Every finding on record at Autumn Lake Healthcare at Beloit

Based on interview and record review, the facility failed to ensure staff verified and honored a resident's advance directive of Do Not Resuscitate (DNR) during a medical emergency before initiating cardiopulmonary resuscitation (CPR) and other resuscitative measures for one resident (R1) of six residents reviewed for code status. R1 had a valid Emergency Care Do Not Resuscitate (DNR) order signed by the resident on [DATE] and by the attending physician on [DATE] and entered into resident's record by the facility on R1's readmission on [DATE]. On [DATE], R1 went unresponsive with a faint pulse. Facility staff did not check R1's advance directives before performing Cardiopulmonary Resuscitation (CPR) chest compressions on R1. After receiving compressions from both facility staff as well as emergency responders, R1 was found to have multiple traumatic injuries associated with resuscitative efforts including rib fractures and a sternal fracture, and was also intubated, received mechanical ventilation, and was admitted to the Intensive Care Unit (ICU.) The facility's failure to honor R1's DNR order led to facility staff completing chest compressions through the act of CPR leading to multiple injuries and medical interventions for R1. These actions created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator of the immediate jeopardy on [DATE] at 4:48 PM. The immediate jeopardy was removed and corrected on [DATE]. The deficient practice is being cited as past noncompliance. Findings include: Review of the facility's policy titled Advance Directive Policy and Procedure, last reviewed 09/2025, indicated: The resident has the right, and the facility will assist the resident to formulate an advance directive at their option. The facility will inform and provide residents with a written description of the facility's policy to implement advance directives. R1's admission Record revealed an admission date of [DATE] with the most recent readmission occurring on [DATE]. Diagnoses included dependence on supplemental oxygen, myocardial infarction type 2, chronic respiratory failure with hypoxia, acute embolism, and thrombosis of unspecified deep veins of lower extremity, bilateral, heart failure, unspecified, chronic kidney disease, stage 3 unspecified, and chronic obstructive pulmonary disease with (acute) exacerbation. R1's 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. R1's Order Summary Report revealed a Do Not Resuscitate order entered on [DATE]. Resident's Electronic Medical Record (EMR) reflected a valid Emergency Care Do Not Resuscitate (DNR) order signed by the resident on [DATE] and by the attending physician on [DATE], directing emergency providers not to perform chest compressions, insert advanced airways, administer cardiac resuscitation drugs, provide ventilator assistance, or defibrillation. R1's Care Plan Report initiated and revised on [DATE], included: [R1] has an Advanced Directive: DNR (Do not resuscitate). R1's Progress Note dated [DATE] at 2:18 PM read: Note Text: CNA (Certified Nursing Assistant) was in (R1's) room assisting him with the urinal, having a conversation with him before he went unresponsive. CNA entered resident's room at 1:26 (PM) and resident went unresponsive with faint pulse at around 1:31 pm. Resident already on 3 liters of oxygen. Emergency services called shortly after with EMS arriving at 1:29 pm. POA (Power of Attorney) and MD updated. A late entry note with an effective date of [DATE] at 2:20 PM, read, Late Entry: Note Text: Error, note EMS arrived approximately at 1:39 pm. CPR initiated approximately at 1:35 pm. During an interview on [DATE] at 9:08 AM, CNA1 said she remembered answering R1's call light and assisting him with the urinal as he sat at the side of the bed. CNA1 said she went to empty the urinal in the bathroom, and upon return, R1 had a blank stare and did not respond when asked if he needed assistance with anything else. CNA1 assisted R1 to his back on the bed. CNA1 said R1 made grunting sounds but was not verbally responding. CNA1 said she yelled for help from R1's doorway, returned to bedside, and noticed R1's face turned red. CNA1 said she checked R1's pulse, it felt faint, and CNA1 yelled for help again. CNA1 said Registered Nurse (RN)1 entered the room, visualized R1, performed a sternum rub, and called out R1's name. RN1 checked R1's pulse when he did not respond. CNA1 said RN1 did not know R1's code status when CNA1 asked and said she would go check the physical chart. CNA1 said she checked R1's pulse again and did not feel a pulse and yelled for help again. CNA1 said she initiated CPR before the crash cart arrived and continued screaming for help. CNA1 said that at some point, the Unit Assistant (UA) arrived with the crash cart and CNA2 entered the room and took over chest compressions. CNA1 said she received training on how to identify a code status, when to perform CPR, and where to look for the code status. CNA1 said she felt like she had to do something and should have waited for verification of R1's code status. During an interview on [DATE] at 4:29 PM, CNA2 said that she vaguely recalled working the unit or on the date of the incident ([DATE]). CNA2 verified that the schedule dated Sunday [DATE] reflected her name and she was assigned to the unit on which R1 resided. CNA2 said that she was not familiar with R1's code status but knew to check the resident's code bracelet and to check the front or spine of the physical chart. CNA2 said that she did not know R1's health status or of any changes in condition before the code. CNA2 said that she overheard someone yelling for help, but a code was not announced overhead. CNA2 said that she ran out of the bathroom (located in the Report Room that was approximately four rooms away from R1's room) to R1's room and chest compressions were being performed on R1. CNA2 said that she did not remember who was performing CPR and initially stated that her participation in the code was limited to passing equipment from the crash cart as requested. After further discussion, CNA2 said that she took over chest compressions and completed 30 chest compressions before she switched off with another staff. CNA2 stated that she is CPR certified. During an interview on [DATE] at 10:17 AM, the Director of Nursing (DON) stated she was notified by phone on [DATE] at approximately 1:42 PM that there was a Code Blue, CPR was initiated, and the emergency medical technicians (EMTs) were on scene. DON said staff informed the EMTs at approximately 2:10 PM that R1 was a DNR when transfer paperwork was handed to them. DON said staff realized that R1 had a DNR code status around 2:11 PM and RN1 notified her at that time. R1's Hospital History and Physical paperwork dated [DATE], states in part: pt. (patient) arrives via EMS from [Nursing Home name] for pulseless nonbreather. Pt initially was altered, but 40 for HR (heart rate). Pt loaded up and attempted intubation, lost pulses, one round ofCPR and epi. Arrives to ER with pulse, intubated. Imaging, CT chest rule out PE (pulmonary embolism). Impression: 1. Rounded left apical hemothorax 2.5cm (centimeter) thick. 2. Pneumonia predominantly affecting the right lower lobe. 3. Anterior right 2nd through 8th rib fractures with 1.3cm maximal displacement. Third and 4th right rib fractures are segmental. 4. Left 2nd through 7th rib fractures. No segmental fractures. Maximum 8mm (millimeter) displacement. 5. Nondisplaced sternal fracture. 6. There is moderate pulmonary emphysema. patient admitted to critical care for out-of-hospital arrest status post 3 rounds of ACLS (Advanced Cardiac Life Support) protocol with achievement of ROSC (return of spontaneous circulation). Resident passed away while at the hospital. Information from CPR: What You Need to Know includes: People who receive CPR may end up with a number of health problems afterward. Broken Chest Bones. Even when done properly, CPR can cause broken bones in the chest area, particularly among women, older adults and people with smaller frames. One study found that after CPR people experienced: broken ribs: 81% broken breastbone (sternum): 69% separation of ribs from the sternum: 22% Neurological Problems. Without normal blood flow, the brain lacks oxygen. Brain damage can begin within 4-6 minutes. Of the roughly 17% of people who survive CPR, two-thirds have good neurological outcomes. The longer oxygen is cut off, the more likely significant brain damage occurs. Vomiting and Aspiration. During chest compressions, it is not uncommon for vomiting to occur. Stomach contents can fall into the lungs and cause pneumonia. Lastly, if personnel is also manually ventilating the patient with a bag-mask, air can enter the stomach causing distension and vomiting. Other complications, often caused by broken ribs and sternum, include internal bleeding, damaged airways, collapsed lung, cuts of the liver and spleen. https://compassionandchoices.org/resource/cpr-what-you-need-to-know/ The facility's failure to honor R1's advance directive of DNR led to facility staff completing CPR chest compressions which led to serious harm for R1, thus creating a finding of Immediate Jeopardy that began on [DATE]. The facility removed the immediate jeopardy on [DATE] when it implemented the following action plan: 1: 1 education given to RN 1 including but not limited to: Importance of leadership roles/Charge Nurse position. Remaining with a resident during an emergency and delegating tasks to other staff. Ensure you are checking and verifying code status prior to initiating or directing a staff member to initiate CPR. Importance of communicating pertinent information with EMS to provide continuity of care. Code Blue Policy and procedure including; Identification process for DNR or Full Code status. Importance of arm/name band check prior to initiating CPR. If no arm/name band is in place, check the residents' chart. Physical charts are in the nurse's station and will include a signed DNR or Full Code status form in the front section of the chart. Importance of following the plan of care regarding DNR/Full code status preference. Never initiate CPR until you are fully aware of code status. CPR should never be performed on a DNR status resident. 1:1 education given to CNA 1 including but not limited to: Code Blue Policy and procedure including; Identification process for DNR or Full Code status. Importance of arm/name band check prior to initiating CPR. If no arm/name band is in place, check the residents' chart. Physical charts are in the nurse's station and will include a signed DNR or Full Code status form in the front section of the chart. Importance of following the plan of care regarding DNR/Full code status preference. Never initiate CPR until you are fully aware of code status. CPR should never be performed on a DNR status resident. 1: 1 education given to CNA 2 including but not limited to: Code Blue Policy and procedure including; Identification process for DNR or Full Code status. Importance of arm/name band check prior to initiating CPR. If no arm/name band is in place, check the residents' chart. Physical charts are in the nurse's station and will include a signed DNR or Full Code status form in the front section of the chart. Importance of following the plan of care regarding DNR/Full code status preference. Never initiate CPR until you are fully aware of code status. CPR should never be performed on a DNR status resident. 1:1 education given to CNA 3 including but not limited to: Code Blue Policy and procedure including; Identification process for DNR or Full Code status. Importance of arm/name band check prior to initiating CPR. If no arm/name band is in place, check the residents' chart. Physical charts are in the nurse's station and will include a signed DNR or Full Code status form in the front section of the chart. Importance of following the plan of care regarding DNR/Full code status preference. Never initiate CPR until you are fully aware of code status. CPR should never be performed on a DNR status resident. 1:1 education given to CNA 4 including but not limited to: Code Blue Policy and procedure including; Identification process for DNR or Full Code status. Importance of arm/name band check prior to initiating CPR. If no arm/name band is in place, check the residents' chart. Physical charts are in the nurse's station and will include a signed DNR or Full Code status form in the front section of the chart. Importance of following the plan of care regarding DNR/Full code status preference. Never initiate CPR until you are fully aware of code status. CPR should never be performed on a DNR status resident. 1:1 education given to RN 2 including but not limited to: Importance of communicating pertinent information with EMS to provide continuity of care. Importance of sending proper paperwork with signed code status with EMS and making copies per protocol. Training was given to All Staff including but not limited to: Code Blue Policy and procedure including; identification process for DNR or Full Code status. Importance of arm/name band check prior to initiating CPR. If no arm/name band is in place, check the residents' chart. Physical charts are in the nurse's station and will include a signed DNR or Full Code status form in the front section of the chart. Importance of following the plan of care regarding DNR/Full code status preference. Never initiate CPR until you are fully aware of code status. CPR should never be performed on a DNR status resident. Training was given to All Licensed Nurses including but not limited to: Importance of leadership roles/Charge Nurse position. Remaining with a resident during an emergency and delegating tasks to other staff. Ensure you are checking and verifying code status prior to initiating or directing a staff member to initiate CPR. Importance of communicating pertinent information with EMS to provide continuity of care. Importance of sending proper paperwork with signed code status with EMS and making copies per protocol. Code Blue Policy and procedure including; Identification process for DNR or Full Code status. Importance of arm/name band check prior to initiating CPR. If no arm/name band is in place, check the residents' chart. Physical charts are in the nurse's station and will include a signed DNR or Full Code status form in the front section of the chart. Importance of following the plan of care regarding DNR/Full code status preference. Never initiate CPR until you are fully aware of code status. CPR should never be performed on a DNR status resident. 100% of staff training was completed by [DATE]. The following quality assurance measures were put into place and the following system changes were made to assist in preventing reoccurrence: The Communication of Code Status Policy and the Emergency Cardiovascular Care Policy were reviewed and revised as necessary to ensure compliance with standards of practice. Physical and Electronic medical charts of all residents were audited to ensure proper code status was in place per residents' preference. Advanced Directive/Code Status care plans for all residents were reviewed and revised as necessary. ADL care sheets and nurse report sheets of all residents were reviewed and revised as necessary to ensure proper code status were listed per residents' preference. Code Blue drills were conducted on each shift with pertinent education provided. The Quality Assurance Committee reviewed and discussed the Communication of Code Status Policy and the Emergency Cardiovascular Care Policy to ensure compliance with standards of practice. Routine compliance audits were conducted to ensure residents have proper code status in place, including identification of code status per their preference and standards of practice. Audits were conducted: Every week xl week, then every 2 weeks x I month, then monthly x2 months, then pm. Random Code Blue drills were conducted to ensure staff are knowledgeable on Code Blue procedure. Drills will be conducted: At least every week x1 week, then every 2 weeks x 1 month, then monthly x2 months, then routinely/pm. The results of the audits have been and will continue to be reviewed at QAPI meetings for further recommendations. Auditing staff knowledge on where to locate code status, advanced directives, etc. is included in the Code Blue mock drills. Staff members demonstrated competency with identification of resident's appropriate code status.

Based on record review and interviews the facility failed to maintain complete and accurate clinical records, including required weekly skin evaluations and daily skilled nursing documentation reflecting the resident's clinical status for two of six residents (R2 and R3) reviewed for medical records. R2 and R3 had incomplete clinical record that did not accurately reflect the resident's condition and risked effective clinical decision-making or a delay in recognition of worsening condition that could lead to hospitalization. Findings include: 1. Review of R2's admission Record located in the electronic medical record (EMR) under the Profile tab revealed admission to the facility on [DATE] with diagnoses including morbid (severe) obesity with alveolar hypoventilation, anxiety disorder, unspecified, acute on chronic systolic (congestive) heart failure and localized edema. Review of R2's hospital nursing home transfer Physician Orders dated 07/09/26 located in the EMR under the Misc tab, revealed an order to Monitor daily weights for weight gain greater than 3 lbs./24 hours or greater than 5 lbs. in week, worsening edema, orthopnea, or increasing shortness of breath. The discharge diagnoses reflected congestive heart failure (CHF) exacerbation, chronic obstructive pulmonary disease (COPD) exacerbation, hypercapnia, hypoxic respiratory failure, and pulmonary edema. Review of R2's Order Summary Report, dated 07/13/26, located in the EMR under the Orders tab, also reflected an order for Daily weight - Notify provider if weight gain is equal or greater to 3lbs/day or >5lbs/week every Day shift. Review of R2's Transfer/Discharge Report located in the EMR under the Profile tab revealed R2 was transferred to an acute care hospital on [DATE] related to altered mental status. The resident did not return to the facility. Review of R2's July Treatment Administration Record (TAR), located in the EMR under the Orders tab, revealed daily weights were not obtained. Review of the Daily Skilled Charting v7, located in the EMR under the Evaluations tab, revealed no charting was completed on 07/11/26 and 07/12/26. During an interview and record review on 07/23/26 at 9:40 AM, Registered Nurse (RN) 2 could not state why she did not enter a progress note or complete the daily skilled charting during her shift on 07/12/26. During an interview and record review on 07/23/26 at 4:29 PM, RN3 could not state why she did not complete the daily skilled charting during her shift on 07/11/26. 2. Review of R3's admission Record located in the EMR under the Profile tab revealed an original admission to the facility on [DATE] and the most recent readmission on [DATE] with diagnoses including encounter for other orthopedic aftercare, unspecified diastolic (congestive) heart failure, myocardial infarction type 2, acute respiratory failure with hypoxia, COPD, unspecified, chronic kidney disease, stage 3 unspecified, and obstructive sleep apnea (adult) (pediatric). Review of R3's Order Summary Report, located in the EMR under the Orders tab, revealed a physician order dated 03/25/26 to begin 03/27/26 for Weekly skin and vitals check on shower day (FRI AM) in the morning every Fri. Review of R3's Weekly Skin Evaluation dated 03/25/25 and 04/26/26 provided by the Director of Nursing (DON) revealed R3 had a surgical incision site to neck. There were no other weekly skin evaluations completed on 03/27/26, 04/03/26, 04/10/26, 04/17/26 or 04/24/26. Review of R3's Daily Skilled Charting v6, located in the EMR under the Evaluations tab, revealed no charting was completed on 03/28/26, 03/29/26, 04/02/26, 04/04/26, 04/05/26, 04/08/26, 04/11/26, 04/12/26, 04/18/26, 04/19/26, 04/25/26, 04/26/26, 04/27/26, 04/28/26, 05/01/26, 05/02/26, 05/03/26, 05/10/26, 05/16/26, 05/17/26, 05/30/26, 06/06/26, 06/07/26, 06/13/26, 06/20/26, or 06/21/26. As of 06/22/26, the Daily Skilled Charting v6 retired and the nurses were expected to complete the Daily Skilled Charting v7. The Daily Skilled Charting v7 was not completed on 06/27/26, 06/28/26, 07/04/26, 07/05/26, 07/11/26, 07/12/26, or 07/13/26. The last completed daily skilled charting was completed on 07/15/26. During an interview on 07/24/26 at 10:17 AM, the DON stated that she expected nurses to complete daily skilled charting as applicable. The DON stated the Clinical RN reviewed orders the next day following new admissions to ensure all orders were entered as listed on the discharge orders from the transfer facility, as well as reviewed by the department head during morning meetings. The DON said that the nurses checked off on the TAR that skin assessments were completed and that reflected skin assessments were completed even when the Weekly Skin Evaluation was not completed. The DON did not respond to actions taken when documentation was missing. A Documentation policy was not provided upon request on 07/23/26 and 07/24/26.

Based on observation, interview and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 80 residents who reside in the facility. Surveyor observed food in circulation that was opened and undated or expired.Facility failed to have a system for manually monitoring the internal temperature of the dishwasher. This is evidenced by: Example 1 (Food dating)FDA Food Code, 2017, include: . Refrigeration Requirements Refrigeration times and temperatures to inhibit C. botulinum and L. monocytogenes must be based on laboratory inoculation study data or follow one of the ROP methods in Section 3-502.12 which specifies the time and temperature combinations. The . package must be marked with a use-by date within either the manufacturer's labeled use-by date or as determined by the laboratory data, whichever comes first . Labeling - Use-by date The shelf life of ROP foods is based on storage temperature for a certain time and other intrinsic factors of the food (pH, aw, cured with salt and nitrite, high levels of competing organisms, organic acids, natural antibiotics or bacteriocins, salt, preservatives, etc.). Each package of food in ROP must bear a use-by date.Facility Food Receiving and Storage Policy revised 8/25 states in part: . Foods shall be received and stored in a manner that complies with safe handling practices. All foods stored in the refrigerator or freezer will be covered, labeled, and dated ( use by date).Facility Supplement Policy revised 5/25 states in part: . Follow manufacturer's guidelines.On 2/10/2026 at 8:35 AM, during initial walk through the kitchen with DM C (Dietary Manager), Surveyor observed In the refrigerator, a package of buns that had expired on 2/8/26. DM C stated that they should be thrown away because they are expired and DMC discarded them into the garbage. On 2/10/2026 at 8:37 AM, Surveyor observed a container of Italian dressing in the refrigerator with no label or date. DM C stated that it should have a label, open date, and expiration date. DM C removed container from the refrigerator and discarded it. On 2/12/2026 at 2:28 PM, Surveyor observed one kitchenette with 23 mighty shakes that were past the 14-day thaw date. The mighty shakes had use by dates of 1/20, 1/26, and 2/10. Surveyor observed the Manufacturers' recommendations on the carton is the shake is good for 14 days once refrigerated. Surveyor asked DM C (Dietary manager) how long mighty shakes are good for after the date when they are pulled out of the freezer. DM C stated they were good for 2 weeks. Surveyor asked if these shakes are expired. DM C stated yes and discarded them into the garbage. Surveyor asked DM C who is responsible for checking expiration. DM C stated everyone on the unit is responsible, but only the nurse gives out the supplement. Example 2 (Dishwasher temperature)US Food Code 2017 includes, in part: . 4-302.13 Temperature Measuring Devices, Manual Warewashing. Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. The effectiveness of cleaners and chemical sanitizers is also determined by the temperature of the water used. A temperature measuring device is essential to monitor manual warewashing and ensure sanitization. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the warewashing machine meet or exceed the required 71 C(160 F). Parameters such as water temperature, rinse pressure, and time determine whether the appropriate surface temperature is achieved. Although the Food Code requires integral temperature measuring devices and a pressure gauge for hot water mechanical warewashers, the measurements displayed by these devices may not always be sufficient to determine that the surface temperatures of utensils are reaching 71 C(160 F). The regular use of irreversible registering temperature indicators provides a simple method to verify that the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of 71 C (160 F) .FDA Food Code 2017 includes, in part: 4-204.115 Warewashing Machines, Temperature Measuring Devices. A WAREWASHING machine shall be equipped with a TEMPERATURE MEASURING DEVICE that indicates the temperature of the water: (A) In each wash and rinse tank; Pf and (B) As the water enters the hot water SANITIZING final rinse manifold or in the chemical SANITIZING solution tank .Dishwasher Manufacturer's Recommendations for Use, include . wash temperature 150 degrees F minimum . Rinse temperature is 180 degrees F . On 2/12/26 at 9:30 AM Surveyor observed DA D (Dietary Aide) run a tray of dishes through the dishwasher. Outside thermometer read 151 degrees. DA D stated that the temperature should be between 160-180. (Note on the machine). DM C (Dietary Manager) told DA D to send through a few empty trays to see if water comes up to temp. 2nd tray 150 degrees. During the 3rd and 4th tray cycle, the needle on the temperature gauge was not moving. DM C stated that they should not put any more dishes in, she will use a test strip to test the water. Surveyor asked DM C how often she uses the test strips. DM C stated that she only uses the 160-degree test strips when they think they have a problem with the temperature. On 2/12/26 at 9:48 AM DM C (Dietary Manager) tested two trays with test strip, first strip did not turn color, did another to check for deficiency of first strip. Second strip turned grey. Surveyor asked DM C what color the test strip should be. DM C reported the test strip should turn black for 160-degree temperature. Surveyor observed that the test strips had no expiration date. DM C stated that they did not order the strips, Ecolab just gave them the strips and said to try them. Surveyor asked DM C if she should have a system in place for manually monitoring the internal temperature of the dishwasher. DM C reported yes. On 2/12/26 at 1:35 PM Surveyor interviewed NHA A (Nursing Home Administrator) Surveyor asked NHA A if the facility should have a system in place for manually monitoring the internal temperature of the dishwasher. NHA A reported yes.

Based on observation, interview, and record review, the facility did not ensure that each resident receives food that is palatable and at a safe and appetizing temperature affecting 4 out of 5 units with the potential to affect all 80 residents (R) residing in the facility. Six residents voiced concerns over hot foods being served cold. (R29, R32, R9, R25, R2, and R76) 2 of 2 test trays were observed to be served at non-desirable temperatures. Evidenced by: The facility policy Food Preparation and Service Policy revised 8/25, states in part: . Thermal cooking temperatures for ground meat is 155 degrees. Fresh, frozen, or canned vegetables are cooked to holding temperature of 135 degrees. Previously cooked food is reheated to an internal temperature of 165 degrees for at least 15 seconds. Example 1 On 02/10/2026 at 9:16 AM Surveyor interviewed R76 during the initial screening. R76 resides on Skyline hallway. R76 indicated that his food was sometimes hot, but mostly not because they do the dining room first then the rooms. Example 2 On 02/10/2026 at 9:27 AM Surveyor interviewed R2 during the initial screening. R2 resides on the Skyline hallway. During the interview R2 indicated that the food was not great. R2 stated they need to put the food in the microwave before they bring it to him, or it's cold. Example 3 On 2/10/26 at 11:01 AM Surveyor interviewed R9 during the initial screening. R9 resides on the Vista hallway. R9 reported that he had cold food in his room, that it was warm not hot. Example 4 On 2/10/26 at 12:00 PM Surveyor interviewed R29 during the initial screening. R29 resides on the Horizon hallway. During the interview R29 indicated that the food is generally cold daily. R29 indicated that they serve the dining room first and by the time they get to her it is lukewarm. R29 indicated they don't have warmers under the plates, and they don't have heated carts. Example 5 On 2/11/26 at 9:58 AM Surveyor interviewed R32 during Resident Council meeting. R32 stated meals are cold quite often. R32 eats her meals in the dining room. R32 resides on the Vista hallway. Example 6 On 2/11/26 at 9:59 AM Surveyor interviewed R25 during Resident Council meeting. R25 stated that he has had cold meals in both his room and the dining room. R25 resides on the Horizon hallway. Example 7 On 2/11/26 at 12:00 PM Surveyor observed trays arriving on Genesis Memory Care Unit. At 12:25 PM Surveyor received the last tray being served in the dining room. The pureed meat had a temperature of 120 degrees and tasted lukewarm. Pureed sweet potatoes temperature was 124 degrees and tasted lukewarm, and pureed peas temperature was 127 degrees and tasted lukewarm. All food items were unpalatable. Example 8 On 2/11/26 at 12:27 PM Surveyor received last room tray on Horizon Hallway. Tray was temped at 125.2 degrees for the Meatloaf and 124.0 degrees for the Sweet Potatoes, and peas. Items tasted lukewarm and were unpalatable. On 2/11/26 at12:35 PM Surveyor interviewed RN G (Registered Nurse). Surveyor asked if she heard anything about cold food on this hallway. RN G stated we have a lot of complaints here about cold food. We do re-heat some of the trays if they want us to. On 2/11/26 at 12:37 PM Surveyor interviewed CNA H (Certified Nursing Assistant). Surveyor asked CNA H if she had heard any concerns of cold food on the floor. CNA H stated that she doesn't hear much about food being cold. CNA H stated that she would heat it up if it was. Surveyor asked CNA H what temperature the food should be when heated up. CNA H stated that she doesn't know how hot the food is when she heats it up because she doesn't have a thermometer up on the floor. On 2/11/26 at 1:15 PM Surveyor interviewed DM C (Dietary Manager). DM C indicated that she would expect hot food to be hot. She indicated understanding with the concerns voiced by residents and test tray temperatures. The facility failed to ensure that each resident receives food and drinks that are palatable and at a safe and appetizing temperature.

Based on interview and record review the facility did not ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 Residents (R) reviewed for Pain (R1) R1 voiced concerns regarding his pain regime not being effective. R1's MAR (Medication Administration Record) indicated that R1 has pain ratings of 0 out of 10 while R1 indicates he is never lower than a 4 out of 10. R1's Comprehensive Care Plan does not contain goals or interventions related to pain management.Evidenced by:Facility policy, titled Pain Management, reviewed 5/25/25, includes, in part: (The facility) ensures that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.In order to help a resident maintain or attain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. Evaluate the resident for pain and the causes upon admission, during ongoing scheduled assessments, and when a significant change occurs. Manage or prevent pain, consistent with the comprehensive assessment/evaluation and plan of care, current professional standards of practice, and the resident's goals and preferences. Verbal indicators a resident may use to report or describe pain: hurting, aching, burning, gnawing, stabbing, heaviness, pressure, numbness, tingling, shooting, needles, soreness, tenderness, discomfort, spasms, feeling rough/tearing/ripping. (the facility) utilizes a pain evaluation tool, which is appropriate for the resident's cognitive status, to assist staff in consistent evaluation of a resident's pain. Based on professional srandards of practice, an assessment or evaluation of pain by appropriate members of the Interdisciplinary Team. gathering the following information as applicable to the resident: History of pain and treatment, including nonpharmacological and pharmacological treatments and whether treatments have been effective. , Asking the patient to rate the intensity of his/her pain using a numerical scale 0 to 10, a verbal or visual descriptor that is appropriate and preferred by resident. Reviewing resident's current medical conditions, . injuries, diabetes neuropathic pain, immobility, . Identifying key characteristics of pain- duration, frequency, location, timing, patterns, radiation. Identifying activities, resident care or treatment that precipitate or exacerbate pain and those that reduce or eliminate pain. Impact of pain and quality of life. The resident's goals for pain management. Based on evaluation, the facility . will develop, implement, monitor, and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission. The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal. On 2/12/26 at 9:12 AM, R1 indicated he has wounds on his legs from an apartment fire he was in last year. R1 indicated his legs are very painful and it causes him to get anxious. R1 indicated his pain, at the time of interview, was between a 6 and an 8.R1 admitted to the facility on [DATE] with diagnoses including: polyneuropathy (damage to many nerves), burn of unspecified body region, burn of second-degree lower leg, burn of third degree left lower leg, burns involving 10-19% of body surface with 10-19% third degree burns, and other complications of skin graft/allograft/autograft.R1's pain risk assessment, dated 11/17/25, includes: Should pain assessment interview be conducted? Yes. Ask resident, Have you had pain or hurting at any time in the last 5 days? No. How much of the time have you experienced pain or hurting over the last 5 days? Rarely or not at all. Over the past 5 days. How much of the time has pain made it hard for you to sleep at night? Rarely or not at all. Pain Interference with daily activities: rarely or not at all. Verbal Descriptor Scale: Please rate the intensity of your worst pain over the last 5 days. Mild. Should a staff assessment for pain be conducted? No. Does the resident have a diagnosis which would give reason to believe he/she would be at risk for pain? List diagnosis: (blank). Location: Choose site and describe the pain: type of pain descriptors- numbness, stabbing, aching, burning, sharp, external, internal, pins/needles, general discomfort, other: (blank). Physical examination of pain site: (blank) Precipitating factors: (blank). Coping: What alleviates pain, non-pharmacological interventions? (blank) What makes pain worse? (blank). Current pain medication regimen: Analgesic: (blank), NSAIDS: (blank), Tricyclics: (blank), Narcotics: (blank), Standing orders: (blank), List modalities: (blank). Patient pain goal: What is the resident's acceptable level of pain? (blank). Plan of care: (blank). Education: (blank)(It is important to note R1's pain risk assessment is not completed as many sections are left blank, including diagnosis, examination of pain site, what alleviates pain, pain medication regimen, pain goal, and plan of care.)R1's Current Comprehensive Care Plan, initiated 7/18/25, includes: Treat pain as per orders prior to treatment/turning etc. to ensure comfort.(It is important to note R1's Care Plan does not contain interventions (such as non-pharmacological) or goals related to pain management.)R1's MAR/TAR (Medication Administration Record/Treatment Administration Record), for January 2026, includes:Pain Assessment every shift: document pain level as per pain scale- 0- no pain, 1-3 mild pain, 4-6 moderate pain, 7-10 severe pain. Order date 12/23/25. All pain levels are recorded as zero in this section, except on 1/9 pain level is 6 on evening shift.Hydrocodone Acetaminophen Oral Tablet 5-325 MG: Give 1 tablet by mouth every 6 hours as needed for pain. Order date 12/23/25.1/5- pain level 6, pain medication effective1/6- pain level 8, pain medication ineffective(It is important to note R1's Nurse Notes do not have documentation of what staff did when R1's pain medication was ineffective.)1/9- pain level 6, pain medication effective1/13- pain level 9, pain medication effective1/16- pain level 8, pain medication effective1/17- pain level 6, pain medication effective1/20- pain level 0, pain medication effective(It is important to note R1's recorded pain rating is a zero and staff administered R1's as needed pain medication.)1/21- pain level- N/A, pain medication effective(It is important to note this pain rating of N/A (not applicable) and the pain medication as being effective.)R1's MAR/TAR, for February2026, includes:Pain Assessment every shift: document pain level as per pain scale- 0- no pain, 1-3 mild pain, 4-6 moderate pain, 7-10 severe pain. Order date 1/27/26. All pain levels are recorded as zero in this section, except 2/11/26 is recorded as a 5 during the evening shift.Hydrocodone Acetaminophen Oral Tablet 5-325 MG: Give 1 tablet by mouth every 6 hours as needed for pain. Order date 12/23/25.2/1- pain level 4, medication effective2/3- pain level 4, medication effective2/4- pain level 7, unknown if medication was effective(It is important to note staff did not record if R1's as needed pain medication was effective or ineffective, instead they recorded the effectiveness was unknown.)2/5- pain level 8, medication effective2/6- pain level 8, medication effective2/7- pain level 7, medication effective2/11- pain level 2, medication effective. pain level 6, medication effective.On 2/12/26 at 8:48 AM, during an interview, R1 stated, I was in a fire that caused burns on my left leg from my thigh down to ankle. My right leg was burned from my knee down and then all the way up to my thigh. R1 indicated his burns cause him discomfort and the pain gets away from him at times. Then it is hard to get back under control. R1 also stated, I would like to be pain free but I'm not. I'm usually around 6 level. I am 6 now. I never am at zero pain. R1 indicated a reasonable pain goal for him would be a 4. R1 indicated he would like staff to try to assist him at staying at or under a level 4 pain.On 2/12/26 at 9:19 AM CNA E (Certified Nursing Assistant) indicated R1's care plan does not contain goals or interventions related to pain and, it should. CNA E indicated she looks at the residents' care plans to know what she can do if they are experiencing pain.On 2/12/26 at 9:23 AM, LPN F (Licensed Practical Nurse) indicated R1 told her yesterday that he was in pain. LPN F indicated R1's care plan should have goals and interventions related to pain management but it doesn't. LPN F indicated she does not know what non-pharmacological interventions staff use to assist R1 in alleviating his pain.On 2/12/2026 at 10:27 AM, DON B (Director of Nursing) and NHA A (Nursing Home Administrator) indicated all sections in R1's pain risk assessment should have been completed, staff should be documenting what they do if medications are ineffective, and R1's care plan should have goals and interventions related to pain management.

Based on interview, and record review, the facility did not provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (R3) of 6 residents reviewed for medication errors. R3 did not receive her ordered Potassium Gluconate (Mineral supplement) on 12/10/25, 12/11/25, 12/12/25, 12/13/25, 12/14/25, and 12/15/25. R3 also did not receive her ordered Calcium and Vitamin D3 (supplement) on 12/11/25, 12/12/25, 12/14/25,12/15/25, 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25, and 12/22/25. Both supplements were not given as ordered due to the medication being unavailable in the facility. This is evidenced by: The facility policy entitled, Medication Error Identification and Prevention, dated 03/25, states, in part: . When a medication error occurs, the Charge Nurse must be notified immediately. A nursing assessment of the resident must take place immediately to ensure that any adverse reactions are correctly determined. Irregardless of the individual making the medication error, the individual discovering the error must take proper steps in reporting and recording the medication error immediately. Steps must be put in place to prevent recurrence of error. Below is a list of definitions of medical errors: 1. Omission Error: Failuree to administer an ordered dose. (Example: Missed scheduled doses not signed out in MAR (Medication Administration Record)). Once root cause is determined, an immediate intervention must be put in place to prevent recurrence of errors. Physicians must be notified of the error. Make a note of instructions given. Once the physician notification is done, the Charge Nurse will notify the On-Call RN. Family will be notified after On-Call RN is notified of the error. This must also be documented in [Electronic Medical Record System]. R3 was admitted to the facility initially admitted on [DATE], with a readmission date on 4/10/25. R3's diagnoses include aftercare following joint replacement surgery, injury of radial nerve (major peripheral nerve in the arm) at wrist and hand level of right arm, pain in right wrist, vascular dementia, morbid obesity, adult failure to thrive, need for assistance with personal care, presence of right artificial hip joint, presence of left artificial shoulder joint, muscle weakness, and chronic congestive heart failure (heart is unable to pump enough blood to meet the body's needs, leading to fluid buildup in the lungs). Surveyor reviewed R3's Medication Administration Record, which indicates: Potassium Gluconate Oral Tablet 550 MG (Milligrams) (Potassium Gluconate) Give 1 tablet by mouth one time a day for supplement. The following dates are marked with a 9 by LPN (Licensed Practical Nurse) E, which indicates Other/See Nurse Notes: 12/10/25, 12/11/25, 12/12/25, 12/13/25, 12/14/25, and 12/15/25. Calcium + Vitamin D3 Oral Tablet 600-5 MG (Milligrams)-MCG (Micrograms) (Calcium Carbonate-Cholecalciferol) Give 1 tablet by mouth one time a day for a supplement. The following dates are marked with a 9 by LPN E, which indicates Other/See Nurse Notes: 12/11/25, 12/12/25, 12/14/25,12/15/25, 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25, and 12/22/25. (Of note: No nurses notes were found indicating the reason either supplement was not administered.) On 1/6/26 at 10:35 AM, Surveyor interviewed LPN E (Licensed Practical Nurse). Surveyor presented a copy of R3's MAR (Medication Administration Record) to LPN E and asked if she remembered why these medications were marked with a 9. LPN E indicates both of these medications were unavailable for the dates indicated. Surveyor asked LPN E if she informed management that these medications were unavailable. LPN E indicates, yes, and that she ordered additional supplies from pharmacy as both medications are over the counter. Surveyor asked LPN E if progress notes should be associated with these MAR entries that are indicated with a 9. LPN E indicates, yes. On 1/6/26 at 3:25 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the process is for restocking medications. DON B indicates for over-the-counter medications, they contact their contracted pharmacy for additional supply. DON B also indicates a staff member working with supplies is notified of the need for additional medication and orders additional stock. The nurses also do audits on medications. Surveyor asked DON B what the process is for medication errors. DON B indicates, the facility has a medication error folder that contains the paperwork that needs to be completed along with immediate education. Staff are expected to fill out all of the information and complete the immediate education. The information for the medication error should then be sent to the family and physician. Monitoring should be completed along with physician notification. Surveyor asked DON B what a 9 indicates on a resident's MAR. DON B indicates it means other and there is usually documentation as to what issue occurred. The staff member should also let management know. Surveyor asked DON B, if a MAR entry is marked with a 9, should there be a note associated with it. DON B indicates, yes. Surveyor asked DON B if medications should be administered as ordered. DON B indicates, yes. Surveyor provided DON B with R3's MAR and the information that the medications were not available. Surveyor asked DON B if she was made aware of these errors. DON B indicates, no. Surveyor asked DON B if she would have been expected to be made aware. DON B indicates, yes.

Based on observation, interview and record review, the facility did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident (R) for 2 of 6 residents reviewed (R3 and R4). The facility assessment indicates a staffing plan that requires 4 licensed nurses on the Day shift, 2-4 licensed nurses on the Evening shift, and 2 licensed nurses on the Night shift. The plan also requires a direct care staff, indicated to be a total of licensed or certified staff, ratio of 1:16-18 on Day shift, 1:16-18 on Evening shift, and 1:20 ratio on Night shift. From 12/23/25 - 1/4/25, the facility had multiple shifts below the facility assessment's required staffing ratio. R3 voiced concerns about being left on the commode too long and that wait times are too long when using the call light. R4 voiced concerns about staff not having enough help, that all the time there is only 1 CNA for 24-25 residents, she has to wait a long time. This is evidenced by: The facility policy entitled, Facility Staffing Policy, dated 5/25, states, in part: Policy: It is the policy of [Facility Name] related to employees for the purpose of ensuring sufficient staff to [NAME] the residents' needs. 1. The Administrator and Human Resource Department will collaborate on the collection and tracking/monitoring of certain data, including: a. Number of employees b. Census c. Employee tenure 2. Data obtained from staff tracking/monitoring may be used for completion of the facility assessment, improvement processes, and other purposes as necessary. The Facility Assessment, dated 7/2025, states, in part: . Staffing plan. RN (Registered Nurse) or LPN (Licensed Practical Nurse) Charge Nurse: Days: 4 licensed nurses; 1:18-22, Evenings: 2-4 licensed nurses; 1:20-40, Nights: 2 licensed nurses; 1:40. Direct care staff 1:16-18 Days (total licensed or certified) 1:16-18 Evenings 1:20 ratio Nights. Example 1The facility schedules were reviewed for the dates 12/23/25 through 1/6/26 for staffing ratios, with inadequate staffing noted as follows: 12/23/25: Surveyor requested the posting for this date for census confirmation however, none was provided.12/24/25: AM (Day) shift: 3 licensed nurses, 1:28 licensed nurses to resident ratio. NOC (Night) shift: 1 licensed nurse, 1:84 ratio. Direct care staff ratio from 10:00 PM to 5:00 AM was 3 staff total, with a ratio of 1:28.12/25/25: AM shift: 3 licensed nurses, 1:28 ratio. PM shift: 2 licensed nurses, 1:42 ratio. NOC shift: 1 licensed nurse, 1:84 ratio.12/26/25: PM shift: from 9:00 PM to 10:30 PM, 1 licensed nurse, 1:84 ratio. NOC shift: 1 licensed nurse, 1:84 ratio. Direct care staff ratio from 5:30 AM to 6:30 AM, 3 direct care staff, 1:28 ratio.12/27/25: AM shift: from 8:00 AM to 2:30 PM, 2 licensed nurses, with a ratio of 1:42. PM shift: 2 licensed nurses, with a ratio of 1:42. NOC shift: 2 licensed nurses, with a ratio of 1:42.12/28/25: AM shift: from 10:00 AM to 2:00PM, 2 licensed nurses, with a ratio of 1:42. PM shift: 2 licensed nurses, with a ratio of 1:42. NOC shift: 2 licensed nurses, with a ratio of 1:42.12/29/25: AM shift: 3 licensed nurses, with a ratio of 1:28. PM shift: 2 licensed nurses, with a ratio of 1:42. NOC shift: 1 licensed nurse, with a ratio of 1:84. Direct care staff ratio from 2:00 AM to 5:00 AM, 3 direct care staff, with a ratio of 1:2812/30/25: AM shift: from 6:00 AM to 8:00 AM, 2 licensed nurses, with a ratio of 1:42. From 8:00 AM to 2:30 PM, 3 licensed nurses, with a ratio of 1:28. PM shift: 2 licensed nurses, with a ratio of 1:42. NOC shift: 1 licensed nurse, with a ratio of 1:84. Direct care staff ratio from 10:00 PM to 10:30 AM, 3 direct care staff, with a ratio of 1:28.12/31/25: AM shift: from 1:00 PM to 2:30 PM, 3 licensed nurses, with a ratio of 1:28. PM shift: from 9:30 PM to 10:30 PM, 1 licensed nurse, with a ratio of 1:84. NOC shift: 1 licensed nurse, with a ratio of 1:84. Direct care staff ratio from 9:30 PM to 10:30 PM, 4 direct care staff, with a ratio of 1:21.1/1/26: AM shift: from 10:00 AM to 2:30 PM, 3 licensed nurses, with a ratio of 1:26. PM shift: 2 licensed nurses, with a ratio of 1:42. NOC shift: 2 licensed nurses, with a ratio of 1:42.1/2/26: AM shift: from 6:00 AM to 8:00 AM, 3 licensed nurses, with a ratio of 1:28. PM shift: from 5:00 PM to 6:00 PM, 1 licensed nurse, with a ratio of 1:84. From 6:00 PM to 10:30 PM, 3 licensed nurses with a ratio of 1:28. NOC shift: from 10:00 PM to 11:30 PM, 2 licensed nurses, with a ratio of 1:42. From 11:30 PM to 6:30 AM, 1 licensed nurse, with a ratio of 1:84. Direct care staff ratio from 3:15 AM to 6:00 AM, 4 direct care staff, with a ratio of 1:21.1/3/26: AM shift: from 6:00 AM to 10:00 AM, 3 licensed nurses, with a ratio of 1:27. From 10:00 AM to 2:30 PM, 2 licensed nurses with a ratio of 1:41. PM shift: from 5:00 PM to 6:00 PM, 1 licensed nurse with a ratio of 1:82. NOC shift: 1 licensed nurse, with a ratio of 1:82.1/4/26: AM shift: 2 licensed nurses, with a ratio of 1:41. PM shift: from 5:00 PM to 6:00 PM, 1 licensed nurse, with a ratio of 1:82.1/5/26: Surveyor requested the posting for this date for census confirmation however, none was provided.1/6/26: AM shift: 3 licensed nurses, with a ratio of 1:26. Example 2R3 was admitted to the facility initially admitted on [DATE], with a readmission date on 4/10/25. R3's diagnoses include aftercare following joint replacement surgery, injury of radial nerve (major peripheral nerve in the arm) at wrist and hand level of right arm, pain in right wrist, vascular dementia, morbid obesity, adult failure to thrive, need for assistance with personal care, presence of right artificial hip joint, presence of left artificial shoulder joint, muscle weakness, and chronic congestive heart failure (heart is unable to pump enough blood to meet the body's needs, leading to fluid buildup in the lungs). R3's Brief Interview for Mental Status of 15 out of 15, indicating she is cognitively intact. On 1/6/26 at 10:40 AM, Surveyor interviewed R3. Surveyor asked R3 how her stay at the facility had been going. R3 indicates staff leave her on the commode too long and has to wait for a long time to have her call light answered. Surveyor asked R3 how long she must wait for the call light to be answered. R3 indicates she must wait an hour to use the bathroom sometimes. R3 then commented the waiting gets out of line. Example 3R4 was initially admitted to the facility on [DATE], with a readmission date of 2/22/24. R4's diagnoses include: acute on chronic congestive heart failure (sudden worsening of the symptoms of heart failure in which the heart fails to pump blood adequately), disorientation, morbid obesity, muscle weakness, difficulty in walking, and adult failure to thrive. R4's Brief Interview for Mental Status of 15 out of 15, indicating she is cognitively intact. On 1/6/26 at 10:48 AM, Surveyor interviewed R4. Surveyor asked R4 how her stay had been going at the facility. R4 indicates the facility does not have enough staff, and there is often only 1 CNA (Certified Nursing Assistant) for a hall of 24-25 residents which she does not feel is adequate. Surveyor asked R4 how often this happens. R4 indicates, this happens all the time, and she has to wait a long time. On 1/6/26 at 2:47 PM, Surveyor interviewed CNA C. Surveyor asked CNA C if she can complete all of the tasks on her shift. CNA C indicates it's hard, but she knows everywhere is short staffed. CNA C notes, 2nd shift on her hall is pretty good.(Of note: Surveyors attempted to interview additional staff during this investigation. Some had questions if they would get in trouble if they answered questions and others were observed to look around the hall before answering questions.) On 1/6/26 at 3:05 PM, Surveyor interviewed CNA D, who is currently working as the facility's scheduler. Surveyor asked CNA D, how long she has been working in this position. CNA D indicates, around 1 year. Surveyor asked CNA D how the scheduling process works for nursing staff. CNA D indicates the full-time and part-time staff have set schedules and a list of openings is sent out to the pool staff. The pool staff then pick up unfilled shifts. Surveyor asked CNA D what happens when shifts don't get filled by pool staff. CNA D indicates she fills some gaps as she is a certified CNA, but she can usually get somebody to fill in for the shift. Surveyor asked CNA D what the process is when a staff member calls-out for their shift. CNA D indicates she usually has enough staff to pull from other areas of the facility, but she tries to fill the shift first. CNA D also indicates some staff will come in early or stay late to cover. CNA D indicates she is usually successful with getting other staff to help such as nurses coming in to work as CNAs. Surveyor asked CNA D if the facility mandates holdovers. CNA D indicates, no. Surveyor asked CNA D how she knows how many staff are needed to fill each shift. CNA D indicates it depends on the needs of the residents and how many residents are currently in the facility. Surveyor asked CNA D if the facility assessment should be followed for adequate staffing ratios. CNA D indicates, yes. Surveyor asked CNA D if there has been any recent staff hires. CNA D indicates, it has been scattered recently, but the facility has 2-3 new nurses starting shortly. Surveyor asked CNA D, based on the facility assessment, how many CNAs does the facility need for each shift. CNA D indicates, she needs 6-8 CNAs for AM and PM shifts, and NOC shift requires a few less, usually between 3 and 4. Surveyor asked CNA D, based on the facility assessment, how many licensed nurses does the facility need for each shift. CNA D indicates, 4 licensed nurses on AM shift, 3-4 licensed nurses on PM shift, and 1-2 licensed nurses on NOC shift. On 1/6/26 at 3:25 PM, Surveyor interviewed DON B. Surveyor notes the Facility Assessment indicates at least a 1:40 nurse to resident ratio for PM and NOC shifts. Surveyor asked DON B if she considers this to be a safe nurse to resident ratio. DON B indicates, yes, because the facility has a lot of ancillary staff such as a wound nurse, infection preventionist nurse, human resources, and a scheduler who can assist. Surveyor asked DON B if staff should be scheduled according to the facility assessment. DON B states, yes. Surveyor asked DON B if it is acceptable to have 1 licensed nurse on shift for a census of 80 or more. DON B indicates night shift sometimes has only one nurse on shift. DON B indicates like many facilities, staffing has been a concern, and it is discussed at every QAPI meeting and is actively being worked on. Surveyor asked DON B if the facility utilizes agency staff. DON B indicates, no as the facility feels agency staff are not committed or work up to the standards of care set by the facility.(Of note: No ancillary staff mentioned are scheduled for any shift on the schedules reviewed).

Based on interview and record review, the facility did not ensure staff postings were accurate which has the potential to affect 80 out of 80 residents residing at the facility. Review of staffing schedules and required staff postings revealed discrepancies between the documents. The total number of staff hours worked was not listed on the documents for licensed and non-licensed staff directly responsible for resident care each shift. This is evidenced by: Surveyor reviewed the schedules and staff postings from 12/24/25 through 1/4/26 and noted the following inaccuracies: None of the postings contained the total number of hours worked, only the actual hours worked for nurses and CNAs. Under the section titled, Staffing Total, the number of staff at each license or certification level is listed but not the total hours worked by that license or certification level. On 1/6/26 at 4:10 PM, Surveyor asked DON B if the staff postings should match the staff schedule. DON B indicates, yes.

Based on observation, interview and record review, the facility did not ensure each resident receives care, consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) and each resident with PIs receives necessary treatment and services, consistent with professional SOP, to promote healing, prevent infection, and prevent new injuries from developing in 2 of 3 sampled residents (R1 and R6). (R6 is being cited at actual harm/isolated).R6 was identified to be at risk for PI development and re-developed a stage IV PI. Observations were made of PI interventions not being used as intended. Wound assessments were not completed weekly, and treatments were not completed as ordered. R6 re-developed a stage IV PI which deteriorated.R1's PI was not staged accurately. R1 did not have PI treatments completed as ordered. This is evidenced by:The facility's policy Wound Care Program, undated, includes: All residents admitted to our care will be comprehensively assessed for risk of and/or current pressure injuries or other alterations in skin integrity upon admission. A treatment plan will be initiated. Our wound protocol is based on the most recent NPIAP (National Pressure Injury Advisory Panel) pressure injury prevention and treatment guidelines. It is the expectation all new or worsening skin alterations will have thorough documentation including adding it to the current plan of care. Stage 2 Pressure Injury: Granulation tissue, slough and eschar are not present. Wound Assessment: Assessment of the wound is necessary prior to developing a plan of care. Assess the pressure injury initially and routinely thereafter and document findings. Wound Rounds It is the policy of [Facility Name] to make routine wound rounds on all resident with open wounds.Wound Rounds will be held on a routine basis in accordance with the NPIAP recommendations. Stage 2 Pressure Injury 4. Pressure redistribution to area: .pressure redistribution cushion to wheelchair. Stage 3 Pressure Injury 13. Pressure redistribution to the area.pressure redistribution cushion in wheelchair.Example 1R6 admitted to the facility on [DATE] and has diagnoses of a stage 4 pressure injury of the sacrum (healed in the facility), chronic venous hypertension with ulcer of bilateral lower extremity (a long-lasting sore that develops in the lower leg due to high pressure in the veins) and chronic myelomonocytic leukemia not having achieved remission (cancer of the blood-forming cells of the bone marrow). R6's comprehensive care plan, printed on 11/25/25, includes: Focus: R6 has chronic admit acq'd (acquired) PI stg (Stage) 4 sacrum resolved in house, recently reopened, hx (History) of (2) stage 2 PI L (Left) shoulder.Goal: will not develop and [sic] avoidable pressure injuries and current chronic resolved PI/scar tissue will remain stable/resolved.Interventions: Administer treatments as ordered and monitor for effectiveness. treatment to healed sacral wound for protection. Apply barrier cream during periods of incontinence/toileting and PRN (As Needed) to help prevent skin breakdown, monitor closely for inct (Incontinent) stools and assist as needed to keep clean and dressed. Check placement of protective foam to coccyx.every shift. Pressure redistribution mattress, pressure redistribution cushion to chair and recliner. Focus: R6 has an ADL (Activities of Daily Living) self-care performance deficit.Goal: R6 will be clean, dry and well-groomed daily.Interventions: Transfers/Ambulation: 1 assist with 2ww (2 Wheeled Walker) stand/pivot transfers. Dressing: 1 assist staff participation. Personal Hygiene/oral care: 1 assist staff participation.R6's physician orders state in part; start 6/18/25. Discontinue 10/30/25. Dermaseptin ointment (skin protectant with cooling menthol) to be applied to buttocks region with all incontinent cares and toileting.every shift. R6's Treatment Administration Record (TAR) states in part; start 6/18/25. Discontinue 10/30/25. Dermaseptin ointment (skin protectant with cooling menthol) to be applied to buttocks region with all incontinent cares and toileting.every shift.The TAR is blank for night shift on 10/1/25.The TAR is blank for day shift on 10/12/25 and 10/15/25. The TAR is blank for evening shift on 10/7/25 and 10/17/25.R6's physician orders state in part; start 9/8/25. Discontinue 10/17/25. Check placement of protective foam to coccyx.q (Every) shift.R6's TAR states in part; start 9/8/25. Discontinue 10/17/25. Check placement of protective foam to coccyx.q (Every) shift.The TAR is blank for day shift on 10/12/25 and 10/15/25. The TAR is blank for evening shift on 10/7/25.R6's physician orders state in part; start 9/22/25. Discontinue 10/31/25. Protective foam dressing to coccyx. Change every 3 days and PRN (As Needed) every day shift.R6's TAR states in part; start 9/22/25. Discontinue 10/31/25. Protective foam dressing to coccyx. Change every 3 days and PRN (As Needed) every day shift.The TAR is blank for 10/16/25, 10/19/25, 10/25/25, and 10/31/25.R6's Weekly Wound assessment dated [DATE]. Wound 3 Date of onset Site 3: 10/14/25. Where acquired: Facility-Acquired. Wound site: Coccyx. Type: Pressure. Length (cm): 3.2. Width (cm) 4.0. Depth (cm) 0.3. Stage: Stage IV. Wound Description/Tissue Type: granulation tissue, slough. Specify the percentage of each tissue type that was chosen: 75% pink tissue with 25% light yellow tissue noted. Progress of site 3: New area. Treatment: cleanse upper buttocks with wound cleanser and dry thoroughly. Place a piece of Calcium Alginate AG+ (with silver) to wound bed. Cover with a foam dressing. Change q3d (Every 3 Days) & PRN (As Needed) until healed. What were the changes? Treatment initiated d/t (Due To) reopening of area.R6's physician orders state in part; start 10/17/25. Discontinue 10/20/25. Nursing Order: Cleanse upper buttocks with wound cleanser and dry thoroughly. Place a piece of Calcium Alginate AG+ (with Silver) to wound bed. Cover with a foam dressing. Change q3d (Every 3 Days) and PRN (As Needed) until healed. (Order to be completed on 10/18/25.)R6's TAR states in part; start 10/17/25. Discontinue 10/20/25. Nursing Order: Cleanse upper buttocks with wound cleanser and dry thoroughly. Place a piece of Calcium Alginate AG+ (with Silver) to wound bed. Cover with a foam dressing. Change q3d (Every 3 Days) and PRN (As Needed) until healed. (Order to be completed on 10/18/25.) The TAR is blank for 10/18/25.Of note, the PI was noted on 10/14/25 but no assessment was completed until 10/15/25. The treatment initiated was not entered into R6's orders until 10/17/25 indicating a delay in treatment.Of note, once a pressure injury has healed and re-opens, the re-opened pressure injury continues at the largest stage prior to healing thus R6's PI would be considered a stage IV.R6's physician orders state in part; start 10/20/25. Discontinue 10/30/25. Nursing Order: keep coccyx clean and dry, generously apply Lanashield/Lantispetic barrier with all incontinence cares and toileting, every shift until healed.R6's Weekly Wound assessment dated [DATE]. Wound 3 Date of onset Site 3: 10/14/25. Where acquired: Facility-Acquired. Wound site: Coccyx. Type: Pressure. Length (cm): 3.2. Width (cm) 4.0. Depth (cm) 0.3. Stage: Stage IV. Wound Description/Tissue Type: granulation tissue, slough. Specify the percentage of each tissue type that was chosen: 75% pink tissue with 25% light yellow tissue noted. Progress of site 3: Unchanged. Treatment: cleanse upper buttocks with wound cleanser and dry thoroughly. Place a piece of Calcium Alginate AG+ (with silver) to wound bed. Cover with a foam dressing. Change q3d (Every 3 Days) & PRN (As Needed) until healed. Were there any treatment changes this week? No. Of note, the treatment for Calcium Alginate was discontinued on 10/20/25.R6's TAR states in part; start 10/20/25. Discontinue 10/30/25. Nursing Order: keep coccyx clean and dry, generously apply Lanashield/Lantispetic barrier with all incontinence cares and toileting, every shift until healed.The TAR is blank for evening shift on 10/22/25.R6's physician orders state in part; start 10/30/25. Keep coccyx clean and dry, generously apply Lanashield/Lantiseptic barrier with all incontinence cares and toileting, every shift until healed.R6's TAR states in part; start 10/30/25. Keep coccyx clean and dry, generously apply Lanashield/Lantiseptic barrier with all incontinence cares and toileting, every shift until healed.The TAR is blank for day shift on 11/1/25, 11/2/25, 11/8/25, and 11/16/25.The TAR is blank for evening shift on 11/8/25.R6's Weekly Wound assessment dated [DATE]. Wound 3 Date of onset Site 3: 10/14/25. Where acquired: Facility-Acquired. Wound site: Coccyx. Type: Pressure. Length (cm): 1.0. Width (cm) 1.0. Depth (cm) 0.2. Stage: Stage IV. Wound Description/Tissue Type: slough. Specify the percentage of each tissue type that was chosen: 100% of wound bed is yellow. Progress of site 3: Improved.Of note, this assessment is 9 days after the previous assessment. The wound bed now has 100% slough when it was previously 25% slough.R6's physician orders state in part; 10/31/25. Check placement of foam to coccyx. every shift for dressing checks.R6's TAR states in part; start 10/31/25. Check placement of foam to coccyx. every shift for dressing checks. The TAR is blank for day shift on 11/1/25 and 11/8/25.R6's Weekly Wound assessment dated [DATE]. Wound 3 Date of onset Site 3: 10/14/25. Where acquired: Facility-Acquired. Wound site: Coccyx. Type: Pressure. Length (cm): 1.0. Width (cm) 1.2. Depth (cm) 0.2. Stage: Stage IV. Wound Description/Tissue Type: slough. Specify the percentage of each tissue type that was chosen: 100% of wound bed is light yellow colored tissue adherent to wound bed. Progress of site 3: Worsened.Of note, this assessment is 14 days after the previous assessment. R6's Weekly Wound assessment dated [DATE]. Wound 3 Date of onset Site 3: 10/14/25. Where acquired: Facility-Acquired. Wound site: Coccyx. Type: Pressure. Length (cm): 1.0. Width (cm) 1.2. Depth (cm) 0.2. Stage: Stage IV. Wound Description/Tissue Type: slough. Specify the percentage of each tissue type that was chosen: 100% of wound bed is light yellow colored tissue adherent to wound bed. Progress of site 3: Unchanged.On 11/25/25 at 8:16 AM, Surveyor observed R6 in the dining room. R6 was sitting in his wheelchair at the breakfast table. R6 was sitting on a disposable chux (a barrier between resident and chair). Surveyor asked R6 about his wheelchair and if he had a cushion in his wheelchair. R6 indicated he was unsure if there was a cushion in the wheelchair. R6 stated surveyor could move the disposable chux pad to look. Surveyor lifted the disposable chux and was unable to see a cushion in R6's wheelchair. On 11/25/25 at 8:23 AM, Surveyor interviewed CNA F (Certified Nursing Assistant) regarding R6's PI interventions. CNA F indicated R6 should have a cushion in his wheelchair. On 11/25/25 at 8:26 AM, Surveyor requested CNA G to look at R6's wheelchair to see if he had a cushion. CNA G looked and indicated she could not see a cushion in R6's wheelchair. On 11/25/25 at 9:43 AM, Surveyor interviewed WCN C (Wound Care Nurse) regarding interventions for R6 related to his PI. WCN C stated R6 did have the cushion in his wheelchair but it was folded up under R6. WCN C indicated the cushion was not effective when being folded up under R6. On 11/25/25 at 9:43 AM, Surveyor interviewed WCN C (Wound Care Nurse) regarding R6's assessments. WCN C indicated the assessments were not completed timely. WCN C indicated R6 was missing an assessment between 10/31/25 and 11/14/25. On 11/25/25 at 10:47 AM, Surveyor interviewed DON B (Director of Nursing) regarding R6's assessments and treatments. DON B indicated treatments should be entered timely and completed. DON B indicated assessments should be completed routinely.On 11/24/25 at 12:01 PM, Surveyor interviewed LPN E (Licensed Practical Nurse) regarding completing treatments. LPN E indicated a blank in the TAR means the nurse didn't chart the treatment and if the treatment is not charted then it was not done. On 11/24/25 at 12:07 PM, Surveyor interviewed LPN D regarding completing treatments. LPN D indicated a blank on the TAR means the treatment was not given or done. LPN D indicated the TAR should not have blanks in it.On 11/24/25 at 1:14 PM, Surveyor interviewed WCN C (Wound Care Nurse) regarding completing treatments. WCN C indicated if the TAR is not signed out (blank); the treatment was not done. WCN C indicated treatments should be completed as ordered. R6 had a history of PI and was at risk for developing a PI. R6 obtained a facility-acquired pressure injury to his coccyx. The facility did not ensure R6's PI interventions were correctly in place. The facility did not assess R6's PI according to standards of practice. The facility did not complete R6's PI treatments as ordered. The Facility did submit additional information that was reviewed for R6. Example 2R1 admitted to the facility on [DATE] with a diagnosis of paraplegia (loss of motor and sensory function in the lower half of the body). R1's comprehensive care plan, printed on 11/25/25, includes: Focus: R1 is high risk for unavoidable PIs/skin alterations.Interventions: Administer treatments as ordered and monitor for effectiveness.R1's Weekly Wound Assessment, dated 8/26/25, includes: Wound 4. Wound Site: Left Heel. Type Other: unavoidable DTI (Deep Tissue Injury) with progression to stage 2 to left lateral heel. Stage: Stage II. Wound Description/Tissue Type: granulation tissue, slough. Specify the percentage of each tissue type that was chosen: 50% pink tissue with 50% light tan base. On 11/25/25 at 9:43 AM, Surveyor interviewed WCN C (Wound Care Nurse) regarding staging for R1's left heel PI. WCN C indicated a stage 2 PI cannot contain slough and was incorrectly staged.R1's TAR (Treatment Administration Record) includes the following:Start 6/25/25. Discontinue 8/26/25. Wound care Sacrum - 2 wounds Vashe wet to moist.cover with foam dressing. Change BID (Two Times a Day) and PRN. Every day and evening shift for wound care.The TAR is blank on day shift on 8/2/25, 8/3/25, 8/5/25, 8/12/25, 8/20/25, and 8/23/25. The TAR is blank on evening shift on 8/1/25, 8/4/25 and 8/16/25. Start 7/13/25. Discontinue 8/26/25. Wound care left ischium-Vashe wound cleanser used to create a wet to moist dressing with Kerlix and 4x4 gauze, light packed into wound cavity. Use skin prep to peri-wlund to keep foam in place.Change daily and PRN and evening shift for wound care. The TAR is blank for day shift on 8/2/25, 8/3/25, 8/5/25, 8/12/25, 8/20/25 and 8/23/25. The TAR is blank on evening shift on 8/1/25, 8/4/25, and 8/16/25. Start 8/4/25. Discontinue 8/25/25. Wash left heel wound with wound cleanser. Pat dry. Apply one layer of xeroform gauze to fit open area. Apply dry dressing to be changed every day and PRN until healed.The TAR is blank on 8/5/25, 8/6/25, 8/12/25, 8/17/25, 8/18/25, 8/20/25, and 8/23/25. Start 8/11/25. Discontinue 8/20/25. Nursing Order: Wash the right heel with wound cleanser. Gently pat dry. Apply skin prep to area of DTI (Deep Tissue Injury). Cover with a protective foam dressing. Change every 3 days and PRN until resolved. Every day shift every 3 days. The TAR is blank on 8/12/25 and 8/18/25. Start 8/26/25. Discontinue 9/7/25. Wound care sacrum - 2 wounds Dakins wet to moist.Cover with a foam dressing. Change BID (Two Times a Day) & PRN. Every day and evening shift for wound care. The TAR is blank for day shift on 9/4/25 and 9/6/25. The TAR is blank for evening shift on 9/4/25. Start 8/26/25. Discontinue 9/11/25. Dakins (full strength) external solution 0.5% .Apply to sacral, R (Right) ischial wounds topically two times a day for wound care.The TAR is blank for day shift on 9/4/25 and 9/6/25. The TAR is blank for evening shift on 9/4/25. Start 8/27/25. Discontinue 10/22/25. For Right heel: paint daily with betadine/povidone iodine.May cover w/ (with) a foam dressing for padding every day shift.The TAR is blank on 8/31/25, 9/3/25, 9/4/25, 9/5/25, 9/6/25, 9/10/25, 9/14/25, 9/17/25, 9/20/25, 9/21/25, 9/28/25, 9/30/25, 10/3/25, 10/5/25, 10/11/25, 10/12/25, 10/16/25, 10/20/25, and 10/21/25. Start 8/27/25. Discontinue 9/7/25. Left heel: hydrogel to wound bed, cover with Calcium Alginate AG+. Change daily and PRN (As Needed). Pressure relieving boots to bilateral feet at all times. Every day shift. The TAR is blank on 8/31/25, 9/1/25, 9/3/25, 9/4/25, 9/5/25, and 9/6/25.Start 8/27/25. Discontinue 10/22/25. Wound Care Left ischium- Dakins wound cleanser.Foam dressing to cover wound. Change daily and PRN. Every day and evening shift for wound care.The TAR is blank for day shift on 9/4/25, 9/6/25, 9/14/25, 9/19/25, 9/21/25, 9/28/25, 9/29/25, 10/3/25, 10/5/25, 10/11/25, 10/15/25, 10/16/25, 10/20/25, and 10/21/25.The TAR is blank for evening shift on 9/4/25, 9/14/25, 9/19/25, 10/2/25, 10/16/25, 10/20/25, and 10/21/25. Start 9/7/25. Discontinue 10/22/25. Left heel: Cleanse w/ (with) wound cleanser and pat dry. Apply Hydrogel to wound bed, cover with.foam dress. Change daily.Pressure relieving boots to bilateral feet at all times. every day shift.The TAR is blank on 9/10/25, 9/14/25, 9/17/25, 9/20/25, 9/21/25, 9/28/25, 9/30/25, 10/3/25, 10/5/25, 10/11/25, 10/12/25, 10/16/25, 10/20/25, and 10/21/25. Start 9/7/25. Discontinue 10/22/25. Wound care sacrum - 2 wounds. Dakins wet to moist.Cover with a foam dressing. Change BID (Two Times a Day) and PRN. Every day and evening shift for wound care. The TAR is blank for day shift on 9/14/25, 9/19/25, 9/21/25, 9/28/25, 9/30/25, 10/2/25, 10/3/25, 10/5/25, 10/11/25, 10/15/25, 10/16/25, 10/20/25, and 10/21/25. The TAR is blank for evening shift on 9/14/25, 9/19/25, 10/2/25, 10/16/25, 10/20/25, and 10/21/25. Start 9/11/25. Discontinue 10/28/25. Dakins (full strength) External Solution 0.5% .Apply to sacral, L (Left) ischial wounds topically two times a day for wound care. The TAR is blank for day shift on 9/14/25, 9/19/25, 9/21/25, 9/28/25, 9/30/25, 10/3/25, 10/5/25, 10/11/25, 10/15/25, 10/16/25, 10/20/25, and 10/21/25. The TAR is blank for evening shift on 9/13/25, 9/14/25, 9/19/25, 10/2/25, 10/16/25, 10/20/25, 10/21/25, 10/23/25, and 10/27/25. Start 10/28/25. Discontinue 11/5/25. Left heel: Wash with wound cleanser. Paint peri wound with betadine. Apply aquacel AG+.cover with secondary foam bordered dressing and change daily & PRN.every day shift. The TAR is blank on 11/1/25 and 11/2/25. Start 10/28/25. Discontinue 11/14/25. Left lateral and right medial foot wounds: pain daily with betadine.every day shift. The TAR is blank on 11/1/25, 11/2/25, 11/9/25, and 11/10/25.Start 10/28/25. Discontinue 11/16/25. Right heel paint peri wound with betadine. Place aquacel.to wound bed. cover with foam dressing and change daily & PRN every day shift.The TAR is blank on 11/1/25, 11/2/25, 11/9/25, 11/15/25, and 11/16/25.Start 10/28/25. Discontinue 11/14/25. Left hip/tuberosity: cleanse with wound cleanser.place calcium alginate.to the wound bed. Cover with secondary foam dressing. Changed daily & PRN.every day shift for wound care. The TAR is blank on 11/1/25, 11/2/25, 11/9/25, and 11/10/25. Start 10/28/25. Discontinue 11/16/25. Sacral & Left ischial: cleanse wound with wound cleanser.gently pack wounds.cover with foam dressing. Changed daily & PRN.The TAR is blank on 11/1/25, 11/2/25, 11/9/25, and 11/10/25. Start 11/14/25. Bilateral heels: Vashe solution and gauze to each wound bed.cover with dry ABDs (gauze pads used to absorb heavy drainage).change daily and PRN every day shift.The TAR is blank on 11/15/25 and 11/16/25. Start 11/5/25. Discontinue 11/14/25. Left Heel: prior to treatment add vashe ten minute soak to each dressing change.pain peri wound with betadine.cover with secondary dressing.change daily and PRN.every day shift. The TAR is blank on 11/9/25. On 11/24/25 at 12:01 PM, Surveyor interviewed LPN E (Licensed Practical Nurse) regarding completing treatments. LPN E indicated a blank in the TAR means the nurse didn't chart the treatment and if the treatment is not charted then it was not done. On 11/24/25 at 12:07 PM, Surveyor interviewed LPN D regarding completing treatments. LPN D indicated a blank on the TAR means the treatment was not given or done. LPN D indicated the TAR should not have blanks in it.On 11/24/25 at 1:14 PM, Surveyor interviewed WCN C (Wound Care Nurse) regarding completing treatments. WCN C indicated if the TAR is not signed out (blank); the treatment was not done. WCN C indicated treatments should be completed as ordered. On 11/25/25 at 10:47 AM, Surveyor interviewed DON B (Director of Nursing) regarding treatments. DON B indicated if the treatments are not signed out, they are not done. DON B indicated all treatments should be completed.

Based on observation, interview, and record review, the facility did not ensure a resident's environment remained free of accidents and hazards for 1 of 3 residents (R3) reviewed for falls. R3 had a comprehensive care plan for being a high fall risk upon his admission on [DATE]. R3 experienced four falls at the facility since his admission. On 9/3/25, R3 experienced an unwitnessed fall without major injury. On 9/14/25, R3 experienced an unwitnessed fall with a subsequent left mandibular (lower bone of jaw) fracture. On 10/7/25, R3 experienced an unwitnessed fall without major injury. On 10/11/25, R3 experienced an unwitnessed fall with a subsequent left tenth rib fracture. R3's comprehensive care plan included interventions of having a urinal at bedside, a reacher and a call light within reach. Observations were made of R3 not having these interventions at bedside.Evidenced by:The facility policy entitled, Falling Star Policy, dated 11/2024, states, in part: The purpose of the Falling Star Program is to facilitate identification by all Facility's department personnel of the Residents who have experienced frequent falls and to dispatch immediate action to prevent further falls. 1) Participation in the Falling Star Program is determined by the IDT (Interdisciplinary Team) and Fall Committee after thorough review and evaluation. a) Frequent falls are defined as 2 or more falls in a month. b) The committee may include Residents as participants who have not fallen 2 or more times in a month through review and evaluation of high fall risk factors. 2) Falling Star participants are identified by the bright pink star logo which is affixed to the name plate outside of the resident's room, affixed to the assistive device, such as wheelchair and walker, and taped to the outside of the residents medical chart spine. 4) A list of Falling Star participants will be distributed to Department Heads and posted in the nursing station on each unit. 5) All Facility staff will respond to the Falling Star participants: a) If a Falling Star Participant is observed by any Facility personnel in an unsafe act that may cause a fall (i.e., unassisted transfers, reaching for an item on the floor, etc.) or a participant's request for help, the employee is to approach the participant and encourage the Resident to wait for help while summoning assistance from a direct caregiver. 6). The Fall Committee/IDT will routinely review the Falling Star participants to discuss continuation on the program.R3 was admitted to the facility on [DATE] with diagnoses that include: muscle wasting atrophy (degeneration of muscle mass), vascular dementia, adult failure to thrive, congestive heart failure (heart fails to pump blood effectively), atrial fibrillation (irregular heart beat), contracture of left hand (shortening of muscles in left hand causing hand to contract), low back pain, Cerebrovascular accident (stroke), hemiplegia (unilateral numbness) and hemiparesis (unilateral paralysis) following CVA affecting left dominant side.R3's admission Minimum Data Set, with Assessment Reference Date of 9/9/25, indicates R3 had a Brief Interview for Mental Status score of 5 out of 15, indicating severe cognitive impairment. Section GG indicates R3 has an upper and lower extremity impairment on one side and utilizes a walker and wheelchair for mobility. R3 is dependent on staff for lower body dressing, putting on/taking off footwear, and toileting hygiene. R3 requires substantial/maximal assistance for upper body dressing, shower/bathe self, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Section H indicates R3 is currently participating in a toileting program and is frequently incontinent of urine and bowel. R3's Minimum Date Set, with Assessment Reference Date of 10/7/25, indicates R3 had a Brief Interview for Mental Status score of 13 out of 15, indicating moderate cognitive impairment. Section GG now indicates R3 requires substantial/maximal assistance for lower body dressing, putting on/taking off footwear, and shower/bathe self. R3 requires partial/moderate assistance for toileting hygiene, upper body dressing, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, walking 10 feet, walking 50 feet with two turns, and walking 150 feet.R3's first Fall Risk Assessment, dated 9/3/25, indicates R3 is at a high risk for falls with a score of 19. R3's Comprehensive Care Plan includes a Focus stating, [R3's Name] is at high risk for falls r/t (related to) recent hospitalization with muscle weakness, FTT (failure to thrive) and multiple recent falls, recent pneumonia, CVA (stroke) with left side weakness (left side is dominant side). Note that [R3's Name] is on anticoagulant (blood thinning) medications (Eliquis). Note that [R3's Name] was added to facility's Falling Star program upon admission. [R3's Name]'s room was moved closer to the nurses station for increased monitoring. Date Initiated: 9/3/25. Revision on: 10/1/25. Interventions: . Assist with ADLs (Activities of Daily Living), transfers, and toileting as necessary. (Refer to ADL for further information). Keep urinal at bedside. Assist to toilet and with HS (bedtime) cares in mid-evening. Hemi-walker with staff assist to help with balance. Date Initiated: 9/3/25. Revision on 10/1/25. Be sure R3's call light is within reach and encourage him to use it for assistance as needed. Note that staff should also anticipate his needs d/t (due to) confusion/forgetfulness. Date Initiated: 9/3/25. CANCELLED: Beveled matt and body pillow. Date Initiated: 10/11/25. Cancelled date: 11/12/25. R3 is now being followed by in-house psych (psychiatric) NP (Nurse Practitioner) [Nurse Practitioner's Name]. Monitor behaviors and collaborate with psych. Follow recommendations as necessary. Date Initiated: 9/16/25. R3 needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night, personal items within reach, auto-lock brakes to w/c (wheelchair), reacher, lipped mattress and body pillow to assist in defining the edge of bed, night light. Date Initiated: 9/3/25. Revision on: 11/21/25 . Due to impaired cognition, R3 may not comprehend when/why/how to use the call light; anticipate and meet his needs and wants. Date Initiated: 9/3/25. Educate family/caregivers about safety reminders and what to do if a fall occurs. Date Initiated: 9/3/25. Encourage activities to minimize the potential for falls while providing diversion and distraction. Date Initiated: 9/3/25. Ensure R3 is wearing appropriate footwear with non-skin soles when transferring or mobilizing in w/c (wheelchair). Date Initiated: 9/3/25. Ensure that bed is locked and lowered to a level that allows R3's feet to be flat on the floor when sitting on the side of the bed. Date Initiated: 9/3/25. Falling Star participant, follow facility protocol. Date Initiated: 9/3/25. Hi low bed (Frame height adjustable bed). Date Initiated: 9/3/25. PT/OT (Physical Therapy/Occupational Therapy) evaluate and treat as ordered or PRN (as needed). Date Initiated: 9/3/25. Review information on past falls and attempt to determine cause of falls. Record possible root causes. After the fall, remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. Date Initiated: 9/3/25.(Of Note: The intervention Assist to toilet and with HS (bedtime) cares in mid-evening was added 9/16/25. The intervention Hemi-walker with staff assist to help with balance was added 10/1/25. The intervention body pillow to assist in defining the edge of bed was added 11/12/25.)R3's Comprehensive Care Plan includes a Focus stating, [Resident's Name] has an ADL Self Care Performance Deficit r/t recent hospitalization with muscle weakness, FTT, and multiple recent falls. assistance needed with ADL tasks. Date Initiated: 9/16/25. Interventions include. Assist R3 in completing ADL tasks as needed. Date Initiated: 9/16/25. Revision on: 10/1/25. BED MOBILITY: 1 assist staff participation to reposition and turn in bed. Date Initiated: 9/16/25. Encourage R3 to participate in therapy sessions to help him improve current level of functioning. Date Initiated: 9/16/25. Revision on: 10/1/25. Encourage R3 to use the call light to call for assistance and anticipate needs d/t confusion/forgetfulness. Date Initiated: 9/16/25. TOILET USE: 1 assist staff participation to use toilet. Frequent incontinence of bowel and bladder; prompt and assist with toileting upon rising, before and after meals, mid evening, at HS, NOC (night shift) rounds and prn. Assist with incontinence cares as necessary keeping R3 clean and dry and applying barrier for protection. Keep urinal at bedside. Date Initiated: 9/16/25. TRANSFER: 1 assist with hemi-walker pivot transfer staff participation with transfers. 1 assist with hemi-walker with ambulating, short distances (up to 8 ft(feet)) W/C (wheelchair) for locomotion, assist as needed. Date Initiated: 9/16/25. On 9/3/25, an Interdisciplinary Team (IDT) Note is written that notes R3 has had multiple recent falls due to weakness. Fall interventions put in place upon admission including lipped mattress, low bed, wheelchair with auto-lock brakes, reacher (Tool that helps people pick up things off the floor), night light, toileting plan, urinal at bedside, and anticipation of needs due to confusion and forgetfulness. Resident was also added to the facility Falling Star program. On 9/3/25, a Fall Huddle Report Sheet is written that indicates R3 experienced a fall on this date at 12:15 PM. The reasonable explanation for why the fall occurred is indicated to be R3 was just admitted , very confused, and agitated. The determined root cause was not wanting to be here. The added intervention related to the determined root cause was taking R3 to the dining room for meals and activities along with providing him snacks.On 9/3/25 at 13:45, a note is written that states R3 experienced an unwitnessed fall at 12:15 PM, when staff were called to the room and found R3 on his knees in front of his wheelchair. R3 was unable to report what he was doing at the time of the fall. On 9/9/25 at 11:45 AM, an IDT note is written indicating a meeting was held to review R3's fall. Root cause was determined by the IDT to be confusion and R3 attempting to transfer himself to his wheelchair from the recliner. The added intervention from the fall huddle report sheet was continued. On 9/14/25, a Fall Huddle Report Sheet was written that indicates R3 experienced an unwitnessed fall on this date at 7:45 PM. The reasonable explanation is listed as self-transferring. The determined root cause is indicated to be self-transferring. The added intervention related to the root cause is possible low blood pressure related to R3's change of position and suggested medication review. Of note: there is no indication of why R3 was self-transferring.On 9/14/25 at 20:59 (8:59 PM), a progress note is written that states R3 experienced a fall in his room near the sink. He did not complain of pain or discomfort and no injuries were noted. R3 was sent to the emergency room for evaluation and treatment. On 9/14/25, R3 received another Fall Risk Assessment with a result of High Risk and a score of 21.On 9/14/25 at 22:27 (10:27 PM) a progress note is written that indicates emergency room staff called the facility and asked facility staff if R3's bruises were old or new. Facility staff advised emergency room staff that the patient arrived at the facility on 9/3/25, following multiple falls at previous home.On 9/14/25 at 22:28 (10:28 PM) a progress note is written that indicates emergency room staff called facility staff and advised R3 had a broken jaw.On 9/15/25, documentation was printed from the hospital following R3's emergency room visit. A CT Maxillofacial Without Contrast (Computed Tomography Scan of the bones and tissues of the face) scan was performed on R3. The findings from this imaging indicate R3 had an acute, comminuted (broken into multiple pieces) variably displaced (bones are not completely aligned) fracture of his mandible (lower bone of jaw) in the condylar and subcondylar regions (upper and lower region of the side of his jaw). The imaging report also indicates there is an associated dislocation of his mandibular condyle anterior to the mandibular fossa (top of the bone of the bottom jaw is displaced where it meets the temporal (side of the skull)). The note titled ED Progress Notes - Physician/Provider contains the section titled History of Present Illness and reports assessment findings including old skin tears but does not state the identification of any bruising. The section titled Physical Examination lists a range of body systems including one titled Skin which states: Warm, dry. The body system titled, Head states Normocephalic (Head is normal size and shape). The section titled, Impression and Plan indicates R3 had a diagnosis of a mandibular fracture.Of note: This imaging was interpreted, and the note was signed by a hospital MD (Medical Doctor). Additionally, the physician's physical exam did not report any signs of bruising to R3's skin. On 9/16/25 at 11:46 AM, an IDT note is written that states the team met to discuss R3's fall on 9/14/25. The team determined the root cause to be R3 attempting to self-transfer in his room, and later stated he was going to the bathroom. The intervention added following the determined root cause was sending R3 to the emergency room for evaluation and a medication review was conducted. IDT also reviewed and revised R3's toileting plan. Staff to assist with HS (bedtime) cares and toileting in the mid-evening. R3 was also indicated to be discussed in the psychiatric medication meeting on this date. Facility's psychiatric Nurse Practitioner was to evaluate R3 on this date and make any necessary recommendations.Of note: The toileting program intervention was first added to the comprehensive care plan on 9/16/25. This intervention was included on the baseline care plan initiated within the first 48 hours following R3's admission.On 10/7/25, a Fall Huddle Report Sheet was written that indicates R3 experienced an unwitnessed fall at 6:45 AM on this date. The reasonable explanation is indicated to be R3 stated he lost his balance. The determined root cause of the fall was that R3 lost his balance. The added intervention related to the root cause section states states going to bathroom unassisted and lost balance and fell.Of note: No actual intervention is listed, this is the 2nd fall regarding R3 self-transferring to the bathroom.On 10/7/25 at 9:23 AM, a progress note is written that states staff heard a loud crash at 6:45 AM on this date and went to R3's room and found R3 on his buttock on the floor near the dresser. R3 reported to staff that he was going to the bathroom and lost his balance and fell. R3 denied hitting his head and no bruising or redness was noted at the time. Staff did note a new small skin tear to his right arm near his elbow. R3 denied any pain or discomfort. On 10/7/25, R3 received another Fall Risk Assessment with a result of Moderate Risk and a score of 13.On 10/11/25, a Fall Huddle Report Sheet was written that indicates R3 experienced an unwitnessed fall at 7:30 AM on this date. The section asking if staff have a reasonable explanation for why the fall occurred states, No- patient reports falling out of bed, getting himself back in bed & not reporting it.The determined root cause and added intervention related to the root cause is blank. Of note: R3 does have a lipped mattress in place since admission to help prevent this type of incident. No new intervention was added following this fall or the fall on 10/7/25.On 10/11/25, R3 received another Fall Risk Assessment with a result of High Risk and a score of 18.On 10/11/25 at 15:11 (3:11 PM), a progress note is written that indicates R3 reported to CNA F before breakfast on this date that he had fallen out of bed but didn't notify anyone. R3 reported he put himself back in bed and was now reporting pain to his left flank. R3 reports he may have broken a rib. R3 requests to be sent to the emergency room after breakfast. An ambulance was called and patient transported to the emergency room according to R3's request. On 10/11/25 at 16:33 (4:33 PM), a progress note is written that states staff received a call from emergency room staff reporting R3 has a fracture of the left 10th rib. On 10/11/25, R3's emergency room documentation includes imaging for a CT Chest, Abdomen, Pelvis w/ Contrast scan which included a finding of a non-displaced (bones are aligned), acute fracture of the left 10th rib. The scan also found healing fractures of the left 7th and 8th ribs. R3 was diagnosed with a fracture of his left tenth rib. Treatment instructions included taking acetaminophen regularly for pain relief, using an incentive spirometer to help R3 breathe deeply and keep his lungs clear, and to follow up with his primary care physician.Of note: A CT Brain, Cervical w/o Contrast scan was conducted and compared to the CT scans of his brain, facial bones, and cervical spine on 9/14/25. The scan conducted on 10/11/25 included findings of an acute, displaced fracture through the condylar process of the left mandible with dislocation at the left temporomandibular joint as noted on the previous study on 9/14/25. This fracture is noted to be unchanged from previous study on 9/14/25.On 10/14/25 at 12:06 PM, an IDT note is written that indicates R3's falls on 10/7/25 and 10/11/25 were reviewed. The root cause of the fall on 10/7/25 was indicated to be R3 attempting to take himself to the bathroom. The intervention added related to the root cause of the fall is indicated to be the toileting plan was reviewed and revised. Staff to offer and assist with toileting and AM (day shift) cares in the early AM shift. R3's fall on 10/11/25 is indicated to have a root cause of R3 rolling out of bed during the NOC (night shift) and that the lipped mattress was in place. The interventions added related to this root cause include sending the resident to the emergency room for evaluation, adding a beveled mat next to R3's bed, and a body pillow was added to assist resident in further defining the edge of the bed. This note also indicates R3 continues to work with therapy to increase his functional abilities. On 11/24/25 at 11:22 AM, Surveyor interviewed R3 who indicated he had fallen a few times at the facility and one time broke his jaw when he fell. Surveyor notes R3 was sitting on his bed, and his call light was on the floor.On 11/25/25 at 10:00 AM, Surveyor interviewed R3 who indicated he was not afraid of falling at the facility. Surveyor went through the list of R3's interventions asking if he knew where certain items were located. R3 was able to point out his call light, which was within reach, and his night light, which was located on the wall next to his bed. Surveyor asked about R3's urinal. R3 looked around his room but indicated he did not have one. Surveyor also was unable to observe a urinal in R3's room. Surveyor asked about R3's reacher. R3 again looked around his room but indicated he did not have one of those either. Surveyor also was unable to observe a reacher in R3's room. Of note: R3's falls on 9/14/25 and 10/7/25 included root causes related to R3 attempting to go to or use the bathroom. Interventions to prevent future falls included placing a urinal at R3's bedside. This intervention was noted not to be in place. On 11/25/25 at 11:21 AM, Surveyor interviewed CNA F (Certified Nursing Assistant) and CNA H. Surveyor asked CNA F how staff knew which residents had fall interventions and the type of fall interventions. CNA F indicates they used the ADL sheet to determine both the residents at risk for falls and which fall interventions each resident requires. Surveyor asked CNA F if a urinal should be in R3's room. CNA F indicated, it should be if it is on the care plan. Surveyor asked CNA H if R3 currently had a urinal in his room. Surveyor and CNA H went into R3's room and CNA H looked around R3's room. CNA H indicated that a urinal was not in R3's room, there should be a urinal in R3's room, and the care plan should be followed. On 11/25/25 at 2:25 PM, Surveyor interviewed LPN I (Licensed Practical Nurse). Surveyor asked LPN I how staff knew which residents were at risk for falls. LPN I indicates if they are a part of the falling star program, there is a star on their wheelchair and walker, their name will be on a list in the nurses' stations, and on the ADL sheet. LPN I also indicates falls and fall risk residents are included on the nurses' report sheets. Surveyor asked LPN I how staff knew what interventions were needed by residents who were at risk for falls. LPN I indicated the ADL sheet. Surveyor asked LPN I if an intervention is listed on the resident's care plan or ADL sheet, should they have that intervention in place. LPN I indicates, yes. Surveyor asked LPN I if she was familiar with R3. LPN I indicated she was not, as she normally worked on a different unit. On 11/25/25 at 3:00 PM, Surveyor interviewed DON B (Director of Nursing) and MDS J (Minimum Data Set Coordinator). Surveyor asked DON B to describe the facility's falling star program. DON B indicates it is used to alert all staff, including direct care and support staff, to residents who are at-risk for falls. This informs staff if they see a trip hazard on the floor to pick it up. Additionally, if staff see a falling star resident reaching for something on the floor or trying to get up, they can alert direct care staff. DON B also indicates the program helps to maintain an active list of fall risk residents in the nurses' station and these residents are reviewed in regular fall meetings. Surveyor asked how residents are added to the falling star program. DON B indicates the fall team will review any resident falls, new admissions, and any residents at-risk to potentially be added to the program. Surveyor asked DON B how often residents at risk for falls are assessed and educated about their interventions. DON B indicates fall risk assessments are conducted quarterly and with changes of conditions. Additionally, staff should be providing education to residents about their fall risk interventions on every shift. Surveyor asked DON B how staff know what interventions or assistance residents need to prevent falls. DON B indicates for the nursing department, interventions are updated through the Care Feed, computer education, updated ADL sheets, and fall packets are done after every fall and will include new interventions. Surveyor asked DON B how the facility monitors staff to ensure they are implementing care-planned interventions. DON B indicates nurses always monitor staff throughout the shift to ensure they are following the ADL sheets. Additionally, the facility's Quality Assurance Coordinator will also make rounds in the facility checking for fall interventions. At this time, DON B requested that MDS J (Minimum Data Set Coordinator) to join the interview and notes that MDS J leads the facility's fall committee. Surveyor asked MDS J what the facility determined the root cause to be for R3's fall on 9/3/25. MDS J indicates the resident was confused and attempting to self-transfer from his wheelchair to his recliner. Surveyor asked MDS J what intervention was put into place as a result of this fall. MDS J indicates R3 was immediately brought to the dining room for snacks and social stimulation. The facility also added the intervention for staff to encourage activity, work with physical and occupation therapy, along with numerous interventions being put in place that day alongside his admission. Surveyor asked MDS J what the facility determined the root cause to be for R3's fall on 9/14/25. MDS J indicated the facility believes it was related to his toileting needs and self-transferring but also recognized his blood pressure was low at the time. Surveyor asked MDS J what intervention was put into place as a result of this fall. MDS J indicates R3 was sent to the emergency room for evaluation, his toileting plan was reviewed and revised, and added staff assisting with toileting mid-evening and with bedtime cares. MDS J also indicates they had R3 evaluated by an in-house psychiatric provider. Surveyor asked MDS J if any injury was present on assessment after the fall. MDS J indicates, no, and that the facility believes the jaw fracture found by the emergency room occurred prior to his admission to the facility. MDS J indicates her assertion is supported by the bruising present on R3's face in his admission photo and he never reported any pain or discomfort after the fall. Surveyor asked MDS J what the facility determined the root cause to be for R3's fall on 10/7/25. MDS J indicates the fall was related to R3 taking himself to the restroom. Surveyor asked MDS J what intervention was put into place as a result of this fall. MDS J indicates R3's toileting plan was reviewed and revised. Surveyor asked MDS J what reviewing and revising the toileting plan means. MDS J indicates all residents who are incontinent when they are admitted are put on an initial toileting plan and if the resident has falls related to toileting they add interventions. Surveyor asked MDS J if this intervention being listed means that active changes were made to the care plan and the care plan would have that documented. MDS J indicates, yes. Surveyor asked MDS J if any injury was present on assessment after the fall. MDS J indicates R3 had a small skin tear. Surveyor asked MDS J what the facility determined the root cause to be for R3's fall on 10/11/25. MDS J indicates the fall was related to R3 rolling out of bed. Surveyor asked MDS J what intervention was put into place as a result of this fall. MDS J indicates R3 already had a lipped mattress in place prior to the fall, and the facility added a beveled mat next to R3's bed and a body pillow placed at the edge of R3's bed to assist him with defining the edge of the bed. Surveyor asked MDS J and DON B if R3's toileting program has ever been adjusted. DON B indicates, they added the mid-evening toileting intervention. Surveyor asked MDS J and DON B if they mean a specific time for the mid-evening intervention or just a generalized block of time. DON B indicates there is no specific time, just a general time. Surveyor asked MDS J and DON B if the facility ever considered every 2-hour toileting program for R3. DON B indicates she feels like it is pretty much every 2-hour toileting program currently. (Of note: The current toileting program only as mid-evening and HS (bedtime) cares listed under the toileting section). Surveyor asked MDS J and DON B if, in their opinion, a more frequent toileting program may have been effective at reducing R3's fall risk. MDS J indicates she believes that what the facility has in place is effective as evidenced by his reduction in the frequency of his falls with R3's last fall occurring a little over a month ago. Surveyor noted that observations were made of R3 not having a urinal at his bedside, when his care plan indicates he should have one at his bedside. MDS J indicates if it is on his care plan he should have it. However, she does note that R3 is frequently organizing and moving the stuff in his room. Surveyor noted that observations were made of R3 not having a reacher at his bedside, when his care plan indicates he should have one at his bedside. MDS J indicates yes, but reiterates it might be in a box as one of his behaviors is packing his belongings. On 12/2/25 at 12:15 PM, Surveyor interview NP K (Nurse Practitioner). Surveyor asked NP K if she was familiar with R3. NP K indicates, yes. Surveyor asked NP K if she recalled the first time she noted bruising on R3's face. NP K indicates she first saw R3 on 11/5/25 as she took over for a different provider. When NP K conducted her initial assessment, she also conducted record review and spoke with facility staff who provided R3's admission picture and statements that facial bruising was present on R3's admission. NP K made the statement that the x-ray taken by the hospital stated the jaw fracture was not acute. Surveyor read the radiology report to NP K, which indicates the jaw fracture was acute at the time of the exam. NP K reviewed R3's file and indicated she did not have that particular exam result in the file. Surveyor asked NP K what her clinical impression was regarding whether R3's jaw fracture was acute or sub-acute. NP K indicates she believes the jaw fracture occurred prior to R3's admission as evidenced by the dark purple bruising in R3's admission photo, the lack of an x-ray of his facial bones during his hospital stay prior to admission, staff reports, and record review. Surveyor asked NP K what was her designated specialty. NP K indicates she is an Adult Gerontology Acute Care Nurse Practitioner. Surveyor asked NP K how long she would estimate a fracture like this would take to heal. NP K indicates around 8 to 12 weeks. She indicates in someone young with no comorbidities it may take as little as 6 weeks, however, since R3 is older and has multiple comorbidities, she would expect an 8 to 12-week healing time. Surveyor asked NP K, so then it would be expected to still see the fracture on the CT scan on 9/14/25 if the fracture occurred prior to admission. NP K indicates, yes. (Of note: The CT scan on 9/14/25, indicates the fracture as being acute, R3 did not have a diagnosis of a fractured jaw upon admission, and the fracture was unchanged on 10/11/25)

Based on observation, interview, record review and policy review, the facility failed to ensure 1 of 5 sampled residents (R2) with an urostomy had their urostomy bag stored in a sanitary manner to prevent cross contamination and the potential spread of infection. Findings include: Review of the Pouch Changes-Colostomy, Urostomy, and Ileostomy Policy dated 10/2023 revealed, Urostomy - a stoma for the urinary system used in cases where long-tern drainage of urine through the bladder and urethra is not possible . items soiled with urine or fecal matter (i.e urostomy bags or tubing) must be handled so as to prevent contamination of the environment with urine or feces. Such items must be placed in closed containers . R2 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm (cancerous tumor) of the bladder and urinary tract infection (UTI). Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/13/23 revealed R2 had a BIMS of 14, which indicated R2 was cognitively intact. R2 utilized an ostomy. Review of R2's Physician's Orders dated 07/30/23 tab revealed an order for, Hook up nighttime urostomy drainage bag at bedtime, every evening shift. Further review of Physician's Orders revealed an order dated 10/19/23, Change overnight bag every two weeks. Review of the Visit Petunia List B instructions for the provision of certified nurse aide (CNA) care dated 11/09/23 and provided by the facility revealed, Empty urostomy completely into drainage bag before resident gets OOB [out of bed] in AM . R2's Care Plan dated 11/09/23 includes a problem of, [R2] has a UTI and is at risk for further UTIs r/t [related to] hx [history] UTIs, confusion at times, urostomy in place, bladder cancer, decreased mobility, CVA [cerebral vascular accident], type 2 DM [diabetes mellitus]. Interventions Change urostomy devices per facility protocol/MD order. R2's Care Plan dated 11/09/23 also includes a problem of [R2] has an ADL [activities of daily living] Self Care Performance Deficit .r/t confusion at times, decreased mobility, UTI and hx UTI, .urostomy in place, bowel incontinence, right side weakness with decreased muscle coordination, assistance needed with ADL tasks. Interventions included, Empty urostomy completely into drainage bag before [R2] gets out of bed in the morning. Empty before or after lunch, before or after dinner and at bedtime (to help prevent it from becoming overly full). [R2] uses a Foley bag at NOC [night]. During an interview on 12/19/23 at 5:02 PM, R2 stated the surveyor should talk to his family member about his care. During an observation on 12/20/23 at 3:25 PM, the Registered Nurse (RN) F and the surveyor entered R2's room and then the bathroom. There was a wire shelf above the toilet on which the overnight urostomy bag was sitting. It was not bagged or in a container and sat directly on the shelf. There was urine noted in the tubing. During an observation on 12/20/23 at 4:00 PM, Family Member N (FM) and the surveyor entered R2's room and bathroom. The overnight urostomy bag continued to sit on the wire shelf. FM N stated, The connector is not covered up. The overnight bag is sitting on the shelf, not bagged .The cord is usually lying on the floor because it [the bag] hangs on the hook. A hook was observed on the wall approximately two thirds of the way up the wall above the toilet. The urine remained in the tubing and FM N stated, The urine should be drained. It should be bagged, and it is not. During an interview on 12/20/23 at 4:15 PM, CNA J stated R2's overnight urostomy bag was stored in the bathroom when it was not in use, and it should be bagged (in a plastic garbage bag). CNA J stated it usually hung on a hook in the bathroom. CNA J stated all the urine should be drained out prior to storing the bag. During an observation on 12/21/23 at 9:55 AM, R2's overnight urostomy bag was hanging on the hook on the wall above the toilet with the tubing wrapped around the hook; it was not bagged. CNA K stated she was R2's CNA for day shift. CNA K stated night shift staff changed the bag prior to the start of her shift. CNA K stated the night urostomy bag should be bagged. On 12/21/23 at 9:57 AM, Licensed Practical Nurse (LPN) D entered R2's bathroom where the nighttime urostomy bag was hanging on the hook and stated it should be bagged. LPN D stated it was important to bag the urostomy bag when not in use to prevent cross contamination and infection. During an interview on 12/21/23 at 3:35 PM, Director of Nursing (DON) B verified R2's overnight urostomy bag should be stored in a bag when not in use to potentially prevent infection.

Based on interview, record review, and review of the Admission Agreement, the facility failed to ensure that 3 of 5 sampled residents (R1, R2, and R3) were provided with choices regarding baths/showers. R1, R2, and R3 were not offered choices regarding the frequency of showers, and each received one shower per week according to the facility shower schedule. R1, R2, and R3 did not receive an adequate number of showers to meet their needs. Findings include: During an interview on 12/21/23 at 7:23 PM, NHA A (Nursing Home Administrator) stated the facility did not have a policy for resident choice/choices; however, there was some information in the Admission Agreement. The facility's undated Admission Agreement states, Each resident is treated with consideration, respect, and full recognition of dignity and individuality .Each resident is encouraged and assisted, throughout the period of stay, to exercise rights .and to this end may voice grievances and recommend changes in policies and services to facility staff and/or outside representatives of choice . Review of the facility's shower schedules dated 12/20/23 revealed the standard number of showers provided to residents was one per week. There were 4 of 79 total residents who were scheduled for more than one shower per week. R2 and R3 were scheduled for one shower per week. R1 was not on the schedule as she had been discharged from the facility. Showers were scheduled according to room number and bed. Example 1 R1 was admitted to the facility on [DATE] and was discharged on [DATE]. The primary admission diagnosis was myocardial infarction (heart attack.) R1's Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/05/23 revealed R1 was moderately impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating R1 was moderately cognitively impaired. This MDS further indicated it was somewhat important for R1 to choose between a tub bath, shower, bed bath, or sponge bath. R1 required moderate assistance with dressing and showering/bathing self. R1's Baseline Care Plan dated 10/31/23 indicated R1 had impaired activities of daily living (ADLs) and required 1 person assistance with grooming, hygiene, and dressing. The provision of showers/bathing was not specifically addressed on the Base Line Care Plan. Review of the facility's documentation found R1 received 1 shower on 11/07/23 during her 12 day stay. During an interview on 12/19/23 at 12:53 PM, FM M (Family Memeber) stated R1 did not get showers while in the facility. FM M stated there were times in which R1 was wet from urinary incontinence and further stated R1 did not receive enough showers during her time at the facility. During an interview on 12/20/23 at 1:07 PM, Certified Nurse Aide (CNA) C stated baths were assigned as part of the CNA workload each shift. CNA C stated residents were bathed once a week. During an interview on 12/20/23 at 1:36 PM, Licensed Practical Nurse (LPN) D stated residents received one shower per week. LPN D stated she did not know if there was a process to determine residents' preferences regarding baths/showers such as what type they preferred, when they preferred to receive baths/showers, the frequency etc. LPN D stated, They (residents) know they get one shower a week. During an interview on 12/20/23 at 2:34 PM, Registered Nurse (RN) E stated the facility did not have an assessment for bathing/shower preferences. RN E stated she was aware of one resident who got two showers a week; however, no one else had ever said they wanted more than one shower per week. Example 2 R2 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm (cancerous tumor) of the bladder and urinary tract infection (UTI). Review of the admission MDS with an ARD of 07/12/23 revealed it was somewhat important for R2 to choose between a tub bath, shower, bed bath, or sponge bath. The quarterly MDS with an ARD of 10/13/23 indicated R2 was cognitively intact. R2 required substantial/maximal assistance for showers/bathing self. Review of the Care Plan dated 11/09/23 revealed, [R2] has an ADL Self Care Performance Deficit . r/t [related to] confusion at times, decreased mobility, UTI and hx [history] UTI, . bowel incontinence, right side weakness with decreased muscle coordination, assistance needed with ADL tasks. Interventions included, Bathing: 1 assist staff participation with bathing. Shower Monday PM and prn [as needed]. Review of the shower schedule dated 12/20/23 revealed R2 was scheduled for a shower once a week on Monday afternoon shift. Facility documentation for October 2023 indicated R2 received showers on 10/02/23, 10/09/23, 10/16/23, and on 10/23/23; he received 4 instead of 5 showers in October 2023 per schedule. November and December shower documentation revealed R2 received showers once per week as scheduled. During an interview on 12/19/23 at 5:02 PM, R2 stated the surveyor should talk to his family member about his care. During an interview on 12/19/23 at 5:05 PM, FM N stated that R2 was supposed to receive a shower on Mondays but he did not always get a shower when scheduled. FM N stated R2's hair was not always washed. FM N stated it was not unusual for R2's ostomy to leak and for him to smell of urine and be wearing urine-soaked clothing. FM N stated R2 did not receive enough showers to meet his needs. FM N stated she filed several grievances with the facility requesting additional showers for R2 due to R2's foul odor. Review of FM N's grievance dated 11/08/23, revealed, Not getting showers for three weeks. Per the grievance, the interdisciplinary team met with F2 on 11/09/23 regarding the shower concerns. During an interview on 12/20/23 at 2:19 PM, LPN L stated showers were scheduled once a week according to room number. LPN L stated No one gets more than one (shower) per week. During an interview on 12/20/23 at 2:40 PM, RN F stated residents were not assessed upon admission or offered choices regarding baths/shower preferences. Example 3 R3 was admitted to the facility on [DATE] with diagnoses including muscle weakness and adult failure to thrive. Review of the admission MDS with an ARD of 10/16/23revealed it was somewhat important for R3 to choose between a tub bath, shower, bed bath, or sponge bath. Review of the quarterly MDS with an ARD of 11/20/23 indicatined R3 was cognitively intact. R3 required substantial/maximal assistance for showers/bathing self. Review of R3's Care Plan dated 12/14/23 included a problem of, ADL Self Care Performance Deficit r/t .weakness, decreased mobility, incontinence of bowel and bladder .assistance needed with ADL tasks. Interventions included, Bathing: 1 assist staff participation with bathing. Shower Friday AM and prn. Review of the shower schedule revealed R3 was scheduled for a shower once a week on Friday afternoon. Review of the shower documentation for October, November, and December 2023 revealed R3 received showers once per week as scheduled. During an interview on 12/19/23 at 4:15 PM, R3 stated she did not get a shower very often, less than weekly. R3 stated the staff never told her how often she would get a shower and staff had not asked about her shower/bath preferences. R3 stated, I would like more showers. During an interview on 12/20/23 at 1:17 PM, CNA G stated baths were part of the CNA assignment and residents got showers once a week. During an interview on 12/21/23 at 4:13 PM the Admission Assistant (AA) H stated when residents were admitted to the facility, she coordinated and completed paperwork with the residents and their families. AA H stated she informed residents that they would get washed daily at bedside and would receive one shower per week. AA H stated, Sometimes that is disappointing to people. AA H stated if a resident or family asked for more than one shower per week, she stated she let the floor nurse or Quality Assurance (QA) staff know to see if more could be provided. During an interview on 12/21/23 at 2:46 PM, NHA stated the facility standard was one shower per week. NHA A stated, It has always been that way.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 77 residents residing at the facility. Surveyor observed walk-in freezer to have water dripping from ceiling, chunks of ice on a box of food, chunks of ice around the freezer door, and ice chips on the floor. Surveyor observed the freezer thermometer to read 25 degrees Fahrenheit. Surveyor observed an open blue bag of broccoli, out of its original packaging, with no label or date. The bag had ice chunks in it. Surveyor observed a bag of biscuits with no date. Surveyor observed a package of hot dogs, out of its original packaging, with no label or date. Surveyor observed microwave to have a black spot on the top of the microwave. Surveyor observed food splatters and crumbs in microwave. Evidenced by: The facility policy, entitled Food Receiving and Storage, states, in part: . Policy Statement- Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation- Food Services, or other designated staff, will maintain clean food storage areas at all times .All foods stored in the refrigerator or freezer will be covered, labeled and dated . On 6/26/23 at 10:00 AM, during the initial walkthrough of the kitchen, Surveyor observed the walk-in freezer to have water dripping from the ceiling, ice chips on a box of food items, ice around the freezer door, and ice chips on floor. Surveyor observed the box of food to have a blue bag of broccoli, out of its original packaging, with no label or date, biscuits with no date, and hot dogs out of original packaging with no label or date. The items were covered in ice. Surveyor and DM N (Dietary Manager) observed the thermometer to read 25 degrees Fahrenheit. DM N indicated she would contact maintenance immediately and that she would remove the food items that were covered in ice. DM N indicated the food items should be labeled and dated. On 6/26/23 at 10:00 AM, during the initial walkthrough of the kitchen, Surveyor observed the microwave to have food splattered on the top, an area that appeared burnt on the top, and crumbs around the side of the microwave. DM N indicated that it appears the black spot on the top is burnt and there are some food splatters. DM N indicated the microwave is very old. On 6/28/23 at 1:28 PM, NHA A (Nursing Home Administrator) and DM N indicated understanding of the above items. NHA A indicated the microwave is going to be replaced.

Based on observation, interview, and record review, the facility did not ensure it maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections. The facility does not have a water management plan that identifies all areas where Legionella and other opportunistic waterborne pathogens can grow and spread. This had the potential to affect all 77 residents (R) in the facility. The facility's water management plan did not identify/assess through text and flow diagrams areas where Legionella and other opportunistic waterborne pathogens can grow and spread. CNA C (Certified Nursing Assistant) did not follow appropriate infection control procedures to prevent the spread of infection. This is evidenced by: The facility policy titled, Water Management Policy, with a Reviewed/Revised date of 4/2023, indicates, in part: Policy: It is the policy of [NAME] Lake Healthcare at Beloit to establish risk reductions of legionellosis and other opportunistic pathogens .in the facility's water systems based on nationally accepted standards (e.g., ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers), CDC (Centers for Disease Control), EPA (Environmental Protection Agency). Definitions: Control measures are things done in the building water systems to limit growth and spread of Legionella, such as heating, adding disinfectant, or cleaning. Control points are locations in the water systems where a control measure can be applied . Water management plans refer to the documents that contain all the information pertaining to the development and implementation of the facility's water management activities for reducing risk of Legionella and other opportunistic pathogens . Policy Explanation and Compliance Guidelines: .2. A risk assessment will be conducted by the water management team to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems .3. Data to be used for completing the risk assessment may include but are not limited to a. Legionella environmental assessment b. Resident infection control surveillance date (i.e., culture results) c. Environmental culture results d. Rounding observation date e. Water temperature logs f. Community infection control surveillance data (i.e., health department data) .12. Documentation of all activities related to the water management program shall be maintained with the Safety Committee [sic] for a minimum of three years . The facility policy, Legionella Management Policy, with a Revised date of 3/2023, indicates, in part: Policy: The aim of this document is to define a policy for the control and management of legionella bacteria in water systems within the facility of [NAME] Lake Healthcare at Beloit. The policy will inform the Legionella Management Operation Procedure . Control of Legionella Bacteria in Water Systems: Approved Code of Practice and Guidance: The principal statutory requirements for the control and management of legionella bacteria are the Health and Safety Commission Approved Code of Practice Guidance L8. The purpose of the regulation is to manage the risk from legionella to employees, residents, and visitors to the facility premises: *Identify and assess the risks of legionella bacteria in water systems *Devise a scheme for eliminating or controlling the risk *Manage the risk, selection, and training of competent personnel *Keep up to date records (electronically and logbooks on site) *Manufacturers, suppliers' installers, and users to address their responsibilities The above requirements will be met by the following actions: *Legionella water samples taken (Annually) Cleaning [sic] and disinfection of shower heads (at least Quarterly) *Checking other outlets on a rotational basis over 12-month period recording temperatures in a logbook per preventative maintenance program *Unused outlets will be flushed per preventative maintenance program . The CDC Legionella Toolkit-Version 1.1 - June 24, 2021, Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings. A Practical Guide to Implementing Industry Standards, indicates, in part: Page 4 - Where can Legionella grow and/or spread? . *Water heaters . *Electronic and manual faucets . *Showerheads and hoses . *Ice Machines . Page 8 - Describe Your Building Water Systems Using Text .You will need to write a simple description of your building water system and devices .This description should include details like where the building connects to the municipal water supply, how water is distributed, and where pools, hot tubs, cooling towers, and water heaters or boilers are located . Page 10 - Describe Your Building Water Systems Using a Flow Diagram .In addition to developing a written description of your building water system, you should develop a process flow diagram . Page 11 - Identify Areas Where Legionella Could Grow & Spread .Once you have developed your process flow diagram, identify where potentially hazardous conditions could occur in your building water system . The facility's policy, Hand Hygiene, revised 5/2023, states, in part, as follows: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, resident, and visitors. Hand Hygiene is a general term for cleaning our hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol -based hand rub (ABHR). Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. The Centers for Disease Control and Prevention (CDC) indicates in part the following: Healthcare personnel should use an alcohol-based hand rub or wash with soap and water or the following clinical indications .After touching a patient or the patient's immediate environment. https://www.cdc.gov/handhygiene/providers/guideline.html Example 1: On 6/28/23 at 12:30 PM, Surveyor interviewed DON B, who oversees the IP Program, along with the COVID IP D, and the MDS E who also assists with the IP program regarding the facility Water Management Plan. Surveyor asked what the facility has in place for Legionella? The IP team indicated they have a Water Management Plan and that Maintenance performs flushing. Surveyor reviewed the Legionella Management Policy and The Water Management Policy with the IP team. Surveyor asked if they had any documentation of what areas in the building had been identified as areas where Legionella or other pathogens could grow. MDS E indicated that she thought they had more information and would get back to Surveyor. MDS E also indicated she would have DOES L (Director of Environmental Services) come speak to Surveyor. Surveyor asked the IP team to provide any text and flow diagrams of their building water system including areas identified for potential bacterial growth. On 6/28/23 at 2:33 PM, Surveyor interviewed DOES L and asked if the facility has text and flow diagrams for their water plan. DOES L indicate they do not. Surveyor asked what the facility is doing to identify areas for pathogen growth or legionella. DOES L indicated that there is only one unit that is not being used, the Rapid unit. Maintenance runs the sinks, toilets, and shower room weekly. Surveyor asked how long these are run? DOES L indicated, I don't know, it's a while. Surveyor showed DOES L a capped off pipe that looked like an old hopper sprayer in the bathroom in the conference room and asked if there are others like this in the building. DOES L indicated she would have to ask Maintenance M. Surveyor clarified with DOES L that right now the facility does not have anything on paper indicating where areas of concern for pathogen growth were identified in the water system. DOES L indicated, correct, Maintenance M has work orders for flushing and running water, but nothing in a water management plan, nothing formal. Surveyor asked DOES L, the only concern area you have identified is the closed unit Rapid? DOES L indicated, yes, because it is sitting. On 6/28/23 at 3:02 PM, Surveyor interviewed Maintenance M with DOES L. Surveyor asked Maintenance M if he is aware of anything in writing or in a water management plan where the facility has identified where pathogens can grow, including Legionella. Maintenance M indicates on the closed unit Rapid; he lets the water run for about 5 minutes. They run all the faucets, flush all the stools, and run the shower in the shower room. Surveyor asked Maintenance M if any other areas in this building have been identified as potential areas for pathogens to grow? Maintenance M indicated, no. Maintenance M indicated, if a unit is shut down for more than a week that the flushing protocol is started. DOES L and Maintenance M indicated that they also de-lime the shower heads quarterly at a minimum and have replaced some of the shower heads. Temperatures are completed monthly on every room and every shower room. Surveyor asked Maintenance M about the capped hopper sprayer in the bathroom. Maintenance M indicated the water to these has been shut off, so no water gets to these any longer. Of note, no further documentation was provided of text and flow diagrams and identified areas of concern. 30992 Example 3: R136 was admitted to the facility 6/19/23 with diagnoses including but not limited to rheumatoid arthritis, acute kidney failure, presence of urogenital implant, catheter, and severe sepsis due to E. coli. R136 is on Enhanced Barrier Precautions (EBP) due to having a catheter. R136's comprehensive care plan indicates the following: Focus: R136 is on EBP and is at increased risk for infection r/t (related to) catheter and altered skin integrity. Goal: Skin will show signs of healing and he will not have complications r/t infection through review date. (Date Initiated 6/26/23) Goal: Skin will show signs of healing and he will not have complications r/t infection. Interventions: All staff providing direct cares follow EBP protocols on donning and doffing PPE (personal protective equipment) . On 6/26/23 at 2:29 PM, Surveyor observed CNA C (Certified Nursing Assistant) answer R136's call light. R136 requested CNA C to change his brief. CNA C set the supplies in R136's wheelchair. While CNA C was pulling supplies off the chair, the Peri Guard Ointment Skin Protectant fell on to the floor. Surveyor observed CNA C pick up the bottle of Peri Guard Ointment Skin Protectant with her gloved hands and proceed to apply the Ointment on R136's buttocks. On 6/26/23 at 2:45 PM, Surveyor spoke with CNA C. Surveyor asked CNA C, if a cream or ointment falls on the floor, what do you normally do? CNA C stated, what am I supposed to do, throw it away? CNA C stated, she was not aware to disinfect the tube or throw it away and get a new tube of cream. On 6/29/23 at 3:41 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B when should staff wash their hands? DON B stated, before they go into the room, if they become soiled or take their gloves off, and when they come out of the room. Surveyor asked DON B, if a tube of cream falls on the floor, what is your expectation? DON B stated, I would say at least wipe the tube off or get a new tube. DON B added, if it's floor stock, I would expect them to get a new container of it. DON B added, if it's a prescribed medication, I would expect they wipe it down with a cavi wipe if it's a medication and wasn't compromised in any way from dropping it on the floor. DON B stated she would expect CNA C to get a new tube or clean the tube off at a minimum. DON B stated, CNA C should not have used the cream after it fell on the floor and should have removed her gloves and washed her hands before proceeding to provide care.

Based on interview, and record review, the facility did not ensure a resident who requires BiPAP respiratory support was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 1 residents (R62) reviewed with BiPAP. R62 indicated to Surveyor it took over an hour and a half on 6/23/23 for staff to assist R62 with BI-PAP machine. R62 indicated she eventually had to call the facility to receive assistance. Evidenced by: The facility policy, ADL Care Sheet Policy, dated 4/23, states, in part: Policy .utilizes ADL care sheets to communicate resident care needs and preferences with nursing staff .The ADL care sheet is based on a collection of data, including but not limited to the resident's comprehensive assessment and is consistent with the resident's needs and preferences Procedure .ADL care sheets include pertinent information for staff to utilize in an easily accessed form to deliver resident care needs. ADL sheets include but are not limited to the following information .Assistive devices . R62 was admitted to the facility on [DATE] with diagnoses including Charcot's joint left ankle and foot, anemia, diabetes, obesity, bipolar disorder, major depressive disorder, anxiety disorder, post-traumatic stress disorder, seizures, migraines, hypertension, heart failure, asthma, chronic respiratory failure, kidney failure, dependence on supplemental oxygen, muscle weakness, weakness, and need for assistance with personal care. R62's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/16/23, indicates R62 has a Brief Interview for Mental Status (BIMS) score of 13 indicating R62 is cognitively intact. R62 is own person. R62's Care Sheet, dated 6/26/23, indicates, in part: .Asst. Devices .Oxygen, CPAP. Special Instructions .ADL's 1 assist .Continuous oxygen, CPAP at night . R62's current orders indicate, .Bi pap at night . R62's Comprehensive Care plan revision date of 6/26/23, indicates, in part: Focus has an altered respiratory status/difficulty breathing r/t (related to) morbid obesity, significant weight gain, type 2 DM, heart failure, non-compliance with MDS recommendations/fluid restriction, COPD (chronic obstructive pulmonary disease), oxygen use, hx. (history) pulmonary embolism, hx. COVID, Bi-PAP. Goal: will have no complications related to SOB (shortness of breath) through next review date. Interventions: Administer medications as ordered. Monitor for effectiveness and side effects. Bi pap at night. Settings: 20/10, 35% FIO2, backup rate=14. Cleanse per manufactures instructions . On 6/26/23 at 2:25 PM, R62 indicated she has been at the facility for around 6 months. R62 indicated the facility is on top of things for the most part. R62 indicated last Friday, 6/23/23, R62 had to wait over one and a half hours before someone came to assist her with her Bi-Pap machine. R62 indicated she had put her call light on around 9:00 PM. R62 indicated she had to eventually call the facility because it was around 10:30 PM and no one had answered her call light. R62 indicated staff told her it was shift change and that someone would be down shortly. R62 indicated there are times there is no CNA (Certified Nursing Assistant) down her hall so the assistance she needs has to wait. It is important to note one other resident indicated having to wait for over an hour and a half for call light to be answered on the evening of 6/23/23 down the same hallway. On 6/28/23 at 2:50 PM, LPN O (Licensed Practical Nurse) indicated she was the staff that took R62's phone call on 6/23/23. LPN O indicated R62 called asking for assistance putting water in Bi-pap machine. LPN O indicated she was not sure how long the call light was on for because she was down a different hallway. LPN O indicated she told R62 she was sorry and that someone would be down shortly because it was during shift change around 10:30 PM. LPN O indicated there was not a CNA on R62's hallway after CNA left at 9:00 PM and CNA came in at 10:30 PM. On 6/29/23 at 3:00 PM, NHA A (Nursing Home Administrator) and RN P (Registered Nurse) indicated an hour and a half wait time for a resident to receive assistance is not an acceptable timeframe.

Based on interview and record review, the facility did not ensure a resident who requires two-person assist for transfers, transfer safely to prevent accidents for 3 out of 23 residents reviewed for accidents. (R62, R3, R66) R62 indicated there are times she is transferred by one staff and R62's care plan indicates she is a two-person transfer assist. R3 indicated there are times she is transferred by one staff and R3's care plan indicates she is a two-person transfer assist. R66 uses a full body lift and facility staff transfer with one staff not two. Evidenced by: The facility policy, Safe Resident Handling/Transfer Policy, dated 2/23, states, in part: Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines .Compliance Guidelines: .4. Mechanical lifts may include equipment such as mechanical hoyer lifts, EZ stand lifts .10. Two staff members must be utilized when transferring residents with a mechanical Hoyer lift .12. Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment 13. Resident lifting and transferring will be performed according to the resident's individual plan of care .14. Staff will perform mechanical lifts/transfers according to the manufacturer's instructions for use of the device Example 1 R62 was admitted to the facility on [DATE] with diagnoses including: charcot's joint left ankle and foot, anemia, diabetes, obesity, bipolar disorder, major depressive disorder, anxiety disorder, post-traumatic stress disorder, seizures, migraines, hypertension, heart failure, asthma, chronic respiratory failure, kidney failure, dependence on supplemental oxygen, muscle weakness, weakness, and need for assistance with personal care. R62's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/16/23, indicates R62 has a Brief Interview for Mental Status (BIMS) score of 13 indicating R62 is cognitively intact. R62 is her own person. R62's Care Sheet, dated 6/26/23, indicates, in part: .Room Transfer High risk for skin breakdown, 2 assist EZ stand . R62's Comprehensive Care Plan, dated 6/26/23, indicates, in part: .TRANSFER: 2 assist Hoyer lift staff participation with transfers. Uses a w/c for locomotion, assist as necessary . On 6/26/23 at 2:25 PM, R62 indicated she transfers by an EZ-stand with support from two staff. R62 indicated there are times that only one staff transfers her due to not having enough staff. R62 indicated there are staff that R62 feels are capable of doing this, but if R62 feels like she is going to be too much for one staff se will tell them, You might need a buddy. Example 2 R3 was admitted to the facility on [DATE] with diagnoses including: multiple sclerosis, other specified disorders of bone density and structure, thoracogenic scoliosis, other muscle spasm, pain, history of falling, personal history of traumatic fracture, and muscle weakness. R3's most recent MDS with ARD of 3/19/23, indicates R3 has a BIMS score of 15 indicating R3 is cognitively intact. R3 is her own person. R3's Care Sheet, dated 6/26/23, indicates, in part: .Room Transfer 2 assist, hoyer lift. Risk for skin breakdown. R3's Comprehensive Care Plan, dated 8/24/22, indicates, in part: .Transfers: 2 assist Hoyer lift staff assistance for transfers. Using a regular w/c at this time. Have her left leg secure on elevated left rest d/t immobilizer On 6/26/23 at 1:42 PM, R3 indicated she transfers by using a Hoyer lift with support from two staff. R3 indicated there are times there is only one staff. R3 stated, They have to do this because there is no staff. On 6/28/23 at 7:30 AM, RN Q (Registered Nurse) indicated when she is working she always makes sure to tell CNAs (certified nursing assistants) she is available to help with transfers. RN Q indicated she knows of times that staff have to transfer residents who require two assist with one staff due to staffing. RN Q indicated, It's not easy to find help, but it's starting to get better because we now have a float CNA. On 6/28/23 at 7:51AM, CNA R (Certified Nursing Assistant) indicated there are times that residents who require two-person assist are transferred by one staff due to staffing. CNA R indicated staff do try to grab someone from another hallway if needed. On 6/29/23 at 3:00PM, NHA A (Nursing Home administrator) and RN P (Registered Nurse) indicated they would expect staff to follow resident care plans that indicate two-person assist for transfers. 39849 Example 3 R66 was admitted to the facility on [DATE] with diagnoses that include, in part: Malignant neoplasm of endometrium; Morbid Obesity; Atherosclerotic Heart Disease .History of falling . R66's most recent Minimum Data Set (MDS) with a target date of 4/17/23, indicates a Brief Interview for Mental Status (BIMS) score of 14, which indicates, cognitively intact. R66's Comprehensive Care Plan, indicates, in part: Focus: R66 has an ADL (Activities of Daily Living) Self Care Performance Deficit . Interventions: .Transfer: 2 assist hoyer lift staff participation with transfers .Revision on: 1/30/22 . R66's Care Sheet, indicates, in part: Room Transfer .Hoyer 2 assist . On 6/26/23 at 11:03AM Surveyor interviewed R66 who indicated that she transfers with a Hoyer (full body lift). Surveyor asked R66 how many staff assist when the hoyer is used. R66 indicated sometimes two people and sometimes one, but mostly one person.

Based on interviews and record review, the facility did not ensure full time DON (Director of Nursing) coverage. This has the potential to affect all 76 residents. This is evidenced by: On 4/10/22 at 10:41 AM, the Surveyor met with the NHA A (Nursing Home Administrator) for an entrance conference. The NHA A stated in the conference that the facility has two RN's (Registered Nurses) that share the role of the IDON (Interim Director of Nursing). One RN works in the IDON role 4 days a week and the other RN works in the role 1 day a week. On 4/10/22 at 12:24 PM, Surveyor interviewed IDON B. Surveyor asked IDON B how many days she works in the role of the IDON. IDON B states, I only work 4 days a week, so IDON/WCC E (Wound Care Certified) does the other day. I have been doing it about 2 months. We are IDON in title only, we still do our normal work and they have distributed the DON work through other staff. I am not completing all that paperwork and IDON E does the wounds. On 4/12/22 at 8:08 AM, Surveyor interviewed IDON/WCC E. Surveyor asked IDON/WCC E what her role is as the IDON. IDON/WCC E stated, I help with DON position, at least 1 time a week and whenever I am here. I do wound care and help with the DON position, help with TB screening, whatever arises. IDON B is doing most of the hours for the DON and I fill in when she is not here. On 4/12/22 at 2:01 PM, Surveyor interviewed IDON B. Surveyor asked IDON B what tasks she completes as the IDON. IDON B stated, I don't actually do DON work it is name only. I do 32-40 hours on the floor, and I am charge nurse too. I have been just filling in since the DON left, the ADON had been doing some of it but 2 weeks ago I was off the weekend and came back and she was gone. They changed it to me though when the DON left abruptly on 1/21/22. There is no way I could do the DON job, run this floor and everything else. On 4/12/22 at 2:08 PM, Surveyor interviewed IDON/WCC E. Surveyor asked IDON/WCC E what tasks she completes as the IDON. IDON/WCC E stated, We do the tasks of DON weekly. I do this roughly about 8 hours a week. Surveyor asked IDON/WCC E how long she has been doing this. IDON/WCC E stated, I have been helping fill in for a couple of weeks, around 2 weeks. Yeah, I would say around 2 weeks. Really just checking with nurses making sure they don't need extra help. Being on call off shifts for questions. The staff are good about splitting up duties between everyone to get it all done. Following up with MD's. Working with the scheduler if needed on stuff. I usually do 24 hours on floor for wound care and 8 hours of IDON work. On 4/13/22 at 7:41 AM, Surveyor reviewed nurse staff schedules from 3/21/22 to 4/13/22. IDON B who is to be in the IDON role is working the floor 4 days a week and acting as charge nurse on the following dates: 3/21/22 plus charge nurse, 3/22/22, 3/23/22, 3/28/22, 3/29/22, 3/30/22, 3/31/22, 4/04/22 plus charge nurse, 4/05/44 plus charge nurse, 4/06/22 plus charge nurse, 4/07/22 plus charge nurse, 4/08/22 plus charge nurse until 10AM, 4/11/22 plus charge nurse, 4/12/22 plus charge nurse, 4/12/22 plus charge nurse. Days not listed IDON B is not scheduled in the building Note: The Previous DON left on 1/21/22 and ADON became the IDON on that date. The ADON left on 4/05/22. Review of Staffing schedules from 3/21/22 to 4/13/22 indicate that the ADON while in the IDON role also was the charge nurse on the following dates, 3/21/22, 3/22/22, 3/23/22, 3/24/22, 3/25/22, 3/28/22, 3/29/22, 3/30/22, 3/31/22, On 4/13/22 at 9:44 AM, Surveyor interviewed NHA A. Surveyor asked NHA A about the IDON's designated work hours in the DON role. NHA A stated, The DON walked out on a Friday afternoon, met with ADON, staff development, and HR (Human Resources). The ADON took over role until we were able to figure it out. We are all doing 15 jobs as it is. I called RFOD (Regional Field Office Director), and she said 40 hours. I hit up IDON B and she and the ADON at the time split the duties. IDON B is the charge nurse on the floor and the ADON at the time was the administrative nurse. I had the ADON covering, and she walked out on 4/06/22. I am back to square one. I don't have bodies to pull from to designate to DON only. IDON B is here 32 hours, and I would say I get 10 hours out of her for the DON role. The facility failed to ensure that it had full-time DON coverage.

Based on interview and record review, the facility did not ensure the Infection Preventionist (IP) of the facility completed specialized training in infection prevention and control. This has the potential to affect all 76 residents in the facility. This is evidenced by: The facility policies related to Infection Control provided to and reviewed by Surveyor, did not address any qualifications required of the IP. On 4/12/22 at 1:30 PM, Surveyor interviewed NC F (Nurse Consultant), who has taken the role of the Infection Preventionist. Surveyor asked NC F if she had taken the required training for IP. NC F stated that she has not taken the training. On 4/13/22 at 9:42 AM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if she would expect the person in the role of IP to have taken the required IP training. NHA A stated yes. When Surveyor asked NHA A if she was aware that NC F had not taken the IP training, NHA A stated yes. The facility did not ensure its Infection Preventionist completed specialized training for the role.

Based on observation, interview and record review, the facility did not ensure no more than 14 hours between a substantial evening meal and breakfast the following day having the potential to affect all 76 residents. Residents on Skyline were served supper on 4/12/22 at 5:30 PM and were not served breakfast until 8:40 AM on 4/13/22. During Resident Council the residents voiced they are never asked if they want a snack, and the meals are always late. Evidenced by: The facility policy, entitled Frequency of Meals, dated 2/22, states, in part: . Policy Interpretation and Implementation- The facility will serve at least three (3) meals or their equivalent daily at scheduled times. There will not be more than a fourteen (14) hour span between evening meal and breakfast .Evening snacks will be offered routinely to all residents .Residents will also be offered nourishing snacks if the time span between evening meal and the next day's breakfast exceeds fourteen (14) hours . Facility's Meal Serving Times: Breakfast Lunch Supper Genesis- 7:25 11:50 4:55 Horizon 7:30 12:00 5:00 Skyline Main 7:40 12:10 5:10 Skyline 2nd 7:50 12:20 5:20 On 4/12/22, at 5:30 PM, Surveyors observed Skyline being served supper. On 4/13/22, at 08:40 AM, Surveyors observed Skyline being served breakfast. 04/13/22, 10:45 AM, Surveyor interviewed AA (Activity Assistant) O and asked when snacks get passed to residents. AA O indicated AA O passes them after breakfast between 10:30 AM - 11:00 AM. AA O indicated AA O passes snacks again after dinner and if residents request, they can have a snack in the evening after supper and before bed. AA O indicated there are two scheduled snack passes a day in between breakfast and lunch and between lunch and supper. On 4/13/22, at 9:26 AM, Surveyor interviewed CNA (Certified Nurse Assistant) N and asked if they had a snack cart and when snack pass occurs. CNA N indicated the facility does not have a snack cart, but residents can get snacks if they ask for them. On 4/13/22, 1:00 PM, Surveyor interviewed DM (Dietary Manager) P and asked how many hours is allotted between supper and breakfast with no snacks after supper. DM P looked up policy and read out loud 14 hours no more between supper and breakfast without a snack. Surveyor informed DM P that Surveyors observed supper going out to Skyline at 5:30 PM on 4/12/22 and breakfast served at 8:40 AM on 4/13/22 with no scheduled snack in between. DM P indicated the time was over 14 hours and shouldn't have been without a scheduled snack in between the meal.

Based on observation and interview the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has a potential to affect all 76 residents who reside in the facility. Surveyor observed old menus posted from two days prior. Surveyor observed the barrel the sugar was stored in was dirty on the rim of barrel and on the top inner part of barrel with built up brown grime. Surveyor observed the flour stored in original packaging with a scoop in it. The package of flour was set inside a rubber barrel with a lid covering. Along the rim of the barrel Surveyor observed built up brown grime. Surveyor observed three trays of fruit cups in the refrigerator and a tray of pudding cups uncovered. Surveyor observed a fruit cup was tipped over and fruit was spilt out on tray. Surveyor observed a tray of 23 vanilla pudding cups uncovered. Surveyor observed a pitcher of cranberry juice undated in the refrigerator. Surveyor observed the inside of the oven door and the inside of the oven covered with brown/yellow greasy grime. Surveyor observed the large mixer's shaft had food on it and water standing under the mixing bowl. Surveyor observed a fan that had built up dust and debris blowing onto clean dishes. Surveyor observed the microwave on the unit with dried stuck on food particles inside and toaster with crumbs on top and brown substance around toaster knobs. Surveyor observed wet stacking of dishes during lunch and a breakfast tray line. Surveyor observed three kitchen staff with hair hanging out of hair nets. Surveyor observed dirty floor in dry storage area. Evidenced by: The facility policy, entitled Food Receiving and Storage, dated 3/22, states, in part: . Policy Statement - Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation - Food Services, or other designed staff, will maintain clean food storage areas at all times .Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date) .All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by) . The facility's policy, entitled Sanitization, dated January 2020, states, in part: .All kitchens, kitchen areas and dining areas shall be kept clean .Food preparation equipment and utensils that are manually washed will be allowed to air dry . The facility's policy, entitled Preventing Foodborne Illness- Employee Hygiene and Sanitary, states, in part: Policy Statement- Food Services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness .Policy Interpretation and Implementation .11. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens . According to the 2017 Food and Drug Administration (FDA) Food Code, epidemiological outbreak data repeatedly identify five major risk factors related to employee behaviors and preparation practices in retail and food service establishments as contributing to foodborne illness: * Improper holding temperatures, * Inadequate cooking, such as undercooking raw shell eggs, * Contaminated equipment, * Food from unsafe sources, and * Poor personal hygiene In addition, the 2017 FDA Food Code designates the elderly as a highly susceptible population (HSP) and as such are extremely vulnerable to foodborne illness. On 4/10/22, at 9:45 AM, Surveyors observed menus posted on the second floor, (Genesis/Horizon), from 4/8/22. Menus posted had not been updated in two days. On 4/10/22, at 10:10 AM, Surveyor did walk through of kitchen with DC R (Dietary Cook). Surveyor observed sugar being stored in a big plastic barrel with wheels and plastic lid. On the rim of the barrel and the lid was observed to have built up brown grime. DC R indicated it was dirty and needed to be washed. Surveyor observed a bag of flour in original packaging with a scoop in it and placed in a big plastic barrel with wheels and a lid. Brown grime was observed around rim of the barrel and on the inner top portion of the barrel. DC R indicated the scoop should not be in bag of flour and took scoop out. DC R indicated the barrel needed to be cleaned due to brown grime on rim of barrel and upper inner portion of barrel. On 4/10/22, at 10:10 AM, during kitchen walk through with DC R, Surveyor observed three trays consisting of 75 fruit cups and a tray of 23 vanilla pudding cups uncovered in the refrigerator and undated. Surveyor and DC R observed a fruit cup spilt over on the tray. DC R indicated the fruit cups and pudding cups should be covered and dated. DC R indicated the aide must have just put those in refrigerator for lunch. DC R indicated she would clean the spilt fruit cup up on the tray. On 4/10/22, at 10:10 AM, during walk through of kitchen with DC R, Surveyor observed a pitcher of cranberry juice covered with saran wrap with no date. Surveyor asked DC R if the pitcher should be dated. DC R indicated the pitcher of cranberry juice should be dated. On 4/10/22, at 10:10 AM, Surveyor continued walk through of the kitchen with DC R. Surveyor observed the inside of the oven and on the inside of the oven door was covered with built up greasy brown grime. Surveyor asked DC R who is responsible for cleaning and if there is a cleaning schedule. DC R indicated DC R was not sure who was responsible for cleaning the oven and did not know where the cleaning schedule is. Surveyor asked DC R if the oven was clean. DC R indicated the oven was dirty and needed to be cleaned. On 4/10/22 at 10:10 AM during the kitchen walk through with DC R, Surveyor observed food on the shaft of the large mixer and water standing under the mixing bowl. Surveyor asked DC R if the shaft was clean and if water should be standing under the mixing bowl. DC R indicated the mixer was used this morning for breakfast and she did not clean it very well. DC R wiped the water up under the mixing bowl and wiped the food off the shaft. On 4/10/22, at 10:10 AM, Surveyor did walk through of the kitchen with DC R and observed a fan that was placed on the floor pointing up toward clean dishes. The fan had built up dirt and debris on it and was blowing air on clean dishes. Surveyor asked DC R to turn fan off and DC R complied. Surveyor asked DC R if the fan was dirty, and DC R indicated the fan was dirty with debris. Surveyor asked DC R if the fan should be blowing air onto clean dishes and DC R indicated it should not be blowing on the clean dishes. DC R had dietary aide remove the fan and put in a separate room. On 4/10/22, at 10:10 AM, Surveyor did walk through of kitchen and Skywalk dining area with DC R. Surveyor and DC R observed the microwave to have small, dried food particles inside and dried brown liquid under glass turntable. The toaster had dried crumbs on it and the toaster knobs had brown substance around them. DC R indicated the appliances were dirty and should have been cleaned after use. On 4/10/22, at 12:10 PM, Surveyor observed dishes that were wet stacked while watching tray line. DC R was serving up dinner onto plates and placing wet cover and bottom lids on plates. Surveyor asked DC R if the covers and lids were put away wet and DC R indicated yes. DC R then proceeded to take the same paper towel to wipe the wetness from the lids and covers that were wet and placed the paper towel onto a metal serving cart. On 4/10/22, at 10:10 AM, Surveyor and DC R did walk through of the kitchen. Surveyor observed DA S, DC R, and DM P with hair hanging out of hair net. On 4/10/22, at 11:30 AM, Surveyor had asked DM P if hair should be hanging out of the hair nets and DM P indicated no. Surveyor informed DM P of DA C, DC R, and DM P all had hair hanging out and DM P indicated it should be under net. DM P instructed staff to get all their hair under hair nets. On 4/13/22, at 8:35 AM, Surveyor observed DC Q serving breakfast. DC Q ran out of covers for plates. Surveyor observed DM P run covers through dish washer and placed them on rack to dry. Surveyor observed DA T take covers out of rack and take the covers to the tray line. Surveyor then watched DC Q start placing the covers, that were still visibly wet, onto the plates. Surveyor asked DM P if those covers were wet, and DM P indicated yes. DA T then took paper towel and wiped each cover before placing over plates.

Based on observation, interview and record review, the facility did not follow proper sanitation and food handling practices in accordance with professional standards for food service safety. This has the potential to affect all 78 residents. The facility failed to consistently check surface temperatures of dishes and utensils in a ware washing machine and failed to take action when temperatures were below minimum wash temperature or outside the range established for the rinse temperature. Additionally on 2/21/21, the external dishwasher temperature gauge was found not to be working. Kitchen staff continued to use the dishwasher and were not testing the dishwasher dish and utensil surface temperature with heat sensitive test strips or a non-regressing thermometer. Failure to ensure systems were in place to ensure wash and rinse temperatures met the identified standard for properly sanitizing dishes and utensils created a finding of Immediate Jeopardy (IJ). The IJ began on 2/21/2021 when the external temperature gauge was no longer working. NHA A (Nursing Home Administrator) was notified of the IJ on 2/25/21 at 3:05 PM. The facility removed the IJ on 2/25/21; however, the deficient practice continues at a scope/severity level F (potential for more than minimal harm/widespread) as the facility continues to implement its removal plan and as evidenced by the following: Juice box containers were dated with receive dates only. Some plastic ware and pink plastic water pitchers were found to be wet stacked. Surveyor observed thirteen (13) cartons of Mighty Shakes thawed, with no thaw date or expiration date noted on the cartons. Findings include: The facility uses the US Food Code as their kitchen's operational standards of practice. 2017 Food and Drug Administration (FDA) Food Code states: 4-302.13 Temperature Measuring Devices, Manual and Mechanical ware washing (B) in hot water mechanical ware washing operations, an irreversible registering temperature indicator shall be provided and readily accessible for measuring the UTENSIL, surface temperature. 4-501.112 .When surface temperatures of utensils passing through ware washing machines using hot water for sanitizing do not reach the required 160 degrees (F) Fahrenheit, it is important to understand the factors affecting the decreased surface temperature. A comparison should be made between the machine manufacturer's operating instructions and the machine's actual wash and rinse temperatures and final rinse pressure. The actual temperatures and rinse pressure should be consistent with the machine manufacturer's operating instructions and within limits specified in sections 4-501.112 and 4-501.113. If either the temperature or pressure of the final rinse spray is higher than the specified upper limit, spray droplets may disperse and begin to vaporize resulting in less heat delivery to utensil surfaces. Temperatures below the specified limit will not convey the needed heat to surfaces. Example 1 The facility's Dish Machine Wash and Rinse Temperature logs note: 1. Check wash and rinse temperature while operating machine 2. Wash temperature must be at least 160 degrees F minimum 3. Rinse temperature must be at least 180 degrees F, 194 degrees F maximum 4. Record wash and rinse temperature and initial 5. If wash or rinse is not at proper temperature notify your supervisor or maintenance immediately. The log contains six temperatures per day, indicating a wash/rinse temperature three times a day. The temperature log for December 1, 2020 - December 31, 2020 notes there were 186 opportunities for dishwasher temperatures. The facility's Dish Machine Wash and Rinse Temperature log documented eleven readings where temperatures were too low or too high (6%) and twenty two readings where no temperature was documented (12%). The temperature log for January 1, 2021 - January 31, 2021 had 186 opportunities for dishwasher temperatures. The facility's Dish Machine Wash and Rinse Temperature log documented forty one readings where temperatures were too low or too high (22%) and eight readings with no temperature documentation (4%). The temperature log for February 1, 2021 - February 22, 2021 had 132 opportunities for dishwasher temperatures. The facility's Dish Machine Wash and Rinse Temperature log documented forty four readings where temperatures were too low or too high temperatures (33%). The facility's Dish Machine Wash and Rinse Temperature log for February 2021 contained no initials on the wash and rinse temperatures. On 2/23/21 at 3:15 PM, Surveyor observed the dishwasher. The dishwasher was running and the temperature gauge was not illuminated. On 2/23/21 at 3:30 PM, Surveyor asked DM D (Dietary Manager) about the non-illuminated temperature gauge on the dishwasher. DM D said the gauge on the dishwasher broke a few days ago, she thought on Sunday 2/21/21. DM D said the kitchen staff told her it was broken. DM D said she contacted MD F (Maintenance Director) on 2/21/21, and he said he would check on it. Surveyor asked how the facility checks the dish surface temperature inside the dishwasher. DM D said they do not have a non-regressing thermometer and do not use test strips to monitor the water temperature of the dishwasher. DM D said they only use the illuminated temperature gauge on the dishwasher to monitor the temperature. Surveyor asked DM D where the temperatures on the dishwasher log for 2/21, 2/22 and 2/23/21 were coming from if the gauge has been broken since 2/21/21. DM D said MD F monitors the dishwasher water temperature daily. MD F disputed the claim made by DM D when interviewed on 2/23/21 at 3:35 PM. MD F said he checks the dishwasher water temperature on the illuminated gauge about once a month. MD F said he checked the dishwasher on 2/21/21 in the afternoon after DM D called. MD F said he saw the gauge was not working. MD F said he used an ambient thermometer to check the temperature of the hot water pipe which supplies the dishwasher with hot water. MD F said the ambient thermometer showed 170 degrees F. MD F said he thought this showed the dishwasher water temperature was within normal limits. Surveyor asked MD F if he correlates temperature checks with a non-regressing thermometer or heat sensitive test strip. MD F said he does not, that is up to the kitchen staff. Surveyor asked MD F if he has the temperature gauge checked by a service company. MD F said he does not. On 2/23/21 at 3:40 PM, Surveyor spoke to DM D and MD F. Surveyor asked DM D how the dishwasher water temperature for the surface dish temperature was being measured if the illuminated gauge was broken. DM D said she was not sure who wrote the temperature numbers on the dishwasher log or how they measured the temperature. On 2/23/21 at 4:20 PM, Surveyor informed NHA A that the dishwasher water temperature was not being monitored for proper temperature of the surface dish temperature. NHA A made a plan to use disposable products until the dishwasher was repaired. However, the next morning, on 2/24/21 at 7:45 AM, Surveyor observed kitchen staff plating food on the facility's china plates. Surveyor stopped kitchen staff from plating food. Surveyor asked DC C why she was not plating food on disposable meal ware. DC C said no one told her to use disposable meal ware. On 2/24/21 at 8:30 AM, Surveyor spoke to NHA A. NHA A said she felt there was miscommunication about using heat sensitive test strips in the dishwasher during the conversation with Surveyor on 2/23/21. NHA A said she interpreted that the Surveyor said the heat sensitive test strips could be used in the dishwasher now, that is why she did not tell kitchen staff to use disposable meal ware. On 2/23/21 at 5:05 PM, Surveyor spoke to DA E (Dietary Aide). DA E said he worked 2/21/21 on the evening shift. DA E said the dishwasher gauge broke that afternoon. Surveyor asked DA E how he obtained the temperature number he wrote on the dishwasher log. DA E said MD F told him to place a food thermometer in the dishwasher and to take the temperature off of the thermometer. On 2/23/21 at 5:20 PM, Surveyor spoke to MD F. MD F said he had told DA E to put the food thermometer in the dishwasher and to use that temperature. Surveyor asked MD F if the thermometer was a non-regressing thermometer. MD F said the thermometer was not a non-regressing thermometer. Surveyor asked MD F if that was the accurate way to measure the dish surface temperature in the dishwasher. MD F said no; using that thermometer was not the most accurate way to measure the dish surface temperature in the dishwasher. On 2/23/21 at 8:35 AM, Surveyor spoke to DA T. Surveyor asked DA T if the dishwasher temperature reading is not in the parameters listed on the log, what he does. DA T said reports it to DM D. DA T said he doesn't do any internal temperatures, DM D does that. On 2/23/21 at 5:30 PM, Surveyor spoke to DC U. DC U said he uses the heat sensitive test strips sometimes. DC U demonstrated how he uses the heat sensitive test strips by dipping them in the dishwasher water. Dipping the heat sensitive test strips in the dishwasher water is not the manufacturer recommended procedure to test the dishwater dish surface temperature. DC U said he doesn't do the dishes usually, so he doesn't monitor the internal temperature except sometimes with the heat sensitive test strips. On 2/25/21 at 10:00 AM, Surveyor and RFOS (Regional Field Office Supervisor) observed the heat sensitive test strip container open to air. The container was uncovered with no lid observed in the dishwashing room exposing the test strips to moisture. Directions on the box, which had no expiration date, said to keep the strips free from moisture. According to the 2013 Food and Drug Administration (FDA) Food Code, Most foodborne illnesses occur in persons who are not part of recognized outbreaks. For many victims, foodborne illness results only in discomfort or lost time from the job. For some, especially preschool age children, older adults in health care facilities, and those with impaired immune systems, foodborne illness is more serious and may be life threatening. According to Why a Dish Needs to Hit 160 Degrees to Really be Clean, Because most bacteria are killed at a temperatures between 140°-150°, 160° is considered a safe industry standard to assure a dish or utensil has been properly sanitized. Common bacteria that may be spread include: Norovirus is a common bacteria which is easy to contract and quite contagious . Salmonella is perhaps the best known of bacterial infections and is present on many raw foods. Although cooking removes the bacteria assuming the inner portion of the food reaches a temperature of 150°, any utensils or surfaces used to prep the food remains infected. Listeria can be a particularly dangerous bacteria as it is able to grow even in refrigeration. Poisoning via Listeria typically resembles a mild flu condition, but can be lethal for small children or the elderly. Staphylococcus aureus (S. aureus) is the typical bacterial variant in foods which are prepared after cooking, such as salads, especially the mayonnaise varieties such as potato or chicken salad. Preventing an outbreak requires diligent hand washing before and after handling each component of the recipe along with proper refrigeration of the food and of course, cleaning the dishes used during storage and serving. ,[MEDICAL CONDITION]. botulinum, commonly known as [DIAGNOSES REDACTED], is one of the rarer bacteria but is more likely to be a fatal infection rather than causing simple stomach problems for a few days. It's important to properly sanitize everything used for canning foods, and boil the food well before serving after the seal is broken. https://paperthermometer.com/blogs/posts/why-a-dish-needs-to-hit-160-degrees-to-really-be-clean The failure to ensure systems were in place to monitor dish and utensil surface temperatures to ensure dishes and utensils were properly sanitized created the potential for spread of foodborne and/or other illness. This failure to ensure safe dish surface temperatures created a finding of Immediate Jeopardy. The Immediate Jeopardy was removed on 2/25/21 when the facility began implementing the following: All facility Dietary and Maintenance staff have been or will be educated prior to their next working shift on the policies and procedures of daily and routine maintenance, and the monitoring of the dish machine. I.e.: If internal temperatures of dishwashing or rinsing are not within range and what corrective actions immediately need to be implemented. The following education was included but not limited to: daily, and routine maintenance and monitoring of the dish machine. This education included but was not limited to: 1. No food shall be served on dishes that have not reached a surface temperature of 160F-170 F wash cycle and 180F-194F rinse cycle. 2. If desired temperature parameters are not met, staff will immediately switch to disposable products for all meals. The staff will immediately notify the charge nurse and Dietary Manager for further investigation. The Dietary Manager will then immediately notify the Maintenance Supervisor and Administrator. Staff will continue use disposable dishes and utensils until notified by the Administrator. 3. If for any reason, staff believe the dishwasher is not reaching desired parameters for surface temperatures, they will switch to disposable dishes immediately and notify the Dietary Manager, who will then notify the Maintenance and Administrator. 4. Documentation of surface temperatures and/or rinsing range on logs for dishwasher at each meal will be monitored and will follow the process/procedure if temperatures are out of range. 5. 1:1 education was completed with the Dietary Manager and Maintenance Supervisor on 2.24.21 of the importance of following procedures to monitor dishwashing temperature guidelines and accurately completing dish machine logs. 6. The Dietary Manager/Maintenance Supervisor/or designee were immediately education on 2.24.21 of the importance of auditing logs for compliance of desired parameters of dish sources and rinsing desired parameter. These daily audits will start immediately. 7. QAPI Monitoring Plan: All residents are potentially at risk and have been identified. Auditing of logs will be completed daily for one month, 3 times/wk. for two weeks, and then weekly and as needed by the DM, Maintenance Supervisor (or designees). 8. Routine audits will be completed randomly ongoing. 9. If audits determine dishwasher out of range, the dishwasher will be immediately halted, maintenance will be notified and paper products will be used until repair is complete. The deficient practice continues at a scope/severity of F (potential for more than minimal harm/widespread) as the facility implements this plan and as evidenced by: Example 2 On 2/23/2021 at 9:50 AM, Surveyor noted the juice containers which supplied the juice machine were documented with receive dates. Surveyor asked DC C (Dietary Cook) what date is documented on the juice boxes. DC C said those are the dates the containers are received. Surveyor asked DC C if kitchen staff mark the juice containers when they are opened. DC C said no. Surveyor observed the clean empty food storage bins, pitchers and pink plastic pitchers. Nine pink pitchers, two large plastic pitchers, two square plastic bins and a rectangle plastic bin had droplets of moisture inside. These items were stacked on top of other pitchers and bins with no air circulation. Surveyor asked DM D (Dietary Manager) if the items stacked were supposed to have moisture in them. DM D said no, they are supposed to air dry on racks before being stacked for storage. Example 3 On 2/25/21 at 8:59 AM, Surveyor completed the Medication Storage task for the 1st floor medication room with ADON I (Assistant Director of Nursing). Surveyor observed 10 chocolate and 3 vanilla Mighty Shakes in the medication room refrigerator. Surveyor observed the Mighty Shakes to be thawed and undated. Surveyor asked ADON I if the Mighty Shakes have a thaw or expiration date indicated on the carton. ADON I looked at the cartons and stated, No. Surveyor asked ADON I how long are Mighty Shakes are good once thawed, according to the manufacturer guidelines. ADON I stated she did not know. Surveyor showed ADON I the manufacturer guidelines on the Mighty Shake carton. The carton indicates, Use thawed product within 14 days once thawed. Surveyor asked ADON I if she knows when these Mighty Shakes were put into the refrigerator. ADON I stated she did not know. Surveyor asked ADON I should the Mighty Shakes be dated when pulled from the freezer. ADON I stated, yes. Surveyor asked ADON I should the shakes in the refrigerator have been dated. ADON I stated, yes. Surveyor requested the facility policy regarding Mighty Shakes. No further information was provided to Surveyor. On 2/25/20 at 4:00 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B what is your policy and procedure for Mighty Shakes. DON B stated, I'm not even sure. Surveyor shared Mighty Shakes manufacturer guidelines that state, Use thawed product within 14 days once thawed. Surveyor asked DON B should the shakes be dated when pulled from the freezer. DON B stated, yes. Surveyor asked DON B should the shakes in the refrigerator have been dated. DON B stated, yes.

Based on observation, interview and record review, the facility failed to ensure residents received adequate fluid intake to maintain acceptable parameters of hydration for 2 of 3 Residents out of a total sample of 5 Residents (R1 and R2). When R1's daily fluid intake was recorded to be less than recommended values to maintain proper hydration, the facility failed to revise approaches to prevent dehydration for R1. R1's dehydration risks where not accurately assessed by the facility. R1 was hosptalized on [DATE] and again on 8/18/20 with critical lab values related to inadequate fluid intake. The facility failed to ensure R1 received adequate fluids to maintain acceptable parameters of hydration even after R1 returned to the facility on [DATE] with orders to PLEASE ADEQUATELY Hydrate. The facility did not have a systematic process in place to monitor and assess R1's daily fluid intake or needs and implement corrective actions to prevent dehydration for R1. R2's fluid intake was not documented or evaluated to ensure he was meeting his required daily fluid needs. R2's Care Plan was not updated with individualized approaches to increase fluid intake to prevent dehydration after R2 was diagnosed with [REDACTED]. The facility did not have a systematic process in place to monitor and assess R2's daily fluid intake or needs and implement corrective actions to prevent dehydration for R2. The facility failed to ensure residents receive adequate fluid intake to maintain acceptable parameters of hydration by its: * failure to consistently record and assess fluid intake data being gathered; * failure to accurately assess and complete assessments for signs and symptoms of dehydration (e.g., sunken eyes, cool/clammy skin, dry tongue, dark colored urine, and sticky saliva); * failure to develop individualized care plan approaches for encouraging fluid intake. These failures created a finding of Immediate Jeopardy that began on 6/8/20. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were notified of the immediate jeopardy on 8/27/20 at 2:30 PM. The Immediate jeopardy was removed on 9/10/20, however the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. This is evidenced by: Facility Policy entitled 'Weight Assessment and Intervention,' states in part: weight assessment. 1. The nursing staff will measure resident weights on admission, and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 2. Weights will be recorded. 3. Any weight change of 5% or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the Dietitian. 4. The Dietitian will review resident weights. Negative trends will be discussed and evaluated by the IDT (Interdisciplinary Team). 1 month - 5% weight loss is significant; greater than 5% is severe. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. 6 months - 10 % weight loss is significant; greater than 10% is severe. 3. If the weight change is desirable, this will be documented and no change in the care plan will be necessary. Analysis: 1. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made .2. The physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss .Care Planning: 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort. 2. Individualized care plans shall address, to the extent possible: a. The identified causes of weight loss; b. Goals; and c. Time frames and parameters for monitoring and reassessment. Interventions: 1. Interventions for undesirable weight loss shall be based on careful consideration of the following: a. Resident choice and preferences; b. Nutrition and hydration needs of the resident; c. Functional factors that may inhibit independent eating; d. environmental factors that may inhibit appetite or desire to participate in meals; e. chewing and swallowing abnormalities and the need for diet modifications; f. Medications that may interfere with appetite, chewing, swallowing, or digestion; g. The use of supplementation and/or feeding tubes; and h. End of life decisions and advance directives . Facility Policy entitled 'Resident Hydration and Prevention of Dehydration,' states in part: .1. The nurse will assess/evaluate all residents for hydration adequacy routinely, and more often as necessary per resident need.3. The facility will include resident preference in distribution of allowed fluid.5. Nursing will assess for signs and symptoms of dehydration during daily care. 6. Nurses' Aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care. 7. If potential inadequate intake and/or signs and symptoms of dehydration are observed, the Physician will be informed. 8. Orders may be written for extra fluids to be encouraged between meals and/or with medication passes . According to Strategies for Ensuring Good Hydration in the Elderly, Dehydration is a frequent etiology of morbidity and mortality in elderly people. It causes the hospitalization of many patients and its outcome may be fatal. Indeed, dehydration is often linked to infection, and if it is overlooked, mortality may be over 50%. Older individuals have been shown to have a higher risk of developing dehydration than younger adults. Modifications in water metabolism with aging and fluid imbalance in the frail elderly are the main factors to consider in the prevention of dehydration. Particularly, a decrease in the fat free mass, which is hydrated and contains 73% water, is observed in the elderly due to losses in muscular mass, total body water, and bone mass. Since water intake is mainly stimulated by thirst, and since the thirst sensation decreases with aging, risk factors for dehydration are those that lead to a loss of autonomy or a loss of cognitive function that limit the access to beverages. The prevention of dehydration must be multidisciplinary. Caregivers and health care professionals should be constantly aware of the risk factors and signs of dehydration in elderly patients. Strategies to maintain normal hydration should comprise practical approaches to induce the elderly to drink enough. This can be accomplished by frequent encouragement to drink, by offering a wide variety of beverages, by advising to drink often rather than large amounts, and by adaptation of the environment and medications as necessary. https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1753-4887.2005.tb .x Example 1: R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1 is Full Code with a court appointed guardian in place. It is noted in R1's record, R1 was receiving hospice services at home before hospital admission on 7/5/20, and R1 did not receive hospice services while at the facility. On 7/13/20 R1 weighed 170.9 pounds On 7/14/20 a licensed practical nurse (LPN) determined R1's dehydration risk score as a 6. The facility's Dehydration Risk Screener notes in part a score of 10 or higher indicates resident is at risk for dehydration and further assessment should be conducted to review residents fluid status. R1's admission MDS (Minimum Data Set) assessment on 7/19/20 indicates a BIMS (Brief Interview for Mental Status) score of 0 indicating severe cognitive impairment. Section G of the MDS notes R1 requires extensive assist of one with meals. On 7/20/20, RD (Registered Dietitian) notes in a progress note: Diet order: cardiac/regular texture/thin liquids . weight on 7/13/20 170.9# (pounds) . IBW (ideal body weight) for age 164-200# . Eating: average meal intake 59% with average fluid intake per meal 240 ML. Per SLP (Speech Language Pathology) screen: patient unable to provide response . Difficulty feeding himself d/t (due to) fine motor issues, right sided facial droop which impairs his oral swallowing function .Estimated nutritional needs: 1875-2092 cal/d (calories per day) fluids: 1875-2100 ML (milliliters) per day . On 7/21/20 R1's Medication Administration Record [REDACTED]. one time a day On 7/22/20 R1 weighed 164.8 pounds = 6.1 pound loss in 9 days, 3.6% weight loss R1's Comprehensive Care Plan notes in part: -On 7/23/20: Focus: ADL Self Care Deficit . Goal: (R1) will improve current level of function with the intervention of rehab services . Interventions: . Eating: 1 assist staff participation to eat. On 7/23/20, RD progress notes state: weight changes: 6.1 # wt. loss/1 week (3.6%) .average meal intake 51% Noted: health shake 4 oz. started 7/22/20 with 100% intake. Resident is fed .RD will monitor weight as information provided at weekly NAR (Nutrition at Risk) meetings. On 7/27/20 R1's dehydration risk score is again 6. Of note, R1's screener is not completed accurately: under D. Weight loss, no weight loss is marked, however R1 was identified with 6.1 pound weight loss on 7/22/20. Review of R1's daily fluid intake are documented as follows: (Of note, there was no documentation of R1's fluid intake for 14 of 45 shifts) 7/13/20- 240 ML 7/14/20- 240 ML 7/15/20-240 ML 7/16/20- no documentation of fluid intake 7/17/20-840 ML 7/18/20-120 ML 7/19/20- 350 ML 7/20/20-400 ML 7/21/20-240 ML 7/22/20-500 ML 7/23/20-400 ML 7/24/20-820 ML 7/25/20-470 ML 7/26/20-700 ML 7/27/20-580 ML (R1 was admitted to hospital) R1's average daily fluid intake for 15 days from 7/13/20-7/27/20 = 408 ML per day, which is significantly (79%-81%) below R1's assessed fluid needs of 1875-2100 ML per day. There is no evidence the facility assessed or totaled R1 daily fluid intake, or placed corrective actions when R1's fluid intake was below assessed daily fluid needs. There is no evidence the facility notified R1's physician of R1 low fluid intake. The facility was not monitoring fluid output for R1 other than noting he was incontinent of urine. Review of R1's meal intake notes incomplete monitoring. Facility staff indicated resident meal percents are to be documented after each meal, breakfast, lunch and supper. R1's meal percents were not documented for 21 meals of a total of 41 meals from 7/13/20-7/27/20, when they should have been. On 7/27/20, R1 was sent to the hospital with lethargy. R1 was readmitted from the hospital to the facility on [DATE]. R1's hospital notes include in part: Patient was brought in due to worsening lethargy . Patient appears to be dehydrated. Tongue and skin is dry . Impression/Diagnosis: [REDACTED].R1's Lab values at the hospital on [DATE] note in part: Critical abnormal values of: Sodium 163, BUN (Blood Urea Nitrogen) 104, and High abnormal values of: Creatinine 3.5, Chloride 126, WBC (White Blood Count) 13.8, and Troponin 0.075. R1 was treated with IV (intravenous) fluids, lab values returned to within normal limits before discharge. On 8/3/20 R1 returned to the facility, R1's physician order [REDACTED].! (Emphasis included on document.), Diet: Nectar thick pureed. Additional instructions from the hospital for R1 include: Patient Education Materials: Discharge Instructions for [MEDICAL CONDITION] . can . be caused if you do not drink enough water. If not treated right away, it is a serious problem that can cause a [MEDICAL CONDITION] or a loss of consciousness. It can also lead to death . Dehydration: .Home care-Drink at least 12 8-ounce glasses of fluid every day to resolve dehydration . Review of R1's MAR (Medication Administration Record) notes order on 8/3/20: offer and assist/encourage fluid intake (may have beverage of choice) as high risk for dehydration, every shift. R1's care plan was updated on 8/4/20 to include: Focus: (R1) has a potential for fluid deficit related to recent hospitalization , AKI (Acute Kidney Injury), Frontal lobe infarct, weakness, decreased mobility, Stage 3 CKD, DM, Dementia . [MEDICAL CONDITION] disorder, agitation, swallowing difficulties, depression, anxiety. Note, (R1) was on hospice cares prior to hospitalization and has a hx. (history) of AKI and dehydration. Goal: will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor . Interventions: .Encourage fluids, assist with fluids as needed .- On 8/4/20 R1 had a dehydration risk score of 6. Of note, R1's dehydration screener is not completed accurately: under F. Risk Factor (check all that apply) 1. Hx of dehydration, was not marked and R1 was identified with symptoms of dehydration for hospitalization [DATE]-[DATE]. R1's Progress Notes: On 8/6/20 at 11:33 AM, Writer updated (name of clinic nurse) R1 has been resistive to cares . and refused additional fluids offered . On 8/6/20 at 1:02 PM, . Call placed to guardian shared (R1) had a water bottle in his room and prefers water and milk to drink and if he has the bottle he is able to better do so himself .we would implement the water bottle . On 8/6/20 at 3:32 PM, RD notes: . IDT (Interdisciplinary Team) noted resident is refusing BG (blood glucose) checks, extra fluids, care . Recommendations: Physician change diet order to: NAS/pureed texture/nectar thick liquids. Start Health Shake 4 oz. p.o. tid (orally, 3 times per day) . Of note, on 8/6/20 a fax was sent to R1's Dr. requesting Health Shake PO TID, but there is no evidence that this was implemented until 8/16/20, 10 days later; review of R1's MAR indicated [REDACTED]. On 8/7/20 staff added the following intervention to the care plan: Monitor and document intake and output per facility policy . Staff to offer (and assist as needed) water bottle versus water pitcher as per resident representative (name) this worked well for him at home and enables him to easily/independently consume fluids. Preference is cold milk and ice water . Progress notes continue: On 8/8/20 at 5:43 AM, Resident refused to drink any fluids tonight. Re-approached several times and by different staff members but still refused. On 8/17/20 at 8:33 AM RD notes: . On 8/13/20 writer sent recommendations to physician for SLP evaluation . On 8/18/20, R1 was sent to the hospital for lethargy. Hospital notes include in part: .Pt. (Patient) is lethargic and unresponsive upon EMS (Emergency Medical Services) arrival. Pt. has not been eating or drinking for 5 days. Initial B/P per EMS 65/40 then 104/66 after 400 ML fluid bolus (at one time) .admitted to the hospital with [REDACTED]. R1's lab values at the hospital on [DATE] note in part: Critical abnormal values of: Sodium 164, BUN (Blood Urea Nitrogen) 112, Creatinine 5.83, and High abnormal values of: Chloride 127, WBC (White Blood Count) 14.7, and Troponin 0.075. R1 was treated with IV fluids, lab values returned to within normal limits before discharge. R1's discharge [DIAGNOSES REDACTED]. These intakes are included in the daily total intakes below with other documented fluid intakes for R1. 8/3/20- 330 ML 8/4/20-720 ML 8/5/20-600 ML On 8/5/20 R1 weighed 167.0 pounds 8/6/20- 450 ML 8/7/20-510 ML 8/8/20-600 ML 8/9/20-780 ML 8/10/20-220 ML 8/11/20- 440 ML 8/12/20-1270 ML Weight: 156.4 pounds = 10.6 pound loss in 7 days, 9.4% weight loss. 8/13/20-540 ML 8/14/20-845 ML 8/15/20-950 ML 8/16/20-820 ML Medication Administration Record [REDACTED]. three times a day for at risk for malnutrition 8/17/20-970 ML Medication Administration Record [REDACTED] On 8/17/20-risk score of 6. Of note, R1's dehydration screener is not completed accurately: under D. Weight loss, no weight loss is marked, however R1 was identified with 10.6 pound weight loss on 8/12/20. F. Risk Factor (check all that apply) 1. History of dehydration, 2. History of refusing fluids, nothing is marked, even though R1 was noted to have dehydration and staff report R1 was refusing fluids. Additionally, R1's Dehydration Risk Screeners were completed by LPN's. 8/18/20- no fluid intake documented, R1 sent to hospital. Of note, R1's average daily fluid intake for 15 days from 8/3/20-8/17/20 = 670 ML per day, which is significantly (64-68%) below R1's assessed fluid needs of 1875-2100 ML per day. There is no evidence the facility assessed or totaled R1 daily fluid intake, or placed corrective actions when R1's fluid intake was below assessed daily fluid needs. There is no evidence the facility notified R1's physician of R1 low fluid intake. Review of R1's meal intake notes incomplete monitoring. Facility staff indicated resident meal percents are to be documented after each meal, breakfast, lunch and supper. R1's meal percents were not documented for 21 meals of a total of 41 meals from 7/13/20-7/27/20, when they should have been. From 8/3/20-8/18/20, R1's meal percents were not documented for 7 of 45 meals, 2 meals documented as refused and 5 meals with zero percent consumed. On 8/24/20, R1 was readmitted to the facility with orders including: aspiration precautions, assist with meals, pureed diet, honey thick liquids with plain water, hospice consult, water to be given only in upright position. R1's ADL (Activities of Daily Living) sheet, dated 8/25/20, notes in part . pureed diet with nectar think liquids-encourage fluids, assist with eating/monitor . -Care plan, updated 8/26/20, notes, Focus: (R1) has potential for a nutritional problem r/t (related to) Disease process . mechanically altered therapeutic diet with honey thick liquids and plain water, water to be given only in upright position, swallowing difficulties, recently d/c (discharged ) from hospice services, assistance needed with eating. Goal: (R1) will eat 50-75% of meals daily and drink fluids offered . Interventions: Monitor/document/report to MD PRN (Medical Doctor as needed) of s/sx (signs/symptoms) of dysphagia: Pocketing, Choking, Coughing . Refusing to eat . OT/ST (Occupational Therapy/ Speech Therapy) to screen and provide adaptive equipment for eating, assistance and recommendations as needed . Monitor intake and record each meal- On 8/26/20 between 9:30 AM and 1:30 PM, Surveyor made multiple observations of R1 in his room, Surveyor observed there was no water/fluids available to R1 in his room except what was provided on lunch tray when staff assisted R1. On 8/26/20 at 12:30 PM, Surveyor interviewed DON B (Director of Nursing) about the facility's process for monitoring resident's total daily fluid intakes. DON B stated no one is assigned to total the resident's daily fluid intake and the intakes are in place for the RD to review. DON B stated R1 nutritional and fluid status was reviewed by the IDT team at NAR meetings. On 8/26/20 at 1:50 PM, Surveyor interviewed ST J (Speech Therapist) about her involvement with R1. ST J stated she had been seeing R1 7/16/20-7/27/20. ST J stated on 8/3/20 R1 came back from the hospital on pureed diet and nectar thick liquids, and there were no orders for speech therapy. ST J stated she wrote an order for [REDACTED]. ST J stated she screened R1 on 8/25/20 for speech therapy but there was confusion on whether R1 would receive hospice or therapy. Of note, after return from the hospital on [DATE], R1 should have received speech therapy and did not. On 8/27/20 at 9:00 AM, Surveyor observed R1 did not have fluids/water bottle at bedside. Surveyor interviewed CNA I (Certified Nursing Assistant) about R1's fluid intake. Surveyor asked CNA I if the facility had provided R1 with a water bottle in his room to drink from. CNA I stated R1 was placed on thickened liquids when he came back from the hospital, and for a time staff provided R1 with thickened water in the water bottle (CNA I pointed out R1's water bottle was now located at the nurse's station). CNA I told Surveyor R1 would throw the water bottle or squirt out the fluid onto the floor. CNA I stated that R1 now takes fluids best from a spoon, and CNA I requests apple juice and thickens it to give R1 extra fluids. Note: The facility did not put regular/unthickened water in the water bottle, and it is likely that the resident was expressing his dislike for what he was being given by throwing the water bottle. On 8/27/20 at 9:55 AM, Surveyor interviewed RD D (Registered Dietitian) about R1's weight loss and poor fluid intake. RD D explained when residents go to the hospital and return, their supplement orders are lost and the facility needs to get the orders again at readmission. RD D stated sometimes nursing or the Health Unit Coordinator catch this on readmission, or RD D will when she is in the facility on Mondays and Thursdays. RD D stated she establishes resident estimated fluid needs, but she does not keep track of resident's daily fluid intakes, nursing does that. RD D stated R1 poor intake was discussed at NAR meetings with the IDT and staff were encouraging fluids for R1. RD D stated R1 is combative at times and it is difficult to get him to take fluids and would push away or throw things. RD D stated DON (Director of Nursing) does provide reminders to staff to track meal percents and fluid intake. RD D stated on 8/6/20 she faxed a recommendation to R1's physician for Health Shake TID, but did not receive a response. RD D stated on 8/13/20 she re-faxed her 8/6/20 recommendations including notification of R1's 10 .6 pound weight loss in one week. This fax was signed by the physician with OK and dated 8/13/20. RD D stated she also sent a fax requesting Speech Therapy for R1. RD D stated sometimes the doctors are slow to respond. On 8/27/20 at 12:45 PM, Surveyor met with DON B, NHA A (Nursing Home Administrator and RN H (Registered Nurse) reviewing a time line the facility had related to R1. Surveyor asked about the accuracy of the R1's Dehydration Risk Screener documents, DON B agreed that these were inaccurate and the facility was starting education with the nurses, however this was after the Surveyor had started asking questions about R1. Surveyor asked DON B about documentation of R1's intakes and DON B agreed intakes were not always documented and should have been. She would be providing education to the staff. The facility was monitoring R1's weights and notifying R1's physician of significant weight loss and did notify physician on 8/6/20 of refusal of fluids. The facility delayed getting orders for nutritional supplements after R1's readmission on 8/3/20 until 8/16/20. The facility failed to accurately assess R1's risk factors for dehydration. The facility did not reinstate Speech Therapy orders upon readmission, and did not have a system in place to consistently monitor fluid intake and did not notify the physician when R1's fluid intake continued to be below assessed needs. The resident was hospitalized twice with dehydration. Example 2: R2 was admitted on [DATE] after hospitalization for femoral arterial thrombectomy with [DIAGNOSES REDACTED]. On 6/3/20 R2's fluid intakes on the evening shift are documented as not applicable and the night shift was left blank. R2's Care Plan, initiated on 6/4/20, indicates nutritional problem r/t (related to) disease process, recent hospitalization , weakness, hx (history) IV (intravenous) fluids in the hospital . Intervention section states in part: Monitor weight weekly/per facility protocol . monitor/record/report to MD (Medical Doctor) PRN (as needed) s/sx (signs and symptoms) of malnutrition: emaciation (cachexia), muscle wasting, significant weight loss: 3lbs (pounds) in 1 week, >5% (greater than 5 percent) in 1 month, >7.5% in 3 months, >10% in 6 months.RD (Registered Dietician) to evaluate and make diet change recommendations PRN. R2's Care Plan on 6/4/20 also indicates R2 is an assist of 1 with toileting and bed mobility. R2 is assist of 1 with a two wheeled walker for transfers and ambulation. Uses a wheelchair for locomotion and is weight bearing as tolerated. R2 requires set-up assistance and is able to feed himself. On 6/4/20 R2's fluid intakes are documented as 360 ml (milliliters) on day shift, and not applicable for evening shift and night shift. On 6/4/20, R2's Dehydration Risk Screener indicates that R2 has a score of 1. (A score of 10 or higher indicates resident is at risk for dehydration.) R2's Admission MDS (Minimum Data Set), dated 6/8/20, indicates R2 has a BIMS (brief interview of mental status) of an 11 out of 15 indicating he is cognitively intact. R2 is able to understand others and is able to make himself understood with clear speech. R2 required extensive assistance of one with bed mobility, transfers and toileting upon admission. R2 required setup assist with meals and his weight was 161 pounds. On 6/5/20 at 7:09 AM, R2's weight was 160.9 lbs (pounds). On 6/5/20 R2's fluid intakes are documented as 360 ml's on day shift, evening shift is left blank and night shift is indicated as not applicable. On 6/5/20, R2's Occupational Therapy Note indicates R2 needed SBA (stand by assist) to move from supine to sitting on EOB (edge of bed). R2 needed CGA (contact guard assist) to transfer to/from the commode using FWW (front wheeled walker). On 6/6/20 R2's fluid intakes are documented as 340 ml on day shift, 360 ml on evening shift, and 240 ml on night shift. On 6/7/20 R2's fluid intakes documentation are blank for day shift, evening shift and night shift. On 6/8/20 at 1:21 AM, R2's Nurses Note states in part: .Resident has been having blood in urine, PM Nurse obtained orders for UA with C&S (urine analysis with culture and sensitivity), labs .Resident has no complaints of pain or frequency, Urine is red in color with no odor. UA obtained, will be taken to lab in the AM .Resident responsible for self, daughter (name) updated. On 6/8/20 at 2:22 PM, R2's Nurses Note, states in part: Blood was noted in commode, I assessed both (R2's) rectum and penis and determined that the blood was coming from his penis during urination, resident reports no pain, no swelling noted. A phone call was made to the primary physician office, information passed to the nurse, currently waiting phone call back (sic) regarding the matter. On 6/8/20 at 5:43 PM, R2's Dietary Note, states in part: eating: own teeth, average meal intake 51-75% with average fluid intake per meal 360ml. skin: surgical incision right groin, bruising all over body. Circulatory: per nursing charting: [MEDICAL CONDITION] . Labs include: 6-2-20; hgb (hemoglobin) 9.5, hct (hematocrit) 27, sodium 128, potassium 4.1, glucose 102, BUN (blood urea nitrogen) 26, creatinine .7 (0.7), GFR non AA 106 (Glomerular filtration rate non African American) . writer met with resident who stated his appetite is Fantastic, and I love the good food you have here.Resident showed writer his right foot/leg which is swollen r/t (related to) blood clot, resident reports the swelling was worse . Resident states he is having regular bm's (bowel movements) but with some difficulty passing them and sometimes the stool is hard . Resident likes water and drinks it between meals which writer explained will help with constipation. Estimated nutritional needs: 1745-1825 cal/d (calories per day) .Fluids: 1800-1900 ml/d (1ml/cal) (milliliters per day) .Nursing: continue to monitor po (by mouth) intake, weights, skin RD will monitor weights as information provided at weights meetings . On 6/8/20 R2's diet changed to NAS (no added Salt) mechanical soft (food that are squishable with a fork) with thin liquids. On 6/8/20, R2's Urine Analysis indicates R2 has large amounts of red blood in his urine and it appears turbid (cloudy). R2's urine indicates he has protein present and [MEDICATION NAME] present in his urine with a pH of 8.5 (normal range is (acidic) 4.6-8.0 (alkaline). On 6/8/20, R2's BMP (Basic Metabolic Panel) lab indicates a sodium level of 130 (low), potassium level 4.2 (normal), BUN of 31 (high) and a creatinine of 1.10 (normal). On 6/8/20 R2's fluid intakes are documented as 580 ml on day shift. Evening shift and night shift are blank. Despite being assessed as needing 1800 - 1900ml fluid per day, staff has monitored intake on only 6 of the last 15 shifts, with daily intake ranging from 360 ml (documented on one shift only) to 940 ml (total for all three shifts). Further, R2 has a urinary tract infection this day, and there was no direction to push fluids. On 6/9/20, R2's Occupational Therapy Note indicates R2 needed CGA (hands on cueing/guiding but non weight bearing assistance, to complete the task) to transfer to toilet/commode. R2 indicated as not feeling well and having increased weakness on this date. On 6/9/20 R2's fluid intakes are documented as 400 ml on evening shift and 240 on night shift. Day shift is left blank. On 6/9/20 R2's Urinary lab report printed on 6/9/20 at 2:00PM, states in part: >100,000 cfu/ml Proteus Mirabilis isolated. Susceptibility to follow. 10,000 cfu/ml gram negative bacilli isolated. Identification and susceptibility to follow. On 6/9/20 (no time), R2's Doctors Order Sheet, states in part: [MEDICATION NAME] 100mg (milligrams) BID (twice daily) PO (my mouth) x 7 days (for 7 days) for UTI (urinary tract infection). Updated (Physician name) ASAP (as soon as possible) with labs (and) orders. Also (hold) ASA 81mg x 1 dose (hold Aspirin 81 mg for 1 dose). Get continued orders from (Physician name) (with) update . R2 is being treated with antibiotics for a UTI at this time and is indicated as having blood in his urine, which indicates a need for increased fluid consumption. This event should have put the facility on notice that R2 required increased fluid intake. The facility failed to inform staff or revise R2's care plan to reflect his need for increased fluids and failed to monitor his intake and output daily to ensure adequate hydration. On 6/10/20 at 2:13 PM, R2's weight was 155.2lbs. R2 has lost almost 5 pounds in 5 days. On 6/10/20 R2's fluid intakes are documented as 540 ml's on day shift and not applicable on evening and night shift. On 6/10/20, R2's Occupational Therapy Note indicates R2 is able to feed himself with setup and toileting with CGA. On 6/11/20 R2's fluid intakes are documented as 240 ml on day shift, and not applicable on evening and night shift. On 6/11/20, a Fax was sent to R2's Physician indicating R2 was down 5.7 pounds, that he went from 160.9 to 155.2 lbs. Indicated to have status [REDACTED]. Physician Response received on 6/15/20 at 11:50 AM indicates no to new orders. On 6/11/20, R2's Occupational Therapy Note indicates R2's bed mobility going from supine (laying down) to sitting requires SBA (stand by assist) while using bed rail. On 6/11/20 R2's Dehydration Risk Screener indicates that R2 scores a 1. R (TRUNCATED)

Based on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (R85) reviewed for fall concerns, out of a total sample of 29 residents. The facility did not complete an accurate and thorough assessment for R85's fall risk at admission, and did not develop an Initial Care Plan to include safety interventions to minimize R85's risk for falls. On the third day after admission to the facility, R85 fell , resulting in rib fractures and a laceration to his left elbow. This is evidenced by: The facility's Fall Prevention Policy, dated 3/19, states, in part: . 9. Fall Safety interventions, care planning process, evaluation and revision: a. Upon admission a fall risk assessment will be completed by the unit nurse in collaboration with the admission team. This assessment will determine basic fall risks and develop fall interventions. Family members, friends and other resources will also be explored if deemed necessary to develop a safe environment for new residents. b. Consider 15 minute checks for new residents and observe the resident for patterns. These 15 minute checks should be time limited based on what information is being sought out. Do these in addition to every hour toilet checks when a further investigation into unknown resident pattern concern . Findings: R85 was admitted to the facility, on 11/1/19, with [DIAGNOSES REDACTED]. R85's History and Physical from the hospital, dated 10/23/19, notes that R85 has a history of falls, with most recent occurring 2 weeks ago at home. R85's Discharge Summary, dated 11/1/19, notes, in part that R85 had a Left Femoral fracture with repair 8/2019 . (R85) demonstrates .physical or cognitive deficits . functional ability is severely compromised and increase risk for injury and re-hospitalization , and is at high risk for infection and increased risk of falling. In addition . (R85) is in need of assistance to enable mobility rated activities of daily living . On 11/1/19- R85's Nursing Evaluation form (a tool that is completed off-site by the Admissions Nurse and is not part of the residents medical record) notes in part Hx # Falls (history of falls) last 30 days, 2 weeks ago without trauma. There is a hand written note in the margin on this document: Fall precautions, no sitter, mat, bed, chair, wears glasses. On 11/1/19- R85's Nursing Admission Assessment and History form notes, in part: Fall Risk: High Risk is left blank; History of Falls is left blank. Confusion is checked, and Needs Assist with transfer and & ambulate is checked. Mobile Status: Assist of 1 is noted, Bladder habit: Toileting is checked. Mental Status: Calm, Alert, Oriented x (times) 2 is noted. On 11/1/19 at 3:28 PM: R85's Fall Risk Evaluation notes R85 is at Moderate Risk for falls, with a score of 10. Under History of Falls No history is noted. This is incorrect in that R85's History and Physical, dated 10/23/19, notes that R85 had a left femoral fracture with repair, 8/2019, and a fall at home in the last 30 days. R85's Baseline Care Plan Summary form, dated 11/1/19, notes, in part: - (R85) Initial Goal: to strengthen and return home. - Current Medication/Treatment this section is not completed and left blank, Fall Risk is not checked. -Personal Care Assist of 1 is marked for Toileting, Bed mobility, Locomotion, Transfers (chair/bed). -Equipment is not completed, left blank not indicating what assistive devices R85 uses for mobility (e.g. Wheelchair, Walker .). (It is important to note that R85's Baseline Care Plan on admission is incomplete and not individualized for R85's fall risk.) R85's Comprehensive Care Plan, initiated on 11/2/19, revised on 11/26/19, notes, in part: Focus: (R85) is high risk for falls . Goal: initiated date on 11/5/19 (R85) will not sustain serious injury through review date. (It is important to note that this goal was initiated after R85's fall with fracture on 11/3/19.) Interventions, initiated on 11/2/19, includes, in part: Administer medication per MD (medical doctor) orders, monitoring for effectiveness and side effect. Due to impaired cognition, the resident cannot comprehend when/why/how to use the call bell; anticipate and meet the resident needs and wants. R85 Original Care Plan Item, dated 11/2/19, notes, in part: the resident is (High, Moderate, Low) risk for falls r/t (related to) Confusion, Gait/Balance problems, Incontinence, Unaware of safety needs. (It is important to note a specific risk level is not identified for R85 and no specific proactive interventions are noted to address R85's confusion, gait/balance, incontinence needs. It was not until after R85's fall with injury, on 11/3/19, that multiple fall interventions were added to R85's care plan including, in part: toilet upon rising, before/after meals . appropriate footwear . hi low bed . beveled mat to be kept at bedside when he is in bed, lipped mattress . body pillow.) R85's Admission (MDS Minimum Data Set) assessment, dated 11/7/19, notes a BIMS (Brief Interview for Mental Status) of 3, indicating severe cognitive impairment. Section G of the MDS notes that R85 requires extensive assist of 1 for transfers and toileting. Section J of the MDS notes R85 had a fall in the month prior to admission, a fall 2-6 months prior to admission, and 1 fall with major injury since admission. R85's Progress Notes reviewed noted, in part: On 11/3/19: at 4:25 AM resident found on his hands and knees in the middle of his room floor . When asked what happened and what he was doing, resident stated I don't know.Resident was last seen by CNA (Certified Nursing Assistant) at 3:30 AM. He was lying in his bed. Last voided at 12 AM. Resident was incontinent of BM (bowel movement) at the time of the fall c/o (complaint of) left side rib pain . Injuries noted: very large skin tear to left lateral upper arm that extends over his left elbow and ends at his left forearm. Small skin tear to left outer finger. Steri strips applied to skin tear to left 4th finger and covered with band aid. Pressure applied to left elbow. Unable to approximate skin flaps. Wrapped with kerlix gauze . MD notified . order received to send to ER (emergency room ) . What current fall intervention is in place and functioning? (no entry, left blank). What new intervention is being implemented? Toilet every 2 hours . On 11/3/19 at 4:25 AM: The facility's Fall Huddle/QA (Quality Assurance) Flow Sheet notes, in part: CNA Plan of Care substantially followed is checked with a hand written note, no ADL (Activities of Daily Living) Sheet, new admission . On 11/3/19 at 6:39 AM: Assessed patient with floor nurse. Patient alert to self only (per baseline) states did not hit his head .c/o left side rib area pain . unwitnessed fall and Xarelto (anticoagulant medication) use .Order to send to ER . On 11/3/19- ED (Emergency Department) Triage Notes: (R85) brought in from nursing home after fall Laceration to left elbow and pain to his chest . Clinical impression: Skin avulsion, closed fracture of multiple ribs of left side. On 11/3/19- R85's Chest CT (Computed [NAME]ography) results notes: Impression: Minimally displaced fractures of the left fourth though ninth ribs . Narrative note: Indication: fall in nursing home, left side chest pain, evaluation for multiple rib fractures. R85's Progress Notes continued: On 11/3/19 at 10:10 AM: R85 returned to the facility .displaced fractures of the fourth through ninth ribs. On 11/3/19 at 4:57 PM: new admit, skin tear, fall, left rib fracture (ribs 4-9). Tylenol given with c/o pain to ribs. Pt (patient) had UA (Unit Assistant) sit with him to prevent self-transfers and reduce risk for fall. On 12/5/19 at 12:58 PM, Surveyor interviewed DON B (Director of Nursing) and NHA A (Nursing Home Administrator) about concerns with R85's fall with rib fracture on 11/3/19. Surveyor reviewed R85's Initial Fall Risk Evaluation not being accurate for his fall history, and not having an individualized care plan developed for safety interventions in place to prevent falls until after R85's fall with fracture. DON B stated that she understood the concerns regarding R85's fall with fracture. On 12/5/19 at 1:18 PM, Surveyor interviewed LPN Q (Licensed Practical Nurse) who stated that she had completed R85's fall assessment and Baseline Care Plan with admitting nurse. LPN Q stated she was aware that R85 had falls prior to admission. LPN Q stated it that would have been her error to not include that on the Fall Risk assessment and the Baseline Care Plan. Surveyor asked what interventions were in place to reduce R85's risk for falls; LPN Q stated she thought R85 had a low bed. LPN Q stated she may not have included that on R85's care plan. R85 was admitted with known risk factors for falls, the facility failed to thoroughly identify risk factors and develop an individualized Baseline Care Plan for adequate supervision to help reduce chance for falls, resulting in R85 falling on the third day after admission sustaining a major injury of fractured 4th-9th ribs.

Based on observation, interview and record review the facility did not ensure that a resident who enters the facility without a pressure injury (PI) does not develop a PI for 3 of 6 residents (R1, R2, and R3). The facility failed to put interventions in place to prevent PI development, and the facility failed to complete the weekly Braden skin assessments per standards of practice. R1 was admitted to the facility without a PI and was identified to be at moderate risk for PI development. R1's physician was not updated when R1 developed an avoidable stage 3 PI on the left buttock that evolved into an infected stage 4 PI to the sacrum. The facility failed to develop a care plan with interventions for staff to follow to prevent PI development, and did not complete the weekly Braden skin assessments. Facility failure to prevent a Stage 4 PI to R1 and the development of infection to the PI created a finding of Immediate Jeopardy (IJ) that began on 10/3/17. NHA A (Nursing Home Administrator) and the DON B (Director of Nursing) were notified of the IJ on 11/20/17 at 2:00 PM. The IJ was removed on 11/17/17 when the facility implemented an action plan. However, the deficient practice continues at a scope and severity of a D (isolated/no actual harm) as the facility continues to implement their plan and as evidenced by the following: R2 and R3 did not have pressure ulcer risk assessments completed as documented in the medical record. This is evidenced by: The National Pressure Ulcer Advisory Panel (NPUAP) at www.NPUAP.com defines PI's in the following catergories: Category/Stage I: Non-blanchable [DIAGNOSES REDACTED] Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Category/Stage II: Partial thickness loss - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguinous filled blister. Category/Stage III: Full thickness skin loss - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. Category/Stage IV: Full thickness tissue loss - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown. Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Suspected Deep Tissue Injury - depth unknown. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. The facility's policy entitled Wound Care Program, undated, includes in part: All residents admitted to our care with pressure injuries or other skin breakdown will be comprehensively assessed. A treatment plan will be initiated. There will be standing orders in place to initiate wound care protocol and may be followed for up to 5 days awaiting physician notification or as directed by wound RN (Registered Nurse). On 11/24/17 at 3:41 PM, additional information received from the facility includes The Geriatric Friendly Skin Plan, which includes in part: 4. a repositioning schedule should be used. Changes Q (every) 2 hours may not be enough for a frail, high risk resident. You may need to reposition Q 60-90 minutes. Document. Example 1 R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's Braden Scale (skin breakdown risk), dated 8/4/17, scored a 13 which indicates R1 is at moderate risk for skin PI development. R1's admission Minimum Data Set (MDS), dated [DATE], with Brief Interview for Mental Status (BIMS) indicated R1 has severe cognitive impairment. Section G0110: Bed mobility indicates R1 requires extensive assistance with 2 physical assist, Section M0150: Risk of PI indicates R1 is at risk for PI development. Section M0210: Unhealed PI indicates R1 does not have a PI. R1's Care Area Assessment (CAA), dated 8/15/17, includes in part: Requires extensive assistance with cares and mobility, weakness. Monitor skin weekly and with cares. Encourage intake. Provide turning and repositioning. Maintain pressure reduction devices. PI assessment: No PI. Pressure: Requires pressure reducing mattress or seat cushion. Requires a regular schedule of turning. [MEDICATION NAME] factors: Decline in mobility, poor nutrition. [DIAGNOSES REDACTED]. Care Plan: Will develop Care Plan. * It is important to know that the facility did not develop a Comprehensive Care Plan for PI prevention until 8/22/17, 18 days after admission. R1 was placed on the facility Panacea redistribution mattress upon admission per RN C. This mattress per manufacturer guidelines indicates it is a foam mattress and is appropriate for use as part of an overall care plan to help prevent and treat decubitus ulcers. Resident specific assessment could alter the usage of this mattress. Certified Nursing Assistant (CNA) Care Sheet, dated 8/4/17, includes in part: Toilet Assist: Has Foley catheter, incontinent of bowels, large brief, and Nutrashield. Special instructions: ADL's - Dependent for toileting, bathing, dressing, and grooming. Needs assist to feed self. Bed mobility - dependent. Assist devices- wheelchair (w/c), Foley catheter, upper and lower dentures, beveled mat. There is a second CNA Care Sheet, dated 8/4/17, which includes EquaGel cushion to w/c, which is written over a blacked out area on the assistive device section where upper and lower dentures, beveled mat were written on the previous CNA Care Sheet. The Care Area for Toilet Assist is blacked out and where incontinent of bowels, large brief, and Nutrashield were written on the first Care Sheet, now lists Nutrashield buttocks/ peri area written in. There are no initials or signature of who completed these entries. * To be noted, the CNA Care Sheets do not include a repositioning schedule, or include the intervention to use a lift sheet to avoid shearing. The CNA Care Sheets are not a part of the resident's permanent record. R1's admission skin assessment, by LPN H (Licensed Practical Nurse), dated 8/4/17, shows the buttocks are circled and documented as #5. The description line includes in part: #5 - redness and shearing. (To be noted: purple discoloration is written next to it with RN C's (Wound Care Certified) initials. RN C did not observe R1 until 8/7/17.) R1's Admission Skin Assessment documentation, dated 8/4/17, by LPN H includes in part: Redness on the buttocks with some skin sloughing, no open areas. On 11/21/17 at 3:45 PM, Surveyor asked LPN H if she recalled R1's admission from 8/4/17. LPN H indicated that she did as R1's friend (named) was with her. Surveyor asked LPN H if she recalled R1's skin assessment on her buttocks. LPN H indicated R1's buttock were red and appeared to have shearing. Surveyor asked LPN H if R1's buttocks looked purple. LPN H indicated that she did not recall R1's buttocks being purple. LPN H indicated she would have documented that. LPN H indicated that purple would be like a deep tissue injury and she did not recall it being purple. Surveyor asked LPN H if she recalls any education provided by RN C regarding documentation of R1's skin assessment. LPN H did not recall any education provided by RN C regarding R1's skin assessment documentation. physician's orders [REDACTED]. Last date 9/1/17. Weekly skin assessment on shower day to begin 8/31/17. (To be noted: the facility does daily skin checks for those residents at higher risk.) Functional Maintenance Program, dated 8/5/17, without a signature, states: Transfers: Hoyer (mechanical) lift with 2 assist. Bed Mobility: Dependent. ADL's /Toileting: dependent for toileting, bathing, dressing, grooming, has a Foley catheter. Needs assist to feed self, but try to encourage her to do as much as she can for herself. Ambulation: Not at this time. Positioning / Splinting: Left blank. * It is important to know: A turning repositioning program and interventions to prevent shearing were not included on the care plan when R1 was admitted and the facility was aware that R1 was at moderate risk for skin breakdown and dependent for bed mobility. Review of R1's wound documentation by RN C, dated 8/8/17, as a late entry for 8/7/17, includes, in part: R1 seen today for initial visit. Skin problems: shearing discolored skin on admission. Location: left upper buttock. Length: 3 centimeters (cm) Width: 1.5 cm Tissue type: sheared with light purple discolored skin. Drainage: none present. Surrounding tissue: intact, pink, there are several larger scar tissue areas newly healed skin white areas surrounding area. There is scarring to the right buttocks as well as posterior upper thighs between legs and scattered fragile newly healed scar tissue. Teaching done: skin care / precautions - resident is uncooperative with cares today during assessment, staff state R1 is non adherent to recommendations for repositioning and is not allowing them to do much for her without being very uncooperative. Procedure done: measured, examined, cleaned, and applied Nutrashield barrier and recommend barrier with all cares to nourish and protect skin. Review of R1's behavior tracking documentation, for 8/4/17 - 8/31/17, indicates R1 was only combative x1 on 8/4/17. The written record and the interview of CNA E (below) do not corroborate the statement that R1 is uncooperative with care. Review of Physician Notification fax, dated 8/7/17, includes in part: R1 has left buttocks discoloration surrounded by several old scar tissues/healed sores/ ulcers. Area is 3 cm x 1.5 cm and was present on admission. Recommend Nutrashield barrier with all cares. * It is important to know: R1's admission assessment did not include a 3cm x 1.5 cm discoloration as R1's buttocks were documented as red and no measurements were taken. Review of R1's Treatment Administration Record (TAR), dated 8/2017, includes in part: On 8/8/17, an order was written for Nutrashield barrier to be applied to R1's buttocks with all cares AM, PM, PRN (when necessary). (To be noted: the first date the Nutrashield is signed out is 8/10/17, on the AM and PM shift. The Nutrashield was not signed out on 8/11/17 PM shift or 8/16/17 PM shift.) R1 did not have the weekly Braden completed that was due on 8/11/17. Review of R1's wound documentation by RN C, dated 8/12/17, includes in part: Skin problems: new area open area. Location: left upper buttock and right upper buttock. Length: 2 cm Width: 2 cm Depth: 0.1 cm Wound tissue: reddened. Drainage: none present. Surrounding tissue: intact. Skin treatment: receives turning repositioning program. Procedure done: cleaned with wound cleanser and covered with a [MEDICATION NAME]. * To be noted: the physician was not updated with the new open areas. Review of R1's wound documentation by RN C, dated 8/16/17, includes in part: Pressure Injury: Full thickness of skin lost, exposing the sub Q (subcutaneous tissue, deepest layer that rests above the fascia) tissue. Presents as a deep crater (Pressure stage 3) shearing and purple discoloration has evolved to stage 3. Location: left upper buttock Length: 1.5 cm Width: 1 cm Tissue type: granulation tissue, slough. Wound tissue: pink light yellow scattered tissue. Drainage: none present. Surrounding tissue: intact, pink. Healing progress: worsening area of shearing is now stage 3 evolving on admission. Procedure done: measured, examined, cleaned, and applied a [MEDICATION NAME] per protocol in place. Skin problems: shearing Location: right upper buttock. Length: 2 cm Width: 1.5 cm Depth: superficial Drainage: none present. Surrounding tissue: intact. Skin treatment: receives turning repositioning program. Procedure done: intact, fragile scar tissue area appears to be fragile scar tissue present on admission that sheared off, measured, examined, cleaned, and applied [MEDICATION NAME] per nursing protocol in place. Teaching done: skin care / precautions, resident is often non-adherent to with recommendation. Can be uncooperative at times with repositioning and cares. Did discuss with R1 importance of allowing staff to reposition. R1 indicates she prefers to lie on her back in bed and does not get up in her w/c for meals and therapy. Can be uncooperative in therapy. *To be noted: R1's behavior tracking indicates that R1 is not combative and has severe cognitive impairment. Skin Treatment: R1 has pressure redistributing device for chair. Has appropriate pressure redistribution cushion and gel cushion in recliner but seldom uses recliner. Has pressure redistribution device for bed. Action: Physician notified by fax with update. The facility sent a Physician Notification fax on 8/16/17, which includes in part: R1's shearing and purple discoloration on admission has evolved to stage 3 PI left upper buttocks - pink scattered yellow 1.5 cm x 1 cm, also has area of shearing right upper buttocks from old scar opening. Recommend cleanse both area with wound cleanser, apply skin prep to surrounding area, and apply [MEDICATION NAME]. Change every 5 days and PRN. May we have an order? R1 seen by NP (Nurse Practitioner) and has a wound nurse referral out. * It is very important to know: the facility did not immediately consult with the physician when R1 developed the stage 3 PI as current standards of practice for physician notification when there is a worsening of a PI. The physician did not return the fax until 8/21/17 and the resident went without a change in treatment for 5 days. On 8/16/17, R1's CNA Care Sheet was updated to include the intervention: encourage side to side in bed. HOB (Height of Bed) up no more than 30 degrees. Has [MEDICATION NAME] on buttock. On 8/18/17, the facility completed R1's second Braden, which scored a 12 indicating R1 is at high risk for skin breakdown. * To be noted: the Braden was due to be completed on 8/11/17 and R1 developed a stage 3 PI on 8/16/17. Review of R1's wound documentation by RN C, dated 8/21/17, includes in part: Pressure Injury: Full thickness of skin lost, exposing the sub Q tissue. Presents as a deep crater (Pressure stage 3) unavoidable. Location: left upper buttock Length: 1.5 cm Width: 1 cm Tissue type: granulation tissue 50 %, slough light yellow 50%. Wound tissue: pink, yellow. Drainage: none present. Surrounding tissue: intact, pink to light purple discoloration. Healing progress: no change. Skin problems: shearing Location: right upper buttock. Length: 1 cm Tissue type: closed [MEDICATION NAME] tissue light purple discoloration Drainage: none present. Surrounding tissue: intact light purple discoloration fragile scar tissue. Skin treatment: receives turning repositioning program. Procedure done: measured, examined, cleaned, and applied a [MEDICATION NAME] per protocol in place. Action: Physician notified original fax had not returned and re-faxed today. RN C spoke with MD G (Medical Doctor) regarding R1's skin condition and general decline. R1 is now Hospice. RN C discussed with MD G that wound is unavoidable due to several comorbidities and poor nutrition and general decline. Maintain or improve status of PI rather than to heal it. CNA Care Sheet, updated on 8/21/17, new intervention low air loss mattress, check function with cares, one disposable chux over air mattress. Encourage use of pressure redistribution boots when in bed. Comprehensive Nursing Care Plan Impairment of skin integrity, dated 8/22/17, includes in part: Assess skin daily and note any changes. Treat as ordered. Monitor use of protective devices. Develop and monitor turning schedule. Low air loss mattress provided per Hospice on 8/22/17. * It is important to know: R1's admission CAA, dated 8/15/17, indicated a care plan would be developed and R1 requires a turning and repositioning schedule. The Nursing Care Plan, dated 8/22/17, intervention includes: develop and monitor a turning schedule. Review of R1's TAR for 8/2017 indicates the daily skin assessments were not completed on 8/5/17 and 8/11/17. On 8/30/17, a Physician Notification fax was sent that includes in part: New area unstageable PI to left posterior heel. 3 cm x 2.4 cm hardened purple discolored area to back of left heel. Recommend skin prep to bilateral heels BID (twice daily) may we have an order? The physician returned the fax on 8/31/17. * The facility did not immediately consult with the physician regarding the new unstageable pressure injury to the heel. On 9/1/17, the facility completed R1's third Braden which scored a 17 indicating R1 is at risk for skin breakdown. R1 is completely dependent and is declining which questions the accuracy of the Braden Score. R1 was to have 5 Braden's completed as of 9/1/17. CNA Care Sheet, dated 9/13/17, includes the following intervention: arrow pointing down in bed, AM and PM nap, and side to side only. Keep off buttocks. Review of R1's wound documentation by RN C, dated 9/15/17, includes in part: Pressure Injury: Full thickness of skin lost, exposing the sub Q tissue. Presents as a deep crater (Pressure stage 3) unavoidable. Location: left upper buttock Length: 2 cm Width: 1.2 cm Tissue type: slough100% Wound tissue: tan. Drainage: scant - moist non measurable serous. Surrounding tissue: intact, pink discolored scar tissue. Pink wound edges, no symptoms of infection. Healing progress: worsening. Description: becoming larger slough, increasing to wound bed. Skin treatment: receives turning repositioning program. Pressure redistribution device for bed and chair. Procedure done: measured, examined, cleaned, skin treatment done per order. Procedure result: treatment ineffective, worsening. Action: Physician notified via fax and Hospice notified. Physician's Notification Fax, dated 9/15/17, includes in part: R1 buttocks wound is worsening, measurements 2 cm x 1.2 cm 100% tan slough. Recommend d/c (discontinue) [MEDICATION NAME], cleanse with wound cleanser, apply Thera honey to wound bed and cover with a dry dressing daily and prn. May we have order? * The facility did not immediately consult with the physician when staff noted that the PI had worsened. The physician signed and faxed the orders back on 9/18/17 (3 days later). Physician's Progress Notes, dated 9/18/17, includes in part: R1 continues to have a stage 2 PI in the buttocks, which the facility has been cleaning up daily with soap and water and applying Thera honey (wound debridement) to the area recently. R1 continues to have a Foley catheter, because of her not being quite mobile and R1 is at risk of skin breakdown as well as some maceration with her incontinence. CNA Care Sheet, dated 9/20/17, includes the following new intervention: reposition every two hours - side to side only. Keep off buttocks. Bedrest for now. Review of R1's wound documentation by RN C, dated 9/20/17, includes in part: Pressure Injury: Full thickness of skin lost, exposing the sub Q tissue. Presents as a deep crater (Pressure stage 3) unavoidable. Location: left upper buttock Length: 2 cm Width: 1 cm Tissue type: granulation 50% slough 50% Wound tissue: yellow to white slough, pink granulation tissue with some beefy red scattered tissue noted. Drainage: small <25% moisture serosanguinous on removed dressing. Surrounding tissue: intact, normal skin discoloration with scattered scar tissue present. Healing progress: improving. Description: appears more clean granulation occurring. Teaching: skin care/ precautions. Skin treatment: receives turning repositioning program. Pressure redistribution device for bed and chair. Procedure done: measured, examined, cleaned, skin treatment done per order. Procedure result: improved treatment effective area is [MEDICATION NAME] as anticipated with honey dressing recommended. Continue with dressing. Review of R1's wound documentation by RN C, dated 9/25/17, includes in part: Pressure Injury: Full thickness tissue loss, in which the base of the ulcer is covered by slough in the wound bed. Unstageable, unavoidable. Location: left upper buttock Length: 2 cm Width: 3 cm Depth: 1 cm to continued bed of slough, unable to determine actual depth, there is undermining approximately 0.3 cm entire edge of wound. Tissue type: slough 50% scattered dark beefy tissue. There is yellow tissue to the extended width of wound. Drainage: Moderate 25-75% moisture serosanguinous. Surrounding tissue: intact, normal skin discoloration scar worsening. Healing progress: worsening. Description: there is [MEDICATION NAME] of slough noted which accounts for the approximate new depth to bed of continued slough. This area is measuring larger and there is undermining present. Teaching: skin care / precautions R1 prefers to lay flat on her back despite risks benefits explained. Will lay on her side with much encouragement from staff. RN C did encourage side to side repositioning only for now and recommend bedrest. Reviewed with R1. (Of note: R1 has severe cognitive impairment.) Skin treatment: has pressure redistribution device for chair. Has EquaGel cushion for Broda chair for extra redistribution. Has pressure redistribution device for bed. Low air loss mattress. Receives turning and repositioning program. Receives nutrition or hydration intervention to manage skin problems. R1's intake varies from refusals to bites to 25%. Supplements range from 25 - 100%. Procedure done: measured, examined, cleaned, skin treatment done per order. Recommend adding calcium alginate with silver to lightly pack dead space of wound. Treatment effective in [MEDICATION NAME] wound. Will add packing. Action: Physician notified by fax requesting an order for [REDACTED]. Physician's Notification fax, dated 9/25/17, includes in part: R1's unstageable PI is larger today 2 cm x 3 cm x 1 cm. Continued slough. Honey is working. Hospice recommends adding alginate silver to current treatment for [REDACTED]. * The facility did not immediately consult with the physician. The physician's fax was signed and returned on 9/28/17 (3 days later). * It important to know: The 9/17 TAR has add calcium alginate silver to pk (pack) wound and there is no date to when this was added to the TAR and no initials that it was added to the wound treatment. The wound treatment is highlighted in yellow and use foam dressing is written to the side of the wound treatment without a date or initials of who wrote the order. On 9/25/17 at 11:57 AM, RN C's note includes: please note buttocks wound should now be read unavoidable unstageable. Physician's Notification fax, dated 9/28/17, per dietitian, includes, in part: R1's wound on coccyx worse. The physician's fax was signed and returned undated with orders for a surgical consult. * R1's 9/17 TAR daily skin assessment was not signed off as completed on 9/7, 9/15, 9/25 - 9/28. R1's 9/17 TAR Apply Nutrashield barrier to buttock was not signed out on 9/1 PM, 9/7 PM, 9/8 AM, 9/18 - 9/20 AM, 9/22 PM, 9/27 PM, and 9/28 PM. Review of R1's wound documentation by RN C, dated 10/5/17, late entry for 10/3/17, includes in part: Pressure Injury: Full thickness tissue loss, which the base of the ulcer is covered by slough in the wound bed. Unstageable, unavoidable. Location: left upper buttocks sacral area. Length: 4 cm Width: 3 cm Depth: 2 cm there is approximately 1 cm undermining from 10:00 to 2 o'clock, and 0.5 cm undermining rest of wound edges. Tissue type: slough necrotic tissue 100% in wound bed. There is some pink tissue noted to sides of depth. Wound tissue: soft, dark black, stringy slough tissue. Drainage: large 75 - 100% moisture odorous serosanguinous purulent. Surrounding tissue: intact, blanchable reddened, normal scar tissue discoloration. Healing progress: worsening. Description: becoming larger, becoming deeper, and sloughing occurring. Skin treatment: has pressure redistribution device for bed. Receives turning and repositioning program. Receives nutrition or hydration intervention to manage skin problems. Receives ulcer care and applications of dressings. Procedure done: measured, examined, cleaned, skin treatment done per order. Procedure result: treatment effect as wound continues to debride the loose stringy slough but there is foul odor today and increased drainage along with the increase size of wound, there is increased general pain noted today during the dressing change. Action: Physician notified Hospice nurse. Will relay message to case manager regarding need for increase pain meds? Antibiotic for comfort signs of infection. Discussed surgical consult order as R1 is hospice and not appropriate for consult. Encouraged R1 to rest and repositioned. Family updated and notified possible antibiotic and increased pain medication. On 10/3/17 at 3:33 PM, Hospice physician's orders [REDACTED]. Keflex (antibiotic) 250 mg 1 po QID (four times daily) x 7 days. On 11/17/17 at 11:00 AM, Surveyor interviewed Hospice RN D regarding R1's wound. Hospice RN D indicated when hospice became involved they immediately changed R1's mattress to a low air loss. Surveyor asked Hospice RN D if she ever did the R1's wound treatment. Hospice RN D indicated that she did the treatment if it was due and she was in the building. Hospice RN D indicated that the wound had an odor and it smelled like infection. Hospice RN D indicated the entire room smelled. Hospice RN D indicated there was a lot of green-yellow drainage in the wound. Physician's Notification fax, dated 10/5/17, includes, in part: update on wound sacral buttocks 4 cm x 3 cm x 2 cm. with increased pain, drainage, slough, and odor. Hospice did get an order for [REDACTED]. Surgery consult not appropriate. May we increase dressing to BID (twice daily)? Second fax to the physician requesting a written response. * The facility did not immediately consult with the physician. The physician's faxed response, dated 10/10/17, with ok to increase dressing changes to BID (5 days later). Review of R1's wound documentation by RN C, dated 10/11/17, includes in part: Pressure Injury: Full thickness tissue loss, in which the base of the ulcer is covered by slough in the wound bed. Unstageable, unavoidable. Location: sacral region. Length: 5 cm Width: 6 cm Depth: 2 cm there is approximately 1 cm undermining from 10:00 to 2 o'clock, and 0.5 cm undermining (eroding of tissue under wound edges) rest of wound edges. Tissue type: slough necrotic tissue 100%. Wound tissue: dark tan to light brown thick stringy slough. There is some pink tissue noted to the sides of the depth edges of the wound. Drainage: large 75 - 100% moisture serosanguinous. No odor today. Surrounding tissue: intact, blanchable reddened, normal scar tissue discoloration. Healing progress: color of wound bed is improving and there is no odor today. Review of R1's wound documentation by RN C, dated 10/17/17, includes in part: Pressure Injury: Full thickness tissue loss, in which the base of the ulcer is covered by slough in the wound bed. Unstageable, unavoidable. Location: sacral region. Length: 5 cm Width: 6 cm Depth: 3 cm there is approximately 1 cm undermining from 10:00 to 2 o'clock, and 1cm undermining. Nursing Comprehensive Impairment of Skin Care Plan, dated 10/20/17, includes, in part: reposition every two hours, follow turning schedule, use lift sheet when moving R1 in bed. Review of Physician's Progress Note, dated 10/21/17, includes, in part: R1 is not doing really well at this time. R1 continues to be immobile now. Hospice is on board, but the main concern is the fact that R1 has a worsening stage 4 sacral decubitus that has gotten much bigger since the last time R1 was seen. The wound has a little yellow to green drainage on it. Physician indicates she will talk with Hospice to see if they could at least allow R1's decubitus ulcer to be debrided by one of the surgeons and see if R1 would be a candidate for a Wound VAC (Vacuum-Assisted Closure). Impression: Stage 4 ulcer on buttocks. Review of R1's wound documentation by RN C, dated 10/24/17, includes in part: Pressure Injury: Full thickness tissue loss, in which the base of the ulcer is covered by slough in the wound bed. Unstageable, unavoidable. Location: sacral region. Length: 5 cm Width: 6 cm Depth: 3 cm there is approximately 1 cm undermining from 10:00 to 2 o'clock, and 1cm undermining. A second fax from the MD was noted, without a date, indicating it was ok to d/c the surgical would consult and watch the wound close. Nursing Comprehensive Impairment of Skin Care Plan, dated 10/30/17, includes in part: PI present unstageable coccyx admission acquired with unavoidable progression. Nursing Progress Note, dated 11/16/17, includes, in part: dressing to coccyx changed per MD order, small amount of bleeding noted. Wound has some eschar and is unstageable at this time. R1 tolerated dressing change well. On 11/17/17 at 9:50 AM, Surveyor interviewed CNA E regarding R1's general care needs. CNA E indicated that R1 is repositioned every 2 hours, catheter care is provided every shift, and they assist to feed as R1 is on a pureed diet. Surveyor asked CNA E if R1 has a sore on her bottom. CNA E indicated that R1 does have a sore and believes it has been there for a few weeks. CNA E indicated she was not sure how it developed. Surveyor asked CNA E if R1 refuses to reposition. CNA E indicated that R1 does not refuse to reposition and is a nice lady. CNA E indicated R1's sore is always covered. CNA E indicated that R1 moans when repositioned. On 11/17/17 at 10:15 AM, Surveyor observed CNA E and CNA F reposition R1. Surveyor asked R1 is the sore on her bottom hurts. R1 indicated no. Surveyor observed R1 to by lying on a blue chux (incontinence pad with a plastic backing). The chux pad was noted to have a very small amount of stool on it. During repositioning R1 moaned and complained that it hurt. Surveyor observed a dressing on R1's sacrum that was intact and dated 11/17/17 at 5AM. CNA E and CNA F placed a second blue chux over the first chux. R1 was repositioned to her right side. R1's heels were observed to be intact and then floated. * Placement of the chux between the resident and t (TRUNCATED)

Based on interview and record review the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 29 residents with a full code status (Resident 1). Resident 1 desired to receive Cardiopulmonary Resuscitation (CPR) in the event of a cardiac or [MEDICAL CONDITION] arrest. When Resident 1 was found pulseless and non-breathing (PNB), the facility failed to immediately initiate CPR for Resident 1. The responding Registered Nurse (RN) did not recognize the immediacy of the situation and left Resident 1 who was PNB and did not initiate CPR or instruct a CPR-certified (CNA) Certified Nursing Assistant to initiate CPR. In addition, facility staff failed to use the public announce (PA) system to overhead page code blue which would have alerted all CPR certified staff to immediately respond and aid in providing CPR for Resident 1. The failure to provide the necessary care including immediately initiating CPR created a finding of immediate jeopardy. The immediate jeopardy began on [DATE]. The Nursing Home Administrator was notified of the immediate jeopardy on [DATE] at 1:10 PM. The facility removed the jeopardy on [DATE], however the deficient practice continues at a scope/severity of D (no actual harm/isolated) as the facility continues to implement its removal plan. This is evidenced by the following: According to < <https://eccguidelines.heart.org/wp-content/uploads/[DATE]-AHA-Guidelines-Highlights-English.pdf> > a guideline entitled Highlights of the 2015 American Heart Association Guidelines Update for CPR and Emergency Cardiovascular Care (ECC) states in part; this Guidelines Highlights publication summarizes the key issues and changes in the 2015 American Heart Association (AHA) Guidelines update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care. Key issues and major changes in the 2015 Guidelines Update recommendations for Health Care Providers HCPs include the following: Trained rescuers are encouraged to simultaneously perform some steps (ie, checking for breathing and pulse at the same time), in an effort to reduce the time to first chest compression. Integrated teams of highly trained rescuers may use a choreographed approach that accomplishes multiple steps and assessments simultaneously rather than the sequential manner used by individual rescuers (eg, one rescuer activates the emergency response system while another begins chest compressions, a third either provides ventilation or retrieves the bag-mask device for rescue breaths, and a fourth retrieves and sets up a defibrillator). HCPs must call for nearby help upon finding the victim unresponsive, but it would be practical for an HCP to continue to assess the breathing and pulse simultaneously before fully activating the emergency response system (or calling for backup). The HCP should check for response while looking at the patient to determine if breathing is absent or not normal. The intent of the recommendation change is to minimize delay and to encourage fast, efficient simultaneous assessment and response, rather than a slow, methodical, step-by-step approach. Summary of High Quality CPR Components for Basic Life Support: Recognition of [MEDICAL CONDITION] Check for responsiveness No breathing or only gasping (ie, no normal breathing) No definite pulse felt within 10 seconds (Breathing and pulse check can be performed simultaneously in less than 10 seconds) Activation of emergency response system If you are alone with no mobile phone, leave the victim to activate the emergency response system and get the Automated External Defibrillator (AED) before beginning CPR otherwise, send someone and begin CPR immediately; use the AED as soon as it is available. The facility's Cardiac or Respiratory Arrest policy dated [DATE] states in part; Policy: CPR is provided for those residents who wish to be a full code. In the event of a cardiopulmonary emergency the following procedure will take place. Procedure: 1. Any facility staff who is made aware of a resident who is not breathing or is pulseless will immediately check the resident for the presence of a blue arm band (full code notification); if no blue band is found the medical record will be checked immediately to confirm code status. 3. If the resident is a full code, upon cessation of heart rate or breathing Basic Life Support (BLS) for healthcare providers, current manual becomes the policy. A. activation of emergency response system. i. call for help - send someone to call. ii. Overhead page Code Blue and room number three times. iii. Call 911. B. start CPR per guidelines. 4. Continue until Emergency Medical Services (EMS) arrives. The facility's Code Blue policy dated [DATE] states in part; Procedure: 1. Identify if the resident is PNB and determine code status. 2. At moment of cardiac and/or [MEDICAL CONDITION] arrest, call 911 immediately and page code blue on the overhead. Follow nursing procedure for code blue. A Memorandum dated [DATE] from Director of Nursing (DON) B regarding full code residents' states in part; effective immediately, any resident who is a full code will have CPR started after a staff member has been assigned to contact 911. Staff will start CPR as per the current standards of the AHA. If it is unknown if a resident is a full code or not, as quickly as possible determine code status of the resident. Do not start CPR efforts on a resident who you are unsure of their code status. In the event of a resident who has been found or becomes not breathing remember the following steps: ensure activation of 911 has taken place; ensure the activation of the in-house code blue by overhead page; start CPR (one man) until the suction cart comes; when the second staff arrives, start ventilation and switch off with compressions per guidelines. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's physician orders [REDACTED]. Resident 1's signed physician orders [REDACTED]. Code Status: full code [DATE] - FYI - check blue code status band daily in AM Resident 1's Medication Administration Record [REDACTED]. Nursing notes dated [DATE] at 1:10 PM state Resident 1's weight was 135.1 pounds. Nursing notes dated [DATE] at 6:53 PM and documented by Registered Nurse (RN) I state in part; Resident 1's blood pressure ,[DATE], radial pulse 62, respirations 14 and temperature 96.1. Circulatory Findings: within normal limits; chest pain: denies pain; [MEDICAL CONDITION]: has no [MEDICAL CONDITION] present. Respirations: breathing pattern is normal; lung sounds: upon auscultation breath sounds normal. Nervous system findings: alert and awake, time/place/person; occasionally forgetful, cues help. Nursing notes dated [DATE] at 10:14 PM and documented by RN I state in part; Circulatory findings: Resident 1 found at 8:50 PM lying on his back in the bathroom; no pulse or respiration; 911 called; CPR initiated; paramedics came and initiated Advanced Cardiac Life Support (ACLS) and unable to resuscitate; pronounced dead at 9:19 PM per MD. Family notified and came in; MD on call notified, may release body when coroner okay with this. Of note, there is no further documentation in Resident 1's medical record regarding the assessment or timeline of events regarding CPR initiation for Resident 1. A Prehospital Care Report from (Fire Department Name) Fire Department (EMS) dated [DATE] states in part; Response time: dispatch notified at 8:58 PM at scene 9:04 PM. Provider Impression: Primary Impression: [MEDICAL CONDITION]. Call type: [MEDICAL CONDITION]; Patient Condition: chief complaint: PNB times 30 minutes; Primary symptom: unresponsive/unconscious. Summary of events: dispatched for a PNB at the facility. Enroute we were advised CPR has been initiated; upon arrival we found two employees initiating care; CPR was in progress; respirations via bag valve mask; 9:05 PM EMS continued CPR; 9:06 PM ECG monitor applied which showed an agonal rhythm (This is a life-threatening [MEDICAL CONDITION]. Agonal rhythm is often the last ordered semblance of organized electrical activity in the heart prior to death). We were told the patient was down in the BR for approximately 30 minutes since anyone saw him last. Nursing home staff started CPR prior to arrival. 9:19 PM ECG monitor showed asystole. MD was contacted with request to cease resuscitation; request granted. [MEDICAL CONDITION] Data: [MEDICAL CONDITION] not witnessed; pre-ambulance AED - no; resuscitation attempted: attempted ventilation and initiated chest compressions. CPR discontinued: 9:19 PM. 1. On [DATE] at 9:30 AM Surveyor interviewed Certified Nursing Assistant (CNA) D regarding Resident 1 and the evening Resident 1 was found PNB. Surveyor asked CNA D who was caring for Resident 1 on the evening of [DATE]. CNA D stated she was Resident 1's CNA. Surveyor asked CNA D when she last had cared or saw Resident 1 in good health. CNA D stated she saw Resident 1 at approximately 7:30 PM Resident 1 was lying on his bed watching TV. Surveyor asked CNA D if Resident 1 was in his usual state of health on [DATE]; CNA D stated Resident 1 did not appear ill and had no complaints on [DATE] and appeared his usual self. Surveyor asked CNA D who found Resident 1; CNA D stated that she and CNA F were completing their nightly check at approximately 8:20 PM, Resident 1's room door was closed; they opened the door and found Resident 1 lying on his back in the bathroom. CNA D stated CNA F went into the room and CNA D ran to tell the floor nurse RN I. CNA D told RN I something was wrong with Resident 1 and CNA D indicated RN I grabbed the vital signs stuff and CNA D then called the Charge Nurse RN E. RN E was on the phone so CNA D told the staff member that answered the phone to tell Charge Nurse RN E there was an emergency with Resident 1 and she was needed right away. CNA D stated she was heading back to Resident 1's room and she met RN I by the nurses station. Of note, Resident 1's room was at the end of the hallway. RN I, according to CNA D, appeared to be walking back to the nurses station with no urgency. CNA D stated RN I stated to her Resident 1 is unconscious. CNA D stated before she was back into Resident 1's room Charge Nurse RN E was behind her. CNA D stated Resident 1 was lying in the bathroom door way so CNA D, CNA F and RN E pulled Resident 1 out of the bathroom. CNA D stated RN E and CNA D began CPR. CNA D stated she overheard RN I state she was checking Resident 1's chart to see if Resident 1 was a full code. CNA D stated Resident 1 was wearing a blue full code bracelet indicating he was a full code. CNA D stated RN I never overhead paged a code blue per facility policy. Other staff that could have responded did not respond until the paramedics arrived. CNA D stated all staff that is CPR certified should respond when a code blue is paged. Surveyor asked CNA D if she was CPR certified CNA D stated, Yes. Surveyor asked CNA D why she did not initiate CPR CNA D stated she went to get RN I and at that point she was not aware Resident 1 was PNB. CNA D stated she left CNA F who is also CPR certified with Resident 1. Surveyor asked CNA D how much time passed from when she and CNA F found Resident 1 until CPR was initiated CNA D stated 3 - 4 minutes. Surveyor asked CNA D if Resident 1 was wearing his blue full code band. CNA D stated he was wearing the band and it was visible. Surveyor asked CNA D if the facility holds mock code drills. CNA D stated she has worked at the facility for 2 years on both day and pm shifts and she has not been present for a mock code drill. A Fall Huddle Staff Statement dated [DATE] provided by CNA D I states in part; Time of Incident: 8:50 PM; When did you last see Resident: 7:30 PM; in bed watching TV. Went to do Resident 1 cares and found resident in bathroom on floor ran to get nurse and called charge nurse. 2. On [DATE] at 2:10 PM Surveyor interviewed CNA F regarding the events on [DATE] with Resident 1 and initiation of CPR for Resident 1. Of note, CNA F is CPR certified. CNA F stated she was helping CNA D complete nightly rounds around 8:40 -8:45 PM. CNA F stated she went into Resident 1's room and found him lying on his back in the bathroom. CNA F stated she put her hand on Resident 1's chest and Resident 1 was not breathing. CNA F stated CNA D ran to get RN I; CNA F stated she did not think Resident 1 was alive. Surveyor asked CNA F if she initiated CPR; CNA F stated she did not initiate CPR because she thought that the nurse had to assess Resident 1 first. Surveyor asked CNA F if she attempted to pull Resident 1 from the bathroom CNA F stated not until CNA D and RN E came into the room. Surveyor asked CNA F if she could have pulled Resident 1 from the bathroom without assistance. CNA F stated I think I could have pulled Resident 1 out of the bathroom but I thought the nurse had to assess Resident 1 first. Surveyor asked CNA F if a nurse came to assess Resident 1. CNA F stated that RN I came into the bathroom and looked at Resident 1 and stated, He is unconscious and left. Surveyor asked CNA F if RN I completed an assessment such as taking Resident 1's pulse, listening for breathing, listening to his heart or attempted to take vital signs. CNA F stated RN I did not; she just looked at him and said he was unconscious then left the room; I assumed to call 911. Surveyor asked CNA F if RN I gave her instruction to initiate CPR CNA F stated RN I did not give her instruction to begin CPR. Surveyor asked CNA F if she noticed if Resident 1 was wearing a code blue band. CNA F stated Resident 1 was wearing a code blue band and it was visible. Surveyor asked CNA F about how much time passed from when she and CNA D found Resident 1 until CPR was initiated CNA F stated several minutes. Surveyor asked CNA F to explain who started CPR. CNA F stated that CNA D and RN E came back to the room and the three of them pulled Resident 1 from the bathroom and RN E started CPR. Surveyor asked CNA F if she had received education since the event with Resident 1 CNA F stated she has spoken with the education nurse and now is aware she should have started CPR immediately. Surveyor asked CNA F if the facility completes mock code drills CNA F stated she has worked at the facility for a couple of years I have not been involved in any mock code drills. Surveyor asked CNA F if she recalled hearing a code blue paged overhead. CNA F stated she did not hear the code blue paged. The following is a portion of an interview statement from CNA F dated [DATE] taken by the facility regarding Resident 1. CNA F stated she had gone over to assist CNA D with laying residents down. She stated when they went into Resident 1's room his door was closed. CNA F stated CNA D opened the door and saw feet and ran to tell the nurse. CNA F stated that she stayed with Resident 1. Resident 1 was lying on the floor in the bathroom. CNA F checked Resident 1; he was unresponsive and Resident 1 did not appear to be breathing or have a pulse. CNA F stated that RN I came in and assessed Resident 1 and then left to call 911. CNA F stated that CNA D and RN E came into the room and the 3 of them moved Resident 1 out of the bathroom and started CPR. Of note, RN I never asked CNA F who was present in the room with Resident 1 if Resident 1 was wearing a code blue band. 3. On [DATE] at 2:20 PM Surveyor interviewed RN E regarding the initiation of CPR for Resident 1. RN E stated she was on the phone regarding another event and a staff member stated there is an emergency upstairs with Resident 1. This was about 8:45 - 8:50 PM. RN E stated she ran upstairs and RN I stated that she was calling 911 and that Resident 1 was a full code. RN E stated she ran to Resident 1's room he was in the bathroom lying on his back he was PNB. CNA D, CNA F and I pulled Resident 1 from the bathroom and we began CPR. CNA C got the ambu bag (bag to provide respirations) RN I came back and I instructed RN I how to set up the ambu bag. RN E stated they continued CPR until EMS arrived and they took over. EMS provided medications but it did not help and he was pronounced dead. RN E stated from the time she began CPR until the time EMS arrived was not long although it seemed like a long time. Of note, Surveyor estimated the distance from the first floor nurses station where RN E was located to Resident 1's room. There are 55 steps from the nurses' station to the stairwell, 15 stair steps to the 2nd floor and 78 steps from the stairwell to Resident 1's room. Surveyor traced this route in a fast pace and it took 70 seconds to complete the entire route. 4. On [DATE] at 9:30 AM Surveyor interviewed Certified Nursing Assistant (CNA) C regarding Resident 1 and the evening Resident 1 was found PNB. CNA C stated she also saw the full code band on Resident 1. Surveyor asked CNA C how she became aware of the situation CNA C stated CNA D informed her of the situation and she responded immediately. CNA C stated that CNA D had called downstairs and stated something was wrong with Resident 1. Surveyor asked CNA C what time this occurred CNA C stated about 8:40 PM. CNA C stated she ran upstairs; CNA C stated when she got upstairs RN E was doing CPR. CNA C stated she ran to get the cart (crash cart) and that was when CNA C stated she saw RN I for the first time. CNA C stated RN I grabbed the crash cart from her and RN I said she had called 911. CNA C stated RN I did not appear to act like the situation was urgent. CNA C stated the family showed up and did not even know that he was deceased . The family stated, He's unconscious, right? Surveyor asked CNA C if the facility holds mock code drills. CNA C stated she has worked at the facility for a year on both day and pm shifts and she has not been present for a mock code drill. This is a written statement from CNA C dated ,[DATE] that was taken by the facility regarding Resident 1. On [DATE] at around 8:40 PM CNA D told me to come upstairs something was wrong with Resident 1. So I ran upstairs, when I got to Resident 1's room Charge Nurse RN E was doing CPR on Resident 1. I grabbed the cart from the dining room on my way back down to Resident 1's room I saw RN I. She jerked the cart away from me and said she called 911. 5. RN I is no longer employed at the facility. The following is an interview statement from RN I dated [DATE] taken by the facility regarding Resident 1. The statement states in part; at 8:50 PM CNA D came to me at the nurses station and reported to me that Resident 1 was on the floor in the bathroom. I grabbed the blood pressure cuff, pulse oximeter and hurried to his room (located at the end of the hallway). CNA D told RN I she was going to get the charge nurse but not that Resident 1 was dead. RN I stated that Resident 1 was lying on the bathroom floor on his back - he had no pulse or respirations. (Of note, CNA F stated RN I did not complete this assessment.) I did not see a blue band on his arm; no one was around, so I hurried back to the nurses' station to double check his code status. (Of note, CNA F had remained with Resident 1 and was in the room; CNA F and several other staff indicated the code blue band was in place.) RN I statement continues: Resident 1 had a blue dot on his chart. RN I states she heard CNA D and RN E coming back and RN I states she was on the phone with 911 and called out to RN E that Resident 1 was a full code. RN I states she hurried back to Resident 1's room and grabbed the ambu bag off the crash cart that CNA C was wheeling down the hall and helped do respirations. RN I stated the facility has not completed mock codes. Of note, RN I could have sent CNA F to look at Resident 1's chart if there was any question, CNA F could have called a code blue and 911 or RN I could have instructed CNA F to initiate CPR. However, RN I did not initiate any of these options; instead, RN I left Resident 1's room without any instructions, stating to staff in the room that Resident 1 was unconscious. Upon arrival at the nursing station RN I, after ensuring the blue dot, called 911 and indicated Resident 1 was PNB. RN I did not instruct a CPR certified CNA to initiate CPR. Although RN I completed her written statement on the night of the event, RN I failed to document detailed nursing notes regarding the timeline of events regarding CPR initiation for Resident 1. A Fall Huddle Staff Statement dated [DATE] provided by RN I states in part; Time of Incident: 8:50 PM; When did you last see Resident: 8:15 PM; was watching TV. CNA reported to writer that resident on floor in bathroom. Writer checked no pulse, no respirations, 911 CPR paramedics unable to resuscitate. Of note, Paramedics were not dispatched per EMS report until 8:58 PM. (See above). 6. On [DATE] at 10:30 AM Surveyor interviewed DON B regarding the facility's CPR policy and initiation of CPR for Resident 1. DON B stated that he reviewed the events that occurred with Resident 1 as he would with any resident that would receive CPR to ensure the standard of practice was followed. DON B stated he did not find any areas of concern except RN I was not calm and professional. DON B stated we let RN I resign her position. When Surveyor asked DON B how long RN I had been employed, DON B stated about 6 weeks but she had over [AGE] years of long term care experience. Surveyor asked DON B what issue he was referring to as a lack of professionalism for RN I. DON B stated that RN I refused to provide the paramedics with report even though RN I was directed to do so by Charge Nurse RN E. Surveyor asked DON B what he knew about the evening of [DATE] and the initiation of CPR for Resident 1. DON B stated that he was aware that Resident 1 liked his door shut, that 2 CNA's entered his room and found him lying on the floor 1 CNA went to get the nurse. RN I went to the room and then left Resident 1's room to call 911. In the meantime, the CNA also called the Charge Nurse RN E. The response time was 1:45 seconds. We responded very quickly. (Note: this differs from the timeline given by the two CNAs who found Resident 1, who stated that it was ,[DATE] minutes and several minutes from the time they found Resident 1 until CPR started.) Surveyor asked DON B if he would expect the nurse to leave a PNB resident to summon 911. DON B stated; I would not have done anything different. It is crucial to call 911 immediately to get the advanced life support on board. Our policy states call 911 then begin CPR. Surveyor asked DON B can only an RN call 911 and a code? DON B stated that anyone can now call a code; this was identified as a problem. Surveyor asked DON B are you stating previously the policy stated that only a nurse could call a code. DON B stated no anyone has had the ability to call a code. Surveyor asked DON B if RN I should have instructed CNA F, who is CPR certified, to initiate CPR. DON B stated Resident 1 was in the bathroom and he was too heavy to move out of the bathroom alone and CPR could not have been started in the bathroom it is too small. (Of note, Resident 1 weighed 135 pounds at the time of his death, and CNA F thought she could have pulled the resident out.) Surveyor asked DON B again if he felt that a RN should leave a PNB resident to summon 911 or if the RN should have instructed a CPR certified staff that was present to initiate CPR. DON B again stated; I would not have done anything different. Surveyor asked DON B if the facility completes mock code drills. DON B stated the facility just held one. Surveyor asked DON B if the facility had any previous drills. DON B provided Mock Code Drills for the following dates: [DATE] on the PM shift of note, this is after Resident 1 expired; [DATE] on the pm shift; and [DATE] on the night shift. On [DATE] at 11:10 AM Surveyor interviewed CNA G regarding the facility holding mock code drills. CNA G stated she has worked at the facility for [AGE] years and she has not been present for a mock code drill. On [DATE] at 11:10 AM Surveyor interviewed CNA H regarding the facility holding mock code drills. CNA H stated she has worked at the facility for 1month and she has not been present for a mock code drill. On [DATE] at 1:00 PM Surveyor interviewed DON B regarding the facility's equipment for CPR. Surveyor asked DON B if the facility has an AED. DON B stated the facility does not have an AED. RN I did not assess Resident 1; did not initiate CPR for Resident 1 who was PNB or give instruction to a CPR certified CNA who was present to initiate CPR. RN I did not overhead page a code blue which would have summoned all CPR certified staff to the scene to assist with CPR. Consequently, minutes were lost before CPR was initiated by the Charge Nurse who responded from the first floor. Because brain death can occur within ,[DATE] minutes of the brain being deprived of oxygen and the chance for a successful outcome decreases 7% - 10% with each minute that CPR and defibrillation is delayed, the failure to immediately assess Resident 1 and to immediately begin CPR created a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when they began education with staff on the facility's CPR policy, starting CPR and notification of 911. Nursing staff were educated on the importance of checking for pulselessness and respiratory status on all unconscious residents and properly assessing residents. All staff was educated on the location of the crash cart and CPR equipment. Nursing staff were educated on the standard of practice for documentation of residents who are pulseless. On [DATE] at 10:30 AM Surveyor interviewed DON B regarding the facility's CPR policy and initiation of CPR for Resident 1. Surveyor asked DON B if the facility provided any education following the code on [DATE]. DON B stated the facility completed a mock code drill as this was noted to be a concern from staff that more code drills were needed. There was some confusion regarding paging a code and who can call 911. A sign was placed at the nurse's station that gives instruction on how to proceed during a code situation. DON B stated education was provided to staff regarding a code situation. DON B provided Surveyor with type written code instructions dated [DATE]. A hand written note on the instruction sheet states signs placed at each main nurse's station. The sign states in part; Code Blue: 1. Determine if resident is a full code. 2. Ensure someone is calling 911 (can be anyone). 3. Initiate CPR per protocol (any CPR certified staff do not have to wait for nurse). 4. Ensure code blue is paged overhead 3 times with location (can be done by anyone). 5. Staff member to remain by door to direct paramedics. 6. Follow directions of nurse for any further help needed.

Based on observation, interview and record review, the facility did not ensure that each resident received the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with a comprehensive assessment, for 2 (Residents 6 and 17) of 19 residents reviewed. Resident 6 reported severe pain related to a lumbar fracture and the facility did not ensure that the doctor was contacted and that the plan of care/treatment was updated to manage Resident 6's pain. Resident 6 had multiple episodes of moderate to severe pain that were not fully assessed or treated. Resident 17 was started on scheduled medication for pain; the facility did not adequately monitor Resident 17's bowel movements per her care plan. This is evidenced by: The facility policy entitled "Pain Management Protocol" Revised 10/2007, states in part: "Pain management is central to the management of the physical and psychological well being of the resident...1. Determine the resident's pain level using the 0-3 scale. 0 = Absence of pain; 1 = Mild pain/discomforting pain; 2 = Distressing/moderate to severe pain; 3 = Excruciating/Severe pain. 2. After determining baseline level pain, provide an [MEDICATION NAME] for pain control starting at the bottom of the [MEDICATION NAME] ladder. Provide any and all comfort measures as well as [MEDICATION NAME] including: repositioning, heat/cold, back rubs, relaxation, visualization and distraction. 3. Evaluate the effectiveness of [MEDICATION NAME] and other measures. If pain control is not attained, then move up the [MEDICATION NAME] ladder...8. Continue to monitor results of pain management regime and document responses to pain relief measures using the Treatment flow sheets for highest level of pain assessed and the Nurses Notes for description of assessment, interventions and outcome..." An evidence-based protocol entitled "Acute Pain Management in the Elderly" by the University of Iowa, written 6/2000, states in part: "...Guide for Monitoring Acute Pain...2. Assess and document characteristics, intensity, duration, and effects of pain using selected assessment tools...Assess pain at least every two to four hours around the clock and during rest, during activity, and through the nighttime when pain is often heightened...Once every eight hours may be appropriate if pain is mild or well-controlled...Ask about pain and observe non-verbal pain-related behaviors during transfers or patient care activities...In all patients, observe for nonverbal cues of pain (e.g. grimacing, guarding) and behavioral changes (e.g. new onset of confusion, agitation and/or withdrawal; sleep disruptions; changes in activity)...3. Document pain in a visible place that can be used by other health care professionals...Information to document include: date; time; pain intensity rating; quality such as sharp, dull, burning, etc.; location; onset and duration; comfort goal; [MEDICATION NAME] information (e.g. drug, dose, route, frequency); other pain interventions; vital signs and side effects...Guide for Pharmacological Management...Pharmacological management for mild to moderate pain should begin, unless contraindicated, with a nonopioid (NSAID (Non-Steroidal Anti-[MEDICAL CONDITION]) or [MEDICATION NAME]). Moderate to severe pain should be treated initially with an opioid [MEDICATION NAME], with or without a nonopioid..." Example 1: Resident 6 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Resident 6's quarterly MDS (Minimum Data Set) Assessment of 2/26/14 listed a BIMS (Brief Interview for Mental Status) score of 14 (out of 15) which indicated that Resident 6 was cognitively intact. The 2/26/14 MDS also indicated that Resident 6 had no reports of pain in the previous 5 days. Resident 6's annual MDS, dated [DATE] also listed no reports of pain in the previous 5 days. A review of the comprehensive pain assessments for Resident 6 in ECS (computerized medical record) included the following: 2/13/14: "Should Pain Assessment Interview be Conducted? Yes. Pain Presence? No What is the acceptable level of pain for the resident? No pain. What makes your pain better? denies pain. What makes your pain worse? denies pain. Number of PRNs in last week? No PRN pain medication in the past 7 days. Number of PRNs in the last 30 days? No PRN pain medications in the past 30 days..." 3/5/14: "Pain: no s/s (signs/symptoms) of pain denies pain" 4/5/14: "Pain: no s/s/ of pain" There is no comprehensive assessment of pain noted after 4/5/14. There is no new assessment of pain after the acute injury sustained on 4/7/14 or after the X-ray showing a lumbar fracture was received on 4/11/14. Resident 6's Plan of Care for "Potential for Comfort, Alteration" dated 12/10/10 Related to: "DJD ([MEDICAL CONDITION] Joint Disease)/[MEDICAL CONDITION]" states in part: "...12/29/2011 Nurses - Assess physical symptoms. Document pain level. Administer pain meds. Monitor/record: med (medication) effectiveness, med side effects. Notify MD prn (as needed), if current interventions ineffective in managing her pain..." Resident 6 had a fall in the facility on 4/7/14. A fax to the physician on 4/10/14 indicated that Resident 6 was continuing to complain of pain in the lower back related to the fall on 4/7/14. A lumbar/sacral spinal X-ray was ordered and revealed an L1 compression fracture. Nurses' notes dated 4/11/14 at 5:36 PM state in part: "X-ray taken of lumbar spine X-ray result received 4/11/14 with Findings: 'There is a moderate L1 vertebral body compression fracture which appears acute or subacute and is new since the prior CT (Computed Tomography scan). There is a mild L3 vertebral body compression fracture, unchanged...notify primary MD and administer previously ordered PRN (as needed) Tylenol as needed for pain." The care plan for comfort/alteration was not updated after the lumbar fracture and new onset of pain related to the fracture. On 4/27/14 at 2:05 PM, Surveyor spoke with Certified Nursing Assistant (CNA) I to observe a transfer for Resident 6. CNA I stated that Resident 6 is currently in bed and will probably not be getting up this afternoon. CNA I stated that Resident 6 has a fractured tailbone and that it hurts "really bad" to sit on it so she (Resident 6) has been lying down after meals. On 4/28/14 at 8:05 AM, Surveyor observed Resident 6 eating breakfast in the main dining room. Resident 6 was up in her wheelchair at the dining table. Resident 6 was eating independently but very slowly. Resident 6 was holding herself very rigidly and was frowning and holding her jaw rigidly as well. Resident 6 ate a few bites of hot cereal and a few bites of toast and then stopped eating and sat looking straight ahead. At 8:20 AM, Registered Nurse (RN) K asked if she was done eating. At 8:20 AM, Resident 6 was moved into the hallway to wait to be taken back to her room. Resident 6 had eaten approximately 25% of the food provided. On 4/28/14 at 8:35 AM, Surveyor spoke with Resident 6 while she was waiting in her wheelchair in the hallway. When asked "how are you this morning?" Resident 6 replied "bad." When asked if she has pain, Resident 6 responded "yes." When asked if it had been hard to eat because of the pain, Resident 6 responded "yes." Resident 6 spoke in a very faint voice and offered only 1-2 word answers for each question. Resident 6 sat rigidly in her wheelchair with her eyes closed until she was taken to her room at 8:55 AM. On 4/28/14 at 8:55 AM, Surveyor observed CNA J transfer Resident 6 from her wheelchair to the bathroom and then back to her wheelchair and into bed. Resident 6 was frowning and holding herself rigidly in her wheelchair prior to the transfer. CNA J observed that it looks like you (Resident 6) "don't feel good today?" Resident 6 shook her head no. CNA J did not ask her any follow-up questions. CNA J completed the transfer by lowering Resident 6 to her bed with a pivot transfer and gait belt. Resident 6 was closing her eyes and moving slowly while being lowered to the bed. After Resident 6 had been laid down, Surveyor asked Resident 6 if she was in pain. Resident 6 said yes in her lower back. Surveyor asked Resident 6 how severe the pain is. Resident 6 responded "severe." Resident 6 had her eyes closed and spoke very faintly. Surveyor asked if the nurse had talked to her this morning or offered her anything for the pain. Resident 6 stated "no." When asked if she is willing to take medication to help the pain, Resident 6 stated "yes." When asked if Surveyor should get the nurse, Resident 6 stated "yes." A review of Resident 6's PRN pain medication log in ECS revealed the following entry: "4/28/14 4:28 AM - PRN MED GIVEN 04:26 AM (Tylenol) [MEDICATION NAME] 325 mg (milligram) Tablet given for pain/discomfort PAIN LEVEL BEFORE MED: 3 Location back resident is currently crying due to the pain in her back. She is lying in the bed and has slept most of the night tonight." There was no follow-up noted to re-assess the pain level after the medication was given. Pain level 3 on the facility scale is "Excruciating/Severe Pain." On 4/28/14 at 9:15 AM, Surveyor interviewed Registered Nurse (RN) K who is the floor nurse during the day shift on Resident 6's wing. Surveyor asked RN K if she had completed a pain assessment for Resident 6 this morning. RN K stated that she had done a pain assessment during morning med pass prior to breakfast (prior to 8 AM). RN K stated that Resident 6 had rated her pain at a 3 (excruciating/severe) at that time. When asked if she had re-assessed Resident 6's pain since then, RN K said that she had not checked in with her (Resident 6) yet. RN K stated that Resident 6 gets Tylenol three times a day and is not due yet for another dose. RN K stated that she (RN K) has talked to Nurse Practitioner (NP) L previously about Resident 6's pain. RN K stated that NP L does not want to give Resident 6 anything stronger for pain because she (Resident 6) is a fall risk. RN K stated that they had started using a [MEDICATION NAME] gel on Resident 6's lower back recently and that she has already done the treatment this morning. RN K stated that she has not contacted the doctor today. RN K stated that she is unable to contact NP L because NP L is not working today. Surveyor asked RN K to re-assess Resident 6 at Resident 6's request because she is still experiencing severe pain. RN K re-assessed Resident 6 and stated that she was still reporting pain level 3. Resident 6's Nurse's Note on 4/28/14 at 9:27 AM states "CALL PLACED TO: physician on call REGARDING: increase in pain level related to fx (fracture) of L1." This notification occurred after intervention by Surveyor . On 4/28/14 at 12:20 PM, Surveyor observed Resident 6 at lunch. Resident 6 was up in her wheelchair in the main dining room. Resident 6 again ate only a few bites of the noodle dish and breadstick offered. At 12:30 PM, Resident 6 was observed to take one bite of the noodles and spit it back on her plate. Resident 6 ate only bites and sips of foods offered. On 4/28/14 at 12:35 PM, Surveyor interviewed CNA J. When asked about Resident 6's normal activities, CNA J stated that she thinks Resident 6 has just been in a lot of pain and has been different lately. CNA J stated that Resident 6 has not been smiling and she can just tell that Resident 6 is not feeling good. CNA J stated that we "ambulated her" earlier and she (Resident 6) still does it but is not able to get as far as usual. On 4/28/14 at 12:40 PM, Surveyor interviewed RN K. RN K stated that she has been trying to get a hold of the doctor. RN K stated that she has called twice and faxed once and still has not heard anything from him. On 4/28/14 at 1:00 PM, Resident 6 had been transferred back to her bed. When asked, Resident 6 stated that her pain has been severe for many days not just today. When asked about eating, Resident 6 stated she is not hungry because of the pain. Surveyor asked if anything else besides medication might help like heat or ice. Resident 6 said "ice." When asked if she had been offered ice, Resident 6 said no. When asked if the gel they put on her back helps the pain, Resident 6 stated "no." On 4/28/14 at 1:20 PM, Surveyor interviewed Resident 6's daughter, family member (FM) M. FM M was in Resident 6's room picking up Resident 6's laundry. FM M stated that Resident 6 has been having a lot of pain since her fall 2 weeks ago. FM M stated that Resident 6 is not a complainer and that you know the pain is bad if Resident 6 says something about pain. FM M stated that the family would be open to a different pain medication if her doctor (MD O) agrees. On 4/28/14 at 1:30 PM, Surveyor interviewed RN K. RN K stated that at the noon pain assessment, Resident 6 had again rated her pain at a 3 (Excruciating/Severe.) RN K stated that she gave Resident 6 her scheduled dose of Tylenol at noon. RN K stated that she has not offered Resident 6 anything else for pain. When asked about other pain relief like heat or ice packs, RN K stated that the therapy department might be giving Resident 6 some kind of pain therapy like TENS (Transcutaneous Electrical Nerve Stimulation) or cold packs. Resident 6 had not been to therapy this morning. RN K stated that the doctor has not yet called back regarding medications. Therefore, Resident 6 has not had any pain intervention beyond the scheduled Tylenol and [MEDICATION NAME] gel since her first report of pain level 3 at 4:26 AM (9 hours ago). On 4/28/14 at 1:45 PM, RN K told Surveyor that Resident 6 was down in the therapy department having an E-Stim (electronic stimulation) treatment. At 1:50 PM, Surveyor observed Physical Therapist (PT) P administer an E-stim treatment to Resident 6. PT P stated that Resident 6 had been unable to rate her pain before beginning the treatment, but PT P estimated a pain level of 6-7 (on a scale of 1-10) based on Resident 6's facial expression and guarding while going from a standing to sitting position. Surveyor asked about a cold pack. PT P stated that she would get a cold pack if Resident 6 wanted one after the treatment. PT P stated that Resident 6 has not been able to be very active in therapy due to pain issues. On 4/28/14 at 2:05 PM, RN K informed Surveyor that the doctor, MD O, had called back with an order for [REDACTED]. On 4/28/14 at 3:30 PM, Resident 6 was lying in her bed with her eyes closed and appeared to be asleep. A review of the MAR (Medication Administration Record) shows that the first dose of [MEDICATION NAME] 5 mg/Tylenol 325 mg (1 tablet every 4 hours as needed) was administered to Resident 6 on 4/28/14 at 6:00 PM. This was 13.5 hours after the first reported complaint of pain at level 3 and 8.5 hours after the physician was first contacted. Resident 6's pain is assessed and documented every shift in the facility "Treatment Record." The treatment record entry states: "Pain Assessment every shift-Use 0-3 scale. For every entry > (greater than) 1 document in Nurses Notes Assessment, Intervention, and Outcomes, NOC (night shift), AM (day shift) PM (evening shift.)" The Treatment Record for April 2014 indicates the following: 4/1/14 to 4/11/14 - 0 (zero) noted for every shift. 4/12/14 - PM shift = 2 4/13/14 - PM shift = 2, NOC shift = 2 4/14/14 - AM shift = 2, PM shift =2 4/15/14 - AM shift = 2 4/16/14 - AM shift = 2 4/17/14 - AM shift = 2, NOC shift = 3 4/18/14 - AM shift = 2, PM shift = 2 4/19/14 - AM shift = 3 4/20/14 - AM shift = 3 4/21/14 - AM shift = 2 4/22/14 - AM shift = 2, PM shift = 1, NOC shift = 2 4/2313 - AM shift = 1 4/24/14 - AM shift = 2, PM shift = 2 4/25/14 - AM shift = 2, PM shift = 1 4/26/14 - AM shift = 2, PM shift = 1 4/27/14 - AM shift = 2, NOC shift = 2, PM shift = blank 4/28/14 = NOC shift = 0 (although Nurse's Notes above indicate a pain level of 3 on this date at 4:26 AM) Pain Medication orders in this time period are: 4/17/14 - Tylenol changed from as needed to routinely scheduled - 650 mg by mouth QID (4x per day). 4/23/14 - Apply [MEDICATION NAME] 2% jelly to lower back QID AM, PM, HS (bedtime), NOC for 30 days. After the Tylenol was routinely scheduled on 4/17/14, there are 13 shifts between 4/18/14 and 4/28/14 with pain noted in the 2 (Distressing/moderate to severe pain) or 3 (Excruciating/Severe pain) range. In that same period, there is no nurse charting regarding pain except for the pain ratings noted above in the Treatment Record. There are no nurse's notes that document the time, the onset, the duration, the quality (sharp, dull, etc), the location, interventions, or outcomes for the 13 instances of pain at the 2 or 3 level. No assessment, intervention or outcome is charted when pain is rated above a 1 as directed on the treatment record. No doctor notifications or treatments for pain were documented in the nurse's notes in this period. The first physician notification regarding pain was documented on 4/28/14 at 9:27 AM after surveyor intervention. The first nurse's note regarding therapy intervention for pain occurred on 4/28/14 at 2:19 PM ("Asked therapy to see resident to find something to assist with pain") after surveyor intervention. Resident 6's weights (in pounds) recorded in the facility for 2014 are: 1/8/14 - 146.2 2/6/14 - 142.0 3/6/14 - 140.8 4/2/14 - 138.4 4/29/14 - 127.4 (11 pound, 7.9% loss since 4/2/14 which was prior to the fracture.) A Nurse's Note for 4/25/14 at 3:12 PM states: "FAX SENT TO: attending physician (MD O) REGARDING: change in condition decreased appetite and potential oral thrush. RESULT: Per (MD O) via fax, Resident is to be scheduled to see (NP L) for evaluation." There is no mention in this communication of multiple episodes of pain in the 2/3 range for Resident 6. There is no assessment or interview noted with Resident 6 to determine if decreased appetite was related to pain. There is no further charting prior to 4/28/14 that Resident 6 had been evaluated by NP L or that NP L had been made aware of the pain or decreased appetite. On 4/29/14 at 11:00 AM, Surveyor observed Resident 6 in her wheelchair in her room. Resident 6 had had 2 doses of the PRN [MEDICATION NAME]/[MEDICATION NAME] (4/28/14 at 6:00 PM, 4/29/14 at 7:14 AM.) When asked if she feels better, Resident 6 stated "yes." Resident 6 was eating a sausage biscuit and milkshake that her daughter brought in. Resident 6's daughter and Power of Attorney (POA) FM N was visiting. FM N stated that her mom had been having severe pain before today. FM N stated that the PM shift nurse had been good about getting the Tylenol scheduled right away but the Tylenol was not helping. FM N stated that she is concerned about falls with the new order for [MEDICATION NAME]. FM N stated that the Director of Nursing (DON) had been very good and had assured the family that the staff would do more frequent checks on Resident 6 to prevent falls. On 4/29/14 at 1:15 PM, Surveyor interviewed DON B. DON B stated that there should be a follow-up pain assessment when pain is noted in the record. There was no follow-up assessment on 4/28/14 at 4:26 AM for a pain rating of 3. DON B stated that the MD notification in the record at 9:27 AM was the follow-up that was completed. DON B was unaware that this follow-up occurred after surveyor intervention. DON B stated that the facility follows current standards for pain assessment and that assessments should include the onset, location, duration, quality/type of pain, interventions and outcomes. Surveyor asked for any additional information for pain assessments or treatments as the nurse's notes did not have assessments noted in the period from 4/18/14 to 4/28/14. Surveyor asked for any therapy records that might indicate that Resident 6 had had pain interventions in therapy prior to 4/28/14. On 4/29/14 at 2:10 PM, DON B provided copies of the documentation noted above. DON B stated that Resident 6 had not been seen in therapy for pain interventions prior to yesterday. DON B stated that things could have been done better yesterday. DON B stated that Resident 6 is not a reliable historian so her reports of pain from prior to yesterday might not be accurate. DON B stated that it is "not typical" for the long delay that they had in getting Resident 6 the pain medication. DON B stated that the doctor had been contacted numerous times throughout the day on 4/28/14 and that the facility was unable to take the medication from the contingency supply until MD O sent the script late in the day. DON B stated that RN K was relying on the judgment of NP L for not increasing pain medications due to the potential fall risk. However, there was no comprehensive assessment of pain or change to the "comfort, alteration" plan of care after the fracture of 4/7/14. There were no full pain assessments documented for multiple instances of moderate to severe/severe pain ratings documented 13 times prior to 4/28/14. There was no documentation of notification to MD O or NP L of 13 instances of pain in the moderate to severe range between 4/18/14 and 4/28/14. RN K did not notify the doctor or offer pain interventions (beyond those that were scheduled and proving ineffective) prior to surveyor intervention on 4/28/14. The facility staff did not follow facility policy for documenting pain assessment, treatment and interventions. The facility did not make attempts to "move up the [MEDICATION NAME] ladder" when pain was not controlled with Tylenol as directed in the facility policy. Resident 6 displayed changes in her ability to walk, to be out of bed, to participate in therapy, and a decrease in appetite and signficant weight loss during the period that her pain was not well-controlled. Example 2 Resident 17's [DIAGNOSES REDACTED]. Resident 17's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4/11/14 indicates Resident 10 is cognitively intact. On 4/30/14 Surveyor reviewed the bowel movement records in Resident 17's medical record. Resident 17 was discharged ,[DATE] and not available at the facility for an interview. Resident 17's bowel record states "none" for the following days: 4/6, 4/7, 4/8, 4/9, 4/10 and 4/11. Staff members did not follow up despite the absence of a bowel movement on record. Resident 17's care plan states a Problem: Potential for Comfort, Alteration related to: [MEDICAL CONDITIONS], advanced age and [MEDICAL CONDITION], history of urinary tract infections and history of constipation. Manifested by: Bladder incontinence, communication of pain description. Goal: Resident 17 will express feelings of comfort or of pain relief, within reasonable time after pain med administration, or non pharmacological interventions. Expressed satisfaction with pain med regimen. Intervention: "Monitor for soft formed bowel movements at least every 3 days. Administer laxative/stool softener as ordered. Encourage fluids. Resident 17 has physician's orders [REDACTED]. On 4/30/14 at 10:34 AM Surveyor spoke with License Practical Nurse (LPN) H. LPN H stated she was not aware that Resident 17 had gone more than three days without a bowel movement or had any issues with constipation while at the facility. LPN H stated that Resident 17's son assists her to the bathroom and does not tell staff if she has a bowel movement. Surveyor asked LPN H what is the process if a resident goes for 3 days or more without a bowel movement. LPN H stated that they would give Milk of Magnesia or a suppository as needed. On 4/30/14 at 1:03 PM Surveyor interviewed Director of Nursing (DON) B. DON B stated the facility does not have a policy for bowel monitoring and management. DON B stated it is his expectation that staff follow care plans. DON B stated that staff was not asking Resident 17 if she had a bowel movement, not recording it and nurses were not following up as they should have done. DON B stated there was no negative outcome, and there is potential for improvement. DON B stated "We need to beef up our system." Surveyor asked DON B what the process is if somebody goes for three days or more without a bowel movement. DON B stated the nurses get a report, on the third day we increase their fiber, on the fourth day we call the doctor and address the situation on an individual basis.

Based on observation, interview and record review the facility did not ensure that 2 residents (Residents 8 and 6) out of a sample of 8 residents reviewed for weight loss maintained acceptable parameters of weight and nutritional status. Resident 8's weight declined from 114.1 pounds on 1/2/13 to 91.8 pounds on 2/13/13. This was a loss of 22.3 pounds and a significant weight loss of 34% over a period of 42 days. The facility failed to assess Resident 8's dietary needs timely, weigh Resident 8 weekly, as per their policy, call the physician when Resident 8 had a weight loss, inquire about Resident 8's likes and dislikes timely, and did not replace the calories timely that Resident 8 lost by not eating her meals. Resident 6 receives all nutritional needs via a Gastrostomy tube. Resident 6 pulls apart his [DEVICE] during the infusion of the nutritional feedings. The practice of pulling part of his [DEVICE] from the nutritional feeding has resulted in a weight loss for Resident 6. This is evidenced by: The facility's policy for "Weight Monitoring", reviewed/revised 5/21/09, includes the following: Policy: It is the policy of [MEDICATION NAME] Rehab to weigh all new residents once a week for four weeks after admission and then monthly unless otherwise instructed by their physician or alternate. readmitted residents are to be weighted and measured again upon re-admission. ... Procedure: 2. Restorative Nursing will be responsible for obtaining all weight, updating and distributing current weekly and monthly weight sheets to the nursing department on a weekly basis. Weight sheets will be distributed on a weekly basis. The scales are checked at least monthly for accuracy. It is then the Nurse Manager's responsibility to document the weights on the Vital Signs flow sheet in the resident ECS chart weekly and prn (as needed). The nurse can compare previous weights and act accordingly regarding any significant weight gains or losses. 3. The Nurse Manager will be responsible for monitoring and reviewing the weekly weights for gains/losses three pounds or greater in one week with appropriate interventions to follow. Residents should be re-weighed for weight variances of 3 pounds or greater. Resident must be re-weighed. 6. If the re-weigh verifies that a significant weight loss or gain has occurred, the attending physician, dietary supervisor, and responsible party shall be notified with documentation completed. 7. Change in weight status shall be communicated by the Dietary Supervisor to the Consulting Dietitian on his/her next scheduled visit. 8. Review resident's overall condition, and consider fluid shift; disease process; and resident/family wishes for aggressive treatment. Discuss pertinent cases at weekly Wound/Weight Nutrition at Risk Committee meetings and determine what interventions have been implemented for significant change. Forward Nutrition at Risk recommendations to the Nurse Manager or designated nurse via Nutrition at Risk Committee Recommendation form. Involve physician, family Social Services and/or resident and add to the Care Plan. How to weigh a resident: 8. Note when weight has a discrepancy of greater than 3 pounds in one week and 5 pounds in one month from the previous weight. Inform supervisor and re-weigh. The facility's "Nutrition at Risk", Reviewed and Revised 10/06/09, includes the following: A. Nutrition / Hydration Risk Criteria, The resident may be considered Nutrition at Risk by evaluation of the Interdisciplinary Team or the Registered Dietician. The following guidelines are some of the indications of Nutrition at Risk but are not an absolute requirement for the resident to be considered Nutrition at Risk. May be triggered by one or more of the following: Significant weigh change of 5% in 30 days or 10% in 180 days ... Poor appetite or change in appetite, wound/pressure area ...Depression, Medication. B. Wound and Weight / Nutrition Risk Committee, 9. Significant weight loss is defined as any resident whose weight has decreased by 5% in one month, 7.5% in three months, 10% in six months. Additionally, these residents will be weighed weekly: Any resident who weighs 100 pounds or less and loses 5 pounds or more in one month. Any other weight loss/gain determined to be significant by the weight loss team. Example 1 Resident 8 was admitted to the facility 1/2/13 and readmitted [DATE] following a 7 day hospitalization . Resident 8's [DIAGNOSES REDACTED]. On 2/6/13 at 2:10 PM Surveyor reviewed the following information in Resident 8's medical record. Resident 8's care plan problem, dated 1/25/13, Alteration in nutrition (less than body requirements) weight loss, related to Alzheimer's or other dementia, inadequate intake, recent surgery, manifested by pressure ulcers, goal (Resident 8) will eat 25 - 50% of meals, drink fluids as offered, have no chewing problems, will have a gradual increase in weight from 99 pounds, dietary provide ordered diet, offer ice cream and hot chocolate with meals, offer replacement food, Registered Dietician consult, prn (as needed). Resident 8's CNA (Certified Nursing Assistant) care sheet, dated 2/5/13, indicates Resident 8 needs assist at times with meals. Resident 8's Admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/23/13, indicates Resident 8 scored a 10 on her BIMs indicating moderate cognitive impairment, has extensive assistance of 1 person for eating, is 62 inches tall, weighs 99 pounds and has had a weight loss of 5% or greater in the past month. Resident 8's MDS also indicates that there was no participation in the assessment by the resident, family or legal representative. Resident 8's diet order on 1/2/13 was Regular diet as tolerated. Resident 8's diet order on 1/17/13 was low cholesterol, low fat, no added salt. Resident 8's diet order on 2/4/13 was no added salt. Resident 8's medical record indicates her weights are as follows: 1/2/13 - 114.1 pounds, admission weight 1/8/13 - 103.2 pounds, 10.9 pound weight loss (entered into computer charting 1/12/13) 1/10/13 - discharged to the hospital following fall with fracture 1/17/13 - readmitted from hospital following surgical repair of fracture 1/15/13 - 108 pounds, 4.8 pound weight gain from 1/8/13 and a 6.1 pound weight loss from 1/2/13 (entered into computer charting 2/3/13) per Surveyor interview with Registered Nurse/Genesis Unit Manager (RN/UC) N on 2/12/13 at 9:30 AM this weight was actually taken on 1/17/13. 1/27/13 - 99.2 pounds, 14.9 pound weight loss (entered into computer charting 2/3/13) 1/29/13 - 95.8 pounds, 18.3 pound weight loss (entered into computer charting 2/3/13) 2/5/13 - 94.4 pounds, 19.7 pound weight loss (entered into computer charting 2/7/13) 2/13/13 - 91.8 pounds, 22.3 pound weight loss (per Surveyor telephone interview with Director of Nursing (DON) B 2/13/13 at 12:45 PM) Resident 8's nurse's notes included the following entries: 1/28/13, 2:22 PM, fax sent to attending physician, regarding labs, pharmacy recommendations, decreased I & O (intake and output), weight loss, dietary recommendations. 1/28/13, 5:15 PM, spoke with attending physician, regarding MD (medical doctor) called regarding faxes, spoke with MD regarding ... decline in weight, I & O, and meal intakes. New orders received and noted. 2/4/13, 11:11 AM, fax sent to attending physician, regarding to change diet to NAS (no added salt). New orders received and noted, 2/4/13 OK to change diet. Resident 8's medical record included the following faxes and telephone orders from her physician: 1/7/13, has a fluid filled blister lateral right heel ... 1/28/13: ... 4. Resident has had an 8.8 pound weight loss in the last week. Resident has decreased swelling in RLE (right lower extremity). Resident has poor intake. Dietary recommends health shake TID (three times a day) if no improvement after 3 - 4 days provide 1 can 2 Cal (a supplement drink) BID (twice a day) also. Any new orders? 1/28/13 telephone order: ... health shakes TID - supplement 1/31/13, May we have an order to change diet to regular NAS per dietary recommendations? Any new orders? Thank you. FYI: Resident had a 3.4 pound weight loss over the last week. Any new orders? Thank you. Physician Response: Which diet does dietary recommend Regular or NAS? Order for additional dietary supplement given yesterday. 2/8/13, ... 2. Resident has had a 19.7 pound weight loss since 1/1/13. Dietary recommends adding 1 can of 2 Cal supplement BID. Any new orders? Physician Response: ... 2. Recommendation accepted. Resident 8's Nursing Admission Assessment and History, dated 1/17/13, includes the following: Both heels have black areas on the outer aspect of heels. Resident 8's intake record indicated she did not always consume her meal entirely. Her meal intake is documented as follows: 1/2/13: Dinner 75% 1/3/13: Breakfast 50%, Lunch 75%, Dinner 100% 1/4/13: Breakfast 75%, Lunch 50%, Dinner 25% 1/5/13: Breakfast 100%, Lunch bites, Dinner 25% 1/6/13: Breakfast 100%, Lunch no documentation, Dinner 25% 1/7/13: Breakfast 75%, Lunch 25%, Dinner 25% 1/8/13: Breakfast 75%, Lunch 25%, Dinner Refused 1/9/13: Breakfast 25%, Lunch out, Dinner 0% 1/10/13: Breakfast 10%, Lunch 25%, Dinner Refused 1/17/13: Dinner bites 1/18/13: Breakfast 25%, Lunch 25%, Dinner 25% 1/19/13: Breakfast 50%, Lunch 50%, Dinner Refused 1/20/13: Breakfast bites, Lunch 0%, Dinner 25% 1/21/13: Breakfast 25%, Lunch bites, Dinner bites 1/22/13: Breakfast bites, Lunch Refused, Dinner 25% 1/23/13: Breakfast 75%, Lunch 25%, Dinner 25% 1/24/13: Breakfast 100%, Lunch bites, Dinner bites 1/25/13: Breakfast 50%, Lunch Refused, Dinner 25% 1/26/13: Breakfast bites, Lunch 75%, Dinner bites 1/27/13: Breakfast 75%, Lunch 25%, Dinner Refused 1/28/13: Breakfast 0%, Lunch 25%, Dinner Refused 1/29/31: Breakfast Refused, Lunch 25%, Dinner bites 1/30/13: Breakfast 25%, Lunch bites, Dinner 8 bites 1/31/13: Breakfast bites, Lunch 25%, 12:00 PM snack 50%, Dinner no documentation, 5:00 PM snack 50% 2/1/13: Breakfast bites, 8:00 AM snack 100%, Lunch bites, 12:00 PM snack 100%, Dinner 50%, 5:00 PM snack 100% 2/2/13: Breakfast 25%, 8:00 AM snack 100%, Lunch 50%, 12:00 PM snack 100%, Dinner Refused, 5:00 PM snack 100% 2/3/13: Breakfast 75%, 8:00 AM snack 100%, Lunch bites, 12:00 PM snack 100%, Dinner bites, 5:00 PM snack 100% 2/4/13: Breakfast 50%, 8:00 AM snack 100%, Lunch 25%, 12:00 PM snack 75%, Dinner 25%, 5:00 PM snack 100% 2/5/13: Breakfast 25%, 8:00 AM snack 100%, Lunch 25%, 12:00 PM snack 100%, Dinner Refused, 5:00 PM snack 100% 2/6/13: Breakfast 25%, 8:00 AM snack 100%, Lunch Refused, 12:00 PM snack 100%, Dinner Refused, 5:00 PM snack 100% 2/7/13: Breakfast Refused, 8:00 AM snack 100%, Lunch 25%, 12:00 snack 75%, Dinner no documentation, 5:00 PM snack 100% 2/8/13: Breakfast 50%, 8:00 AM snack 100%, Lunch 25%, 12:00 PM snack 75%, Dinner Refused, 5:00 PM snack 100% 2/9/13, Breakfast 100%, 8:00 AM snack 100%, Lunch 75%, 12:00 PM snack 100%, Dinner bites, 5:00 PM snack 100% 2/10/13: Breakfast 75%, 8:00 AM snack 100%, Lunch bites,12:00 PM snack 100%, Dinner bites, 5:00 PM snack 100% 2/11/13: Breakfast 25%, 8:00 AM snack 100%, Lunch 25%, 12:00 PM snack 100%, Dinner 25%, 5:00 PM snack 100% The 8:00 AM, 12:00 PM and 5:00 PM snack documented above was Health Shake. The following are the assessments and progress notes written by the Dietician and Dietary Manager. Initial Assessment, completed by the Dietary Manager, 1/11/13, included the following information: Height 62 inches. Weight 114 pounds. Diet order: Regular. Comments on meal intake: 25 - 100%. Communication/Cognitive status: confused. Chewing/swallowing: edentulous. Feeding ability: self with setup. Skin: surgical wound. Notes: (Resident 8's) weight is 114 pounds. She is able to feed herself and is able to make likes and dislikes known. No chewing or swallowing problems are noted, though endentous, regular diet. Appetite 25 - 100%. She does like ice cream as a snack. She tends to wander on her unit. Monitor weight weekly or as ordered, offer alternatives for refused foods, encourage fluids and food and monitor healing of surgical wound. Initial Dietary Review, completed by a Dietician, dated 1/24/13, included the following information: wt. (weight) is stable, current diet order: low fat, low cholesterol, NAS. Risks: [MEDICAL CONDITIONS]. Appetite: poor appetite. Height: 62 inches. Weight: 114.1 pounds. BMI: 20.9. BMI Class: Low for age. IBW: 110 pounds. %IBW 104%. Estimated Nutrition Needs: Energy 1381 - 1933 kcals. Protein: 78 - 104. Fluid: 1297 ml. (Resident 8) is present for recovery from recent surgery to her right distal femur. She is currently on a low fat, low cholesterol, NAS diet and is also receiving [MEDICATION NAME] sulfate, Vitamin D, MVI (multivitamin), and Vitamin C supplements. Eats independently at meals. Intake has been poor, averaging only 26% consumption of foods with 630 fluid daily at meals. Surgical wound on bilateral leg present in addition to open areas on left and right lateral heels. Low HGB/HCT (hemoglobin/hematocrit) is low. Low HGB/HCT, open skin areas, inadequate intake and recent surgery all indicate increased protein/energy needs. Weight is low for age; [MEDICAL CONDITION] is also noted. Without [MEDICAL CONDITION], resident is at a greater risk for being underweight. Recommend providing 4 oz. (ounces) Health Shake tid with meals. If appetite and wts do not improve, also recommend providing 1 can 2Cal bid in between meals. Recommend liberalizing diet to NAS. ... Monitor wts, fluid status, open skin area, labs as available. Will continue to monitor prn (as needed). Readmission note, completed by the Dietary Manager, dated 1/25/13, included the following information: Weight: 99 pounds. Comments on meal intake: 25% or less. Communication/cognitive status: alert x 1, confused. Feeding ability: self with set up/needs encouragement and assistance. Skin: surgical wound/open area bilateral heels. Notes: (Resident 8's) weight has decreased 8.8 pounds since admission, down 14.9 pounds since original admission. Current weight is 99.2 pounds. Weight loss likely related to reduced [MEDICAL CONDITION] and inadequate intakes of food and fluids. (Resident 8) is alert x 1, poor intakes at meals. ... Dietary Progress Note, completed by the Dietician, dated 1/31/13, included the following information: Weight loss. Weight: weight is decreasing. Current diet order: cardiac. Risks: severe wt loss, underweight BMI. Appetite: very poor appetite. (Resident 8) has triggered for severe wt loss. Resident has lost 14.9 pounds in 1 week, current wt of 99.2 pounds brings resident BMI of 18.2. BMI indicates underweight status. (Resident 8) is currently receiving a low fat, low cholesterol, NAS diet with 4 oz. Health Shake tid. Intake at meals has been very poor - resident is refusing most meals and when she does eat usually consumes 25% of foods provided. Intake of supplements has been good, resident averaging 25 - 100% intake. admitted with [MEDICAL CONDITION], wt loss may be related to fluid loss from [MEDICAL CONDITION]. Increased energy needs related to open areas to bilateral heels. Recommend liberalizing diet to NAS. Recommend encouraging resident to eat meals and finish supplement. Small portions to encourage intake. Recommend providing an additional 60 cc (cubic centimeters) 2Cal tid in between meals to supplement intake. With encouragement, smaller portions, and additional supplement, resident's weight is expected to increase. 1/31/13, 12:01 PM, written by the Dietician, Update to previous note: 2Cal supplement not recommended for time being. Will try mixing Health Shake with ice cream to encourage po (oral) intake. Nursing staff noted that meds (medications) will be changing which is expected to increase appetite. Will continue to monitor wts and intake; if wts and appetite do not increase from current interventions will consider additional 2Cal supplement. 2/7/13, 2:04 PM, written by the Dietary Manager, 14 day note. (Resident 8's) weight is 96 pounds, continues to decline. She is able to feed herself, needs encouragement. Her appetite remains poor and intakes are inadequate. Diet has been liberalized to NAS. ... 2/7/13, 2:52 PM, written by the Dietician, (Resident 8) triggered for significant wt. loss. (Resident 8) continues to lose wt. current wt. of 94.4 pounds marks 19.7 pound loss (17.3%) brings BMI to 17.6, which is underweight. ... Intake of meals has been very poor, averaging 0 - 25%. However, resident has tolerated Health Shake supplement very well, usually consuming 100% of supplement when offered. Original request for additional 2Cal supplement was declined by MD. Spoke with nursing staff-mentioned that this was likely declined since Health Shake order had recently been started and MD wanted to determine whether resident would tolerate supplement well. ... Recommend providing 1 can 2Cal bid and monitor tolerance. For meals, recommend smaller portions and fortified foods. Also, liberalize diet from cardiac to NAS to encourage intake at meals. ... On 2/11/13 at 5:25 PM Surveyor interviewed Family Member (FM) X. FM X is Resident 8's HealthCare Power of Attorney. FM X stated he was at the facility today (2/11/13) to visit Resident 8. FM X stated facility staff told him that Resident 8 had lost 20 pounds. FM X stated that facility staff had asked what Resident 8's food likes and dislikes were. FM X stated this was the first time the facility had asked him about Resident 8's likes and dislikes. On 2/12/13 at 9:30 AM Surveyor interviewed Registered Nurse/Genesis Unit Manager (RN/UM) N. RN/UM N stated the Restorative Certified Nursing Assistants (RCNA) collect the weights. RN/UM N stated the RCNAs have a printed form with all the residents' names on, collect and document the weights on the form and the following day give the form to the nurse. RN/UM N stated the weights on the Genesis Unit are collected on Tuesdays, unless the resident refuses, then they collect the weight another day. RN/UM N stated that the physician should be updated with any weight gain or loss of 2.5 pounds the same day the weight was collected. RN/UM N stated Resident 8's physician should have been contacted when Resident 8's weight first started to decline. RN/UM N stated Resident 8 was on Rapid Rehab wing when she was first admitted and came to the Genesis Unit on 1/17/13. On 2/12/13 at 10:25 AM Surveyor interviewed Registered Nurse/Rapid Rehab Unit Manager (RN/UM) O. RN/UM O stated new residents have weekly weights taken on Rapid Rehab on Wednesdays. RN/UM O stated Resident 8 was admitted after having surgery and had [MEDICAL CONDITION]. On 2/12/13 10:45 AM Surveyor again interviewed RN/UM O. RN/UM O stated Resident 8 was admitted to the facility on [DATE], and had a weekly weight on 1/8/13. RN/UM O stated Resident 8 was discharged from the facility to the hospital on [DATE]. RN/UM O stated Resident 8's weekly weight information was not given to her until after Resident 8 was discharged from the facility and since Resident 8 was discharged from the facility she did not address it. On 2/12/13 at 11:15 AM Surveyor interviewed RCNA P. RCNA P stated that there are two Restorative CNAs, RCNA P and another. RCNA P stated that the Restorative CNAs are responsible for collecting the weights for all the residents in the building. RCNA P stated the weights are documented on the weight sheets. The weight sheets are taken to the weekly Weight/Wound Meeting held every Thursday and given to the Unit Managers then. RCNA P stated if there is a weight gain or loss the resident is re-weighed the same day and the nurse on the unit is informed verbally, the weight is written on the weight sheet and given to the Unit Manager on Thursday. On 2/12/13 at 2:00 PM Surveyor interviewed Director of Nursing (DON) B. DON B stated Resident 8's weight that was collected on 1/8/13 should have been reported to the physician on 1/8/13. DON B stated Resident 8 was readmitted on [DATE] and her weight was up 4.8 pounds from the 1/8/13 weight. DON B stated that the facility did put interventions in place after Resident 8 was weighed on 1/27/13 and was noted to have lost weight again. On 2/12/13 at 2:45 PM Surveyor interviewed Dietary Manager (DM) E. DM E stated the Dietician does the initial detailed dietary assessment for all residents. DM E stated she does the MDS and Quarterly dietary assessments. DM E stated she reviews the weight sheets at the weekly Weight/Wound Meeting held every Thursday. DM E stated Resident 8's weight may have been discussed on Thursday 1/10/13, but she was in the hospital at that time It is important to know Resident 8 was discharged to the hospital at 6:15 PM on 1/10/13. DM E stated she did the initial dietary MDS assessment for Resident 8. DM E stated that when Resident 8 was readmitted her weight was down 6 pounds from her initial admission on 1/2/13 but was up 5 pounds from when she was discharged [DATE]. DM E stated her weight was addressed on 1/31/13 when her weight from 1/25/13 was discussed at the weekly Weight/Wound Meeting. DM E stated her weight was noted to be down 14.9 pounds. DM E stated she does not make recommendations, the Dietician does. The Dietician is in the building on Thursday only. DM E stated she refers any weight issues to the Dietician and he will assess and make recommendations. DM E stated she passes out the recommendations to the nursing staff on Fridays. DM E stated she had not met or talked with Resident 8's family regarding likes and dislikes. DM E stated nursing had talked with the family and was not sure if the nursing staff had asked about likes and dislike. Resident 8 was admitted on [DATE] weighing 114.1 pounds, her weight on 1/8/13 was 103.2 pounds. The weight loss was not addressed by the facility and the physician was not contacted. During this time Resident 8 continued to lose weight. Resident 8 did not have a Dietary Assessment completed until 1/24/13 surgically repaired, developed pressure wounds on her heels and no interventions were put and a dietary care plan was not written until 1/25/13. Resident 8 was weighed on 1/27/13 weighing 99.2, her physician was contacted and Health Shakes were ordered TID, however Resident 8's intake was between 0 - 25%. Resident 8 continued to lose weight. Example 2 Resident 6 was admitted to the facility on [DATE]. Resident 6 has the following diagnoses; Depression, Gastrostomy Tube (also called [DEVICE], is a tube inserted through the abdomen that delivers nutrition directly to the stomach.), [MEDICAL CONDITION], [DIAGNOSES REDACTED], Dysphagia, [MEDICAL CONDITIONS] Resident 6's care plan titled Alteration in Nutrition, dated 3/4/09, Related to: Potential for Aspiration related to feeding tube placement, and history of removing [DEVICE], tendency to gain weight... Approaches: 1. Suction as needed... 2. Monitor for signs and symptoms of aspiration...3. Administer medications... 4 Draw Laboratory test as ordered... 5. Measure feedings for accuracy... 6. Provide oral care... 7. maintain Resident 6 Nothing by mouth (NPO)... 8. Vital signs... 9. Approach added 9/21/12; Registered Dietician as needed. Assess nutritional status and Hydration. ... Goal: Resident 6 will not have aspiration and will tolerate feeding tube daily. Resident 6's care plan does not address Resident 6's weight loss or Resident 6's pulling apart his [DEVICE] feeding. Resident 6's current physician order [REDACTED]. Resident 6's Minimum Data Set (MDS), dated [DATE], states Resident 6 receives his nutritional approach via Tube Feeding. Resident 6 receives 51 to 100% of his nutritional needs via the tube feeding. Resident 6's Care Area Assessments (CAAs),dated 12/14/12, states Current Eating Pattern: Resident 6 receives a tube feeding. Risk Factors: Resident 6 is at nutritional risk. Potential for skin breakdown, refuses tube feeding at times. Monitor weekly weights.. Continue current plan... Reason for Tube feeding: Resident 6 is unable to swallow or to eat food and unlikely to eat within a few days due to physical problems in chewing and swallowing... Diagnostic conditions: Anxiety, Depression, resistive to feeding on occasions, will attempt to or will dislodge [DEVICE] requiring re-insertion... Resident 6's nursing notes, dated 1/1/13 at 3:08 PM, Behavior of resist cares: Resident 6 was resistive to cares, pulls out TF port at times will push hands away at times to prevent cares, medications or feeding... Resident 6's Nursing notes, dated 1/2/13 at 1:34 PM, Fax sent to Resident 6's Physician regarding updated on 3 pound weight loss in one week... Resident 6's Nursing notes, dated 1/11/13 at 5:04 AM, states Resident 6 refused Fibersource nutritional supplements via the [DEVICE]. Resident 6's Nursing notes, dated 1/15/13 at 12:23 AM, states Resident 6 refused Fibersource nutritional supplements via the [DEVICE]. Resident 6's Nursing notes, dated 1/15/13 at 12:23 AM, states Resident 6 refused Fibersource nutritional supplements via the [DEVICE]. Resident 6's Nursing notes, dated 1/19/13 at 12:03 AM, states Resident 6 refused Fibersource nutritional supplements via the [DEVICE]. Resident 6's Nursing notes, dated 1/22/13 at 1:23 AM, states Resident 6 TF apart. Small amount of feeding noted on Resident 6's bed, unable to measure amount lost. Resident 6's Nursing notes, dated 1/22/13 at 12:13 AM, states Resident 6 refused Fibersource nutritional supplements due to Resident 6 pulled out [DEVICE]. Resident 6's Dietary progress note, dated 1/24/13, states Resident 6 has lost 8.0 pounds (4.7% of body weight).. Nursing staff has also noted that Resident 6 is pulling apart TF recently. Weight loss is likely to this... Current order is appropriate, recommend monitoring and providing encouragement during feedings to ensure intake. Resident 6's Nursing notes, dated 1/25/13 at 4:43 AM, states Resident 6 refused Fibersource nutritional supplements due to Resident 6 pulled tube apart during feeding. Majority of Resident 6's feeding is on the floor. Resident 6's physician progress notes [REDACTED]. Resident 6 seen and examined in room very alert and awake... Resident 6 agrees very depressed, pulls out tube feeding secondary to bot wanting to be alive... Impression: Resident 6 with weight loss with refusal/pull out tube feeding at times... Plan:... @ Await dietary recommendation... Monitor weight/refusal of tube feeding... Resident 6's Nursing notes, dated 1/29/13 at 9:28 PM, Fax sent to Resident 6's weight loss of 4.2 pounds in one week and Resident 6 has been pulling tube feeding apart... Resident 6's Nursing notes, dated 2/3/13 at 1:10 AM, states Resident 6 pulled out [DEVICE]... Resident 6's Nursing notes, dated 2/9/13 at 12:03 AM, states Resident 6 refused Fibersource nutritional supplements via the [DEVICE]. Resident 6 attempting to pull out [DEVICE]. On 2/12/13, at 10:25 AM PM, Surveyor spoke with Director of Nursing (DON) B regarding Resident 6's current Nutrition during [DEVICE] feeding and the intervention by the Dietician to monitor to ensure intakes. DON B stated Resident 6's has no new approaches to prevent or to monitor Resident 6 to ensure he receives his nutritional feedings or to monitor Resident 6 from pulling apart the [DEVICE] during Nutritional supplement intake. No further information was provided to Surveyor . On 2/12/13, at 11:05 AM, Surveyor spoke with Licensed Practical Nurse (LPN) C regarding Resident 6's nutrition during [DEVICE] feeding and changes made to Resident 6's plan of care. LPN C stated Resident 6 continues to pull apart [DEVICE] at times. LPN C also stated nurses do not remain in the room to monitor or ensure Resident 6 receives his entire Nutritional [DEVICE] feeding. LPN C continued to state no changes have been made for Resident 6's [DEVICE] feedings.

Based on observation, interview, and record review, the facility did not ensure that based on the comprehensive assessment of a resident, a resident who enters the facility without pressure ulcers does not develop pressures ulcers unless the individual's clinical condition demonstrates that they were unavoidable, and that a resident having pressure ulcers receives the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 1 of 10 residents reviewed for pressure ulcers (Resident 10). Resident 10 entered the nursing home without a pressure ulcer, Resident 10 had a previous history of pressure ulcers and Resident 10 acquired a stage 3 pressure ulcer to her left Ischial tuberosity. The facility did not adequately care plan, and implement interventions for Resident 10's pressure ulcer risk and care. This is evidenced by: An article entitled "How much time does it take to get a pressure ulcer?" published by Ostomy Wound Management in October 2008 indicated severe pressure ulcers and deep tissue injury are associated with high mortality rates, longer hospital stays and costly treatment. Time is a critical factor in commonly employed measures to prevent pressure ulcers and deep tissue injury. Findings from three model studies conducted indicated pressure ulcers in subdermal tissue under bony prominence very likely occur between the first hour and four to six hours after sustained loading. Resident 10 was admitted to the facility on [DATE] with the following diagnoses; Dementia and [MEDICAL CONDITION]. Resident 10's pressure ulcer risk assessment, dated 1/10/11, indicates the following; Mental status: Resident 10 is lethargic, disorientation and slow to respond. Ambulatory and mobility: Resident 10 is chairfast and non ambulatory, Transfer with assist. Bladder and bowel: Resident 10 is incontinent and has no control of her bowel or bladder. Nutrition and weight: Resident 10's appetite is good and eats 50% of her meals... Resident 10's total risk score is 11 which indicates Resident 10 is at high risk for pressure ulcers. Resident 10's comprehensive Minimum Data Set (MDS), dated [DATE], indicates the following: Resident 10 is at risk for skin breakdown. Resident 10 is cognitively impaired and has moderately impaired decision making. She needs extensive assist of 1 with bed mobility and eating. Resident 10 also needs total dependent assist with transfers, and toilet use. Resident 10 is always incontinent of urine. In addition, Resident 10 had no unhealed pressure ulcers during this assessment period. Resident 10's Care Area Assessments (CAAS), dated 1/21/11 indicate, Pressure ulcer assessment: Resident 10 has no pressure ulcers. Risk Factors: Resident 10 requires staff assistance to move sufficiently to relieve pressure over any one site confined to a bed or chair most of the time. Resident 10 requires a pressure reducing mattress or seat cushion. Resident 10 requires regular schedule for turning and repositioning...Description of problem: Resident 10 is at high risk for pressure ulcers per her pressure Ulcer Assessment. Resident 10 is dependent on staff to assist her in making positional changes while in her wheel chair or in her bed... Resident 10 is to be assisted with repositioning every 2 hours... Resident 10 is totally incontinent of bowel and bladder and needs assist with perineal hygiene, applying a skin barrier and changing incontinent briefs to manage her incontinence... Although the CAA indicates that Resident 10 requires pressure reducing seat cushion the facility did not implement this measure. Resident 10 has an E-Z transfer Slider Pommel cushion in her wheelchair. The manufacturer's information on this product states: Purpose: Skil-Care E-Z transfer Slider Pommel is intended to prevent sliding in the wheel chair by maintaining pelvic neutrality. E-Z transfer Pommel Slider Pommel - 1. Comfortable foam padded pommel maintains pelvic neutrality. 2. Keeps legs in abduction. 3. Velcro attached pommel removes for easy transfer. 4. May be used with or without a cushion. 5. Covered in wipe clean nylon. The Pommel cushion also limits forward movement of the hips by keeping the legs in an abduction position. There is no indication that this cushion has pressure reducing qualities. Resident 10's nursing note, date 3/17/11 at 3:53 PM indicates Resident 10 has a stage 2 pressure ulcer to her coccyx area. Resident 10's nursing notes, dated 3/20/11, at 2:58 PM indicate Resident 10's physician was updated due to Resident 10's condition declining, and Resident 10's weight loss. Resident 10's Physician also updated on Resident 10's refusal of medication and refusal to eat. (It is important to note with the decline and the change in condition to Resident 10 and the presence of a pressure ulcer there was no change in Resident 10's care plan for Resident 10's wheel chair cushion.) Resident 10's nursing notes, dated 3/28/11, at 3:02 PM indicate Resident 10's pressure ulcer to her coccyx has full thickness of skin loss and is current a stage 3 with the pressure ulcer tissue is slough and yellow in color. There were no changes to Resident 10's wheel chair cushion. Resident 10's pressure ulcer risk assessment, dated 4/12/11, indicates Resident 10 is at high risk for pressure ulcers. Resident 10's nursing note, dated 4/12/11, at 4:36 PM indicates Resident 10 has 3 non blanchable pressure ulcers stage 1 to her left shoulder. (It is important to note Resident 10 did not receive a change in her care plan for her wheel chair cushion with a current increase in pressure ulcers and a decrease in her nutritional intake to help prevent pressure ulcer and promote healing.) Resident 10's nursing note, date 4/13/11, at 12:55 PM indicates the following... Resident 10 was seen for weekly wound (pressure ulcer) rounds. Resident 10 scoots down in her wheel chair favoring her left side, and prefers to lie on her left side when in bed. Resident 10 has a Stage 3 pressure ulcer to her coccyx... Resident 10's nursing notes, dated 6/1/11, at 8:05 AM indicates Resident 10 has a healing full thickness of skin loss (stage 3) to her coccyx pressure ulcer. Resident 10 also has a dressing clean dry and intact to her left hip and left shoulder for protection. (It is important to note with a decline in nutrition, current history of pressure ulcer and multiple areas of skin breakdown Resident 10 care plan was not changed for her pommel cushion to her wheel chair.) Resident 10's pressure ulcer risk assessment, dated 7/11/11, indicates Resident 10 is at high risk for pressure ulcers. Resident 10's care plan potential for injury, dated 9/8/11, indicates the care plan is related to: Unsteady gait, impaired vision, history of falls, non-ambulatory, cognitive decline and unavoidable open area. Nurse aides are to provide periods of rest for Resident 10 in her bed after meals and as needed. Resident 10 is to be up in the wheel chair for meals only and repositioned from side to side when in bed. Resident 10's Wound evaluation report indicates the following: The pressure ulcer site is the left Ischial tuberosity. On 10/3/11 type of wound is indicated as pressure. The wound stage is documented as an unavoidable Stage 3 wound base color is yellow. There are no changes to Resident 10's care plan for the type of device Resident 10 is sitting on in her wheel chair (E-Z transfer Slider Pommel). Resident 10's nursing note, dated 10/3/11, at 1:19 PM indicates the following; Skin problem; open area (pressure ulcer). Pressure ulcer: Resident 10 has an unavoidable full thickness skin loss exposing the subcutaneous tissue presents as a deep crater (pressure ulcer stage 3). Location: the left tuberosity... Skin treatment: Has a pressure relieving device to her chair (Resident 10 has a pommel cushion in her wheel chair which does not relieve pressure.) Resident 10 has several protective dressings over bony area. (History of pressure ulcers) Comments: Resident 10's pressure ulcer is unavoidable (it is important to note a wheelchair pressure relieving device is not in place for Resident 10 at the time of this pressure ulcer.) Resident 10's skin has frail skin and has poor nutrition as Resident 10's appetite is poor. Have instructed staff to only have Resident 10 up for meals and reposition her from side to side when in bed have orders for Occupational Therapy to evaluation and treat for wheel chair positioning as resident ability to it up in wheel chair has declined... No changes were made to Resident 10's wheel chair non pressure relieving cushion. Resident 10's Minimum Data Set (MDS), dated [DATE], indicates the following: Resident 10 is at risk for skin breakdown. Resident 10 is cognitively impaired and has severe impaired decision making. She needs extensive assist of 1 with bed mobility and eating. Resident 10 also needs total dependent assist with transfers, and toilet use. Resident 10 is always incontinent of urine. In addition, this MDS indicates Resident 10 had 1 unhealed pressure ulcer at a stage 3. A stage 3 has a full thickness loss of subcutaneous fat which may be visible but bone, tendon, and muscle are not exposed. Slough may be present but does not obscure the depth of the tissue loss. Resident 10's nursing note, dated 11/14/11, at 2:51 PM indicates Resident 10's left Ischial tuberosity pressure ulcer appears scabbed wound tissue is blackish red in color (Unstageable according to the National Pressure Ulcer Advisory Panel standards of practice). Resident 10's pressure ulcer is larger in size than last week measuring 1 cm by 1 cm by 0.1 cm deep... Skin treatment: Resident 10 has a pressure relieving device for her chair, and a pressure relieving device for her bed. Comments: Resident 10 is at risk for further unavoidable pressure ulcers due to her appetite is poor and over all health condition. (It is important to note Resident 10 remains on the pommel cushion to her wheel chair the device is not pressure relieving device.) Resident 10's Certified Nursing Assistant (CNA) care sheet, dated 11/21/11, indicates Resident 10 is a 2 assist with a Hoyer electric lift, is at high risk for skin breakdown. Resident 10 has a Pommel cushion to her wheel chair and a lipped mattress on her bed. On 11/22/11 at 7: 28 AM Surveyor observed Resident 10 up in her wheel chair with pommel cushion in place; no other cushion was present under or on top of the pommel cushion in Resident 10's wheelchair. On 11/22/11 at 11:30 AM Surveyor Spoke with CNA F regarding Resident 10 and repositioning schedule CNA F stated Resident 10 was checked and changed this morning and returned to Resident 10's chair. CNA F stated Resident 10 does not get placed in to bed until after lunch and that Resident 10 did not lie in bed this morning except to do a check and change of her depends. Resident 10 was not up for meals only as indicated in her care plan. On 11/22/11 at 1:00PM Resident 10 observed Resident 10 transferred to her bed by CNA F. CNA F removed Resident 10's pants to expose her legs and her buttock. Resident 10 was observed to have a pressure ulcer measuring approximately 2 centimeter (cm) by 2 cm on her left Ischial Tuberosity. The pressure ulcer area was yellow slough in color approximately measuring 1.5 cm by 1.5 cm in the center of the pressure ulcer with a red surrounding area measuring approximately 0.5 cm by 0.5 cm. The dressing to the left Ischial tuberosity was removed by CNA F when the incontinent depends was removed. (Resident 10 was up in her wheel chair, and although provided with incontinence care was otherwise up in the wheelchair for approximately 6 hours, contrary to the care plan intervention of up for meals only. On 11/22/11 at 1:00 PM Resident 10 also was observed to have a red the [MEDICATION NAME] dressing rolled up in half to Resident 10's coccyx area. Resident 10's coccyx presents with a red macerated area measuring approximately 2 cm by 2 cm to her coccyx area. In addition, CNA F indicated she would need to inform Licensed Practical Nurse (LPN) E of the removal of the [MEDICATION NAME] dressings from the coccyx area and the pressure ulcer area of Resident 10. Resident 10 was observed by Surveyor to be in bed resting on a lipped mattress. On 11/22/11 at 3:40 PM Surveyor spoke with LPN E regarding Resident 10's [MEDICATION NAME] dressing to her pressure ulcer on the left tuberosity. LPN E stated CNA F did not inform him that Resident 10's dressings were not in place when she laid Resident 10 in bed at 1:00 PM. LPN E stated he did not replace Resident 10's dressing to her pressure ulcer area. LPN E also stated he was not aware the dressing came off Resident 10's pressure ulcer area. In addition, LPN E indicated the CNA's are to report all new skin breakdown areas and any treatments or dressings that may have fallen off during the course of the CNA's cares to the nurse. (Resident 10 has been lying in bed with out a dressing for 1 1/2 hours.) Resident 10's nursing note, dated 11/22/11, at 4:13 PM indicates LPN E went back to Resident 10's hall and checked all dressings on Resident 10. The coccyx dressing was rolled up and no open area was noted... The dressing on the left Ischial tuberosity had rolled up and was off Resident 10. Resident 10's pressure ulcer was cleansed and measured 1.4 cm by 1.6 centimeter with a yellow base and the wound nurse was contacted... The pressure ulcer was cleansed and assessed 3 hours after the pressure ulcer became uncovered. Resident 10's nursing note, dated 11/22/11, at 4:30 PM indicates Resident 10's pressure ulcer was seen today per routine wound rounds and at the request of the Unit Manager (LPN E). Resident 10's left Ischial tuberosity stage 3 pressure ulcer measure 1.6 cm by 1.4 cm with yellow slough. The healing process is worsening and becoming larger with the base of the wound yellow in color. Skin treatment: Resident 10 has a pressure relieving device for her chair and has a pressure relieving device for her bed... (It is important to note Resident 10 has a pommel cushion to her chair a non pressure relieving device.) Resident 10's nursing note, dated 11/23/11, at 3:04 PM indicates Resident 10's lipped mattress was removed and a low air loss mattress (a pressure relieving mattress) was placed on Resident 10's bed. Resident 10 no longer moves around in her bed and Resident 10 is reposition every 2 hours. There is a low risk Resident 10 will roll out of bed but a higher risk that Resident 10's pressure ulcer will get worse if she continues with the lipped mattress. On 11/28/11 at 7:00 AM Surveyor observed Resident 10 sitting up in her wheel chair. Resident 10's cushion was observed to be a pommel cushion a non pressure relieving device. Resident 10 did not have a pressure reducing or relieving cushion in her wheel chair other then the pommel cushion. On 11/29/11 at 7:00 AM Surveyor observed Resident 10 sitting in her wheel chair. Resident 10's wheel chair cushion was a pommel cushion. Resident 10 was observed up in her wheel chair until 11:00 AM when Resident 10 was placed in bed on her left side. Resident 10's current stage 3 pressure ulcer is on Resident 10's left side. Resident 10 was up in a chair for 4 hours and did not return to bed right after the breakfast meal, per the care plan. On 11/29/11 at 1:15 PM regarding Resident 3's stage 3 pressure ulcer. DON B indicated Resident 10 remains on the pommel cushion and no changes have been made to the plan of care. DON B also indicated Resident 10's pressure ulcer area was unavoidable due to decline in condition and poor appetite. DON B indicated there was not a pressure relieving cushion on Resident 3's wheel chair and indicated that a pressure relieving device for Resident 3's bed was placed last week, on 11/23/11. Resident 10's wheel chair cushion was assessed for positioning but not for pressure reducing or relief. No further information was given to Surveyor .

Based on record reviews, interviews, and observation, the facility did not ensure that 1 of 10 sampled residents (Resident 2) was provided the necessary supervision and assistive devices to prevent falls. Resident 2 fell on [DATE] and the facility did not implement therapy or diabetic shoes as indicated. Resident 2 fell on [DATE] and fractured his hip. Documentation states his wheelchair was too small and he did not use it appropriately which contributed to the fall. Resident 2 was observed on 11/22/11 sitting on his bed with his wheelchair in reach and self transferring on 11/28/11. Resident 2's current care plan states his wheelchair should be out of his room and a floor mat in place when in bed and his care plan indicates he requires 1 staff and EZ stand to assist him with transfers. As evidenced by: The facility's "Falls Policy and Procedure" with revision date of 10/1/10 states the facility will identify residents with fall incidents, attempt to identify root causes of falls, and develop interventions to prevent recurrence of incidents. Under procedure it states 2. b. Determine a potential root cause or root causes of the fall, c. develop an intervention to address that root cause or other possible root causes, evaluate those interventions, change those interventions as necessary to promote the health and well being of the residents. 15. All relevant information regarding the fall will be entered into the residents medical record. Under Additional information Developing Reasonable Interventions for Fall Prevention: Each time a resident falls, there must be a logical root cause analysis of the fall incident. This will include gathering and interpretation of the data around the cause of the fall. This will include a preliminary evaluation of the residents' medical condition, the environment, and the resident's activity at the time of the fall. The resident will be asked if they are aware of what happened. Based on this information an intervention will be formulated and placed in the resident's medical record. The purpose of the Falls Policy is to promote safety of residents who have fallen to prevent injury and recurrence of falls. Resident 2 was admitted to the facility on [DATE]. Resident 2 is 86 and has current [DIAGNOSES REDACTED]. Resident 2's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 12/23/10 indicates he was moderately cognitively impaired, was independent with bed mobility and needed supervision only with transferring. The facility did a fall assessment stating Resident 2 was at risk for falls on 12/28/11. Resident 2's medical record states he fell ambulating pushing his wheelchair to the bathroom on12/30/10. On 3/16/11 Resident 2 fell from his bed. One of the interventions was to have physical therapy (PT) evaluation Resident 2 for bed positioning. Resident 2's Therapy Screen Report dated 3/16/11 states PT/OT (Occupational Therapy) intervention not appropriate at this time due to Resident 2 refusal to participate in therapy and no therapy recommendations made. On 11/29/11 at 3:30 PM Surveyor interviewed Regional Therapy Director (RTD) G and OT H who stated that a Therapy Screen is not an evaluation. RTD G stated that a screen involves viewing a resident, reviewing a resident's medical documentation, talking to CNAs (certified nursing assistant), nurses or other staff and comfortably saying that she does not see anything to warrant an evaluation or a resident does need an evaluation. OT H stated that a screen is not hands on, but an evaluation would be hands on such as measuring a wheelchair, making sure resident joints are positioned properly and identifying deficits such as poor positioning. Resident 2's medical record states on 4/19/11 Resident 2 fell reaching for his wheelchair. The new intervention on 4/19/11 was an OT referral. A late entry on 4/25/11 for 4/20/11 stated that it was being investigated for Resident 2 to receive diabetic shoes. Resident 2's medical record states on 4/23/11 Resident 2 fell transferring from his bed to his wheelchair. It states under possible cause that Resident 2's wheelchair is too small and sits too low to the ground for Resident 2. Resident 2 reported right hip pain after the fall and was admitted to the hospital with [REDACTED]. The facility Incident Witness Statement written 4/23/11 by RN I states, Did you notice anything that could have caused the incident (fall)? Resident 2's wheelchair is too small/low to the ground for Resident 2. What could be done to prevent reoccurrence? A new larger wheelchair (for Resident 2). What did (Resident 2) say about this incident? He (Resident 2) was trying to get up and ready for the day but he tipped over in/on his wheelchair. (Resident 2) reported hitting his head on the door or floor (he wasn't sure), hip pain and he stated "I think it's broken." The facility Incident Witness Statement written 4/23/11 by RN J states after Did you notice anything that could have caused the incident (fall)? Resident (2) uses his wheelchair for a walker and the wheelchair really rolls fast. Was there anything unusual about this incident? Resident (2) just fell (4/19/11) days ago regarding his wheelchair. He doesn't seem to handle his wheelchair very well and uses it for a walker. What do you think could prevent reoccurrence? Different wheelchair, more stable wheelchair. He (Resident 2) does not want to use a walker. An update on Resident 2 falls dated 4/25/11 given by DON (Director of Nursing) B to Surveyor states Resident 2 fell on [DATE] at 4:30 AM. Resident 2 fell a few days earlier and was related to wheelchair positioning. Although (Resident 2) has dementia he is self-determined and refused any type of therapy intervention. (It should be noted that no documentation from nursing or therapy was provided by the facility to support his statement.) RN K also looked into getting different footwear for (Resident 2) as a secondary fall intervention. (It is important to note that no documentation was provided from the facility that Resident 2 received different footwear before his fall on 4/23/11). Therapy (staff) stated that RN K was notified that Resident 2 refused (therapy). RN K when questioned stated she had no knowledge Resident 2 had refused therapy. (It is important to note this document does not indicate who completed it and no other documentation was provided by the facility indicating who did the interviews or when.) Resident 2's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 5/6/11 indicates he was moderately cognitively impaired, needed extensive assistance of 1 staff with bed mobility and needed extensive assistance of 2 staff with transferring. Resident 2's Care Area Assessment 5/19/11 states Resident 2 was not ambulatory and required extensive assist in most activities of daily living. Resident 2 is presently non-ambulatory and transferred or toileted with use of an EZ stand (mechanical lift). On 7/9/11 Resident 2 fell in his room attempting to transfer himself to bed. An intervention was added to take Resident 2, when done eating, first from the dining room after supper, toilet and assist to bed. Resident 2 fell on [DATE] self transferring and did not use call light or ask for assistance. A new intervention of anti-rollback was put on Resident 2's wheelchair. Resident 2 fell self transferring on 9/22/11 with interventions added: meet with family and fix anti rollbacks on Resident 2's wheelchair. There is no indication why the anti-rollback device needed fixing or for how long this was necessary. Social Service noted dated 9/28/11 states Resident 2's Power of Attorney (POA) N met with facility staff and discussed "Falls, refusal of medications and cares" Resident 2 has refused numerous safety interventions including the bed and chair alarms and chooses not to use his call light when he needs assistance ... Physical therapy is offered and Resident 2 refuses to attend on a regular basis. POA N acknowledged that Resident 2 has been choosing not to accept help and stated each time POA N visits Resident 2 agrees to allow staff to help, but Resident 2 goes back to choosing to refuse assistance. POA N expressed understanding of Resident 2's choice to refuse and the risks and complications related to that choice ... Resident 2's POA said he did not have any other suggestions for interventions to try ... Resident 2 fell [DATE] ambulating unassisted. A new intervention of gripper socks at night was added for Resident 2. Resident 2's Care Plan printed 11/29/11 addresses on 5/19/11 that he refuses cares and indicates as of 2/1/10 transfers, ambulation per ADL sheet: ADL sheet for Resident 2 dated 11/18/11 states Resident 2 requires 1 staff and EZ stand for transfers, his wheelchair is to be removed from his room (when he is in bed), beveled floor mat when in bed, take from dining room first, toilet and get ready for bed (evening's), and anticipate and meet Resident 2's needs as he doesn't use his call light. On 11/22/11 at 8:30 AM Surveyor observed Resident 2 sitting at his bedside with his wheelchair in front of him and no staff present in the room with him. On 11/28/11 at 8:05 AM Surveyor observed Resident 2 propel himself out of the dining room down the hall and go into his room. At 8:14 AM Resident 2 transferred himself into his bed from his wheelchair and lay down on his bed. His wheel chair was next to his bed and his floor mat was not in place. On 11/28/11 at 8:17 AM Surveyor interviewed CNA M, in Resident 2's hallway, who stated Resident 2 does require 1 staff and the EZ stand to assist him with transfers but "If you don't see him (Resident 2) or catch him he just does it "(self-transfers). CNA M did enter Resident 2's room, put the floor mat in place and removed his wheelchair. On 11/29/11 at 1:00 PM Surveyor interviewed DON B who stated he could not find documentation of a therapy assessment done for Resident 2 after his fall on 4/19/11. He also stated that therapy and nursing staff did not communicate that Resident 2 refused therapy so that a new intervention could be implemented. DON B stated that he believed that the incident of Resident 2 sitting on the arm of his wheelchair on 4/23/11 could not have been predicted as Resident 2 had never done that before. DON B stated that Resident 2 is self determined and does self transfer. DON B stated that he did not indicate on the care plan that Resident 2 was able to self transfer because he does not want CNA staff to think it's ok not to assist Resident 2. (It is important to note that Resident 2's care plan does not indicate that he can self-transfer).