Wound NP-L assessed the coccyx pressure injury. The measurements are 1.3 cm by 1.5 cm by 0.4 cm with 60% slough and 40% granulation tissue. Wound NP-L stated the aquacel is doing it's job. On 5/22/24, at 12:30 p.m., Surveyor interviewed Wound NP-L regarding R40 coccyx pressure injury. Surveyor asked Wound NP-L why she continued with the zinc ointment order until 5/15/24 even though R40's pressure injury had slough in the wound on 4/24/24. Wound NP-L stated she was relying on the facility staff to do more repositioning and keeping the area clean because R40 is incontinent. Surveyor asked Wound NP-L why she assessed the pressure injury as a stage 2 when there was present of slough and on 5/8/24 she assessed the pressure injury as a stage 4 when there was significant presence of slough. Wound NP-L stated that she probably should have assessed it as an unstageable pressure injury. No further information was provided. 38146 2) R259 admitted to the facility on [DATE] and had diagnoses that include Cerebral Infarction, Vascular Dementia, obstructive and reflux uropathy, Hypertension, vascular disorder of intestine, presence of urogenital implants, Hemiplegia and Hemiparesis following Cerebral Infarction, BPH (Benign Prostatic Hyperplasia), retention of urine, Diastolic (Congestive) Heart Failure, Atrial Fibrillation and Chronic Kidney Disease stage 3. R259's Admission Data Collection and Baseline Care Plan Tool dated 1/26/24 documents: Does the resident have any skin issues upon admission (i.e. scars, bruises, surgical sites, tube placements, rashes, open areas, pressure injuries, blister(s), etc? None of the above. R259's Care Plan documented: The resident has Urinary Catheter: Obstructive Uropathy, BPH, chronic urinary retention - initiated 1/30/24, revision on 2/5/24. Interventions included: -Monitor for s/sx (signs and symptoms) of discomfort on urination and frequency - initiated 1/30/24 revision on 4/29/24. -Monitor s/sx of catheter complications i.e. leaking, obstruction, etc. (etcetera) - initiated 1/30/24, revision on 4/29/24. -Monitor/document for pain/discomfort due to catheter - initiated 1/30/24, revision on 4/29/24. -Monitor/record/report to MD (medical doctor) for s/sx UTI (urinary tract infection): Pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns - initiated 2/5/24, revision on 4/29/24. R259's Admission Minimum Data Set assessment dated [DATE] documented no pressure injuries. Other ulcers, wounds and skin problems: No. Facility progress notes document: On 4/10/24, at 1:37 AM, CNA (Certified Nursing Assistant) reported to the writer that the resident's penis is swollen and inflamed, and red. Blood was present on his depends during the change. The writer went in to assess the resident to find him moaning and groaning in pain. Upon further assessment, the resident's penis is split open with bleeding at the site of injury and swelling present. No bleeding is present in the catheter drainage bag, urine is yellow, and free of odor and sedimentation. VSS (vital signs stable). BP (blood pressure) 146/76, pulse 71, SPo2 (oxygen saturation) 95 RA (room air) temperature 97.8. (Physician) was notified and ordered that the resident be sent out to the hospital. The resident's emergency contact was notified and DON (Director of Nursing). The progress note was entered by Registered Nurse (RN)-F. The Emergency Department (ED) AVS (after visit summary) dated 4/10/24 documented (in part) . .Your diagnosis is: Erosion of the urethra due to Foley catheter. Urology referral. Pt (patient) arrives via (ambulance) from (facility). Facility was changing pt depends when they notices a lac on penis. Pt is a chronic Foley user. A&O (alert and oriented) x 2 at baseline. Penis not bleeding upon arrival. Urology assessed clinical image. Likely chronic urethral erosion. Pt okay for outpatient workup. Will likely need suprapubic catheter on outpatient basis. Subsequent facility progress notes document: On 4/10/24, at 8:42 AM, The resident returned to the facility around 0600 (6 AM) from (hospital) via (ambulance). The resident was diagnosed with urethral erosion due to prolonged use of a urinary catheter. No medical treatment was provided, resident was referred to a urologist for further treatment. The resident currently resting in the room with no complaints. On 4/10/24, at 8:47 AM, The Resident's daughter called for an update and wants her father to be sent out again to the hospital for treatment and pain control management. The writer and administrator explained to the daughter that the hospital might not provide any treatments and that further evaluation must be done by a urologist. Per the daughter's orders, the resident was sent out again to (hospital). R259 was admitted to the hospital. The hospitalist history and physical documents (in part) . . presented to the hospital today due to penile pain. Staff at his facility reportedly noted a laceration on his penis yesterday which was felt to be due to chronic erosion from his Foley. Penis with swelling noted. Large erosion of catheter into ventral aspect of penis with erythema. Malodor noted with some beefy redness. Assessment/Plan: Penile laceration with shaft erosion and partial Paraphimosis (common urological emergency that occurs in uncircumcised males when the foreskin becomes trapped behind the corona of the glans penis. This can lead to strangulation of the glans and painful vascular compromise, distal venous engorgement, edema and even necrosis). Recommendation for suprapubic placement tomorrow. R259 readmitted to the facility on [DATE]. On 4/13/24, at 12:02 AM, Admission/Re-Admission Summary: Resident readmitted back to facility on 4/12/24, at 1700 (5:00 PM). Resident returned from stay at hospital where a suprapubic catheter was placed d/t (due to) penile wound causing shaft erosion d/t Foley catheter. Suprapubic cath was placed on 4/11/24. Resident has no c/o (complaint of) pain/discomfort. Will require catheter exchange and upsize in 4-6 weeks. Suprapubic cath is draining well. Wound care orders for posterior penile shaft meatal opening. R259's April 2024 Treatment Administration Record documented: Wound Care for penile laceration with shaft erosion and partial paraphimosis: Cleanse with hypochlorous solution/Vashe and gauze soaking for 5 minutes. Pat dry. Place silver alginate/Melgisorb AG to affected area. Cover/secure with 2 inch roll gauze. Follow with light Coban wrap. Change daily and PRN (as needed). One time a day for penile wound - start date 4/13/24. Surveyor's review of R259's medical record revealed no evidence of an assessment or measurements of R259's penile wound upon readmission to the facility on [DATE]. The first documentation of an assessment/measurements were on the facility Skin Impairment/Wound Evaluation form dated 4/16/24 which documented: Open lesion Penis, Left, Medial, Middle 4.6 x 3.9 x 1.6 cm (centimeters). There was no description of wound characteristics. The most recent Skin Impairment/Wound Evaluation form dated 4/24/24 documented: Meatus/penis 1.1 x 3.8 x 0.1 cm. 100% granulation. R259 discharged to another Skilled Nursing Facility on 4/26/24. Surveyor asked the facility twice for documentation for April 2024 regarding evidence of R259's catheter care. No information was provided. On 5/22/24, at 12:04 PM, Surveyor spoke with Registered Nurse (RN)-F who reported she normally worked with R259. Surveyor asked about the night of 4/10/24. RN-F reported when the aid called her to the room, R259 was having moderate bleeding from the end of his penis, where the catheter was resting on the skin. Surveyor asked if it looked like a cut or trauma. RN-F stated: No, it was like a crater where the tubing rested. When I talked to the doctor he told me that sometimes happens when residents have a catheter, if the tubing is laying against a surface of the penis head, it will erode. Surveyor asked RN-F if she recalled seeing erosion from the catheter on R259's penis prior. RN-F stated: No, this was the first time, but I don't usually do his cares, I'll just check to make sure he has urine output and stuff like that. I know that it (referring to the erosion) wasn't there when he admitted , and when I talked to his daughter she said he never had that before. Surveyor asked if R259 was wearing a lock or leg strap to keep the Foley tubing secure. RN-F stated: I don't remember. On 5/22/24, at 1:47 PM, Surveyor advised Director of Nursing (DON)-B of concern regarding R259's pressure injury/penile erosion from the Foley catheter. Surveyor asked if the facility completed an investigation as to the cause of the erosion/pressure injury or if there was any additional information. No additional information was provided. Surveyor noted there was no documentation regarding penile erosion/pressure injury or issues with R259's penis or catheter upon admission to the facility on [DATE]. The facility did not recognize the erosion/pressure injury to R259's penis from the Foley catheter prior to 4/10/24. The facility was unable to provide evidence of Foley catheter care provided. There was no evidence the facility completed an investigation as to the cause of the penile erosion/pressure injury. In addition, there was no evidence of a comprehensive assessment or measurements of R259's penile erosion/pressure injury upon readmission to the facility until 4/16/24. 16584 3) R77 was originally admitted to the facility on [DATE] with diagnosis that included Hemiplegia and Hemiparesis, type 2 diabetes, morbid (severe ) obesity, depression. Chronic kidney disease, pressure ulcer left buttock (stage 3) 9/9/23. Major depressive disorder, anemia. Admission Braden assessment was completed 10/6/23 with an assessed score of 17, indicating R77 is at risk for pressure ulcer development. The most current Braden assessment completed due to significant change of condition on 5/14/24 is a score of 14- moderate risk. Surveyor conducted a review of R77's plan of care which documents the resident has potential for impairment to skin r/t morbid obesity w/ BMI>40, dx DM, hx CVA, depression, dysphagia, HTN, anemia Date Initiated: 10/05/2022, Revision on: 05/02/2024 o The resident will maintain or develop clean and intact skin by the review date. Date Initiated: 10/05/2022, Revision on: 04/15/2024,target Date: 08/24/2024 Revision on: 10/06/2022 o encourage and assist resident to Turn and position q2-3hrs and prn. resident often refuses to reposition. requires many cues and encouragement. aware of risks of not repositioning. reapproach as needed Date Initiated: 12/22/2022 o Encourage and assist to elevate heels off surface of bed using heel lift boots, pillows or heels up device Date Initiated: 10/06/2023 o Encourage good nutrition and hydration in order to promote healthier skin Date Initiated: 10/05/2022 o Encourage resident to float heels. Date Initiated: 12/22/2022 o Follow facility protocols for treatment of injury. Date Initiated: 10/05/2022 o Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. Date Initiated: 10/05/2022 o Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable Nursing note dated 3/29/2024 05:47 a.m.; Skin/Wound Note Text: While assisting an aide with cares writer noticed that the resident (R77) had a couple open areas on her buttocks. Cleaned area and applied some skin protection. Further review of the record did not provide information as to how many areas had been observed and if a comprehensive assessment had been conducted by a registered nurse. There was also no documentation that the physician had been notified and an order for treatment had been obtained. On 5/21/24 at 3:00 p.m., Surveyor interviewed Administrator- A and Director of Nursing- B regarding the nursing note on 3/29/24 stating that R77 had a couple of open areas on her buttocks. Administrator- A stated that she would need to review the chart and would get information to the Surveyor. Surveyor was provided with a skin and wound evaluation, dated 4/2/24. The evaluation indicates that R77 has a pressure ulcer , stage #2, to the rear right thigh, in-house acquired. The assessment is blank for the question- how long has the wound been present? Exact date is also blank. Wound measurements are 2.0 centimeters by 7.2 centimeters by 1.8 centimeters. 100 % granulation. Section H of the evaluation pertains to the treatment. The only box checked is -other. The evaluation does not state what treatment is being used for wound healing. Practitioner notified- yes and resident/ representative notified- yes. Surveyor was provided with a skin and wound evaluation, dated 4/2/24. The evaluation indicates that R77 has a pressure ulcer, stage #2, to the left gluteus. The evaluation does indicate if the wound was acquired in-house or present on admission. The assessment is blank for the question- how long has the wound been present? Exact date is also blank. Wound measurements are 6.6 centimeters by 4.9 centimeters by 1.8 centimeters. 100 % granulation. Section H of the evaluation pertains to the treatment. The only box checked is -other. The evaluation does not state what treatment is being used for wound healing. Practitioner notified- yes and resident/ representative notified- yes. Surveyor asked Administrator- A for clarification if the above assessments where from the areas observed on 3/29/24. Administrator- A stated that she was not sure and that what she could gather is R77 developed a new pressure ulcer on 4/2/24 which healed 5/1/24 and reopened 5/8/24. Further review of R77's medical chart showed that the facility did not update R77's plan of care until 5/16/24, indicating that R77 now has a Stage #3 pressure ulcer to the right buttock and left buttock. R77's plan of care states: R77 has one Stage 3 Pressure Ulcer to her Right Buttock and one Stage 3 Pressure Ulcer to her Left Buttock area. She has MASD's to her Bilateral Breasts Date Initiated: 05/16/2024, Revision on: 05/16/2024 Interventions include: o The resident's will Pressure ulcer will show signs of healing and remain free from infection by/through review date. Date Initiated: 05/16/2024, target Date: 08/24/2024 o Inform the resident/family/caregivers of any new area of skin breakdown. Date Initiated: 05/16/2024 o Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length X width X depth), stage. Date Initiated: 05/16/2024 A review of the treatment orders for R77 showed that on 4/9/24 an order was received for wound care for buttocks : Cleanse with soap and water ; Apply zinc ; 3x . Offload, clean dry skin every shift. On 5/22/24 at 11:00 a.m., Surveyor interviewed Director of Quality Assurance regarding R77's treatment to her buttocks. Director of QA- D stated that CNA's are able to apply barrier cream. Nursing is to ensure that the Zinc treatment is applied daily. Nursing works with the CNA's when there is an incontinence episode to ensure the Zinc is applied after cares are completed. Nursing documents daily that the treatment is complete. On 05/22/24 a 12:15 PM , Surveyor made observations of R77 receiving wound care from the nurse practitioner. Observed all areas of buttocks, groin and gluteal. NP said, you're skin is looking a lot better, there's only 1 area left on your right butt and it's barely open. Area cleansed, dried, measured: 0.6 x 0.3 x 0.1 cm. Wound bed red, no slough or necrosis. No active drainage or odor. No redness to surrounding skin. Layer of Zinc Oxide 20% applied to area and surrounding buttocks of previous open areas. Interview w/NP following TX: Asked about facility documentation 3/29 regarding couple area on buttocks w/no assessment, measurements. Then 4/2 documented right rear thigh and L gluteal wounds. NP stated, that must've been what they were referring to, but those areas are healed. Why pictures clearly indicate 3 separate wounds, but you measure as 1? I measure wounds that are in close proximity as 1 wound, but I will document that there is 3 separate wounds. NP reported residents' wounds are a bit of both MASD complicated by pressure. Feels her wounds are likely unavoidable because she is resistant to changing and turning/repositioning. As of the time of exit, the facility was not able to provide additional information as to why a comprehensive assessment was not completed for R77 on 3/29/24 when facility staff observed a couple of areas to the buttocks. The facility did not provide additional information as to why a treatment order was not obtained on 3/29/24 and why the physician wasn't notified. In addition , there was not further information as to why the plan of care was not updated until 5/16/24 to reflect that R77 had developed areas to the right and left buttocks.

Based on observation, interview and record review the facility did not ensure 2 (R26 and R81) of 21 residents had acceptable care and treatment. R26 had an appointment to have a cystoscopy and left ureter stent removal on 2/29/24. R26 did not make it to that appointment and another appointment was scheduled on 4/11/24 for the same procedure. R26 did not make it to the 4/11/24 appointment due to being transferred to the hospital for a change in condition. The hospital record indicates R26 was admitted with sepsis and had the stent removed. The facility has no evidence R26 was educated on risk and benefits of canceling the 2/29/24 appointment for the stent removal. The facility has no evidence R26's urologist was consulted regarding R26 canceling the 2/29/24 stent removal appointment. R81 developed blisters on their buttocks that were not comprehensively assessed upon discovery. There was not an assessment to determine causative factors with interventions. Findings include: 1.) R26 was admitted to the facility on [DATE] with diagnoses of hydronephrosis due to obstruction of ureter, nephrolithiasis, pyelonephritis and type 2 diabetes. The quarterly MDS (Minimum Data Set) assessment dated [DATE] indicates R26 is cognitively intact. On 5/19/24, at 9:50 a.m., Surveyor interviewed R26. R26 did not have any concerns with her care at the facility. Surveyor reviewed R26's medical record and discovered an appointment letter indicating on 2/29/24 R26 was to have a cystoscopy and left stent removal. The medical record does not indicate if R26 went to for the procedure on 2/29/24 and if R26 did not go to that procedure there is no documentation the urologist was made aware of this cancellation. R26's medical record documented another appointment letter for a rescheduled appointment on 4/11/24 for a cystoscopy and left stent removal. Nurses note dated 3/29/24 indicate R26 was complaining of significant pain and R26 was transferred to the hospital. The hospital record indicate R26 was admitted to the hospital for septic shock and had a right flank abscess. The hospital record also indicates R26 was supposed to have a stent removed from the left ureter and R26 had missed multiple appointments. On 5/22/24, at 9:21 a.m., Surveyor interviewed Nursing Home Administrator (NHA)-A regarding R26. Surveyor asked NHA-A why did R26 not go to the 2/29/24 appointment. NHA-A stated she would look into it. On 5/22/24, at 4:30 p.m., during the exit meeting with NHA-A, Director of Quality Assurance-D and Director of Nursing (DON)-B, NHA-A stated R26 refused to go to the appointment. Surveyor asked if there is any documentation of this refusal. Surveyor asked if R26's urologist was made aware of R26's refusal to go to the appointment. Surveyor stated there is no documentation R26 was made aware of the risk vs benefits of not going to get the stent removed. NHA-A stated she would provide documentation. After the final exit with the facility, Surveyor received a typed up summary dated 5/24/24 indicating R26 is her own person and makes her own appointments and rides with the assistance of Community Care. The facility also provided a late entry note back dated to 2/29/24, written by Director of Quality Assurance-D indicating R26 canceled appointment on this date for cystoscopy/stent removal due to being sick. Resident was in isolation for pneumonia was symptomatic and taking antibiotics. Community care was notified and requested appointment be rescheduled. The facility did not provide any documentation R26 was provided risk vs benefits of rescheduling the stent removal. The facility did not provide any documentation regarding notifying R26's urologist of the missed appointment with the stent removal and if the facility needed to do any additional monitoring until R26 could have the stent removed. 21855 2.) On 5/19/24, at 10:56 AM, Surveyor spoke with R81 in their room. R81 indicated they have no bedsores, however has pimples on their buttock with pus. R81 was observed on 5/19/24, 5/20/24 and 5/21/24 without a fitted sheet on their bed. R81 has an air mattress on with a ill-fitted flat sheet underneath them. R81's medical record was reviewed by Surveyor. R81 has a Skin Impairment/Wound Evaluation completed on 5/20/24 by (Licensed Practical Nurse) LPN-I. This indicates a blister (does not indicate type) with 100% granulation (pink/red bumpy tissue that forms in the wound bed) on the superior left buttock measuring 1 cm (centimeter) by 1.4 cm and the left inferior buttock measuring 0.5 cm by 0.5 cm. There are Physician orders on 5/20/24 for: Wound Care for left inferior buttock: Cleanse with saline, apply medihoney to wound every day, f/b (followed by) foam border dressing every day. every day shift for wound care; Wound Care for left superior buttock: Cleanse with saline, apply medihoney to wound every day, f/b foam border dressing every day. R81's Skin Impairment/Wound Evaluation does not indicate the type or appropriate characteristic of a blisters. There is 100% granulation which indicates a wound bed. There is no information on possible causative factors or revisions in care. On 5/21/24, at 9:13 AM, Surveyor observed LPN-I complete the wound treatment on R81's buttocks. LPN-I did don PPE (personal protective equipment) and indicated it was for enhanced barrier precautions. There was no indications when entering R81's room they were on enhanced barrier precautions. R81 does require staff assistance for dressing and incontinence care. R81 indicated the blisters popped yesterday and LPN-I put a bandage on it. The day before the staff applied zinc cream. On 5/21/24, at 11:57 AM, Surveyor spoke with (Director of Nurses) DON-B. DON-B indicated initial skin assessments are done by the floor nurse, which typically are (Licensed Practical Nurse) LPN's. DON-B indicated an LPN is doing the skin assessment and a RN (Registered Nurse) has 24 hours to put eyes on the resident to assess. The staff nurses do not update the plan of care. The Wound (Nurse Practitioner) NP comes on Wednesday's and will update the plan of care and the DON will update it. Surveyor shared the only assessment information in R81's medical record is the LPN documentation of 2 blisters with granulation. There is no other information. On 5/21/24, at 3:04 PM, at the facility Exit Meeting with Nursing Home Administrator-A, (Director of Nurses) DON-B, (Chief Innovative Officer) CIO-H and (Director of Quality Assurance) DQA-D. Surveyor shared the concerns with R81's blister assessment. No further information was provided. R81's medical record was again reviewed by Surveyor. There was a Nurses Note documented on 5/21/2024, 6:08 PM, which states: Note Text: IDT (interdisciplinary team) meeting s/p (status post) resident new skin issue (blisters) - Root cause analysis, Resident is independent with bed mobility. Resident often encouraged to reposition/turn to relieve pressure off of her back/buttock. Resident stated she frequently gets blisters and informed the nurse that she may possibly have a blister prior to skin assessment. 2 abrupted blisters noted upon assessment. Resident has no other noted skin issues/impairments. Nursing intervention - Resident currently has air mattress d/t (due to) decreased mobility and size. MD updated on skin impairment and order entered for treatment daily. Resident re-educated on importance of turning/off-loading for pressure injury prevention. Resident verbalized understanding. Care plan reviewed and updated.

Based on observation, interview, and record review, the facility did not ensure 4 residents (R67, R18, R40 & R11) at risk for or with a history of falls had comprehensive assessments to prevent falls and the completion of root cause analysis with possible care plan revisions to prevent future falls. -R67 was at risk for falls. R67 obtained head lacerations requiring hospital sutures on 2/10/24 and 3/26/24 following falls within the facility. On 2/17/24 a hospital evaluation was needed post fall for a possible head injury. The falls were not comprehensively assessed, the interventions were not reviewed to determine effectiveness or to determine if revisions were needed to prevent future falls. -R18, who is dependent on staff for bed mobility, sustained a fall out of bed on 2/3/24. R18 was found on the floor with tube feeding coming out of her mouth. R18 was sent to the hospital. The facility did not thoroughly investigate the fall despite R18 being dependent upon staff for bed mobility. R18 developed aspiration pneumonia as a result of aspirating on tube feeding formula during the fall. -On 5/14/24, R40 had a fall from bed with an intervention of bolsters in bed. During survey, bolsters were not observed on the bed. -R11 was lowered to the floor on 4/6/24 while being assisted by 1 staff member. Surveyor could not determine if R11's transfer status at the time of their fall was accurate based off of conflicting interviews with staff throughout the survey. R11 was transferred off the floor by 3 staff members when the Hoyer lift was broken and unable to raise R11 off the floor. During the 3 person transfer a pop/crack sound was heard. R11 was hospitalized on [DATE] with a minimal displaced fracture of the 9th thoracic vertebrae. Findings include: The facility's Falls policy and procedure, revised 5/17/2021, was reviewed by Surveyor. The policy indicates that all residents will receive adequate supervision, assistance, and assistive devices to prevent falls. Each resident will be evaluated for safety risks, including falls and accidents. Care plans will be created and implemented based on the individual's risk factors to aid in preventing falls. All falls will be investigated and monitored. 1.) R67's medical record was reviewed by Surveyor. Review of the record indicates R67 had 3 falls in the past 3 months. R67 has medical diagnoses of epilepsy and dementia. R67's Annual MDS (minimum data set) assessment completed on 4/16/24 indicates a BIMS (Brief Interview for Mental Status) score of 5, indicating severe cognitive impairment. The MDS indicates R67 uses a wheelchair and is independent in rolling left and right, going from sitting to lying and from lying to sitting on the edge of the bed. R67 requires partial/moderate assistance for transfers from chair to bed and supervision/touch assistance for toilet transfers and walking 10 feet. The Fall Assessment Section indicates R67 had 2 or more falls without injury, 1 fall with minor injury, and 1 fall with major injury since last Quarterly MDS assessment completed on 1/18/24. The 1/18/24 Quarterly MDS indicates the same functional data for R67 as the 4/16/24 MDS assessment. However, it does not reflect R67 as having falls since the prior assessment as the 4/16/24 MDS indicates. R67's current plan of care for falls, initiated 4/13/22 with a Goal Date of 7/23/24, include the following interventions: -10/24/22 staff not to leave room when resident is on toilet. -9/27/22 ensure all needs are met prior to exiting the room. -9/1/23 helmet to protect head from seizure activity. Resident will remove per self. -7/15/22 fall mat. -4/14/22 ensure the resident is wearing appropriate footwear. -8/11/23 encourage resident to remain in high traffic areas during waking hours. -9/18/23 resident to be toileted upon rising, before and after meals, at bedtime and as needed. On 5/19/24 at 10:07 AM, Surveyor observed R67 awake in bed. R67 had a low bed against the wall with a landing strip (flat mat) next to the bed. R67 did not have any head protection on or around them in bed. On 5/20/24 at 8:47 AM, Surveyor observed R67 in the dining room. R67 was dressed, sitting in a wheelchair. R67 had shoes on with socks. R67 did not have anything on their head. On 5/21/24 at 7:45 AM, Surveyor observed R67 was dressed and sitting in a wheelchair. R67 had shoes on with socks. R67 was observed to not have anything on their head. R67 had the following falls in the facility per Nurses Notes and Facility Fall Investigations: * On 2/10/24 at 11:00 PM, R67 was found in bed with blood on the bed and floor. R67 was sent to the hospital via 911 and received sutures. R67 was unable to state what happened. R67 had a recent room change. Staff statements indicated R67 was toileted an hour before the fall and had gripper socks on. The call light was not activated; staff heard R67 call out for help. The intervention upon return from the hospital was 1:1 supervision. The plan of care for Falls initiated 4/13/2022 indicates for revision: - 2/12/24 a sleep study, 2/12/24 body pillow resolved (started 7/15/22), 2/12/24 gripper socks on and walker at bedside resolved (started 4/21/22), 2/12/24 (revised) helmet to protect head from seizure activity and resident will remove per self (started on 9/1/2023 helmet to protect head from seizure activity). R67's Sleep Study from 2/12/24 - 2/14/24, Indicates the resident sleeps during the day and does not want a sleeping medication. There was no fall intervention change made related to the outcome of the sleep study. R67's fall was not comprehensively assessed to indicate if fall interventions were in place at the time of fall to determine effectiveness. * On 2/17/24 at 4:00 PM, staff heard a noise and R67 was discovered in their bathroom. Resident went unresponsive for 10 seconds then started talking. There was no injury however, R67 went out to the hospital for further evaluation. The hospital performed suture removal from previous fall. The hospital performed lab work and a head scan. The Fall Investigation does not indicate what interventions were in place or information from staff of events prior to the fall. Surveyor noted R67's care plan indicates to not leave the room when R67 is toileting. The plan of care for Falls initiated 4/13/2022 indicates a revision: -2/17/24 fall intervention for evaluation. Valproic acid drawn in the emergency room . The plan of care for ADL (activity of daily Living) self-care performance deficit related to weakness and falls initiated 4/13/2022 indicates: -3/24/2023 started 1:1 at all times for fall prevention/safety. This was noted as resolved on 3/26/24. R67's fall was not comprehensively assessed to indicate if fall interventions were in place at the time of fall along with the completion of a root cause analysis of the fall to prevent future falls. * On 2/28/24 at 3:32 PM, staff heard a noise and R67 was on the floor in their bathroom. There was no injury. The Fall Investigation indicates R67 was in bed prior to the fall and was toileted at 1:30 PM. R67 did not have anything on their feet. The fall interventions in place at the time of the fall is resident on (sic) chair in high traffic area. The immediate intervention was R67 was toileted, transferred with a Hoyer lift to a chair in a high traffic area. Another staff statement indicated R67 transferred themselves to the wheelchair, was standing in the bathroom, and was transferred onto the toilet. Then R67 was transferred out to the main dining room. R67's bed was in the lowest position and they had gripper socks on. R67 Nurses Note indicates: On 2/28/2024 at 5:45 PM Note Text: The writer hear a noise and rushed to the resident's (R67). upon arrival, the resident was sitting on his butt, facing the toilet seat, his back against the wall. Unit manager called, vitals within the resident's range. No injury, mechanical Hoyer used to put the resident back to safety. Surveyor noted R67 had a care planned intervention to be on 1:1 supervision at this time that is not referenced as being implemented. Surveyor also noted R67 is not to be left alone while going to the bathroom according to R67's care plan. The plan of care for ADL (activity of daily Living) self-care performance deficit related to weakness and falls initiated 4/13/2022 indicates: -3/24/2023 started 1:1 at all times for fall prevention/safety. This was resolved on 3/26/24. The plan of care for Falls initiated 4/13/2022 indicates: -2/28/24 review medication. R67's fall was not comprehensively assessed to indicate if fall interventions were in place at the time of fall and a root cause analysis was not completed. * On 3/26/24 at 2:50 AM staff heard a noise. Resident yelling out help in their room. R67 had a gash to the back of their head. Staff applied pressure to area, took R67 to the bathroom, then removed their gown and got them dressed. R67 was sent out to the hospital and received sutures to their head. The Staff Statement indicates R67 wanted to go to the bathroom and 3 staff assisted. The only fall interventions mentioned was the floor mat was not in place at the time of the fall. There is no indication of other interventions in place at the time of the fall, nor what R67's events were prior to the fall. The plan of care for ADL (activity of daily Living) self-care performance deficit related to weakness and falls initiated 4/13/2022 indicates: -3/24/2023 started 1:1 at all times for fall prevention/safety. This was resolved on 3/26/24. (There is no information regarding 1:1 and being resolved on 3/26/24.) The plan of care for Falls initiated 4/13/2022 indicates: -3/26/24 staff member providing care to leave bathroom door cracked when resident is toileting and remain outside of cracked door for safety. -3/26/24 toilet resident twice during the night and prompt toileting during wake hours. Surveyor noted according to R67's care plan R67 should have had 1:1 supervision at the time of this fall and should not have been left unsupervised in the bathroom. On 5/20/24 at 3:00 PM, at the facility Exit Meeting with Administrator-A, (Director of Nurses) DON-B, (Chief Innovative Officer) CIO-H and (Director of Quality Assurance)DQA-D, Surveyor asked who to discuss R67's fall assessments with noting there is new Administration staff. CIO-H indicated to speak with (Licensed Practical Nurse) LPN-G who is a full-time nurse on R67's unit. On 5/21/24 at 9:40 AM Surveyor spoke with LPN-G. LPN-G indicated R67 has not been on their unit long. They encourage R67 to be in the wheelchair. They have never seen a helmet used by R67. At night R67 has a sitter. On 5/21/24 at 3:04 PM at the facility Exit Meeting with Administrator-A, (Director of Nurses) DON-B, (Chief Innovative Officer) CIO-H and (Director of Quality Assurance)DQA-D. Surveyor shared concerns with R67's fall assessments and interventions. DON-B indicated they (R67) takes off the helmet themselves. On 5/22/24 at 9:14 AM Surveyor observed R67 wearing a helmet, dressed, and seated in a wheelchair in the dining room/common area. Surveyor spoke with CIO-H who was present. Surveyor asked CIO-H about R67's falls and interventions to prevent falls. CIO-H shared R67 was 1:1 for supervision at night awhile ago. CIO-H thought during one of the falls staff was in the room and the bathroom door was closed. CIO-H wasn't sure which fall this happened on or what the 1:1 parameters (duration) were for R67 or why discontinued. On 5/22/24 at 9:54 AM Surveyor spoke with (Director of Rehab) DR-N. DR-N indicated R67 is actively in speech therapy for swallowing concerns. DR-N will provide Therapy Notes. R67 had physical therapy on 12/5/23 for an evaluation. R67 was not a therapy candidate. R67 frequently self transfers and ambulates in their room. Supervision has been recommenced due to poor safety and cognition, repeated falls and seizures. On 5/22/24 at 10:37 AM (Director of Quality Assurance) DQA-D provided Surveyor with 1:1 information. DQA-D indicated the 1:1 started on 3/24/23 and was resolved on 3/26/24. DQA-D was not part of the conversation to resolve the 1:1 on 3/26/24. DQA-D did not have any further information. 20025 2.) R18 was admitted to the facility on [DATE] with diagnoses of quadriplegia, type 2 diabetes, gastrostomy and anoxic brain damage. The annual Minimum Data Set (MDS) dated [DATE] indicates R18 is cognitively impaired and is always incontinent for bowel and bladder. The Certified Nursing Assistant (CNA) documentation indicates R18 is dependent for bed mobility. The physician orders dated 11/28/22 indicates R18 receives continuous tube feeding at a rate of 55ml/hr (milliliters/hour). The physician orders dated 2/8/24 indicates R18 is to have the head of the bed elevated 30 to 45 degrees at all times during feeding and at least 30 to 40 minutes after the feeding is stopped. R18 care plan with initiation date of 11/25/22 indicates R18 is at risk for falls. The at risk for falls care plan has the following interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Date initiated 11/25/22 Educate the resident/family /caregivers about safety reminders and what to do if a fall occurs. Date initiated 2/12/24 Follow facility fall protocol. Date initiated on 11/25/22 with revision on 1/9/23. Replacement of air mattress. Date initiated 2/12/24 Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. Date initiated 2/12/24 Surveyor noted there are no individualized interventions for R18 despite being at risk for falls. A nurses note dated 2/2/24 at 3:24 a.m. indicates R18 fell out of bed. The nurses notes state Upon writer doing rounds at 0300, writer entered resident's room to check tube feed and noted that resident was on the floor between her window and her bed. Her head, upper body, and left leg were on the ground and her right leg was resting on the bed still. Writer noticed a pool of tube feeding formula around resident's head on the ground and quickly unhooked tube feed to further assess. Noted that there was no leaking tube feed formula coming out from tube feed site but instead from nose and mouth d/t (due to) the way resident was laying on floor. Resident heavily breathing and could hear the rasping in her breathing. Resident rolled on to her side and it was noted resident was holding tube feed formula in her mouth. Able to get out of mouth and cleared nasal passage. Resident hoyered back into bed in a sitting position. Unable to obtain BP, Pulse: 126 O@: 93% on RA, R:16. Ambulance called for transport to ED. The nurses note dated 2/2/24 indicate the IDT met regarding this fall and determine the fall may have been caused by the air mattress and the facility replaced the air mattress. The note does not specify what was wrong with the mattress or when the mattress was last checked. The hospital documentation dated 2/2/24 indicates R18 was found with left sided infiltrate and was started on antibiotics for the pneumonia as a result of aspiration during the fall. On 5/20/24 Surveyor reviewed the facility's investigation into R18's 2/2/24 fall. The fall investigation had a summary of the nurses note dated 2/2/24. The investigation did not indicate if staff were interviewed, when was R18 last rounded on, what made the IDT think there was an issue with the air mattress and how or if the bed moved away from the wall so that R18 could fall between the bed and the wall. The investigation does not indicate if the air mattress was properly inflated and a stable surface for R18. It also does not include details on whether the head of the bed was elevated and if elevated was it at the correct elevation per physician orders. On 5/20/24 at at 3:14 p.m. during the daily exit meeting with DON-B, NHA-A and Director of QA-D, Surveyor explained the concern R18 is dependent for bed mobility and was found on the floor between the bed and the wall with tube feeding coming out of her mouth. Surveyor explained the concern the facility did not do a thorough investigation into R18's fall which resulted in hospitalization for pneumonia. 3.) R40 was admitted to the facility on [DATE] with diagnoses of dementia, cerebral aneurysm, hypertension and atrial fibrillation. The significant change MDS dated [DATE] indicates R40 is cognitively impaired and is always incontinent of bowel and bladder. The CNA documentation indicates R40 is dependent for bed mobility. R40's care plan indicates at risk for falls r/t (related to) impaired mobility, dementia, incontinence and medication regimen with initiate date of 10/6/21. The following are the interventions for the at risk for falls care plan: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Date initiated 10/6/21 Bolsters on air mattress date initiated 5/15/24 Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Date initiated 10/6/21. Ensure that the resident is wearing appropriate footwear. Date initiated 10/6/21. PT evaluate and treat as ordered or PRN. Date initiated 10/15/21. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate resident/family/caregivers/IDT (interdisciplinary team) as to causes. Date initiated 10/15/21. The nurses note dated 5/14/24 indicates R40 had a fall out of bed and her fall interventions of low bed and mat on the floor were in place at the time of the fall. The note indicates R40 had a red bruise to the right side of the forehead and was sent out to the hospital due to R40 being on blood thinners and hitting her head. The hospital record indicates no injuries were noted from the fall. Surveyor reviewed the fall investigation and the facility's investigation revealed R40 can move around in bed at times and despite the low bed and mat on the floor R40 did fall out of bed. The IDT (interdisciplinary team) indicates bolsters to the bed was initiated as a fall intervention. R40's care plan was updated to indicate bolsters on air mattress with date initiated on 5/15/24. During the survey, Surveyor observed R40 to be in bed with low bed and mat on the floor but the air mattress did not have bolsters. On 5/20/24 at at 3:14 p.m. during the daily exit meeting with Director of Nursing (DON)-B, Nursing Home Administrator (NHA)-A and Director of Quality Assurance (QA)-D, Surveyor explained the concern R40 is dependent for bed mobility and was found on the floor and the intervention was for bolsters on the bed following a fall. Surveyor explained during the survey no bolsters were observed on R40's bed. As of 5/22/24 Surveyor was not provided any additional information. 42037 4.) R11 was admitted to the facility on [DATE]. R11's diagnoses include Ankylosing Spondylitis, muscle weakness and chronic pain. R11's Significant Change Minimum Data Set (MDS) Assessment with Assessment Reference Date (ARD) of 4/13/24 R11's admission MDS with ARD of 8/28/23 indicates that R11 required substantial to maximal assistance with changing from sitting to standing position and bed to wheelchair transfers requiring use of a walker and 1 staff assist. At the time of R11's Admission, R11's MDS triggered for CAA (Care Area Assessment) for mobility and falls. R11's Quarterly MDS Assessment with ARD 2/14/24 indicates that R11 required substantial to maximal assistance with changing from sitting to standing position and bed to wheelchair transfers requiring use of a walker and 1 staff assist. R11's Significant Change MDS Assessment with ARD of 4/13/24 indicates a Brief Interview of Mental Status (BIMS) Score of 15 indicating that R11 is cognitively intact and able to participate in daily decision making. R11 was unavailable for interview at the time of survey. The MDS indicates R11 did not have any falls within the previous 6 months and requires substantial to maximal assistance with changing from sitting to standing position and bed to wheelchair transfers requiring use of a mechanical lift. At the time of assessment, R11's MDS triggered for CAA for mobility and falls. R11's activities of daily living (ADL) care plan with a initiation date of 8/28/23 and revision date of 4/11/24 indicated that R11 had initially required an assist of 1 and a gait belt for transfers. On 4/11/24, care plan reflects that R11 requires use of a EZ stand lift with 2 assist. Surveyor reviewed R11's medical record. The facility provided Surveyor with a Facility Reported Incident regarding R11 being lowered to the floor by Certified Nursing Assistant (CNA)-V during a transfer on 4/6/24 at approximately 12:30 PM. R11 had complained of a pop in their back at the time of incident while waiting to be transferred from floor to chair. R11 was assisted off of the floor at this time by CNA-V, CNA-W and Agency RN-Y with a gait belt. The Facility's self-report indicated that R11 complained of severe back pain on 4/6/24 at approximately 4:00 PM. R11 was sent to the emergency room where it was identified that they had sustained a unspecified minimally displaced fracture of the 9th thoracic vertebrae. On 5/21/24, Surveyor requested to interview Agency RN-Y. Nursing Home Administrator (NHA)-A told Surveyor that they would attempt to contact Agency RN-Y. Surveyor was unable to conduct an interview with Agency RN-Y during the survey. On 5/21/24 at 2:29 PM, Surveyor conducted an interview with CNA-W. Surveyor asked CNA-W what their involvement had been in providing care for R11 on 4/6/24. CNA-W told Surveyor that they weren't very familiar with R11, was not aware of R11's transfer status and that they had not witnessed R11's lowering to the ground. CNA-W told Surveyor that they had helped CNA-V and Agency RN-Y get R11 back to their wheelchair from the floor. Surveyor asked how R11's transfer from floor to wheelchair had been completed. CNA-W told Surveyor that they had gotten a Hoyer lift to help R11 from the floor but that the Hoyer lift would not reach down low enough to transfer R11. CNA-W told Surveyor that CNA-V, Agency RN-Y and themselves utilized a gait belt to help R11 back to their wheelchair. Surveyor asked CNA-W what the facility's protocol is for transferring residents off the floor. CNA-W told Surveyor that they would typically utilize a Hoyer lift for safety to transfer someone from the floor. CNA-W added that they would not have attempted to move R11 from the floor manually had the Hoyer lift been working properly. On 5/22/24 at 8:49 AM, Surveyor conducted interview with CNA-V. Surveyor asked CNA-V what their involvement had been in providing care for R11 on 4/6/24. CNA-V told Surveyor that they had been assigned as R11's caregiver on 4/6/24 but they had usually worked on a different assignment. Surveyor asked CNA-V if they recalled what R11's transfer status had been on 4/6/24. CNA-V told Surveyor that they had checked R11's CNA Kardex which had indicated that R1 was a 1 assist not specifying how the transfer was to be completed other than by 1 staff. Initially CNA-V said they had gotten a sit to stand lift in R11's room to use to transfer them but R11 told them that they were a 1 assist. CNA-V told Surveyor that they always follow each resident's Kardex to know how to care for the resident. CNA-V had then attempted to transfer R11 from bed to wheelchair when R11's knees began to buckle. CNA-V told Surveyor that they slowly lowered R11 to the floor at this time. CNA-V then went to R11's doorway to holler for help. CNA-V told Surveyor that R11 told them at this time that they felt a crack in their back. CNA-W and Agency RN-Y came at this time to R11's room. CNA-W had brought a Hoyer lift to utilize to lift R11 from the floor. CNA-V told Surveyor that the Hoyer lift would not reach all the way down to the floor and it wasn't working properly. CNA-V told Surveyor that Agency RN-V had assessed R11 at this time and did not note any obvious injuries. CNA-V told Surveyor that CNA-W, Agency RN-Y and themselves had manually lifted R11 off the floor at this point and back to the wheelchair. Surveyor asked CNA-V what the facility's protocol for lifting residents from the floor would be after a fall. CNA-V told Surveyor that they usually will use a Hoyer lift to transfer someone from the floor. CNA-V added that they were later told by a staff member in administration that R11 should have been an EZ stand lift with 2 assist prior to being lowered to the floor on 4/6/24 per therapy recommendations. CNA-V told Surveyor that they did not reprimanded for R11's fall because CNA-V had been following R11's care plan as they had been trained to do during orientation. CNA-V told Surveyor that R11 is currently requiring an EZ stand lift for transfers and was able to verify this on R11's current CNA kardex. On 5/21/24 at 2:35 PM, Surveyor conducted interview with Licensed Practical Nurse (LPN)-X. Surveyor asked LPN-X if a resident is observed on the floor how staff should be transferring them back to safety. LPN-X told Surveyor that no matter what, if a resident is observed on the floor after a fall that staff should use a Hoyer lift with a 2 assist to help the resident back to safety. On 5/22/24 at 11:20 AM, Surveyor conducted interview with Director of Rehab-N. Surveyor asked with Director of Rehab-N if they were familiar with R11. Director of Rehab-N told Surveyor that they were not super familiar with R11 but feel like R11 had been discussed at morning stand up meetings at facility. Surveyor asked Director of Rehab-N if they were aware of any discussion of R11's transfer status requiring a sit to stand lift prior to their fall on 4/6/24. Director of Rehab-N told Surveyor that from what they knew of R11 that they think a sit to stand lift with a 2 assist by staff would have been most appropriate prior to their hospitalization in April 2024. Director of Rehab-N was unable to verify R11's transfer status from previous therapy documentation for Therapy dates of Service from 12/7/23-3/25/24. On 5/22/24 at 1:15 PM, Surveyor conducted interview with Director of Nursing (DON)-B and Director of Quality Assurance (QA)-D. Surveyor asked what protocol should be followed if a resident is observed on the floor. DON-B told Surveyor that the resident should be assessed for injuries, that vital signs should be obtained and that neurological checks should be conducted if a resident has an unwitnessed fall or if they were noted with a head or scalp injury. Surveyor asked if the facility's protocol requires staff to utilize a Hoyer lift to safely get residents off the floor after sustaining a fall. DON-B responded that that would be an appropriate thing to do. DON-B added that R11 would definitely need a Hoyer lift to get off of the floor safely due to their transfer capabilities. On 5/22/24 at 3:15 PM, Surveyor conducted interview with Nursing Home Administrator (NHA)-A. Surveyor shared concerns that there had been conflicting information from staff regarding R11's transfer status prior to their fall on 4/6/24. Surveyor shared that there were additional concerns related to R11 feeling a pop/crackling sensation in their back, being assisted back to their wheelchair without use of a Hoyer lift and R11 subsequently being sent to the emergency room where they were noted with a thoracic fracture. No additional information was provided to Surveyor by the exit of the Survey.

Based on observation, interview and record review, the facility did not ensure that residents with a pressure injury (PI) or at risk for PIs received necessary treatment and services, consistent with professional standards of practice, to prevent the development of PIs and to promote healing for 5 of 6 residents (R) reviewed for PIs. (R3, R17, R4, R2, and R18) R3 was admitted to the facility without any PIs. R3 developed multiple stage 3 PIs, and recurrent PIs, one of which developed into a stage 4 PI. The facility had no positioning program for off-loading pressure and inconsistent assessments of the multiple PIs. This resulted in 3 hospitalization s over the last 2 months due to deteriorating wound condition. R17 was admitted to the facility without any PIs. R17 developed a stage 2 PI to the left heel and a deep tissue injury (DTI) PI to the sacrum. The facility had no positioning program for off-loading pressure, an inappropriate mattress, heels observed without heel boots in place, and inadequate protein and hydration to promote healing of PIs. This resulted in R17's left heel PI declining to a stage 4 and sacrum PI declining to a stage 3 PI. Facility failure to implement interventions to prevent development of PIs and promote healing of pressure injuries for R3 and R17 including the failure to develop a positioning program for off-loading pressure, the failure to provide appropriate pressure reducing devices, and the failure to ensure adequate nutrition created a finding of immediate jeopardy that began on 08/22/23. Nursing Home Administrator (NHA) A and Director of Nursing (DON) B were notified of the immediate jeopardy on 10/05/23 at 12:45 PM. The immediate jeopardy was removed on 10/06/23 however the deficient practice continues at a scope/severity of D based on the following examples. R4 was admitted to the facility with a stage 3 PI. R4 did not receive daily wound treatments as ordered by the physician. R2 developed a facility-acquired pressure injury on 07/25/23 which the facility documented as being resolved on 08/08/23. There were no additional interventions incorporated to prevent additional wounds from developing. R18 was admitted to the facility without any PIs. R18 developed a facility acquired stage 3 PI to the right ischial tuberosity which recently healed on 09/26/23. R18 has current moisture associated skin damage (MASD) to left buttocks. R18 was not repositioned consistent with professional standards of practice to prevent development or recurrence of PIs. Findings include: According to the National Pressure Injury Advisory Panel (NPIAP) Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, 2019, Reposition all individuals with or at risk of pressure injuries on an individualized schedule, unless contraindicated. Determine repositioning frequency with consideration to the individual's level of activity and ability to independently reposition. Reposition the individual in such a way that optimal offloading of all bony prominences and maximum redistribution of pressure is achieved. Example 1 R3 was admitted to the facility on [DATE] with diagnoses, in part of traumatic subdural hemorrhage without loss of consciousness, altered mental status, severe protein-calorie malnutrition, unspecified dementia, Alzheimer's dementia with early onset, anemia, and vitamin D deficiency. According to R3's admission Minimum Data Set (MDS) assessment, dated 07/28/23, R3 had severe cognitive impairment and required extensive assistance of one person for bed mobility and toileting and required extensive assistance of two persons for transfers. R3 was frequently incontinent of urine and always incontinent of bowel. R3 was assessed at risk for developing PIs but had no unhealed PIs at the time of admission. R3 had a Braden risk assessment completed on 07/28/22 with a score of 19, which meant at risk for developing PIs. R3's care plan included the following focus area: .The resident has potential/actual impairment to skin integrity venous stasis, resident will picking [SIC] and scratch at skin. hx [history] of refusal of nail care. 10/27/22-bloodfilled blister RT [right] heel-unstageable-changed to stage 3-12/27/22, changed to unstageable 01/10/23 (resolved 03/21/23) .04/19/23 pressure ulcer to coccyx (resolved 04/25/23) 04/30/23 nodule to buttocks (changed to stage 3 PU [pressure ulcer] 05/02/23 (resolved 05/23/23) reopened 06/14/23 as MASD. Date initiated: 07/22/22, date revised: 06/14/23 . This focus area has the following interventions, in part, .10/27/22-heel boots on at all times-may remove to assess skin and cares q [every] shift and prn [as needed] .Provide pressure relieving device: APM [alternating pressure mattress] to bed and cushion to chair. Date initiated: 12/20/22. Turn and position as necessary Date initiated: 07/28/22, revision date: 10/27/22 . The Certified Nursing Assistant (CNA) care plan noted the following areas, in part: .Bed Mobility: The resident requires extensive assistance x 1 staff to turn and reposition in bed .Toilet use: The resident requires total assistance by (1) staff for toileting .Skin care: 10/27/22-heel boots on at all times-may remove to assess skin and cares q [every] shift and prn [as needed] .Provide pressure relieving device: APM [alternating pressure mattress] to bed and cushion to chair . Surveyor noted there was no scheduled frequency for turning, repositioning, or toileting noted on either the comprehensive care plan or the CNA care plan. Surveyor also noted there was no update or revision in the turning and repositioning interventions when R3 developed PIs to include off-loading of pressure areas or repositioning frequency. Record review identified R3 developed a PI to the right heel on 10/27/22, which progressed to a stage 3 PI and resolved on 03/21/23. The record further identified a skin/wound note, dated 04/19/23, Aide alerted floor nurse to development of a new area on resident's coccyx. Wound care RN assessed. NP [Nurse Practitioner] alerted and wound care MD [medical doctor] contacted for tx [treatment] orders. Floor nurse contacted POA [Power of Attorney] for update. 04/19/23 Skin and wound evaluation identified the wound as a new in-house acquired Stage 3: Full-thickness skin loss pressure injury to the coccyx measuring 4.2 centimeters (cm) long by 0.8 cm wide, and no measurable depth. The wound bed was described as 30% epithelial and 70% granulation. No evidence of infection with light serosanguinous drainage and no odor. This is the first mention of a stage 3 PI to the coccyx. 04/25/23 Skin and wound evaluation identified stage 3 PI to coccyx measured 2.6 cm by 1.2 cm with 100% of wound covered, surface intact. The note indicated no drainage. The wound care physician documentation from same date noted moderate serosanguinous drainage and recommended Zinc ointment apply 3 times per day and as needed; off-load wound; Reposition per facility protocol: Group-2 mattress. Surveyor noted there was no revision in the turning/repositioning intervention on R3's care plan at that time. Resident had an alternating pressure mattress on bed since 12/20/22. 04/30/23 Skin Impairment/Wound Form identified R3 did not have a PI. The note identified R3 had a nodule on Sacrum. There was no measurement of the nodule with wound bed noted as 100% epithelial and no drainage. No treatments were noted on the documentation. 05/02/23 Skin and wound evaluation noted a stage 3 PI to the coccyx with start date of 04/19/23. Wound measured 2.1 cm by 2.9 cm with no measurable depth. Wound bed 20% epithelial and 80% granulation tissue. No signs of infection with moderate serosanguinous drainage. Wound physician documentation from same date noted wound progress deteriorated. New wound treatment orders for Leptospermum honey apply to wound bed and cover with foam silicone border dressing daily. Again, wound MD recommended Off-load wound; Reposition per facility protocol; and Group-2 mattress. Surveyor noted there was no revision in the turning/repositioning intervention to include off-loading pressure to wound, or a turning schedule on R3's care plan at that time. 05/09/23 Skin and wound evaluation and wound MD note identified stage 3 PI to coccyx measured 1.5 cm by 1.1 cm with no measurable depth. Wound status improving with no changes to treatment orders. 05/16/23 Skin and wound evaluation noted stage 3 PI to coccyx measured 1.0 cm by 0.8 cm with wound bed 90% epithelial and 10% granulation. Light serosanguinous drainage. No assessment by wound MD and no changes to treatment. 05/23/23 wound assessment by nurse and wound MD noted stage 3 PI to coccyx resolved. No noted updates to care plan related to skin care or turning or repositioning schedule to prevent recurrence of PI to coccyx. 06/14/23 Skin Impairment/Wound Form noted non-pressure MASD to R3's left buttock measuring 5.2 cm by 3.6 cm by 0.1 cm deep. Wound bed was described as 100% pink and moist with scant serosanguinous drainage. No treatment was noted on the document. No change in skin plan of care noted. 06/20/23 Skin and wound evaluation noted Incontinence Associated Dermatitis (IAD) to left gluteus measuring 4.8 cm by 1.1 cm with no measurable depth. Wound bed 100% granulation with moderate amount of serosanguinous drainage. The wound MD documentation from same date described the wound as non-pressure MASD to sacrum. New treatment orders for leptospermum honey to wound with gauze island border dressing daily. MD recommendations for off-load wound, reposition per facility protocol and group-2 mattress. No changes were made to skin/wound care interventions to include off-loading wound and repositioning schedule. 06/27/23 Skin and wound evaluation noted IAD to left gluteus measured 2.1 cm by 1.4 cm with no measurable depth. The wound bed was now noted to have 50% granulation and 50% slough which is a noted deterioration of the wound bed. The note identified moderate serosanguinous drainage. MD documentation note for the same date for non-pressure MASD to sacrum noted same assessment as the nursing assessment but noted no change in wound progress even though there was newly identified slough in the wound bed. No changes were made to treatment orders or wound/skin interventions on care plan. No wound assessments with measurements were documented between 06/27/23 to 07/11/23. 07/11/23 Skin wound evaluation IAD to left gluteus measured 2.1 cm by 2.3 cm with no measurable depth. The wound bed was noted to have 70% granulation with 30% slough and moderate serosanguinous drainage. Wound MD documentation for non-pressure MASD to sacrum noted same measurements and wound bed description. Wound progress documentation noted no change even though the wound measurements identified a 0.9 cm increase in width of the wound. No changes were made to treatments. 07/18/23 Skin wound evaluation of IAD to left gluteus and wound MD documentation for non-pressure MASD to sacrum noted measurement 1.5 cm by 1.1 cm with 100% granulation in wound bed and moderate serosanguinous drainage. No changes made to wound treatment or care plan interventions for wound/skin care. 07/25/23 There was no nursing skin wound evaluation documentation found on R3's medical record. The wound MD documentation for that date noted MASD to sacrum measured 1.5 cm by 1.0 cm by 1 cm deep. This was a noted deterioration in wound since the previous assessment indicated there was no measurable depth to the wound. Treatment orders were modified to include alginate rope to the previous daily wound treatment. No changes were made to R3's care plan interventions to include off-loading pressure or scheduling a turning or toileting plan. 08/01/23 Skin wound evaluation of IAD to left gluteus noted wound measured 1.2 cm by 1.2 cm by 1.6 cm deep. This was another notable increase in depth of the wound bed. Wound bed was described as 100% granulation with moderate serosanguinous drainage and no signs of infection. The wound MD documentation for the same date now described the wound as stage 3 pressure injury to sacrum. The measurements and wound bed are the same as nursing assessment. Wound treatment orders changed to alginate rope and gauze packing strips (iodoform) covered by a gauze island dressing with border daily. No changes were made to R3's care plan interventions to include off-loading pressure or scheduling a turning or toileting plan. This is the first note indicating a stage 3 PI to sacrum. It is unclear if this a recurrence of the stage 3 PI of the coccyx first identified on 04/19/23. 08/08/23 Skin wound evaluation now identified the wound as stage 3 PI to left gluteus, instead of MASD, with measurements of 1.3 cm by 1.8 cm by 2.5 cm. This was another significant increase in depth of the wound. There was noted increased purulent drainage with a faint odor. There was no documentation of undermining or tunneling in the wound measurements. R3 was sent to the hospital for evaluation of deteriorating wound with signs of infection. Hospital documentation did not provide any description of wound or measurements. Due to no fever, elevated white blood cell count, or other signs of infection, R3 was not treated with antibiotics for wound infection at the hospital. R3 was discharged back to the facility on [DATE] with wound care orders to pack the wound with Dakins 1/4 strength dampened packing strip beginning with the circumferential undermining and cover with a super absorptive dressing daily. 08/15/23 Skin wound evaluation of stage 3 PI to left gluteus noted measurements of 0.9 cm by 1.2 cm by Not Applicable for depth, however previous measurement noted depth of wound 2.5 cm. The wound MD documentation for stage 3 PI to sacrum for same dated noted a wound depth of 1.1 cm. Wound bed described as 100% granulation with moderate serosanguinous drainage. Wound treatments were increased to twice per day with Dakins 1/4 strength gauze packing. No changes were made to R3's skin/wound care plan interventions to address off-loading, turning/repositioning schedule, or toileting/incontinence care schedule. 08/22/23 Skin wound evaluation of stage 3 PI to left gluteus noted measurements of 0.8 cm by 0.6 cm by 2.4 cm. There was no mention of undermining or tunneling of the wound. The skin wound evaluation on the same date also identified 2 new wounds, a stage 4 PI to left gluteus measuring 1.0 cm by 0.8 cm by 0.8 cm. No undermining or tunneling was noted and wound bed described as 80% granulation and 20% slough with moderate serosanguinous drainage. The third wound described as a new stage 3 PI to left iliac crest measuring 1.0 by 0.5 cm with no measurable depth. 08/22/23 Documentation from wound MD described R3's wounds as follows: Stage 3 PI sacrum with same measurements and descriptions as nursing assessment of stage 3 PI to left gluteus. New stage 3 PI of left hip measuring 0.98 cm by 0.53 cm by 0.1 cm. New unstageable (due to necrosis) of the left buttock measuring 0.98 cm by 0.8 cm by 0.8 cm. New treatment orders were initiated for the two newly identified facility acquired pressure injuries. No changes were made to R3's care plan interventions to include off-loading pressure or scheduling a turning or toileting plan. 08/28/23 Skin wound evaluation for stage 3 PI left gluteus noted measurements of 1.5 cm by 1.0 cm by 2.0 cm with newly documented undermining of 10 cm. Wound bed 100% granulation with increased serosanguinous drainage with faint odor. There was no documentation for the previously identified stage 4 PI to left gluteus. The stage 3 PI to left iliac crest measured 0.9 cm by 0.6 cm by 1.8 cm depth and 10.0 cm undermining. The measurements one week previous noted no measurable depth or undermining to this wound. R3 was sent to the hospital due to deteriorating wound condition. Hospital discharge summary, dated 08/30/23, noted in part, .left sacral decubitus ulcer with associated large (8cm) subcutaneous air and debris filled collection extending to the bone. No fistula to rectum. Currently on Vancomycin [antibiotic]. Patient previously admitted [DATE] to 8/9/23 due to similar concerns from wound care nurses at assisted living facility .Left buttock wound was first assessed by wound care team on 08/09/23. At that time, it measured 1cm x 0.6cm x 2.4 cm and was stage IV . The wound was surgically debrided on 08/29/23 and resident as discharged back to the facility on [DATE]. There were no discharge measurements or description of wound following debridement. 08/31/23 Skin wound documentation identified stage 4 PI to left gluteus resolved due to surgical debridement and opening of all three wounds into one large wound. Stage 3 PI of left gluteus measured 5.6 cm by 1.1 cm by 2.4 cm with 1.5 cm undermining and 3.0 cm tunneling. Wound bed 90% granulation with moderate serosanguinous drainage. R3 showed signs of pain rated 4 on PAINAD scale requiring pre-medication prior to treatment. 09/05/23 Skin wound documentation for stage 3 PI of left gluteus noted wound measured 5.7 cm by 2.3 cm by 5 cm deep with no undermining and 3.0 cm tunneling. Wound bed 100% granulation with moderate serosanguinous drainage. R3 showed signs of pain rated 3 on PAINAD scale requiring pre-medication prior to treatment. 09/05/23 Wound MD documentation for stage 3 PI of sacrum noted measurement 5.66 cm by 2.3 cm by 5 cm. No tunneling or undermining measurements were documented. The stage 3 PI of left hip was noted resolved. The unstageable wound to left buttock was noted resolved. Wound treatment was changed to wound vac treatment change three times per week. No changes were made to R3's care plan interventions to include off-loading pressure or scheduling a turning or toileting plan. 09/12/23 Skin wound evaluation of stage 3 PI to left gluteus noted measurement of 3.9 cm by 1.6 cm by 3.5 cm with no undermining and 4.5 cm of tunneling. This was an increase of 1.5 cm in tunneling since previous measurement. R3 showed signs of pain rated 4 on PAINAD scale requiring pre-medication prior to treatment. 09/12/23 Wound MD documentation now noted to be a stage 4 pressure wound of sacrum. This is the first note indicating the PI to the sacrum had deteriorated to a stage 4. The measurements matched nursing assessment and measurements of stage 3 PI to left gluteus, except noted undermining 4 cm at 6 o'clock and no mention of tunneling. Wound vac treatment continued the same except the addition of leptospermum honey to peri wound. No changes were made to R3's care plan interventions to include off-loading pressure or scheduling a turning or toileting plan. 09/19/23 Skin wound evaluation of stage 3 PI to left gluteus noted measurements 3.8 cm by 1.5 cm by 2.5 cm, no undermining and 5.0 cm tunneling noted. Wound bed 100% granulation with moderate serosanguinous drainage. 09/19/23 wound MD documentation of stage 4 PI to sacrum noted same measurements and wound description as above nursing assessment, except noted 4 cm undermining at 6 o'clock and no mention of tunneling. The wound MD documentation also included a new unstageable deep tissue injury (DTI) of right buttock. Wound treatment for that area was initiated. No changes were made to R3's care plan interventions to include off-loading pressure or scheduling a turning or toileting plan. 09/26/23 Skin wound evaluation now staged the PI to left gluteus as stage 4 with measurements 3.1 cm by 1.2 cm by 3.5 cm with no undermining or tunneling noted. Wound bed 100% granulation with moderate serosanguinous drainage. The nursing skin wound evaluation also identified a new stage 3 PI of the right gluteus measuring 4.0 cm by 3.9 cm with no measurable depth, undermining or tunneling. Wound bed 100% granulation with moderate serosanguinous drainage. 09/26/23 wound MD documentation of stage 4 PI of sacrum with same measurements as nursing assessment of stage 4 PI of left gluteus, except noted 4 cm undermining at 6 o'clock. Wound vac treatment discontinued, and calcium alginate covered by ABD pad twice per day ordered. The previously described DTI of right buttock now described as stage 3 PI. Measurements and wound description same as nursing assessment from same date. Wound treatment added calcium alginate daily. Nursing note dated 10/02/23, identified R3 was transferred to the hospital .due to pustula [SIC] on right buttock, enlarged darkened sacral wound bed area, increased malus odor and increased drainage. Hospital discharge note dated 10/04/23, noted CT scan of abdomen showed New right sacral decubitus ulcer since 08/28/23. Improving left sacral decubitus. New small subcutaneous gas and fluid collection at the L4-L5 level could be a additional ulcer or extension of one of the lower sacral decubitus ulcers . On 10/03/23, R3 had Excisional Debridement of sacral decubitus ulcer, including necrotic skin, subcutaneous tissue, and fascia to level of presacral fascia, total of 96 sq cm . Discharge diagnosis decubitus ulcer of sacral region, unstageable. Wound measurements on day of discharge 14 cm by 4 cm by 3 cm. R3 returned to the facility with an indwelling Foley catheter and orders for wound vac dressing changes to sacrum twice per week. On 10/03/23 at 2:18 PM, Surveyor interviewed R3's spouse who reported they felt R3's wounds were directly related to poor care at the facility. R3's spouse stated when they came to visit, R3 was always lying on his back in soiled briefs and R3's roommate told R3's spouse he had been laying like that for hours. R3's spouse stated they had to ask the staff to come in and change R3's brief and reposition R3 because they would never come in the room unless they asked and R3 could not push the call light or speak for himself. R3's spouse stated they had talked to the head nurse about their concerns and stated they needed to check on the aides on all shifts to verify they were turning and changing R3, but R3 did not believe any changes were made. R3's spouse stated the sores on R3's bottom just keep getting worse and this is the third time R3 had been in the hospital since the beginning of August due to the wounds. On 10/04/23 at 8:55 AM, Surveyor interviewed R7, who was R3's roommate for several months. R7 stated they were very concerned about R3 because the wound on R3's bottom kept getting worse and this was the third time R3 was in the hospital because of it. R7 stated it smelled so bad like it was rotting. R7 stated the night shift would neglect R3 because R3 could not speak for himself and push the call button. R7 stated they would often not check and change or turn R3 for the entire night shift. R7 stated sometimes R7 would put the call light on and ask the staff to please change R3 because it smelled so bad of urine and stool. R7 stated they would check, change, and turn R3 maybe a couple of times per shift on the day and evening shifts. On 10/04/23 at 1:41 PM, Surveyor interviewed Director of Nursing (DON) B about what interventions were in place prior to R3 developing the PIs to his bottom and what interventions they changed when R3 had recurrent or deteriorating PIs. DON B stated R3 had an Alternating Pressure Air mattress on the bed since last December and had been receiving Ensure nutritional supplements three times per day since admission. Surveyor asked how often R3 was provided with incontinence cares and repositioned to off load pressure from wounds. DON B stated staff was supposed to check R3 every two hours, but R3 was often resistant to cares and repositioning. Surveyor asked for documentation showing staff provided incontinent cares and repositioning every two hours. On 10/04/23 at 3:30 PM, Surveyor received documentation of CNA Tasks: Skin Care/Monitoring and Bladder Function for the last two weeks. The skin care task stated, Barrier cream applied after cleansing with each incontinent episode and as needed during shift. 09/21/23 yes checked at 2:49 PM and 10: 29 PM. 09/22/23 yes checked at 2:29 PM and 10:29 PM. 09/25/23 yes checked at 2:29 PM and 10:29 PM 09/26/23 yes checked at 2:29 PM and 10:29 PM 09/30/23 yes checked 2:29 PM 10/01/23 yes checked at 2:29 PM 10/02/23 yes checked at 2:29 PM The Bladder function task had urinary incontinence marked one time on 9/21/23, one time on 9/22/23, twice on 9/25/23, one time on 9/26/23, one time on 9/29/23, one time on 10/01/23 and one time on 10/02/23. The documentation had no evidence of frequent positioning or incontinence cares for R3 to prevent PIs from developing or to promote healing of the current PIs. On 10/04/23 at 7:44 AM, Surveyor interviewed CNA I who reported R3 had returned from the hospital last evening with a Foley catheter. CNA I reported that prior to R3's recent hospitalization she would check on him first at the start of her shift because she would often find him in double briefs and saturated in urine and sometimes stool. CNA I stated it appeared R3 had not been attended to for the entire night shift. CNA I stated they did not have specific instructions for how often R3 was supposed to be checked, changed, and repositioned, but she tried to do it every 2 hours when she worked. CNA I stated she knew that did not happen every shift, especially the night shift. CNA I stated R3 never refused or resisted cares or repositioning. On 10/05/23 at 8:55 AM, Surveyor interviewed Med Tech (MT) R, who reported R3 was receiving Ensure supplements with meals for many months, and usually drank all of it. MT R stated R3 was getting Pro Stat protein supplement twice per day for wound healing, but that had only been for about the past month. MT R stated R3 was always incontinent and supposed to be turned and changed regularly, but MT R did not think that happened regularly on evening and night shifts. MT R stated R3 refused or resisted cares. 47284 Example 2 The facility policy, entitled Wound Management - Wound Prevention and Treatment, dated 5/09/22, states: .Protecting against external mechanical forces: All residents who are in bed and have been assessed to be at risk for skin breakdown should be repositioned at least every two hours (unless a tissue tolerance test indicates otherwise). This repositioning should also take place when residents are in a chair or wheelchair . .Pressure redistribution devices: Residents who are constantly immobile should have pressure reducing devices used to totally relieve pressure on heels and raise the heels completely off the bed . .Proper side lying position: Don't ever position a resident directly on their side or trochanter. This 90-degree position will cause breakdown on the hip. Position a resident at a 30-degree angle when they are to turn on one side or the other. Side lying position does not literally mean on the side, it means the right or left side of the body will be slightly raised to get it off the bed. This is accomplished by placing the body at a 30-degree angle to the bed . .Limit time in chairs: All residents at risk for skin breakdown should avoid long periods of sitting in a chair without being repositioned .According to the Agency for Healthcare research and Quality (AHRQ) guidelines, the resident should be repositioned, shifting the points under pressure at least every hour or be placed back in bed .Momentary lift or shift in position of less than one minute may not be enough for capillary refill to take place . .Ensure adequate nutrition and hydration: Poor diet intake can play a role in pressure ulcer development and delayed healing. Therefore, it may be necessary to supplement a resident's diet with protein and vitamins. A nutritional evaluation should be completed on all residents in order to maintain skin integrity and prevent pressure ulcer development. A resident with a pressure ulcer who continue to lose weight either needs additional caloric intake or correction (when possible) of conditions that are creating a poor nutritional state . R17 was admitted to the facility on [DATE] without any pressure injuries. On 07/07/23, R17 developed a stage 2 left heel PI. On 08/15/23, R17's left heel PI became larger in size with necrotic tissue present. On 08/29/23, R17's left heel PI was debrided of the necrotic tissue to reveal stage 4. As of 10/05/23, R17's left heel PI continued to be stage 4. On 9/12/23, R17 developed a DTI to the sacrum. On 09/26/23, R17's sacrum PI charted as a stage 3. As of 10/05/23, R17's sacrum PI continued to be a healing stage 3. R17's diagnoses in part included traumatic subdural hemorrhage, cerebral infarction, hemiplegia, and hemiparesis to left non-dominant side, muscle weakness, polyneuropathy, cognitive communication deficit, and mild neurocognitive disorder. R17's admission MDS (minimum data set) assessment dated [DATE]: Brief Interview of Mental Status (BIMS) was 14, cognitively intact. Functional status: extensive assist of 2+ people for bed mobility, extensive assist of 2+ people for transfers, extensive assist of 2+ people for toileting; frequently incontinent of urine; always incontinent of bowel; assessed to be at risk for developing PI, no unhealed PI on admission, pressure relieving devices in chair and bed. R17's quarterly MDS assessment dated [DATE]: BIMS was 12, moderately impaired. Functional status: activity only occurred once or twice with 1-person physical assist for bed mobility, extensive assist of 2+ people for transfers, activity only occurred once or twice with 1-person physical assist for toileting; frequently incontinent of urine; always incontinent of bowel; assessed to be at risk for developing PI, 1 unstageable PI slough/eschar, pressure relieving devices in chair and bed, nutrition/hydration intervention and PI care. R17's Braden risk assessment completed on 05/23/23 had a score of 14, which meant moderate risk for developing PIs. On 06/09/23 score of 14, moderate risk. On 06/27/23 score of 16, which meant at risk for developing PIs. On 08/30/23 score of 14, moderate risk. R17's care plan included the following focus area: 1.The resident has potential / actual impairment to skin sacrum stage 3, left heel stage 4 integrity (Started 05/23/23 and last revised with current wounds on 10/03/23). Interventions for this plan included the following: Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of injury. Identify/document potential causative factors and eliminate/resolve where possible. Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs of infection, maceration etc. to MD [Medical Doctor]. Obtain blood work if any open wounds as ordered by Physician. Turn and position as necessary . These interventions were in place on 05/23/23 and 05/25/23. No other interventions for impaired skin integrity were added to R17's care plan as the PI on heel worsened and new sacrum wound started and worsened. 2.The resident has an ADL [Activity of Daily Living] self-care performance deficit (start date 05/23/23). Interventions for this problem area included: The resident requires assistance by 1 staff to turn and reposition in bed. The resident requires assistance by 1 staff for toileting. The resident requires sit to stand and 2 staff members to transfer . R17's Wound Documentation and Orders: Left Heel: On 07/07/23, on the Skin Impairment/Wound form, the facility documented the development of a new stage 2 PI to R17's left heel that measured 7.8 centimeters (cm) x 7 cm with scant serous drainage.Current wound/skin treatment/interventions: Elevate heels. Wound education provided: Writer [RN M] told resident to try to elevate her heels . Wound Care to the left heel: Apply Dakin's-soaked gauze to affected area and wrap with kerlix. two times a day for wound care. Started 07/07/23, end 07/13/23. On 07/13/23, on the Skin Impairment/Wound form, the facility

Based on interview and record review, the facility did not maintain acceptable parameters of nutritional status, such as usual body weight for 3 of 7 (R17, R2, and R12) residents reviewed for nutritional status. R17 is cited at severity level 3. R17's nutritional interventions and care plan were not revised or implemented to address R17's decreased food and fluid intake. This resulted in an unplanned severe weight loss of 13.65% in 4 months and impaired wound healing, as R17 developed a stage 4 and stage 3 Pressure Injury (PI). R2 was admitted with a high risk for weight loss and malnutrition. There was no evidence documented that the facility made attempts to encourage or assist R2 with her meal intakes, no weight monitoring, and no care plan interventions to attempt or assist R2 with improving meal intakes. R12 was admitted with diagnoses of malnutrition, unintended weight loss, and poor appetite. R12 had orders to be weighed weekly. The facility obtained one weight during R12's admission (05/05/23 - 06/08/23.) Findings include: The facility policy entitled, Nutrition/Hydration Status Maintenance, dated 01/01/21, states: The facility will ensure that a resident: -Maintains acceptable parameters of nutritional status (such as usual body weight or desirable body weight range and electrolyte balance .) -Is evaluated and nutritional needs are addressed on an individual basis. -Receive a therapeutic diet as ordered and the facility should take into account the resident's clinical conditions and preferences. -Offered sufficient fluid intake to maintain proper hydration and health. Meal intake: -The residence meal intake will be documented and percentage after each meal and entered into the residence medical record. -If the meal consumption is less than 25% for 3 consecutive meals or meal refusals are noted, an alert will be triggered for a further review to be conducted and physician notification if a change in condition is identified. The facility policy entitled, Weight Management, dated 3/01/21, states: -All residents admitted to the facility will be weighed according to the following schedule: Upon admission and weekly times four weeks. -All residents will be weighed every month unless otherwise ordered by the physician or deemed necessary by the dietician or the interdisciplinary team. -The Dietician should evaluate weights, notify appropriate disciplines of significant changes, and initiate corrective measures. -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. -All weights will be documented in the resident's electronic medical record. -The resident's nurse will notify the physician and the resident or resident representative of any significant unexpected or unplanned weight changes. R17 was admitted to the facility on [DATE] with diagnoses in part included traumatic subdural hemorrhage, cerebral infarction, hemiplegia, and hemiparesis to left non-dominant side, muscle weakness, polyneuropathy, diverticulosis, gastritis, irritable bowel syndrome without diarrhea, cognitive communication deficit, and mild neurocognitive disorder. Upon admission, R17 weighed 170 pounds. There was no evidence uncovered that the facility monitored R17's weights consistently to determine if she was receiving adequate nutrition. There were only two other weights recorded, 07/07/23 (R17 weighed 158 pounds) and 09/26/23 (R17 weighed 146.8 pounds). R17 was admitted to the facility without any pressure injuries. On 07/07/23, R17 developed a stage 2 left heel PI. On 08/15/23, R17's left heel PI became larger in size with necrotic tissue present. On 08/29/23, R17's left heel PI was debrided of the necrotic tissue to reveal stage 4. As of 10/05/23, R17's left heel PI continued to be stage 4. On 09/12/23, R17 developed a deep tissue injury (DTI) to the sacrum. On 09/26/23, R17's sacrum PI charted as a stage 3. As of 10/05/23, R17's sacrum PI continued to be stage 3. R17's admission MDS (minimum data set) assessment dated [DATE]: Brief Interview of Mental Status (BIMS) was 14, cognitively intact. Functional status: Functional status: Eating - Supervision with one-person physical assist. R17's quarterly MDS assessment dated [DATE]: BIMS was 12, moderately impaired. Functional status: Eating - Supervision with one-person physical assist. Unable to determine weight loss as no weight was recorded. R17's care plan included the following focus areas: 1.The resident has potential fluid deficit related to constipation. (Started 06/05/23) Interventions for this plan include in part the following: Monitor / documents / report PRN any signs or symptoms of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes . (Started 06/05/23) 2.The resident has potential for alteration in nutrition status related to past medical history including subdural hemorrhage, hemiplegia, essential tremor, hypothyroidism, IBS, diverticulosis, depression, anxiety, pressure-related compromised skin integrity, and need for mechanically altered diet. (Started 05/25/23, revised 08/28/23) Interventions for this plan include in part the following: - Administer medications as ordered. Monitor/document for side effects and effectiveness. (Start 05/25/23) - Assist resident as needed / indicated at meals. (Start 08/28/23) - Monitor and record skin state. (Start 08/28/23) - Monitor and record weight per orders. Notify responsible party, MD and RD Resident occ. Refuses to be weighed. (Start 05/30/23, revised 09/12/23) - Monitor/document/report PRN any signs or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts as swallowing, refusing to eat, appears concerned during meals. (Start 05/25/23) - Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. (Start 05/25/23) - Provide, serve diet as ordered. Monitor intake and record every meal. (Start 05/25/23) - RD to evaluate and make diet change recommendations PRN. (Start 05/25/23) R17's Care Kardex (Used by the Certified Nursing Assistants (CNA)s to know how to care for the residents) printed on 10/04/23, indicated under the Eating/Nutrition category: The resident (R17) is able to feed self with set up. Monitor meal performance and monitor/document/report as needed any signs or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. R17's Orders: - Diet orders, including supplements, and enteral nutrition, may be delegated to the Registered Certified Dietitian started 05/23/23. - May receive calorie, protein and/or nutrient supplements per dietician recommendation started 05/23/23. - Weekly weights x 4 weeks then monthly started 05/24/23, ended 06/21/23. - Weight +/- 3 lbs (pounds) per day or +/- 5 lbs per week, update MD started 05/23/23. - Mirtazapine 15mg by mouth at bedtime related to depression started 05/23/23. - Ensure with meals for supplementation started 07/14/23. Note: No orders for ProStat (Protein Supplement), Multi-Vitamin / Mineral. During this survey (10/03/23 through 10/05/23) the Surveyor observed R17's pale, fragile, dry skin, eyes sunken, mouth and lips dry, tongue extremely dry with multiple furrows. All of these are indications of dehydration/poor nutrition. On 05/30/23, the Registered Dietician (RD) JJ completed the admission nutrition assessment for R17. RD JJ noted the following in her documentation, .MNA (Mini Nutritional Assessment) score of 10 suggest possible risk of malnutrition. CNA documentation indicates resident requires varied levels of assistance with meals, ranging from independent feeding with staff set up assist to staff physical assist for eating. Varied intakes noted. Current BW (body weight) is 170 pounds (facility weight), which concurs with hospital weight of 170 pounds 10.2 ounces. Height 65 inches. BMI (Body Mass Index): 28.3 - within normal weight range or geriatric BMI scale. No pressure related alterations to skin reported. Labs 05/19/23: H/H (hemoglobin and hematocrit) 11.8/36, Na (Sodium) 138, K (Potassium) 3.5, Cl (Chloride) 99, BUN (Blood Urea Nitrogen) 13, Creatine 0.57, Glucose 60, Phosphorous 3.2, Magnesium 2.0 . Estimated nutritional needs based on current BW (77.3 kg/kilograms): 25-30 kcal/kg BW: 1933-2319 kcal/day; Protein: 0.8-1.0g/kg BW: 62-77g protein/day; Fluid: 1ml/kcal: 1933-2319 ml fluid/day. Diet appropriate; continue to assist, monitor. Refer RD PRN (as needed). On 07/14/23, facility follow up visit by the Nurse Practitioner stated, .[R17's] daughter had called, spoke with provider .Daughter expresses concerns regarding weight loss .[R17] is taking 15mg mirtazapine po QHS (by mouth every night) and receiving nutritional shakes, will increase to each meal from bid (twice a day) .Review of systems included weight loss .Diagnosis weight loss .Plan feed with assist. Note: Mirtazapine was prescribed for R17 for depression, but it can be used to stimulate appetite to help increase weight. On 07/18/23, the Wound Care Doctor [MD V] planned to discuss patient's (R17) abnormal BMI with current dietitian and recommend dietician consultation for abnormal BMI. The facility's documentation did not identify an abnormal BMI on 07/18/23. The wound doctor continued with recommendations for dietary consultation for R17. Note the RD only assessed R17 upon admission on 05/30/23 and on 08/28/23. On 08/28/23, RD JJ completed the quarterly nutrition assessment for R17. RD JJ noted the following in her documentation, MNA score of 7 suggests malnutrition .PO (by mouth) intakes frequently 0 to 25%, at times, higher, with varied intakes. CNA documentation indicates no difficulty with meal tolerance, and resident at time feeds self independently with PRN staff meal set up, at other times requires extensive feeding assistance. 08/14/23 provider note states staff reports appetite is good at least one meal per day and resident requires encouragement at meals. Current BW: 07/07/23 158.0 pounds; 05/23/23 weight 170.0 pounds. This suggests 12 pound / 7.1% significant weight loss for approximately 1 month, not planned or desired .08/22/23 skin/wound eval states presence of unstageable PI to left heel .Recommend: obtain and record updated facility weight. Add ProStat [Protein Supplement] 30ml PO BID [by mouth twice a day] for wound healing support, as well as MVI/MIN [multi-vitamin / mineral]. Continue to provide assistance and encouragement at meals to promote increased PO intake. Refer RD PRN Addendum: Mirtazapine in place, stated as for depression. This prescription may stimulate appetite. Continue to monitor. There was no evidence the facility provided R17 with the ProStat or multi-vitamin/mineral. On 10/05/23, Surveyor asked for the response from R17's provider to RD JJ's recommendations from 08/28/23. The facility provided the Dietary Recommendations for Physician Approval dated 08/28/23 with the recommendations listed from the RD assessment note above. MD W responded on 09/05/23 to disagree with the RD's recommendations as R17 was already on Ensure. Protein / Meal Intake: According to the NPIAP Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, 2019, .Unintended weight loss is a marker for malnutrition .Malnutrition can impact pressure injury development and healing. Both inadequate nutritional intake and undernutrition have been linked to the development of pressure injuries, pressure injury severity, and protracted healing .Provide protein intake of 1.25 to 1.5 g [gram]/kg [kilogram] body weight/day for adults with a pressure injury who are malnourished or at risk for malnutrition . R17's last weight was 146.8 pounds or 66.7 kg. Per recommended protein needs, R17 should receive at least 83.4 grams of protein a day. R17 was prescribed Ensure TID (three times a day) with meals. Regular Ensure has 16 gms of protein per 8 ounces. R17 was receiving Ensure three times a day = 48 grams of protein, much less than the standard of practice recommendation. R17's order for Ensure with meals for supplementation started 07/14/23. R17 is not meeting the recommended 83.4 grams of protein a day to help with nutrition and wound healing. Review of R17's documentation for meal intake the last 30 days (09/08/23 - 10/04/23) had 11 days documented with 12 times 0-25% intake, 6 times 26-50% intake, 0 times 51-75% intake, and 6 times 76-100% intake. Multiple days and meals were missing documentation of meal intake. Fluid Intake: According to the NPIAP Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, 2019, .Provide and encourage adequate water/fluid intake for hydration for an individual with or at risk of a pressure injury .In healthy people, water/fluid intake should be approximately 30 ml[milliliter]/kg body weight per day . R17's weight of 66.7kg indicated that she should be receiving 2001 ml of fluid per day. R17's documentation for fluid intake the last 30 days (9/08/23 - 10/04/23) had 11 days documented with 240 ml the lowest documented in a day to the highest of 1320 ml in a day. Multiple days were missing documentation of fluid intake. R17's nutritional status indicated she was not receiving the appropriate amount of nutrients and fluids to help with wound healing and basic needs of life. No documentation of R17 refusing cares/treatments/food/fluids/weight. R17 was not weighed again until 09/26/23, which indicated an 11 pound weight loss from the 07/07/23 weight and a 23 pound weight loss from admission weight on 05/23/23. This was a 13.65% weight loss in a four-month period, indicating severe weight loss. Observations/Interviews: On 10/04/23 at 8:30 AM, Surveyor observed R17's meal tray delivered to her room. CNA T helped R17 eat. On 10/04/23 at 10:45 AM, Surveyor spoke with R17 who said she was thirsty. Surveyor asked R17 to stick out her tongue. R17's tongue was very dry with multiple furrows (an indication of dehydration). Surveyor asked R17 if staff help her to eat. R17 said sometimes staff help and sometimes they do not. R17 said she ate breakfast, it was okay. On 10/04/23 at 11:05 AM, Surveyor interviewed CNA T about R17's nutritional intake. CNA T said R17 does refuse to eat at times, but if encouraged to eat and educated on importance to eat to help with wound healing, then R17 will eat. CNA T said she does not have trouble with getting R17 to eat because she takes the time to help R17 eat and educate her. Surveyor asked CNA T about weighing R17. CNA T said weights do not really matter because R17 sometimes refuses to eat. On 10/04/23 at 11:25 AM, Surveyor interviewed LPN U concerning if R17 ever refused to eat. LPN U said R17 needed to be explained the importance of eating and then she will eat. Surveyor asked LPN U if R17 had received ProStat and MVI/Mineral. LPN U said R17 was getting Ensure, she was not getting ProStat or MVI/Mineral. On 10/04/23 at 12:30 PM, Surveyor interviewed Family Member (FM) X about R17. FM X said the family had concerns about the care for the residents at the facility. FM X said we were concerned about R17 losing weight and we had to tell staff she needs to be weighed, but still it was not done. Then we almost had to demand for her to be weighed and it was done. We bring in protein shakes for R17. We had left multiple messages for administration to contact us to talk about our concerns for R17 and no response. We get no updates from the facility on how R17 was doing. No communication from the facility. R17 was not out of bed for some time, then we asked staff to get her out of bed. R17 had no wounds prior to admission to this facility. On 10/04/23 at 1:30 PM, Surveyor interviewed Dietary Manager (DM) J about R17's weight loss. DM J said R17 had been refusing meals lately, so DM J had been adjusting the food to what she likes to eat. DM J said R17 will eat good if helped by staff to eat. On 10/04/23 at 2:00PM, Surveyor interviewed Registered Dietician (RD) E and asked about R17's weight loss and lack of being weighed. RD E said the standard weighing schedule was to weigh the resident weekly four times upon admit, then monthly after that unless the doctor wanted it to be different. R17 had quarterly nutrition assessment done on 08/28/23 that triggered for weight loss. RD JJ asked for R17 to be weighed, recommended ProStat, MVI/Mineral. The facility management team would receive the information from the request made by the RD. The facility would also notify the provider of the weight loss. RD E said the provider needed to have the plan of care changed since triggered for weight loss. The RD cannot add an order, the provider needed to do that. RD E and RD JJ had not spoken with the provider; the provider did not answer back on the RD recommendations. RD E said she had not spoken with the resident/family about what they wanted. On 10/05/23 at 2:00 PM, Surveyor interviewed the facility's Medical Director (MD W), who is also R17's primary physician, concerning RD JJ's recommendation for R17 to add ProStat and MVI/Mineral and have R17 reweighed. MD W said that R17 was on Ensure and that had enough minerals, nutrients, protein. Surveyor asked MD W even though R17 had lost weight and had two PIs, Ensure was enough extra mineral and nutrients that the RD's recommendations were not necessary. MD W said yes, Ensure was enough. Surveyor asked MD W why R17 only had three weights recorded with her being triggered for significant weight loss by the RD. MD W said the residents are not weighed because it is difficult to weigh residents who are bedridden. We would only weigh residents who have signs and symptoms of weight loss such as looking thin or not eating. Surveyor asked MD W if he had been contacted by R17's family with concerns they had of weight loss. MD W said he was not contacted by R17's family with concerns. If he had been contacted by them, he would talk to them and if concerns of weight loss, then would weigh the resident. 17661 Example 2 R2 was hospitalized from her home 06/05/23 - 07/11/23. The diagnoses during this hospitalization included septic encephalopathy with Haemophilus Influenzae (H. Influenzae) meningitis, a bacterial infection, sinusitis, and sepsis. Other pertinent diagnoses for R2 included chronic respiratory failure with hypoxia, moderate protein-calorie malnutrition, chronic pain, major depressive disorder, generalized anxiety disorder and unspecified dementia with behavioral disturbance. Hospital records indicated R2 was identified as a high risk for nutritional concerns as she manifested poor intakes while hospitalized [DATE] -07/11/23. Hospital weights were recorded as decreasing (06/05/23 was 159.2 and 07/07/23 was 142.4). Upon admission to the facility, R2 weighed 141 pounds and was 65 inches tall. R2 was discharged to her Power of Attorney's (POA L) home on 08/30/23. Record review confirmed RD E's statements. According to the most recent Minimum Data Set Assessment (MDSA) completed for R2, which was an admission assessment dated ,d+[DATE].23, R2's speech was clear, and she had the abilities to express herself and comprehend others. Her cognitive status was identified as being moderately impaired with a Brief Interview of Mental Status of 10/15 (A score of 8-12 indicates moderate impairment). This MDSA identified R2 as being 65 inches tall and weighed 141 pounds on admission and was independent with eating after staff set up her tray. In reviewing R2's care plan, Surveyor noted the facility included the following problem areas: 1. The resident has an ADL self-care performance deficit meningitis, altered mental status, sepsis, H. influenza infection (initiated 07/19/2023). Interventions for this plan included: - The resident is able to feed self with set-up, may require assistance of one - Monitor and document and report as needed, any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. 2. The resident has impaired cognitive function/dementia or impaired thought processes related to dementia with behavioral disturbance, altered mental status and encephalopathy (initiated 07/18/23). Interventions included: - Communicate with the resident/family/caregivers regarding resident's capabilities and needs - The resident understands consistent, simple, direct sentences. Provide the resident with necessary cues- stop and return if agitated. - Cue, reorient and supervise as needed - Keep the residents routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion 3. The resident has potential nutritional problem related to cognitive deficits, depression, status post sepsis, protein calorie malnutrition (initiated 07/18/2023). Goal: The resident will improve nutritional status as evidenced by maintaining stable weight, no signs or symptoms of malnutrition, and consuming at least 75% of at least 2 meals daily through review date (initiated 07/18/2023). Interventions for this plan included: - Provide, serve diet as ordered. Monitor intake and record every meal (initiated 07/18/2023) - Monitor, document, and report as needed, any signs of dysphagia, pocketing, choking, coughing .refusal to eat, appears concerned during meals (initiated 7/18/23) - Weigh at same time of day and record as ordered (initiated 07/18/2023). 4. The resident has an active order for antidepressant medication (s) for depression and poor appetite (initiated 7/24/23). Surveyor then reviewed documentation completed by staff for meal intakes and noted the following for the time period R2 resided in the facility: Meal Intakes: Note: R2 was admitted [DATE] in the evening hours. July 2023: 60 meal opportunities, three meals per day (07/12-07/31): Refused: x11 0-25% intake: x2 26-50% intake: x1 51-75% intake: x3 76-100% intake: x14 Not recorded: x29 Snacks: Morning: 20 opportunities Not offered: x9 Not documented: x10 accepted: x0 Refused: x1 not applicable: x0 Evening Snacks: 20 opportunities Not offered: x2 Not documented: x7 Accepted: x2 (liquids only) Refused: x0 Not applicable: x9 August Meal Intakes: 30 days or 89 meals (08/1/23 - 08/30/23 noon meal) Refused: x11 0-25% intake: x9 26-50% intake: x3 51-75% intake: x8 76-100% intake: x22 Not recorded: x36 August Snacks 30 opportunities Morning: - Accepted: x0 - Not offered: x17 - Not recorded: x13 - Refused: x0 - Not applicable: x0 Evening: 29 opportunities - Accepted: x6 (liquids documented) - Not offered: x9 - Not recorded: x10 - Refused: x1 - Not applicable: x3 There was no documentation located to indicate why R2 refused meals, interventions staff attempted to encourage R2 to eat, or education given to R2. Daily Skilled Nursing documentation and Interdisciplinary Team Progress Notes made no mention of R2's poor appetite or refusals to eat. Surveyor's interview with the facility's former Registered Dietician (RD E) was completed on 10/04/23 at 2:48 PM via telephone. RD E was contracted by the facility through a dietary service, and no longer services the facility. During this interview, RD E stated there was ongoing process improvement in the facility related to staff monitoring dietary intakes and weights. RD E stated R2 had poor intakes while hospitalized and it was important for staff to monitor her weights in order for staff to implement interventions specific to the resident. RD E stated the facility has an always available menu that staff could offer if a resident refused the served menu. Staff often did not document whether these were offered, and staff frequently did not document intakes for R2. RD E stated weight loss is a clear indicator of poor intakes and the fact that R2 was receiving Mirtazapine, an antidepressant for appetite stimulation, should have alerted staff to monitor and record her poor intakes. RD E stated that she was frequently requesting weights on R2, but they were not completed. RD E also stated R2's physician ordered staff on 07/19/23 to monitor weights weekly for four weeks, a total of 4 weights during her initial month of stay in the facility. If a resident loses weight during that time, it should prompt staff to attempt additional interventions in order to improve intakes and weights. RD E stated this was not done. Note: There was one recorded weight for R2 dated on the date of admission, which was 141 pounds. Surveyor's interview via telephone was completed with POA L on 10/04/23 at 6:18 PM. POA L expressed that she noticed R2's extreme weight loss when she brought her to her home. POA L stated that R2 required assistance with meals and was concerned that staff were not assisting her. She stated that during her two weeks visit in July, staff would bring the meal trays into the room and leave. Staff did not return to R2's room with the exception of picking up the tray. POA L stated no staff offered assistance or alternatives to R2. POA L also acknowledged that R2 would refuse meals, and when she visited for the two weeks in July, would bring food in from restaurants for R2 to eat. POA L stated R2 was very emaciated when she removed R2 from the facility, stating, . You could see her ribcage. Her face and hands sagged. her clothing was literally dropping off her. Her cheeks were sunken, and her cheekbones stood out. She was very skeletal, drawn out and bony . On 10/5/23 at 9:12 AM, Surveyor interviewed CNA I regarding R2 and her refusals and acceptance of meals. CNA I was R2's primary caregiver and indicated that she worked with R2 each day she was on duty. CNA I stated that R2 would not eat the facility food, stating that R2 felt the food was poisoned, . even if we tried to make it look like carry out, she would refuse. I would ask her why she wasn't eating, and she would say it was poisoned . sometimes she would accept food brought in by a friend of hers. Her family would bring in stuff and she'd refuse that. She thought they were poisoning her to keep her here and steal her property. She was very confused . Surveyor asked CNA I what the facility practice of documenting refusals was. CNA I stated, We are supposed to document any resident refusals and tell the nurse what we all tried. If there isn't any documentation found, well, then it probably wasn't tried. I can't speak for everyone though. It may have gotten busy, and they just didn't document . We [CNAs] are to tell the nurses what we tried, and they should be documenting whatever the CNA tells her they tried. I'm not sure if they do or not but all staff were aware of her behaviors . At 10:02 AM, Surveyor interviewed Wound Nurse AA and Registered Nurse (RN) M, who is the nurse supervisor, regarding R2 and the expectations of staff. Wound Nurse AA was more well versed on R2 and stated that whenever a resident refuses cares, whether it was meals, showers or bathing, staff are expected to keep going back to retry the task. She stated the CNA staff are to notify the nurse on the floor and the nurse was to document any attempts and interventions. RN M agreed with Wound Nurse AA's statement and added, Yes, we are to keep trying and document, so we know what works and what doesn't- different approaches to try. At 10:55 AM, Surveyor interviewed Licensed Practical Nurse (LPN) K regarding resident refusals and her practices. LPN K stated, If a resident refuses cares or meals, the CNAs code the refusal in their charting and notify us [nurses]. I am then to chart in the progress notes the refusal and what other things were tried. When asked the reason for documenting this information, LPN K stated, So we know what was tried, what didn't work and what does work for that resident. Of concern is that even though R2 would occasionally refuse meals, staff did not consistently enter this information in R2's record. There was no documentation located to indicate interventions attempted, those that failed or interventions that were effective in order to provide individualized care for R2. 44863 Example # R12 was admitted to the facility on [DATE]. Diagnoses included surgical and diabetic wounds, tissue loss to bilateral feet, malnutrition, unintended weight loss, poor appetite and not meeting needs for wound healing as evidenced by need for supplemental nutrition. On 05/08/23, the facility entered a physician order to obtain R12's weekly weights. On 05/12/23, the facility completed a Mini Nutritional Assessment (MNA). R12 scored 3/14, indicating R12 was malnourished. Dietary note stated R12 was diagnosed in the hospital with severe protein-calorie malnutrition. R12's hospital weight was used for MNA, as there was no weight obtained since R12's admission to the facility. On 05/18/23, a weight of #117.8 was documented for R12. On 06/08/23, R12 discharged from facility. There were no other weights documented for R12 to ensure nutritional parameters were maintained for R12.

Based on interview and closed 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 (R19) of 5 Residents reviewed for pressure injuries. R19 was readmitted to the facility on [DATE] without any pressure injuries. On 11/1/22, R19 developed a Stage 3 sacrum pressure injury. There was no revision to R19's skin integrity care plan after this development. On 11/8/22, R19's sacrum pressure injury was noted to have 100% slough and the treatment was changed to Santyl & border foam dressing daily. On 11/22/22, Wound NP-CC documents R19's sacrum pressure injury has deteriorated, discontinued the Santyl treatment, and ordered calcium alginate with border cover dressing daily. The facility did not implement this new treatment and continued with the Santyl treatment. On 12/6/22, R19's sacrum pressure injury resolved. The facility did not discontinue the Santyl treatment order and continued with this treatment on R19's intact skin until 12/20/22. On 12/15/22, Wound NP-CC documented a new right lateral foot pressure injury, Stage 2. Wound NP-CC documents in this note per staff this area was initially a blister. There is no evidence in R19's medical record regarding a blister and no treatment for the blister prior to Wound NP-CC's note. Wound NP-CC ordered to cleanse the pressure injury with wound cleanser, apply calcium alginate with silver, cover with ABD (abdominal) and kerlix three times a week. This treatment was not implemented until 12/21/22. On 12/15/22, the skin integrity care plan was revised to include boots to elevate heels. On 12/20/22, R19's right lateral foot had declined to a Stage 3 with 40% slough and Wound NP-CC documented the status of this pressure injury as declined. Conservative sharp debridement was performed to R19's foot ulcer for removal of nonvital tissue to promote healing. On 1/10/23, R19's right lateral foot pressure injury declined and was now Unstageable with 50% adherent eschar. The treatment was changed to apply oil emulsion gauze, calcium alginate with silver, and cover with ABD and kerlix 3x/week and PRN. This treatment was started on 1/13/23. On 1/17/22, R19's right lateral foot pressure injury had 100% dry eschar. The treatment was changed to Cleanse with soap and water. Paint with betadine, wrap with ABD and kerlix daily and PRN. This treatment was never implemented. On 1/24/23, R19's right foot ulcer was Unstageable. The pressure injury wound bed had 30% slough, 30% eschar, 20% granulation, & 20% epithelial. There was large seropurulent drainage. The Peri-wound is fragile & intact. R19's pressure injury has increased wound size, has increased drainage, and purulent drainage expressed from wound which is concerning for local wound infection. R19's pressure injury has declined. R19 was transferred and admitted to the hospital. Emergency department diagnoses at time of transfer are Osteomyelitis of R (right) foot, hyponatremia & hydrocephalus. Condition on admission is documented as serious. On 2/7/23, R19's right foot was amputated. The failure to assess & treat R19's right foot blister which then de-roofed on 12/15/22, the failure to not start the treatment on 12/15/22 until R19's right lateral foot pressure injury declined to a Stage 3 on 12/20/22 & treatment was implemented on 12/21/22, the failure to initially treat R19's pressure injury led to a subsequent decline from Stage 2, to Stage 3 to Unstageable on 1/10/23. On 1/17/23, facility staff continued with the previous treatment which softened the eschar and failed to implement a new treatment on 1/17/23 for R19's pressure injury with 100% dry eschar. On 1/24/23, R19's Unstageable pressure injury wound bed has 30% slough, 30% eschar, 20% granulation & 20% epithelial with large seropurulent drainage. On 1/24/23, R19 was discharged to the hospital to rule out Osteomyelitis. These failures created a situation of immediate jeopardy which started on 12/20/22. On 4/4/23 at 8:45 a.m. Administrator-A was informed of the Immediate Jeopardy. The Immediate Jeopardy was removed on 2/9/23 and corrected on 2/13/23 when the facility conducted skin sweep audits every two weeks, revised the new skin alteration checklist/packet & educated licensed nursing staff on this process/procedure, inserviced license nursing staff on preventing pressure injuries, and inserviced CNAs (Certified Nursing Assistants) on skin checks with cares & ADLs (activities of daily living) including removal of socks & notifiy nurse of new issues. Current deficient practice was not identified. Findings include: The Wound Management Wound Prevention and treatment policy & procedure with an effective date of 2/24/21 under provision and policy includes documentation of 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 are 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. For Etiology and Risk Factors for Pressure Injury under accurate documentation documents Accurate documentation is needed to ensure continuity of care. The plan of care should address efforts to stabilize, reduce or remove underlying risk factors; monitor the impact of the interventions; and modify the interventions as appropriate. The care plan should specifically address risk factors, pressure points, under nutrition and hydration deficits and moisture and its impact. R19 was originally admitted to the facility on [DATE], has a readmitted [DATE], and was discharged on [DATE]. R19's POA (power of attorney) for healthcare was activated on 9/20/22. Admitting diagnoses includes non traumatic subarachnoid hemorrhage, obstructive hydrocephalus, unspecified severe protein calorie malnutrition, hypertension, chronic kidney disease stage 3, schizophrenia, and hyperkalemia. The potential for impaired skin integrity care plan initiated 10/6/22 and revised 1/18/23 has the following interventions: * Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Initiated 10/6/22. * Encourage good nutrition and hydration in order to promote healthier skin. Initiated 10/6/22. * Follow facility protocols for treatment of injury. Initiated 10/6/22. * Identify/document potential causative factors and eliminate/resolve where possible. Initiated 10/6/22. * Monitor for side effects of the antibiotics and over-the-counter pain medications: gastric distress, rash, or allergic reactions which could exacerbate skin injury. Initiated 10/6/22. * Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. to MD (medical doctor). Initiated 10/6/22. * Obtain blood work such as CBC (complete blood count) with Diff (differential), Blood Cultures and C & S (culture and sensitivity) of any open wounds as ordered by Physician. Initiated 10/6/22. * Turn and position as necessary. Initiated 10/6/22 and revised on 1/10/23. Surveyor noted there was no change in verbiage. * Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Initiated 10/6/22. * Implement pressure reducing devices air mattress. Initiated & revised 10/7/22. * Implement pressure reducing devices i.e. w/c (wheelchair) cushion, air mattress, off loading boots etc. Initiated 10/7/22. The two previous interventions were revised on 1/18/23 to: * Implement pressure reducing devices air-mattress, cushion to chair. Initiated 10/6/22 & revised 1/18/23. * Boots to elevate heels. Initiated 12/15/22. The admission assessment dated [DATE] documents right buttocks 3 open areas Stage 1. There are no areas of impairments documented on this assessment for R19's feet. The Braden assessment dated [DATE] has a score of 11 which indicates high risk. The nurses note dated 10/6/22 documents Resident arrived to unit room [number] via gurney transferred by Ambulance service. Resident was awake, alert, nonverbal. Transferred onto bed. Respiratory ate even and unlabored, on room air, chest rises symmetrically. Noted abdominal binder covering PEG tube with Lopez valve intact. no redness or drainage at PEG tube site. Noted just above right antecubital space was pressure dressing from central line removed prior to discharge from facility. Resident does have an outer right ear a an intact very thin red line marking that measures .5 cm (centimeter) in length. Heels are intact with boot on. Right buttock has three small open areas noted. #1 is 1.7 cm L (length) X (times) 1 cm W/H (width/height) (Stage 1). Next #2 is .5 cm L x .5 cm W/H (Stage 1). Last #3 is .2 cm L x .2 cm W/H (Stage 1). Area cleansed and border applied until on call notified for treatment orders. When turned and repositioned resident was able to grasp and hold onto side rails for assistance. Followed simple commands, non verbal at this time. HOB (head of bed) elevated, clean, depends placed, call light in reach, TV on and remote near on bedside table. Bed in low position. The nurses note dated 10/8/22 documents Resident in transport [name] hospital via [name] ambulance. Accompanied by POA (power of attorney). The Admission MDS (minimum data set) with an assessment reference date of 10/8/22 documents short & long term memory problems and severely impaired for cognitive skills for daily decision making. R19 requires extensive assistance with one person physical assist for bed mobility & toilet use, doesn't ambulate, eating is coded as supervision with one person. R19 is always incontinent of bowel and bladder. R19 is at risk for pressure injury development and is coded as having 3 Stage 1 pressure injuries. The Pressure injury CAA (care area assessment) dated 10/11/22 under analysis of findings documents The resident has potential/actual impairment to skin integrity to R (right) buttocks. History of protein calorie malnutrition, dysphagia, SAH (subarachnoid hemorrhage), aspiration PNA (pneumonia), COVID 19 + (positive). The nurses note dated 10/9/22 documents Received call from [hospital name]. Stated that resident admitted due to aspirating and hyperkalemia. Administration records faxed. The admission/Re-admission summary dated 10/12/22 documents Resident arrived to the facility by [name] EMS (emergency medical services) ambulance at 1930 (7:30 p.m.), on the stretcher. Vitals upon arrival: BP (blood pressure) 151/88 HR (heart rate) 65, BS (blood sugar) 134. Per hospital, resident is on continuous tube feeding until assessed by the dietician-Resident fail the shallow sic (swallow) test [name] POA is informed. Area on the buttocks are closed (reddened). Orders confirmed by [name], PA (physician assistant) w/ (with) [name of medical group] @ (at) 2022 (8:22 p.m.). Osmolite 1.2 tube feeder order was changed to 1.5. Resident is resting comfortably, no distress or discomfort noted by the writer. There is no documentation in this admission/re-admission summary R19 had any areas of skin impairment on R19's feet. The Braden assessment dated [DATE] has a score of 9 which indicates very high risk. The nurses note dated 10/14/22 documents Resident alert and responsive. Verbal this am (morning) but not able to make needs known. Tube feeding running as ordered and patent. Medications administered as ordered without difficulty. Resident kept clean and dry. Repositioned. Mouth care given. The Braden assessment dated [DATE] has a score of 15 which indicates at risk. The Braden assessment dated [DATE] has a score of 16 which indicates at risk. The wound NP note dated 11/1/22 indicates the sacrum is now Stage 3 from MASD (moisture associated skin damage). Measurements are 1.00 x 0.5 x 0.1 and the wound bed is described as 100% granular tissue. The Facility did not revise R19's skin integrity care plan. The wound NP note dated 11/8/22 documents R19's sacrum pressure injury is a Stage 3. Measurements are the same as the previous week but the wound bed is now 100% slough. The treatment has been changed to apply Santyl daily and cover with border foam dressing. This treatment was not started until 11/10/22. The Facility's weekly skin impairment/wound form dated 11/8/22, no is answered for the question does the resident have a pressure injury. Under the non pressure section includes the sacrum with measurements of 0.5 x 0.3 x 0.1. with 100% slough for the wound bed. The Braden assessment dated [DATE] has a score of 14 which indicates moderate risk. The physician order dated 11/15/22 documents Prostat - Sugar free three times a day for supplement 30 ml (milliliter) via PEG. This was discontinued on 12/13/22. Wound NP-CC's note dated 11/22/22 under physical exam documents Sacrum -Stage 3 pressure injury Full thickness wound measuring 2.0 x 3.0 x 0.4 cm 100% smooth red tissue. Scant serous drainage. Periwound is moist, pink. No s/sx (signs/symptoms) infection. Status- deteriorated. Plan cleanse with soap and water. Discontinue Santyl. Apply calcium alginate dressing and bordered cover dressing. Change daily and PRN ( as needed) given incontinence. Offload. Surveyor noted Santyl was not discontinued and the Facility did not start this new treatment. Wound NP-CC's dated 12/6/22 under physical examination documents Sacrum Stage 3 pressure injury resolved. Continue [NAME] oxide paste BID (twice daily) and PRN to protect skin. The facility continued with the Santyl treatment after R19's sacrum pressure injury was healed and did not discontinue this treatment until 12/20/22. The physician order dated 12/13/22 documents Prostat AWC (advanced wound care) three times a day for supplement 30 ml via PEG. This order was discontinued on 12/23/22. Wound NP (Nurse Practitioner)-CC's note dated 12/15/22 includes documentation of New wound to R (right) lateral foot, started as a blister per staff. Under physical examination documents Right foot ulcer Stage 2 pressure injury. Partial thickness wound measuring 5.0 x 6.2 x < (less) 0.1 cm (centimeter). Was initially a blister that has since de-roofed. 80% moist pink, 20% epithelial. Moderate serosanguinous drainage. Periwound fragile, intact. No s/sx (signs/symptoms) infection. Status- New. Plan- Cleanse with wound cleanser, apply calcium alginate with silver and cover with ABD (abdominal) and kerlix 3x (times)/week and PRN (as needed). Offload with Prevalon boots/pillows. There is no documentation in R19's medical record regarding a blister on R19's right foot until documented on 12/15/22 by Wound NP-CC. There was no treatment for R19's blister. The facility never started this treatment until 12/21/22 when R19's right lateral foot pressure injury declined to a Stage 3. Wound NP-CC's note dated 12/20/22 documents under physical examination Right foot ulcer - Stage 3 pressure injury. Partial thickness wound measuring 6.5 x 6.0 x 0.2 cm. 60% moist pink, 40% slough. Moderate serosanguinous drainage. Peri-wound fragile, intact. No s/sx infection. Status-Decline Plan- Cleanse with wound cleanser, apply calcium alginate with silver and cover with ABD and kerlix 3x/week and PRN. Offload with Prevalon boots/pillows. Under procedure documents Conservative sharp debridement performed to R foot ulcer for removal of nonvital tissue to promote healing. No bleeding with procedure. Patient tolerated well. Dressing applied post procedure. The physician's order dated 12/21/22 documents Monitor dressing placement to right foot ensure dressing is clean dry and intact. Replace dressing if missing or breakthrough drainage is noted. every shift. The physician's order dated 12/21/22 documents Monitor wound to right foot for signs or symptoms of infection such as pain, swelling, warmth, redness, odor, purulent drainage, etc. and deterioration. Notify MD (medical doctor) if s/sx (signs/symptoms) of infection or deterioration noted. three times a day. Wound NP-CC's note dated 12/27/22 documents under physical examination Right foot ulcer-Stage 3 pressure injury. Partial thickness wound measuring 6.2 x 5.1 x 0.1 cm 50% moist pink, 50% adherent eschar. Moderate serosanguinous drainage. Peri-wound fragile, intact. No s/sx infection. Status- Improved. Plan- Cleanse with wound cleanser, apply calcium alginate with silver and cover with ABD and kerlix 3x/week and PRN. Offload with Prevalon boots/pillows. Under procedure documents Conservative sharp debridement performed to R foot ulcer for removal of nonvital tissue to promote healing. No bleeding with procedure. Patient tolerated well. Dressing applied post procedure. Surveyor was unable to locate note for Wound NP-CC on 1/3/23. The skin impairment/wound form dated 1/3/23 for location documents right foot. Stage of pressure injury is Stage 3 Pressure Injury: Full Thickness skin loss. Measurement of wound is 7.6 x 7.4. The wound bed is 40% eschar and 60% moist pink. There is scant serosanguineous drainage. The current treatment is Cleanse with wound cleanser, apply calcium alginate with silver and cover with ABD and kerlix 3x/week and PRN. The quarterly MDS with an assessment reference date of 1/6/23 documents R19 has short & long term memory problems and is severely impaired for daily decision making. R19 requires extensive assistance with one person physical assist for bed mobility & toilet use, dependent with two plus person physical assist for transfer, does not ambulate, is depending with one person physical assist for eating, and always incontinent of bowel and bladder. R19 is at risk for pressure injury development and is coded as having one Stage 3 pressure injury. Wound NP-CC's note dated 1/10/23 under physical examination documents Right foot ulcer- Unstageable pressure injury. Partial thickness wound measuring 6.3 x 8 x UTD (unable to determine) cm, 10% moist pink, 50% adherent eschar, 40% epithelial. Moderate serosanguinous drainage. Peri-wound fragile, intact. No s/sx infection. Status- Decline. Plan- Cleanse with wound cleanser, apply oil emulsion gauze, calcium alginate with silver and cover with ABD and kerlix 3x/week and PRN. Offload with Prevalon boots/pillows. This treatment was started on 1/13/23. Wound NP-CC's note dated 1/17/23 under physical examination documents Right foot ulcer- Unstageable pressure injury. Partial thickness wound measuring 5.5 x 6 x UTD cm. 100% dry eschar. Moderate serosanguinous drainage. Peri-wound fragile, intact. No s/sx infection. Status-Stable. Plan-Cleanse with soap and water. Paint with betadine, wrap with ABD and kerlix daily and PRN. The facility did not start the betadine treatment to keep the eschar dry and continued with the treatment of oil emulsion gauze, calcium alginate with silver and cover with kerlix 3x/week and PRN. An oil emulsion dressing is impregnated with white petrolatum with an oil emulsion blend. This dressing would soften the eschar and not keep the eschar dry. The social service note dated 1/23/23 documents DOSS (Director of Social Service) and NP called resident's daughters over the phone today. NP explained that resident's weight is declining and resident's therapy did not improve his condition. DOSS and NP explained what hospice is and how it works. Resident's daughters did not want hospice at this time. Daughters are thinking about getting him private therapies here at the facility. Wound NP-CC's note dated 1/24/23 under physical examination documents Right foot ulcer- Unstageable pressure injury. Partial thickness wound measuring 14 x 5.5 x UTD cm. 30% slough, 30% eschar, 20% granulation, 20% epithelial. Large seropurulent drainage. Peri-wound fragile, intact. Increased wound size, increased drainage, purulent drainage expressed from wound- concerning for local wound infection. Status- Decline. Plan- Cleanse with soap and water. Apply dermafoam blue, superabsorbant pad, kerlix 3x/week and PRN. Under procedure documents Conservative sharp debridement performed for removal of necrotic tissue to promote healing. No bleeding, no pain behaviors noted. Clean, dry dressing applied post-procedure. Under assessment documents Place of care discussed with wound RN (Registered Nurse). Wound likely to decline unavoidably given patient's multiple comorbidities. Prevalon boots at all times to offload. Discussed patient with [Name] IM (Internal Medicine) NP- agree that patient needs to be sent out for further work up of foot infection. The nurses note dated 1/24/23 documents It was requested by [Name], NP that resident be sent out to hospital to r/o (rule out) Osteomyelitis. Wound care NP and nurse was in by resident performing wound care to right heel which appears to be worsening. VSS (vital signs stable). [Name] (sister/POA) aware and requested resident be sent to [Name] medical center. The nurses note dated 1/24/23 documents Per ER (emergency room ) nurse @ 2130 (9:30 p.m.), resident admitted @ [Name of hospital]. The hospital ER notes dated 1/24/23 under ED (emergency department) clinical impressions and diagnosis documents 1. Osteomyelitis of R (right) foot. 2. Hyponatremia. 3. Hydrocephalus. Condition on admission is documented as serious. R19 was administered two antibiotics starting in the emergency room of Vancomycin 1250 mg (milligrams) in sodium chloride 0.9% 250 ml IVPB (intravenous piggy back) & Cefepime 2000 mg in sodium chloride 0.9% 100 ml IVPB which was started in the emergency department. The XR (x-ray) foot 3+ View Right dated 1/24/23 final result under impression documents soft tissue defect over the lateral right foot with extensive soft tissue swelling and questioned subtle cortical irregularity of the proximal fifth metatarsal. This is nonspecific but may represent early Osteomyelitis. Consider MRI for further evaluation. The hospital note dated 1/25/23 documents Wound care RN consult placed for foot and chest ulcer. Photos reviewed this wound is necrotic. Called floor RN and advised that this requires Wound Care MD consult instead. It is out of scope for a RN to treat this wound. This RN order canceled. The hospital Wound MD note dated 1/25/23 includes documentation of Extremities: Right lateral foot ulcer with depth over the fifth met head to muscle. No bone palpable. Ulcer and Wound: One: Location- feet right, Lateral Size- Length 12cm, Width 9cm and Depth 1.4cm Grade- Wagner grade 3 (deep ulcer with abscess or Osteomyelitis) Granulation Tissue- 50 % Epithelial Tissue- 0 % Drainage- Purulent, Serosanguinous and Bloody. The hospital orthopedic consult dated 1/25/23 includes documentation under physical exam of RLE (right lower extremity: large pressure type wound over the lateral foot, large eschar in central part of wound, open wound just superior to large wound where purulence can be expressed from, do not appreciate palpable bone but close, no malodor or crepitus, palpable DP (dorsalis pedis). The hospital MRI hindfoot without contrast dye dated 1/26/23 under preliminary results documents concerning for Osteomyelitis at the base of the right fifth metatarsal and the right cuboid (small bones on the outside side of the midfoot) with large overlying wound as described above. The hospital physician's note dated 2/7/23 documents Discussed at length with wound care, podiatry, and NICU services. Per podiatry, there is no Osteomyelitis on the 5th digit or otherwise. Given the infected wound (improving on aggressive IV antibiotics) and difficulty healing I advocate for surgical intervention in order to reduce the risk of ongoing infection and eventual seeding of a future VP (ventriculoperitoneal) shunt as much as possible. Options include BKA (below knee amputation) vs debridement to healthy tissue and aggressive wound care. Per R19's POA R19's right foot was amputated on 2/7/23. On 3/28/23 at 4:02 p.m. Surveyor spoke to CNA (Certified Nursing Assistant)-FF regarding R19. CNA-FF informed Surveyor R19 was a tall lanky man, kind of rigid, didn't communicate but thought he could understand. Surveyor asked CNA-FF if R19 had any skin concerns. CNA-FF informed Surveyor he had a bandage on his coccyx or buttocks. Surveyor asked CNA-FF if R19 had any bandages on his feet. CNA-FF informed Surveyor not that she could remember. Surveyor asked CNA-FF if R19 could reposition himself in bed. CNA-FF replied no. Surveyor asked if R19 wore pressure relieving boots. CNA-FF replied most all the time. Surveyor asked when R19 was provided with the pressure relieving boots. CNA-FF informed Surveyor she doesn't remember. On 3/30/23 at 1:40 p.m. Surveyor asked LPN (Licensed Practical Nurse)-U if she recalled if R19 had a blister on his foot. LPN-U informed Surveyor there was a blister and he wore boots as well. Surveyor inquired if there was a treatment for the blister. LPN-U informed Surveyor R19's treatments were done on the evening shift and thought a nurse on the evening shift noticed the blister had opened. Surveyor inquired who would put the treatment orders in. LPN-U informed Surveyor the Wound nurse would and she rarely came to them to put the orders in. Surveyor inquired who would review Wound NP-CC's wound notes. LPN-U replied I don't know. Surveyor asked LPN-U if she knew when R19's blister developed. LPN-U replied No I do not. Surveyor asked why the treatment for Santyl continued after R19's sacrum pressure injury healed. LPN-U informed Surveyor they probably didn't discontinue it and just applied Santyl as a healing regime for R19. On 3/30/23 at 1:47 p.m. Surveyor asked LPN-II if she remembered R19. LPN-II replied yes. Surveyor asked LPN-II if R19 had a blister on his right foot. LPN-II informed Surveyor she honestly doesn't remember but knows he had something on his foot. On 3/30/23 at 2:20 p.m. Surveyor asked CNA-JJ if she remembers R19. CNA-JJ informed Surveyor she remembers R19. Surveyor inquired if she remembered R19 having a blister on his foot. CNA-JJ informed Surveyor she doesn't remember if R19 had a blister or if his feet had to be offloaded. On 4/3/23 at 8:01 a.m. Surveyor spoke with LPN-GG on the telephone regarding R19. Surveyor asked LPN-GG what she could tell Surveyor about R19. LPN-GG informed Surveyor R19 did have an area on his coccyx & heel and the evening shift did the treatment. R19 had a feeding tube, believes R19 was working with therapy, not making much progress, complete assist with cares and had pressure relieving boots on at all times. Surveyor asked LPN-GG if she had to monitor R19's pressure injury dressing. LPN-GG replied yes and explained she just make sure it was clean, dry & intact and had no drainage. Surveyor asked LPN-GG if she noted any change in the dressing the days prior to R19 being discharged to the hospital. LPN-GG informed Surveyor she thinks she was on vacation during this time and when she came back R19 was in the hospital. On 4/3/23 at 8:16 a.m. Surveyor asked LPN-Q what she could tell Surveyor about R19. LPN-Q informed Surveyor when he was with them he had a feeding tube, non verbal but once in a while talk a little bit, had eschar on coccyx when admitted and after developed a blister. Surveyor informed LPN-Q Surveyor did not note any documentation or treatment regarding R19's blister on his foot. Surveyor informed LPN-Q Surveyor had noted she did the treatment for R19's right foot the day before R19 went to the hospital and asked if she had noticed whether the pressure injury looked worse. LPN-Q explained she went to [NAME] after Christmas and didn't come back to work until around the 20th of January. LPN-Q informed Surveyor when she left for vacation, R19 had the blister. LPN-Q informed Surveyor she thought R19's pressure injury was dry. On 4/3/23 at 10:40 a.m. Surveyor asked DON (Director of Nursing)-B regarding what prompted the Facility to review R19's wound & treatment orders on 1/24/23. DON-B informed Surveyor Prior Wound Nurse-HH informed her she didn't put the orders in for R19's treatment of betadine. DON-B informed Surveyor Prior Wound Nurse-HH came from assisted living, was struggling with the wounds and the decision was made to remove her from being the wound nurse and was moved to unit manager. DON-B informed Surveyor Prior Wound Nurse-HH has since resigned. DON-B also informed Surveyor that Wound NP-CC wasn't uploading her notes which had the order timely. DON-B informed Surveyor they had a meeting with [name of medical group]. Surveyor inquired if licensed during staff were educated about treatment orders. DON-B replied no and explained it was more of [name of medical group] issue. Surveyor informed DON-B R19's 12/15/22 treatment was not started until 12/21/22 and the betadine treatment ordered on 1/17/23 was never started. On 4/3/23 at 11:21 a.m. Surveyor spoke with APNP (Advanced Practice Nurse Prescriber)-KK regarding R19. APNP-KK informed Surveyor she saw R19 when he initial came from the hospital, then two to three times a week and then weekly. APNP-KK explained she does her dictation in the room and describes what she sees. Surveyor inquired about R19's feet. APNP-KK informed Surveyor R19 wore Prevalon boots. Surveyor asked if staff spoke to her about Resident's pressure injury. APNP-KK explained if it's a chronic ulcer they would speak with the wound NP and if it's a new development they would let us know if they wanted us to take a look at it and let the Wound NP know. Surveyor asked APNP-KK if anyone spoke to her about a blister on R19's right foot. APNP-KK informed Surveyor she thought the Wound NP was seeing R19. Surveyor asked APNP-KK if she knew why R19's pressure injury declined. APNP-KK informed Surveyor the Wound NP would have more information. On 4/3/23 at 12:14 p.m. Surveyor spoke with Wound NP-CC regarding R19's pressure injury. Surveyor asked Wound NP-CC if she was informed R19 had a blister on his foot. Wound NP-CC replied not that I recall and explained the first day she became aware was when she did her note. Surveyor inquired when Wound NP-CC documents her notes. Wound NP-CC informed Surveyor she usually documents in real time, as soon as she can. Wound NP-CC informed Surveyor back at the time of R19 she wasn't charting in real time and had a meeting with the facility. Surveyor asked Wound NP-CC if she wasn't documenting in real time when would her note be in R19's record. Wound NP-CC informed Surveyor the latest her note would be in would be the next day. Surveyor asked Wound NP-CC if she was aware R19's treatment she ordered on 12/15/22 wasn't started until 12/21/22. Wound NP-CC informed Surveyor not that she remembers. Surveyor asked Wound NP-CC if she was aware the treatment she ordered on 1/10/23 wasn't started until 1/13/23 and the treatment she ordered on 1/17/23 was never started. Wound NP-CC informed Surveyor if they told her it would be documented. Surveyor asked Wound NP-CC why R19's right foot pressure injury declined. Wound NP-CC informed Surveyor she doesn't know as R19 had boots on, was on an air mattress and sometimes wounds decline. Surveyor asked Wound NP-CC if staff ever notified her between her visits regarding R19's pressure injury. Wound NP-CC informed Surveyor she doesn't remember and if they did it would be documented. Wound NP-CC informed Surveyor R19 was sent out due to concern of infection.

Based on interview and record review, the Facility did not ensure 3 of 3 Residents (R3, R6, & R7) reviewed for dialysis received such services consistent with professional standards of practice and the comprehensive person-centered care plan. There are 16 Residents in the Facility who receive dialysis, 15 who are receiving dialysis in a clinic located on property and 1 Resident who goes out for dialysis. R3 was admitted to the facility on [DATE] with diagnoses which include end stage renal disease & dependence on hemodialysis. The dialysis center was unaware R3 had been admitted to the facility and R3 was not placed on the list of residents needing dialysis. R3 did not receive dialysis on Tuesday 11/15/22 & Thursday 11/17/22. The physician orders did not include a dialysis order and there was no monitoring for complications of R3's access site. On 11/18/22, the nurse was unable to obtain a blood sugar reading as the glucometer read HI. APNP (advanced practice nurse prescriber) recommended R3 be transferred to the hospital. Prior to transfer to the hospital on 11/18/22, the Facility was notified of critical labs drawn that morning of a blood sugar 517 (reference range 70-99 mg/dl (milligram per decilitre,) Potassium 7.1 (reference range 3.6-5.0 mmol/L (millimoles per litre,) and Creatinine 9.9 (reference range 0.60-1.00 mg/dl.) R3 was admitted into the hospital's intensive care unit with diagnoses including sepsis with acute renal failure and hyperkalemia (high level of potassium in the blood that is impacted by not receiving dialysis in an individual with end stage renal disease.) R3 received dialysis in the hospital after admission to the hospital. The Facility's failure to provide dialysis to R3 created a finding of immediate jeopardy that began on 11/15/2022. Surveyor notified Administrator-A, DON (Director of Nursing)-B, CNO (Chief Nursing Officer)-C and VP (Vice President) Clinical/RN (Registered Nurse)-D of the immediate jeopardy on 12/1/22 at 11:38 a.m. The immediate jeopardy was removed on 12/2/22 however the deficient practice continues at a scope/severity of E (potential for harm/pattern) as evidenced by the following examples, the 16 additional residents in the facility receiving dialysis, and as the facility implements its action plan. R6 was admitted to the facility on [DATE]. There are no physician orders for dialysis, no monitoring of the access site for complications, and the communication sheets to dialysis are not consistently completed by the Facility staff. The facility does not have a system in place to ensure a resident receiving dialysis receives meals post dialysis if a meal is missed. R7 does not have a physician order for dialysis, there is no monitoring of the access site for complications, communication sheets to dialysis are not consistently completed, and the facility does not have a system in place to ensure R7 receives a meal that is missed when at dialysis. Findings include: The Dialysis Policy dated 2/1/22 under policy statement documents, The facility shall provide adequate Dialysis Services management to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. Guidelines document, The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Under Clinical Responsibilities will include but are not limited to the following a. Daily assessment and documentation of fistula or graft site. b. Documentation of post-dialysis weights as determined by the interdisciplinary team in collaboration with the dialysis center. c. Monitor fluid status. d. Manage fluid restrictions if ordered. e. Manage dietary restrictions as ordered. f. Manage post-dialysis complications. g. Manage abnormal lab values between dialysis center and facility. h. Revise and update the resident's care plan as needed. 1) R3 was admitted to the facility on [DATE] with diagnoses which include hypertension, chronic kidney disease Stage 3, diabetes mellitus, end stage renal disease, & dependence on renal dialysis. The Cardiothoracic Surgery Discharge Summary for date of discharge 11/14/22 documents under discharge diagnoses ESRD (end stage renal disease) on HD (hemodialysis.) Under condition at discharge documents, Patient was discharged to extended care/transitional care unit/rehab in stable condition. The admission data collection and baseline care plan tool dated 11/14/22 is checked for dialysis. Under dialysis planning it is documented - Focus: The resident needs dialysis (SPECIFY type hemo/peritoneal). Goal: The resident will have no s/sx (signs/symptoms) of complications from dialysis through the review date. Interventions: * Check and change dressing daily at access site. Document. * Do not draw blood or take B/P (blood pressure) in arm with dialysis site. * Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis (specify frequency). The hemodialysis care plan initiated 11/14/22 & revised on 11/17/22 includes the following interventions: * Check and change dressing daily at access site. Document. Initiated 11/14/22. * Do not draw blood or take B/P in arm with dialysis site. Initiated 11/14/22. * If bleeding noted at dialysis access site, immediately hold direct pressure over the area and call for help. DO NOT leave resident unattended. Initiated 11/17/22. * Monitor for dry skin and apply lotion as needed. Initiated 11/17/22. * Monitor labs and report to doctor as needed. Initiated 11/17/22. * Monitor/document report to MD (medical doctor) s/sx of depression. Obtain order for mental health consult if needed. Initiated 11/17/22. * Monitor/document/report PRN (as needed) any s/sx of infection to access site: Redness, Swelling, warmth, or drainage. Initiated 11/17/22. * Monitor/document/report PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Initiated 11/17/22. * Monitor/document/report PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. Initiated 11/17/22. Surveyor reviewed R3's physician orders and noted there is not an order for dialysis. Surveyor reviewed R3's progress notes, November 2022 MAR (medication administration record,) & November 2022 TAR (treatment administration record) and was unable to locate monitoring of R3's dialysis access site for complications. The nurses note dated 11/14/22 documents: New Admit: 74 yr (year old) female, Alert & ox2 (orientated times two) with confusion/anxiety noted. Full code, Allergy-Sulfa Drugs. admitted to room (number.) S/P DX (status post diagnoses): HTN (hypertension,) Weakness, Chronic Pain, DMII (diabetes mellitus 2,) Dialysis on T-Th-SAT (Tuesday, Thursday, Saturday.) Fistula right chest wall. Diet Renal, G/J (gastrostomy/jejunostomy) tube of Nepro 2000-0800 (8:00 p.m.-8:00 a.m.) Wt (weight) 182.22, LBM (last bowel movement) 11/13/22. Incont. (incontinent) of bowel, (loose stools) wears briefs. Resp (respirations) even non labored. Lungs CTA (clear to auscultation.) No s/s (signs/symptom) of distress. No SOB (shortness of breath.) C/o (complaint of) pain, given Oxycodone 5 mg (milligrams.) Effective. Assist of 2 with pivot transfers. PT (physical therapy) to eval. (evaluate.) Skin W/D (warm/dry) to touch. Incision pack with w/d (wet to dry) dressing, D/T (due to) Wnd (wound) vac D/C'd (discontinued.) Stage 1 sacral wnd (wound.) Barrier cream applied. Redness noted to ABD (abdominal) folds, Nystatin cream applied as per order. All medication orders called into (name) NP (Nurse Practitioner), on call for Dr. (name.) All medications orders faxed to pharmacy. Vss (vital signs stable.) This note was written by LPN (Licensed Practical Nurse)-X. Surveyor was unable to interview LPN-X. The skilled daily note dated 11/14/22 written by LPN-X documents Nepro on @ (at) 2000 (8:00 p.m.) Off @ 0800 (8:00 a.m.) Dialysis on T-Th-SAT. S/P Wnd Vac ABD, DM2, PT (physical therapy)/OT (occupational therapy)/ST (speech therapy) as per MD orders. The nutritional assessment progress note dated 11/16/22 includes documentation of Res (Resident) reports she has been on hemodialysis for the past 6 months. The nurses note dated 11/17/22 at 2:37 p.m. documents, Writer notified NP (Nurse Practitioner) [name] of BS (blood sugar) 567. Received order to give additional 16 units of Humalog. rechecked BS it was 522. Notified NP received order to give additional 20 units of Humalog. Rechecked BS was 357. Received order to give 62 units of NPH with tube feeding at 2000 (8:00 p.m.). (Cross-reference F760). The nurses note dated 11/18/22 at 7:23 a.m. documents Pt (patient) alert, some confusion noted. Able to make needs known. 0 (zero) c/o pain, Tube feeding running as ordered throughout the night. Tolerating well. 0 SOB (shortness of breath) or respiratory distress noted. 0 N/V (nausea/vomiting). The order administration noted dated 11/18/22 at 11:31 a.m. documents, Resident sent to hospital d/t (due to) not being able to obtain BS. reading on glucometer read HI. The nurses note dated 11/18/22 at 11:42 a.m. documents: Resident sent to [name of] hospital d/t hyperglycemia. Writer attempted to obtain residents BS at approx (approximately) 0800 (8:00 a.m.). Both glucometers read hi, I was not able to obtain a number. Resident didn't receive insulin from bedtime. [Name], NP notified, and recommended resident be sent to ER (emergency room ). [Name] (daughter/POA (power of attorney)) notified and aware of situation. Ambulance arrived at 0910 (9:10 a.m.) to facility. During the transfer, writer received a call from lab regarding critical lab work from morning lab draw. Glucose 517, Potassium 7.1, Creatinine 10.7. Information was provided to ambulance to give to hospital. A report was called into [name] nurse at [hospital name] prior to ambulance arrival. DON (Director of Nursing) aware. The lab report dated 11/18/22 under communication logs documents: [Name of facility] [name of unit] called by [name]. Comment: The following critical results were read back and knowledge by [name] (LPN). Glucose: 517 mg/dL High Panic (Ref (reference) Range: 70-99) Potassium: 7.1 mmol/L High Panic (Ref Range 3.6-5.0) Creatinine: 10.70 mg/dl High Panic (Ref Range 0.60-1.00) There is a handwritten notation on the lab report of in hospital [name of] NP aware 11/18/22. The order administration note dated 11/18/22 at 12:19 p.m. documents: In hospital at [name of hospital]. The nurses note dated 11/21/22 at 8:40 a.m. documents, Spoke with nurse at [name of] hospital this am (morning) resident admitting dx (diagnoses) sepsis with acute renal failure, and hyperkalemia. Resident currently in ICU. Per nurse resident doing well and was at dialysis at time of call. Surveyor reviewed the 24-hour board for R3's unit from 11/14/22 to 11/18/22. Surveyor noted on 11/14/22 & 11/15/22, R3 is not on the 24-hour board. On 11/16/22, R3 is listed as a new admit. Day shift documents c/o (complaint of) pain, evening shift ok, without concerns, and night shift is blank. 11/18/22 day shift sent to [name of] hospital hyperglycemia and critical labs. On 11/29/22 at 10:39 a.m., Surveyor spoke to CNA (Certified Nursing Assistant)-U regarding R3. CNA-U informed Surveyor she doesn't remember too much about R3 but did remember she received tube feeding, used a bed pan, and kind of slept most of the time. Surveyor inquired if R3 went to dialysis. CNA-U informed Surveyor she didn't think she made it, not the couple of days she was there. Surveyor asked CNA-U how she knows if a resident goes to dialysis. CNA-U informed Surveyor usually the nurses let them know. Surveyor inquired if dialysis residents have a book they bring to dialysis. CNA-U replied, Yeah a binder. On 11/29/22 at 11:16 a.m. Surveyor interviewed RN/DRM (Registered Nurse/Dialysis Regional Manager)-V who explained prior to dialysis the Resident has to be financially & medically approved and she will receive an email from their corporate informing her of this. RN/DRM-V informed Surveyor they usually get an email from AD (Admissions Director)-J if a Resident has been admitted and then she will put the Resident on their schedule. RN/DRM-V informed Surveyor their dialysis company started in June, and she has an in-service with the Facility's staff on Thursday as to what the expectations are as they do not always receive a pre-weight, or the information is not filled out when residents come for dialysis from the facility. RN/DRM-V explained she held an in-service in June. Surveyor asked RN/DRM-V if she received an email informing her R3 was being admitted and required dialysis. RN/DRM-V informed Surveyor they never saw R3. RN/DRM-V then went to her computer and stated to Surveyor we don't have that she was admitted to us. RN/DRM-V informed Surveyor she received an email that R3 was financially approved but didn't get an email from AD-J and did not have orders. RN/DRM-V informed Surveyor the only way she knew R3 was at the Facility is because she received a telephone call from the nephrologist at the hospital asking her if R3 was one of her patients. On 11/30/22 at 7:31 a.m. Surveyor asked LPN-O how would [name of] dialysis know there is a new admission who required dialysis. LPN-O informed Surveyor she surmises that the admission lady would tell them. Surveyor asked LPN-O if she has to notify [name of] dialysis. LPN-O replied no we have not had to contact dialysis. On 11/30/22 at 8:00 a.m. Surveyor asked Administrator-A if LPN-X still works at the facility. Administrator-A replied yes but she is out right now. On 11/30/22 at 8:45 a.m. Surveyor asked RN-Y if R3 received dialysis. RN-Y replied, I don't know, and explained they get half of the patients up for dialysis and R3 wasn't one of them. RN-Y informed Surveyor she doesn't know if R3 was on the list or not. On 11/30/22 at 9:54 am., Surveyor asked LPN-F if R3 received dialysis. LPN-F replied, I don't know, I'm not sure, and explained R3 wasn't here that long. On 11/30/22 at 10:01 a.m., Surveyor asked APNP (Advanced Practice Nurse Prescriber)-E if she was aware R3 was not receiving dialysis when she was at the facility. APNP-E replied no, she didn't know that. Surveyor asked APNP-E about R3's critical labs. APNP-E informed Surveyor the blood sugar would be due to not getting the NPH insulin (Cross-reference F760) and the critical potassium & creatinine is because of not receiving dialysis and DKA (diabetic ketoacidosis) plays a role. On 11/30/22 at 10:40 a.m., Surveyor met with AD (Admissions Director)-J to discuss the process of an admission receiving dialysis. AD-J explained she sends a referral out to [name of] dialysis company and someone in their office reviews the referral and then they send her a list of everything that is needed. Once everything is provided, the dialysis company will email her when the patient is medically and financially approved. AD-J informed Surveyor then she will let the dialysis company & RN/DRM-V know the resident is being admitted or when they are being admitted . AD-J informed Surveyor she emails this information. Surveyor asked AD-J if R3 received dialysis. AD-J informed Surveyor R3 was on the list, she was approved and everything. AD-J informed Surveyor she had been working on R3 since 9/20/22 as the hospital had a diagnosis of acute kidney injury and she needed the hospital to change the diagnosis to end stage renal disease. AD-J provided Surveyor with emails between herself and [name of] dialysis company. Surveyor noted RN/DRM-V is not on the email list and asked AD-J about RN/DRM-V not being on the list. AD-J informed Surveyor RN/DRM-V wasn't on the email thread at that time. Surveyor informed AD-J RN/DRM-V was not aware R3 had been admitted . On 11/30/22 at 1:22 p.m. Surveyor met with CNO (Chief Nursing Officer)-C and DON (Director of Nursing)-B regarding dialysis. Staff explained once a resident is admitted , the admitting nurse will verify the order with the medical provider from [name of group]. Prior to the resident being admitted , AD-J will send the information to [name of] dialysis company. Once the dialysis company approves the Resident and the resident is admitted , [name of] dialysis company will put them on their schedule. The dialysis company emails the schedule, and the unit secretary will print and post the schedule at the nurse's station. Residents are brought down to the dialysis unit by nursing staff and the dialysis center will call when the resident is ready for pick up. Surveyor inquired about monitoring a Resident's access site for complications. Surveyor was informed they monitor for bleeding post dialysis, thrill, bruit, & ensure the port area access is intact. Surveyor inquired where this would be located. Surveyor was informed in the progress notes, MAR, or TAR. Surveyor inquired how often the access site is assessed for complications. Surveyor was informed daily. The facility's failure to ensure R3 received dialysis following admission to the facility contributed to R3 experiencing critical Blood Sugar, Potassium, & Creatinine lab values and hospitalization in the ICU (intensive care unit) and created a situation of immediate jeopardy. The immediate jeopardy was removed on 12/2/22 when the facility implemented the following action plan: * An audit was conducted to identify that all dialysis residents had the appropriate interventions/orders for dialysis. Any variances were corrected. * Licensed Nursing staff educated on identifying dialysis residents and entering the appropriate orders required. Started 11/30/22 and continued 12/1/22. Any nurse that has not received training will be educated prior to the start of their next scheduled shift. * Meeting to occur with [name of] dialysis center and IDT (interdisciplinary team) to review the communication system for newly admitted dialysis residents. Admission Director will validate that the dialysis appointment is set up via email/phone confirmation from [name of] or outside dialysis facility. Education with the Admissions Director on the system for communicating with the dialysis center and facility staff on admitting dialysis residents. * The Regional Nursing Director of [dialysis name] will begin to attend the facility QAPI (quality assurance performance improvement) meetings. * The admission nursing checklist was revised to reflect the requirements for dialysis residents. * Post admission validation process reviewed with current leadership. * IDT to conduct admissions audit review to ensure all admitted dialysis residents have the appropriate orders and treatment schedule. This will be conducted 5x (times) a week during the morning IDT meet for 4 weeks. Then weekly for 4 weeks. The collected data from the audit will be brought to QAPI for further review and any need for change in process. The deficient practice continues at a scope/severity of E (potential for harm/pattern) as evidenced by the following examples, the 16 additional residents in the facility receiving dialysis and as the facility implements its action plan. 2.) R6 was admitted to the facility on [DATE] with diagnoses which include diabetes mellitus, end stage renal disease, and dependence on renal dialysis. The hemodialysis care plan initiated 11/2/22 and revised 11/7/22 has the following interventions. * Check and change dressing daily at access site. Document. Initiated 11/2/22. * Do not draw blood or take B/P (blood pressure) in arm with dialysis site. Initiated. * If bleeding noted at dialysis access site, immediately hold direct pressure over the area and call for help. Do NOT leave resident unattended. Initiated 11/4/22. * Monitor for dry skin and apply lotion as needed. Initiated 11/4/22. * Monitor labs and report to doctor as needed. Initiated 11/4/22. * Monitor/document report to MD (medical doctor) s/sx (signs/symptoms) of depression. Obtain order for mental health consult if needed. Initiated 11/4/22. * Monitor/document/report PRN (as needed) any s/sx of infection to access site: Redness, swelling, warmth, or drainage. Initiated 11/4/22. * Monitor/document/report PRN for s/sx of rental insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lunch sounds. Initiated 11/4/22. * Monitor/document/report PRN for s/sx of the following: Bleeding, hemorrhage, bacteremia, septic shock. Initiated 11/4/22. The admission MDS (minimum data set) with an assessment reference date of 11/8/22 documents a BIMS (brief interview mental status score) of 15 which indicates cognitively intact. R6 is checked for dialysis while a resident & not a resident. The nurses note dated 11/1/22 at 5:30 p.m. includes documentation of also has newer fistula present on left arm & also has right permcath site that was removed very recently last wk (week) Wednesday 10/26/22. The nurses note dated 11/2/22 at 10:30 p.m. documents Resident is being monitored for new admit status. No c/o (complaint of) any pain/discomfort per resident. Took all sch. (scheduled) meds (medication) as directed. No concerns @ (at) this time. VSS (vital signs stable) afebrile. Will be attending HD (hemodialysis) as planned on Tues/Thurs/Sat @ [name of dialysis] (downstairs), unknown of the exact time of HD. The nurses note dated 11/6/22 at 6:51 a.m. documents Pt (patient) A & O (alert and orientated). Able to make needs known. 0 (zero) c/o pain or discomfort. Dressing to L (left) AV (arteriovenous) fistula (C/D/I (clean/dry/intact). 0 bleeding or s/s (signs/symptoms) of infection noted. +Bruit/Thrill. 0 cough or SOB (shortness of breath) noted. 0 N/V (nausea/vomiting). The nurses note dated 11/9/22 at 10:30 p.m. documents Adjusting well to facility/room/unit. VSS afebrile. Left AV fistula has + Bruit/Thrill present. Will cont. (continue) to monitor resident. The APNP (Advanced Practice Nurse Prescriber) progress note dated 11/15/22 under assessment and plan includes End stage renal disease: Continue dialysis (T (Tuesday), TH (Thursday), Sat (Saturday)). Continue sevelmer. Avoid nephrotoxins. Monitor. The APNP progress note dated 11/17/22 under subjective documents Pt (patient) was seen in the dialysis room. AAOx3 (awake alert orientated times three). No c/o (complaint of). Tolerating treatment well. Vital signs stable. Pt with no urgent concerns during my visit. No new problems were reported by the nursing or dialysis staff. Under assessment and plan includes End stage renal disease: Continue dialysis (T, TH, Sat). Continue sevelamer. Avoid nephrotoxins. Monitor. The APNP progress note dated 11/23/22 under assessment and plan includes End stage renal disease: Continue dialysis (T, TH, Sat). Continue sevelmer. Avoid nephrotoxins. Monitor. The APNP progress note dated 11/25/22 under assessment and plan includes End stage renal disease: Continue dialysis (T, TH, Sat). Continue sevelmer. Avoid nephrotoxins. Monitor. Surveyor reviewed R6's physician orders and noted there are no orders for dialysis or care of the access site. Surveyor reviewed R6's November 2022 MAR (medication administration record) and November 2022 TAR (treatment administration record) and did not note any monitor of R6's access site or any care provided. On 11/30/22 at 9:48 a.m. Surveyor asked LPN (Licensed Practical Nurse)-F when a Resident is newly admitted is admitting this resident part of her responsibility. LPN-F replied yes. Surveyor inquired if the Resident is on dialysis is there anything she is required to do. LPN-F informed Surveyor if the Resident has end stage renal disease and is not on the list, she will then question this. Surveyor inquired regarding the list. LPN-F informed Surveyor the list has names of Residents who go to dialysis and the time they go. Surveyor inquired who develops this list. LPN-F replied, I don't know. Surveyor inquired who obtains doctors' orders for dialysis. LPN-F replied I don't know the answer for that either. Surveyor inquired where would surveyor be able to locate monitoring of the access site for complications. LPN-F informed Surveyor there are binders and if not in the binder, then dialysis would have it. LPN-F informed Surveyor they check the access site. Surveyor asked where this would be located. LPN-F informed Surveyor it's in the MAR or TAR. On 11/30/22 at 10:19 a.m. Surveyor observed R6 sitting in a wheelchair in his room watching TV. Surveyor inquired how dialysis is going. R6 replied fine. R6 informed Surveyor they take him downstairs and pick him up. Surveyor inquired if he has to wait an extended time to be brought back upstairs. R6 replied sometimes and explained he doesn't have a busy lift, so he waits his turn, and it doesn't bother him. Surveyor asked R6 if he has a dialysis binder. R6 informed Surveyor it's at the back of the nurse's station. R6 informed Surveyor a couple of times there wasn't any sheets in the binder, and they don't have it downstairs at dialysis. Surveyor inquired on dialysis days if he receives lunch. R6 informed Surveyor up until recently he didn't get lunch and would have to wait until dinner. R6 informed Surveyor he's had lunch on dialysis days only two times in the last month. Surveyor asked R6 on the dialysis days when he doesn't receive lunch is he hungry. R6 replied yes. On 12/1/22 at 6:55 a.m. Surveyor reviewed R6's dialysis binder which contains communication report sheets. Surveyor noted according to this sheet the report is to be initiated by the Facility Nurse. The Report is to be filed in the Facility Patient Record and a copy in the Dialysis Patient Record. The section for the Facility nurse to complete includes the patient name, code status, date, vital signs for time, temperature, pulse, respirations, & blood pressure, blood glucose if applicable, pre-weight in kilograms, Food intake: Ate prior to treatment yes/no, Mental status (check all that apply): alert & orientated yes, no person, place time, Pain yes/no Pain Medication Administered & time administered, Any change in condition since last dialysis (include any new medication or falls):, Precaution Type & Site: and Completed by (name & title). Surveyor noted on 11/3/22 the Facility section is not completed, for 11/5/22, 11/10/22, & 11/15/22 there are no sheets, on 11/19/22 the Facility section is not completed, on 11/22/22 & 11/24/22 there are no sheets, and 11/29/22 the Facility section is not completed. At the bottom of the communication sheet documents ATTENTION FLOOR NURSE: Continue to assess patient's blood pressure and access dressing. If bleeding should occur after dialysis treatment apply pressure to access site and notify dialysis staff. Remove dressing no later than 8 hours post treatment and leave open to air. Catheter (CVC) dressing must remain intact at all times. If removed by the patient, make sure that clamps are closed, and Leur-lock caps are in place. Cleanse exit site with alcohol prep pad, Chlora-prep, or Betadine wipe/swab, and apply a sterile dressing. Promptly notify dialysis staff. 03357 3.) On 11/30/22 Surveyor interviewed R7 while in her room. R7 reported going to dialysis 3 times a week (Tuesday, Thursday, and Saturday) and liked the nurses and the girls in dialysis. R7 stated she receives dialysis located on the first floor of the facility. R7 reported she has not missed any dialysis and has a catheter/port for dialysis in her chest area. R7 stated once done with the dialysis treatment, the certified nursing assistants (CNAs) are responsible to take you back to your room. R7 informed Surveyor that sometimes it takes 1 1/2 hours before they come to bring her back from dialysis and as a result, she misses her lunch. R7 stated, I told them to hold my lunch and they don't. I've been here over 3 weeks now and get nothing for lunch on dialysis days. Surveyor asked R7 if she is hungry by the time supper comes and R7 stated, absolutely. R7 reported, I tell them to bring a lunch to my room and they can always heat it up, but they don't. R7 stated that's on the aides here and not dialysis (referring to not getting her lunch). R7 stated, every day I talk to the nurse about her lunch. On Wednesday 11/30/22 at 12:20 pm, Surveyor asked Dietary Staff Member K what he does with the lunch trays for Residents who receive dialysis. Dietary Staff Member K reported he places the tray in the refrigerator behind the steam table and staff heat it up when the Resident returns from dialysis however, by that time, Dietary Staff Member K has left for the day. On Wednesday 11/30/22 Surveyor observed R7 received her lunch tray while in her room. Surveyor noted the dietary ticket on her tray had documented, Tuesday, Thursday, and Saturday save lunch and reheat when Resident arrives back from dialysis. Surveyor pointed this out to R7 stating that the dietary ticket states, Tuesday, Thursday, and Saturday save lunch and reheat when Resident arrives back from dialysis. R7 responded, they don't do it. On 11/30/22 Surveyor reviewed R7's medical record. Surveyor reviewed R7's care plan which addresses a Focus area of, The resident needs dialysis Hemodialysis, ESRD, RIJ (Internal Jugular) cath indwelling peritoneal dialysis catheter, has not been used. initiated on 11/4/2022. The Goal: The resident will have immediate intervention should any s/sx of complication from dialysis occur through the review date. initiated 11/7/22 Interventions dated 11/7/22 include: If bleeding noted at dialysis access site, immediate hold direct pressure over the area and call for help. Do NOT leave resident unattended. Monitor for dry skin and apply lotion as needed. Monitor labs and report to doctor as needed. Monitor/document report to MD s/sx of depression. Obtain order for mental health consult if needed. Monitor/document/report PRN any s/sx of infection to access site: Redness, swelling, warmth or drainage. Monitor/document/report PRN for s/sx of renal insufficiency: Changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Monitor/document/report PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. Surveyor noted R7's dialysis care plan does not address how R7 will receive their lunch meal because of being in dialysis. R7's dialysis care plan does not address staff transporting R7 to and from dialysis. Surveyor reviewed R7's physician's orders and noted no physician's orders for dialysis. Surveyor also reviewed R7's Medication Administration Record (MAR) and the Treatment Administration Record (TAR) and did not see any documentation that R7's RIJ catheter was being monitored for signs and symptoms of infection and/or complications. On 11/30/22 at 1:22 pm Surveyor spoke to Director of Nursing (DON) B and Chief Nursing Officer C regarding the monitoring of the IJ dialysis catheter. DON B and Chief Nursing Officer C stated the dialysis port is assessed and is documented in the progress note along with dialysis doing their own charting. DON B and Chief Nursing Officer C reported the monitor of the catheter/port would not be in the MAR or TAR. DON B and Chief Nursing Officer C also indicated that they assess the cath/port daily. Surveyor reviewed the progress notes in R7's medical record and did not see documentation of monitoring of the cath/port aside from a progress note on 11/5/22 which included . dressing to L upper chest permacath C/D/I (clean, dry, intact). 0 bleeding or s/s of infection. PD site clean and dry. No redness or drainage noted and 11/12/22 resident received dialysis this morning. Returned on unit, tolerated procedure well. Dressing to dialysis site C/D/I. No active bleeding. On 12/1/22 at 7:55 am, Surveyor interviewed LP [TRUNCATED]

Based on interviews and record reviews, the facility did not ensure 1 (R3) of 1 Residents reviewed was free of significant medication errors. On 11/17/22 R3's blood sugar was 567. Advanced Practical Nurse Prescriber (APNP)-E was notified and ordered an additional 16 units of Humalog. R3's blood sugar was rechecked with a blood sugar of 522. APNP-E was notified and ordered 20 additional units of Humalog. R3's blood sugar was rechecked with a blood sugar of 357. APNP-E ordered to give 62 units of NPH (Neutral Protamine [NAME]) insulin with tube feeding at 8:00 p.m. R3 did not receive the 62 units of NPH and APNP-E was not notified the Facility did not have the NPH to administer to R3. On 11/18/22 the Facility's glucometer read HI when R3's glucose was checked. APNP (advanced practice nurse prescriber)-E recommended R3 be transferred to the hospital. Prior to transfer to the hospital on 11/18/22 the Facility was notified of critical labs drawn that morning of a blood sugar 517 (reference range 70-99 mg/dl (milligram per decilitre). According to https://www.mayoclinic.org/diseases-conditions/diabetic-ketoacidosis/symptoms-causes/syc-20371551 Seek emergency care if: Your blood sugar level is higher than 300 milligrams per deciliter (mg/dL), or 16.7 millimoles per liter (mmol/L) for more than one test . Remember, untreated diabetic ketoacidosis can lead to death. R3 experienced multiple readings of blood sugars greater than 500. R3 was admitted into the hospital's ICU (intensive care unit) on 11/18/22. Following admission to the facility APNP-E was adjusting R3's insulins to try to have R3 receive Humalog as her primary insulin. During this adjustment R3's blood sugar levels became unstable which increased the need for R3 to receive the NPH as ordered and increased monitoring. The Facility's failure to ensure nursing staff obtained NPH and contacted the medical provider when R3's NPH was not available created a finding of immediate jeopardy that began on 11/17/22. Administrator-A, DON (Director of Nursing)-B, CNO (Chief Nursing Officer)-C and VP (Vice President) Clinical/RN (Registered Nurse)-D of the immediate jeopardy on 12/1/22 at 11:38 a.m. The Facility removed the immediate jeopardy on 12/2/22 and the deficient practice continues at a scope and severity of an E (potential for harm/pattern) as the Facility continues to implement its action plan. Findings include: The Unavailable Medications policy & procedure revised January 2018 under policy documents Medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion. This situation may be due to the pharmacy being temporarily out of stock of a particular product, a drug recall, manufacturer's shortage of an ingredient, or the situation may be permanent because the drug is no longer being made. The facility must make every effort to ensure that medications are available to meet the needs of each resident. Under Procedures documents A. The pharmacy staff shall: 1) Call or notify nursing staff that the ordered product(s) is/are unavailable. 2) Notify nursing when it is anticipated that the drug(s) will become available. 3) Suggest alternative, comparable drug(s) and dosage of drug(s) that is/are available, which is covered by the resident's insurance. B. Nursing staff shall: 1) Notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy(ies) that are available. a. If the facility nurse is unable to obtain a response from the attending physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or direction. 2) Obtain a new order and cancel/discontinue the order for the non-available medication. 3) Notify the pharmacy of the replacement order. R3 was admitted to the facility on [DATE] with diagnoses which included hypertension, chronic kidney disease Stage 3, diabetes mellitus, end stage renal disease, & dependence on renal dialysis. Surveyor reviewed R3's physician orders and noted the following insulin orders: Order date 11/14/22 NPH 62 units at bedtime with directions if tube feeding is held do not give dose. This order was discontinued on 11/15/22. Order date 11/14/22 regular insulin per sliding scale four times a day. Order date 11/14/22 Glargine insulin 10 units at bedtime. Order date 11/17/22 Humalog 16 units one time. Order date 11/17/22 Humalog 20 units one time Order date 11//17/22 NPH 62 units at bedtime with directions if tube feeding is held do not give dose. The nurses note dated 11/14/22 documents New Admit: 74 yr (year old) female, Alert & ox2 (orientated times two) with confusion/anxiety noted. Full code, Allergy-Sulfa Drugs. admitted to room [number]. S/P DX (status post diagnoses): HTN (hypertension), Weakness, Chronic Pain, DMII (diabetes mellitus 2), Dialysis on T-Th-SAT (Tuesday, Thursday, Saturday). Fistula right chest wall. Diet Renal, G/J (gastrostomy/jejunostomy) tube of Nepro 2000-0800 (8:00 p.m.-8:00 a.m.). Wt (weight) 182.22, LBM (last bowel movement) 11/13/22. Incont. (incontinent) of bowel, (loose stools) wears briefs. Resp (respirations) even non labored. Lungs CTA (clear to auscultation). No s/s (signs/symptom) of distress. No SOB (shortness of breath). C/o (complaint of) pain, given Oxycodone 5 mg (milligrams). Effective. Assist of 2 with pivot transfers. PT (physical therapy) to eval. (evaluate). Skin W/D (warm/dry) to touch. Incision pack with w/d (wet to dry) dressing, D/T (due to) Wnd (wound) vac D/C'd (discontinued). Stage 1 sacral wnd (wound). Barrier cream applied. Redness noted to ABD (abdominal) folds, Nystatin cream applied as per order. All medication order called into [name] NP (Nurse Practitioner), on call for Dr. [name] All medications orders faxed to pharmacy. Vss (vital signs stable). This note was written by LPN (Licensed Practical Nurse)-X. Surveyor was unable to interview LPN-X. The nurses note dated 11/17/22 at 2:37 p.m. documents Writer notified NP (Nurse Practitioner) [name] of BS (blood sugar) 567. Received order to give additional 16 units of Humalog. rechecked BS it was 522. Notified NP received order to give additional 20 units of Humalog. Rechecked BS was 357. Received order to give 62 units of NPH with tube feeding at 2000 (8:00 p.m.). The nurses note dated 11/18/22 at 7:23 a.m. documents Pt (patient) alert, some confusion noted. Able to make needs known. 0 (zero) c/o pain. Tube feeding running as ordered throughout the night. Tolerating well. 0 SOB (shortness of breath) or respiratory distress noted. 0 N/V (nausea/vomiting). The order administration note dated 11/18/22 at 11:31 a.m. documents Resident sent to hospital d/t (due to) not being able to obtain BS. reading on glucometer, read HI. The nurses note dated 11/18/22 at 11:42 a.m. documents Resident sent to [name of ] hospital d/t hyperglycemia. Writer attempted to obtain residents BS at approx (approximately) 0800 (8:00 a.m.). Both glucometers read hi, I was not able to obtain a number. Resident didn't receive insulin from bedtime. [Name], NP notified, and recommended resident be sent to ER (emergency room ). [Name] (daughter/POA (power of attorney)) notified and aware of situation. Ambulance arrived at 0910 (9:10 a.m.) to facility. During the transfer, writer received a call from lab regarding critical lab work from morning lab draw. Glucose 517, Potassium 7.1, Creatinine 10.7. Information was provided to ambulance to give to hospital. A report was called into [name] nurse at [hospital name] prior to ambulance arrival. DON (Director of Nursing) aware. The lab report dated 11/18/22 under communication logs documents [NAME] of [NAME] (2 South) called by [name]. Comment: The following critical results were read back and knowledge by [name] (LPN). Glucose: 517 mg/dL High Panic (Ref (reference) Range: 70-99) Potassium: 7.1 mmol/L High Panic (Ref Range 3.6-5.0) Creatinine: 10.70 mg/dl High Panic (Ref Range 0.60-1.00) There is a handwritten notation on the lab report of in hospital [name of] NP aware 11/18/22. The order administration note dated 11/18/22 at 12:19 p.m. documents In hospital at [name of hospital]. The nurses note dated 11/21/22 at 8:40 a.m. documents Spoke with nurse at [name of] hospital this am (morning) resident admitting dx (diagnoses) sepsis with acute renal failure, and hyperkalemia. Resident currently in ICU. Per nurse resident doing well and was at dialysis at time of call. (Cross-reference F698). On 11/29/22 at 2:46 p.m. Surveyor spoke with RN (Registered Nurse)-W who was the evening shift nurse on 11/17/22. Surveyor asked RN-W if she was able to administer the 62 units of NPH with R3's tube feeding. RN-W replied no, didn't have NPH and thought R3's blood sugar wasn't very high. Surveyor asked RN-W if she contacted the doctor or NP (nurse practitioner) to let them know she didn't have NPH. RN-W replied no, not the doctor, called the pharmacy. Surveyor asked RN-W if the NPH arrived from the pharmacy during her shift. RN-W replied no, not on her shift and informed Surveyor maybe it came in on nights. Surveyor inquired if NPH is in contingency. RN-W informed Surveyor they don't have NPH in contingency. On 11/30/22 at 9:52 a.m. Surveyor spoke with LPN (Licensed Practical Nurse)-F regarding R3 and her nurses note dated 11/17/22. Surveyor asked LPN-F about the order she received for 62 units of NPH. LPN-F informed Surveyor this was at shift change. LPN-F informed Surveyor she told the 2nd shift nurse R3 is supposed to get 62 units NPH, she put a note in the computer and the order in the MAR. LPN-F informed Surveyor she told them they had to the call the pharmacy for R3's NPH and everything else was done. Surveyor inquired how they notify pharmacy of an order. LPN-F informed Surveyor they can call, fax, or reorder through PCC (pointclickcare). LPN-F stated she told the 2nd shift nurse they still needed to contact the pharmacy for the NPH. On 11/30/22 at 10:01 a.m. Surveyor spoke with APNP-E regarding R3. Surveyor asked APNP-E if she was contacted regarding the Facility not having NPH to administer the 62 units at time of her tube feeding at 8:00 p.m. APNP-E informed Surveyor no one called her. APNP-E informed Surveyor when she came in the next day and was notified the nurse couldn't obtain R3's blood sugar as the glucometer read HI she looked at [name of company] notes to see if anyone was notified during off hours and there were no notes. APNP-E informed Surveyor she was notified of the critical labs from the lab draw on 11/18/22 but R3 was in the ER (emergency room ) and informed Surveyor the ER would draw their own labs. Surveyor asked APNP-E why she thought R3's blood sugar was critical. APNP-E informed Surveyor from not getting her NPH. Surveyor noted R3 had previous orders for NPH. APNP-E shared with Surveyor they were attempting to adjust R3's insulin to have her receive Humalog as her primary insulin but R3's blood sugars became unstable. Surveyor asked if this increased the need to monitor R3 and ensure she received her insulins as ordered. APNP-E indicated yes. The facility's failure to ensure R3 received NPH 62 units at time of tube feeding on 11/17/22 during a situation where R3 was undergoing elevated blood sugar levels and insulin medication changes led to R3 having critical blood sugar lab values and hospitalization in the ICU (intensive care unit) created a situation of immediate jeopardy. The immediate jeopardy was removed on 12/2/22 when the facility implemented the following action plan: * Re-education initiated on 11/30/22 and continued on 12/1/22 to licensed nursing staff. Any nurse that has not received training will be re-educated prior to the start of their next scheduled shift. * Education consists of 1:1 in person nursing education on Facility policy for Unavailable medication and Change of Condition. * Unavailable Medication Education consisted of: Medications must be administered as ordered by provider. If medication is not available, RN/LPN (Registered Nurse/Licensed Practical Nurse), must contact the pharmacy and call the provider to notify that the medication is not available in the facility and to inquire if provider wants to hold or substitute medication. Progress note must be entered to document notification. * Change of Condition Education consisted of notification of change of condition such as vital signs or lab values out of normal range. Notification must be made to a resident's medical provider of any change of condition or variation in physical state. Progress note must be entered to document notification and/or new orders. Insulin awaiting arrival from pharmacy will be listed on the 24-hour board and will include verification of MD notification and be discussed during shift-to-shift report. DON/designee will monitor to ensure that follow up has been completed. 24-hour boards will be brought to daily stand up, Monday through Friday, for review. Education has been started with nursing staff on what medications are available in contingency. Binders will be placed in each medication room by 12/2/22 with a list of all medications available in contingency. * On 11/30/22, the facility IDT reviewed policy and procedures on Unavailable Medications and Change of Condition with medical director and updated as appropriate. * DON/designee will conduct insulin administration audits daily, Monday through Friday, x (times) 4 weeks and then weekly for an additional 4 weeks to ensure insulin is being administered as ordered. This review will be a continued process conducted during the daily clinical meeting. The DON/designee will be responsible to submit this information t to the QAPI to determine the need for ongoing education and monitoring.

Based on observation, interview, and record review, the Facility did not ensure Residents with pressure injuries receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (R4) of 1 Residents reviewed for pressure injuries. The hospital information dated 10/20/22 documents right heel deep tissue injury with a treatment. The skin impairment/wound form dated 10/20/22 for the right heel documents Stage 1 Pressure Injury: Non blancheable erythema of intact skin. There are no further Facility assessments of R4's right heel and vascular surgery consults did not comprehensively assess R4's right heel pressure injury. From 11/10/22 to 11/21/22 the Facility did not implement a change in treatment to R4's right heel of Adaptic vs Cuticerin (petroleum gauze) and cover with dry padded dressing (ABD (Abdominal) preferred). On 12/1/22 Surveyor observed the heel pressure injury during a treatment and observed the heel to be open with bloody drainage on the dressing. The facility assessed the area on 12/1/22 to be a Stage 3 pressure injury. Findings include: The Wound Management - Wound Prevention and Treatment policy and procedure revised 5/9/22 under Provision and Procedure documents 10. 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. R4 was admitted to the facility on [DATE] with diagnoses which include prediabetes, hypertension, artherosclerotic heart disease, peripheral vascular disease, and adult failure to thrive. The potential/actual impairment to skin integrity care plan initiated 10/20/22 & revised 10/25/22 has the following interventions: * Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Initiated 10/25/22. * Encourage good nutrition and hydration in order to promote healthier skin. Initiated 10/20/22. * Follow facility protocols for treatment of injury. Initiated 10/20/22. * Identify/document potential causative factors and eliminate/resolve where possible. Initiated 10/25/22. * Monitor for side effects of the antibiotics and over-the-counter pain medications: gastric distress, rash, or allergic reactions which could exacerbate skin injury. Initiated 10/25/22. * Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc to MD (medical doctor). Initiated 10/25/22. * Obtain blood work such as CBC (complete blood count) with Diff (differential), Blood Cultures, and C & S (culture and sensitivity) of any open wounds as ordered by Physician. Initiated 10/25/22. * Provide pressure relieving device(s): pressure relief mattress, offloading boots. Initiated 10/20/22 & revised 10/25/22. * Turn and position as necessary. Initiated 10/20/22. The skin impairment/wound form dated 10/20/22 for the question does the resident have a pressure injury yes is marked. Location is Right heel. Stage of pressure injury is Stage 1 Pressure Injury: Non-blancheable erythema of intact skin. Measurement of wound is 4cm (centimeters) (L) (length x (times) 4 cm (W) (width). Under additional comments documents, No tunneling/undermining. Area closed. Red, soft. Current treatment is blank. Under additional wound for location documents left heel. Stage of pressure injury is Stage 1 Pressure Injury: non -blancheable erythema of intact skin. Measurement of wound 4 cm (L) x 4cm (W). Under additional comments documents No tunneling/undermining. Area closed. Red, soft. Current treatment is blank. Under current wound/skin integrity interventions documents: Border gauze dressing was noted to bilateral heels and heel boots were on. Heels (both) were intact, soft, some redness noted. Resident stated they were put on to protect my heels. No pain. This skin impairment/wound form was completed by RN/UM (Registered Nurse)/(Unit Manager) L. Surveyor was unable to interview RN/UM L as RN/UM L was out on leave during the survey. The admission MDS (minimum data set) with an assessment reference date of 10/27/22 documents a BIMS (Brief Interview for Mental Status) score of 15 which indicates cognitively intact. R4 requires extensive assistance with one person physical assist for bed mobility and does not ambulate. R4 is at risk for pressure injuries and is coded as not having any pressure injury. Surveyor reviewed R4's progress notes from 10/20/22 to 12/01/22 and noted only the following notes regarding R4's right heel: Skin Impairment/Wound Note dated 10/20/22 at 11:35 a.m. documents Note Text: Pressure Injury Barriers to wound healing: Current Wound/Skin Treatment/Interventions: Wound Education Provided: Non-Pressure Barriers to wound healing: Current Wound/Skin Treatment/Interventions: Wound Education provided: Comments: The skilled daily note dated 11/16/22 documents acute infection IV (intravenous) abx (antibiotic) PICC (peripherally inserted central catheter) line therapy. PEJ (Percutaneous Endoscopic Jejunostomy) feeding nightly. PICC line abx given for acute infection. Right flap, right lower extremity incision, right lower extremity wound, heel. No new signs of infection, redness, bleeding, drainage PT (physical therapy), OT (occupational therapy), ST (speech therapy). The APNP (advance practice nurse prescriber) note dated 11/21/22 under Skin-Wound/Incision documents Right heel deep tissue injury - tissue purple. The follow up section for Vascular surgery dated 11/10/22 includes documentation of Right heel and posterior leg excoriation appear to let. DC (discontinue) use of Mepilex border dressings and change to Adaptic VS Cutericin remain (petroleum gauze) and covered with a dry padded dressing ABD (abdominal) preferred. Continue to wear her boots at all times when resting. Surveyor reviewed R4's treatment orders and noted the following orders: Order date 10/30/22 Continue to pad/protect R dorsal foot, rt (right) heel and rt post leg tears/lesions with dry padded dressing (Mepilex or similar) one time a day for wound care. There is no end date for this treatment. Order date 11/21/22, Apply Mepilex bordered dressing to R (right) dorsal foot, R post heel and R distal post leg wounds (ok to change these every 2-3 days as long as they remain clean/intact) every 48 hours for wound care. Surveyor reviewed R4's October 2022 TAR (treatment administration record) and noted there was no treatment for R4's right heel until 10/30/22. Surveyor noted this treatment is initialed as being completed on 10/30/22 & 10/31/22. Surveyor reviewed R4's November 2022 TAR and noted the treatment to protect R4's right heel with Mepilex or similar dressing is initialed as being completed daily from 11/1/22 to 11/30/22. From 11/10/22 to 11/21/22 the Facility did not implement a change in treatment to R4's right heel of Adaptic vs Cuticerin (petroleum gauze) and cover with dry padded dressing (ABD (Abdominal) preferred). On 11/21/22 there was a change in R4's right heel treatment to apply Mepilex bordered dressing every 48 hours. The Facility continued with daily Mepilex treatments Both treatments of daily and every 48 hours are initialed as being completed on 11/21/22, 11/23/22, 11/25/22, 11/27/22, & 11/29/22. On 11/30/22 at 10:57 a.m., Surveyor observed the treatment for R4's right lower leg non pressure areas and left groin with LPN (Licensed Practical Nurse) O. During this observation at 11:10 a.m., Surveyor asked LPN O about the dressing on R4's right heel. LPN O informed Surveyor she can lift up the dressing as the dressing sticks well and removed the dressing partially from R4's right heel. Surveyor observed there is bloody drainage on the dressing and observed a pressure injury approximately half dollar size with a pinkish wound bed and another portion is purple. At 11:16 a.m., LPN O informed Surveyor she is going to change R4's right heel dressing; removed her gloves, stated she needs to review the treatment as she does not usually do the right heel, and doesn't know what the treatment entails. While LPN O was checking the treatment, Surveyor asked R4 if she came in with the area on her right heel. R4 replied I believe I did. Surveyor inquired if R4 usually wears the prevalon boots. R4 replied yes. At 11:18 a.m. LPN O reentered R4's room with a bordered foam dressing, washed her hands, and placed gloves on. LPN O removed the border foam dressing and replaced the dressing with a comfort foam border dressing. LPN O removed her gloves and washed her hands. On 12/1/22 at approximately 11:55 a.m., Surveyor informed DON (Director of Nursing) B Surveyor is unable to locate any assessments for R4's right heel pressure injury after the initial assessment on 10/20/22 and asked DON B if she would be able to locate any. On 12/1/22 at approximately 3:00 p.m., Surveyor reviewed vascular surgery and plastic surgery consults provided by the Facility and noted the following: The vascular visit dated 10/28/22 under focused exam for right lower extremity includes documentation of Post heel with dry denuded transparent epidermis/eschar, no fluctuance/drainage/erythema/TTP (thrombotic thrombocytopenic purpura) (a blood disorder in which platelets clump in small blood vessels). Under patient instructions documents continue to pad/protect R (right) dorsal foot, R heel and R post leg skin tears/lesions with dry padded dressings (Mepilex border or similar). Surveyor noted there is not a comprehensive assessment of R4's right heel pressure injury. There is no stage, measurements, or percentage of the wound bed. The plastic surgery note dated 11/08/22 does not have documentation of R4's right heel pressure injury. The vascular surgery visit dated 11/10/22 under focused exam for right lower extremity includes documentation of Post heel with superficial ulcer measuring 4.5 x 3.5 cm (centimeters), base slightly macerated with pink-red tissue, no drainage/erythema. Under nursing notes includes documentation of 4.5 x 3.5 cm. Adaptic, ABD (abdominal), Kerlix. Under patient instructions documents R heel and posterior leg excoriations appear too wet, so please d/c (discontinue) use of the Mepilex border dressings and change to Adaptive vs Cuticerin (petroleum gauze) and cover with dry padded dressing (ABD preferred) Continue to wear air boots at all times when resting. Surveyor noted this vascular visit does not stage R4's right heel pressure injury. The Facility did not implement this new treatment. The vascular surgery visit dated 11/21/22 under focused exam for right lower extremity includes documentation of Post heel ulcer measures 1.8 x 1.5 cm x superficial, base moist and red, trace to mild peri-wound maceration, no drainage/erythema. Under patient instructions documents Apply Mepilex border dressings to R dorsal foot, R post heel and R distal post leg wounds (OK to change these every 2-3 days as long as they remain clean/intact. Surveyor noted this vascular visit does not stage R4's right heel pressure injury. The plastic surgery note dated 11/29/22 does not have documentation of R4's right heel pressure injury. On 12/1/22 at 4:00 p.m., Surveyor requested VP (Vice President) Clinical/RN (Registered Nurse) D accompany Surveyor to observe R4's right heel pressure injury. VP Clinical/RN D washed her hands, placed gloves on, and removed R4's right prevalon boot. VP Clinical/RN D removed the dressing and measured the right heel with measurements of 2.0 cm x 1.5 cm stating the periwound is blancheable. The wound base is 50% pale pink and 50% purple. The pale pink has an open area measuring .5 cm x 1 cm. There is small serosanguinous drainage, no odor and small maceration to peri wound. VP Clinical/RN D asked R4 if she is having any pain which R4 replied no. VP Clinical/RN D removed her gloves and washed her hands. Surveyor asked VP Clinical/RN D what stage is she staging R4's pressure injury. VP Clinical/RN D replied Stage 3. On 12/1/22 at 4:23 p.m. VP Clinical/RN D informed Surveyor she spoke with vascular and they said they would stage R4's right heel pressure injury as a DTI (deep tissue injury) as part of the DTI is being reabsorbed so she is going to keep it as a DTI. Surveyor informed VP Clinical/RN D the Facility assessed R4's right heel on date of admission 10/20/22 but there are no further facility assessments. VP Clinical/RN D confirmed there are no further assessments and explained one of the nurses who assessed wounds has been out on leave and another nurse no longer works at the Facility. Surveyor informed VP Clinical/RN D R4's vascular surgery visits dated 10/28/22, 11/10/22, & 11/21/22 do not comprehensively assess R4's right heel pressure injury and there are no assessments during the weeks of 10/30/22 to 11/5/22 and 11/13/22 to 11/19/21. VP Clinical/RN D verified there were no comprehensive assessments or no assessments. Surveyor informed VP Clinical/RN D the facility did not implement a change of treatment from 11/10/22 to 11/21/22. VP Clinical/RN D reviewed R4's electronic record and informed Surveyor the treatment is not in there. On 12/1/22 at 5:37 p.m., Administrator A, DON (Director of Nursing) B and VP (Vice President) Clinical/RN (Registered Nurse) D were informed of the above.

Based on observation, interview and record review the facility did not ensure residents with pressure injuries received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent pressure injuries from developing for 4 of 7 (R3, R8, R10 and R17) residents reviewed for pressure injuries. R3 did not have a comprehensive assessment of his pressure injuries and interventions were not implemented timely. R8 did not have a comprehensive assessment of his pressure injuries and interventions were not implement timely. R10 did not have a comprehensive assessment of her pressure injuries. R17 did not have a comprehensive assessment of his pressure injuries and treatment was not immediately implemented. The facility policy entitled: Wound Management - Wound Prevention and Treatment, dated revised 5/9/22, documents (in part) . .Policy: 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 no-pressure-related wounds. 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. 2. Upon admission, the resident will receive a head-to-toe skin check to identify any skin issues. A licensed nurse will assess any noted pressure injuries. 3. The licensed nurse will conduct weekly skin checks. The skin checks will be documented in the resident's Electronic Medical Record (EMR). c) Pressure Relief . iii. As needed, position and reposition the resident with pillows and other supportive devices. 5. Daily, during routine care, the Certified Nursing Assistant (CNA) will observe the resident's skin. When abnormalities are noted, this will be communicated to the licensed nurse, and the licensed nurse will evaluate and implement a skin event if applicable. 6. Interventions will be implemented in the resident's care plan to prevent pressure ulcer development when the resident has no areas of concern. 7. When the resident is admitted with a pressure ulcer(s), the admitting nurse will document the size, location, appearance, odor (if any), drainage (if any), and current treatment ordered. 8. Interventions will be implemented in the resident's care plan to prevent deterioration and promote the pressure ulcer's healing. 9. The admitting nurse will notify the attending physician of the condition of the pressure ulcer. 10. 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. 11. The nurse will notify the physician when the pressure ulcer shows signs of deterioration or infection and request treatment order changes. 12. The nurse will notify the resident and or the resident's representative of any changes related to the improvement, deterioration, and/or treatment changes on an ongoing basis. 1) R3 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Hospital Discharge Summary dated 5/12/22, had no documentation of pressure injuries. R3's Braden score dated 5/12/22, documented a score of 14, indicating moderate risk for the development of pressure injuries. R3's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/19/22, section G0110 documented: Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate furniture, as extensive - 1 person physical assist. Section M0100 documented: Number of Stage 3 pressure ulcers - 1 present on admission. Number of unstageable pressure injuries presenting as Deep Tissue Injury (DTI) - 1 present on admission. R3's Admission Data Collection form, dated 5/12/22, documented: Coccyx open area noted. DTI to left heel. There was no documentation of a comprehensive assessment to include a description of the wound characteristics, measurements or staging of the wounds. R3's May 2022, Treatment Administration Record (TAR) documented: Coccyx stage 2: Cleanse with NS (normal saline) and cover with bordered foam dressing one time a day, every 3 days - start date 5/13/22. L (left) heel DTI: [MEDICATION(S)] two times a day (BID) - start date 5/12/22. R3's Care Plan Focus area initiated 5/17/22 documented: The resident has Diabetes Mellitus type 2. Interventions included: Perform thorough diabetic foot check daily. Check all surfaces, including between toes. Notify primary physician of any skin abnormalities; Inspect feet daily for open areas, sores, pressure areas, blisters, [CONDITION(S)] or redness. R3's Care Plan Focus area initiated 5/17/22 and revised 5/23/22, documented: The resident has potential/actual impairment to skin integrity r/t (related to) weakness, [CONDITION(S)], DM II (2), admitted with a stage III (3) to coccyx and a DTI to heel. Interventions initiated 5/17/22 included: Educate resident/family/caregivers of causative factors and measures to prevent skin injury; Encourage good nutrition and hydration in order to promote healthier skin; Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Identify/document potential causative factors and eliminate/resolve where possible; Monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to MD (Medical Doctor); Turn and reposition as necessary. Care Plan Focus area initiated 5/25/22 and revised 5/31/22 documented: (R3) has impaired skin integrity as evidenced by unstageable pressure injury to his left heel and right and stage 3 to the coccyx and DM ulcers to the plantar aspect of the right foot related to impaired mobility, incontinence, [CONDITION(S)] and [CONDITION(S)]. Interventions included: Perform thorough diabetic foot check daily. Check all surfaces, including between toes. Notify primary physician of any skin abnormalities - initiated 5/25/22; Surveyor noted the care plan documented R3 admitted with stage 3 pressure injury, however there was no documentation of a comprehensive assessment to include staging of the wound upon admission. In addition, the care plan did not include interventions such as offloading of R3's heels or a specialty mattress appropriate for stage 3 pressure injuries. Surveyor located no documentation of a comprehensive assessment of R3's pressure injuries until 5 day later when he was seen by the Nurse Practitioner (NP). NP Wound Care assessment dated [DATE] documented: Pressure ulcer stage 3 sacrum - admitted with. Full thickness: Wound measures 3.0 cm (centimeters) x 3.5 cm. The wound base is covered with 40% granulation, 40% slough, and 20% skin. Scant serosanguinous drainage. Periwound: No [CONDITION(S)], no induration, no [CONDITION(S)], no maceration. No signs and symptoms of infection. Plan: Soap and water wash to sacrum. Skin prep to the surrounding tissue. Apply [MEDICATION(S)] dressing. Change 2X (times) week and as needed if missing or soiled. Left heel DTI - admitted with. Full thickness: Wound measures 2.0 x 2.2 cm. The wound base is covered with 100% purple tissue. No drainage. Periwound: No [CONDITION(S)], no induration, no [CONDITION(S)], no maceration. No signs and symptoms of infection. Plan: [MEDICATION(S)] BID (twice a day). Surveyor noted the NP documented R3's sacral pressure injury as stage 3 present on admission, however there was no evidence the facility completed a comprehensive assessment to include staging of the pressure injury upon admission. In addition, R3's TAR documented the pressure injury as stage 2. No revisions were made to R3's care plan to include off loading of heels or a specialty mattress appropriate for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] NP Wound Care assessment dated [DATE] documented the same information and wound measurements as documented on 5/17/22. NP Wound Care assessment dated [DATE] documented: Sacrum - full thickness measures 5 x 2.5 cm. The wound base is covered with 100% necrosis. Scant serosanguinous drainage. No signs and symptoms of infection. Status: Deteriorated, tx (treatment) changed. Plan: Clean sacral wound with NS, apply Santyl f/b (followed by) calcium alginate and cover with [MEDICATION(S)] daily and as needed. Left heel DTI. Full thickness measures 7 cm x 6 cm. The wound base is covered with unable to determine, blister open. Scant serosanguinous drainage. No signs and symptoms of infection. Status: Deteriorated, tx changed. Plan: [MEDICATION(S)], ABD (abdominal pad) and kerlix wrap. NP Wound Care assessment dated [DATE] identified 3 new pressure injuries. Documentation: Sacrum - full thickness measures 10 x 7 x UTD (unable to determine) cm. The wound base is covered with 70% necrosis, 30% slough, 10% granulation tissue. Moderate serosanguinous drainage. No signs and symptoms of infection. Status: Deteriorated, patient is educated on proper nutrition and frequent repositioning. Plan: Clean sacral wound with NS, apply Santyl f/b calcium alginate and cover with [MEDICATION(S)] daily and as needed. Left heel DTI - full thickness measures 7 x 6.5 x UTD cm. The wound base is covered with 100% eschar. No drainage or signs and symptoms of infection. Plan: [MEDICATION(S)], ABD and kerlix wrap. Right heel DTI - facility acquired. Full thickness measures 7 x 7 x UTD cm. The wound base is covered with 80% non-blanchable [CONDITION(S)], 20% granulation. Scant serous drainage, no signs and symptoms of infection. Plan: Cleanse right heel with NS, apply [MEDICATION(S)] to dry areas, apply Xeroform cut to size over the open area, place an ABD pad and wrap with kerlix. Right superior plantar - facility acquired. Full thickness measures 2 x 3 x UTD cm. The wound base is covered with 100% eschar. No drainage or signs and symptoms of infection. Plan: [MEDICATION(S)] to the plantar right foot eschar BID. Right inferior plantar - facility acquired. Full thickness measures 3 x 3 x UTD cm. The wound base is covered with 100% eschar. No drainage or signs and symptoms of infection. Plan: [MEDICATION(S)] to the plantar right foot eschar BID. Surveyor noted there was no documentation by nursing in between NP visits weekly. There was no documentation of an assessment or wound progress (improvement or deterioration) with treatment changes. Surveyor noted the only documentation of R3's pressure injuries were by the NP during weekly wound rounds, which documented deterioration with each visit. Surveyor noted R3's Care Plan documented daily foot inspection initiated 5/17/22 and Diabetic foot check every shift initiated 5/25/22. R3 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, Surveyor noted while the Care Plan indicated foot checks to be completed, this formation did not get entered onto R3's TAR, thus there was no evidence foot checks were completed for R3. The NP was monitoring R3's laboratory results. Facility records documented R3's vital signs were stable, and he was afebrile (without fever) until 5/31/22. There was no documentation of urine abnormalities. CBC (Complete Blood Count) results on 5/19/22 documented white blood cells within normal limits. CBC results on 5/31/22 documented elevated white blood cells and the NP ordered a stat (immediate) UA (urinalysis) and 2 view chest Xray. The resident was subsequently sent to the hospital and admitted . Surveyor was unable to obtain hospital records. On 6/22/22 Surveyor spoke with VP (Vice President) of Clinical Services-E. VP-E advised Surveyor she called the hospital and was informed records indicated sacral dressing for full thickness wound was done in the hospital, which would indicate the sacral pressure injury was stage 3 upon admission. VP-E reported she was attempting to obtain the records. Surveyor advised of concern the facility did not complete a comprehensive assessment of the pressure injuries upon admission, there was no evidence of continued monitoring of pressure injuries except for the NP weekly wound rounds, and appropriate interventions were not implemented for treatment and prevention of pressure injuries upon admission. No additional information was provided. On 6/23/22 at 12:11 PM Surveyor advised Director of Nursing (DON)-B of concern the facility did not comprehensively assess R3's pressure injuries upon admission and appropriate interventions (i.e.: foot checks, offloading of heels, air mattress) were either not implemented or not implemented in a timely manner. DON-B reported the facility prefers a Registered Nurse (RN) do initial assessment of wounds. If a Licensed Practical Nurse (LPN) see's wounds first, she expects documentation of wound appearance and measurements, and the RN can come after to look and sign off if she agrees with the assessment. Surveyor advised of concern there was no evidence of assessment or continued monitoring of the wounds except for the weekly NP rounds, which documented progressive deterioration of the wounds and the NP identifying 3 new pressure injuries. DON-B stated: We don't have the same nurse assigned to the same unit every day, so if a nurse does a treatment, she may not necessarily know if there is a decline in the wound, she may just think this is what the wound looks like. We don't expect nurses to do daily charting on wounds. Surveyor advised review of R3's TAR documented consistently the same nurse's initials from 5/13 to 5/23/22 which indicated consistent nursing staff worked with R3. No additional information was provided. 2) R8 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8 was admitted to Hospice care on 5/8/22. R8's Quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Refrence Date) of 2/17/22, section G0100 documented: Bed mobility as extensive assistance - 1 person physical assist. No pressure injuries were documented. R8's Braden scale, dated 2/14/22, documented a score of 16, indicating R8 to be at risk for pressure injuries. Facility progress notes dated 3/4/22 documented: Resident returned from [CONDITION(S)] at this time. Resident complaining of left heel pain. NP (Nurse Practitioner) updated. Skin intact. New order received for skin prep to left heel every shift. Surveyor noted there was no documentation of a comprehensive assessment incuding if R8's heel was reddened or blanchable, or the firmness of the skin. R8's March, 2022 TAR (Treatment indicated interventions of diabetic foot checks and offloading of heels was not implemented until 3/8/22 (4 days after R8 complained of heel pain). On 3/8/22, R8 was seen by the wound NP. Documentation: Left heel diabetic wound facility acquired. Full thickness measuring 3.0 cm (centimeter) x 3.0 cm. The base of the wound is covered with 100% non-blanchable [CONDITION(S)] with bogginess. Entire foot is covered with discoloration and slight [CONDITION(S)]. Patient is being sent to the emergency room (ER). R8 returned from the ER with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An ultrasound completed on 3/10/22 was negative for deep vein [CONDITION(S)] (DVT). Radiology report dated 3/31/22, was negative for fracture or dislocation. No acute findings. R8 was seen at the vascular clinic on 4/12/22. Progress note documented: Left heel pressure wound with poor arterial flow resulting in delayed healing. Non-ambulatory and dependent for all care, so not a revascularization candidate. R8 continued to be followed by the wound NP - treatment was changed accordingly. Surveyor noted discrepancy between the NP documenting the wound as a diabetic ulcer and the vascular physician documenting the wound as pressure. On 6/23/22, at 8:51 AM, Surveyor spoke with Nurse Manager-D who reported the wound care nurse and NP do wound rounds weekly. If a wound is found upon admit or at any time, expectation is for the nurse to documented a description of the wound and measurements. Nurse Manager-D stated the nurse is not expected to stage necessarily, due to not being wound care certified, but should document what the wound looks like and measurements. Nurse Manager-D stated she would expect the nurse to call the wound care nurse also to look at as soon as possible to do own assessment. On 6/23/22, at approximately 10:30 AM, DON-B was notified of concern the facility did not do a comprehensive assessment of R8's heel after he reported heel pain. Interventions including diabetic foot checks and offloading of heels was not implemented until 4 days later, when the NP identified the wound. No additional information was provided. 3) R17 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R17's Admission MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 2/4/22 section G0110 documented bed mobility as extensive assistance two persons physical assist. Section M0100 documented an unstageable pressure injury present on admission. R17's Admission assessment dated [DATE], documented: Coccyx 1 (inch) x ½ open area. There was no documentation of a comprehensive assessment to include description of the wound characteristics, measurements or staging of the wound. (Calculation of measurements in centimeters is 2.54 cm x 1.27). Review of R17's January and February 2022 TAR (Treatment Administration Record) revealed no treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/1/22, R17 was seen by the wound NP. Documentation: Sacrum pressure ulcer unstageable. Full thickness measures 4.0 x 1.5 x 0.1 cm. Base of the wound appears with 80% granulation and 20% slough. Scant serosanguinous drainage. Periwound: No [CONDITION(S)], no maceration, no [CONDITION(S)], no induration. No s/s (signs or symptoms) of infection noted. Plan: Cleanse coccyx wound with normal saline. Apply Xeroform to the wound bed. Cover with a bordered dressing daily and as needed. There was no evidence R17 received treatment to his sacral pressure injury until after he was seen by the wound NP on 2/1/22. The NP assessment and measurements of the pressure injury on 2/1/11 indicated the wound was larger in size than the Admission Assessment completed on 1/28/22. Surveyor identified no concerns with treatment once initiated. The wound NP followed R17's wound weekly and the wound did improve. NP note on 2/8/22 documented: 100% granulation, measurements 0.3 x 0.3 x 0.1 cm. Facility progress note, dated 2/10/22, (day before R17 discharged ) documented: Wound care done to sacrum - almost resolved. On 6/22/22, at approximately 3:00 PM Surveyor advised DON (Director of Nursing)-B of concern the facility did not complete an admission comprehensive assessment of R17's sacral pressure injury to include a description of the wound characteristics, measurements or staging of the wound. In addition, the facility did not initiate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional information was provided. 4) R10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's MDS (Minimum Data Set) assessment dated [DATE], indicates Resident has a BIMS (Brief Interview of Mental Status) score of 15, indicating R10 is cognitively intact related to daily decision making. R10 requires extensive assistance of 2 staff members for bed mobility. The MDS indicates R10 is at risk for the development of pressure injuries and R10 was admitted to the facility with community acquired pressure injuries. On 6/22/22, Surveyor conducted an interview with R10. R10 told Surveyor that they were admitted to the facility with multiple pressure injuries. R10 shared concern with Surveyor that they are worried their wounds are not going to heal because the facility staff are often unable to perform wound dressing changes and treatments are being missed. Surveyor noted R10 had pressure relieving interventions in place including bilateral heel boots and an air mattress. On 6/22/22, Surveyor reviewed R10's admission assessment dated [DATE]. Surveyor noted the facility did not complete a comprehensive assessments of R10's 4 community acquired pressure injuries, including measurements and wound characteristics, upon admission to the facility on [DATE]. Admission assessment is signed by DON (Director of Nursing)-B. Surveyor reviewed a skin impairment/wound form, dated 4/12/22. Surveyor noted comprehensive assessments of R10's 4 community acquired pressure injuries, including measurements and wound characteristic which was conducted by an RN on 4/12/22. Weekly wound assessments are being conducted weekly. Weekly wound assessments indicate R10's wounds are stable and have not worsened since 4/12/22. On 6/23/22, Surveyor reviewed R10's TAR (Treatment Administration Record) for April 2022-June 2022. Surveyor notes that there is no documented treatments being conducted to R10's community acquired pressure injuries on 4/14/22, 4/16/22, 4/18/22, 4/20/22, 4/22/22, 4/26/22, 5/6/22, 5/7/22, 5/9/22, 5/13/22, 6/4/22, 6/5/22, 6/6/22, 6/8/22, 6/9/22, 6/10/22, 6/11/22, 6/12/22 and 6/18/22. On 6/23/22, at 3:20 PM, Surveyor conducted interview with DON-B. Surveyor asked DON-B who is responsible for weekly wound assessments. DON-B responded the facility has a wound nurse who conducts weekly wound assessments. Surveyor asked why R10's community acquired pressure injuries were not comprehensively assessed by an RN upon admission to the facility. DON-B responded that R10 had told DON-B that they did not want to have wounds assessed on 4/7/22 because they were tired from admitting to the facility from the hospital. Surveyor asked why R10's pressure injuries were not assessed by an RN the following day. No further information was available at this time. On 6/23/22, at 3:30 PM, Surveyor shared concerns with Chief Innovation Officer-C related to R10's lack of comprehensive wound assessments upon admission to facility on 4/7/22 and that there is no documented comprehensive assessment of R10's pressure injuries until 4/12/22 (5 days after admission). Surveyor also shared concerns multiple instances of missing documentation of treatments and dressing changes for R10's pressure injuries since admission to facility in April 2022. No additional information was supplied to Surveyor at this time.

Based on observation, interview, and record review, the facility did not ensure residents received adequate supervision and assistance devices and with interventions implemented to prevent falls for 3 (R297, R25, and R27) of 4 residents reviewed for falls. R297 sustained a fall on 9/13/2021 with care plan interventions not in place to prevent the fall. R297 sustained a subdural hematoma that led to death. R25 sustained multiple falls that were not investigated to determine a root cause, interventions were not implemented to prevent future falls, and on 9/13/2021 fell and sustained a laceration to the scalp that required staples. R27 sustained multiple falls that were not investigated to determine a root cause and interventions were not implemented to prevent future falls. Findings: The facility policy and procedure entitled Fall Policy dated 5/17/2021 states: All residents will receive adequate supervision, assistance, and assistive devices to prevent falls. Each resident will be evaluated for safety risks, including falls and accidents. Care plans will be created and implemented based on the individual's risk factors to aid in preventing falls. All falls are to be investigated and monitored. PROCEDURE 1. INVESTIGATIVE GUIDELINES a. Check resident for injuries b. Vital Signs c. Neuro-checks for head injuries or un-witnessed falls, and the resident cannot communicate if he hit his/her head. d. Visual check for cuts, bruises, abrasions, redness, or deformities. e. Notify physician, family/responsible party of fall f. Complete Incident/Event Report g. Obtain detailed statements form ANY witnesses. h. Document in the Nurses Notes i. Continue to observe resident throughout the shift and provide a thorough report for the next oncoming shift (includes Nurses and C.N.A.s (Certified Nursing Assistant)) j. Each nurse will observe the resident and document for 72 hours in the resident's medical record. 2. Quality Assurance Guidelines a. Review Incident report for completeness b. Complete Investigative Report c. Take the incident to stand up meeting for review and care plan review d. Therapy to screen resident that falls as referred and recommend appropriate interventions. e. The care plan is to be updated with any new interventions. f. The nursing staff is to document every shift for 72 hours. h. The Interdisciplinary Plan of Care (IPOC) team will meet within the same period and discuss the causative factors, interventions to prevent another fall, make therapy referral as necessary, and revise the care plan if necessary. 1. R297 was admitted to the facility on [DATE] with diagnoses of: Alzheimer's disease, chronic kidney disease, [CONDITION(S)], history of COVID-19, and malnutrition. R297 had an activated Power of Attorney (POA) and elected a Do Not Resuscitate code status. R297's Annual Minimum Data Set (MDS) assessment, dated 6/7/2021, indicated severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 3 and assessed R297 as needing assistance with bed mobility, transfers, and walking. The Fall Care Area Assessment (CAA) that correlated with the annual MDS assessment dated [DATE] stated R297 required assistance with most activities of daily living; R297 was able to transfer and ambulate with a wheeled walker and limited assistance. The CAA stated R297 was up in a wheelchair for locomotion, and was able to propel self for some distance; R297 was incontinent of both bladder and bowel. The CAA stated diagnoses included hypertension, chronic kidney disease, [CONDITION(S)], Alzheimer's dementia, chronic [CONDITION(S)], a history of right knee medial meniscus tear, gastroesophageal reflux disorder, [CONDITION(S)] and [CONDITION(S)]. The CAA stated R297 received antihypertensive, proton pump inhibitors, [CONDITION(S)] medication, stool softener and supplement medications. The CAA stated R297 had a history of falls with a Fall Risk Score of 16 (High). The CAA stated the diagnoses, medications, and fall risk score all put R297 at risk for falls and R297 was in physical and occupational therapy. R297's Fall Care Plan was initiated on 7/11/2020 and the following interventions were in place on 9/13/2021: -anticipate and meet needs (7/14/2020) -be sure call light is within reach and encourage to use it for assistance as needed (7/14/2020) -follow facility fall protocol (7/21/2020) -bilateral body pillows to define the edge of the bed when R297 is in bed (7/15/2020) -bed in lowest position when R297 is in bed (7/15/2020) -scheduled toileting: staff to assist every 2 hours and 30 minutes after each meal (4/17/2021) -scoop mattress (6/17/2021) -fall mats (6/17/2021) From the time of admission on 7/11/2020 through 9/13/2021, R297 was determined to be a high risk for falls as determined by a fall risk assessment done weekly on admission and then quarterly. Morse Fall Scoring: High Risk: 45 and higher Moderate Risk: 25-44 Low Risk: 0-24 7/11/2020 Morse Fall Score: 50 high risk 7/13/2020 Morse Fall Score: 75 high risk 7/21/2020 Morse Fall Score: 65 high risk 8/17/2020 Morse Fall Score: 90 high risk 9/18/2020 Morse Fall Score: 75 high risk 9/27/2020 Morse Fall Score: 75 high risk 10/13/2020 Morse Fall Score: 75 high risk 12/4/2020 Morse Fall Scoring: 75 high risk Fall Risk Assessment Scoring: 10 or above is a high risk 3/9/2021 Fall Risk Assessment - 13 high risk 6/7/2021 Fall Risk Assessment - 16 high risk 9/13/2021 Fall Risk Assessment - 14 high risk On 9/13/2021 at 3:56 AM in the progress notes, nursing charted the nurse was notified by a Certified Nursing Assistant (CNA) at 3:25 AM that R297 was on the floor and bleeding. The nurse charted R297 was lying on the right side and breathing rapidly with no response to name calling and a hematoma was forming on the left side of the forehead and bleeding. The nurse charted the CNA was told to contact the nursing supervisor immediately. R297's blood pressure was 114/52 with a pulse of 114. The nurse was unable to obtain an oxygen level or temperature. The nurse charted 911 was called and pressure was held to the head to stop any active bleeding. The physician and POA were contacted. The nurse who wrote the progress note on 9/13/2021 at 3:56 AM was no longer employed by the facility at the time of survey and was unavailable for interview. On 9/13/2021 at 4:11 AM in the progress notes, the Registered Nurse (RN) charted the RN was called to R297's room and observed R297 lying on the right side next to the bed between the bed and the window. The RN charted a large amount of blood was noted on the floor near R297's head. The RN charted R297 was breathing but was not responsive and 911 was called at 3:29 AM. Pressure was applied to the wound and R297 was not moved per dispatcher's instructions until the paramedics arrived at 3:38 AM. The RN who wrote the progress note on 9/13/2021 at 4:11 AM was no longer employed by the facility at the time of survey and was unavailable for interview. On 9/13/2021 at 7:46 AM in the progress notes, nursing charted the emergency room was contacted for follow up on R297 following the fall. R297 was being admitted with an [CONDITION(S)] and was being placed on comfort care. R297 had not had a fall since 9/27/2020, one year prior. Surveyor reviewed the Fall Incident Report for the fall on 9/13/2021. The nursing description of the event stated: Resident bed was lowered to the ground upon entering the room and call light was within reach. Surveyor was unable to determine the height of the bed when R297 fell out of bed. Staff statements were obtained and written in the report: CNA-U made the statement R297 was last checked and changed after 1:00 AM where R297 had been sleeping with no issues or concerns and was found on the floor when making rounds at 3:00 AM for the next check and change. Another CNA made the statement R297 had been seen at approximately 3:00 AM from the hallway and had been sleeping in bed. The investigation did not include interventions that were in place per the Fall Care Plan. The report indicated the Interdisciplinary Team (IDT) met on 9/15/2021 and reviewed the fall; the bed was in low position with call light within reach but not activated and had last been seen about 30 minutes before the fall in bed sleeping. The IDT determined the fall was consistent with rolling out of bed and Will obtain bumper mattress to prevent further falls from bed. Per the Fall Care Plan, a scoop mattress should have been in place since 6/17/2021. The interventions of fall mats and bilateral body pillows were not documented as being in place at the time of the fall. In an interview on 1/26/2022 at 10:02 AM, Surveyor asked Licensed Practical Nurse (LPN)-Q and RN Manager-M what the facility process was when a resident falls. LPN-Q stated the floor nurse and the nurse manager work together. LPN-Q stated an RN has to assess the resident after a fall to determine if there is an injury and the nurse manager updates the care plan. LPN-Q stated the floor nurse does the initial documentation, neuro checks, and updates the physician. RN Manager-M stated RN Manager-M started in this position two days ago and as the nurse manager, will go up and down the hall to see what interventions are in place by staff and make sure the care plans match the interventions being used. LPN-Q stated if a resident falls out of bed, a scoop mattress is put in place right away before it is on the care plan. RN Manager-M stated as soon as a fall happens, notification is done right away, neuro checks are started right away and x-rays are obtained if needed. RN Manager-M stated the resident is sent out immediately if there are any concerns; better safe than sorry. In an interview on 1/27/2022 at 8:38 AM, Surveyor reviewed with MDS RN-S R297's Fall Care Plan. Surveyor asked MDS RN-S what prompted the interventions of the fall mats and the scoop mattress to be added to the Fall Care Plan on 6/17/2021. MDS RN-S stated the resident's care plan is reviewed quarterly after doing an MDS and the Nurse Manager may have put in the intervention. MDS RN-S stated R297 was in therapy at the time of the annual MDS and therapy may have recommended the interventions to the Nurse Manager. MDS RN-S stated the interventions would show up on the CNA Kardex under the safety section. MDS RN-S stated the Nurse Manager checks with staff to make sure the interventions are in place and may do a safety round to see what is in place for each resident and then update the Care Plan, but MDS RN-S was not sure of the process. MDS RN-S stated Maintenance would have to bring up the scoop mattress. MDS RN-S stated the nurse on the unit would just call down to Maintenance to bring up the mattress, but now there is a new administrator and the new process is to fill out a slip to get equipment. Surveyor asked MDS RN-S if they could recall a scoop mattress in place on R297's bed. MDS RN-S could not recall what type of mattress was on the bed. In an interview on 1/27/2022 at 9:01 AM, Surveyor asked Therapy Director-P if therapy had any records for R297 indicating the recommendation of a scoop mattress for a fall intervention. Therapy Director-P stated at the time when R297 was getting therapy in 6/2021, the therapy department used a different type of charting system and was unsure if they would be able to gain access to see the notes. No further information was provided by Therapy Director-P. In an interview on 1/27/2022 at 9:28 AM, Surveyor reviewed with Director of Nursing (DON)-B R297's fall on 9/13/2021. Surveyor shared the interventions that were in place per the Fall Care Plan and the concern the interventions were not documented on the fall investigation. DON-B recalled a discussion about a fall mat in regards to R297 after the fall occurred, but stated the fall mat would not have been between the bed and the window because there was very little room to place a fall mat and stated the fall mat was on the other side of the bed. DON-B recalled a discussion about one body pillow on the left side of R297, but did not recall two body pillows. DON-B did not remember R297 having a scoop mattress, but never saw the bed and did not recall any discussion about the mattress. In a phone interview on 1/27/2022 at 9:59 AM, CNA-U stated CNA-U was working on 9/13/2021 the night R297 fell and was the one who found R297 on the floor. CNA-U stated the nurse was notified right away and the nurse called 911 immediately. Surveyor asked CNA-U what kind of mattress was on R297's bed. CNA-U could not recall, but thought it might have been an air mattress. Surveyor asked CNA-U if R297 had any body pillows on the bed. CNA-U stated R297 did not have any body pillows. Surveyor asked CNA-U if they could recall how high or low the bed was that night. CNA-U stated the bed was as low as it could go. Surveyor asked CNA-U if R297 had a fall mat. CNA-U did not recall a fall mat. Surveyor asked CNA-U if R297 was agitated or acting out that night. CNA-U stated R297 had been sleeping. In an interview on 1/27/2022 at 10:30 AM, Surveyor asked Nursing Home Administrator (NHA)-A if staff had to notify Maintenance to get a scoop mattress or a fall mat. NHA-A stated Maintenance would have information about the mattress and Maintenance also delivers fall mats unless it is in the middle of the night and then the nurse will get it. In an interview on 1/27/2021 at 11:38 AM, Surveyor asked Maintenance Director-T what the process was for staff to obtain a scoop mattress or a fall mat. Maintenance Director-T stated the maintenance area in the basement has an area that is accessible to any staff that has scoop mattresses and fall mats. Maintenance Director-T stated no records are kept of what is taken out of the area or where it is taken to or for what resident. In an interview on 1/27/2022 at 1:11 PM, NHA-A stated the Nurse Manager at the time in 6/2021 put interventions into care plans after seeing interventions in use after doing a walk around to see what was in place for each resident. Surveyor shared with NHA-A the concern with R297 falling on 9/13/2021 and sustaining a hematoma needing hospitalization that ultimately resulted in R297 dying; R297 was a high risk for falls per fall risk assessments, interventions were not documented to be in place at the time of the fall, and R297 had a history of falls in the past. Surveyor shared the concern a bolster mattress was the intervention determined by the IDT after the fall on 9/13/2021 when a scoop mattress was already in the Fall Care Plan which indicated a scoop mattress was not in place at the time of the fall. No further information was provided at that time. 2. R25 was admitted to the facility on [DATE] with diagnoses of end stage renal disease requiring [CONDITION(S)], chronic obstructive pulmonary disease, coronary artery disease, diabetes, Alzheimer's disease, depression, anxiety, and history of cancer of the bladder and liver transplant. R25's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R25 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 5 and needed extensive assistance with activities of transfers and bed mobility. The Fall Care Area Assessment (CAA) with the MDS stated R25 was a new admit to the facility and was alert and oriented, able to make needs known but has very poor short term memory. The Fall CAA stated R25 was at risk for falls due to debility, medications, and stroke; R25 had no falls since admission and does show good safety awareness despite the short term memory loss. R25 had an activated Power of Attorney (POA). R25's Fall Care Plan was initiated on 5/2/2021 with the following interventions: -be sure call light is within reach and encourage resident to use it for assistance as needed -educate resident/family/caregivers about safety reminders and what to do if a fall occurs -ensure resident is wearing appropriate footwear -follow facility fall protocol 2.1 On 5/23/2021 at 8:03 PM in the progress notes, nursing charted R25 was found sitting on the floor in resident's room stating resident tried to walk over to the roommate and sat on the floor. Nursing charted R25 was assessed by the Registered Nurse (RN) manager and no injuries were sustained. R25 was put back in bed using a mechanical lift, the Nurse Practitioner was updated and the POA was notified. On 5/27/2021 at 9:59 AM in the progress notes, nursing charted the Interdisciplinary Team (IDT) note stating R25 was self-ambulating in the room and requires assist of one with all transfers and cares. The IDT note stated R25 had a recent room change from a private to a semi private room with a roommate and therapy was working with R25 on room management and transfers. The IDT note stated the IDT reviewed and updated the plan of care. Surveyor reviewed the Fall Incident Report for the fall on 5/23/2021. The report indicated R25 was not wearing appropriate footwear as per care plan; R25 was barefoot. Surveyor noted that R25's fall investigation did not include any staff statements, any documentation of when R25 was last seen or toileted, or a root cause analysis of R25's fall. R25's Fall Care Plan was not revised with an intervention to address the fall on 5/23/2021 to prevent future falls. 2.2 On 6/5/2021 at 2:30 PM in the progress notes, nursing charted R25 was attempting to self-ambulate from the room to the hallway and had a fall in the doorway. Nursing charted R25 had poor safety awareness and required one assist for transfers and ambulation. Nursing charted the Nurse Practitioner was notified of the fall. No IDT note was documented after the fall on 6/5/2021 for the IDT to determine a root cause analysis. Surveyor reviewed the Fall Incident Report for the fall on 6/5/2021. The report indicated R25 hit the right posterior head on the wall and sustained a 2 cm round slightly raised area to the right posterior head. The report stated no injuries were observed post incident. That statement contradicts the reddened area to the back of the head. The report stated R25's spouse had visited thirty minutes prior to the incident and R25 stated R25 was leaving and thought R25 could walk out of the room and then go outside and leave. The injury to the back of the head was not documented in R25's medical record. Surveyor noted that R25's fall investigation did not include any staff statements, any documentation of when R25 was last seen or toileted, or a root cause analysis of R25's fall. R25's Fall Care Plan was revised on 6/7/2021 with the following intervention: call to spouse to bring in personal items to personalize room. On 6/7/2021 at 4:55 PM in the progress notes, social services charted R25's POA was contacted to bring in personal items to make the room more homelike; R25's POA did not agree with bringing in items due to R25's poor vision. R25's Fall Care Plan was not revised with an appropriate fall intervention based on the events surrounding R25's fall on 6/5/2021. 2.3 On 7/17/2021 at 8:00 AM in the progress notes, nursing charted R25 had an unwitnessed fall and sustained a skin tear and hematoma to the right upper arm and a hematoma to the scalp. Nursing charted an x-ray was done on the right arm with no abnormal findings. Nursing charted R25's POA was notified and requested R25 be sent to the hospital for evaluation. No IDT note was documented after the fall on 7/17/2021 for the IDT to determine a root cause analysis. Surveyor reviewed the Fall Incident Report for the fall on 7/17/2021. The report stated the fall occurred in the bathroom with the wheelchair not in the vicinity and R25 stated R25 was trying to go to the bathroom. The report stated a skin tear and swelling was noted to the right elbow. The report of immediate action taken was bleeding controlled and wound steri-stripped to the skin tear and an ice pack and x-ray was ordered for the swelling. The report also stated No Injuries Observed Post Incident. That statement contradicts the report of swelling and a skin tear to the right elbow. Surveyor noted that R25's fall investigation did not include any staff statements, any documentation of when R25 was last seen or toileted, or a root cause analysis of R25's fall. R25's Fall Care Plan was not revised with an intervention to address the cause of the fall on 7/17/2021 to prevent future falls. 2.4 On 9/6/2021 at 9:38 PM in the progress notes, nursing charted R25 was sitting in the wheelchair in the dining room at 4:45 PM and staff heard a loud noise and noted R25 was lying on the floor on the left side. Nursing charted R25 denied pain stating R25 was trying to walk across the dining room. Nursing charted the nursing supervisor assessed R25 and got R25 up off the floor with a mechanical lift. Nursing charted the Nurse Practitioner and spouse were updated of the fall. Nursing charted R25 was noted to have bruising to the left thigh and right hand after the fall. No IDT note was documented after the fall on 9/6/2021 for the IDT to determine a root cause analysis. Surveyor reviewed the Fall Incident Report for the fall on 9/6/2021. The report stated no injuries were observed at the time of the incident, but then listed a bruise to the back of the right hand and the front of the left thigh. Surveyor noted that R25's fall investigation did not include any staff statements, any documentation of when R25 was last seen or toileted, or a root cause analysis of R25's fall. R25's Fall Care Plan was not revised with an intervention to address the cause of the fall on 9/6/2021 to prevent future falls. 2.5 On 9/13/2021 at 1:12 AM in the progress notes, nursing charted an overhead page at approximately 12:08 AM was heard calling nurse to R25's room. Nursing charted R25 was found lying on the floor on the right side with a large amount of blood on the floor around the head. Nursing charted 911 was called at 12:10 AM; pressure was applied to the open area on the right top side of R25's head. Nursing charted R25 was alert and able to answer questions appropriately stating R25 was not sure what happened but thought R25 was attempting to ambulate. Nursing charted R25 was not moved and pressure was applied until Emergency Medical Services arrived at 12:20 AM. On 9/13/2021 at 2:08 AM in the progress notes, nursing charted the hospital called with report of R25's status; R25's CT was negative, R25 received two staples to the wound on the top of the head and one staple to the wound towards the front of the head and would be returning to the facility. No IDT note was documented after the fall on 9/13/2021 for the IDT to determine a root cause analysis. R25's Fall Care Plan was revised on 10/1/2021 with the following interventions: -floor mat on both sides when resident is on the bed -bed in low position when resident is on the bed Surveyor reviewed the Fall Incident Report for the fall on 9/13/2021. The report stated there were no predisposing environmental or situation factors. The report indicated the IDT met on 10/4/2021, three weeks after the fall, to review the incident and interventions such as floor mat on both sides of the bed and bed in low position when R25 is in bed were determined to be appropriate for the root cause of the fall. Those interventions were added to the Fall Care Plan on 10/1/2021, eighteen days after the fall. Surveyor noted that R25's fall investigation did not include any staff statements, any documentation of when R25 was last seen or toileted, or a root cause analysis of R25's fall. 2.6 On 10/29/2021 at 1:39 AM in the progress notes, nursing charted R25 had an unwitnessed fall and was found crawling on the floor towards the wheelchair; R25 was incontinent of bowel. No injuries were noted. No IDT note was documented after the fall on 10/29/2021 for the IDT to determine a root cause analysis. Surveyor reviewed the Fall Incident Report for the fall on 10/29/2021. The report stated the fall occurred on 10/28/2021 at 11:30 PM. The report stated incontinence was the predisposing physiological factor. Surveyor noted that R25's fall investigation did not include any staff statements, any documentation of when R25 was last seen or toileted, or a root cause analysis of R25's fall. R25's Fall Care Plan was revised on 10/29/2021 with the following intervention: bowel patterning for 72 hours. No documentation of follow-up was found following the bowel patterning. 2.7 On 11/4/2021 at 6:55 PM in the progress notes, nursing charted the nurse was called to the dining room at 4:20 PM because R25 got up and started walking without the walker and refused to sit down. Nursing charted when the nurse got to the dining room, R25 was observed walking unsteadily and went to intercept R25 but before the nurse could get to R25, R25 fell on the right side without hitting the head. RN supervisor assessed R25 and no injuries were sustained; R25 was put back in the wheelchair with a mechanical lift. Nursing charted R25 was encouraged to ask for assistance when getting up or walking so proper equipment could be used to keep R25 safe. Surveyor reviewed the Fall Incident Report for the fall on 11/4/2021. The report stated confusion/disorientation, impaired memory, and impaired decision were predisposing physiological factors. Surveyor noted that R25's fall investigation did not include any staff statements, any documentation of when R25 was last seen or toileted, or a root cause analysis of R25's fall. R25's Fall Care Plan was revised on 11/8/2021 with the following intervention: resident will continue to work toward goals with therapy. On 11/10/2021 at 10:26 AM in the progress notes, the IDT charted R25's fall on 11/4/2021 was reviewed; R25 was currently in therapy and working on transfers and ambulation. The IDT charted therapy reassessed R25 after the fall and stated R25 had poor safety awareness and needs assistance and a walker when ambulating. The IDT charted lab work had been completed and was unremarkable. The IDT determined R25 would walk to meals with a walker and staff assistance. R25's Fall Care Plan was revised on 11/10/2021 with the following intervention: encourage to ambulate to meals with walker and staff assistance. R25's Fall Care Plan was revised on 11/18/2021 with the following intervention: physical therapy to evaluate and treat as ordered or as needed. On 1/25/2022 at 8:32 AM, Surveyor observed R25 in bed. The bed was in a low position and fall mats were in place on both sides of the bed. In an interview on 1/26/2022 at 10:02 AM, Surveyor asked Licensed Practical Nurse (LPN)-Q and RN Manager-M what the facility process was when a resident falls. LPN-Q stated the floor nurse and the nurse manager work together. LPN-Q stated an RN has to assess the resident after a fall to determine if there is an injury and the nurse manager updates the care plan. LPN-Q stated the floor nurse does the initial documentation, neuro checks, and updates the physician. RN Manager-M stated RN Manager-M started in this position two days ago and as the nurse manager, will go up and down the hall to see what interventions are in place by staff and make sure the care plans match the interventions being used. LPN-Q stated if a resident falls out of bed, a scoop mattress is put in place right away before it is on the care plan. RN Manager-M stated as soon as a fall happens, notification is done right away, neuro checks are started right away and x-rays are obtained if needed. RN Manager-M stated the resident is sent out immediately if there are any concerns; better safe than sorry. In an interview on 1/26/2022 at 3:24 PM, Surveyor reviewed R25's falls with Director of Nursing (DON)-B and the concern the IDT did not meet to determine a root cause for each fall to implement an appropriate intervention to prevent future falls. Surveyor shared the concern R25's Fall Care Plan was not revised after each fall, was not revised with an appropriate intervention, or was not revised in a timely manner. DON-B agreed F25's falls were not investigated thoroughly and interventions were not implemented as would be expected. No further information was provided at that time. 3. R27 was readmitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], Vascular Dementia with Behavioral Disturbance, [CONDITION(S)] and Unsteadiness on Feet. R27's Significant Change in Status MDS (Minimum Data Set) dated 11/8/21 documents a BIMS (Brief Interview for Mental Status) score of 5, indicating that R27 is severely cogitatively impaired. Section G (Functional Status) documents that R27 requires extensive assistance and a one person physical assist for her transfer and bed mobility needs. R27's Falls CAA (Care Area Assessment) dated 1/8/21 documents under the Analysis of Findings section, The resident is at risk for falls r/t (related to) poor safety awareness and behaviors secondary to [CONDITION(S)] diagnosis. R27's Fall Risk Scoring Tool assessment dated [DATE] documents a score of 10, indicating that R27 is at high risk for falls. 3.1 R27's fall Investigation dated 7/1/21 at 5:58 p.m. documents, Resident found on right side fetal position parallel to bed; Other Information: Food on Flood at supper time; Witnesses: No witnesses found. Surveyor noted that R27's fall investigation did not include any staff statements, any documentation of when R27 was last seen or toileted, a root cause analysis of R27's fall or what fall interventions were in place prior to R27's fall on 7/1/21. 3.2 R27's fall investigation dated 7/7/21 at 9:46 p.m. documents, I was at the nurse's station when a woman came and told me and an aide that the resident was on the floor. I asked her if she could sit with her while I paged an RN (Registered Nurse). Me and the aide then went into the resident's room to help her get up; Description: We picked up all the food and garbage she had on the floor. Did a complete bed change and put the bed into the lowest position. I reminded the resident to pull her call light if she needs anything; Witnesses: No witnesses found. Surveyor noted that R27's fall investigation did not include any staff statements, any documentation of when R27 was last seen or toileted, a root cause analysis of R27's fall or what fall interventions were in place prior to R27's fall on 7/7/21. 3.3 R27's fall investigation dated 10/17/21 at 1:59 p.m. documents, Resident was found by CNA (Certified Nursing Assistant) laying on the floor next to her bed on top of her blanker on there left side. When asked resident what happened she stated 'I fell off my bed'; Description: RN assessed resident, no injuries noted and resident was put in a wheelchair. Resident was not taken to the hospital. Resident would not allow vitals to be taken, used hoyer lift to put resident back to safety .Resident was advised to use her call light to ask for help getting out of bed; Witnesses: No witnesses found. Surveyor noted that R27's fall investigation did not include any staff statements, any documentation of when R27 was last seen or toileted, a root cause analysis of R27's fall or what fall interventions were in place prior to R27's fall on 10/17/21. 3.4 R27's fall investigation dated 11/6/21 at 11:29 a.m. documents, PT (physical therapy) found resident on floor and called writer for assistance. Resident was sitting on the floor between her wheelchair and the side of bed. It appears resident was trying to self transfer to bed and loss balance; Description: Vital signs attempted but resident refused. Resident transferred assist of 2 with hoyer lift to bed. Intervention: Sleep study and therapy to assess for antiroll bars; Witnesses: No witnesses found. Surveyor noted that R27's fall investigation did not include an [TRUNCATED]

Based on interview and record review the facility did not ensure 1 (R20) of 1 residents reviewed who displayed or had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not identify R20's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not assess if R20's care needs related to the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not assess R20's symptoms of agitation, aggression and food seeking behaviors in order to create an individualized person centered care plan addressing R20's behaviors and needed interventions. The facility staff relied on the local police department and county crisis intervention services to de-escalate R20's high level of anxiety and stress resulting in deterioration of R20's emotional and psychosocial well-being requiring hospitalization and eventual transfer to a state mental health institution. Failure to ensure that a resident diagnosed or displaying a mental disorder received appropriate services to maintain his highest practicable mental and psychosocial well-being led to additional weight gain, expressions of suicide with a plan, and behavioral disturbances that resulted in calling 911 or the local crisis team. R20's behavioral disturbances ultimately led to placement in a state mental health institution. This created a situation of immediate jeopardy that began on 9/9/21. Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-AA and Chief Innovations Officer-OO were notified of the immediate jeopardy on 10/20/21 at 3:26 pm. The immediate jeopardy was removed on 10/21/21 when the facility implemented an action plan. The deficient practice continues at a scope and severity of a D (potential for harm/isolated) as they continue to implement their plan. Findings include: Mental disorder is defined in the Interpretive Guidelines at F741 as .a syndrome characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. R20 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R20's hospital discharge paperwork, dated 8/16/21, documents: .Condition upon discharge: Patient was discharged to rehabilitation facility in stable condition. Ht (height) 1.473 m (meters) (4' (foot) 10 (inches), Wt (weight) 174.4 kg (killograms) (384 lbs (pounds). R20's Preadmission Screen and Resident Review (PASARR), dated 8/16/21, documents: The resident is not suspected of having a serious mental illness or developmental disability; does not have a major mental disorder under the Diagnostic and Statistical Manual of Mental Disorders; within the past six months the person has received [CONDITION(S)] medication(s) to treat symptoms or behaviors of a major mental disorder, receives [MEDICATION(S)]; does not exhibit symptoms of suicidal statements, gestures or acts, hallucinations, delusions, or other psychotic symptoms, or severe and extraordinary thought or mood disorders; is diagnosed or has a history of intellectual disabilities, is not diagnosed with [CONDITION(S)], [CONDITION(S)], autism, [CONDITION(S)] or other conditions. Other than mental illness, that results in impairment of general intellectual functioning or adaptive behavior similar to that of intellectually disabled persons; short term exemptions for exemption for Level II screening: hospital discharge exemption-30-day maximum elected; the person does not qualify for an abbreviated Level II screening due to severe medial conditions or severe cognitive deficits. The facility did not correctly complete R20's PASARR as the facility did not identify R20 as having a documented developmental disability and physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility elected a hospital discharge exemption while completing the PASARR. This election identifies R20 as being exempt from the need for a Level II PASARR screening. The facility did not request county approval for this exemption as evidenced by not receiving a signed F form from the county for R20's admission to the facility. R20 stayed at the facility past the 30-day hospital exemption timeframe and the facility did not complete a new level I screen and submit it to the PASARR contractor requesting a Level II screen to determine if R20 has a developmental disability and/or a serious mental illness as defined by the federal PASARR regulations. This resulted in the facility not being made aware whether or not R20's needs were required to be met by the facility by providing specialized services. (Cross Reference F645) On 8/17/21, at 14:26 (2:26 PM), R20's Medical Record documents: [R20] admitted for therapy related to shortness of breath and chest pressure. PMH (Primary Medical History): Scoliosis, CHF (Congestive Heart Failure) EF (Ejection Fraction) 52-56%, OSA, Obesity, [NAME]-[NAME] Syndrome, ADHD, OCD, ODD, Osteopenia. Resident status indicates BMI (Body Mass Index) 79.8, being classified as obesity class III. Resident reports UBW (Usual Body Weight) 350# (pounds). He doesn't report any wt (weight) changes over last few weeks/months. He has a good appetite, normally eats three meals/day as well as a snack. He reports food preferences & (and) writer worked on specific requests. Discussed about diet modifications as well as fluid restrictions given co-morbidities, he verbalizes understanding of plan. Nutrition Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Goals: Resident will comply with current diet order, resident will lose wt. to maintain back his dry wt./UBW, resident will consume 75-100% of food and fluids at each meal, . Facility dietary staff did not identify R20's symptoms of constant hunger and food seeking behaviors as being related to R20's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not implement person centered interventions to assist R20 with concern for food seeking and overeating behaviors. R20's Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/23/21, documents: R20 is considered by the state level II PASARR (Preadmission Screen and Resident Review) process to have a serious mental illness and/or intellectual disability, identified as having a serious mental illness; Brief Interview of Mental Status (BIMS) score of 15, indicating R20 is cognitively intact for daily decision making; Patient Health Questionnaire (PHQ-9) score of 1, indicating minimal depressive symptoms; no behavior concerns documented . weight 391 pounds . R20's Care Area Assessment (CAA)s, dated 8/23/21, document: Nutritional Status: Body mass index (BMI) is too low or too high as indicated by: BMI of 81.7 indicating obese class III for height d/t (due to) excessive caloric intake, co-morbidities, and decreased physical activity. Resident desires to return back to UBW (Usual Body Weight) 350# (pounds). Therapeutic diet is used as nutritional approach as indicated by: therapeutic diet while a resident. Resident currently has a heart healthy diet given his co-morbidity diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R20's CAA for [CONDITION(S)] Drug Use, dated 8/23/21, documents: Resident is a new admit to this facility from acute care hospital stay for CHF. Other diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [R20] is alert and oriented and able to make his needs known. [R20] can hold a conversation. [R20] is very demanding and has poor safety awareness. [R20] goal is short term with his plan to return to ALF (assisted living facility). [R20] is receiving antipsychotic and antidepressant medications. [R20] has shown no unwanted side effects from these medications; adverse consequences of antipsychotics exhibited by this resident: lethargy; adverse consequences of anxiolytics exhibited by this resident: sedation manifested by short term memory loss, disturbance of balance, gait, positioning ability; care plan considerations: maintain current level of functioning, minimize risks. R20's Care Plan, dated 8/30/21, revised on 9/24/21, documents: The resident is/has the potential to be verbally aggressive towards other r/t (related to) ineffective coping skills, poor impulse control. Will tend to swear at staff when upset. Also tends to throw self on floor. Resident can display accusatory behavior and will tend to refuse cares. When the resident is upset he tends to call his mom and mom will in turn call the police. Interventions include: Administer medications as ordered. Monitor/document for side effects ad effectiveness. Date initiated: 8/30/31; Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. (etcetera). Date initiated: 8/30/21; Assess resident's coping skills and support system. Date initiated: 8/30/21; Monitor resident for being verbally aggressive towards others. Document observed behavior and attempted interventions. Date initiated: 8/3021, date revised: 8/30/21. R20's Care Plan, dated 8/17/21 and revised on 9/9/21, documents: Resident is at nutritional risk r/t (related to) CHF (Congestive Heart Failure), obesity, ADHD (Attention-Deficit/[CONDITION(S)] Disorder), OCD (Obsessive Compulsive Disorder), ODD (Oppositional Defiant Disorder), Osteopenia, currently on a heart healthy diet with 1500 mL (milliliter) fluid restriction diet, he verbalized understanding. Resident has a good appetite with food preferences noted. Resident can feed self. 9/21: Wt (Weight) gain undesirable 5.1%. Interventions include: Allow adequate time for the resident to consume food served. Date initiated: 8/17/21; Offer substitute if less than 50% of meal is consumed. Date initiated: 8/17/21; Resident to be weighed as per physician or as requested. Date initiated: 8/17/21; Resident will continue heart health/low sodium, 1500 mL, FR (fluid Restriction), regular texture, thin liquid diet order. Date initiated: 8/17/21, revisions on: 9/29/21; Resident will eat in the dining room by self to prevent overeating. Date initiated: 8/30/21; Resident will have only snacks provided by mother. Date initiated: 8/30/21; Staff will continue to redirect resident's attention and monitor during meals times to prevent overeating. Dated initiated 9/3/21; Staff will monitor for skin integrity and [CONDITION(S)]. Date initiated: 8/17/21, revision on:8/17/21. R20's Care Plans do not address R20's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R20's care plan does not include person centered interventions staff can implement to assist R20 with symptoms and behaviors. R20's Kardex report dated 10/20/21, used by certified nursing assistants to provide care to R20, documents: Behavior/Mood: Monitor resident for being verbally aggressive towards others. Document observed behavior and attempted interventions; offer resident activities when appropriate R20's Karadex does not document R20's physician ordered diet, fluid restriction or identify symptoms associated with R20's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .e. Behavior problems, constant hunger and food seeking leading to obesity. On 8/22/21 at 14:04 (2:04 PM), R20's Medial Record documents: Alert/responsive, eating/drinking off of dirty food trays, redirected within 2 verbal cues, decided not to stay in room despite unit quarantine, adhered to spacing guidelines with verbal cues . Facility staff did not identify R20's behavior of food seeking and constant hunger as being related to R20s' diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/24/21, at 12:16 PM, R20's Medical Record documents: Writer spoke with resident this morning about the importance of maintaining 1500 mL fluid restriction diet. He has been receiving sodas from outside facility fluids. Writer discussed ways to limit outside fluid intake to optimize nutritional status. Writer spoke with mother this afternoon, discussed his fluid intake during the day. She plans on buying smaller cans of soda for preference (7.5 oz. (ounce)) given he typically has one/day. Specifically worked on fluid preferences/updated. RD (Registered Dietitian) to f/u (follow/ up) PRN (As Needed). The intervention of R20's mother providing smaller sodas was not added to R20's Care Plan or Kardex. On 8/25/21, at 14:35 (2:35 PM) R20's Medical Record documents: Writer spoke with mother who is guardian, Guardian gave verbal consent for psych (psychiatric) services after expressing that she is concerned about resident's behavior. Care conference also set up to discuss how resident is doing. No further concerns. Will continue to follow. R20 is seen by facility contracted psychiatric services on 9/10/21, which documents: Current cognitive and/or [CONDITION(S)] medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Chief Complaint: Nervous and agitation; Psychiatric History: Behaviors related to [NAME]-[NAME] Syndrome, depression; . Symptom Review: concentration/attention/confusion: alert/attentive; decreased energy: difficult walking d/t (do to) morbid obese; appetite change: 401 #, sleep disturbance: pt. (patient) denies; depressed mood: chronic; anxiety/panic: pt. denies; suicidality: pt. denies desire to harm self and others; anger/irritability: mild irritated by all the questions asked during interview; hallucinations: pt. denies; alert; . Impression: Behaviors r/t [NAME]-[NAME] Syndrome and MDD (Major Depressive Disorder); Treatment Recommendations: No changes at this time- Pt. adjusting to facility and staff. May benefit from Psychological visit if staying long term, continue to monitor for escalation of behaviors and update PRN; Follow Up Appointment: 1 month. (Note: Resident has gained 10 lbs, in 18 days.) Facility staff scheduled R20's psychiatric evaluation with the facility contracted psychiatry provider and did not attempt to schedule the appointment with R20s' community psychiatric provider or consult with R20's community psychiatric provider for continuation of care. R20's hospital discharge paperwork, dated 8/16/21, documents: [R20] followed by psychiatry for behavioral issues; seen by televisit 7/20/21; continue with [MEDICATION(S)] 80 mg p.o. (per oral) twice per day and [MEDICATION(S)] 20 mg p.o, daily. On 8/27/21, at 13:54 (1:54 PM), R20's Medical Record documents: Alert/responsive, verbally aggressive & shouting with staff r/t dietary restrictions being followed, redirected with reminders of diet & how to conduct himself & speak respectfully, refused daily weight, accepted shower after multiple approaches & education on risk on skin breakdown especially folds. On 8/30/21, at 13:08 (1:08 PM), R20's Medical Record documents: BMI: 82.6 Obese class III. Wt. gain ~ (approximate) 3.5 % x (in) almost two weeks, likely rational (sic) for wt. gain related to noncompliance fluid restriction & excessive intake. Spoke to resident this morning, discussed about his fluid restriction plan, he states following, but observed multiple 12 oz. cans of soda when supposed to have 7.5 cans. Mother unaware of 12 oz. cans in his room, she has only brought 7.5 oz. can since our previous discussion (8/24). He reports having additional snacks in between meals provided by mother usually fruits and vegetables. Resident has refused daily weights & staff members attempt to redirect resident's attention to help his dietary restrictions when asking for additional items noted per progress note. RD (Registered Dietitian) discussed about recent wt. gain and importance of food intake. RD spoke with mother over phone, food preferences reviewed and updated. Discussed about eating in his room instead of dining room to limit possibly eating other resident's food. Resident prefers to eat in dining room. Resident needs monitoring throughout meal to not attempt to eat other resident's food & eat at table by himself. Mother does not provide resident with money anymore. Previously resident had double portions at all meals, now resident has double portions at L&D (lunch and dinner) only vegetables. NP (Nurse Practitioner) made aware of situation, plans to increase [MEDICATION(S)] dosage for three days. The intervention of monitoring R20 in the dining room to prevent overeating is not added to R20's care plan until 9/3/21. The intervention of having R20's mother provide 7.5 oz. sodas was not added to the care plan. On 8/30/21, at 15:14 (3:14 PM), R20's Medical Record documents: APNP (Advanced Practice Nurse Practitioner) with [name of medical group] assessed resident, res (resident) was found eating pizza and had several cans of soda in room, writer and APNP questioned where res obtained these from and res stated I ordered them myself, res re-educated again on the importance of following fluid restriction and diet restrictions, re-educated on risks of over eating and non-compliance with this, res shook his head as he understood but continued to eat pizza and drink soda. Res refused for us to take pizza and soda away, yelling loudly this is mine! . Recommendations: continued education on fluid restriction and diet restrictions, increase [MEDICATION(S)] and daily weights. Facility staff did not identify R20's extreme difficulty controlling his body weight and powerful compulsion to eat as much food as possible as related to R20's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R20 has the need for intervention and support from professionals with experience with individuals with [NAME]-[NAME] syndrome and continued re-education related to diet and fluid restrictions will not provide enough support. On 8/31/21, at 16:18 (4:18 PM), R20's Medical Record documents: Spoke with res POA (Power of Attorney) (mother) about dietary concerns. Discussed res taking food off of other trays. Will modify food to be placed in separate bowels (Specifically double portion vegetables) to make him feel he's receiving enough at meal time. POA in agreement with intervention. Will continue at a table by himself in the dining room. This intervention was not added to R20's care plan. On 8/31/21, at 22:21 (10:21 PM), R20's Medical Record documents: . Res continues to be non-compliant with fluid restriction and diet. Res did take 7 chocolate chip cookies off of snack cart when staff was in other residents' rooms. Education done again with resident on importance of following diet and fluid restriction, res remains non-complaint. On 9/2/21, at 22:45 (10:45 PM), R20's Medical Record documents: Resident tried to get multiple snacks after dinner while standing @ (at) the nurses station. Resident asked several diff (different) staff to get HS (hour of sleep) snacks from & also asked another residents family member to get him some fruit/vegetables from the store d/t resident not getting any veg (vegetables)/fruits from his mother @ any time. Writer told resident not to ask other residents family members to get stuff for him @ the store d/t resident getting snacks/food from his mother & staff. On 9/3/21, at 14:20 (2:20 PM), R20's Medical Record documents: Meeting this afternoon with resident, resident's mother, social worker, administration, unit manager/RN (Registered Nurse) and dietitian to discuss recent concerns. Resident eats out in dining room for meals asking for seconds as well as snacks. Recently reported asking resident's family members for fruits/vegetables. Observed multiple cans of soda present in room today, resident reports staff member (activity manager) provided it. Director of Activities stated resident had money in the beginning and used it. Later on, the director did buy resident 3-4 cans of soda as a pay-back system that resident stated his mother would pay him back given no visitation protocol previously related to covide-19. Staff continue to redirect resident's attention and monitor during meal time. Writer informed the food manager, aware of the situation. Care Plan updated. Because the facility had not educated all staff on the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R20's Care Plan was updated on 9/3/21, with intervention of, Staff will continue to redirect resident's attention and monitor during meal time to prevent over eating. The intervention of R20's mother providing 7.5 oz. cans of soda and R20 having only small cans of soda to allow for adherence to fluid restriction was not added to R20's care plan thus all staff were not aware of this intervention and provided R20 with regular size sodas which went against R20's physician prescribed fluid restriction. On 9/9/21, at 9:45 AM, R20's Medical Record documents: Alert/responsive, very disruptive during b/fast (breakfast) r/t requesting extra food started yelling @ staff & beating on table when behavior didn't have desired effect resident started verbalizing suicidal ideations unable to redirect despite social service assistance & calling mother. 1:1 monitoring initiated immediately. NHA (Nursing Home Administrator) aware MPD (Milwaukee Police Department) in to assess safety demeanor risk for self-harm & has cleared scene per crisis management, resident calm & free from injury @ this time, without pain/discomfort. Facility staff did not identified person centered interventions to address R20's food seeking and overeating behavior that lead to agitation and suicidal ideation and relied on the local police and crisis management team for de-escalation of R20's behaviors. R20's physician documents on 9/10/21, the facility contacted R20's physician on 9/9/21 to report R20's suicidal ideation and informed R20's physician MPD and suicidal crisis were both aware of the patient's behavior and suicidal ideation and cleared R20 to stay at the facility. On 9/9/21, R20's physician gave orders for stat (immediate) lab work to be drawn to r/o (rule out) behavior r/t infection. Antidepressant and antipsychotic meds reviewed. Follow up: Social Worker to follow-up with psych consult. On 9/9/21, at 14:08 (2:08 PM), R20's Medical Record documents: Writer witnessed resident yelling that he wanted oatmeal during breakfast. Writer approached resident to try and calm down. Resident stated that if he doesn't get his oatmeal, that he would kill himself by walking out the door and into traffic. Staff were unsuccessful at attempting to de-escalate the resident. A CNA (Certified Nursing Assistant) with the resident on a 1:1 basis. Writer called mother stated that resident makes those comments at home. Writer informed Admin (administrator) who initially helped writer find more oatmeal for the resident and then instructed writer to contact [city facility is located in] non-emergency police department for crisis services. After receiving oatmeal resident was calmer and content. Writer called non-emergency and police officer showed up with 2 others. Wanting to speak with the resident, resident appeared to be asleep in chair and refused to open eyes and talk with them. Writer called mother asking if she had any advice on how to convince him to talk since the police stated that they cannot leave until they are able to talk with him. One of the officers then did a sternum rub on resident to awake him. Resident was not happy after that and continued to scream and use inappropriate language. Nurse manager went to get a nurse from second floor that resident really respects. After seeing the nurse resident became calmer and was willing to speak with the officer. Resident stated that he meant the comment in the moment but does not anymore. Officer called the crisis team and they decided that they did not need to come out for resident. Mother upset that writer called non-emergency as resident says it often. She though it was unnecessary for the facility to have called anyone and the facility should be able to manage the resident behavior. Administrator explained that this is not a mental health facility and none of the staff are trained to make a decision on when a resident's allegation of self-harm are pretend. Later on that day resident was in therapy and refused to leave OT (Occupational Therapy) gym, stating, the Social Worker called the cops on me and they stole my chest. Resident continued to call writer inappropriate names and did not want to see writer. While writer went to admin (Administrator) to see what else could be done, nurse manager stated with resident and reported that res threw a toaster on the ground. Writer grabbed Director of Social Services to see if resident would speak with him. Resident spoke with him but would not leave the OT gym. Nurse Manager went to see if nurse on the second floor was still here. Nurse came down and convinced resident to go to the unit and relax there for a bit. R20's Care Plan was not updated to address R20's behavior of expressing suicidal ideations or identify person centered interventions to address R20's suicidal ideations. On 9/15/21, R20's Medical Record documents a progress note from R20's physician, which documents: Chief Complaint: Behavior and significant weight gain. Subjective: Provider notified that patient continues to have behaviors. On 9/13 pt called 911 constantly and reported that staff would not assist him with his shorts. Per staff patient is not easily redirected at times. Patient is again reeducated on compliance regarding his fluid restriction, continue to gain significant amount of weight. Social Worker to contact psych for follow up. On 10/19/21, at 2:54 PM, Surveyor interviewed Director of Social Services (DSS)-JJ who stated she did not contact psychiatric services for a follow up nor arrange a follow up appointment for R20 with psychiatric services due to not being aware R20's physician had requested such. On 9/19/21, at 13:22 (1:22 PM), R20's Medial Record documents: Orders entered per [Nurse Practitioner's name] today for [MEDICATION(S)] level 9/21/21 and [MEDICATION(S)] 125 mg BID). [R20's Legal Guardian's name] agreeable to lab, adamantly declines [MEDICATION(S)] states resident didn't do well on med (medication) previously. Surveyor unable to locate documentation that the prescribing nurse practitioner or R20's physician was informed R20's legal guardian declined to approve the new order for [MEDICATION(S)]. The facility arranged psychiatric services with facility preferred provider and did not attempt to coordinate services with R20's community psychiatric services for continuity of care. On 9/20/21, at 19:53 (7:53 PM) R20's Medical Record documents: Called to writer's attentions while passing medications on 1 south that alarm was triggered, upon searching resident was found walking out of the building stating that he wants to stand in front of oncoming cars and die and go to heaven, writer spoke with resident but he started being loud, administrator was called and she stated to call resident's mom to notify her of resident's behavior due to mom being the POA. Resident mom was called awaiting return call with message. On 9/20/21, at 19:55 (7:55 PM), R20's Medical Record documents: Residents mom called, message left on voice mail to call the facility. Administrator notified and she stated to call 911 and request for crisis intervention to come also. 1958 (7:58 PM) [name of city facility is located in] police officers here behind the facility since that was where the resident was sitting outside. Unable to redirect resident, crying and talking loudly. On 9/20/21, at 22:00 (10:00 PM), Resident remains un-redirected, resident's mom called at 2000 (8:00PM) until mom returned call at 2026 (8:26 PM) when mom returned call and attempted to talk to resident to no avail, with resident crying and telling his mom good bye, that he was going to kill himself and go to heaven. His mom was upset and asking numerous questions and stated that his friend does not want to be his friend again which might have triggered resident behavior of rejection, writer informed to come in since every intervention has failed. At 2100 (9:00 PM) officers tried to no avail, res started scratching his legs and body when writer informed resident to let us go in so as to apply cream to his legs, resident was happy and followed writer in and cream was applied to bilateral legs, crisis case worker came in and stated that resident was not fit for mental health and made her recommendations. Residents mom came in and spoke with her. Resident was spoken to by one of his favorite staff and was able to diffuse the situation. Added on 24-hour report. Administrator stayed on the phone during all this process and was updated all through out. R20's Care Plan was not updated to address R20's behavior of expressing suicidal ideations or identify person centered interventions to address R20's suicidal ideations. Due to the lack of identified behavior interventions the facility staff had to call the local police and crisis management team for assistance in managing R20. On 9/22/21, at 18:55 (6:55 PM) R20's Medical Record documents: Held care conference today with resident and mother. Resident is declining in therapy related to weight. Facility talked about discharge planning related to more appropriate placement. DOSS (Director of Social Services) talked about [NAME]-[NAME] Syndrome home in Oconomowoc. Mother reports that he was in that home and she did not like it at all and would never put him there. Mother reports that day cares do not work related to food problems. DOSS will fax referral to [name of facility] in Illinois. On 9/29/21, at 13:34 (1:34 PM), R20's Medical Record documents: [Name of facility in Illinois] reached back out to writer. Stating that they are unable to take resident, that is not an appropriate placement for resident. Writer informed mother. No further questions or concerns. Will continue to follow. On 10/4/21, at 19:30 (7:30 PM), R20's Medical Record documents: Res walked outside behind building with CNA, upset regarding an argument with another resident, laid down on the ground and refused to get up, this RN (Registered Nurse) and CNA outside with resident sitting on grass trying to ask resident what is going on and how we can help, res refused to talk then stated I want to go to the hospital NOW, send me to the hospital, my chest hurts and I can't breathe, I want to go to the hospital now res is alert and oriented baseline, no acute resp (respiratory) breathing issues at this time, vital cart unavailable as we are outside sitting in grass, res never lost consciousness and is now responding to writers questions, res does display some SOB (Shortness of Breath) d/t (do to) weight and size but no acute issues (gasping for air, loss of color, et) noted. 911 called immediately after res stated chest pain and requested to go to the ER (emergency room ). On call APNP with [name of medical group] call

Based on interview and record review, the facility did not ensure that a resident who entered the facility without a Pressure Injury (PI) did not develop a PI and received appropriate care, treatment and preventative measures to promote healing for 2 (R14 & R9) of 7 Residents reviewed for pressure injuries. * On 3/21/21 R14 was identified with a wound on the left heel. The next day the RN Wound nurse identified this area as unstageble. There was no revision in R14's skin integrity care plan. On 6/9/21 R14 was identified with a left buttock Stage 2 pressure injury by a LPN (Licensed Practical Nurse). There was no RN assessment until 6/14/21, five days later when this area was identified as being unstageable. There were no revisions in the care plan until 6/15/21. R14 was hospitalized from 6/19/21 to 6/23/21. The hospital discharge summary dated 6/23/21 documents an infected left heel ulcer. Upon readmission to the Facility R14 was identified as having 2 new pressure injuries. There were no revisions in R14's care plan. On 6/28/21 R14's left buttock pressure injury was identified as deteriorated with an increase in size. There were no revisions in the care plan. On 7/5/21 the wound bed description of R14's left buttock pressure injury includes 10% bone. The Facility continued to incorrectly stage this pressure injury as unstageable instead of Stage 4 through the rest of R14's stay at the Facility. A pressure injury which includes bone should be staged as a Stage 4. There was no revision in R14's skin integrity care plan. On 7/19/21 R14 was identified as having a deep tissue injury on the left hip. A suspected deep tissue injury to left hip care plan was developed on 7/21/21. On 7/26/21 the left hip pressure injury was identified as unstageable and on 8/9/21 the left hip was a Stage 4. There were no revisions in the care plan. On 8/2/21 R14 was identified with a deep tissue injury on the right hip with no revisions to the care plan. On 8/9/21 R14 had a Stage 4 pressure injury on the sacrum & left hip and the right hip is unstageable. There were no revisions in the care plan. There were no Facility assessments after 8/9/21. Wound MD (Medical Doctor)-M's assessment on 8/16/21 identified R14 with a sacrum & left hip Stage 4 pressure injury, an unstageable right hip pressure injury and a suspected deep tissue injury on R14's right shin. Wound MD-M ordered a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This treatment was not implemented and there were no revisions in R14's skin integrity care plan. Wound MD-M's assessment on 8/23/21 identified R14 with a sacrum & left hip Stage 4 pressure injury, an unstageable right hip pressure injury and a suspected deep tissue injury on R14's right shin. R14's [MEDICATION(S)] treatment was still not implemented. On 8/28/21 R14 was discharged to the hospital. The facility's failure to assess R14's pressure injuries, to correctly identify stages of wounds, to revise R14's care plan as wounds continued to develop and deteriorate, and to implement treatment as ordered by the physician created a finding of Immediate Jeopardy beginning on 7/5/21. On 9/8/21 at 4:23 p.m. Interim DON-B was informed of the Immediate Jeopardy findings. The immediate jeopardy was removed on 9/10/21. The deficient practice continues at a scope severity of a D (potential for more than minimal harm/isolated) as the Facility continues to implement their action plan and for R9 as evidenced by the following: * R9 was admitted to the facility on [DATE] with a Stage 2 pressure injury to the left buttock per hospital discharge summary and no comprehensive assessment was completed for skin by the facility upon admission or during facility stay. Findings include: 1. R14 was admitted to the facility on [DATE] and discharged on [DATE]. R14 was reviewed as a closed record. R14's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS (Minimum Data Set) with an assessment reference date of 2/17/21 documents a BIMS (brief interview mental status) score of 14 which indicates cognitively intact. R14 is dependent with one person physical assist for bed mobility, transfer, & toilet use, required extensive assistance with one person physical assist for eating, and was always incontinent of urine and bowel. R14 is coded as not having any behaviors including rejection of cares. R14 is at risk for pressure injury development and is coded as not having any pressure injuries. The pressure injury CAA (care area assessment) dated 2/19/21 for care plan considerations documents [R14] is at risk for pressure ulcers due to impaired mobility, incontinence, history of skin ulcers. He has a pressure relief mattress on his bed. Staff assist with repositioning through out the shifts. Preventative skin treatments and he is on a nutritional supplement. See Braden assessment, see PCC (pointclickcare), see progress notes, see TAR (treatment administration record). Will proceed with care plan with revisions as needed. The nurses note dated 3/21/21 (Sunday) documents New opened wound found on the resident's left heel. Xeroform, gauze and [MEDICATION(S)] applied. [Name of] (Son) notified at 1415 (2:15 p.m.). Wound care nurse to evaluate on Monday per [name of] NP's (Nurse Practitioner) request at 2220 (10:20 p.m.) Resident is resting comfortably, denies any pain or discomfort and is able to make needs known. This note was written by a LPN (Licensed Practical Nurse). The nurses note dated 3/22/21 documents Dressing changed, Tylenol given for pain. Wound care nurse [name of] notified by RN (Registered Nurse) supervisor of new wound. No concerns this shift. The nurses note dated 3/22/21 documents No noted changes to o/a (open area) on left heel. New treatment done per treatment nurse will continue to monitor. The skin impairment/wound form with an effective date 3/20/21 and signed on 3/22/21 documents for location left heel, stage of pressure injury Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Measurement of wound 3 x (times) 4 x 0.1. Wound bed is 20% granulation and 80% slough. Drainage is moderate and type of drainage is checked for serous. Surveyor was unable to speak to RN (Registered Nurse)-R regarding the effective date of 3/20/21 as RN-R, who was the wound nurse, is no longer employed at the Facility. The actual pressure injury care plan initiated 3/24/21 & revised 7/15/21 has interventions of: * APM mattress, check function and placement q (every) shift. Initiated 3/24/21 & revised 6/15/21. * Appetite stimulant ordered for w/t (weight) loss. Initiated 3/24/21. * Blue boots. Initiated 3/27/21. * Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Initiated 3/24/21. * Encourage good nutrition and hydration in order to promote healthier skin. Initiated 3/24/21. * I am followed by [name of wound doctor] weekly. Initiated 3/24/21. * Identify/document potential causative factors and eliminate/resolve where possible. Initiated 3/24/21. * Turn and position frequently as allowed and as needed, preferably every 2 hours. Initiated 3/24/21 & revised 7/15/21. * Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Initiated 3/24/21. * Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Initiated 3/24/21. The IDT (interdisciplinary team) note dated 3/24/21 documents Review of new area to left heel reveals that resident has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He has an air mattress in place and wears offloading blue boots. Transfers with assist of two and use of mechanical lift due to unable to bear weight. Staff repositions q (every) 2-3 hours and prn (as needed). Interventions also include nutritional supplement for additional support for wound healing. Resident frequently refuses Juven. Is followed by wound team and [name of wound company] MD (Medical Doctor) for wound care. Treatment in place. Surveyor noted weekly wound assessments of R14's left heel unstageable pressure injury through 6/14/21. The quarterly MDS with an assessment reference date of 5/20/21 documents a BIMS score of 11 which indicates moderately impaired. R14 requires extensive assistance with one person physical assist for bed mobility & eating, didn't transfer or ambulate, and is dependent with one person physical assist for toilet use. R14 is always incontinent of bowel and urine and is coded as not having any behaviors including refusal of care. R14 is at risk for pressure injury development and is coded as having one unstageable slough &/or eschar. The nurses note dated 6/9/21 documents Open area noted to left buttock, by therapy during cares, wound bed pink, no bleeding or drainage, small amount or scar tissue to surrounding area, denies pain NP [name of] updated, treatment in place, repositioned Q2H (every two hours). This note was written by an LPN. The nurses note dated 6/9/21 documents Above noted. Area with some eschar noted. [Wound MD-M] aware and will follow resident. Surveyor was unable to interview RN (Registered Nurse)-V who wrote this note as RN-V is no longer employed at the Facility. The skin impairment/wound form dated 6/9/21 documents for location left buttock, stage of pressure injury Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. Measurement of wound 3 x 1.5. For Wound Tissue bed indicate the percentage of each tissue type present in the wound bed has not been completed. Drainage is none. This assessment was completed by an LPN. There were no revisions in the skin integrity care plan until 6/15/21, six days later and there is no RN assessment until 6/14/21 five days later. The nurses note dated 6/11/21 documents Resident is being monitor for wound to left side of buttocks. Res. (Resident) was repositioned during Q 2 hours and as needed. Resident was given PRN (as needed) Tylenol for pain. The nurses note dated 6/13/21 documents Dressing to Left buttocks is C/D/I (clean/dry/intact). No complaint of pain or discomfort. The skin impairment/wound form dated 6/14/21 documents for location left buttock, stage of pressure injury Unstageable Pressure Injury. Measurement of wound 6 x 2 x 0.1. For Wound Tissue bed indicate the percentage of each tissue type present in the wound bed is 20% epithelial, 20% granulation, & 60% slough. Drainage is moderate and type of drainage is serous. Under additional comments documents stable. Barriers to wound healing documents poor mobility. This RN assessment was completed five days after the pressure injury was identified. The skin impairment/wound form dated 6/14/21 documents for location left heel, stage of pressure injury Unstageable Pressure Injury. Measurement of wound 2 x 2 x 0.1. For Wound Tissue bed indicate the percentage of each tissue type present in the wound bed is 30% granulation and 70% slough. Drainage is moderate and type of drainage is serous. R14's actual pressure injury care plan documents an intervention of APM mattress, check function and placement q shift. Initiated 3/24/21 & revised 6/15/21. The nutrition noted dated 6/15/21 documents Notified of a new US (unstageable) pressure area to resident's sacrum. Wound seen by [Wound MD-M] with treatment ordered. Resident would benefit from additional protein. Order written to add 30ml (milliliter) Pro State AWC BID (twice daily) to be mixed with cranberry juice for increased acceptance. POC (plan of care) updated. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Currently under wound care. Dressing is intact, in place. Wound care is provided by Wound Care specialist coming to the facility. He needs full assistance with repositioning due to right-sided [CONDITION(S)] and generalized muscle weakness. He denies chest pain, palpitation, headache, dizziness, [CONDITION(S)]. He has defibrillator. Date of last interrogation is unknown. Heart rate is controlled. He prefers to eat snacks instead of whole meal, enjoys drinking soda provided by family. Working currently with Physical Therapy to improve muscle strength and right-sided [CONDITION(S)]. Under physical exam for skin documents Open area on sacrum. Dressing intact. There is no documentation regarding R14's left heel pressure injury. The SBAR (situation, background, assessment, recommendation) note dated 6/19/21 documents Resident found lethargic, not responding to writer. Temp (temperature) 100.7 BP (blood pressure) 125/78, P (pulse) 138, R (respirations) 20 SP02 (oxygen saturation) 95% on RA (room air). Blood glucose 141. Open area noted to left flank. Unable to assess d/t (due to) the priority of unresponsiveness. The nurses note dated 6/20/21 documents admitted to [name of] hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R14 was hospitalized from 6/19/21 to 6/23/21. The hospitalist history and physical dated 6/19/21 under history of present illness documents Patient is a [AGE] year-old male with history of MS, previous stroke, previous IVC (inferior vena cava) thrombus on chronic anticoagulation as of November with [MEDICATION(S)], last admitted to hospital November with COVID-19 infection to [name of hospital] presents in the emergency room this evening due to increased confusion and decreased level of alertness per nursing home staff. Was febrile to 100.6 at skilled nursing facility and temp (temperature) in the emergency room was 101.7. Was [CONDITION(S)] initially to 130s. White blood cell count is 10.2. Lactic acid was 1.7. He was given fluids in the emergency room . Urinalysis shows whites but no significant bacteria, no nitrates, no leukocyte esterase. Chest X-ray is negative. Patient has stage II (2) sacral decubitus ulcer which did not appear infected. He also has a left heel decubitus ulcer which may be the source of his infection. He is quite tender to palpation foul-smelling. Initially was given [MEDICATION(S)] in the ER (emergency room ) for concerns of [CONDITION(S)] (urinary tract infection). Under physical exam for skin documents Warm and dry. Stage II sacral decubitus ulcer. Non stage herbal left calcaneal pressure ulcer, boggy, painful, foul-smelling exudate. The hospital discharge summary dated 6/23/21 under hospital course documents Infected left heel ulcer: Presented with [CONDITION(S)] on admission. Now has resolved. X-ray of calcaneus with no evidence of [CONDITION(S)]. Seen by ID (infectious disease) and podiatry. Appreciate recommendations. As per podiatry no debridement needed. Blood cultures growing Gram-negative bacteria. Received broad-spectrum antibiotics. Antibiotics will be discontinued on discharge as POA (power of attorney) decided to pursue hospice. He will be discharged back to his facility. The nurses note dated 6/23/21 documents, Skin check performed by writer & another nurse. Existing wounds to Left heel, Left Buttock, & Right Flank noted, as well as new wound to Right Elbow. All are Pressure - Unstageable. See Skin/Wound assessments for details. The skin impairment/wound form dated 6/23/21 documents for location left heel, stage of pressure injury Unstageable Pressure Injury. Measurement 2 x 2 x 0.1. 100% slough. Drainage is moderate and type of drainage is serous. Under additional comments documents stable. The skin impairment/wound form dated 6/23/21 documents for location left buttock, stage of pressure injury Unstageable Pressure Injury. 3 x 2.5 x 0.1. 10% slough & 90% eschar. Drainage is moderate and type of drainage is serous. Under additional comments documents deteriorated. The skin impairment/wound form dated 6/23/21 documents for location Right Flank, stage of pressure injury is Unstageable. 1.5 x 1. 100% slough. Drainage is moderate and type of drainage is serous. Under additional comments documents stable. The skin impairment/wound form dated 6/23/21 documents for location Right Elbow, stage of pressure injury is Unstageable. 2 x 1.5 x 0.1. 50% granulation and 50% slough. Drainage is moderate and type of drainage is serous. Under additional comments documents present on admission. Under barrier to wound healing documents poor mobility. There were no revisions in R14's skin integrity care plan when R14 returned from the hospital with two additional pressure injuries. The nurses note dated 6/28/21 documents Wound to Right Elbow is Resolved - Tx (treatment) D/C'd (discontinued). The skin impairment/wound form dated 6/28/21 documents for location left heel, stage of pressure injury Unstageable Pressure Injury. 1 x 1.5 x 0.2. 90% granulation & 10% slough. Drainage is moderate and type of drainage is serous. Under additional comments documents Improved. The skin impairment/wound form dated 6/28/21 documents for location left buttock, stage of pressure injury Unstageable Pressure Injury. 7 x 3 x 0.5. 100% slough. Drainage is moderate and type of drainage is serous. Under additional comments documents Deteriorated. Surveyor noted the measurements of R14's pressure injury have increased and there is no revision in the plan of care. The skin impairment/wound form dated 6/28/21 documents for location Right Flank, stage of pressure injury is Stage 3. 1 x 1 X 0.1. 100% granulation. Drainage is moderate and type of drainage is serous. Under additional comments documents Improved. Under barriers to wound healing documents Poor mobility. The significant change MDS with an assessment reference date of 6/30/21 documents a BIMS score of 11 which indicates moderately impaired. R14 is not coded as having any behavior including rejection of care. R14 is dependent with one person physical assist for bed mobility, eating, & toilet use. R14 is coded as having an indwelling catheter and is always incontinent of urine and bowel. R14 is at risk for pressure injury development and is coded as having one Stage 3 pressure injury and two unstageable slough &/or eschar. R14 is checked for hospice care while a resident. The pressure injury CAA dated 7/1/21 under analysis of findings documents [R14] currently has unstageable pressure injuries to L (left) buttock, L heel and R (right) chest wall/flank with scheduled treatment and followed by Wound RN and by [name of] wound service. He requires total assistance with most of his adls (activities daily living). He transfers with Hoyer lift and 2 assists, but has been staying in bed most times for comfort. Also see ADL CAA. He remains totally incontinent of urine and bowel. He has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Receives antidepressants, [MEDICATION(S)], antihypertensive, statin, antiplatelet and iron supplement. Appetite varies from 0-75%, dependent of staff with eating. Braden Score = (equals) 12 (High Risk). Treatment as ordered was added to the care plan and initiated 7/1/21. The nurses note dated 7/5/21 documents Wound to Right Flank is Resolved. Tx D/c'd. The skin impairment/wound form dated 7/5/21 documents for location left heel, stage of pressure injury Unstageable Pressure Injury. 1 x 1 x 0.1. 90% granulation & 10% slough. Drainage is moderate and type of drainage is serous. Under additional comments documents improved. The skin impairment/wound form dated 7/5/21 documents for location left buttock, stage of pressure injury Unstageable Pressure Injury. 6 x 3 x 2. Under tunneling/undermining documents 3 @ (at) 12:00. 30% granulation, 60% slough and under other 10% bone. Drainage is moderate and type of drainage is serous. Under additional comments documents Improved. Barriers to wound healing documents Poor Mobility. Surveyor noted R14's left buttock has been incorrectly staged and should be staged as a Stage 4. There were no revisions in R14's skin integrity care plan. Surveyor noted Wound MD-M staged R14's sacrum pressure injury as a Stage 4 on 7/5/21. The skin impairment/wound form dated 7/12/21 documents for location L (left) heel, stage of pressure injury Unstageable Pressure Injury. 0.8 x 0.8 x 0.1. 90% granulation & 10% slough. Drainage is moderate and type of drainage is serous. Under additional comments documents [Wound MD-M assessed wound, area shows signs of improvement. Area debrided and patient tolerated procedure well. Continue with current treatment. The skin impairment/wound form dated 7/12/21 documents for location sacrum, stage of pressure injury Unstageable Pressure Injury. 6 x 3 x 2. Under tunneling/undermining documents 3 @ (at) 12:00. 30% granulation, 60% slough and under other 10% bone. Drainage is moderate and type of drainage is serous. Under additional comments documents Wound MD-M] assessed wound. area is stable with no real changes noted. Continue with current treatment. Under Barriers to wound healing: documents This patient has [CONDITION(S)], the ability for this patient to reposition himself or change positions is very limited which can further damage existing pressure injuries. This presents a barrier to the wounds healing. Surveyor noted the location has been changed to sacrum from left buttocks and continues to be incorrectly staged. Surveyor noted R14's actual pressure injury care plan was revised on 7/15/21 from Turn and position frequently and as necessary to Turn and position frequently as allowed and as needed, preferably every two hours. On 7/15/21 there were no other revisions made to the plan of care. The skin impairment/wound form dated 7/19/21 documents for location left heel, stage of pressure injury Unstageable Pressure Injury. 0 x 0. 100% re-epithelialization. Under additional comments documents [Wound MD-M] assessed wound. Wound is resolved. Continue to protect area with silicone foam weekly and prn (as needed). The skin impairment/wound form dated 7/19/21 documents for location sacrum, stage of pressure injury Unstageable Pressure Injury. 6 x 6 x 2. Under tunneling/undermining documents 3 @ (at) 12:00. 30% granulation, 60% slough and under other 10% bone. Drainage is moderate and type of drainage is serous. Under additional comments documents [Wound MD-M] assessed wound. Area is deteriorated. Wound was debrided and tolerated well by patient. Treatment changed due to deterioration. Surveyor noted R14's pressure injury continues to be staged incorrectly and should be staged as a Stage 4. The skin impairment/wound form dated 7/19/21 documents for location L (left) hip, stage of pressure injury Deep Tissue Injury and measurements of wound 4.5 x 4.5. 100% epithelial. Drainage is none. Under additional comments documents [Wound MD-M] assessed wound. Area is new as of this visit. Protect area with silicone foam and change weekly. This wound is unavoidable due to the patients general decline. Barriers to wound healing documents This patient has [CONDITION(S)], the ability for this patient to reposition himself and change positions is very limited which can further damage existing pressure injuries. This presents a barrier to the wounds healing. There were no revisions in R14's skin integrity care plan until a suspected deep tissue injury care plan was developed on 7/21/21. The suspected deep tissue injury pressure ulcer to left hip care plan initiated & revised 7/21/21 has interventions of: * Administer treatments as ordered and monitor for effectiveness. Initiated 7/21/21. * Assess/record/monitor wound health (SPECIFY FREQ (frequency)) Measure length, width and depth were possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD (medical doctor). Initiated 7/21/21. * Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Initiated 7/21/21. * Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . * Inform the resident/family/caregivers of any new area of skin breakdown. Initiated 7/21/21. * Monitor dressing (SPECIFY FREQ) to ensure it is intact and adhering. Report lose dressing to Treatment nurse. Initiated 7/21/21. * Monitor nutritional status. Serve diet as ordered, monitor intake and record. Initiated 7/21/21. * The resident needs (SPECIFY: monitoring/reminding/assistance) to turn/reposition at least every 2 hours, more often as needed or requested. Initiated 7/21/21. * The resident needs (SPECIFY: Pressure relieving/reducing devices) on (SPECIFY: bed/chair). Initiated 7/21/21. * Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Initiated 7/21/21. This care plan was not individualized for R14. It did not specify how frequently to monitor dressing, did not specify whether R14 needed monitoring, reminding or assistance to turn every two hours, and did not specify what pressure relieving/reducing devices the resident needed and where these were needed (bed or chair). It did not specify if R14 needed turning/repositioning every two hours or more often as needed. The skin impairment/wound form dated 7/26/21 documents for location sacrum, stage of pressure injury Unstageable Pressure Injury. 6 x 6 x 2. Under tunneling/undermining documents 3 @ (at) 12:00. 50% granulation, 40% slough and under other 10% bone. Drainage is moderate and type of drainage is serous. Under additional comments documents [Wound MD-M] assessed wound, area is improving. Wound was debrided and tolerated well by patient. Continue with pan sic (plan) of care for wounds. Surveyor noted R14's pressure injury continues to be staged incorrectly and should be staged as a Stage 4. The skin impairment/wound form dated 7/26/21 documents for location L (left) hip, stage of pressure injury Unstageable Pressure Injury 5 x 4.5. 100% slough. Drainage is moderate and type of drainage is serous. Under additional comments documents [Wound MD-M] assessed wound, area is deteriorating and wound was debrided. Patient tolerated procedure well. Treatment changed to (sic) There were no revisions in R14's skin integrity care plans. Surveyor reviewed R14's July TAR (treatment administration record) and noted treatment to the left hip is not initialed as being completed on 7/28/21, 7/29/21, 7/30/21 & 7/31/21. There is no documentation regarding this treatment in R14's medical record. The skin impairment/wound form dated 8/2/21 documents for location sacrum, stage of pressure injury Unstageable Pressure Injury. 5.5 x 4 x 1.5. Under tunneling/undermining documents 1.5 @ (at) 7:00. 80% granulation, 10% slough and under other 10% bone. Drainage is moderate and type of drainage is serous. Under additional comments documents Improved. Surveyor noted R14's pressure injury continues to be staged incorrectly and should be a Stage 4. The skin impairment/wound form dated 8/2/21 documents for location Left hip, stage of pressure injury Unstageable Pressure Injury 5.5 x 6 x 1. 100% slough. Drainage is moderate and type of drainage is serous. Under additional comments documents Deteriorated. There were no revisions in R14's skin integrity care plans even though the pressure injury is deteriorated. The skin impairment/wound form dated 8/2/21 documents for location Right Hip, Stage of pressure injury Deep Tissue Injury 1.5 x 1.5. 100% epithelial. Drainage is none. Under additional comments documents new. Under barriers to wound healing documents Poor mobility. There were no revision in R14's skin integrity care plans. The skin impairment/wound form dated 8/9/21 documents for location sacrum, stage of pressure injury Unstageable Pressure Injury. 6 x 5 x 2. Under tunneling/undermining documents 2 @ (at) 7:00 & 2 @ 2:00. 80% granulation, 10% slough and under other 10% bone. Drainage is moderate and type of drainage is serous. Under additional comments documents Deteriorated. Surveyor noted R14's pressure injury continues to be staged incorrectly and should be staged as a Stage 4. There were no revisions in R14's skin integrity care plans. The skin impairment/wound form dated 8/9/21 documents for location Left hip, stage of pressure injury Stage 4 and measurements of wound 7 x 8 x 1. 100% slough. Drainage is moderate and type of drainage is serous. Under additional comments documents Deteriorated. There were no revisions in R14's skin integrity care plans. The skin impairment/wound form dated 8/9/21 documents for location Right Hip, Stage of pressure injury Unstageable 2.5 x 3 x 0.1. 100% slough. Drainage is moderate and type of drainage is serous. Under additional comments documents deteriorated. Under barriers to wound healing documents Poor mobility. There were no revisions in R14's skin integrity care plans. Surveyor was unable to locate skin impairment/wound forms for R14's sacrum, left and right hip pressure injuries after 8/9/21. Surveyor reviewed Wound MD-M's wound evaluation & management summary for assessments of R14's pressure injuries. Wound MD-M's wound evaluation & management summary dated 8/16/21 documents for focused wound exam (site 2) Stage 4 Pressure Wound Sacrum Full Thickness. Etiology Pressure. Wound size is 7 x 7 x 2 cm (centimeters). Undermining is 2 cm at 7 o'clock, exudate moderate serous, slough 10 %, Granulation tissue 80% and other viable tissues 10% bone. Wound progress no change. Focused Wound Exam (site 3) documents Stage 4 pressure wound of the left hip full thickness. Etiology Pressure. Wound size is 9 x 9 x 1 cm (centimeters). Exudate Heavy serous, slough 100 %. Wound progress Deteriorated. Focused Wound Exam (site 4) documents Unstageable (Due to necrosis) of the right hip full thickness. Etiology Pressure. Wound size is 4 x 3 x 0.1 cm (centimeters). Exudate Moderate serous, slough 100 %. Wound progress Deteriorated. Focused Wound Exam (site 5) documents Unstageable DTI (deep tissue injury) of the right shin partial thickness. Etiology Pressure. Wound size is 22 x 3 x not measurable cm (centimeters). Exudate none. Under dressing treatment plan documents [MEDICATION(S)] apply once daily for 30 days. Surveyor noted the DTI on R14's right shin is a new pressure injury and there is no revision in R14's plan of care. Surveyor reviewed August 2021 TAR (treatment administration record) and did not note this treatment on the TAR. Other than Wound MD-M's documentation there is no other documentation of this new pressure injury in R14's medical record. Wound MD-M's wound evaluation & management summary dated 8/23/21 documents for focused wound exam (site 2) Stage 4 Pressure Wound Sacrum Full Thickness. Etiology Pressure. Wound size is 7 x 7 x 2 cm. Undermining is 2 cm at 7 o'clock, exudate moderate serous, slough 10 %, Granulation tissue 80% and other viable tissues 10% bone. Wound progress no change. Focused Wound Exam (site 3) documents Stage 4 pressure wound of the left hip full thickness. Etiology Pressure Wound size is 9 x 9 x 1 cm (centimeters). Exudate Moderate serous, slough 100 %. Wound progress No change. Focused Wound Exam (site 4) documents Unstageable (Due to necrosis) of the rig [TRUNCATED]

Based on interview, observation and record review, the facility did not ensure 1 (R6) of 3 residents reviewed for quality of care received treatment and care in accordance with professional standards of practice. R6 had a change of condition on [DATE] while a resident at the facility. The nursing staff was alerted to R6 having emesis at 9:00 AM, complaints of not feeling well and a request to go to the hospital at 12:15 PM. R6 was not assessed by an RN, the MD was not updated and the resident was not sent to the hospital. The resident was found deceased by staff at 3:30 PM. Findings include: Surveyor reviewed facility's Change in Condition Process policy with a date of [DATE]. Documented was: POLICY STATEMENT: The purpose of this policy is to promptly implement a system for a resident having a change in condition. A change of condition is defined as an improvement or decline in their physical, mental, or psychosocial status. PROCEDURE: Change of Condition: 1. When a change in condition or change from baseline is observed and reported, the licensed nurse is responsible for evaluating the Resident's condition. Examples of a condition change are as follows, but not limited to; a. Abnormal or change in vital signs . e. Nausea and vomiting . 2. The licensed nurse will evaluate the change in condition. Depending upon the circumstances, the licensed nurse will begin the nursing process (assessment/plan/implement/evaluate). 3. The physician will be notified . Surveyor reviewed facility's Resident Rights - Self Determination policy with a date of [DATE]. Documented was: POLICY STATEMENT: It is the facility's policy to provide care and services in such a manner to acknowledge and respect resident rights. Exercising rights means that the residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and received care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement . R6 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R6's Advanced Directives which noted R6 as her own person and Power of Attorney for Healthcare (POAHC) not activated noting she was in charge of making her own decisions. Surveyor reviewed R6's Preferred Intensity of Medical Care and Treatment with a date of [DATE]. Documented under Initial Your Choices was Resuscitate (Full Code) and Hospitalize and was signed by R6. Surveyor reviewed R6's Progress Notes. Documented on [DATE] at 9:00 AM by Licensed Practical Nurse (LPN)-N [Certified Nursing Assistant (CNA)-F] caring for resident told writer that resident had an emesis. [CNA-F] did not tell writer if emesis was dry or amount. Writer did not see emesis. There was no documented RN assessment of the resident or update to MD or Nurse Practitioner (NP) after the emesis. Documented on [DATE] at 9:30 AM by LPN-N was [CNA-F] told writer that resident did not eat any breakfast but drank juices. Resident's appetite usually poor. Documented on [DATE] at 10:30 AM LPN-N was Writer was in room with resident [approximately] 20 minutes. Doing treatment to right lower leg. Resident was alert talking with writer with no c/o (complaint of) not feeling well. Documented on [DATE] at 12:15 PM by LPN-N was [CNA-F] called writer to room and told writer that resident was not feeling well, Vitals stable. [Blood pressure (BP)] ,d+[DATE], pulse 88, Respiration 20 non-labored. Alert and talking to writer. Resident drank 120cc of juice from writer. [CNA-F] told writer that resident did not eat lunch but drank 2 glasses of cranberry juice and her milk. There was no documented RN assessment of the resident or update to MD or Nurse Practitioner (NP) after R6 complained of not feeling well. There are no further assessments or documentation of R6's condition. CNA-F was unable to be interviewed as she was not employed at the facility. Surveyor reviewed CNA-F's witness statement taken by Nursing Home Administrator (NHA)-A that documented .the resident had an emesis in the morning, sometime between ,d+[DATE] AM which she cleaned up and reported to the nurse. [CNA-F] stated the she did inform the nurse between 12:00p-12:30p, that while she was assisting the resident with lunch the resident stated again she was not feeling well again. Resident took fluids but did not eat anything. Per [CNA-F], she informed the floor nurse. She checked on the resident again around 1:15 pm. On [DATE] at 12:51 PM Surveyor interviewed CNA-K. CNA-K was working on R6's unit on second shift after CNA-F's shift. Surveyor asked CNA-K about the events that happened on [DATE]. CNA-K stated she got report from CNA-F who told her R6 had emesis and had not been feeling well and she reported it to LPN-N. CNA-K stated she started her rounds at 3:00 PM after report and went to check on R6 about 3:30 PM. CNA-K stated she noted R6 was very pale and stiff. CNA-K stated she felt for a pulse on her wrist but R6 was cold and had no pulse. CNA-K stated she notified Registered Nurse (RN)-O and RN-Q. CNA-K stated CPR was started, 911 was called and the Paramedics arrived. R6 was pronounced deceased at the facility by MD. On [DATE] at 10:00 AM Surveyor interviewed LPN-N. Surveyor asked LPN-N about the events that happened on [DATE]. LPN-N stated CNA-F reported R6 had emesis in the morning around 8:00 AM but LPN-N stated she did not see it because CNA-F had cleaned it up. Surveyor asked if she had notified a supervisor, MD or saw the resident after CNA-F reported the 8:00 AM emesis. LPN-N stated she went back to R6's room at 10:00 AM and did her wound treatment. LPN-N stated R6 was not having any pain and was alert and responsive. LPN-N stated she went back in R6's room after noon when CNA-F told her R6 was not feeling well and wanted to go to the hospital. LPN-N stated she took R6's vital signs and they were stable and left the room about 12:30 PM. Surveyor asked if LPN-N asked R6 if she wanted to go to the hospital. LPN-N stated no but she did not ask me either. Surveyor asked if R6 would have been able to answer her if she had asked. LPN-N stated yes. LPN-N stated R6 was alert and orientated, sometimes confused, but able to make her needs known. Surveyor asked if she had notified a supervisor, MD or saw the resident after she left the room at 12:30 PM. LPN-N stated no. LPN-N stated she gave report to RN-O and RN-Q at 2:30 PM. LPN-N stated she reported R6 was not feeling well but her vital signs were stable. Surveyor asked if she reported the emesis from the morning or that she asked the CNA to go to the hospital. LPN-N stated no. Surveyor asked what the process was if a resident asks to go to the hospital in a non-life threatening emergency. LPN-N stated she would call the MD or NP and get an order to send the resident to the hospital and call an ambulance to come transport them. On [DATE] at 2:58 PM Surveyor interviewed RN-O. Surveyor asked if he had received a report from LPN-N about R6. RN-O stated LPN-N had reported R6 wasn't feeling well earlier and her vital signs were stable. Surveyor asked if LPN-N had reported emesis or wanting to go to the hospital. RN-O stated no. On [DATE] at 3:25 PM Surveyor interviewed RN-Q. Surveyor asked if she had received a report from LPN-N about R6. RN-Q stated LPN-N had reported R6 wasn't feeling well earlier and her vital signs were stable. Surveyor asked if LPN-N had reported emesis or wanting to go to the hospital. RN-Q stated no. On [DATE] at 10:00 AM Surveyor interviewed NP-S. Surveyor asked what she would expect the facility to do if a resident has emesis. NP-S stated assess the resident and contact her or the MD/NP on call. Surveyor asked if a resident has emesis would she expect to be updated. NP-S stated yes, she expects the facility to update her with any change of condition. Surveyor asked if a resident asks to go to the hospital what the facility should do. NP-S stated they need to send her out, it is the resident's right. NP-S stated the facility should call her or the MD/NP on call and get an order to send the resident out to the hospital. Surveyor asked if she would expect the facility to do an assessment on the resident. NP-S stated yes, that is Nursing 101. NP-S stated she would also expect the facility to ask the resident why they want to be sent to the hospital. On [DATE] at 12:29 PM Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked if emesis was a change in condition. DON-B stated sometimes, it needs a deeper assessment because some residents have GERD, etc. Surveyor asked what the facility's process is if a resident has a change in condition. DON-B stated an LPN would tell an RN and an assessment would be done by the RN, the MD would be updated and the POAHC (power of attorney for health care) would be updated. Surveyor asked if a CNA observes a resident having emesis what is the process. DON-B stated the CNA would let any nurse know and if it was an LPN they would escalate the information to the RN for assessment. Surveyor asked if the [DATE] emesis that R6 had should have been escalated to an RN. DON-B stated I would have said something to an RN as a standard of practice. Surveyor asked if a resident wanted to go to the hospital what the facility's process was. DON-B stated they get sent to the hospital. DON-B stated LPN-N stated to her that she was not aware R6 asked to go to the hospital. Surveyor noted LPN-N stated in interview that CNA-F told her R6 wanted to go to the hospital. Surveyor noted LPN-N also wrote a witness statement that documented she was aware R6 wanted to go to the hospital. DON-B stated she was unaware of this. Surveyor asked if LPN-N should have asked her if she wanted to go to the hospital. DON-B stated LPN-N probably should have asked and possibly escalated the situation to an RN. On [DATE] at 12:58 PM Surveyor interviewed NHA-A. Surveyor asked who would have been responsible for assessing and sending out R6 on [DATE]. NHA-A stated the nurse on the floor. NHA-A stated LPN-N should have notified a RN and sent the resident to the hospital.

Based on interview, observation and record review, the facility did not ensure 3 (R1, R2, and R6) of 4 residents reviewed for pressure injuries (PI) received care, consistent with professional standards of practice, to prevent pressure injuries from developing or worsening. *R1 was admitted to the facility on [DATE] with no open areas or pressure injuries. R1 did not have a care plan in place for preventing PI until 3/2/21. A weekly skin assessment was not performed on R1 that week. On 3/9/21 an unstageable PI was found to R1's sacrum. *R2 was admitted to the facility on [DATE] with no pressure injuries. R2 was assessed on admission with boggy left heel but did not have interventions in place for preventing further breakdown to left heel. The Nurse Practitioner was assessing his lower limb [CONDITION(S)] and found R2's heels not floated and an open, draining blister on left heel on 3/26/21. A Nurse assessed this wound as a Stage 2 on 3/26/21 but no treatment or interventions were put in place until 3/28/21. On 3/29/21 an unstageable PI was assessed to the left heel. *R6 was admitted to the facility on [DATE] with no pressure injuries. R6 was assessed by the facility to be at risk for the development of pressure injuries upon admission to the facility. The facility did not put a baseline plan of care in place to prevent the development of pressure injuries. On 2/16/21 R6 developed a pressure injury to the right heel. The pressure injury developed into an unstageable pressure injury that was observed to cause R6 pain. Findings include: Surveyor reviewed facility's Pressure Ulcer Prevention policy with no date. Documented was Etiology and Risk Factors for Pressure Injury Definition: Pressure Injury - A pressure injury is localized damage to the skin and/or underlying soft tissue over a bony prominence or to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue . Risk Factors Primary Risks - Impaired/decreased mobility and decreased functional ability are the primary risk factors for pressure ulcers. Secondary Risks - after identifying residents who are chairfast or bedfast, the following characteristics further increase the risk of pressure ulcer development: Advanced age Drugs such as steroids that may affect wound healing Decreased sensory perception Impaired diffuse or localized blood flow, for example, generalized atherosclerosis or lower extremity arterial insufficiency Exposure of skin to urinary and fecal incontinence Resident refusal of some care and treatment Under nutrition, malnutrition, and hydration deficits Healed pressure ulcer [History and Physical (H&P)] Altered level of consciousness or cognitive impairment Increased pain level Co-morbid conditions, such as end stage [CONDITION(S)], [CONDITION(S)] disease or diabetes mellitus Friction and shear [CONDITION(S)] Above risk factors in Italics are included in standardized risk assessments. All individuals, regardless of mobility must be assessed for pressure ulcer development on admission, weekly for the first four weeks after admission, then quarterly using a valid pressure ulcer risk assessment (i.e. Braden or Norton). Risk Assessment Tools The facility should use a validated pressure ulcer risk assessment tool to determine the amount of risk, and the degree to which mobility and activity levels are limited. The Braden and Norton scale have been used extensively and are both excellent tools, however, all risk factors must be assessed. The risk assessment should identify which factors can be removed or modified. All risk factors should be addressed even if the total risk score does not place the resident at risk for developing pressure ulcers. Skin Care and Early Treatment Systematic Skin Assessment An integral part of any skin care program is a systematic skin assessment. It is through these inspections that early skin problems can be detected and intervention started. These inspections start on admission. According to the Guidance to Surveyors for Long Term Care Facilities: The admission evaluation may identify pre-existing signs (such as a purple or very dark area that is surrounded by profound redness, [CONDITION(S)], or induration) suggesting that deep tissue damage has already occurred and additional deep tissue loss may occur. This deep tissue damage could lead to the appearance of an unavoidable Stage III or IV pressure ulcer or progression of a Stage I pressure ulcer to an ulcer with eschar or exudates within days after admission. Assessment must continue according to an appropriate schedule. Staff should evaluate skin condition and should pay attention to bony prominences . Accurate Documentation Accurate documentation is needed to ensure continuity of care. The plan of care should address efforts to stabilize, reduce or remove underlying risk factors; monitor the impact of the interventions; and modify the interventions as appropriate. The care plan should specifically address risk factors, pressure points, under-nutrition and hydration deficits and moisture and its impact. Pain Management Monitor the resident for pain and put protocol in place to assist in pain management. Pain management should include administration of medication prior to dressing change and around the clock if needed . Protecting Against External Mechanical Forces All residents who are in bed and have been assessed to be at risk for skin breakdown should be repositioned at least every two hours (unless a tissue tolerance test indicates otherwise). This repositioning should also take place when residents are in a chair or wheelchair. Positioning Devices Positioning devices should be used to keep bony prominences from direct contact with each other. These devices may be in the form of pillows or foam wedges. Pressure Redistribution Devices Residents who are consistently immobile should have pressure-reducing devices used to totally relieve pressure on heels and raise the heels completely off the bed. Do not use donut-type devices since these increase pressure around the heel and cause breakdown . 1. R1 was admitted to the facility on [DATE]. R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R1's Admission Data Collection and Baseline Care Plan with a date of 2/26/21. Documented under Skin Condition was Site: 15) Right antecubital. Description: Dissipating bruise noted. There were no other skin impairments or pressure injuries documented. Under Skin Integrity Planning there were no focus items, goals or interventions checked to trigger a care plan for skin integrity and maintain current status. Surveyor reviewed R1's Braden Scale for Predicting Pressure Sore Risk with a date of 2/26/21. Documented was Braden Risk Scale Score: 16 which indicated at risk for pressure injuries. Surveyor reviewed R1's Progress Notes. Documented on 2/28/21 was Resident has a new skin issue-nurse to assess. New admit with skin issues. Documented on admission. There is no assessment of these skin issues. There was no other documentation noted for new skin issues. Surveyor reviewed R1's Comprehensive Care Plan with an initiation date of 3/2/21. Documented was Focus: The resident has potential/actual impairment to skin integrity r/t impaired mobility secondary to deconditioning. Goal: The resident will maintain or develop clean and intact skin by the review date. Interventions: Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Implement pressure reducing devices i.e. w/c cushion, air-mattress, off-loading heels, etc. Turn and position as necessary Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. There were no interventions or care plan in place from 2/26/21 through 3/2/21 to prevent skin breakdown. Surveyor reviewed R1's MDS admission assessment with an assessment reference date of 3/5/21. Documented under Cognition was a BIMS (brief interview mental status) score of 14 which indicated cognitively intact. Documented under Functional Status for Bed Mobility was 3/2 which indicated Extensive Assistance - resident involved in activity, staff provide weight-bearing support; One person physical assist. Documented under Functional Status for Transfer was 3/3 which indicated Extensive assistance - resident involved in activity, staff provide weight-bearing support; Two plus persons physical assist. Documented under Bowel and Bladder was Urinary Incontinence 9. Not rated, resident has a catheter . and Bowel Incontinence 3. Always incontinent. Documented under Skin Conditions was Is this resident at risk of developing pressure ulcers/injuries? 1. Yes and Does this resident have one or more unhealed pressure ulcers/injuries? 0. No. Surveyor reviewed R1's Care Area Assessment (CAA) related to Pressure Ulcer/Injury with an assessment date of 3/5/21. Documented under Nature of the Problem/Condition was [R1] is a new admit to this facility for rehab following hospitalization after a fall at home with a T10 compression [fracture] along with acute on chronic back pain. Other diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She is alert and orientated, able to make her needs known and hold a conversation. At this time [R1] is at risk for pressure injury due to decreased mobility, pain, bowel incontinence. She is assisted in repositioning by staff, therapies working towards goals of going home, she is on a pressure reducing mattress and cushion. She has no pressure injury at this time. Surveyor reviewed Assessments for R1. There was no other weekly or as needed skin assessments for R1 from 2/27/21 through 3/9/21. Surveyor reviewed R1's Progress Notes. Documented on 3/9/21 at 3:44 PM was Writer called to room by [Certified Nursing Assistant (CNA)-F], resident has an open area to her sacrum, writer had [Wound Registered Nurse (RN)] come and access with writer. Wound document and new orders received, resident is aware of unstageable pressure ulcer to her sacrum. Surveyor reviewed R1's Skin Impairment/Wound Form with a date of 3/9/21. Documented was 1b. Stage of pressure injury: e. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss . 1c. Measurement of Wound (L x W x D): 5 x 9 x 0.1 cm . 3. Barriers to wound healing: poor oral intake unable to reposition frequently by self [due to] fracture in spine . 5. Wound Education provided: Educated on reposition side to side, to avoid prolonged periods on her coccyx. Stated understanding. The MD was updated and treatment put in place. R1 then had altered mental status and was sent to the hospital and admitted . On 5/4/21 at 12:38 PM Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked how often head to toe skin assessments were completed. DON-B stated on admission, weekly on shower days and as needed. Surveyor noted that R1 did not have a skin assessment completed after initial assessment on 2/26/21 until unstageable pressure injury was found on 3/9/21. DON-B stated they should have done one the week of 3/1/21. On 5/5/21 at 12:50 PM Surveyor interviewed CNA-G. Surveyor asked if she remembered finding a wound on R1's sacrum. CNA-G stated she does not remember finding it but remembers she had a large wound to her bottom. Surveyor asked about preventative measures for R1 to prevent breakdown. CNA-G stated it was hard because R1 refused to get out of bed and only got up when therapy was working with her. CNA-G stated R1 had a back brace so she could not move much. CNA-G stated she had a second CNA help reposition her when she could because she was hard to move alone. CNA-G stated she was always on her back because of the brace. 2. R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R2's Admission Data Collection and Baseline Care Plan with a date of 3/16/21. Documented under Skin Condition was Site: 12) Chest. Description: red/hive like rash all over chest. Site: 13) Vertebrae (upper-mid). Description: red rash/hive like. Site: 14) Abdomen. Description: red/hive like rash. Site: 16) Left antecubital. Description: bruising. Site: 17) Right elbow. Description: bruise. Site: 30) Left hand (back). Description: bruising. Site: 50) Left heel. Description: spongy/boggy will have wound nurse see resident. Site: 6) Right shoulder (front). Description: Perm [catheter], dressing clean dry and intact. Site: Other (specify). Description: left forearm scab left underside of forearm scabbed area. Site: Other (specify). Description: red rash/hive like pretty much all over body. Surveyor reviewed R2's Braden Scale for Predicting Pressure Sore Risk with a date of 3/16/21. Documented was Braden Risk Scale Score: 20 which indicated not at risk for pressure injuries. This contradicted the admission assessment of multiple open areas and bruising and multiple co-morbidities putting R2 at risk. Surveyor reviewed R2's Body Check assessment with full body drawings dated 3/16/21. Circled was the back of the left heel and written next to it was boggy. Surveyor reviewed MD orders for R2. Documented with a start date of 3/16/21 was Apply skin prep to [bilateral lower] heels at bedtime for skin prevention. Surveyor reviewed R2's Comprehensive Care Plan with an initiation date of 3/16/21. Documented was Focus: The resident has potential/actual impairment to skin integrity. He has a skin tear to right arm, left elbow abrasion and [incontinence associated [CONDITION(S)] (IAD)]. Goal: The resident will develop clean and intact skin by the review date. Interventions: Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Provide pressure relieving device(s): [Specify] Turn and position as necessary. There is no mention of R2's boggy left heel or prevention of further breakdown of heels. Surveyor reviewed Wound Registered Nurse (RN)-D Skin Impairment/Wound Form with a date of 3/17/21. Documented was assessments of the left upper arm abrasion and left elbow abrasion. There is no assessment by the wound nurse for the boggy heel as stated in the Admission Data Collection. Surveyor reviewed RN-C's Skin Observation Tool with a date of 3/17/21. Documented was the abrasion to left elbow and skin tear to left upper arm. There was no other wounds assessed. Surveyor reviewed RN-D Skin Impairment/Wound Form with a date of 3/22/21. Documented was assessments of the left upper arm abrasion and left elbow abrasion. There is no assessment by the wound nurse for the boggy heel as stated in the Admission Data Collection. Surveyor reviewed Wound MD-J's Initial Wound Evaluation & Management Summary with a date of 3/22/21. Documented were assessments of the left elbow wound and IAD on buttocks. There is no assessment of the left heel. Surveyor reviewed R2's MDS admission assessment with an assessment reference date of 3/23/21. Documented under Cognition was a BIMS score of 09 which indicated moderately impaired. Documented under Functional Status for Bed Mobility was 2/2 which indicated Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance; One person physical assist. Documented under Functional Status for Transfer was 2/2 which indicated Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance; One person physical assist. Documented under Bowel and Bladder was Urinary Incontinence 1. Occasionally incontinent and Bowel Incontinence 1. Occasionally incontinent. Documented under Skin Conditions was Is this resident at risk of developing pressure ulcers/injuries? 1. Yes and Does this resident have one or more unhealed pressure ulcers/injuries? 0. No. Surveyor reviewed R2's Care Area Assessment (CAA) related to Pressure Ulcer/Injury with an assessment date of 3/23/21. Documented under Nature of the Problem/Condition was [R2] is a new admit to this facility for a short term rehab stay following a hospitalization for [CONDITION(S)], CHF, Acute kidney disease with [CONDITION(S)]. He is alert and orientated and easy to make conversation and his needs known. He is at risk for pressure ulcers due to decreased mobility and debility. No pressure injury noted, on a pressure reducing mattress and cushion and assisted in bed mobility by staff. Staff will continue to provide preventative cares, assist in repositioning. IDT will proceed to care planning. Surveyor reviewed R2's Comprehensive Care Plan with a revision date of 3/24/21. Documented interventions that were added was Provide treatment per MD orders. Left heel treatment. Blue boots to [bilateral lower extremities (BLE)] when in bed. Implement pressure reducing devices i.e. w/c cushion, air-mattress, off-loading heels, etc. Keep skin clean and dry. Use lotion on dry skin. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. The blue boots were not added to MD orders until 3/26/21. Surveyor reviewed R2's Braden Scale for Predicting Pressure Sore Risk with a date of 3/25/21. Documented was Braden Risk Scale Score: 21 which indicated not at risk for pressure injuries. This contradicted the admission assessment of multiple open areas and bruising and multiple co-morbidities putting R2 at risk. Surveyor reviewed R2's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Documented was Addition to previous progress note: Open blister/wound noted on [left (L)] heel with small amount of serosanguinous drainage. Pt not aware of wound. Nurse notified. Wound care already following, but order placed for them to reassess. Keep area clean and dry. Highly recommend nursing staff to offload heels with pillows to prevent any further injury. Surveyor reviewed MD orders for R2. Documented with a start date of 3/26/21 was Apply blue boots to bilateral feet every shift to prevent skin breakdown and Offload pressure points, especially bilateral heels, with pillows every shift. These interventions were not put in place until the 3/28/21 when a treatment was first started as well. On 5/5/21 at 9:59 AM Surveyor interviewed NP-K. Surveyor asked who informed her of the heel wound. NP-K stated I found it when I was assessing his leg [CONDITION(S)]. NP-K stated there was blood on the bed from his left heel so she lifted his leg and noted the open blister to his left heel. NP-K stated there was a rolled up bandage just above the wound stuck to R2's ankle. NP-K stated she informed RN-G about the wound and asked that the Wound RN follow-up. Surveyor asked if R2's heels were floated or any device was on the bed to protect them. NP-K stated no, his heels were laying on the mattress. Surveyor reviewed R2's Skin Impairment/Wound Form with a date of 3/26/21 documented by RN-G. Documented was 1b. Stage of pressure injury: b. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis . 1c. Measurement of Wound (L x W x D): 6cm x 3 cm (Estimated) . 3. Barriers to wound healing: Rubbing against sheets, shoes, feet rubbing against foot board. Current Wound/Skin Treatment/Interventions: DSD applied. Have wound MD and RN see resident. Blue boots to protect skin. Wound Education provided: Explained what I was doing to resident Wound MD to see resident. Surveyor reviewed R2's Skin Impairment/Wound Form with a date of 3/29/21 documented by Wound RN-D. Documented was 1b. Stage of pressure injury: e. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss . 1c. Measurement of Wound (L x W x D): 6 x 5 x 0.1 cm . 3. Wound tissue bed: Indicate the percentage of each type of tissue type present in the wound bed: 40% epithelial, 60% eschar. On 5/5/21 at 10:23 AM Surveyor interviewed Wound RN-D. Surveyor asked if he was aware of the wound to R2's left heel prior than his assessment date of 3/29/21. Wound RN-D stated he did not remember. Surveyor asked why he did not assess the wound on 3/26/21. Wound RN-D stated that was his weekend off and he would have assessed it that Monday when he was doing wound rounds with MD-J. Surveyor reviewed Wound MD-J's Wound Evaluation & Management Summary with a date of 3/29/21. Documented was Unstageable (Due to Necrosis) of the Left Heel. Etiology (quality): Pressure . Wound Size (L x W x D): 6 x 5 x 0.1 cm . Thick adherent black necrotic tissue (eschar): 60%. Wound MD-J used Surgical Excisional Debridement Procedure during this visit to remove necrotic tissue and establish the margins of viable tissue. Surveyor reviewed R2's Skin Impairment/Wound Form with a date of 4/5/21 documented by Wound RN-D. Documented was 1b. Stage of pressure injury: e. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss . 1c. Measurement of Wound (L x W x D): 6 x 5 cm . 3. Wound tissue bed: Indicate the percentage of each type of tissue type present in the wound bed: 100% eschar. Surveyor reviewed Wound MD-J's Wound Evaluation & Management Summary with a date of 4/5/21. Documented was Unstageable (Due to Necrosis) of the Left Heel. Etiology (quality): Pressure . Wound Size (L x W x D): 6 x 5 x 0.1 cm . Thick adherent black necrotic tissue (eschar): 100%. Wound progress: No Change . Wound MD-J used Surgical Excisional Debridement Procedure during this visit to remove necrotic tissue and establish the margins of viable tissue. The wound remained unchanged through R2's discharge on 4/12/21. 3. R6 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress notes on 1/29/21 at 6:22 pm document Resident was hospitalized d/t [due to] weakness and admitted to facility for rehab. Other Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . BLE [bilateral lower extremity] leg pain, [CONDITION(S)] [hypertension], dementia, diastolic HF [heart failure]. A progress note on 1/29/21 at 6:35 pm documents .No a/o's [open areas] present. A Braden Scale for Predicting Pressure Sore Risk, completed on 1/29/21 by LPN (licensed practical nurse) -E on 1/29/21, scores R6 at 16 indicating R6 is at risk for the development of pressure injuries. A Braden Scale for Predicting Pressure Sore Risk, completed on 2/9/21 by LPN-E, scores R6 as a 13 indicating R6 has increased risk for pressure injuries from the previous assessment on 1/29/21 and is now considered moderate risk for pressure injuries. A Minimum Data Set Assessment, with an assessment reference date of 2/5/21 documents R6 required extensive assistance of two plus persons for bed mobility, was at risk for the development of pressure injuries, and had no pressure injuries. R6's Admission Data Collection and Baseline Care Plan Tool, signed by DON (Director of Nursing)-B on 2/17/21, documents under Skin Condition Check all that apply: Surveyor noted options of: Reddened, Pale, Jaundiced, Cyanotic, Ashen, Dry, Moist, Warm, Cold, [CONDITION(S)], None of the above. The form is blank with nothing checked, including none of the above. The form is also blank under Skin Integrity Planning, with the focus area for the resident has potential/actual impairment to skin integrity not checked or interventions to prevent skin impairment not checked. Review of R6's baseline plan of care does not include interventions to prevent pressure injuries. On 5/5/21 at 11:33 am the surveyor interviewed DON-B. The surveyor asked how a baseline care plan is developed. DON-B stated the initial assessment (the Admission Data Collection and Baseline Care Plan Tool) is completed that triggers the initial care plan. The surveyor asked how someone would trigger skin for a baseline care plan. DON-B stated it is part of the assessment tool, if the Braden is indicating at risk, a care pla should be developed indicating the resient is at risk. DON-B stated she has been telling nurses there should be pain, skin, falls, and activities of daily living care plans on all new admission. DON-B stated he basic feeling is everyone is at risk for skin issues if there, as they generally have mobility issues. The surveyor informed DON-B of being able to find a baseline care plan for skin integrity for R6. DON-B reviewed R6's plan of care and confirmed being able to find one. On 2/16/21 progress notes document Resident noted a blister of 6 cm length x 4 cm width to inner side of R [right] heel; with pink skin surrounding; no drainage noted; MD notified: new orders apply skin prep to bilateral heels Bid [twice a day] x 14 days and blue boots. An assessment of the wound on 2/16/21 inaccurately stages the wound as a stage 1 pressure injury, despite the wound being documented as a blister. On 2/17/21 R6's plan of care was updated to include a focus are related to The resident has actual impairment to skin integrity r/t [related to] fragile skin. 2/16/21 has blister noted to right heel. Interventions put into place on 2/17/21 include Provide pressure relieving device(s): bilateral blue boots. The surveyor noted R6 did not a have a plan of care in place prior to 2/17/21 to prevent the development of pressure injuries. On 2/22/21 R6 was seen by Wound Physician-J. The wound physician documents R6 as having a 6 x 5 x not measurable unstageable deep tissue injury to the right heel. The wound was continued to be assessed weekly by Wound Physician-J. On 3/8/21 the wound was noted to be 6 x 5 x not measurable with 100% black necrotic tissue (eschar). On 3/15/21 the wound is documented as being unstageable due to necrosis, 4 x 4 x not measurable with 10% slough, 10% granulation tissue and 80% skin. On 3/29/21 the wound is documented as having deteriorated, documented as being unstageable due to necrosis 3 x 3 x 0/1cm with 100% slough. The wound was continued to be assessed weekly by Wound Physician-J. On 5/3/21/ the wound is documented as being 6 x 6 with 100% eschar. On 5/5/21 at 12:50 pm the surveyor observed Wound RN (registered nurse)-D perform R6's treatment to the right heel. The surveyor observed R6's wound to be black with slough noted. The surveyor observed R6 yell out during the treatment and indicate that it hurt. Following the treatment the surveyor asked Wound RN-D if R6 had received any pain medication prior to the treatment. Wound RN-D stated no, that he did not believe R6 had any orders to be pre-medicated prior to the treatment.

Based on interview and record review the facility did not ensure 1 (R56) of 1 residents receiving [MEDICAL TREATMENT] received the necessary fistula care and treatment from facility nursing staff. On [DATE], R56 had a ruptured fistula and the nursing staff did not have the necessary competency to address R56's ruptured fistula; as a result R56 expired at the facility. The facility's failure to have competent nursing staff to respond to the emergency of a ruptured fistula, created a finding of immediate jeopardy that began [DATE]. Surveyor notified NHA (nursing home administrator) A of the immediate jeopardy on [DATE] at 2:15 p.m. The immediate jeopardy was removed on [DATE]. However the deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. As of [DATE] the facility identified 8 residents presently in the facility with either a fistula or a picc line (R13, R64, R65, R66, R67, R68, R69 and R70). Findings include: R56 was admitted to the facility on [DATE] for rehabilitation following pneumonia. R56 was admitted with [DIAGNOSES REDACTED]. The medical record indicates R56 was alert and able to make his needs known. The hospital discharge summary dated [DATE] (R56 discharge date was [DATE]) indicates R56 had several episodes of bleeding from fistula post [MEDICAL TREATMENT], one requiring General Surgery evaluation. Fistulagram .performed and without evidence of abnormality. The nurses note dated [DATE] at 11:00 a.m. indicates after R56 had a shower the staff noted bleeding noted from fistula left upper arm. Pressure applied and bleeding stopped. The nurses note does not indicate how long R56 fistula was bleeding. R56 [MEDICAL TREATMENT] care plan dated [DATE] indicates R56 received [MEDICAL TREATMENT] and to monitor for s/s (signs/symptoms) of [MEDICAL TREATMENT] complications: [MEDICAL CONDITION], decrease cardiac output, irregular pulse, systemic infection. It also indicates protect shunt site from injury and note fistula site for bruit and thrill. The care plan was not updated to include R56 spontaneous fistula bleeding episode on [DATE] or having a history of spontaneous bleeding from the fistula while at the hospital. The care plan does not indicate what should be done if the fistula starts to bleed. The nurses notes indicate on [DATE] around 2:15 a.m. R56 experienced bleeding from the [MEDICAL TREATMENT] fistula on the left forearm. The facility investigation indicates staff applied direct pressure onto the fistula to help stop the bleeding and also called 911. R56 expired at the facility. Cause of death was listed as uncontrolled bleeding. (Cross reference F684.) Interviews confirm that staff (CNA XXX) first responded to a call for help around 2:00 AM; staff did not call 911 until 2:24 AM. On [DATE] at 1:30 p.m. Surveyor interviewed CNA (certified nursing assistant) XXX regarding R56 incident on [DATE]. CNA XXX stated she was in a room assisting a resident when she heard someone call for help. CNA XXX stated she went out to hall and heard R56 call out. CNA XXX stated she went into R56 bathroom and saw R56 sitting on the toilet and he was bleeding. CNA XXX stated at first she trying to find where the bleeding was coming from and saw it was from R56 fistula site. On [DATE] at 12:36 p.m. Surveyor interviewed CNA XXX for clarification regarding the [DATE] interview. CNA XXX stated she was never trained for this type of emergency. CNA XXX stated she was never trained on fistula care or the care and treatment of [REDACTED]. On [DATE] at 3:05 p.m. Surveyor interviewed RN VVV regarding R56 incident on [DATE]. RN VVV stated she was on break and was in her car when a CNA alerted her to the situation with R56 bleeding. RN VVV stated she went to R56 room and saw CNA XXX and RN Supervisor TTT with R56. RN VVV stated RN Supervisor TTT was applying pressure to R56 fistula site and LPN KKK was on the phone with the 911 operator telling the 911 operator when R56 was breathing. Surveyor asked RN VVV if she received any training regarding the care and treatment of [REDACTED]. On [DATE] at 10:15 a.m. Surveyor interviewed RN Supervisor TTT regarding R56 incident on [DATE]. RN Supervisor TTT stated she was on the 2 south unit dealing with an issue when she was notified R56 was bleeding and CNA XXX needed assistance. RN Supervisor TTT stated when she arrived at R56 room she observed CNA XXX applying pressure to R56 fistula site. RN Supervisor TTT stated she did not receive any training regarding [MEDICAL TREATMENT] resident's fistulas but know if it's bleeding you need to apply pressure to stop the bleeding. RN Supervisor TTT stated the R56 fistula just would not stop bleeding even with pressure. On [DATE] at 10:35 a.m. Surveyor interviewed LPN KKK regarding R56 incident on [DATE]. LPN KKK stated she was on the 2 south unit with RN Supervisor TTT when she was made aware of R56 bleeding. LPN KKK stated she went to R56 room. LPN KKK stated when she got to R56 room RN Supervisor TTT was there applying pressure and talking with the 911 operator. LPN KKK then took over talking with the 911 operator. LPN KKK stated she did not receive any training but is aware to apply pressure to stop the bleeding. On [DATE] at 12:45 p.m. Surveyor interviewed CNA ZZZ regarding the [DATE] incident with R56. CNA ZZZ stated she was working on the first floor and heard CNA XXX ask for help. CNA ZZZ told CNA XXX that she needed to call RN CNA ZZZ stated she did not have any training regarding fistula care or what to do when a fistula ruptures. On [DATE] at 9:50 a.m. Surveyor asked NHA A for a policy and procedure regarding the care and treatment of [REDACTED]. On [DATE] at 11:10 a.m. Surveyor interviewed Interim DON (director of nursing) LLL regarding R56 incident on [DATE]. Surveyor asked Interim DON LLL if there is any documentation regarding training nursing may have received on residents receiving [MEDICAL TREATMENT] regarding the care and treatment and the care of fistulas and other [MEDICAL TREATMENT] access. Interim DON LLL stated she is looking for any training. On [DATE] at 1:35 p.m. Surveyor interviewed Davita [MEDICAL TREATMENT] Clinical Coordinator WWW regarding R56. Davita [MEDICAL TREATMENT] Clinical Coordinator WWW stated R56 received [MEDICAL TREATMENT] the afternoon of [DATE] and there wasn't anything unusual with R56 fistula or the [MEDICAL TREATMENT] treatment. Davita [MEDICAL TREATMENT] Clinical Coordinator WWW also stated R56 did not receive any [MEDICATION NAME] or blood thinners. Surveyor asked Davita [MEDICAL TREATMENT] Clinical Coordinator WWW if any training was provided to the facility nursing staff regarding the care and treatment of [REDACTED]. Davita [MEDICAL TREATMENT] Clinical Coordinator WWW stated the [MEDICAL TREATMENT] center did not provide any training and any training would be provided by the facility. On [DATE] at 3:00 p.m. Surveyor explained to NHA (nursing home administrator) A the concern the facility staff have not been trained to care for the access sites for [MEDICAL TREATMENT] residents. Surveyor also explained the concern of the facility not having a policy and procedure regarding residents receiving [MEDICAL TREATMENT] and the care and treatment of [REDACTED]. On [DATE] Surveyor received an email from Interim DON LLL which indicated R56 had to have first aid due to the [DATE] fistula bleeding episode. Interim DON LLL stated R56 was bleeding for 10 minutes. Interim DON LLL also stated the facility does not provide any care or treatment to fistula sites unless it is first aid to stop bleeding. On [DATE] at 12:50 p.m. Surveyor explained to NHA A and Interim DON LLL the new concerns Surveyor explained CNA XXX indicates she found R56 around 2:00 a.m. and left R56 bleeding, because she could not locate the bleeding, to call for help. CNA XXX did not express the emergent nature of bleeding to any staff. CNA XXX did not provide immediate assistance to stop the bleeding. The RN Supervisor TTT was not aware R56 was bleeding from a fistula and thought it was a picc line. The nursing staff were not educated and aware on ways to stop a bleeding fistula. The nursing staff stated they only provided pressure, using a towel, onto the site but no other methods of first aid were provided. On [DATE] Surveyor reviewed the recording of the 911 call from the incident. Surveyor noted the call was submitted at 2:24 am. Surveyor noted this was approximately 24 minutes after CNA-XXX indicates she first hears R56 calling out for help and observed bleeding. Review of the call indicates staff was quite panicked and not at all prepared for the situation involving R56. The initial nurse on the call indicates she had no idea what happened, that there was blood everywhere and R56 was sitting on the toilet. She kept repeating he needs to go now. When asked if R56 was conscious the nurse is heard calling out the resident's name and indicated at the request of the operator that R56 was occasionally breathing with a light pulse. When asked by the operator about the bleeding: What was it? Where from? The nurse did not know, she stated it was from a picc line. At this time the phone is handed off to a second nurse who repeats she thinks R56 pulled out his picc line, you know, brachial to the heart. When asked for details about R56, staff was not able to convey details including approximate age etc. Staff was heard in the background and stating directly to the 911 operator that they did not know R56, did not know anything about him. Surveyor noted while listening to the call staff were very panicked. During the call the 911 operator told the nurse they were going to do a breathing detector because staff could not convey whether R56 was breathing or not. The 911 operator told staff to tell them each time R56 takes a breath - start now - staff was not able to onsisitently communicate to the operator the status of R56's breathing. During the call staff did eventually state R56 was not breathing and had no pulse. The 911 operator is heard telling the nurse to get R56 on to the floor. Staff is heard stating there is a lot of blood . The 911 operator asked staff again about the source of the blood, was it a catheter? The nurse on the phone is heard asking RN-TTT by name is it a fistula? You can hear RN-TTT say she knows nothing about him (R56). Surveyor noted RN-TTT was the house nurse supervisor for that night. When asked if they had placed R56 flat staff communicated no, that he was still on the toilet. Breathing? Kind of . The operator again tells staff they need to get him flat on the floor. Staff tells her they are working on it, that they cannot lift him. When asked by the operator can you lift by the arms it is relayed that they do not know how to do it, can't lift him. Staff again is heard repeating they need help. Surveyor noted upon finishing review of the call that staff did not appear prepared to deal with the type of emergency that R56 presented to staff. Staff was panicked and unable to carry out emergency steps presented by 911 until first responders arrived to help save R56. The failure to have adequately trained and competent staff to care for emergent situations with resident who have a [MEDICAL TREATMENT] access, created a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when it implemented the following plan: Actions taken for the 8 residents identified to be receiving [MEDICAL TREATMENT] and having an A/V fistula in place: ~ Each Resident's Care plan and Care Card were reviewed and revised by Nurse Managers to reflect their current needs. Examples of the current needs may be the access type, the [MEDICAL TREATMENT] center, the days [MEDICAL TREATMENT] is performed, monitoring of the site for complications and infection, an emergency contact number for [MEDICAL TREATMENT] center, and notification of the physician with any changes in condition. ~ Care plans will be individualized to include any past history of significant complications or risk factors unique to the resident. ~ Each Resident was added to the 24 hour report to ensure that resident's condition is monitored on each shift. Each Resident will remain on the 24 hour report for the duration of their stay at Brookfield Rehab and Specialty Care. ~ Bruit and Thrill were checked and recorded in the resident record. Any abnormal results were communicated to the Resident's Physician and responsible party. ~ All Fistulas and Central Venous Catheters were visually inspected to ensure that no abnormalities were present. ~ All Resident records were reviewed and it was determined that there were no additional residents who had the potential to be affected by this deficient practice. ~ Staff Development Coordinator conducted education for all nursing staff on Facility's policy on [MEDICAL TREATMENT] Care. The education includes: -Facility responsibilities for caring for a [MEDICAL TREATMENT] patient -[MEDICAL TREATMENT] Center's responsibilities for caring for a [MEDICAL TREATMENT] patient -Fistula Care -Central Venous Catheter Care -Bruit and Thrill (Licensed Nurses) -What to do when a fistula is bleeding -Emergency First Aid -Code Blue and Emergency Response Policy & Procedures ~ Facility has developed a [MEDICAL TREATMENT] competency program. All nursing staff will be required to complete the competency program until 100% compliance is achieved. Competencies to include: -Facility responsibilities for caring for a [MEDICAL TREATMENT] patient -Fistula Care -Central Venous Catheter Care -Bruit and Thrill (Licensed Nurses) -What to do when a fistula is bleeding -Emergency First Aid -Code Blue and Emergency Response Policy & Procedures ~ Individualized [MEDICAL TREATMENT] competencies will be performed by all nursing staff and CNAs upon hire, annually, and as needed, in accordance with facility assessment. ~ Facility assessment of needs was completed for availability of emergency equipment. Facility inspected emergency equipment and determined it was adequate and readily available for quick retrieval by staff. ~ An ad-hoc performance improvement meeting was conducted with facility staff and [MEDICAL TREATMENT] director to determine what emergency supplies will be maintained in individual [MEDICAL TREATMENT] resident rooms. This protocol will be followed for any future [MEDICAL TREATMENT] residents. ~ Bruit and Thrill will be checked every shift, and recorded in the resident record. Any abnormal results will be communicated to the Resident's Physician and responsible party. ~ A [MEDICAL TREATMENT] communication form will be developed and will include facility and [MEDICAL TREATMENT] center's pre and post [MEDICAL TREATMENT] responsibilities. ~ Any new potential admissions will be screened using the facility assessment tool as a guide for appropriateness of placement. No residents will be admitted unless staff is fully trained and competent to care for their specific conditions. ~ DON, or designee, will educate staff of appropriate staffing coverage during breaks. DON will be responsible for monitoring appropriate staffing coverage. ~ DNS and/or Nurse Managers will meet weekly with [MEDICAL TREATMENT] staff to ensure that systemic changes are being followed and remain appropriate. DNS or designee will modify systemic changes as deemed appropriate. ~ Weekly, the DNS will meet with Administrator and leadership to determine the effectiveness this plan. The deficient practice continues at a scope and severity of an E (potential for harm/pattern) as the facility continues to implement their action plan and ensures the proper care of the 8 residents (R13, R64, R65, R66, R67, R68, R69 and R70) currently residing in the facility with either a fistula or catheter port

Based upon interview and record review the facility did not ensure 1 (R56) of 1 residents reviewed for [MEDICAL TREATMENT] fistula care received the necessary care and services for the fistula. R56 had a [MEDICAL TREATMENT] fistula that sustained a rupture and the nursing staff did not provide prompt emergency care, had no training for the care and treatment of [REDACTED]. The facility also did not have a policy and procedure that instructed the facility staff on the care and treatment of [REDACTED]. The facility's failure to promptly care for R56's ruptured fistula, adequately train staff to care for emergent situations with resident who have a [MEDICAL TREATMENT] access, to update the care plan based on previous history of spontaneous bleeding from the fistula and have policies and procedures that address the care and treatment of [REDACTED]. Surveyor notified NHA (nursing home administrator) A of the immediate jeopardy on [DATE] at 2:15 p.m. The immediate jeopardy was removed on [DATE]. However the deficient practice continues at a scope/severity of E (potential for harm/pattern) as the facility continues to implement its action plan. As of [DATE] the facility identified 8 residents presently in the facility with either a fistula or a picc line (R13, R64, R65, R66, R67, R68, R69 and R70). Findings include: R56 was admitted to the facility on [DATE] for rehabilitation following pneumonia. R56 was admitted with [DIAGNOSES REDACTED]. The medical record indicates R56 was alert and able to make his needs known. The hospital discharge summary dated [DATE] (R56's discharge date was [DATE]) indicates R56 had several episodes of bleeding from fistula post [MEDICAL TREATMENT], one requiring General Surgery evaluation. Fistulagram .performed and without evidence of abnormality. Surveyor noted upon review of R56's medical record no immediate plan of care was developed for R56. The nurse's note dated [DATE] at 11:00 a.m. indicates after R56 had a shower the staff noted bleeding noted from fistula left upper arm. Pressure applied and bleeding stopped. The nurse's note does not indicate how long R56's fistula was bleeding. R56's [MEDICAL TREATMENT] care plan dated [DATE] indicates R56 received [MEDICAL TREATMENT] and to monitor for s/s (signs/symptoms) of [MEDICAL TREATMENT] complications: [MEDICAL CONDITION], decrease cardiac output, irregular pulse, systemic infection. It also indicates protect shunt site from injury and note fistula site for bruit and thrill. The care plan was not updated to include R56's spontaneous fistula bleeding episode on [DATE] or having a history of spontaneous bleeding from the fistula while at the hospital. The care plan does not indicate what should be done if the fistula starts to bleed. The nurse's notes indicated on [DATE] around 2:15 a.m. R56 experienced bleeding from the [MEDICAL TREATMENT] fistula on the left forearm. The facility investigation indicates staff applied direct pressure onto the fistula to help stop the bleeding and also called 911. R56 expired at the facility. The facility self-report indicated R56 was discovered at 2:15 a.m. bleeding from the fistula and the medical examiner arrived on scene and pronounced at approximately 2:30 a.m. On [DATE] at 1:30 p.m. Surveyor interviewed CNA (certified nursing assistant) XXX regarding R56's incident on [DATE]. CNA XXX stated she was in a room assisting a resident when she heard someone call for help. CNA XXX stated she went out to hall and heard R56 call out. CNA XXX stated she went into R56's bathroom and saw R56 sitting on the toilet and he was bleeding. CNA XXX stated at first she was trying to find where the bleeding was coming from and saw it was from R56 fistula site. CNA XXX stated she applied pressure and called for another CNA to assist her. CNA XXX stated the other CNA called the RN (registered nurse) upstairs to come down to assist CNA XXX with R56 bleeding fistula. CNA XXX stated RN Supervisor TTT came down to the unit within a couple minutes and assisted in applying pressure to the fistula. CNA XXX stated RN Supervisor TTT was also calling 911 and was receiving instruction from the 911 operator. CNA XXX stated R56 was still breathing when the police arrived. CNA XXX stated the police and paramedics arrived around the same time. CNA XXX stated R56 was capable of ambulating to the bathroom on his own and was alert and able to make his needs know. CNA XXX stated she went in to R56 room around 1:00 a.m. to assist R56 to the bathroom or assist with the urinal and R56 stated he didn't want to be bothered. On [DATE] at 12:36 p.m. Surveyor interviewed CNA XXX for clarification regarding the [DATE] interview. CNA XXX stated she heard R56 yelling out around 2:00 a.m CNA XXX explained when she saw R56 on the toilet, CNA XXX could not identify where the bleeding was coming from. CNA XXX stated she went in the hall and yelled for help. CNA XXX stated CNA ZZZ instructed CNA XXX to call upstairs to speak with RN Supervisor TTT because RN VVV was on break. CNA XXX then called upstairs and LPN (licensed practical nurse) KKK answered the phone. CNA XXX told LPN KKK she needed to talk with RN Supervisor TTT. CNA XXX stated she told RN Supervisor TTT that R56 was on the toilet bleeding. CNA XXX stated she then went to R56 room and found where the bleeding was coming from and took a towel to hold pressure on the site. CNA XXX stated within a few minutes RN Supervisor TTT arrived to R56 room and took over holding pressure. CNA XXX stated she had never experienced this kind of emergency. CNA XXX stated she was never trained on fistula care or the care and treatment of [REDACTED]. On [DATE] at 3:05 p.m. Surveyor interviewed RN VVV regarding R56 incident on [DATE]. RN VVV stated she was on break and was in her car when a CNA alerted her to the situation with R56 bleeding. RN VVV stated she went to R56 room and saw CNA XXX and RN Supervisor TTT with R56. RN VVV stated RN Supervisor TTT was applying pressure to R56 fistula site and LPN KKK was on the phone with the 911 operator telling the 911 operator when R56 was breathing. When RN VVV was in the room, LPN KKK handed the phone to RN VVV to continue talking with the 911 operator while LPN KKK went to the front to let the police in the building. RN VVV stated the 911 operator instructed the staff to assist R56 off the toilet and onto the floor but RN VVV stated R56 was dead weight and it was unsafe to move R56 because the floor was so slippery with blood and the staff couldn't get a good grip to get him on the floor. RN VVV stated R56 was still breathing but very sporadic breathing, when the police arrived. Surveyor asked RN VVV if she received any training regarding the care and treatment of [REDACTED]. On [DATE] at 10:08 a.m. Surveyor interviewed RN VVV regarding some clarification needed from the [DATE] interview. RN VVV stated she went on break around 2:00 a.m. and around 2:15 a.m.-2:20 a.m. CNA ZZZ told RN VVV she was needed in R56's room. RN VVV stated when she arrived to R56 room, RN Supervisor TTT was holding pressure on R56's site. On [DATE] at 10:15 a.m. Surveyor interviewed RN Supervisor TTT regarding R56's incident on [DATE]. RN Supervisor TTT stated she was on the 2 south unit dealing with an issue when she was notified R56 was bleeding and CNA XXX needed assistance. RN Supervisor TTT stated when she arrived at R56 room she observed CNA XXX applying pressure to R56 fistula site. RN Supervisor TTT instructed a different CNA to get the crash cart and at the same time LPN KKK came in the room and RN Supervisor TTT instructed LPN KKK to call 911. RN Supervisor TTT stated constant pressure was being applied to R56 fistula site. RN Supervisor TTT stated about a few minutes after the 911 call was made the police arrived. RN Supervisor TTT stated the 911 operator instructed the staff to assist R56 off the toilet and onto the floor. RN Supervisor TTT stated the staff were unable to safely move R56 onto the floor. RN Supervisor TTT stated when the police arrived, the police were able, with much difficulty, move R56 onto the floor. RN Supervisor TTT stated she did not receive any training regarding [MEDICAL TREATMENT] resident's fistulas but know if it's bleeding you need to apply pressure to stop the bleeding. RN Supervisor TTT stated that R56's fistula just would not stop bleeding even with pressure. On [DATE] at 8:50 a.m. Surveyor interviewed RN Supervisor TTT regarding clarification needed from interview on [DATE]. Supervisor TTT stated she was the nurse for 2 EW (east/west) and 1 east, she was also responsible for fire watch due to the pipes freezing which affected the sprinkler system. RN Supervisor TTT stated she had just completed the 2:00 a.m. fire watch walk thru and was on 2 south with LPN KKK and the CNAs on that unit dealing with personnel issues. RN Supervisor TTT stated the phone rang and LPN KKK answered the phone. RN Supervisor TTT stated LPN KKK stated CNA XXX was on the phone. RN Supervisor TTT stated when she finished talking with the CNAs and she then went to pick up the phone. RN Supervisor TTT stated there was no one on the line so she hung up. RN Supervisor TTT stated as soon as she hung up, the phone rang so she picked up the phone and CNA XXX was on the line telling her R56 was on the toilet bleeding. RN Supervisor TTT stated this phone call occurred around 2:15 a.m., because she was getting ready to do another fire walk thru, she then went downstairs to R56's room. RN Supervisor TTT stated when she went in R56's room she noticed CNA XXX applying pressure to R56's left upper arm. RN Supervisor TTT stated she thought R56 pulled out a picc line and didn't know R56 had a fistula until RN VVV arrived on the scene and stated it was not a picc line but a fistula site. RN Supervisor TTT stated she started calling out for someone to get the code cart, a phone and R56's chart. RN Supervisor TTT stated she is not sure who got her these items but when she received the phone she called 911. RN Supervisor TTT stated the code cart is not a crash cart. The only items on the cart is the back board, treatment type items and oxygen. RN Supervisor TTT stated there weren't any items on the cart that could assist to stop the bleeding, such as a tourniquet. RN Supervisor TTT stated she has been a nurse for [AGE] years and at the facility for 2 years. On [DATE] at 10:35 a.m. Surveyor interviewed LPN KKK regarding R56's incident on [DATE]. LPN KKK stated she was on the 2 south unit with RN Supervisor TTT when she was made aware of R56's bleeding. LPN KKK stated she went to R56 room. LPN KKK stated when she got to R56's room RN Supervisor TTT was there applying pressure and talking with the 911 operator. LPN KKK then took over talking with the 911 operator. LPN KKK stated she was informing the 911 operator when R56 was breathing and that R56 still had a pulse. LPN KKK stated she went to the front to open the door for the police and showed them to R56's room. LPN KKK stated she opened the door to let the paramedic in and showed them to R56's room. LPN KKK stated she did not receive any training but is aware to apply pressure to stop the bleeding. On [DATE] at 9:58 a.m. Surveyor interviewed LPN KKK regarding clarification needed from [DATE] interview. LPN KKK stated on [DATE], not sure of time, CNA XXX called upstairs and stated she needed to talk with RN Supervisor TTT. LPN KKK stated CNA XXX did not state why she needed to talk with RN Supervisor TTT. LPN KKK stated she informed RN Supervisor TTT of the phone call then went to attend to a resident receiving tube feeding. LPN KKK stated she when she was done with the resident she came out and RN Supervisor TTT was no longer at the nurses station. LPN KKK stated maybe five minutes later she received a phone call from a CNA (not sure which CNA) telling her RN Supervisor TTT needs her in R56's room. LPN KKK stated she was not aware of the emergency with R56 until she arrived at R56's room. LPN KKK stated RN Supervisor TTT was on the phone with 911 when LPN KKK arrived to R56's room On [DATE] at 9:50 a.m. Surveyor asked NHA A for a policy and procedure regarding the care and treatment of [REDACTED]. On [DATE] at 11:10 a.m. Surveyor interviewed Interim DON (Director of Nursing) LLL regarding R56's incident on [DATE]. Surveyor asked Interim DON LLL if there is any documentation regarding training nursing may have received on residents receiving [MEDICAL TREATMENT] regarding the care and treatment and the care of fistulas and other [MEDICAL TREATMENT] access. Interim DON LLL stated she is looking for any training. On [DATE] at 1:35 p.m. Surveyor interviewed Davita [MEDICAL TREATMENT] Clinical Coordinator WWW regarding R56. (Davita is the clinic R56 received [MEDICAL TREATMENT] services at.) Davita [MEDICAL TREATMENT] Clinical Coordinator WWW stated R56 received [MEDICAL TREATMENT] the afternoon of [DATE] and there wasn't anything unusual with R56's fistula or the [MEDICAL TREATMENT] treatment. Davita [MEDICAL TREATMENT] Clinical Coordinator WWW also stated R56 did not receive any [MEDICATION NAME] or blood thinners. Surveyor asked Davita [MEDICAL TREATMENT] Clinical Coordinator WWW if any training was provided to the facility nursing staff regarding the care and treatment of [REDACTED]. Davita [MEDICAL TREATMENT] Clinical Coordinator WWW stated the [MEDICAL TREATMENT] center did not provide any training and any training would be provided by the facility. On [DATE] at 3:00 p.m. Surveyor explained to NHA (Nursing Home Administrator) A the concern that facility staff have not been trained to care for the access sites for [MEDICAL TREATMENT] residents. Surveyor also explained the concern of the facility not having a policy and procedure regarding residents receiving [MEDICAL TREATMENT] and the care and treatment of [REDACTED]. On [DATE] the facility provided additional information. The facility provided a policy and procedure [MEDICAL TREATMENT] Guidelines with a date of [DATE]. This policy and procedure explains how the facility staff can do [MEDICAL TREATMENT] at the bedside. This facility does not conduct [MEDICAL TREATMENT] at the bedside. All residents receiving [MEDICAL TREATMENT] are sent to an independent [MEDICAL TREATMENT] center. This policy and procedure does not explain how the facility staff care for [MEDICAL TREATMENT] residents [MEDICAL TREATMENT] and the care and treatment needed for those residents. On [DATE] Surveyor received an email from Interim DON LLL which indicated R56 had to have first aid due to the [DATE] fistula bleeding episode. Interim DON LLL stated R56 was bleeding for 10 minutes. Interim DON LLL also stated the facility does not provide any care or treatment to fistula sites unless it is first aid to stop bleeding. On [DATE] at 3:34 p.m. Surveyor received a phone call from Police Detective AAAA regarding R56's incident on [DATE]. Detective AAAA stated the police officer's report indicated R56 was found at 2:00 a.m. bleeding from the fistula site and the 911 call was placed at 2:24 a.m. and the police officers arrived to the facility about seven and half minutes later. Detective AAAA stated she was concerned with the timeline and the fact the facility staff appears to not have acted promptly to the emergency and not aware what needed to be done. This new information from Detective AAAA prompted Surveyor to reinterview the staff involved with R56's [DATE] incident. On [DATE] at 9:44 a.m. Interim DON LLL gave Surveyor the crash cart checklist. The items in the crash cart consist of a cardiac board, E-Cylinder, tank tag, regulator, xmas tree for O2 (oxygen), ambu-bag, non-rebreather mask, nasal cannula, box of gloves, box of masks, isolation gowns, stethoscope, b/p (blood pressure) cuff, suction machine, tubing for machine, [MEDICATION NAME] and pen and notebook. On [DATE] at 12:45 p.m. Surveyor interviewed CNA ZZZ regarding the [DATE] incident with R56. CNA ZZZ stated she was working on the first floor and heard CNA XXX ask for help. CNA ZZZ told CNA XXX that she needed to call RN Supervisor TTT upstairs because RN VVV was on break. CNA ZZZ stated she couldn't leave her unit because there was no other staff on her unit. CNA ZZZ stated later, RN Supervisor TTT instructed CNA ZZZ to get RN VVV from break. CNA ZZZ stated the only other duty she assisted with was trying to assist R56 off the toilet but they were unable to get R56 off the toilet and the police arrived, who assisted R56 off the toilet. On [DATE] at 12:50 p.m. Surveyor explained to NHA A and Interim DON LLL the new concerns related to the interview with Detective AAAA and all reinterviews. Surveyor explained CNA XXX indicates she found R56 around 2:00 a.m. and left R56 bleeding, because she could not locate the bleeding, to call for help. CNA XXX did not express the emergent nature of bleeding to any staff. CNA XXX did not provide immediate assistance to stop the bleeding. The RN Supervisor TTT was not aware R56 was bleeding from a fistula and thought it was a picc line. The nursing staff were not educated and aware on ways to stop a bleeding fistula. The phone call to 911 was not completed until 2:24 a.m., approximately 24 minutes after CNA XXX stated she found R56. The nursing staff stated they only provided pressure, using a towel, onto the site but no other methods of first aid were provided. The facility self-report lacked concrete and accurate timelines as to the events that occurred on [DATE]. On [DATE] the police report was reviewed related to the [DATE] incident involving R56. The report indicates at approximately 02:24 hours, police officers were advised of a male who was not conscious and was bleeding heavily. The police officers noted in their report, upon arrival, (R56) was observed sitting on the toilet, unconscious and not breathing. An extensive amount of blood was on the floor and walls. The report indicates that one of the police officers and two of the nurses picked up R56 to put him on the ground to perform life saving measures. An officer applied a tourniquet and the other checked for pedal pulses. Upon not finding pedal pulses CPR was started. The Fire Department arrived on the scene and took over life saving measures and upon determination there was nothing else they could do, lifesaving care was stopped. Supplemental narratives in the police report accounts: immediately upon entering R56's room arterial blood patterns were observed on the wall leading to the bathroom located in the room. The narrative describes a pool of blood and fecal matter in R56's bed along with arterial blood on the side of the bed facing towards the doorway. A pattern was observed that started on the floor and sprayed up the night stand on the side of the bed and up the wall onto a small bulletin board continuing along the wall to the bathroom. Blood spray was observed on the wall of the bathroom along with a pool of blood on the floor. The police report indicates it is the belief R56 started bleeding from the left arm while lying in bed and the spray was consistent with R56 walking to the bathroom. The narrative indicates a small hole was observed near the bicep in R56's left arm to which police applied a tourniquet. The narrative indicates officers were dispatched to the facility for a patient who had struck his head. Police indicate R56 had bled from his fistula and there were clear indications R56 had received [MEDICAL TREATMENT] earlier in the day. Autopsy information in the police report indicates R56's death was the result of uncontrolled bleeding from his [MEDICAL TREATMENT] fistula. The police report includes interviews with CNA-XXX, RN-TTT and RN-VVV. In interview, CNA-XXX indicated she had heard R56 scream for help and CNA-XXX ran to the toilet and observed, upon turning on the lights, a large amount of blood on the wall and R56 not breathing. CNA-XXX indicates she turned the call light on but was unable to find any help so she left R56 to find a nurse. RN-TTT indicated upon arrival she immediately started to apply pressure, that there was a heavy amount of blood and she was unable to get R56 to the ground to perform CPR due to his weight so she had CNA-XXX apply pressure while RN-TTT called 911. Interview with RN-VVV indicates she was the nurse assigned to R56 that night but that she had not made contact with R56 yet that night. CNA-XXX indicated she had been the only staff to make contact with R56 at approximately 01:00 am when she had asked R56 if he needed to use the restroom; which he did not. CNA-XXX indicated it was approximately 02:00 am when she heard R56 calling for help. RN-VVV indicated R56 had a fistula and had previous incidents with the fistula not clotting appropriately. RN-VVV indicated that R56 had gotten [MEDICAL TREATMENT] that Wednesday morning on [DATE] at approximately 11:00 hours. RN-VVV was unable to provide to the police officers with R56's daily routine saying she was the night nurse. On [DATE] Surveyor reviewed the recording of the 911 call from the incident. Surveyor noted the call was submitted at 2:24 am. Surveyor noted this was approximately 24 minutes after CNA-XXX indicates she first hears R56 calling out for help and observed bleeding. Review of the call indicates staff was quite panicked and not at all prepared for the situation involving R56. The initial nurse on the call indicates she had no idea what happened, that there was blood everywhere and R56 was sitting on the toilet. She kept repeating he needs to go now. When asked if R56 was conscious the nurse is heard calling out the resident's name and indicated at the request of the operator that R56 was occasionally breathing with a light pulse. When asked by the operator about the bleeding: What was it? Where from? The nurse did not know, she stated it was from a picc line. At this time the phone is handed off to a second nurse who repeats she thinks R56 pulled out his picc line, you know, brachial to the heart. When asked for details about R56, staff was not able to convey details including approximate age etc. Staff was heard in the background and stating directly to the 911 operator that they did not know R56, did not know anything about him. Surveyor noted while listening to the call staff were very panicked. During the call the 911 operator told the nurse they were going to do a breathing detector because staff could not convey whether R56 was breathing or not. The 911 operator told staff to tell them each time R56 takes a breath - start now - staff was not able to consistently communicate to the operator the status of R56's breathing. During the call staff did eventually state R56 was not breathing and had no pulse. The 911 operator is heard telling the nurse to get R56 on to the floor. Staff is heard stating there is a lot of blood . The 911 operator asked staff again about the source of the blood, was it a catheter? The nurse on the phone is heard asking RN-TTT by name, is it a fistula? You can hear RN-TTT say she knows nothing about him (R56). Surveyor noted RN-TTT was the house nurse supervisor for that night. When asked if they had placed R56 flat staff communicated no, that he was still on the toilet. Breathing? Kind of . The operator again tells staff they need to get him flat on the floor. Staff tells her they are working on it, that they cannot lift him. When asked by the operator can you lift by the arms, it is relayed that they do not know how to do it, can't lift him. Staff again is heard repeating they need help. Surveyor noted upon finishing review of the call that staff did not appear prepared to deal with the type of emergency that R56 presented to staff. Staff was panicked and unable to carry out emergency steps presented by 911 until first responders arrived to try to help save R56. The failure to promptly care for R56's ruptured fistula, adequately train staff to care for emergent situations with residents who have a [MEDICAL TREATMENT] access, to update the care plan based on previous history of spontaneous bleeding from the fistula and have policies and procedures that address the care and treatment of [REDACTED]. The facility removed the immediate jeopardy on [DATE] when it implemented the following plan: Actions taken for the 8 residents identified to be receiving [MEDICAL TREATMENT] and having an A/V fistula in place: ~ Each Resident's Care plan and Care Card were reviewed and revised by Nurse Managers to reflect their current needs. Examples of the current needs may be the access type, the [MEDICAL TREATMENT] center, the days [MEDICAL TREATMENT] is performed, monitoring of the site for complications and infection, an emergency contact number for [MEDICAL TREATMENT] center, and notification of the physician with any changes in condition. ~ Care plans will be individualized to include any past history of significant complications or risk factors unique to the resident. ~ Each Resident was added to the 24 hour report to ensure that resident's condition is monitored on each shift. Each Resident will remain on the 24 hour report for the duration of their stay at Brookfield Rehab and Specialty Care. ~ Bruit and Thrill were checked and recorded in the resident record. Any abnormal results were communicated to the Resident's Physician and responsible party. ~ All Fistulas and Central Venous Catheters were visually inspected to ensure that no abnormalities were present. ~ All Resident records were reviewed and it was determined that there were no additional residents who had the potential to be affected by this deficient practice. ~ Staff Development Coordinator conducted education for all nursing staff on Facility's policy on [MEDICAL TREATMENT] Care. The education includes: -Facility responsibilities for caring for a [MEDICAL TREATMENT] patient -[MEDICAL TREATMENT] Center's responsibilities for caring for a [MEDICAL TREATMENT] patient -Fistula Care -Central Venous Catheter Care -Bruit and Thrill (Licensed Nurses) -What to do when a fistula is bleeding -Emergency First Aid -Code Blue and Emergency Response Policy & Procedures ~ Facility has developed a [MEDICAL TREATMENT] competency program. All nursing staff will be required to complete the competency program until 100% compliance is achieved. Competencies to include: -Facility responsibilities for caring for a [MEDICAL TREATMENT] patient -Fistula Care -Central Venous Catheter Care -Bruit and Thrill (Licensed Nurses) -What to do when a fistula is bleeding -Emergency First Aid -Code Blue and Emergency Response Policy & Procedures ~ Individualized [MEDICAL TREATMENT] competencies will be performed by all nursing staff and CNAs upon hire, annually, and as needed, in accordance with facility assessment. ~ Facility assessment of needs was completed for availability of emergency equipment. Facility inspected emergency equipment and determined it was adequate and readily available for quick retrieval by staff. ~ An ad-hoc performance improvement meeting was conducted with facility staff and [MEDICAL TREATMENT] director to determine what emergency supplies will be maintained in individual [MEDICAL TREATMENT] resident rooms. This protocol will be followed for any future [MEDICAL TREATMENT] residents. ~ Bruit and Thrill will be checked every shift, and recorded in the resident record. Any abnormal results will be communicated to the Resident's Physician and responsible party. ~ A [MEDICAL TREATMENT] communication form will be developed and will include facility and [MEDICAL TREATMENT] center's pre and post [MEDICAL TREATMENT] responsibilities. ~ Any new potential admissions will be screened using the facility assessment tool as a guide for appropriateness of placement. No residents will be admitted unless staff is fully trained and competent to care for their specific conditions. ~ DON, or designee, will educate staff of appropriate staffing coverage during breaks. DON will be responsible for monitoring appropriate staffing coverage. ~ DNS and/or Nurse Managers will meet weekly with [MEDICAL TREATMENT] staff to ensure that systemic changes are being followed and remain appropriate. DNS or designee will modify systemic changes as deemed appropriate. ~ Weekly, the DNS will meet with Administrator and leadership to determine the effectiveness this plan. The deficient practice continues at a scope and severity of an E ( potential for harm/pattern) as the facility continues to implement their action plan and ensures the proper care of the 8 residents (R13, R64, R65, R66, R67, R68, R69 and R70) currently residing in the facility with either a fistula or catheter port.

Based on observation, interview, and record review, the Facility did not provide the necessary care and services to prevent development of pressure injuries and promote healing of pressure injuries for 11 of 21 sampled Residents (R8, R2, R3, R16, R20, R1, R7, R13, R12, R14, & R23). *R8 acquired a stage 4 pressure injury with exposed tendon, to the right inner ankle. There is no evidence the facility had off-loading interventions in place to prevent R8'S pressure injury prior to discovery. There is no evidence the facility correctly assessed the pressure injury upon initial discovery or implemented interventions to prevent further decline of R8's pressure injury. Surveyor made multiple observations of the facility not off-loading R8's legs, heels, and ankles during the survey, as well as R8's air mattress not in the on position. *R2's weekly wound note dated 1/3/17 documents on the right buttock MASD (moisture associated skin disorder). The weekly skin checks dated 3/4, 3/11, 3/17 & 3/25 are not completed. On 3/28/17 the weekly wound documentation for upper & lower coccyx documents 25% yellow slough and 75% pink tissue. This area continues to be classified incorrectly as MASD and there has been no revision in R2's plan of care. On 4/4/17 the weekly wound note documents the right buttocks previously classified as MASD is now staged as Unstageable due to 100% slough, the upper coccyx previously MASD is now changed to Stage 4. The bone is not visible but palpable. The lower coccyx is changed from MASD to Unstageable. R2's skin integrity plan of care has not been revised. Physician-H, who is the Facility's wound doctor, does not measure the pressure injuries and does not consistently document on all pressure injuries. The weekly skin assessments starting on 5/30/17 are completed by LPN (Licensed Practical Nurse) Manager-J who is not wound certified. An RN (Registered Nurse) cosigns LPN Manager-J's notes but has not assessed R2's pressure injuries during this time. The manufacturer's information for the 2 inch foam wheelchair cushion provided to R2 does not indicate this cushion is effective for a Resident with an unstageable or Stage 4 pressure injury. The Facility's failure to provide the necessary care and services to R8 & R2 created a finding of Immediate Jeopardy beginning on 4/4/17. Administrator-A and DON (Director of Nursing)-B were informed of the Immediate Jeopardy on 9/18/17 at 3:25 p.m. The Immediate Jeopardy was removed on 9/20/17 when the Facility implemented an action plan related to proper pressure injury care. The deficient practice continues at scope/severity of G (harm/isolated) for the examples related to R3 & R16. *On 7/4/17 R3's right gluteal open area was incorrectly staged by LPN (Licensed Practical Nurse) Manager-J. R3's right gluteal and right elbow pressure injuries were not assessed by a RN (Registered Nurse) until 8/1/17. R3's plan of care was not revised after R3's pressure injuries declined, there is no evidence the cushion is R3's Broda chair is effective for a Stage 3 pressure injury and there are observations of R3's heels not being offloaded. *An unstageable left heel pressure injury was discovered on R16. The facility had not developed and implemented clear plans of care for off-loading R16's heels from pressure and a clear plan was not established for staff to check on off-loading. R16's weekly pressure injury assessments were completed by a Licensed Practical Nurse without an RN participating in the assessment. Additionally, R16's physician was not consulted with when R16's pressure injury deteriorated including increase in eschar or increase in size. As of 9/19/17 R16's left heel is now a stage 3, facility acquired pressure injury. Additional examples of deficient practice identified, but at severity level 2 (potential for harm that is not immediate jeopardy) include: *R20 was observed without the pressure injury dressing on 9/18/17, the pressure injury has been incorrectly staged, and her heels were not offloaded. *R1's heels were not offloaded. *R7 is at risk for pressure injury and staff were observed sheering R7 with a brief. *R13's heels were not offloaded and the care plan was not updated. *R12's heels were not offloaded, the care plan was not updated, and R12 had an incorrect cushion in the wheelchair.*R14's heels were not offloaded. *R23's heels were not offloaded. Findings include: The facility's Skin and Wound Management Program policy and procedure revised on 3/10/15 indicates the following: 1.0: Purpose .The resident does not develop pressure ulcers unless clinically unavoidable and the facility provides care and services to: *Promote the prevention of pressure ulcer development. *Promote the healing process of pressure ulcers that are present. *Prevent the development of additional pressure ulcers. *Ensure the resident's pain is monitored during treatment. Section 3.0: Procedure indicates the following: 2. Any resident identified at risk for development of pressure ulcers, as indicated by Braden Scale Risk Assessment score of 18 or less, will have the Initial Plan of Care initiated by the admitting nurse, to minimize the risk of developing a pressure ulcer. 4. A visual head to toe skin review will be performed at least weekly by a certified Nursing Assistant (CNA), preferably during bath/shower, to identify any new areas of skin concerns, or other types of skin breakdown. Results will be verified and documented by a licensed nurse. The skin check and verification will be documented on the weekly skin check form. 5. Whenever a new wound is identified, a licensed nurse will complete a comprehensive evaluation, and document the findings on the Initial Wound Review Form. It is the position of Five Star Senior Living that: staging of pressure ulcers be performed by a Registered Nurse (RN) or a Licensed Practical/Vocations Nurse (LPN/VN) who holds a current certification as a wound care nurse, unless otherwise indicated in your state specific scope and standards of nursing practice. a. If a new wound is determined to be a pressure ulcer, and there is no RN or current wound certified LPN/VN available at the time of discovery to stage the pressure ulcer, the licensed nurse will complete the Initial Wound Review, and an RN or LPN/VN wound certified nurse will complete pressure ulcer staging with documentation on the Initial Wound Review as soon as possible. 6. The licensed nurse will initiate the New Wound Quality Improvement Checklist, to be used as a guideline to ensure that the resident receives need services and support which includes review of surface devices, notification of members of the interdisciplinary team (IDT), and documentation requirements. This form is not part of a resident's medical record and is used for Quality Assurance purposes only, and therefore not subject to release when a medical record request is made. 7. ALL WOUNDS will be monitored daily, as required by a licensed nurse, with documentation on the Daily Wound Review form, to include date observed and: a. review of the pressure ulcer if no dressing is present. b. review of the status of the dressing if present i. whether dressing is intact ii. Whether drainage is present, and is/is not contained in the dressing. c. review of the surrounding skin that can be observed without removing the dressing. d. presence of possible complications such as signs of infection/redness, swelling, increased drainage, color. e. review if pain is present, and if present that it is adequately controlled. f. pain scale 0-10. 8. All wounds will be monitored at least weekly by a licensed nurse during wound rounds, with documentation on the Weekly Wound Progress Review form, to include date observed and: a. Location, and staging (if pressure ulcer). b. Size-Measurement of greatest length and width, depth. c. Presence, location and extent of undermining or tunneling. d. Exudate/drainage (if present): type (purulent, serous), color, odor and approximate amount. e. Pain if present, nature and frequency (episodic or continuous). f. Wound bed: Color, type of tissue/character including evidence of healing (granulation) or necrosis (eschar or slough). g. Description of wound edge and surrounding tissue (rolled edges, maceration, induration, redness). 10. If the certified wound care licensed nurse or registered nurse determines that there is no improvement toward healing with 2 weeks, according to CMS standards, the resident, the wound and the plan of care will be re-evaluated, and the physician will be notified for a change in treatment modality. a. With each treatment and/or dressing change, the licensed nurse will monitor for any signs that a change in treatment may be indicated, such as wound improvement, deterioration, signs of infection, increase or decrease in exudate, or other complications. The practitioner should be notified immediately regarding any signs of wound deterioration. 14. While there are residents that are at high risk related to their medical condition, pressure ulcer PREVENTION should always be the goal, with review and implementation of interventions initiated immediately upon admission with periodic re-review of effectiveness. The facility's policy goes on to include the definition of Unavoidable according to CMS meaning that 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 intervention that are consistent with resident needs, goals and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. For a pressure ulcer to be considered unavoidable, the following criteria must be met: a. Review of resident condition. b. [DIAGNOSES REDACTED]. c. Implementation and defined interventions consistent with resident needs and standards of practice. d. Review and monitor impact of interventions. e. Revise interventions as needed. f. If no progress toward healing in 2 weeks, clinical condition and interventions should be reviewed. g. A clinical review is completed by a licensed nurse and physician and documented on the Unavoidable Pressure Ulcer Quality Improvement Tool. The facility additionally has a policy and procedure titled: General Principles of Skin Care dated 3/10/15 indicating the following in addition to the above: *Skin will be inspected with each assisted toileting or incontinence care episode - any reddened areas and/or breaks in the resident's skin that are noted will be immediately reported to the nurse - the licensed nurse will inspect any reddened areas and/or breaks in the resident's skin and initiate the appropriate documentation. *Skin will be inspected with each application or removal of medical device - any reddened areas and/or breaks in the resident's skin that are noted will be immediately reported to the nurse - the licensed nurse will inspect any reddened areas and/or breaks in the resident's skin and initiate the appropriate documentation. *All nursing assistants and licensed staff should be educated that any time they are interacting with the resident such as repositioning, bathing, or cleaning a resident is an opportunity to inspect their skin. - if skin changes occur, re-evaluation of the repositioning care plan should occur. 1.4 Protection: .Use silk-like fabrics rather than cotton or cotton-blend fabrics to reduce shear and friction. Use care to minimize the force and friction applied to the skin. 1.) R8 was admitted to the facility on [DATE]. On 7/3/17, R8 was sent to the hospital and was diagnosed with [REDACTED]. R8 returned to the facility on [DATE] and had [DIAGNOSES REDACTED]. R8's hospital summary dated 7/5/17 indicated, .Unfortunately (R8) was not cooperative with placement of the knee immobilizer. It would be helpful if the (right knee) knee immobilizer could be placed. The flexion of (R8)'s knee right now is contributing to deformity at the fracture site Prior to discharge from the hospital on [DATE] at 1:15 P.M., a Registered Nurse (RN) from the hospital performed a skin assessment and documented no lower extremity skin concerns for R8. Upon readmission the facility on 7/5/17, a signed physician telephone order dated 7/5/17 at 3:00 P.M. indicated R (right) leg brace to be worn at all times check skin integrity Q (every) shift. On 7/5/17, upon readmission, the facility performed an admission/readmission skin review for R8 which indicated swelling to the right leg but no further skin issues to R8's lower extremities. R8's 7/5/17 Braden skin assessment (which predicts pressure injury risk) was scored as an 8; a Braden score of 8 indicates severe risk for pressure injury. The facility performed a significant change Minimum Data Set (MDS) assessment for R8 after R8's readmission to the facility. The MDS assessment reference date was 7/13/17 and specified R8 was at risk for developing a pressure injury. R8 was additionally noted to have unclear speech and only sometimes understood others. The assessment showed R8 required extensive assistance from one staff member with bed mobility. Bed mobility means how a resident turns side to side and positions one's body while in bed, and R8 was unable to independently reposition when in bed. The MDS further noted R8 to have functional limitations in range of motion for both legs and severely impaired daily decision making skills. R8 would therefore require staff assistance for offloading pressure to the heels and ankles while in bed. R8's Care Area Assessment (CAA) dated 7/18/17 indicated R8 was at risk for a pressure injury. The CAA stated, (R8) is at risk for pressure ulcers r/t immobility, incontinence, limited ability to communicate needs and poor nutritional intake. The care plan decision was noted as yes and the reason listed as, will care plan r/t risk factors. On 7/20/17, at 10:00 A.M., R8's Nurse's Notes state, (R8) has 2 open areas to inner R ankle. Wound 1 measuring 1.5 cm (centimeter) x 1.5 cm. Wound 2 measures 2 x .9 cm .Deep tissue injury to same area measure .9 x 1.7 cm. Immobilizer on to R leg d/t (due to) tx. This entry is signed by Licensed Practical Nurse (LPN)-P. On 7/20/2017 LPN-P filled out an Initial Wound Review form indicating the following measurements for R8's Right inner ankle pressure injuries: Wound #1: Location: Right Inner ankle - Type: Pressure - Stage: 3 (A stage 3 pressure injury indicates full thickness skin loss but no muscle, bone or tendon is showing). Length: 1.5 cm, Width: 1.5 cm. No drainage or tunneling was noted upon initial review. Redness was noted on the surrounding skin. The written description of the pressure injury stated, Open area to R inner ankle measures 1.5 cm x 1.5 cm. Wound base yellow. Surrounding tissue red. (No) drainage. Area is distal to R ankle. Tx order N/S (normal saline) cleanse F/B (followed by) Santyl, F/B 2 x 2 F/B [MEDICATION NAME] (sic) daily. According to the Nurse's Notes and Initial Wound Review Form, LPN-P was the only licensed staff nurse to view R8's right ankle #1 pressure injury on 7/20/17. There is no evidence indicating an RN assessed the pressure injury upon initial discovery to confirm accurate staging and analyze LPN-P's data collection. Wound #2: Location: Right Inner ankle. Type: Pressure. Stage: 3. Length: 2.0 cm Width: 0.9 cm No drainage or tunneling was noted upon initial review. Redness was noted on the surrounding skin. The written description of the wound stated, Open area to R inner ankle measures 2.0 cm x 0.9 cm. Wound base yellow. 0 (no) drainage. Surrounding tissue red. Area is middle open area. Tx order N/S cleanse F/B Santyl F/B 2 x 2 F/B [MEDICATION NAME] (sic) daily. According to the Nurse's Notes and Initial Wound Review form, LPN-P was the only licensed staff nurse to view R8's right ankle #2 pressure injury on 7/20/17. There is no evidence indicating an RN assessed the pressure injury upon initial discovery and analyzed LPN-P's data collection for accurate staging of R8's #2 pressure injury. Wound #3: Location: Right Inner ankle. Type: Deep tissue injury. Stage: No stage is noted. (The NPUAP classifies a deep tissue injury as pressure injury and describes the following, this injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss.). Length: 0.9 cm Width: 1.7 cm. No drainage or tunneling was noted upon initial review. This area was intact. Redness was noted on the surrounding skin. The written description of the deep tissue injury stated, Deep tissue injury-area dark purple in color, surrounding tissue red measures .9 x 1.7 cm. area is top DTI on R ankle. Tx to skin prep daily. According to the Nurse's Notes and Initial Wound Review form, LPN-P was the only licensed nurse to view and collect data for R8's right ankle #3 pressure injury on 7/20/17. There is no evidence indicating an RN assessed the pressure injury upon initial discovery to confirm accurate staging of the wound. Wisconsin Chapter N6 entitled, Standards of Practice for Registered Nurses and Licensed Practical Nurses, specifies the minimum practice standards for which RNs and LPNs are responsible and clarifies the scope of practice for RNs and LPNs. N6.03 Standards of practice for registered nurses (1) states, General Nursing Procedures. An RN shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to LPNs or less skilled assistants . N6.04 Standards of practice for licensed practical nurses (1) Performance of acts in basic patient situations. In the performance of acts in basic patient situation, the LPN shall, under the general supervision of an RN or the direction of a provider: (a) Accept only patient care assignments which the LPN is competent to perform. (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient. (d) Consult with a provider in cases where an LPN knows or should know a delegated act may harm a patient. (e) Perform the following other acts when applicable: 1. Assist with the collection of data. 2. Assist with the development and revision of a nursing care plan. An RN's role is to perform a patient assessment and analyze the data collected during the assessment. An RN would plan interventions and change current nursing interventions as needed with the ultimate goal as the promotion and healing for the patient. There was no RN assessment or evidence of the nursing process executed for R8 upon initial discovery of R8's pressure injuries to the right medial ankle. On 9/13/17during a morning discussion, Surveyor interviewed DON-B, an RN, who indicated DON-B had not assessed the pressure injury on 7/20/17. DON-B indicated the pressure injury was from the brace, and when asked if the skin was being checked every shift, how did the wound come to be, DON-B indicated if the skin was being checked every shift then it should not have happened. DON-B indicated Wound Certified LPN-KK was present within the facility at the time of R8's pressure injury development. LPN-KK was unavailable for interview. On 9/14/17, at 9:30 AM, Surveyor interviewed RN-E and asked RN-E's expectation when an LPN discovers a wound. RN-E indicated, as the current unit manager, an LPN would notify RN-E so RN-E could assess the wound. Surveyor asked RN-E who should assess the wounds upon initial discovery, and RN-E stated, Should be the RN. On 9/14/17, at 8:45 A.M., Surveyor interviewed the RN Manager, RN-I, regarding R8's right inner ankle pressure injury. RN-I was the RN in the facility who performed wound rounds. RN-I indicated R8 was not seen during wound rounds with the wound physician since R8 was on hospice. RN-I indicated to Surveyor that RN-I did not assess the pressure injury when discovered on 7/20/17. There is no evidence in R8's medical record that R8's pressure injury was assessed by an RN or Wound certified LPN on 7/20/17-initial discovery. R8's Skin Integrity Care Plan, rewritten on 3/29/2017, was not resident specific. There was no evidence R8's Skin Integrity Care Plan was updated on 7/5/17 to reflect R8's change in condition upon readmission. There was no notation of R8's brace placement to the right knee and leg. The care plan does not acknowledge R8's 7/5/17 Braden score risk assessment score of 8 indicating R8 was at severe risk for pressure injury. There is no evidence R8's interventions were updated or changed upon readmission to reflect R8's need for repositioning and offloading of both legs due to the brace placement. The 3/29/17 care plan was in place until rewritten on 7/24/17. There was no evidence the facility updated R8's 3/29/17 care plan and nursing interventions or the 7/24/17 care plan and interventions when the facility made the initial discovery of R8's pressure injury on 7/20/17. The 7/24/17 Skin Integrity Care Plan had the identical nursing interventions as the 3/29/17 Skin Integrity Care Plan which are listed below: 1. Inspect skin daily. (There was no update on 7/5/17 for staff to assess skin integrity under the brace every shift). 2. Preventative skin care as ordered. (There were no details listed regarding specific preventative skin orders). 3. Monitor of s/s (signs and symptoms) of infection: (increase) temp, drainage, redness, warmth, pain, odor. 4. Tx (treatment) as ordered by MD (doctor)/WCC (wound care certified) RN as indicated. (There were no details listed regarding treatments added for R8 on 7/20/17). 5. Do not slide resident-lift or use assistive devices to (decrease) friction. 6. Dietary referral as indicated. 7. Provide, serve, monitor intake of meals, fluids, and supplements. 8. PT as indicated. 9. OT as indicated. 10. Air mattress pressure reduction support surface in bed. Applied 7/12/17. (Please note, this intervention is added 7 days after readmission to the facility and the Braden risk assessment score of 8). 11. Avoid prolonged sitting. 12. Update MD, and family as needed. 13. Consider Wound care clinic as needed. 14. Include Wound MD with P(NAME) (plan of care). 15. Labs as ordered. 16. Assist with repositioning with rounds as needed. Utilize support devices if needed to protect bony prominences. (There is no indication on the care plan that the facility added support devices to protect R8's right inner ankle upon readmission. There are no details on the care plan regarding support devices added on 7/5/17 or on 7/20/17 once the pressure injury was noted. There are no specific repositioning frequencies noted on the care plan). 17. Assist with per (sic) care if incontinent. Keep clean and dry. 18. Monitor labs, wt. and intake. 19. Risk assessment per protocol. (The Braden score of 8, indicating severe risk, is not listed). 20. Monitor pain and administer pain meds as ordered. 21. Involve/Educate resident and/or family members re: P(NAME). Update with any changes. 22. Adapt res. Activity programs to accommodate current situation as needed. 23. If [MEDICAL CONDITION]/Diabetic wounds: tighten glucose control-update MD as indicated. Utilize proper fitting foot ware. (There is no indication R8 was diabetic). 24. Pressure relief to heels as warranted. (There is no indication the care plan was updated to reflect pressure relief to heels was warranted). 25. Report any signs of skin breakdown, (sore, tender, red, or broken areas.) (sic) 26. Keep linens clean and dry-free from wrinkles. 27. __ Heels (up) pad. (This intervention is not checked indicating this was not an intervention for R8). 28.__ Off Loading boots applied. (This intervention is not checked indicating this was not an intervention for R8). 29. Other: gerisleeves Bil (bilateral) arms on AM off HS. 30. Other:__ (No intervention noted). 31. Other:_(No intervention noted). R8's CNA Care Card, with no date, indicated the following skin care for R8: *Gerisleeves to both forearms On am off HS (hours of sleep). *Pressure ulcers to right inner ankle-pillow between legs while side lying. *Rx (prescription) cream to right breast for rash. None of the above interventions indicate a repositioning frequency for CNA staff to follow or direction related to offloading the heels or ankles. There is no evidence R8 is to wear blue boots or heel protectors. LPN-P completed a Braden risk assessment for R8 on 7/20/17 with no evidence of an RN signature ensuring accuracy. The Braden on 7/20/17 listed R8's Braden score as a 10. This would indicate an improvement in R8's pressure injury risk from 7/5/17 when R8's score was an 8. Due to R8 acquiring a pressure injury, R8's Braden Risk score should not have improved after 7/20/17. Upon review of R8's nursing progress notes from 7/5/17 and 7/20/17, there is no notation indicating R8 was repositioned every 2 hours while in bed or that R8's ankles and heels were offloaded while in bed. Surveyor reviewed the Treatment Administration Record (TAR) and found no evidence staff were assisting R8 with regular and frequent repositioning and offloading of the heels and ankles. On 7/24/17 R8's Weekly Wound Progress Review Form indicated a decline of R8's wound #1 and wound #2. The following are measurements for R8's Right inner ankle wounds on 7/24/17: Wound #1: Location: Right medial ankle Type: 1 (Pressure Injury). Stage: Unstageable (An unstageable pressure injury indicates slough tissue is covering the wound base so the specific stage cannot be determined). Length: 2.5 cm Width: 3.0 cm. The wound edge was defined and the wound base was yellow. Yellow drainage was documented. Redness was noted on the surrounding skin. The written description of the wound stated, Wound has declined, measuring 2.5 x 3.0 cm. Wound base 100% slough. Peri wound reddened. Moderate yellow drainage on old dressing. No odor or sign of infection present. Medicated prior to treatment for [REDACTED]. Continue (with) P(NAME). Wound #2: Location: Right medial ankle. Type: 1 (Pressure Injury). Stage: Unstageable. Length: 2.0 cm Width: 1.3 cm. The wound edge was defined and the wound base was yellow. The drainage was documented as moderate and yellow in color. Redness was noted on the surrounding skin. The written description of the wound stated, Wound to R medial ankle continues to deteriorate measures 2.0 x 1.3 cm. Would bed is 100% yellow slough. Peri wound is reddened. Pre-medicated prior to treatment for [REDACTED]. No odor or sign of infection present. Currently on hospice care. Continue with P(NAME). Wound #3: Location: Right Inner ankle. Type: 1 (Pressure Injury). Stage: DTI. Length: 0.9 cm Width: 1.7 cm. No drainage or tunneling was noted upon initial review. This area was intact. The color of the wound was noted as B (brown). The written description of the wound stated, DTI to R medial ankle remains unchanged measuring 0.9 x 1.7 cm no c/o pain during the treatment. No sign of infection. Continue current P(NAME). A different facility LPN signed the review form as well as RN-I on 7/24/17. The LPN completing the form was unavailable for interview during the survey. On 9/14/17, at 8:45 AM, Surveyor interviewed RN-I and RN-I indicated to Surveyor that RN-I just signed the Skin Review Form but did not see or assess the wound even though the wound had deteriorated. RN-I shared by signing the form, RN-I is indicating that they believe that the LPN collecting the data knows what she is doing. New treatment orders were obtained 7/24/17 to discontinue the treatment to the right ankle. The new treatment was R distal inner ankle cleanse with NS F/B nickel thick layer of Santyl to base F/B bordered foam dressing BID (twice daily). To R medial ankle cleanse with NS, F/B Santyl, F/B bordered foam BID. Skin prep to DTI R medial ankle BID. There was no evidence on R8's Skin Integrity Care Plan the facility changed R8's nursing interventions or when the right medial ankle pressure injuries declined on 7/24/17. The treatment change on 7/24/17 is not listed on R8's care plan. On 7/26/17, six days after the initial discovery of the pressure injury, there was a signed physician's orders [REDACTED]. That intervention is not added on the Skin Integrity Care Plan rewritten 7/24/17, but is present on the CNA care card. There is no date indicating when the intervention was added to the CNA care card. The intervention was added to the 8/8/17 Skin Integrity Care Plan with no date of initiation noted. There was no evidence of additional nursing interventions to offload the right medial ankle. On 7/31/17, the facility documented R8's three pressure injuries measurements as follows: Wound #1: stage: unstageable. Length: 1.6 cm. Width: 1.9 cm. The form indicated slough was present for #1 wound with light exudate. Wound #2: Stage: Unstageable. Length: 2.0 cm. Width: 0.7 cm. The form indicated slough was present for wound #2 with light exudate. Wound #3: Stage: Deep Tissue Injury. Length: 0.9 cm. Width: 1.7 cm. The interventions listed on the form included an air mattress and special wheelchair cushion. Some interventions not listed from the form specifically for R8 include off-loading side to side, blue boots, heel lift/pads, repositioning. On 8/2/17, at 3 PM, there was a signed physician order [REDACTED]. There was a second order stating, Start Rt. Medial and distal ankle cleanse (with) ns, FB iodosorb, F/B bordered foam BID. On 8/7/2017 R8's Weekly Wound Progress Review Form indicated R8's right medial ankle pressure injury had deteriorated and all three wounds had merged into one wound. An LPN and RN-I signed the weekly wound progress review form. The following were the measurements for R8's Right inner ankle pressure injury on 8/7/17: Wound #1: Location: Right medial ankle. Type: 1 (Pressure Injury). Stage: 4 (According to the NPUAP, a stage 4 pressure injury is full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, ligament or bone). Length: 4.0 cm. Width: 4.0 cm. The wound edge was defined and the wound base was indicated as white, black, yellow, and beefy red. No percentages are listed. Moderate yellow and red drainage was noted. Redness was noted on the surrounding skin. The written description of the wound stated, Wound to right ankle has deteriorated with all three wounds merging into one which measures 4.0 x 4.0 cm. Bone is visible in wound base. Yellow and black slough present. Pre medicated prior to treatment for [REDACTED]. Remains on hospice care. Continue (with) P(NAME). This note was signed by RN-I and an LPN. On 9/14/17, at 8:45 AM, Surveyor asked RN-I if RN-I assessed the wound on 8/7/17. RN-I indicated to Surveyor that R8 was not followed by the wound team and RN-I noted that she did not assess the wound on 8/7/17 when the wound deteriorated. Surveyor asked if the physician had been made aware on 8/7/17 regarding the deterioration in the right medial ankle pressure injury. RN-I indicated the doctor may have been notified, but that RN-I did not know because it was not documented. RN-I indicated the doctor saw R8 on 8/8/17 and wrote no new orders or changes to the treatment for [REDACTED].

Based on interview, and record review, the facility did not ensure the Primary Physician or family representative was updated when 3 of 24 Residents (R8, R20, R1) experienced a change in condition or need for change in treatment. R8 had a [DIAGNOSES REDACTED]. The wound was assessed weekly, and on 9/5/17, there was no exposed tendon in R8's pressure injury. On 9/11/17, the wound was assessed as having exposed tendon. That was a change in condition of the pressure injury. There is substantial evidence the physician was not made aware of the exposed tendon until 9/18/17 when Surveyor interviewed the physician regarding the wound. The physician indicated through interview on 9/18/17, R8 needed to be seen by a wound specialist right away. The delay in physician notification from 9/11/17 to 9/18/17 resulted in a delay of treatment by a wound specialist for R8's stage 4 pressure injury. R20's family representative (Power of Attorney-POA) was not notified on 7/12/17 or 8/10/17 when there was a change in R20's treatment. R1's primary physician was not notified of a change in treatment. Findings include: The facility's physician notification guideline policy dated 11/19/16 identifies resident condition changes and condition changes for notifications under section 2. Urgent: A situation/condition that would require physician notification and a physician response within 2-4 hours. Such conditions include, but not limited to the following: Chest pain relieved by [MEDICATION NAME], if more than one occurrence Fever greater than 101 degrees that responded to intervention (i.e. Tylenol) Cough persisting more than 24 hours, even with intervention, if ordered Persistent nausea/vomiting or headache Complaints of pain without specific indication of injury and is not chronic with pain interventions already in place (i.e. pain/burning with urination) Pressure ulcer and/or skin tear notifications for treatment orders Changes in vital signs or level of consciousness in a resident who has a DNR (do not resuscitate)/No hospitalization order and/or is receiving palliative care Acute onset of increased agitation or change in resident behavior Consultant reports with a need to obtain orders to begin immediate treatment Lab results that fall outside clinical reference ranges as per Healthcare Practitioner order. Under expectations document 1. Licensed nurses (staff and management) are expected to recognize resident situations/conditions that require physician notification. The nurse shall complete an assessment of the condition, including level of urgency. The nurse shall implement appropriate interventions and have accurate information available when contacting the physician. 2. Documentation of the resident condition change and proper notification shall be the responsibility of the nurse who observes and assess the change. 3. Changes in resident condition must be documented in the following locations: Resident chart 24 Hour Report Incident/Accident Report (if applicable) 4. The licensed nurse shall also notify the: Unit/Nurse Manager or Nursing Supervisor Resident and/or family 5. The Unit/Nurse Manager or Nursing Supervisor is responsible for: Assessing any resident with a condition change Verify proper notification and documentation of the condition change Ensure proper implementation/follow up of interventions ordered. 1) R8 was readmitted to the facility on [DATE] with a fractured right leg. R8 wore a leg brace at all times and on 7/20/17, a pressure injury was discovered on R8's right inner ankle. During the initial facility tour on 9/11/17, Registered Nurse (RN)-E indicated to Surveyor that R8's pressure injury had exposed tendon. Surveyor reviewed R8's weekly wound documentation signed by RN-E. Surveyor noted no documentation of exposed tendon the week prior on the 9/5/17 wound documentation. The document stated as follows: Wound #1: Location: Right medial ankle Type: 1 (1= code for Pressure Ulcer) Stage: 4 Length: 4.2 cm Width: 4.0 cm No depth Moderate yellow drainage No odor was noted The wound edge was defined and the wound base was indicated as yellow 50% and beefy red (indicating healthy tissue) 50%. Moderate yellow drainage was noted. Redness was noted on the surrounding skin. The written description of the wound stated, .50% beefy red moist granulation tissue 50% yellow slough noted to base of wound with defined edges. Moderate drainage noted on dressing. Yellow in color. 25% noted. No odor present. [DIAGNOSES REDACTED] noted around the wound- non-blanchable .Hospice updated on wound status- here assessing resident. New order for [MEDICATION NAME] once daily. (PCP) to come in today to assess resident This note was signed by RN-E. Surveyor reviewed R8's 9/11/17 documentation of R8's stage 4 pressure injury. RN Manager-E assessed the pressure injury and indicated R8's tendon was exposed within the wound. The wound documentation form 9/11/17 is as follows: Wound #1: Location: Right medial ankle Type: 1 (1= code for Pressure Ulcer) Stage: 4 Length: 4.6 cm Width: 4.0 cm No depth Moderate red and yellow drainage No odor was noted The wound edge was defined and the wound base was indicated as yellow slough 10% and beefy red (indicating healthy tissue) 90%. The written description of the wound stated, .Full thickness skin and tissue with exposed tendon noted in the ulcer. 90% beefy red granulation tissue with 10% slough noted. Moderate amount of serosanguineous drainage Noted- greater than 25% noted on dressing- no odor present. Surrounding skin reddened and non-blanchable Air mattress to bed for protection. Broda chair rest in bed with repositioning. Total assist with all ADL's(activities of daily living). Continue with hospice care. Hospice here to assess tx changed to [MEDICATION NAME]. POA/MD updated 9/5/17.This note was signed by RN-E. There is no evidence hospice or the physician was updated on 9/11/17 regarding the change in R8's wound which now includes exposed tendon. On 9/12/17, at 9:06 A.M, Surveyor observed R8's pressure injury during an observation of the treatment to the right ankle pressure injury. Surveyor observed a stage 4 pressure injury on the right ankle with exposed beefy red tissue extending out of the wound. Surveyor observed tendon exposed in the pressure injury. On 9/14/17, at 9:30 A.M., Surveyor interviewed RN-E. RN-E indicated RN-E assessed the wound on 9/5/17 and 9/11/17. RN-E indicated RN-E saw tendon at that time. RN-E indicated there was 10% slough in the wound, and RN-E stated it was the first time R8's tendon was visible in the wound. RN-E stated, (It was) the first time I saw Tendon. RN-E did not indicate Hospice or Physician-QQ was updated at that time as both had been updated on 9/5/17. R8's current skin integrity care plan, rewritten on 8/8/17, indicated the following approaches related to physician notification: Update MD (medical doctor), and family as needed. Consider wound care clinic as needed. Include Wound MD with P(NAME) (plan of care). On 9/18/17, at 11:58 A.M., Surveyor interviewed Physician-QQ via phone interview regarding R8's wounds. Physician-QQ indicated the facility sometimes calls her to update her on the wounds, but that Physician-QQ could not say with a 100% guarantee they call all the time. Physician-QQ indicated they think the facility updates them. Physician-QQ indicated they see the wounds when present at the facility and will take a nurse with if one is available, or will go by herself to assess the wounds. There is evidence Physician-QQ saw the wound on 9/6/17. On 9/18/17, at 1:16 P.M., Physician-QQ called Surveyor back. At that time, Physician-QQ indicated she was not aware of the situation (R8's wound condition). Physician-QQ indicated after Surveyor interviewed her about R8's wounds, Physician-QQ called the facility to question the status of R8's wound. Physician-QQ indicated she was not aware that R8's tendon was now exposed until after calling the facility herself, and indicated R8 needed to be sent out right away for wound care. Surveyor asked Physician-QQ if R8's hospice status changes the urgency of R8 being seen by a wound specialist. Physician-QQ stated, It is still important for (R8) to be seen. Surveyor reviewed R8's physician progress notes [REDACTED]. There is no documentation Physician-QQ saw or assessed R8 after 9/6/17. Surveyor reviewed R8's physician telephone orders, and there is no evidence Physician-QQ changed R8's orders after 9/6/17 until 9/18/17. On 9/18/17, the following physician order [REDACTED].>Resident to see (Physician-QQ) for consult right away to eval and treat stage 4 wound. This order was given at 1:15 P.M. The weekly wound documentation on 9/18/17 indicated the wound to decrease in size measuring 3.8 cm by 4.0 cm but with an increase in drainage from moderate to moderate/heavy. The documentation indicated 80% beefy red tissue which is a decrease from the 9/11/17 assessment which indicated 90% beefy red tissue. Surveyor notified the facility on 9/18/17 of the above concerns at the daily facility meeting. Director of Nursing-B indicated to surveyor that the facility had the order for R8 to be seen by the wound clinic, but that the facility was having difficulty getting R8 seen due to R8's hospice status. Additional information was provided to surveyor by Nursing Home Administrator-A after the survey (9/29/17) indicating Physician-QQ's involvement and notification during the months of July and August. The statement indicated dates from 7/20/17 to 8/6/17 and evidence of Physician-QQ's notification. The statement did not demonstrate physician notification on or after 9/11/17 regarding R8's wound. On 9/18/17, Physician-QQ was made aware after Surveyor spoke with Physician-QQ at 11:58 A.M. Physician-QQ called the facility after speaking to Surveyor and was then made aware. Physician-QQ was updated and gave an order for [REDACTED].M indicating Physician-QQ was not aware until 9/18/17 of the exposed tendon. 2.) Surveyor reviewed R20's medical record on 9/18/17 & 9/19/17. R20 has [DIAGNOSES REDACTED]. R20's power of attorney was activated on 2/19/15. The nurses note dated 7/12/17 documents New order received to change (triangle sign) treatment to coccyx wound from wound gel to Iodosorb. Surveyor did not note R20's POA (power of attorney) was notified of the change in treatment. The next nurses note is dated 7/17/17 which documents Optum NP (Nurse Practitioner) updated re (regarding) change (triangle sign) in size to coccyx wound. The nurses note dated 8/10/17 documents Physician-H here new orders to DC (discontinue) current tx (treatment) to coccyx start NS (normal saline) cleanse F/B (followed by) skin prep to periphery F/B nickel thick Santyl to wound bed & cover with bordered foam dsg. (dressing) daily, pre-[MEDICATION NAME] in AM (morning). Surveyor did not note R20's POA was notified of the change in treatment. The next nurses note is dated 9/11/17. On 9/19/17 at 8:55 a.m. Surveyor met with RN (Registered Nurse) Manager-E to discuss R20. Surveyor asked RN Manager-E when there is a change of treatment for [REDACTED]. RN Manager-E replied yes, should be. Surveyor informed RN Manager-E on 7/12/17 and 8/10/17 there was a change in treatment for [REDACTED]. RN Manager-E replied honestly don't have an answer. RN Manager-E explained all the nurses know they are suppose to update the POA and will address this with them. 3.) Surveyor reviewed R1's medical record on 9/11/17 to 9/14/17. R1's power of attorney was activated on 8/28/17. The nurses note dated 8/25/17 documents Called to room to see R1 lying on her back in the middle of the floor. She stated she tried to reach for her walker & fell . Denies hitting head. States her big toe hurts when asked if having any pain/discomfort. Hand grasps equal. ROM (range of motion) to all extremities WNL (within normal limit). Lg. (large) skin tear noted to length of (R) shin. Day supervisor & DNP (Doctor Nursing Practice)-O in room to assess. The nurses note dated 8/25/17 documents New order written for x ray of lt (left) hip and Lt shoulder 1 view. Therapy notified for reacher. DNP-O notified of fall Message left for POA (power of attorney) and community care ___ updated. New order to cleanse area with NSW (normal saline wash) f/b (followed by) wound gel f/b 4 x 4 gauze f/b abd (abdominal) pad f/b kerlix wrap change twice daily steri strips applied nurse to monitor. R1 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. The nurses note dated 9/5/17 documents Resident has had (2) loose smelly jelly like consistently stools. T (temperature) 98 Sates she sometimes has the chills. Physician-MM aware N.O. (new order) to send stool for C (,[MEDICAL CONDITION].) diff (difficile)& Rx (prescription) to Rt. (right) shin was changed (triangle). Message left for Family Member-NN to ret. (return) call for an update. The physician telephone order dated 9/5/17 documents May send stool for[DIAGNOSES REDACTED] (foul smell, jelly like stools). DC (discontinue) current Rx to Rt. shin skin tear. Cleanse Rt shin skin tear with N/S (normal saline), dry, apply (1) [MEDICATION NAME] (1) abd (abdominal) & kerlix wrap daily at HS (hour sleep) for protection. The nurses note dated 9/5/17 documents Family Member-NN aware of wgt. (weight) loss, N.O. (new order) for med pass & loose stools. Thanked writer. On 9/11/17 at 1:57 p.m. Surveyor conducted a family interview with Family Member-NN. During this interview Surveyor inquired if she is notified of any changes regarding R1. Family Member-NN informed Surveyor the Facility will call her with medication changes but she wasn't notified of the treatment to R1's right lower leg. Family Member-NN informed Surveyor they are usually pretty good with notifying her. On 9/14/17 at 9:52 a.m. Surveyor met with LPN (Licensed Practical Nurse) Manager-J to discuss R1. Surveyor informed LPN Manager-J during R1's record review Surveyor noted R1's treatment to her right shin skin tear was changed. Surveyor noted R1's family member was notified of weight loss, med pass and loose stools she was having but did not see where the family member was notified. Surveyor informed LPN Manager-J Surveyor had spoken with the family member who voiced a concern that she was not notified of the treatment. On 9/19/17 at 10:00 a.m. during the daily exit conference Administrator-A and DON (Director of Nursing)-B were informed of the above.

Based on observation, interview, and record review, the facility did not ensure 7 of 21 sampled Residents' (R7, R3, R1, R5, R12, R18, R19) environments were free from accident hazards in addition to not ensuring adequate supervision and devices to prevent accidents. * R7 had multiple falls at the facility and there was no thorough root cause analysis done for 2 of the 3 falls reviewed. Surveyor observed no Dycem in R7's chair which is a fall prevention intervention for R7. * R3 sustained a skin tear on 9/3/17 when R3 was transferred improperly with only one staff member. * R1 is at risk for falling, and R1's bed was observed left in the high position with no staff present. R1 also did not have the floor mat in place when in bed which is a fall prevention intervention. * R5 had multiple falls with no thorough fall root cause analysis performed by the Facility. * R12 sustained a fall from the bed and fall/safety interventions were observed not in place after the fall. * On 9/13/17, R18 who is at risk for falls, was observed left alone in the bathroom contrary to R18's care plan which states, Do not leave alone in bathroom. * On 8/11/17, R19 who has dementia with behavioral symptoms returned from a hospital emergency room visit. According to staff interview, R19 received IM (Intra muscular injection) Ativan and Haldol while in the emergency room and was returned back to the facility. Knowing R19 received IM Ativan and Haldol, both which may cause increased dizziness and drowsiness, there was no plan to increase the supervision of R19. Shortly upon return, R19 fell and sustained altercation on right side of head and over right eye. R19 was sent back to the hospital on [DATE] and was admitted for observation and a psych evaluation. R19 has exhibited increasingly agitated behavioral symptoms related to dementia, resulting in resident to resident altercations. The facility did not have a comprehensive assessment pertaining to Resident's dementia and behaviors symptoms (F309). The facility responds to these resident to resident altercations upon occurrences however, R19's care plan does not specify the amount of supervision necessary to ensure the safety of R19 and other residents. There is no evaluation as to what situations or conditions may increase R19's potential for such altercations. Findings include: The facility policy entitled, Fall Management & Investigation Program (SNF), revised 10/15/2011 contains the following: Purpose: To utilize all reasonable efforts to provide a system to review the resident's risk potential for falls and provide a proactive program of supervision, assistive devices and interventions to manage and minimize falls and identify resident's continued needs. .Fundamental Information: 1) All residents are considered to be at risk for falls on admission until all review processes are completed and reviewed. 2) A fall care plan and all interventions are to be resident specific. .Procedures Identification process to determine a resident's risk for fall 1) The Data Collection Tool must be completed within 8 hours of admission/readmission, annually, or with significant change in status 2) A fall care plan will be developed within 8 hours of admission, readmission or change in status addressing potential risk factors for all residents (unless resident is deemed a non-risk through the review process). Interventions and Care Plan Process 1) The resident's data tool will be reviewed for potential fall risks. 2) A resident's care plan will be developed by a qualified healthcare professional and will include all identified risks with appropriate interventions. 3) The residents' plan of care will be reviewed and revised in conjunction with the MDS (Minimum Data Set assessment) review, or when there is a significant change in condition or a fall occurs. 4) A resident's care plan will be reviewed and updated with each additional fall which might occur. Post fall: 1) A licensed nurse will evaluate the resident immediately when the fall has occurred . 2) Immediate first aide intervention if indicated. 3) Determination if resident requires urgent care. 4) The attending physician will review the incident, document and if indicated modifies the resident's treatment and interventions accordingly. 5) An incident/accident report must be completed when a resident falls within 24 hours of the accident. Follow-up Post Fall Plan of Care: 1) Fall interventions will be reviewed for continued effectiveness. 2) Interventions will be revised as indicated by the incident and current resident needs. 3) Revised interventions will be routinely reviewed and updated to ensure effectiveness. 4) Interventions will be reviewed with the staff, family and resident for compliance. Investigations: 1) A careful review and analysis of the possible contributing factors to the fall with or without injuries will be completed using QA Post Fall Investigation CL-RS0102.F1 by the QA committee. 2) All falls will be recorded on the appropriate incident report. 3) All resident falls will be investigated, reported, and documented by a qualified healthcare professional. 4) The incident, and all follow-up will be documented in the resident's record. 5) . The Director of Nursing (or designee) will analyze results from trends and patterns in resident falls to use as a basis for implementation of process improvement. Results and process improvement plans are reported to the QA committee. A trend analysis includes, but is not limited to the following: o Time of day that the fall occurred (meal times, change of shift, same shift etc.). o Day of the week (weekdays versus weekends). o What were staffing patterns like (related to shift, staff/resident assignment)? o Location (resident room, common area, nursing unit) The Administrator and the Director of Nursing (or designee) shall as a matter of Quality Assurance conduct a full investigation . 1) R7 had [DIAGNOSES REDACTED]. R7's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated R7 had mild cognitive impairment and severely impaired daily decision making ability. R7's Care Area Assessment (CAA) dated 4/21/17 stated, (R7) is alert and able to make some of his needs known to staff. He has a history of falls with last fall noted on 10/21/16 without injury. Safety measures are in place. He has a bariatric air mattress with mat on the floor. The CAA continues with the decision to care plan marked as yes. The CAA further stated, Will care plan as at risk for falls due to over general decline and (R7)'s limitations to follow safety recommendations. R7's CNA Care Card, with no date, stated: A&O x 2-3 (alert and oriented to person and place and sometimes time). Phy agg (physical aggression). Grabs, shakes, choking, hitting. Remove res to room offer snacks or TV. Impulsive-picks at wounds Fidgeting-Tries to get OOB (out of bed). Enc res to ask for help Non-comp w/safety measures. R7's Safety Interventions list Dycem in w/c (wheelchair) as a safety intervention. On 9/12/17 at 7:27 A.M., Surveyor observed R7 in bed and observed no Dycem placed on or around R7's wheelchair. Surveyor observed cares on 9/12/17 at 8:19 A.M., and observed R7 transferred to the wheelchair and no Dycem was placed at that time. On 9/13/17, at 8:20 A.M., Surveyor observed R7 in bed and no Dycem in R7's wheelchair or in R7's room. R7's Impaired Physical Mobility with Potential for Injury care plan initiated 4/21/17 stated risks including the following evidence: *Weakness *Noncompliance with transfers *Attention seeking puts self on floor *Non-compliant with safety The care plan notes the above risks are related to the following: *Altered cognitive status *History of incidents *Dementia and stroke The goal of the care plan is for R7 to be free from significant injury and be provided a safe environment through 10/2017. The following approaches are listed in order for R7 to achieve the goal: * . encourage to call for assistance with ADL's or transfers *Teach pt. safety precaution as needed * .Body pillows Blue boots at all times *Broda chair *6/21/17 Maintenance to check wheelchair function *6/26/17 Continue with Plan of care (P(NAME)) *7/14/17 Track bowel pattern with 3 day B+B (bowel and bladder). *7/18/17 will assess for front anti-tip bars *8/21/17 education provided to resident to use call light and wait for assistant *9/5/17 continue with P(NAME) Surveyor reviewed R7's Incident report from R7's 8/20/17 fall. The incident report noted a brief description of the incident. The description stated, Resident found on floor mat next to bed with (left) arm over leg of over-bed (sic) table. States was attempting to reach for food on table and fell . Floor wet with spilled over mat (sic) and bowl broken on floor. The report indicated R7 sustained no injury. Attached to the incident report is a form entitled, Additional QA Data for Falls Investigation. The form is not signed or dated. The form indicated R7 was found to be incontinent of bowel and bladder at the time of the fall. The form continues to list interventions to prevent future falls as, Resident continues to be educated to use call light+ wait for staff to assist. Attached to the incident report is an additional form entitled, Quality Improvement Post Fall Investigation, and the form refers to R7's 8/20/17 fall. There is no signature and no date listed on the form. The form is blank and marked with * next to the question, Last time resident was toileted. There is no evidence the facility assessed R7's incontinence at the time of the fall to be a contributing factor to the fall and the facility did not assess the last time R7 was toileted. As noted in the above listed CAA assessment from 4/21/17, R7 is able to make some needs know. The intervention listed after the 8/20/17 fall was to educate R7 to use the call light and wait for help. Surveyor reviewed R7's fall incident report from 9/5/17. The description stated, CNA heard resident yelling out. CNA walked to room found resident sitting on floor on mat. The incident report indicated R7 sustained no injury. The incident report was not signed and no date was noted. The Quality Improvement Post Fall Investigation, with no signature or date noted, indicated R7 was last seen and assisted with toileting at 12:00 A.M. The form indicated R7 was checked on at 1:40 A.M. The form also indicated slippers and a floor mat were the interventions in place at the time of the fall. The additional QA Data for Falls Investigation form, with no date or signature indicated R7 was wearing gripper socks and was not incontinent of at the time of the fall. A nursing note is attached to the fall investigation that states, Regarding (R7) Fall 9/5/17 Was resident incontinent 2:30 A.M 9/5/17. There is a circle around yes. The form additionally indicated the body pillow was in place at the time of the fall. There is no evidence the facility assessed R7's incontinence related to the 9/5/17 fall. There is no evidence a through root cause analysis was performed to analyze the circumstances around R7's fall. The intervention for R7's 9/5/17 fall was to continue with the plan of care, but there is no evidence R7's safety interventions were thoroughly assessed and updated in order to maintain a safe environment for R7. The above concerns were shared with the facility Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A on 9/19/17 at 11:00A.M. After the meeting on 9/19/17, DON-B indicated DON-B observed no Dycem in R7's wheelchair, but personally placed Dycem in R7's wheelchair for safety. No additional information as provided to Surveyor. 2.) Surveyor reviewed R3's medical record on 9/11/17 to 9/14/17. The significant change MDS (minimum data set) with an assessment reference date of 7/24/17 and signed as complete on 7/31/17 documents a BIMS (brief interview mental status) score of 3 which indicates severe impairment. R3 requires extensive assistance with one person for bed mobility & toilet use, extensive assistance with two plus person physical assist for transfers, and does not ambulate. The nurses note dated 9/3/17 documents Resident was transferred back to bed with caregiver & caregiver states she sustained a skin tear to left lower leg. Shaped like this (U shaped) 5 cm (centimeters) across edges well approximated & steri strips applied. NP (Nurse Practitioner)-GG & (name of son) updated. Resident offers no c/o (complaint of) pain. BP (blood pressure) 110/66, 76, 16, 97.2 Ax (axillary). On 9/13/17 at 3:58 p.m. during the daily exit conference with Administrator-A and DON (Director of Nursing)-B Surveyor requested the Facility's investigation for the skin tear R3 sustained on 9/3/17. On 9/18/17 at 7:06 a.m. Surveyor received R3's incident report for date of incident 9/3/17. Under brief description of incident documents Sustained a 5 cm (centimeter) skin tear to left lower leg during a transfer. She was transferred with (1) assist & she is a (2) assist. Under final outcome/disposition documents CNA (Certified Nursing Assistant) education. Attached to the incident report is an education acknowledgement form dated 9/7/17 which documents under summary of training CNA (Certified Nursing Assistant)-II & I spoke about the information contained on the care cards and the importance of following the transfer status. On 9/18/17 at 9:58 a.m. Surveyor met with LPN (Licensed Practical Nurse) Manager-J to discuss R3. Surveyor informed LPN Manager-J during R3's record review Surveyor noted R3 sustained a skin tear on 9/3/17 while being transferred to bed. LPN Manager-J informed Surveyor the CNA transferred R3 by her self and she educated the CNA on following the Resident's care card. Surveyor asked if R3 should have been transferred with an assist of 2. LPN Manager-J replied yes. Surveyor inquired when R3's transfer status changed from one assist to two assist. LPN Manager-J informed Surveyor 8/23/17. Surveyor asked LPN Manager-J when she spoke with the CNA did the CNA say why she transferred R3 by her self. LPN Manager-J replied no. Surveyor informed LPN Manager-J Surveyor has a concern as the CNA did not follow R3's care card and sustained a 5 cm skin tear. On 9/19/17 at 10:00 a.m. during the daily exit conference Administrator-A and DON-B were informed of the above. 3.) Surveyor reviewed R1's medical record on 9/11/17 to 9/14/17. R1 was originally admitted to the facility on [DATE] and was hosptalized on [DATE] to 8/29/17. R1 has a history of falls and started receiving hospice services on 8/29/17. The hospice progress note dated 8/29/17 documents under summary of care admitted to Horizon ordered bedside mats, oxygen 1-5 lpm (liters per minute). The significant change MDS (minimum data set) with an assessment reference date of 9/5/17 and signed as complete on 9/11/17 documents R1 requires extensive assistance with one person physical assist for bed mobility, transfers, & toilet use, and does not ambulate. R1 is frequently incontinent of bladder and always incontinent of bowel. The fall CAA (care area assessment) dated 9/12/17 under analysis of findings documents R1 is recently readmitted to long term care under hospice services. She had a fall prior to her hospitalization which did not result in any fractures. She has not had any falls upon her return. She requires extensive assistance with all her ADL's (activities daily living). She remains alert and able to communicate her needs. Potential for falls remains d/t (due to) bowel and bladder incontinence, decline in ADL function and mobility. She requires extensive assistance with toileting and transfers. On 9/11/17 at 9:17 a.m. during the initial tour, Surveyor observed R1 in bed on her left side. Surveyor observed the left side of the bed is against the wall, the bed is in a low position and there is a folded mat approximately two feet from the foot board. On 9/11/17 at 12:18 p.m. Surveyor observed R1 in bed on her left side. Surveyor observed the left side of the bed is against the wall, there is a mat on the floor on the right side and the bed is in a low position. On 9/12/17 at 7:40 a.m. Surveyor observed R1 in bed on her back. Surveyor observed the bed is in the low position and the floor mat is folded up by the wall. On 9/12/17 after finishing morning cares at 8:46 a.m., CNA (Certified Nursing Assistant)-U placed the mat on the floor along the right side of the bed. On 9/12/17 at 10:17 a.m. Surveyor observed R1 in bed on her back. Surveyor observed the bed is in the low position and the floor mat is by the side of the bed. On 9/12/17 at 11:06 a.m. Surveyor observed CNA (Certified Nursing Assistant) Restorative-UU enter R1's room. R1 informed CNA Restorative-UU that she has to go to the bathroom. CNA Restorative-UU informed R1 she has a bed pan. CNA Restorative-UU removed the bedding, raised the height of the bed and unfastened R1's incontinence brief. CNA Restorative-UU assisted R1 with rolling to her left, placed the bed pan under R1 and R1 was assisted on her back. CNA Restorative-UU asked R1 if she was comfortable, asked if she wanted water, removed her left glove and gave R1 a drink. At 11:12 a.m. CNA Restorative-UU informed R1 she was going to get her something, washed her hands and left the room. Surveyor observed when CNA Restorative-UU left R1's room the mat was not placed down and the bed was in a high position. At 11:15 a.m. CNA Restorative-UU returned with a glass of water & foam toothbrushes. At 11:17 a.m. CNA Restorative-UU asked R1 if she was ready to get off the bed pan. R1 indicated she wasn't. At 11:22 a.m. CNA Restorative-UU informed R1 she would be back and left the room. Surveyor observed when CNA Restorative-UU left R1's room the mat was not placed down and the bed was in a high position. At 11:25 a.m. CNA Restorative-UU returned to R1's room, washed her hands and placed gloves on. CNA Restorative-UU washed R1's frontal perineal area, rolled R1 to her left side, and removed the bed pan. CNA Restorative-UU rinsed the bed pan, removed her gloves, washed her hands. CNA Restorative-UU stated she needed more wash cloths and left R1's room. Surveyor observed when CNA Restorative-UU left R1's room the mat was not placed down and the bed was in a high position. At 11:34 a.m. CNA Restorative-UU returned with basin and towels. On 9/13/17 at 7:07 a.m. Surveyor observed R1 in bed on her left side. The bed was in the low position and Surveyor observed the mat is not next to R1's bed. On 9/14/17 at 7:23 a.m. Surveyor observed R1 in bed on her back. Surveyor observed the bed is in the low position and there is a mat on the floor next to the bed on the right side. On 9/14/17 at 9:52 a.m. Surveyor met with LPN (Licensed Practical Nurse) Manager-J to discuss R1. Surveyor inquired when R1 is in bed should there be a floor mat on the right side. LPN Manager-J informed Surveyor she would have to look into this and get back to Surveyor. Surveyor asked during cares if staff have to leave the room should the bed be lowered down. LPN Manager-J inform Surveyor when staff walk away the bed should be lowered down. Surveyor informed LPN Manager-J of the observations of R1's bed being left in the high position when there was no staff in the room. On 9/18/17 at 9:55 a.m. LPN Manager-J informed Surveyor Hospice brought R1 a bedside mat on 8/29/17 when she was placed on hospice. LPN Manager-J informed Surveyor she wrote a clarification order for the mat to be down. Surveyor inquired how would the nursing staff at the Facility know that hospice brought a mat in. LPN Manager-J informed Surveyor typically hospice writes a telephone order in the chart, the nurse would see the order, and she would update the care card. LPN Manager-J informed Surveyor hospice didn't write a telephone order. On 9/19/17 at 10:00 a.m. during the daily exit conference Administrator-A and DON (Director of Nursing)-B were informed of the above. 4.) R5's medical record was reviewed 9/11 - 9/19/17. R5 had a care plan, initiated 3-23-17, that indicated she had impaired physical mobility related to: weakness, altered cognitive status, Degenerative Joint Disease, and vertigo. R5's transfer status indicated that she needed extensive assistance from two staff and R5's walker was to be used during transfers. FALL 5-27-17 On 5-27-17 at 3:30 PM, the Nurse's Note documented the following information. The CNA reported that, while taking care of R5, R5 sat on the floor and said that she was not going to stand anymore. R5 then lay down on the floor. On 9-13-17 at 11:15 am, RN Manager - I informed the surveyor that the facility had not reviewed R5's fall. A root-cause analysis of the fall had not been completed in an attempt to prevent further falls for R5. FALL 9-8-17 On 9-12-17 at 2 PM, R5's family reported to the surveyor that R5 had fallen on 9-8-17. The facility had completed a root-cause analysis of the fall. It indicated that on 9-8-17 at 10 PM, CNA - OO and CNA - PP were transferring R5 from the toilet. R5 was standing when she said, I'm falling. R5's knees buckled and the CNAs lowered R5 to the floor. R5 was not injured. Although the facility had completed a root-cause analysis; it was not complete. It did not indicate if R5 was transferred in accordance with her care plan, which indicated that her walker was to be used. On 9-13-17 at 10:20 am, RN Manager - I was interviewed. RN Manager - I confirmed that the investigation did not indicate whether or not R5's walker was used during the transfer. RN Manager - I and the surveyor then reviewed R5's Nurse's Notes. The note indicated that R5 had been holding on to grab bars when she fell . RN - I then suggested that she and the surveyor speak with CNA - PP, who was currently working. CNA - PP, RN - I, and the surveyor went to R5's bathroom and CNA - PP re-enacted the fall. CNA - PP said that the walker was not used during the transfer on 9-8-17 because there is not enough room in the bathroom for the walker. CNA - PP also said that R5 is too weak to use the walker and seems to need a Hoyer Lift (mechanical lift) for transfers. CNA - PP said that nursing staff had been informed of the concerns regarding R5's inability to use the walker. RN Manager - I then informed the surveyor that she had planned to have R5 evaluated by the therapy department as part of the post-fall intervention. (This was also documented on the facility's root-cause analysis form dated 9-12-17.) On 9-14-17 at 7:55 am, RN Manager - I said that R5 had been evaluated by therapy. It was determined that R5 should be transferred using the Hoyer Lift. RN Manager - I indicated that R5's care plan had been updated to reflect the change and provided a copy to the surveyor. In summary, R5 had a fall on 5-27-17 and the facility had not completed a root-cause analysis of the fall in an attempt to prevent further falls for R5. R5 also had a fall on 9-8-17. Although the facility had completed a root-cause analysis, it was not complete. It did not assess whether or not R5's transfer had been completed in accordance with her care plan, which indicated that R5 should be transferred using her walker. After this was questioned by the surveyor, CNA - PP reported that R5 was too weak to use the walker. 5.) Surveyor reviewed R12's medical record from 9/11/17 to 9/19/17. R12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R12's MDS (Minimum Data Set) dated 8/21/17 documented a BIMS (Brief Interview for Mental Status) score of 12, indicating that R12 is moderately cognitively impaired. Section G (Functional Status) documents that R12 requires extensive assistance and a one person physical assist for her bed mobility and transferring needs. Section G0300 (Balance During Transfers and Walking) documents that R12 is not steady when moving from a seated position and is only able to stabilize herself with staff assistance. R12's Falls CAA (Care Area Assessment) with assessment reference date of 8/21/17 documents, R12's potential for falls remains due to weakness, extensive assistance needed in mobility, frequent incontinence and history of seizures. R12's Impaired Physical Mobility/Falls plan of care dated 7/18/17 documents, Bilateral body pillows; encourage soft cushion helmet when up. R12's Impaired Physical Mobility/Falls plan of care dated 7/18/17 documents, Minimal A (assistance) for transfers with gait belt and helmet on; bilateral body pillows; encourage soft cushion helmet when up and soft touch call light. Surveyor noted that the interventions listed on R12's Impaired Physical Mobility plan of care did not include documentation to reflect the date each intervention was implemented. R12's fall investigation for fall on 7/28/17 documents under the Interventions to Prevent Future Falls section, Helmet in place; body pillows in bed and soft touch call light. R12's CNA (Certified Nursing Assistant) care card dated 9/7/17 documents under the Safety Interventions section, Bilateral body pillows; soft touch call light and soft cushion helmet when up if tolerating. ADL (Activities of Daily Living) area documents, Soft cushion helmet when up. On 9/11/17 at 12:32 p.m., Surveyor observed R12 not wearing her soft cushion helmet as documented in R12's Impaired Physical Mobility plan of care. The soft cushion helmet was attached to the back of the wheelchair and out of R12's reach. On 9/12/17 at 7:16 a.m., Surveyor observed R12 not wearing her soft cushion helmet as documented in R12's Impaired Physical Mobility plan of care. The soft cushion helmet was attached to the back of the wheelchair and out of R12's reach. On 9/12/17 at 10:19 a.m., Surveyor observed R12 not wearing her soft cushion helmet as documented in R12's Impaired Physical Mobility plan of care. The soft cushion helmet was attached to the back of the wheelchair and out of R12's reach. On 9/13/17 at 12:20 p.m., Surveyor observed R12 not wearing her soft cushion helmet as documented in R12's Impaired Physical Mobility plan of care. The soft cushion helmet was attached to the back of the wheelchair and out of R12's reach. On 9/11/17 at 2:04 p.m., Surveyor observed R12 in bed sleeping supine. One body pillow was resting at the foot of her bed lengthwise across the width of the mattress. The second body pillow was under the R12's head being used as a pillow. Surveyor noted that R12's body pillows were not positioned bilaterally as documented in R12's Impaired Physical Mobility plan of care. On 9/11/17 at 3:07 p.m., Surveyor observed R12 in bed sleeping supine. One body pillow was resting at the foot of her bed lengthwise across the width of the mattress. The second body pillow was under the R12's head being used as a pillow. Surveyor noted that R12's body pillows were not positioned bilaterally as documented in R12's Impaired Physical Mobility plan of care. On 9/14/17 Surveyor informed RN (Registered Nurse) Manager-E of above findings. Surveyor asked RN Manager-E how the staff would determine when R12 should wear her soft cushion helmet and how to place her body pillows in bed. RN Manager-E informed Surveyor, the interventions were ambiguous and she would clarify and update R12's plan of care. RN Manager-E informed Surveyor, the soft cushion helmet should be worn when the staff is assisting R12 with transfers, walking and standing in the bathroom out of the wheelchair. RN Manager-E informed Surveyor, the body pillows should be placed on either side of R12 when in bed to define the edges of the bed and prevent falls. On 9/19/17 at 11:18 a.m., during the daily exit conference, Surveyor informed Administrator-A and DON (Director of Nursing)-B of the above findings. No further information was provided as to why the facility did not implement fall interventions to prevent future falls and accidents. 6.) On 9/13/17 at 10:01 am, CNA (Certified Nursing Assistant)-EEE was assisting R18 to the toilet in her room. R18 was situated on the toilet with CNA-EEE standing outside the bathroom with the bathroom door closed, leaving only a crack in the door to peek in on R18. When R18 was finished, CNA-EEE stepped inside of the bathroom to assist R18 to wash her hands and ambulate R18 to her chair in her room. At 10:15 am, CNA-EEE came back into the room stating, I can't leave her in her room by her self, lets go for a walk now. R18's Minimum Data Set ((MDS) dated [DATE] indicates 1 fall since admission/entry or reentry or the prior assessment and 2 falls with no injury. The MDS indicates R18 is not steady, only able to stabilize with staff assistance when moving from seated to standing position and when moving on and off the toilet. According to the Care Area Assessment under urinary incontinence dated 7/26/17, R18 is at risk for falls. The Falls Care Area assessment dated [DATE] states Resident has had falls during the look back, poor balance with impaired safety judgement, at risk for falls, potential for injury. According to the current CNA Care Card, not dated, R18 has a background which includes a left hip fracture (surgery on 8/5), dementia with behavior disturbance, late onset Alzheimer's without behavioral disturbance, sundowning at night, talks to people who are not there, delirium. The CNA care card indicates toileting transfer with moderate 2 person assistance. Under Safety Interventions, the CNA Care Card states, Resident not to be left alone in bathroom. According to R18's care plan for Impaired Physical Mobility with Potential for Injury dated 8/16/17, an approach on the care plan states, Do not leave alone in the bathroom. On 9/13/17, CNA-EEE was observed assisting R18 to transfer self off the the toilet with 1 person assistance, and not per 2 person assist as per CNA Care Card directions. On 9/13/17, CNA-EEE was observed leaving R18 alone in the bathroom while CNA-EEE peered in to check on her. On 9/18/17 at 10:45 am, Rehab Director -Q was observing CNA-EEE transfer R18 to the bathroom. During this time CNA-EEE stated R18 gets agitated with 2 person assist referring to (when transferring to the toilet.) On 9/19/17, the above observation was shared with Administrator A and Director of Nursing (DON)-B. Surveyor asked DON-B what the expectation would be if the care plan stated do not leave unattended in the bathroom. DON-B stated, Inside bathroom as (R18) does get up. Additionally, according to an incident report dated 9/10/17, on 8/5/17 at 2155 (9:55 pm), R18 was self ambulating out of another resident's room when lost balance falling backwards landing on her buttock, then back and finally hitting head on the ground. R18 sustained a 3 cm x 3 cm abrasion/hematoma to the back of her head. First aid was administered by cleansing and applying ice. The physician and POAHC was notified. The facility indicated the scope and severity level was a level 1, no apparent injury or occurrence that results in minor injury. Final outcome/disposition: Continue with P(NAME) (Plan of Care). Attached to this incident report was Additional QA Data for Falls Investigation dated 9/7/17 with conclusion to Continue with P(NAME). A Quality Improvement Post Fall Investigation dated 9/7/17 indicates to continue with P(NAME). An employee statement was obtained and neurological checks conducted. In review of R18's P(NAME) , there is a Health Maintenance Deficit Care plan re-written on 8/10/17. There are various preventative approaches on this care plan such as

Based on observation, staff interview, and record review, the facility did not ensure that 1 (Resident #1) of 2 residents at risk for falls received adequate supervision and assistance to prevent further falls. Resident #1 is at risk for falls. The facility did not: evaluate the effectiveness of implemented interventions, identify the hazards that put Resident #1 at risk for falls (attempts to self-toilet), and implement new interventions to prevent further falls. After falling twice on 10-8-12, Resident #1 sustained a hip fracture. Findings include: Surveyor # reviewed Resident #1's medical record 10/16 - 10/17/12. Resident #1 is [AGE] years old and was admitted to the facility on [DATE]. Resident #1 has [DIAGNOSES REDACTED]. Resident #1's 5-18-12 Initial MDS (Minimum Data Set) noted that she had fallen prior to admission. Resident #1 was also noted to have 2 falls while at the facility. Resident #1 was determined to be at risk for falls. Resident #1 had 4 falls between 8-30-12 and 10-9-12. On 9-1-12 at 1:20 PM, Resident #1 was found in her room on the mat next to her bed. She had previously been in her bed. She sustained a skin tear to her right elbow and steri-strips were applied. When asked about the fall, the resident said that she was "pulled out of bed." According to Resident #1's Fall Care Plan dated 5/12, Resident #1 was to have a mat on the floor next to her low bed. The facility's 9-1-12 Incident/Post Fall Investigation noted that Resident #1 "makes choices to sit on the floor at times." According to the Post Fall Investigation Form, the facility determined that the fall had been evaluated and did not require additional interventions because the resident chose to self-transfer despite being directed not to do so and "mitigation of injury was care planned." However, Resident #1 sustained an injury, despite the use of a low bed with a mat. The facility did not evaluate the effectiveness of the known interventions - the low bed and mat. The facility did not determine how the resident sustained [REDACTED].#1 fall from her bed again. On 9-23-12 at 10:30 am, Resident #1 was found sitting on the floor, outside of the bathroom in her room. She sustained no injury. When asked about the fall, the resident said that she had used the bathroom and had removed her chair alarm. According to Resident #1's Fall Care Plan, with interventions noted through 8-6-12, she was to have a 1/2 lap tray on her wheelchair, an alarm on her wheelchair, and an alarmed self-release seat-belt. The facility's 9-23-12 Incident/Post Fall Investigation Form, noted that the fall had been evaluated and required the following interventions. Resident #1 was to be toileted at 10:30 am, after breakfast and it was noted that she was also being seen by the therapy department. However, the facility did not evaluate the effectiveness of the known interventions - the 1/2 lap tray, the chair alarm, and the alarmed seat belt. The facility did not determine if these interventions were in place at the time of the fall, why they did not prevent Resident #1 from falling and in light of that information, what new interventions might be appropriate. Resident #1 said that she had removed the alarm. There is no information which alarm she removed - the chair or seat belt? There is no information documenting if either of the alarms were sounding and why or why not? The facility did not determine if the resident did indeed remove an alarm and, if so, were alarms an appropriate intervention to prevent further falls? Additionally, the intervention to toilet the Resident at 10:30 am was not documented on the 9/12 CNA care card; nor was it documented on Resident #1's Care Plan that was updated on 9-23-12. On 10-8-12 at 1:10 PM, Resident #1 was found sitting on the bathroom floor in her room. No injury was observed. When asked, the resident said that she was trying to toilet herself. According to Resident #1's Fall Care Plan, she had the same interventions, as noted above. This included a 1/2 lap tray on her wheelchair, an alarm on her wheelchair, and an alarmed self-release seat belt. The facility's 10-8-12 Incident/Post Fall Investigation Form, noted that there was no pattern to the falls, even though this was the second fall Resident #1 had while she was trying to toilet herself. The form also noted that the fall had been evaluated and required the following interventions: A UA (urine analysis) was ordered to determine if Resident #1 was experiencing confusion. However, the facility did not evaluate the effectiveness of the known interventions - the 1/2 lap tray, the chair alarm, and the alarmed seat belt. The facility did not determine if these interventions were in place at the time of the fall, why they did not prevent Resident #1 from falling, and in light of that information, what new interventions might be appropriate. On 10-8-12 at 6:30 PM, Resident #1 was found sitting on the bathroom floor in her room. The resident had attempted to transfer herself to the toilet and was incontinent of urine. Initially, it appeared that the resident sustained [REDACTED]. On 10-9-12 at 6:10 am, the resident complained of right leg pain. An x-ray was ordered and she was diagnosed with [REDACTED]. She was see by an Orthopedic Surgeon on 10-10-12 and it was determined that surgery was not needed. Review of Resident #1's Nurse's Notes indicate that Resident #1 experienced pain and change in routine post fall: ~10/9/12 13:00 (1:00 pm): Res. (resident) continues to display slow, sluggish movement and response. Res, c/o pain to right side, hip and knee... ~10/9/12 17:00 (5:00 pm): Resident son in to visit, able to help resident eat supper. Resident tearful at this time, states "I will get better." ~10/9/12 20:30 (8:30 pm): Resident c/o right hip pain, Tylenol 650 mg given will continue to monitor. ~10/10/12 11:35 am: F/u (follow up) right hip fracture: Resident continues with alignment on left side, Tylenol 650 mg given earlier this am with positive results. Resident states pain is returning to right hip rating 6/10, N.O (new order) Oxycodone noted. Oxycodone 5/325 given at this time. No seizure activity... ~10/10/12 17:45 (5:45 pm): Resident c/o right hip pain. Pain 8/10 scale. Oxycodone 5-325 mg given at this time. Will continue to monitor. ~10/11/12 02:00 am: Resident crying as states having right hip pain... ~10/11/12 13:05 (1:05 pm): Resident in bed at this time, resident received Oxycodone 5/325 at 9:50 for sharp pains to right hip prior to therapy... ~10/11/12 21:00 (9:00 pm): Resident remained in bed per request. Appetite poor... ~10/16/12 19:30 (7:30 pm): ...Writer fed resident... Resident #1's Fall Care Plan, updated 9-23-12, noted the following interventions: 1/2 lap tray on her wheelchair, an alarm on her wheelchair, and an alarmed self-release seat belt. The facility's 10-9-12 Incident/Post Fall Investigation Form noted that there was no pattern to Resident # 1's falls, even though this was the third fall that Resident #1 had while attempting to toilet herself. The form also noted that the fall had been evaluated and required the following interventions: Resident #1 was scheduled to see the Orthopedic Surgeon on 10-10-12 for further assessment of her hip fracture. The facility did not evaluate the effectiveness of the known interventions - the 1/2 lap tray, the chair alarm, and the alarmed seat belt. The facility did not determine if these interventions were in place at the time of the fall, why they did not prevent Resident #1 from falling, and in light of that information, what new interventions might be appropriate. There were no updates made to Resident #1's Fall Care Plan. Surveyor # observed Resident #1 on 10-16-12 and 10-17-12. She continued to have the same fall interventions as noted above. When in bed, she had a low bed and a mat on the floor. When she was in her wheelchair, she had a 1/2 lap tray, chair alarm, and an alarmed self-release seat belt. On 10-17-12 at 4 PM, Surveyor # reviewed the preceding information with the Administrator, Director of Nursing, and Corporate Consultant - C. The DON said that all interventions to prevent falls for Resident #1 had been attempted and all were unsuccessful. The DON said that the facility's Medical Director had said that Resident #1's falls were "medically unavoidable." The DON said that the only other option would be to provide 1:1 staff supervision for Resident #1. Corporate Consultant - C said that no new interventions had been implemented after Resident #1's last fall on 10-8-12, because the resident had a decrease in her mobility. The resident used to independently propel herself about the facility and she no longer did this. The Consultant and DON implied that because the resident's mobility needs had decreased, her safety needs had also decreased. The consultant said that the resident had a significant change in her condition and the facility had 14 days to evaluate Resident #1's significant change in condition. Surveyor # agreed that Resident #1 was not propelling her wheelchair about the facility and therefore her mobility had changed. However, Surveyor # was unsure how Resident #1's safety needs had changed and how the facility had evaluated this, i.e., how did the facility know that Resident #1 would not attempt to transfer herself to the bathroom and sustain another fall. Surveyor # confirmed that the facility had 14 days to evaluate Resident #1's significant change; but the facility did not have 14 days to address Resident #1's safety needs related to her repeated falls.

Based on observation, staff interview, record review and policy review, the facility did not maintain and implement an infection control program designed to prevent the development and transmission of infection. The Facility's infection control program failed to prevent the spread of a gastrointestinal illness because the facility did not recognize an outbreak of GI (gastrointestinal) illness at the facility when three Residents on the Galleria North developed signs/symptoms of GI illness on 2/9/12. The facility did not implement their infection prevention and control program and did not: ~Follow their policies and did not implement their established procedure for tracking all residents with signs/symptoms of acute gastroenteritis. The Facility did not follow their policies to immediately implement appropriate precautions when multiple residents on a common unit presented with symptoms of acute onset of diarrhea and/or vomiting. ~Notify the infection preventionist of an outbreak until 2/11/12 when approximately twenty Residents had had become ill with the GI signs and symptoms. ~Ensure that Residents who exhibited GI signs and symptoms were isolated to their rooms for 48 hours after their last symptom. ~ Place isolation signs on or near the Residents door to ensure that staff implemented appropriate precautions. ~Assure that Residents who were identified as currently having GI symptoms were observed eating in the units dining rooms with Residents who were not ill. ~Assure that housekeeping and therapy was using a disinfectant that killed the Norovirus. ~Suspend resident gatherings for group activities in the activities room to ensure that residents who were not ill and had no symptoms were not exposed to residents who were presenting with signs/symptoms of acute gastroenteritis and to prevent further transmission of a potentially infectious agent. ~Develop a line listing for those staff who developed GI signs and symptoms to ensure that staff did not return to work until 48 hours after their last symptom. ~Ensure that the dish machine was reaching appropriate temperature to sanitize. Cross reference F371. This deficient practice has the potential to affect all 158 Residents currently residing in the Facility. The failure of the facility to immediately implement appropriate procedures to limit the transmission of disease created a situation of Immediate Jeopardy, which began on 2/9/12 when the facility did not recognize an outbreak of GI (gastrointestinal) illness at the facility when three Residents on the Galleria North developed signs/symptoms of GI illness. The Administrator, Director of Nursing and Corporate Consultant were notified on 2/14/12 at 1:55 p.m. by Surveyor # that an Immediate Jeopardy situation existed. The finding of Immediate Jeopardy was removed on 2/16/12 and continues at a scope and severity of an F (potential for harm that is not immediate jeopardy/widespread) as the facility continues to implement corrective action related to infection control practices. Examples of continuing noncompliance include: ~Staff did not use proper hand hygiene in 2 of 8 Resident personal cares and 2 of 4 treatment observed. ~The Facility did not calculate and trend baselines for each infection type or causative organisms. Staff only calculated the total number of infections. The facility did not calculate infection rates for their most common infections so baseline rates could be identified and used to quickly identify potential outbreaks. ~ Resident #1 was not accurately listed on the January 2012 Infection Control Log. Resident #1 was admitted to the Facility with MRSA, VRE, and[DIAGNOSES REDACTED]. These infections were not listed on the January 2012 log. Incomplete logs do not present an accurate picture of how many and what types of infections are in the facility. Accurate information is needed to develop interventions to control and prevent future infections. Findings include: MANAGEMENT OF GI OUTBREAK On November 14, 2010, the Department of Health Services, Division of Quality Assurance sent out via email list serve an announcement that directed providers to the link <http://www.dhs.wisconsin.gov/rl_DSL/Publications/pdfmemos/10-033attach.pdf> to view DQA Memo 10-033/Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in WI Long-Term Care Facilities (LTCF). This document notes the following to include, but is not limited to: Facilities are required to maintain an infection prevention and control program that includes a surveillance program for infections common to Long Term Care Facilities (LTCFs) including viral gastrointestinal disease. An outbreak of viral gastroenteritis should be suspected when two or more residents and/or staff develop new onset of vomiting and/or diarrhea within one to two days. On 12/15/10, the Wisconsin Division of Public Health (WDPH) revised the definition to state: an outbreak of viral gastroenteritis should be suspected when three or more cases of illness among residents and/or staff within a 72 hour period with vomiting and diarrhea. A new "case" definition of suspected Norovirus is "3 or more loose stools in a 24 hour period in a resident or staff member and whose symptoms have no other apparent cause." The 5/1/2009, "Recommendations for Prevention and Control of Viral Gastroenteritis Outbreaks in Wisconsin Long-Term Care Facilities" include: Management of Staff and Residents: - Immediate isolation of the resident and restricting access to affected areas is essential; - Confine symptomatic residents to their rooms until 48 hours after symptoms cease. The Wisconsin Division of Public Health (WDPH) recommendations indicate facility staff should use only chlorine bleach or a U.S. Environmental Protection Agency approved disinfectant in controlling Norovirus outbreaks. WDPH notes that " Norovirus outbreaks can be detected early by recognizing the typical symptoms of illness, and can be controlled by promptly implementing aggressive infection control measures to prevent the virus from being transmitted from person to person. When appropriate prevention and control measures are not implemented immediately, outbreaks can continue for weeks causing many illnesses, some hospitalization s and the occasional death from dehydration and other complications of vomiting and diarrhea. " On 2/13/12 at 6:46 a.m., Surveyor # observed the DON (Director of Nursing) coughing as he was passing the Pathway's nurses station. The DON stated, "I'm not sick." The DON proceeded to inform Surveyor # that twelve staff members, four nurses and eight CNA's (Certified Nursing Assistant) called in and there are about thirty Residents sick with GI symptoms but they sent in samples. On 2/13/12 at 6:48 a.m., Surveyor # asked RN (Registered Nurse)-HH and LPN (Licensed Practical Nurse)-II if there were any Residents who currently have GI symptoms on the Pathway unit. LPN-II informed Surveyor # that there are twelve Residents. RN-HH informed Surveyor # that she wore a mask most of the night. LPN-II informed Surveyor # that the Residents had been eating in their room and were on a brat diet (banana, rice, applesauce, and toast). On 2/13/12 at 6:55 a.m., Surveyor # observed a sign on the door leading into the Pathway unit regarding Residents with GI symptoms. The DON informed Surveyor # that they had placed the sign on the door Saturday morning (2/11/12). ~The facility did not place isolation signs on or near the Residents door to ensure that staff implemented appropriate precautions. On 2/13/12 at 6:58 a.m., Surveyor # walked through the Pathway's unit and noted only room [ROOM NUMBER] had an isolation sign on the door with an isolation cart in the hallway. No other Resident rooms had an isolation sign on their door. On 2/13/12 at 6:58 a.m., Surveyor # asked LPN-JJ if there are any Residents who currently have GI symptoms on the Terrace East unit. LPN-JJ informed Surveyor # that the night nurse informed her that Residents #33, #29, #34, #35, & #36 have symptoms. Surveyor # noted that Resident #34's room does not have an isolation sign on the door. On 2/13/12 at 7:04 a.m., Surveyor # asked LPN-Y if there are any Residents who currently have GI symptoms on the Galleria North Unit. LPN-Y informed Surveyor # that Residents #37, #38, & #39 were ill. Surveyor # then toured the Galleria North unit and did not observe any isolation signs on Resident #37, #38, & 39's room. At 7:06 a.m. Surveyor # asked CNA-DD if there were any Residents that she had to wear protective equipment in. CNA-DD informed Surveyor # that for Resident #37 she has to wear a mask and constantly wash her hands. On 2/13/12 at 7:13 a.m., Surveyor # asked RN-KK if there are any Residents who currently have GI symptoms on the Galleria South Unit. RN-KK informed Surveyor # that Residents #40, #41, #42, #43, #44, #45, #46, #6, #18, #47, #48, #7 & #5 have symptoms. Surveyor # then toured the Galleria South Unit and did not observe any isolation signs on the Residents #40, #41, #42, #43, #44, #45, #46, #6, #18, #47, #48, #7 & #5 room doors. On 2/13/12 prior to 7:40 a.m., facility staff informed Surveyor # that 12 residents on the Pathway Unit were experiencing signs and symptoms of a GI infection. At 7:40 a.m., Surveyor # toured the Pathway Unit. Only one room had an isolation sign on the door. The room belonged to Resident #27. Surveyor # had previously observed this isolation sign on Resident #27's door on 2/8/12, prior to the GI Outbreak. On 2/8/11 at approximately 9 a.m., Surveyor # had asked RN-R about the sign. This sign was not related to the GI outbreak. RN - R said that the isolation sign had been posted because Resident #27 had a VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]) infection in her urine. On 2/13/12 (Monday) at 8:45 a.m., Surveyor # spoke with Resident #4 who was in bed to inquire about her weekend. Resident #4 informed Surveyor # that she started vomiting and had diarrhea on Saturday and the diarrhea continued on Sunday. Surveyor # observed there is no isolation sign on Resident #4's door. On 2/13/12 at 1:34 p.m., Surveyor # interviewed RN-D. Surveyor # inquired why Residents ' rooms didn't have isolation signs. RN-D replied, "We should have signs on the doors." On 2/15/12 at 9:04 a.m., Surveyor # asked RN-QQ if there were any new Residents who came down with the GI symptoms on the Galleria North unit. RN-QQ informed Surveyor # that Residents #1 & #49 were ill. At 9:04 a.m., Surveyor # observed that Resident #49's door does not have an isolation sign. ~ The infection preventionist was not notified of an outbreak until 2/11/12 when approximately twenty Residents had become ill with the GI signs and symptoms. On 2/13/12 at 1:34 p.m., Surveyor # interviewed RN-D, who is responsible for infection control at the Facility, to inquire about the Residents who had GI symptoms. RN-D informed Surveyor # that he received a phone call Saturday (2/11/12) about 6:00 a.m. from the night supervisor that were about 20 Residents with vomiting and diarrhea. Surveyor # asked RN-D when the symptoms began? RN-D stated late Friday night (2/10/12) and there were a couple emeses on Thursday (2/9/12). RN-D stated that he came into the Facility and inserviced the staff working on Norovirus and hand washing. Housekeeping called in extra staff, and he attempted to call the Health Department, Residents were kept in their room, were given a clear liquid diet and a sign was placed on the door into the first floor unit and receptionist about the outbreak. RN-D stated he told staff to follow contact isolation, wear a mask if the Resident had emesis but gowns and gloves were automatic. Surveyor # inquired why he wasn't notified until 20 Residents were sick. RN-D replied that the symptoms must have come on all together. Surveyor # asked if he had a list of Residents who became ill on the 2/11/12. RN-D informed Surveyor # that when he came in on Saturday he gave each unit papers to start a line listing. Surveyor # asked RN-D who currently has GI symptoms. RN-D stated, "Just what's on these sheets." RN-D explained that when he gave the nurses the sheets on Saturday he thought that staff would continue with the line listing on one sheet. Instead the nurses started a new sheet every shift since Saturday. RN-D stated that he has not had time to put the information together as he had been passing medication upstairs since they had a number of nurses call in. RN-D stated that he would have to look at the 24 hour reports with the sheets. On 2/13/12 at 2:12 p.m., Surveyor # asked if he had a line listing of Residents who currently have the GI symptoms. RN-D stated, "They are not filling out sheets correctly" so it doesn't help. RN-D informed Surveyor # that the information would be on the 24 hour reports but he hasn't had time to look. On 2/13/12 at 3:43 p.m., Surveyor # asked RN-D to inquire if he knew who currently has GI symptoms. RN-D informed Surveyor # that he is going to start working on it. On 2/14/12 at 7:18 a.m., Surveyor # met with RN-D. RN-D informed Surveyor # that he took the sheets which were a "mess," sat at the table with the 24 hour reports and went line by line. RN-D showed Surveyor # the line listing stating, "This is what it should have looked like." Surveyor # reviewed the Resident line listing and noted there are 68 Residents listed. Surveyor # noted on 2/9/12 the following number of Residents with GI symptoms: Pathways: 1 Resident Terrace East: 1 Resident Galleria South: 1 Resident Galleria North: 3 Residents. Surveyor # asked RN-D why wasn't the GI outbreak identified as starting on 2/9/12 as there were 3 Residents on one unit with GI symptoms. RN-D informed Surveyor # that he wasn't aware there were 3 Residents on one unit and thought there was only one Resident on each unit. Surveyor # asked if RN-D should have been notified before the 11th. RN-D stated, "They should have." ~The Facility did not follow their policies to immediately implement appropriate contact precautions when multiple residents on a common unit presented with symptoms of acute onset of diarrhea and/or vomiting. On 2/13/12 at 9:45 a.m., MD (Medical Director)-S met with the Survey team. Surveyor # asked if MD-S was notified of Residents with the GI symptoms. MD-S replied that he was aware as some of his patients became ill and he was in the Facility on Sunday. MD-S informed the survey team that they re-educated staff on hand washing, encouraged staff who were ill to stay home and changed Residents diets to clear liquid to reduce the risk of aspiration. Surveyor # asked if the Residents were placed on any type of isolation. MD-S informed the survey team that the Residents were not confined to their rooms. There was GI isolation which was hand washing and appropriate gloves. Surveyor # inquired if staff would have to wear masks. MD-S responded that it was not necessary. Surveyor # inquired why the Residents would not have to be isolated. MD-S indicated that GI was not really spread person to person and usually involved food. Surveyor # inquired if MD-S was involved in the Facility's outbreak policy. MD-S replied "yes" and that the Facility has a history of excellent infection control policies and is superior in the way it is handled. According to the Wisconsin Division of Public Health, " Viruses (norovirus specifically) cause most ...(gastroenteritis) outbreaks, and they are almost always transmitted from person-to-person (including residents, staff, visitors and volunteers). Norovirus can persist in the environment and is resistant to most disinfectants, and as a result contamination of the environment plays a key role in transmission. Only occasionally is an outbreak in a LTCF caused by contaminated food. " WDPH notes that staff should " Wear personal protective equipment to include gloves, and gown (mask and goggles or face shield if vomitus present) upon entry to the room and when in contact with the symptomatic resident. " On 2/13/12 at 7:36 a.m., Surveyor # observed the DON carrying a box of isolation gowns onto the Galleria North unit. Surveyor # overhead the DON instructing staff to use them "judiciously as this is all we have." At 9:11 a.m., on 2/15/12, Surveyor # observed CNA-L enter Resident #49's room without any personal protective equipment. At 9:23 a.m., Surveyor # observed that CNA-L continues to be in Resident #49's room without any personal protective equipment. At 9:25 a.m., Surveyor # asked CNA-L if she was told in report that there were any Residents on isolation that she would have to wear personal protective equipment. CNA-L replied, "No there are no new cases." Surveyor # asked if she had to wear a gown or gloves in Resident #49's room. CNA-L responded, "Nobody in this room. None of the rooms I have." On 2/15/12 at 9:37 a.m., Surveyor # asked if there were any new Residents who came down with the GI symptoms on the Galleria South unit. RN-KK informed Surveyor # Resident #50. At 9:45 a.m., Surveyor # observed Resident #50's room does not have an isolation sign. At 9:46 a.m., Surveyor # asked CNA-H when he takes care of Resident #50 or her roommate does he have to wear a gown or any other personal protective equipment. CNA-H replied, "No." On 2/16/12 at 7:48 a.m., Surveyor # reviewed the Galleria North infection line list provided by the Director of Nursing. Surveyor # observed Resident #39's room did not have an isolation sign on the door. At 7:50 a.m., Surveyor # asked CNA-DD if Resident #39 was on isolation. CNA-DD informed Surveyor # that Resident #39 came off isolation today. Surveyor # asked CNA-DD who told her this. CNA-DD informed Surveyor # her nurse and the Director of Nursing. At 7:50 a.m., Surveyor # reviewed Resident #39's medical record. Surveyor # noted the nurses note dated 2/14/12 at 1300 (1:00 p.m.) documents, "loose stools times two per staff" and at 1600 (4:00 p.m.) documents, "no n/v (nausea/vomiting) loose stools times two this shift." On 2/16/12 at 7:58 a.m., Surveyor # asked the Director of Nursing why Resident #39 was taken off isolation. The Director of Nursing informed Surveyor # that he had reviewed Resident #39's record and hasn't had any symptoms for 48 hours. Surveyor # read the Director of Nursing Resident #39's note dated 2/14/12 at 1:00 p.m. The Director of Nursing informed Surveyor # that he took Resident #39 off about an hour ago and would put Resident #39 back on isolation. ~DINING ROOMS The facility experienced a Gastro-Intestinal (GI) Outbreak that began on 2/9/12. Ill and non-ill residents were allowed to eat both breakfast and lunch together in the same dining rooms and the facility was not taking steps to isolate residents who were ill. On 2/13/12 at 8:30 a.m., Surveyor # observed nineteen Residents in the Galleria South dining room for breakfast. Surveyor # observed that Residents #7, #41, #45, #18, & #47 were in the dining room sitting with other Residents at the dining room table. On 2/13/12 at 9:02 a.m., Surveyor # observed Resident #48 being wheeled into the Galleria South dining room and placed at a table with another Resident who was not identified as having GI symptoms. On 2/13/12 at 11:54 a.m., Surveyor # observed Resident #7 and #18 sitting in the Galleria South dining room near the TV with four other Residents. Resident #7 and #18 were identified as having GI symptoms. On 2/13/12 at 12:23 p.m., Surveyor # observed Resident #18, #7, #45 and #48 in the Galleria South dining room. There was a total of 26 Residents in the dining room. Resident #18, #7, #45, & #48 were identified as having GI symptoms. At 12:37 p.m. Surveyor # observed Resident #47, who was identified as having GI symptoms, eating lunch with another female Resident in the Galleria South dining room. Surveyor # reviewed Resident #18's medical record on 2/14/12 and noted the nurses note dated 2/12/12 documents, "Resident had loose stool early morning. Physician-S aware." The nurses note dated 2/13/12 documents, "Resident alert and responsive some loose noted vs (vital signs) 97.4, 18, 78, 128/76 appetite good." On 2/14/12 at 4:00 p.m., Surveyor # reviewed the Facility's 24 Hour Nursing/Supervisor report dated 2/13/12. Surveyor # noted under the day shift documents, "loose stool noted appetite good." Resident #18 should not have been in the Galleria South dining room. On 2/13/12, Surveyor # asked the Administrator for a list of residents on the Pathway Unit who were experiencing GI symptoms. At 9:50 a.m., Surveyor # received the names of 12 residents who were experiencing GI symptoms. Included in that list were Resident #21 and Resident #28. Earlier on 2/13/12, facility staff had told Surveyor # that Resident #29, who lived on the 1 East Unit was also experiencing GI symptoms. On 2/13/12 at 8:20 a.m., during the breakfast meal, Surveyor # observed Resident #21, who was noted to be experiencing GI symptoms, eating in the first floor dining room with 11 other residents from the first floor who were non-ill and were not experiencing GI symptoms. Additionally, the facility allowed Resident #17, who lived on the second floor and was not ill, to eat in the first floor dining room with Resident #21, who lived on the first floor and was ill. On 2/13/12 at 12:15 p.m., during the lunch meal, Surveyor # observed Resident # 21, #28, and #29 all who were noted to be experiencing GI symptoms, eating in the first floor dining room with 12 other residents from the first floor who were non-ill and were not experiencing GI symptoms. Additionally, the facility allowed Resident #17, who lived on the second floor and was not ill, to eat in the first floor dining room with Resident #21, #28, and #29 who lived on the first floor and were ill. On 2/13/12 at 1:34 p.m., Surveyor # interviewed RN-D, who is responsible for the facility's infection control program. Surveyor # asked how long should Residents stay in their room. RN-D informed Surveyor # that they should stay in their rooms until 48 hours after their last symptoms. Surveyor # informed RN-D of observations of Residents being in the dining room and activities. RN-D informed Surveyor # that he would have to look at their medical records. On 2/13/12 at 2:05 p.m., Surveyor # met with RN - D, RN-D confirmed that Resident #21 and #28 had been placed on the facility's infection control log as experiencing GI symptoms. The date of onset for these residents had not been noted. RN-D confirmed that Residents #21 and #28 should not have been eating in the dining room. The facility began their infection control log on 2/11/12 and therefore neither of these residents would have been symptom free for 48 hours when they were observed on 2/13/12 in the dining room. ~ACTIVITIES The facility did not suspend resident gatherings for group activities in the activities room to ensure that residents who were not ill and had no symptoms were not exposed to residents who were presenting with signs/symptoms of acute gastroenteritis and to prevent further transmission of a potentially infectious agent. On 2/13/12 at 9:00 a.m., Surveyor # interviewed RA (Recreation Assistant)-LL to inquire what activities will be occurring. RA-LL informed Surveyor # that the entertainer Elvis was canceled. RA-LL informed Surveyor # that she wasn't sure if it was because there are some Residents sick or he may be sick. RA-LL informed Surveyor # that they are going to continue with the activities that are on the calendar. Surveyor # reviewed the calendar and noted the following activities are scheduled for 10:30 a.m. Trivia on Terrace East, Valentines Craft in Recreation room, and Oh Shout in Galleria North. At 2:30 p.m. Name Game is scheduled in Galleria North, Glamour in Pathways, Penny Ante in Recreation room, and Crafty people in Galleria South. On 2/13/12 at 10:28 a.m., Surveyor # observed RA-LL conducting an activity in the Galleria South dining room. Surveyor # observed there were twelve Residents in the activity including Resident #41, #45, and #18 who were identified as being ill with GI symptoms. Surveyor # observed Resident #7 watching TV near the group activity. Resident #7 was identified as having GI symptoms. On 2/13/12 at 10:48 a.m., Surveyor # observed RA-MM conducting a group activity in the Galleria North dining room with nine Residents. On 2/13/12 at 10:35 a.m., Surveyor # observed a trivia activity in the facility's Recreation Center. Resident #32, who lived on the second floor, was observed at the activity with 3 other residents from the first floor. Although none of these residents were noted to be experiencing GI symptoms, the facility did not attempt to contain the infection by limiting resident activity to their specific units. On 2/13/12 at 1:34 p.m., Surveyor # interviewed RN-D and asked why group activities continued on the units. RN-D informed Surveyor # that each activity staff member works on the same unit and there are a "high number of not ill Residents that want them." On 2/15/12 at 7:35 a.m., CC (Corporate Consultant)-C informed Surveyor # that yesterday there were four additional Residents who became ill with the GI signs and symptoms. CC-C informed Surveyor # they implemented the corporation ' s Norovirus policy and procedure. CC-C explained that they canceled activities, are having Residents stay in their rooms, and placed isolation signs on the doors. Surveyor # asked CC-C why this policy was not implemented prior. CC-C informed Surveyor # that there were some things that she had instructed the Facility to do but they did not follow through. ~HOUSEKEEPING The facility did not ensure that housekeeping was using a disinfectant that killed the Norovirus for resident rooms who were in isolation. On 2/13/12 at 11:04 a.m., Surveyor # interviewed Housekeeper-NN to inquire what was in her bucket. Housekeeper-NN informed Surveyor # it was "Virex." Surveyor # asked what she cleaned with the Virex. Housekeeper-NN replied the bathroom, night stands, and tables. Surveyor # asked if there was anything else other than the water and Virex. Housekeeper-NN informed Surveyor # only Virex. Surveyor # asked Housekeeper-NN if she was given any instructions on cleaning the Residents ' rooms today. Housekeeper-NN stated, "No." Surveyor # asked Housekeeper-NN how often she changes the water for cleaning the floor. Housekeeper-NN stated, "Twice a day." Surveyor # asked how she knows when to change the water. Housekeeper-NN stated, "When it's dirty." On 2/14/12 at 8:35 a.m., Surveyor # asked HD (Housekeeping Director)-K if Virex contained bleach. HD-K informed Surveyor # that it does not contain bleach but they have a bleach cleaner that they use. Surveyor # asked if she was notified of the GI outbreak. HD-K informed Surveyor # that she was and that she had instructed her staff to use Virex and bleach. Staff is supposed to wipe down everything including over bed tables, door knobs, and hand rails. Surveyor # inquired which rooms staff should clean first. HD-K informed Surveyor # that the housekeepers should first do the Resident rooms with symptoms then do the regular rooms. Surveyor # asked how often they should change the buckets that they wash the floors. HD-K informed Surveyor # they should change the water every four rooms for regular rooms and for isolation rooms after each room. Surveyor # informed that during an interview with one of her housekeepers, the staff member informed Surveyor # that she was using only Virex. ~STAFF ILLNESS/ LINE LISTING The facility did not develop a line listing for those staff who developed GI signs and symptoms to ensure that staff did not return to work until 48 hours after their last symptom. On 2/13/12 at 1:08 p.m., Surveyor # interviewed Scheduler-OO inquiring as to whom staff call into when they are sick. Scheduler-OO informed Surveyor # that nursing staff would call in to the supervisor and other departments would call into their Department heads. Scheduler-OO indicated that if the nursing supervisor is busy then the receptionist would give her the call. Surveyor # asked when staff call in, are they required to inform the Facility of their symptoms? Scheduler-OO replied, "They are supposed to." Surveyor # asked if there were any staff who called in with GI symptoms? Scheduler-OO informed Surveyor # that RN-D would know but thought there were about five employees. Surveyor # asked when staff have GI symptoms when can the staff come back to work? Scheduler-OO informed Surveyor # that staff is supposed to stay out until 48 hours after their last symptom. On 2/14/12 at 7:32 a.m., Surveyor # asked RN-D if he has a line listing for staff who have been ill with the GI symptoms. RN-D replied, "Yes." Surveyor # asked if Surveyor could see the list. RN-D showed Surveyor # copies of call in slips. Surveyor # noted there were 4 call in slips for 2/13/12, 2 call in slips for 2/12/12 and 2 call in slips for 2/11/12. Surveyor # informed RN-D that Surveyor # was informed that there were four nurses and eight CNA's that called in 2/13/12 but RN-D only has 4 call in slips. RN-D informed Surveyor # that he needs to check the supervisor's book. On 2/14/12 at 8:18 a.m., Surveyor # spoke with CNA -G. Surveyor # informed CNA-G that Surveyor # did not see her yesterday and asked if she was off. CNA-G replied, "No, was sick." CNA-G explained that she called in sick on Sunday as she threw up a couple times and yesterday still was not feeling well and had a fever. On 2/14/12 at 10:23 a.m., Surveyor # reviewed the Facility's daily schedule for 2/12/12 and noted CNA-G's name is circled indicating that CNA-G called in. CNA-G returned to work before she was symptom free for 48 hours. On 2/14/12 at 11:06 a.m., the Survey team met with the Administrator, Director of Nursing, RN-D, and CC-C. Surveyor # asked if the Facility had a line listing for employees who called in sick with GI symptoms. The Director of Nursing informed the Survey team that he doesn't know of any Federal or State regulation and it's not in their policy to have a line listing for employees. Surveyor # inquired how does the Facility ensure staff do not come to work before they have been symptom free for forty eight hours? CC-C informed the survey team that employees receive education on their policies and it is also in the employee handbook. CC-C stated, "There is no line listing." CC-C stated, "You wanted a line listing for employees, we don't have one." CC-C informed the survey team in order for the Facility to compile a line listing for employees she would have to run it by corporate. ~THERAPY The facility did not ensure therapy was using a disinfectant that killed the Norovirus for resident equipment. On 2/14/12 at 8:27 a.m. Surveyor # went to the therapy department to inquire what they clean their equipment with. Therapy-PP informed Surveyor # that they clean the equipment between each Resident with soap & water and wipe with a Sani Cloth Plus. At the end of the day the equipment is sprayed with Virex 256. Surveyor # noted that the Sani Cloth Plus container does not list bleach as one of the ingredients. The Virex 256 bottle label documents "quaternary ammonium compounds" and does not list bleach. On 2/14/12 at 3:04 p.m. Surveyor # asked Housekeeping Director-K what housekeeping cleans in the therapy department. Housekeeping Director-K informed Surveyor # that they clean the floors, bathroom, and take out the trash. Housekeeping Director-K informed Surveyor # they don't do any equipment. Therapy cleans the equipme

Based on observation, interview, and record review, the facility did not distribute food under sanitary conditions. * The facility did not properly sanitize dishes during a GI (Gastro-Intestinal) outbreak that occurred at the facility starting on 2/9/12 and in which approximately 72 of 158 residents became ill during this outbreak. * The facility did not date the food items in 1 of 4 refrigerators, where residents stored their personal food. Findings include: 1. The 2009 FDA (Food and Drug Administration) Food Code specifies that the final rinse in the dishwasher should be 180 degrees Fahrenheit. On 2/10/12 at 10:43am, Surveyor # made observations in the kitchen as the dishwasher was used to clean the breakfast dishes. The dishwasher's final rinse temperature registered at 170 degrees Fahrenheit. Dietary Manager- W, was present during this observation. Dietary Manager- W stated that the final rinse temperature should reach 180 degrees, according to the manufacturer's specifications. Dietary Manager - W said he would need to contact the outside company that was responsible for servicing the machine. At this same time, Surveyor # reviewed the facility's "Dish Machine Temperature Log" for February 2012. The final rinse temperature did not reach 180 degrees Fahrenheit on the following six days. 2/05/12: 170 degrees F (Fahrenheit) at breakfast 2/06/12: 170 degrees F at breakfast and lunch 2/07/12: 170 degrees F at breakfast; 165 degrees F at lunch; and 160 degrees at dinner 2/08/12: 160 degrees F at breakfast 2/09/12: 170 degrees F at breakfast; 160 degrees F at dinner 2/10/11: 170 degrees F at breakfast Dietary Manager- W said that he had not been made aware that the dishwasher was not reaching the appropriate rinse temperature on these days. On 2/10/12 at approximately 1:30 p.m., Surveyor # met with Dietary Manager - W and Ecolab Service Rep - X, (service representative providing routine maintenance to the facility's dishwasher.) Service Rep - X said that the facility's "Booster Heater was tripped." Service Rep - X said that he "re-set" the heater and that the dishwasher's rinse cycle was then able to reach 180 degrees Fahrenheit. At this time, the facility's dishwasher was operating. Surveyor # observed the dishwasher rinse cycle, which registered 180 degrees Fahrenheit. On 2/13/12, Dietary Manager - W provided Surveyor # with documentation indicating that on 2/10/12 all dietary staff had been re-inserviced. The purpose of the in-service was to remind staff that when the dishwasher failed to reach the proper rinse temperature, a supervisor must be notified. Surveyor noted that starting on 2/9/12, the facility residents started experiencing a GI (Gastro-Intestinal) outbreak and in which approximately 72 of 158 residents became ill during this outbreak. Among the residents who became ill, but was not limited to were the following Residents # 4, 5, 6, 7, 18, 29, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, and 48. Cross Reference F441. 2. On 2/16/12 at 8:45 a.m., Surveyor # observed in the medication room located in the Galleria unit a refrigeration marked "food items only" the following: A piece of cake for Resident #30 that was not dated. A sandwich in a Ziploc type bag that was not dated and did not have a Resident's name. A plastic container for Resident #31 which contained pasta/vegetables which was not dated. A plastic grocery type bag with a container of cottage cheese & pineapple and a package of Swiss cheese which was not dated and did not have a Resident's name. Surveyor # showed RN (Registered Nurse)-F the food items which were not labeled or dated. RN-F informed Surveyor # that she does not know anything about these food items.

Based on observations, record review and staff interviews, the facility did not always ensure they provided an environment that remains as free from accident hazards as possible and provided adequate supervision and assistance devices to prevent accidents to 5 out of 7 sampled residents ( #26, #11, #10, #20,and #23) who were at high risk for falls. Resident #26 was assessed to be at risk for falls and had several falls at the facility. The facility staff did not always ensure that they assessed for new falls interventions, even after Resident #26 had a fall with injury. Resident #11 is at risk for falls and was observed to be transferred without the use of the gripper socks as per plan of care. Resident #10 is at risk for falls and was observed to be in bed and the mat was not next to the bed as per the plan of care. Resident #20 is at risk for falls and was observed to be left lying in bed, that was in the high position without adequate supervision from staff. Resident #23 is at risk for falls and was observed to be transferred without the use of a gait belt. The facility did not follow through with the use of recommended new falls interventions such as the use of a scoop mattress and to have a new toileting schedule. This is evidenced by: 1. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/9/10 the facility completed the " Fall Risk Review Tool" stating that Resident #26 is moderate risk for falls. According to the plan of care, dated 7/9/10, Resident #26 is at risk for falls and is to have the bed in the lowest position, call light usable wand within reach, all staff to be informed of my fall risk and fall documentation and analysis is completed if fall (s) occur to investigate root cause(s) and other prevention techniques. Nursing note 7/21/10 at 9:30 states that at 9:00 p.m. Resident #26's roommate informed writer that Resident #26 had fallen on the floor at around dinner time. No injuries noted. The interdisciplinary team meet on 7/22/10 and noted that Resident #26 is being seen by physical, occupational, and speech therapy and they will continue to follow Resident #26. Will reeducate Resident #26 on informing staff of falls. It was noted that the plan of care was updated on 7/22/10 to have a mat on the floor next to the bed. According to the "Resident Fall Management Guidelines," dated 10/30/10, the facility staff are to implement an immediate intervention plan to prevent recurrence and they are to utilize the " Fall Investigation Worksheet." On 3/8/11, Surveyor # asked to review the " Fall investigation worksheet" for the fall on 7/21/10. This worksheet was unable to be located by facility staff. Nursing Note 7/26/10 at 6:00 p.m., states that Resident #26 was found on the floor at around 5:30 p.m., holding his wheelchair, spill of water on the floor by him and he tried to refill water by going to the bathroom and slipped and fell . The Interdisciplinary team met on 7/27/10. Therapy will screen for safety with transfers, Speech therapy will work on cognition and safety awareness, will check multistick of urine. Nursing Note dated 7/27/10 at 9:10 p.m. states that Resident #26 was found on the floor in the sitting position, no injuries noted. Mat in place next to bed, continue to monitor. The Interdisciplinary team met on 7/28/10 and indicated that Resident #26 has a mat on the floor, attempts to transfer self with poor safety awareness. Therapy working on transfers, Resident #26 is slightly confused, psych to see patient. Surveyor # conducted further medical record review, noting that Resident #26 had a Psychiatric consultation on 7/27/10, the day before the fall and then another consultation was not conducted until 9/24/10. On 3/9/11 at 9:05 a.m., Surveyor # interviewed Assistant Director of Nursing (ADON)- C who was able to verify that Resident #26 was not provided with a psychiatric consult until 9/24/10. Nursing Note 7/31/10 at 10:05 states that Resident #26 fell from the wheelchair hitting his head on the desk. Resident #26 stated he was trying to get the lady's attention. Physician was notified and new order for 15 minute checks. It was noted that this entry into the nursing notes was written by a Licensed Practical Nurse and that there was no evidence that a registered nurse had assessed Resident #26 after he fell , hitting his head. Surveyor # conducted a review of the facility's " Incident Report Form," dated 7/31/10 which states that Resident #26 had a fall and suffered an abrasion to his right temporal. Nursing Note dated 8/1/10 at 5:30 a.m. is written by a registered nurse and stated that there was follow-up after the fall on 7/31/10 and there is no apparent injuries. The interdisciplinary team meet on 8/2/10 and recommended that Resident #26 has his medications reviewed by pharmacy and therapy is to provide a reacher, Speech Therapy to assess cognition and nurse practitioner to assess patient. It was also noted that Resident #26 was placed on 15 minute checks. It was noted that on 8/2/10 the individual plan of care was updated to list the new interventions. On 8/2/10 the facility conducted the " Fall Risk Review Tool" indicating that Resident #26 was at moderate risk for falls. Nursing Note dated 8/8/10 at 6:30 p.m. states that Resident #26 was found sitting on the floor in front of his wheelchair, " I slid out," wheelchair cushion on edge of seat assisted to bed with 2. A review of the " Falls investigation Worksheet" dated 8/8/10 did not indicate that any new interventions were immediately put into place to prevent further falls. The Interdisciplinary team met on 8/9/10 and noted to have Physical Therapy screen for seating, will add Dycem, pharmacy to review medications. Nursing Note 8/16/10 at 6:00 p.m. states that Resident #26 fell at 5:00 p.m. in the dining hall he was trying to reach salt from the next table and he fell . Laceration noted to right forearm. The Interdisciplinary team met on 8/17/10 and noted that Resident #26 is on the physical therapy caseload and he ambulates with a walker. Intervention is have pharmacy review medications. Resident #26 has Parkinson's [DIAGNOSES REDACTED]. It was noted that after this fall, there was not any new interventions recommended to continue to help Resident #26 and his risk for falling. Nursing Note dated 8/25/10 at 10:40 a.m. states that Resident #26 was found sitting on the floor trying to get into bed, no injuries noted. The Interdisciplinary team met on 8/26/10 and noted that Resident #26 is seen by Physical, Occupational and Speech therapy and that Resident #26 has cognitive impairments and can be impulsive. Intervention will be that Resident #26 will be placed on every 15 minute checks, therapy to evaluate for a drop seat. It was noted that Resident #26 was placed on 15 minute checks, per physician order, on 7/31/10. There was no indication within the medical record that the 15 minute checks had been discontinued. The individual plan of care still stated that Resident #26 was on 15 minute checks. It was also noted that the Interdisciplinary team recommended for physical therapy to evaluate Resident #26's seating in the wheelchair on 8/9/10. On 3/9/11 at 11:08 a.m., Surveyor # interviewed Director of Rehabilitation Services- GG in regards to Resident #26 and his falls and therapy interventions. Surveyor # asked Rehab Director- GG about the screen that was to be done on Resident #26's seating on 8/9/10. Rehab Director- GG, as this time, was unable to provide any documentation that physical therapy had conducted a screen on Resident #26's seating. It was noted that on 8/25/10 a trial was conducted for a drop seat in the wheelchair for Resident #26, and then a trial was started on 8/26/10 for Resident #26 to use a broda chair. On 3/9/11 at 11:45 a.m., Surveyor # interviewed ADON-C in regards to Resident #26 and the use of the 15 minute checks as a fall intervention. ADON- C stated that the 15 minute checks were discontinued on 8/4/10 and she verified this because Resident #26 was no longer on the 24-hour report. ADON- C was not able to provide evidence at this time that a physician order [REDACTED]. The care plan was not updated to take Resident #15 off the 15 minute checks on 8/4/10 and then placed back on the 15 minute checks on 8/26/10. ADON- C was able to verify that there was no additional new interventions put into place after the fall on 8/25/10. Nursing Note dated 8/26/10 at 10:45 a.m. states that Resident #26 was found on the floor at 10:30 a.m. and complained of pain to the right rib-cage and raised area to the right side of head. Cran- checks were initiated and the Nurse Practitioner was updated. Tylenol was given for pain to the rib cage. Nursing note dated 8/26/10 at 2:30 p.m. states that Resident #26 complaining of increased pain and unable to rate the pain, new order for x-ray. Nursing Note dated 8/26/10 at 8:00 p.m. states that Resident #26 was transferred to the hospital after the x-ray concluded that Resident #26 had broken ribs. A review of the "Incident Report" dated 8/26/10, indicates that Resident #26 did have a fall in his room and the final outcome was fracture to the 10th and 11th ribs. The Interdisciplinary team meet on 8/27/10 and stated that the intervention was to have physical therapy assess for a new wheelchair. It was noted that there was no immediate interventions put into place after Resident #26 had returned to the facility on [DATE] with 2 fractured ribs. It was also noted that physical therapy had already been assessing Resident #26 and his wheelchair. It was noted that there was no updates made to the individual plan of care. Nursing Note dated 8/30/10 states that it is a late entry for 8/28/10 at 10:30 p.m. and that Resident #26 was found on the floor next to the bed facing the doorway, no complaints of pain. It was noted that the interdisciplinary team did not meet about the fall on 8/28/10 and that there were no new interventions put into place. The facility staff did not list any new interventions on the " Fall investigation worksheet" dated 8/28/10, and did not update the individual plan of care. It was also noted that there was no Registered Nurse assessment of the fall on 8/28/10 that was documented within the medical record. On 3/9/11 at 9:05 a.m., Surveyor # interviewed ADON- C in regards to the fall on 8/28/10. ADON- C stated that she talked with the facility nurse about the late charting and that at the time of this interview there was no evidence of any new interventions put into place or that a Registered Nurse has assessed Resident #26 after the fall on 8/28/10. Nursing Note dated 8/29/10 at 9:25 p.m. states that Resident #26 had a fall at 8:30 p.m., Resident #26 denies any pain. It was noted that the interdisciplinary team did not meet about the fall on 8/29/10 and that there was not new interventions put into place. The facility staff did not list any new interventions on the " Fall investigation worksheet" dated 8/29/10, and did not update the individual plan of care. It was also noted that there was no Registered Nurse assessment of the fall on 8/29/10 that was documented within the medical record. On 3/9/11 at 9:10 a.m., Surveyor # interviewed ADON- C in regards to the fall on 8/29/10. ADON- C stated, at the time of this interview, there was no evidence of any new interventions put into place or that a Registered Nurse has assessed Resident #26 after the fall Nursing Note dated 8/31/10 a 8:15 a.m. states that at 6:40 a.m. on 8/31/10, Resident #26 was found on the floor with right side of face making contact with the mat. Resident #26 complained of neck pain of a "20" on a scale of 1 to 10., grabbled speech and lethargic initially then wakened and very alert., other injury is an eccomotic area to the right flank 2 by 1.5 inches deep red, assisted by 3 back to bed, Physician notified and order received to send out to hospital. Nursing note dated 8/31/10 at 3:00 p.m., stated that Resident #26 returned to the facility with a stable neck fracture and soft collar in place. Surveyor # reviewed the hospital discharge paperwork form St. Mary's Milwaukee dated 8/31/10. The hospital discharge paperwork indicated that Resident #26 had a stable neck fracture and no surgical intervention was needed. On 3/9/11 at 11:50 a.m., Surveyor # interviewed ADON- C in regards to the falls on 8/28/10 and 8/29/10 and 8/31/10. ADON- C was unable to provide any evidence that the facility had comprehensively assessed these falls and placed new interventions in place to try to stop Resident #26 from falling. It was after these falls, that Resident #26 fell again on 8/31/10 and resulted in a neck fracture. 2. On 3/3/11 at 7:28 a.m., Surveyor # observed CNA-Q (Certified Nursing Assistant) transfer Resident #11 from the bed and onto the wheelchair. CNA-Q applied regular type socks and a gaitbelt and transferred Resident #11 into the wheelchair. On 3/3/11 at 1:53 p.m., Surveyor # reviewed Resident #11's plan of care on Resident #11's bathroom door. The plan of care, dated 1/7/11, indicates to use gripper socks during transfers. On 3/8/11 at 7:14 a.m., Surveyor # spoke with RN-P (Registered Nurse). RN-P indicated that Resident #11 should be using gripper socks with transfers so Resident #11 does not slip during the transfer. On 3/8/11 at 3:20 p.m., Surveyor # shared the observation transfer at the facility exit meeting. No further information was provided. 3. On 3/7/11 at 7:01 a.m., Surveyor # observed Resident #10 dressed in bed. Resident #10's mat was folded in half and stored between the nightstand and bed frame. Resident #10 was in bed without a mat next to the bed on the floor. Resident #10's plan of care, dated 3/11, includes that Resident #10 is at risk for falls. An intervention for this risk is to use a mat on the floor next to the bed. On 3/7/11 at 3:07 p.m., Surveyor # shared Resident #10 not having the mat on the floor while in bed at the facility exit meeting. 4. On 3/9/11 at 7:15 a.m., Surveyor # observed morning cares on Resident #20 by CNA-S (Certified Nursing Assistant). Resident #20 was in a low bed and had a mat on each side of the bed. CNA-S started cares on Resident #20 by raising the bed. CNA-S washed Resident #20's face and nightgown was removed. CNA-S left Resident #20 to obtain soap from the bathroom. Resident #20 was then left alone with the bed raised in a high position. CNA-S then returned from the bathroom and completed upper body cares. CNA-S left Resident #20 to obtain soap from the bathroom. Resident #20 was left alone with the bed in a high position. CNA-S then returned and washed Resident #20 front peri-area. CNA-S left Resident #20 to go into the bathroom and removed her gloves and washed her hands. Resident #20 was left alone with the bed in a high position. CNA-S returned from the bathroom and dressed Resident #20 upper half and half of Resident #20 lower body. CNA-S then left Resident #20 and obtained a container to empty Resident #20 Foley urine bag. Resident #20 was left alone with the bed in a high position. CNA-S then returned to the bathroom and emptied the container in the toilet. CNA-S then removed her gloves and washed her hands in the bathroom. Resident #20 was left alone with the bed in a high position. CNA-S then returned and washed Resident #20's buttocks and applied a new depends. CNA-S then left Resident #20 alone and went into the bathroom. CNA-S emptied a wash basin of water, removed her gown and gloves, and washed her hands. Resident #20 was left alone with the bed in a high position. CNA-S returned and lowered Resident #20 bed. CNA-S indicated that she needed to leave the room to get the lift. On 3/9/11 at 8:50 a.m., Surveyor # spoke with the DON-B (Director of Nurses) regarding bed positions. DON-B indicated that the bed should be in a low position when staff is not at bedside. Surveyor # did share Resident #20 observation of the bed being in a high position. On 3/9/11 at 10:25 a.m. Surveyor # spoke with RN-P (Registered Nurse). RN-P indicated that Resident #20 is a moderate fall risk due to confusion and poor judgement. 5. Resident #23 is an [AGE] year old male admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The CNA (Certified Nursing Assistant) care card for Resident #23 dated 12/10 for transfer assist documents, "1 with gait belt." Under safety devices the care card documents, "keep call light within reach" and "low bed" & "mat on floor" are circled. Under toileting schedule the care card documents, "Staff to assist with toileting upon rising, before & after meals upon HS (hour of sleep) care rounds prn (as needed)." On 3/8/11 at 7:07 a.m., Surveyor # observed CNA (Certified Nursing Assistant)-F place gloves on and move the bedside commode near Resident #23's bed. CNA-F assisted Resident #23 to stand by holding onto Resident #23 arm, and then pulled down the pajama bottoms and incontinence pull up. CNA-F then assisted Resident #23 with sitting on the bedside commode. CNA-F did not use a gait belt when transferring Resident #23. CNA-F placed a new incontinence brief on Resident #23 and informed Resident #23 that she was going to wash him up. CNA-F washed Resident #23's upper body, placed slacks, gripper socks and shoes on Resident #23. CNA-F removed her gloves, washed her hands, and placed new gloves on. CNA-F wet a washcloth and assisted Resident #23 to stand by holding under Resident #23's left arm. Resident #23 stated, "can't hold on too long." CNA-F washed Resident #23's scrotum and buttocks and then pulled up the incontinence product and pants. CNA-F asked Resident #23 to sit down so she could fasten his pants and assisted Resident #23 with sitting back on the commode. CNA-F zipped and fastened Resident #23's pants and pulled down the shirt in the back. CNA-F assisted Resident #23 to stand by holding under his right arm and holding his hand. Resident #23 then shuffled a couple of steps and with the assistance of CNA-F sat in the wheelchair. CNA-F did not use a gait belt when transferring Resident #23 from the commode into the wheelchair. On 3/8/11 Surveyor # reviewed Resident #23's medical record and noted the following: The Resident care plan for "I need assistance with my ADL's (activities of daily living) Dx (diagnosis) legal blindness" with a date set of 12/10 includes an intervention of "I transfer with assist of one & use of gait belt." The fall risk review tool dated 12/4/10 has a total score of "14" which indicates low risk. Surveyor # noted that the vision section was incorrectly scored as "0" adequate (with or without glasses). Resident #23 is legally blind and should have been scored "4" for legally blind (cataracts, visual disturbances) which would have scored him as "18" moderate risk. The nurses notes dated 12/28/10 documents, "Writer in to assess res. (Resident) s/p (status [REDACTED]. found on buttocks sitting next to bed. ROM (range of motion) WNL (within normal limits) to upper lower extremities. LOC (level of consciousness) A & O (alert and orientated) as per usual." The nurses note dated 12/28/10 documents, "IDT (interdisciplinary team) met to review fall from 12/28/10 @ (at) 0500 (5:00 a.m.). Res. on therapy case load. Will check a multistick of urine. Pharmacy to review med. (medication)." The interdisciplinary rehabilitation screening form dated 12/29/10 documents, "Screen for fall 12/28/10 resident stated, "I rolled out of bed onto the floor but I didn't get hurt." Recommend scoop mattress be placed on bed. Pt. (patient) on OT (occupational therapy) PT (physical therapy) case load." On 3/8/11 at 7:07 a.m., Surveyor # did not observe a scoop mattress on Resident #23's bed. The nurses note dated 2/15/11 documents, "Resident was found sitting on buttocks next to bed. Resident states he was trying to take self to bathroom. Call light was not "on." The nurses note dated 2/15/11 documents, "IDT met to review fall. Res. (Resident) to be screened by therapy. Pharmacy to review meds." The interdisciplinary rehabilitation screening form dated 2/16/11 documents, "Found sitting on mat next to bed to get to bathroom. Was in wheelchair at the time. Pt. (patient) educated to use call light and wait for assistance for mobility function. Recommend toileting schedule." "Safety remains an issue." Surveyor # noted the last three day bowel and bladder patterning is dated 12/4/10, 12/5/10 and 12/6/10. On 3/8/11 at 2:09 p.m., Surveyor # interviewed RN (Registered Nurse)-C to inquire when staff are transferring Resident #23 how should they transfer him. RN-C replied, "1 assist with a gait belt." Surveyor # informed RN-C of the observation of Resident #23 being transferred without a gait belt. Surveyor # informed RN-C that therapy had recommended after 12/28/10 fall that a scoop mattress be placed on Resident #23's bed and Surveyor # did not observe the mattress. Surveyor # informed RN-C after the 2/15/11 fall therapy recommended a toileting schedule and the Surveyor # did not locate this in the medical record. RN-C informed Surveyor # that she would have to look into this. On 3/8/11 at 2:15 p.m., Surveyor # accompanied RN-C to Resident #23's room. RN-C verified there was not a scoop mattress on the bed. RN-C informed Surveyor # that she did not remember that recommendation from therapy. On 3/8/11 at 3:30 p.m., during the daily exit conference the Administrator and Director of Nursing were informed of the above. On 3/9/11 at 9:59 a.m., Surveyor # asked the Administrator for the fall investigation worksheets for Resident #23's falls and any other information that was not in the medical record. On 3/9/11 at approximately 11:00 a.m., Surveyor # reviewed the fall investigation worksheet dated 2/15/11 and noted under recommendations to prevent further falls documents, "Therapy to screen" and "3/8/11 toileting eval to start on 3/9/11 days."