Every finding on record at Autumn Lake Healthcare at Greenfield

Based on observation, interview and record review, the facility failed to ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 7 (R66, R109, R34, R10, R33, R5 and R8) of 13 residents reviewed for pressure injuries from a sample of 19. *R66 has a history of a healed stage 4 pressure injury to the sacrum and is at high risk for pressure injuries. R66's sacral pressure injury reopened on 1/17/25 and again on 6/10/25. On 11/21/25, R66's sacral pressure injury showed signs of infection and a wound culture was ordered. Results on 11/24/25 documented a staph infection. Wound Nurse Practitioner (NP)-F ordered an MRI to the sacrum to rule out osteomyelitis. The MRI was not completed until 2/25/26. After the MRI diagnosed osteomyelitis of the sacrum, R66 received intravenous (IV) antibiotics to treat the wound infection. R66 developed multiple other stage 2 and 3 pressure injuries between January and September 2025. Facility staff did not always update R66's care plan when a pressure injury developed or worsened. A comprehensive assessment was not always completed when a new or reopened pressure injury developed. At times, R66's pressure injuries were staged incorrectly. Facility staff did not always follow Wound NP-F's recommendations for treatment of R66's wounds. Surveyor observed care plan interventions not in place while on Survey. *R109 did not receive care to prevent the development of a stage 3 pressure injury to R109's coccyx. R109 also developed a device associated pressure injury to R109's right back that developed staph aureus and staph lugdunensis infections. *R34 developed 3 facility acquired, stage 3 pressure injuries. R34's care plan was not revised. R34's Left heel pressure injury became infected requiring intravenous antibiotics. Surveyor observed R34's care plan interventions not being implemented during the survey. *R10 developed 2 stage 3 pressure injuries in the facility. R10 did not have a comprehensive assessment for causative factors contributing to the onset of wounds. R10's care plan was not revised to prevent worsening or further development of pressure injuries. Surveyor observed R10's care plan interventions not being implemented during the survey. One of R10's pressure injuries became infected twice and required antibiotics twice. The facility's failure to provide prevention, care, and treatment to R66, R109, R34, and R10 created findings of immediate jeopardy for these resident examples. The finding of immediate jeopardy began on 11/21/25 when R66's sacral pressure injury became infected. Surveyor notified the Nursing Home Administrator (NHA)-A of the immediate jeopardy on 6/9/26 at 4:05 PM. The facility removed the immediacy on 6/16/26 when it implemented an action plan. The deficient practice continues at a scope and severity of G (actual harm/isolated) related to an additional example regarding R33. *R33 is at risk for developing pressure injuries. On 3/29/26, facility staff found a stage 3 pressure injury to the right buttocks that was not comprehensively assessed when identified. On 4/28/26, facility staff found a stage 2 pressure injury that was not comprehensively assessed when identified. Observations of care plan interventions were observed to not be in place throughout the onsite survey. The finding of a facility acquired stage 3 pressure injury created actual harm to R33. There are additional examples regarding R5 and R8 that are examples of noncompliance with a potential for harm. *R5 did not receive care to prevent the development of two new pressure injuries to R5's feet. *R8 returned from the hospital with three new wounds, two were pressure injuries. The wounds were not assessed until the next day. New interventions were not added to R8's care plan, and a nutrition assessment was not completed until four weeks after admission. Findings include: The facility policy dated 2/1/26 and titled, Pressure Injury Prevention and Management, documents, in part: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings should include type of wound, wound measurements., other wound characteristics (color, exudate, odor, pain, tissue type in wound bed), and treatment and interventions implemented. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate intervention. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); Minimize exposure to moisture and keep skin clean.; Provide appropriate pressure-redistributing, support surfaces; Maintain or improve nutrition and hydration status, where feasible. Interventions will be documented in the care plan and communicated to all relevant staff. Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include: Changes in resident's degree of risk for developing a pressure injury. New onset or recurrent pressure injury development. Lack of progression towards healing. 1.) R66 was admitted to the facility on [DATE] with diagnosis that include Parkinson's disease), Quadriplegia, Chronic Kidney disease, Neuromuscular dysfunction of the bladder and Gastrostomy tube. R66's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents R66 is severely cognitively impaired. R66 is dependent on staff for all cares, mobility and transfers. R66 has a catheter and is always incontinent of bowel. R66 is at risk of developing pressure ulcers. R66 does not have a pressure ulcer/injury. R66's Pressure Injury Care Area Assessment (CAA) dated 6/17/24, documents, in part: [R66] has alteration in skin integrity [related to] pressure, immobility, history of pressure ulcers. [Body mass index (BMI)] 22.1. Braden score of 14 moderate risk of skin breakdown. R66's Braden Scale assessment dated [DATE] documents that R66 is at high risk for developing pressure injuries. R66's Wound MD note dated 7/2/24 documents R66's stage 4 pressure injury to their sacrum has resolved. R66's skin integrity care plan initiated on 11/8/24 documents the following pertinent interventions: Alternating air mattress to bed. Apply bilateral Prevalon boots while in bed. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Follow MD orders for treatment of wounds. Follow facility protocols for treatment of injury. Identify/document potential causative factors and eliminate/resolve where possible. Keep skin clean and dry. Use lotion on dry skin. Provide assistance with turning and repositioning [every] 2 hours. Provide brief change and peri cares after each incontinent episode. R66's MD order with a start date of 12/20/24 documents: Apply barrier cream to [bilateral] groins and [bilateral] buttocks daily and [as needed]. Every shift. R66's progress note dated 12/21/24 at 1:53 PM documents: Resident being [monitored] for excoriated bottom, zinc oxide cream applied per wound care nurse orders, repositioned [every 2 hours] and incontinence cares provided by assigned [Certified Nursing Assistant (CNA)] [every 2 hours]. R66's progress note dated 12/25/24 at 9:46 PM documents, in part: Resident being monitored for excoriated buttocks. [Treatment] applied as ordered. Repositioned throughout the shift per staff. R66's progress note dated 1/1/25 at 6:59 AM documents: Resident monitored for new excoriation to buttocks and peri area; barrier cream applied with incontinence cares. Surveyor noted multiple documentations of an excoriated buttocks starting on 12/21/24. R66's Advanced Practice Nurse Practitioner (APNP) note dated 1/3/25, documents, in part: . complaining of buttocks excoriation. has previous history of sacral pressure ulcers to the area. Relies upon staff for pressure reduction efforts and turning. Currently laying on back/buttocks. Unable to position/reposition self. Skin- redness and erythema buttocks area. No open areas noted.Stage 1 pressure ulcer coccyx, acute on chronic.Plan-Follow with wound. Strict pressure offloading and wound cares. Calazime paste twice daily. Aggressive peroneal care to avoid recurrence of pressure wounds. Surveyor noted that R66's APNP documented that R66 had a stage 1 pressure ulcer. R66's MD order with a start date of 1/3/25 documents:: Calmoseptine External Ointment 0.44-20.6 % (Menthol-Zinc Oxide) Apply to [bilateral] Buttocks and Groin topically every shift for dermatitis. Surveyor reviewed R66's medical record and noted that facility staff did not comprehensively assess R66's newly diagnosed stage 1 pressure injury on 1/3/25 and did not document an assessment weekly from 1/3/25 through 1/17/25. Surveyor reviewed R66's skin integrity care plan and noted that R66's care plan was not updated with an intervention to prevent worsening after R66 developed a new area of excoriation on 12/21/24 and the care plan was not updated after R66's APNP diagnosed a stage 1 pressure injury on 1/3/25. R66's progress note dated 1/17/25 at 3:22 PM, documents, in part: Writer summoned to [R66's] room per floor staff to assess [resident] buttocks for skin concern. [R66] noted with 3 new wounds: 1) Stage 3 to Sacrum- 1.0 x 1.0 x 0.1, 50% slough and 50% granulation to wound bed. scant serosanguinous drainage, no odor noted. peri wound inflamed but stable. 2) Stage 2 to Left Buttock- 1.0 x 1.0 x 0.1, 100% granulation, light serosanguinous drainage without odor. peri wound with inflammation. 3) Stage 2 to Right Buttock- 9.0 x 2.0 x 0.1, 100% granulation, light serosanguinous drainage without odor. peri wound is normal skin. NP made aware with [treatment] orders initiated. [Resident] will return to being seen weekly by wound MD and wounds will be treated and followed until all wounds are resolved. [Resident] is on a Low Air loss mattress and does wear [bilateral] heel boots at all times. Surveyor noted R66 had a healed stage 4 pressure injury to their sacrum. Surveyor noted facility staff incorrectly staged R66's sacrum pressure injury as a stage 3 to R66's sacrum. On 6/4/26 at 1:42 PM, Surveyor interviewed Wound NP-F. Surveyor asked if a previous stage 4 pressure injuries should be down staged to a stage 3. Wound NP-F stated that they do not typically down grade wounds. Surveyor reviewed R66's care plan and noted facility staff did not document that they reviewed or revised R66's care plan with an intervention after the sacrum pressure injury re-opened or after 2 new pressure injuries were found. R66's weekly wound assessment dated [DATE] documented that R66's Left buttock pressure injury had resolved. R66's Wound MD note dated 2/4/25 documents, in part: Stage 3 sacrum 2.4 x 1.9 x 0.2. 40% slough. 60% granulation. Stage 2 right buttock 3.5 x 2.2 x 0.1. Stage 3 left upper buttock 2.1 x 2.5 x 0.1. 80% granulation. 20% slough. Surveyor noted that the Wound MD incorrectly staged the sacrum pressure injury and noted that the sacrum pressure injury increased in size. Surveyor noted that R66's left buttock pressure injury re-opened and is now a stage 3 pressure injury. On 2/6/25, R66's care plan was updated with the following intervention: Encourage [R66] to be up for 1.5 hours for breakfast, and 1.5 hours at lunch, and 1.5 hours for dinner every day. Lay [R66] back down after 1.5 hours or as tolerated. R66's Wound MD note dated 2/11/25 documents Stage 2 pressure wound of the right buttock resolved. Stage 3 pressure wound of the left upper buttock resolved. R66's Wound MD note dated 2/25/25 documents Stage 3 pressure wound sacrum resolved. Surveyor noted by 2/25/25, R66's 3 pressure injuries had been resolved. R66's MD order with a start date of 2/25/25 documents: Apply barrier cream to [bilateral] buttocks and Sacrum [every] shift and [as needed] as preventative. R66's progress note dated 4/7/25 at 7:25 PM documents, in part: . Writer noting a skin tear on [right] lower buttock and pink bottom. Writer cleaned with [normal saline], applied Medi honey, and covered with dry bordered gauze. Barrier cream applied to coccyx. Surveyor noted that facility staff documented a new open area to R66's lower buttock. Surveyor reviewed R66's medical record and noted facility staff did not document a comprehensive assessment with measurements or wound characteristics when the wound was found on 4/7/25. R66's progress note dated 4/8/25 at 8:30 AM, documents: Wound team followed up [related to] reports of new open area to right buttock. [Resident] is noted with open area to right ischium/right lower buttock. Wound appears to be pressure in nature. Wound bed noted with slough and granulation. Inflammation to peri wound. Light serosanguinous drainage. [Resident] will be seen by Wound MD today. R66's Wound MD note dated 4/8/25 documents, in part: Stage 3 pressure wound of the right ischium. 2.6 x 3.1 x 0.1. 40% slough. 60% granulation. Surveyor reviewed R66's medical record and noted that facility staff did not document the possible cause of R66's new stage 3 pressure injury. Surveyor reviewed R66's comprehensive care plan and noted that facility staff did not document that they reviewed or revised R66's care plan with an intervention after R66 developed a new stage 3 pressure injury. On 6/3/26 at 11:48 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C. Surveyor asked why ADON-C thinks R66 developed this new pressure injury on 4/7/25. ADON-C stated that R66 moves a lot in bed due to R66's Parkinson's disease. This is R66's baseline. This movement causes friction. ADON-C stated that R66 is on medication for the constant movement. ADON-C stated that R66 will be repositioned and then will wiggle out of the position. Surveyor asked if the friction is what caused R66's right ischium pressure injury. ADON-C stated that they started working at the facility in May of 2025 and ADON-C did not have a good answer for that. R66's Wound MD note dated 4/29/25 documents, in part: Stage 3 pressure wound of the right ischium resolved. Surveyor noted R66's stage 3 pressure injury was resolved and R66 has no pressure injuries at this time. On 5/13/25, R66 experienced a change in condition. R66 was sent to the hospital on 5/13/25. R66 was hospitalized until 5/22/25 due to bladder and renal stones that caused Urosepsis. R66 was readmitted to the facility on [DATE]. R66's progress note dated 5/22/25 at 10:35 PM documents, in part: Arrived via Ambulance. Resident lying comfortably in bed with [bilateral] Prevalon boots on. Writer completed a head-to-toe assessment. Foley [discontinued] during hospital stay. Surveyor noted that R66's foley catheter was removed while in the hospital. Surveyor noted that the increase in moisture from bladder incontinence would put R66 at great risk skin breakdown. R66 comprehensive care plan documents the following interventions initiated on 5/22/25: Clean peri-area with each incontinent episode. R66's admission skin assessment dated [DATE] did not document any areas of pressure on R66's skin. R66's Wound MD note dated 6/10/25 documents, in part: Stage 3 pressure wound sacrum 1.7 x 1.5 x 0.2. 50% slough. 50% granulation. Stage 3 pressure wound of the left buttock. 1 x 0.8 x 0.1. 100% granulation. Stage 3 pressure wound of the right buttock. 0.8 x 0.8 x 0.1. 100% granulation. Surveyor noted that 2 weeks after readmission to the facility, facility staff found 3 reopened pressure wounds. Surveyor noted R66's sacrum was incorrectly staged as a stage 3 pressure injury when it had previously been staged as a stage 4. Surveyor reviewed R66's medical record and noted that facility staff did not document the possible cause of R66's 3 pressure injuries that had reopened. Surveyor reviewed R66's comprehensive care plan and noted that facility did not document that they reviewed or revised R66's care plan after R66's 3 pressure injuries had reopened. On 6/4/26 at 1:08 PM, Surveyor interviewed ADON-C. Surveyor asked why R66's sacrum pressure and 2 other pressure injuries reopened on 6/10/25. ADON-C stated that R66 had an overall decline in health and did require multiple hospitalizations. ADON-C stated that R66's movements and friction also played a part because when R66 is sick, R66 will have more movements in bed. Surveyor reviewed R66's care plan and did not locate a new care plan intervention to address R66's increased movements and friction. R66's Wound MD note dated 6/17/25 documents, in part: Stage 4 pressure wound sacrum. 1.7 x 1.2 x 1.3. 50% slough. 50% granulation. Stage 3 pressure wound of the left buttock resolved . Stage 3 pressure wound of the right buttock 0.6 x 0.8 x 0.1. 100% granulation. Surveyor noted that R66's left buttock pressure injury was resolved. Surveyor noted that R66's sacrum pressure injury had increased in depth. In one week, the depth increased from 0.2 to 1.3. Surveyor noted that R66's sacrum pressure was now staged correctly as a stage 4 pressure injury. R66's care plan was updated with the following intervention on 6/18/25: Use draw sheet for all repositioning. R66 experienced a change of condition due to continued urological issues and was hospitalized from [DATE] through 7/2/25. R66's Weekly wound assessment dated [DATE] documents, in part: Right heel pressure Suspected Deep Tissue Injury (DTI) Present on admission. 2.3 x 2.9. Purple/maroon in color. Left buttock stage 3 pressure injury 11.5 x 7.5 x 0.1. 100% granulation. Right buttock stage 3 pressure injury 12.3 x 8.8 x 0.1. 100% granulation. Sacrum stage 4 pressure injury. 2.3 x 2.5 x 2.3. 50% granulation, 50% slough. Surveyor noted that R66 developed a Right heel DTI while hospitalized . Surveyor noted R66's left buttock reopened while hospitalized . Surveyor reviewed R66's care plan and noted that facility staff did not document that they reviewed or revised R66's care plan when R66 returned from the hospital with a new heel pressure injury and a reopened left buttock pressure injury. R66's Weekly Wound assessment dated [DATE] documents: R66's Right heel DTI and Stage 3 left buttock pressure injury had resolved. R66's Wound MD note dated 7/8/25 documents, in part: Stage 4 pressure sacrum 5.5 x 7.6 x 1.9. 50% slough. 50% granulation. Stage 3 right buttock 3.2 x 1 x 0.1. 100% granulation. Surveyor noted R66's Stage 4 sacrum injury width more than doubled in size. Surveyor reviewed R66's care plan and noted that facility staff did not document that they reviewed or revised R66's care plan when R66's stage 4 pressure injury worsened and doubled in size. R66's Wound MD note dated 7/15/25 document, in part: 6 x 9 x 1.9. 50% slough. 50% granulation. Stage 3 right buttock 4 x 2 x 0.1. Stage 3 pressure wound of the left buttock 10 x 3 x 0.1. 100% granulation. Re-opening of previously healed wound. Surveyor noted that R66's sacrum and right buttock pressure injury grew and R66's left buttock pressure injury reopened. Surveyor reviewed R66's care plan and noted that facility staff did not document that they reviewed or revised the care plan when R66 pressure injuries grew, and the left buttock reopened. Surveyor reviewed R66's skin integrity care plan and noted R66's care plan intervention of Apply bilateral Prevalon boots while in bed was canceled and no longer on the care plan starting on 7/21/25. On 6/4/26 at 1:08 PM, Surveyor interviewed ADON-C about the Prevalon boot intervention. ADON-C indicated that the electronic health system had a glitch, and the intervention was canceled by the system. ADON-C confirmed that the heel boot intervention was not on R66's care plan starting on 7/21/25. R66 experienced a change of condition related to continued urological issues. R66 was hospitalized from [DATE] through 7/28/25 and again on 8/6/25 through 8/11/25. R66's weekly wound assessment dated [DATE] documents, in part: Stage 4 sacrum 2.9 x 2 x 2. 60% granulation. 40% slough . Right buttock pressure stage 3. 1 x 0.6 x 0.1. 100% granulation. Left buttock pressure injury resolved. R66's Wound MD note dated 8/19/25 documents, in part: Stage 4 pressure wound sacrum 2.9 x 2 x 2. 40% slough. 60% granulation. Stage 3 pressure wound of the right buttock resolved. Surveyor noted as of 8/19/25 R66 had one stage 4 pressure wound to the sacrum and all other pressure injuries had resolved. Surveyor reviewed R66's care plan and noted that facility staff had not entered an intervention for off-loading of R66's heels after it had been cancelled on 7/21/25. R66's Wound MD note dated 9/30/25 documents, in part: Stage 4 pressure wound sacrum 2.9 x 1.6 x 1. 100% granulation. Unstageable DTI of the right heel. 5.2 x 3.8. Recommendation: . Float heels in bed. Surveyor noted R66 developed a new DTI to the right heel. Surveyor reviewed R66's care plan and noted that facility staff did not document that they reviewed or revised the care plan when R66 developed a new right heel DTI. Surveyor noted that the Wound MD recommended heel offloading and facility staff did not add an intervention to prevent the worsening of R66's new wound. R66's Wound NP-F note dated 10/17/25, documents, in part: Stage 4 sacrum 3 x 3.1 x 0.6. 25% bone. 75% granulation. Stage 3 pressure ulcer right heel. 2 x 2.5 x 0.1. 100% granulation. Seen today for sacral pressure ulcer stage 4, and DTI now stage 3 pressure ulcer. Surveyor noted R66's sacrum pressure injury grew, and bone is seen in the wound. Surveyor noted R66's heel DTI had opened and is now a stage 3 pressure injury. Surveyor reviewed R66's care plan and noted that facility staff did not document that they reviewed or revised the care plan when bone was seen in R66's sacrum wound and when the heel DTI progressed to a stage 3 pressure injury. R66's Wound NP-F note dated 10/31/25 documents, in part: Stage 4 pressure ulcer Sacrum 2.5 x 2.2 x 0.5. 50% slough. 50% granulation. Stage 3 pressure ulcer right heel 0.5 x 0.5 x 0.1. 100% dermis. Medical Device related pressure injury. Light serous exudate. 100% dermis. R66's Weekly wound assessment dated [DATE] documents, in part: Right buttock stage 2 pressure. 100% dermis. Medical device related. Surveyor noted that Wound NP-F and Facility staff documented a new medical device-related pressure injury to R66's right buttock. Facility staff documented this as a stage 2 pressure injury. Surveyor noted that no measurements were completed of the new stage 2 pressure injury. On 6/4/26 at 1:42 PM, Surveyor interviewed Wound NP-F and Wound Nurse-E. Surveyor asked what medical device caused R66's new stage 2 pressure injury on 10/31/25. Wound NP-F stated that R66's Foley catheter got stuck under R66's buttocks. Wound NP-F stated that R66's skin breaks down so fast but indicated that they had caught it right away. Surveyor asked if Wound NP-F would measure a medical device-related stage 2 pressure injury. Wound NP-F stated that they typically would measure that and did not have an answer why it was not measured. Surveyor reviewed R66's care plan and noted that facility staff did not document that they reviewed or revised the care plan to include an intervention to prevent recurrence when R66's catheter caused a pressure injury. R66's Wound NP-F note dated 11/7/25 documents, in part: . [Medical device related pressure injury] to right buttock has resolved. [Pressure ulcer] to sacrum and right heel are improving. Treatment plan updated. No new concerns. Stage 4 pressure ulcer sacrum 2 x 2.2 x 0.5. 10% slough. 90% granulation. Heavy serous exudate. Macerated edges. Treatment recommendation: Collagen to wound bed, layer with calcium alginate, fill remaining depth with dry gauze. Cover with [border foam]. Change daily and [as needed]. Surveyor noted R66 had an increase in heavy drainage to the wound and noted that the treatment plan for R66's sacrum changed to Collagen, then calcium alginate. R66's MD order with a start date of 11/7/25 documents, in part: Wound Care Sacrum: Cleanse with [Normal Saline]. Pat Dry. Apply collagen to wound bed then layer with calcium alginate with silver. Fill remaining void with dry gauze and cover with bordered foam. Every, day shift for Wound Management. Surveyor noted that facility staff put Collagen, then calcium alginate WITH silver in the wound treatment order. Surveyor noted that facility staff added silver to the treatment of R66's wound and this is not documented as part of the recommendation from Wound NP-F. R66's Wound NP-F note dated 11/14/25 documents, in part: Pressure ulcer Sacrum 2 x 2.5 x 0.5. Moderate Serosanguinous exudate. 100% granulation. Macerated edges. Treatment recommendations: Collagen to wound bed, layer with calcium alginate, fill remaining depth with dry gauze. Cover with [border foam]. Change daily and [as needed]. Pressure ulcer heel right 0.5 x 0.5 x 0.1. 100% dermis. Wounds are stable. Surveyor noted Wound NP-F documented the same treatment recommendations as the week prior. Surveyor reviewed R66's Treatment Administration Record (TAR) and noted that facility staff continue to treat R66's sacrum wound with calcium alginate WITH silver which was not part of Wound NP-F's recommendation. R66's Wound NP-F note dated 11/21/25 documents, in part: Pressure ulcer Sacrum 2.5 x 2.5 x 0.5. Heavy purulent exudate. 80% granulation. 20% slough. Treatment recommendations: Sacrum- Collagen to wound bed, followed by Hydrofera blue. Cover with [border foam]. Change daily and [as needed]. Add wound culture to [rule out] superficial infection. Pressure ulcer to sacrum has deteriorated. Pressure ulcer to right heel is improving. Treatment plan updated. Surveyor noted that R66 sacrum wound was worsening. A wound culture and a new treatment was ordered. R66's MD order with a start date of 11/21/25 documents: Wound Care Sacrum: Cleanse with [Normal Saline]. Pat Dry. Apply Hydrofera Blue to wound bed. Cover with bordered foam. Every, day shift for Wound Management Surveyor noted that Wound NP-F recommended Collagen to wound bed followed by Hydrofera blue. Facility staff entered the MD order and did not include Collagen in the treatment order. R66 went from 11/21/25 to 11/24/25 treating R66's sacrum wound without the recommended collagen. On 6/4/26 at 1:42 PM, Surveyor interviewed Wound Nurse-E and Wound NP-F. Surveyor asked if the treatment listed in Wound NP-F's note is what the facility should follow. Wound NP-F indicated yes. Surveyor asked if Wound NP-F was aware that R66's wound was not treated as Wound NP-F ordered. Wound NP-F stated that their notes can take 3 days to get to the facility. Wound NP-F stated that facility started with Hydrofera blue and added collagen after seeing Wound NP-F note. Wound Nurse-E stated that Hydrofera blue is what was done at the bedside. Wound Nurse-E entered that as the order after completing wound rounds with Wound NP-F. Surveyor asked if Wound NP-F wanted collagen as part of the treatment. Wound NP-F indicated that they wanted Collagen. R66's MD orders dated 11/24/25 documents: Wound Care Sacrum: Cleanse with [Normal Saline]. Pat Dry. Apply collagen and Hydrofera Blue to wound bed. Cover with bordered foam. Every, day shift for Wound Management Surveyor noted facility staff updated R66's sacrum treatment orders to reflect Wound NP-F's recommendations. R66's Wound culture results dated 11/24/25 document, in part: Staphylococcus Aureus, Enterococcus faecalis. R66's progress note dated 11/24/25 at 5:30 PM, documents: Notified Wound NP of culture results and sensitivities. NP has ordered that a midline be placed. NP also ordered cefepime IV. NP has ordered an x-ray of the sacrum. R66's X-ray results dated 11/25/25 document, in part: Impression: . No obvious evidence of osteomyelitis is seen. MRI of sacral region is suggested clinically indicated. R66 MD order dated 11/25/25 documents: MRI of Sacrum dx follow-up from x-ray results, Osteomyelitis rule out, stalled wound healing and ESR (lab test that will indicate the presence of inflammation in the body) elevation. Surveyor noted that Wound NP-F ordered a midline, IV antibiotics and a MRI after R66's wound culture resulted as positive. Surveyor reviewed R66's progress notes and noted R66 had symptoms of a Urinary Tract infection (UTI) while the sacrum wound was being worked up for infection. R66's MD-I note dated 11/25/25 documents, in part: I was called to evaluate [R66] for possible. wound infection. [R66] seems to be at [their] baseline mental status: No fevers, clinically does not show any signs infection. Urine culture showing Proteus, Staph and Vanco sensitive enterococcus lesion, likely contaminated. Proteus is sensitive to multiple antibiotics including Amoxicillin. Wound cultures also reviewed, given lack of systemic signs of infection, may not need IV antibiotics as suggested previously by the provider, may [discontinue] PICC line placement transfer to hospital and IV cefepime. Augmentin for 10 days to cover for UTI as well as wound infection. R66's progress note dated 11/25/25 at 1 PM documents, in part: Notified by floor nurse that [MD-I] was here to see [R66] and disagrees with wound provider's recommendation for IV antibiotics to manage infection. [MD-I] recommends switching from Keflex to Augmentin to manage both wound infection and UTI. Notified wound NP. Wound NP chooses to defer to primary in Augmentin choice, pending wound condition at next follow-up by NP or if the resident's status deteriorates, antibiotics will be escalated to IV. Notified NP of sacrum x-ray results. NP recommends the resident get an MRI of sacrum. On 6/4/26 at 1:42 PM, Surveyor interviewed Wound NP-F. Surveyor asked about the wound culture completed on 11/21/25. Wound NP-F stated that R66's wound was deteriorating and stated that if the things that they are doing are not working, Wound NP-F would ask if t

Based on interview and record review, the facility failed to ensure 4 (R21, R66, R109, and R7) of 19 sampled residents received treatment and care based upon a comprehensive assessment and a comprehensive person centered plan of care and in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act.) *R21 returned from an appointment outside of the facility on 10/27/25 with a large hematoma on the front of R21's left shin. R21's leg wound opened and needed to be debrided on 11/19/25. On 11/26/25, R21's left leg wound became infected. Facility staff did not follow Wound Nurse Practitioner (NP)-F's treatment orders. R21's wound required placement of a midline IV (intravenous) and 2 different IV antibiotics to treat the infection. *R66 experienced a respiratory change of condition in the early morning of 2/15/26. Facility staff contacted a doctor and received orders for a STAT (immediate) X-ray, 2 Duo-neb treatments (prescription inhalation solution), Oxygen (O2), Vital signs every hour for 3 hours and O2 saturation monitoring. The STAT X-ray, Duo-neb treatments, Vital signs and O2 saturation monitoring were not completed or documented by facility staff. R66's condition worsened. R66 was sent to the hospital and diagnosed with Pneumonia and Sepsis. *R109 was admitted to the facility with wounds initially identified as pressure injuries that were reclassified as vascular in nature. The facility did not ensure an assessment of R109's individual needs and risk factor was completed to develop an individualized plan of care to prevent deterioration of R109's wounds. R109 developed additional wounds and had wounds that developed systemic infections requiring treatment with antibiotics. R109 did not receive care and treatment to prevent the development of additional vascular wounds. R109's wounds became infected and required antibiotic treatment. The facility's failure to provide R21, R66, and R109 with the necessary care and treatment per current standards of practice by not following provider treatment orders and/or not implementing treatment orders, not completing RN assessments of newly discovered wounds, not updating care plans timely with new interventions, and not obtaining an x-ray order as ordered (STAT) created a finding of immediate jeopardy. The immediate jeopardy began on 11/26/25 when R21's left leg wound developed an infection that required IV antibiotics. Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Assistant Director of Nursing (ADON)-C were notified of the immediate jeopardy on 6/9/26 at 4:08 PM. The immediate jeopardy was removed on 6/15/26 when the facility implemented their action plan, however, the deficient practice continues at a scope/severity of D (potential for harm/isolated) based upon the example for R7. *R7 had an unwitnessed fall on 4/13/2026 and the facility could not provide evidence that neurological checks were completed post fall. Findings include: On 6/9/26, Surveyor asked for the facility's Change of condition policy and a non-pressure related wound care policy. Surveyor was not provided with either. The facility policy dated 3/20/26 and titled, Diagnostic Testing Services, documents, in part: This facility will provide the appropriate diagnostic services (laboratory and radiology) required to maintain the overall health of its residents and in accordance with State and Federal guidelines . According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. 1.) R21 was admitted to the facility on [DATE] with diagnoses to include Spinal stenosis of the lumbar region, Chronic Obstructive Pulmonary Disease (COPD), Hypertensive heart and kidney disease, dependence on supplemental oxygen, and Coronary Artery Disease. R21's Annual Minimum Data Set (MDS) assessment dated [DATE] documents R21 is cognitively intact and is dependent on staff for all cares, mobility, and transfers. R21 does not have any pressure injuries, skin ulcers, wounds, or skin problems. R21's skin integrity care plan initiated 4/18/23 documents the following pertinent interventions: Keep skin clean and dry. Follow facility protocols for treatment of injury. Follow MD (Medical Doctor) order for wound cares. Obtain and follow MD orders for treatment of wound. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. On 6/1/26 at 9:48 AM, Surveyor interviewed R21. R21 informed Surveyor that a few months ago, R21 obtained a large bruise on her way back from an appointment outside of the facility. R21 stated she thinks the transport driver placed the bottle of oxygen on her legs and she got a large dark purple bruise. R21 stated the facility staff had to open it up and it took months to heal the wound. R21's progress note dated 10/27/25 at 8 AM documents: Resident is being pick[ed] up via [name of transport company] transportation. R21's progress note entered by Licensed Practical Nurse (LPN)/Unit Manager (UM)-BB, dated 10/27/25 at 11:45 AM, documents, in part: Upon return writer noted [R21's] Left shin is bluish-purple to colored, oval in shape, skin is intact, skin is raised and pain (sic) to touch, updated ADON (Assistant Director of Nursing) [C], DON (Director of Nursing) [B] and administrator. No drainage noted. Measurements is [sic] 4 (centimeters) x 3.5 x 0.1 . Notified NP (Nurse Practitioner) [G] new order obtained to HOLD anticoagulant for days and apply skin prep 2 times a day and as needed. Surveyor reviewed R21's medical record and did not find evidence of a Registered Nurse assessment completed and documented by facility staff on 10/27/25. R21's MD order with a start date of 10/27/25 documents, in part: Apply skin prep to left . shin hematoma 2 times a day and as needed. Surveyor reviewed R21's skin integrity care plan and noted facility staff added the following intervention on 10/27/25: Hold Eliquis for 3 days. Surveyor did not find evidence that any other care plan updates were added to R21's care plan. Surveyor noted there were no new interventions to address the care of R21's new skin wound or identify interventions to prevent worsening of the wound. On 6/9/26 at 11:02 AM, Surveyor interviewed DON-B. Surveyor asked when a resident's care plan should be updated with new interventions to address new skin concerns. DON-B indicated it is usually within a day or two. DON-B stated the Interdisciplinary Team (IDT) will talk about new wounds and talk about what should be added to the care plan. R21's Wound Nurse Practitioner (NP)-F note dated 10/29/25 documents, in part: [R21] is being seen for evaluation and treatment recommendation regarding a hematoma to left leg. 0.4 x 4 x 0.1. 100% epithelial . No intervention needed at this time. Recommend Every shift neurovascular assessment. On 6/9/26 at 9:40 AM, Surveyor interviewed Wound NP-F. Surveyor asked what Wound NP-F was looking for in every shift neurovascular assessments. Wound NP-F stated they wanted to monitor for compartment syndrome (a painful and potentially dangerous medical condition caused by a dangerous buildup of pressure within a muscle compartment) in the setting of a hematoma. Wound NP-F stated staff should be looking for the 6 Ps (pain, pallor, pulses, paresthesia, paralysis, poikilothermia [temperature]). Surveyor reviewed R21's Electronic Medical Record (EMR) and noted facility staff did not implement neurovascular assessments every shift as Wound NP-F had recommended. Surveyor reviewed R21's Treatment Administration Record (TAR) and noted facility staff continued to treat R21's left leg hematoma with skin prep 2 times a day even though Wound NP-F documented in their note on 10/29/25 that no intervention was needed. On 11/5/25 and 11/12/25, Wound NP-F notes document, in part: R21's left leg hematoma 4 x 4 x 0.1. No intervention needed at this time. Recommend every shift neurovascular assessment . Surveyor reviewed R21's EMR and noted facility staff did not implement neurovascular assessments every shift as Wound NP-F had recommended on 10/29, 11/5, and 11/12/25. Surveyor reviewed R21's TAR and noted facility staff continued to treat R21's left leg hematoma with skin prep 2 times a day even though Wound NP-F documented in Wound NP-F's note on 11/5 and 11/12/25 that no intervention was needed. R21's skin integrity care plan was updated on 11/18/25 with the following pertinent interventions: Maintain communication with [Named] wound care [Provider] for wound care orders and evaluation. Follow wound Provider orders for wound treatment. Use draw sheet for all repositioning to reduce friction and protect skin integrity. Encourage and assist resident to reposition every 2 hours while in bed. Build rapport with resident to ease anxiety and support cooperation for dressing changes . Surveyor noted R21's care plan was not updated with wound specific interventions until 3 weeks after R21's new skin issue was identified. On 6/9/26, Surveyor interviewed DON-B and asked if it typically takes over 3 weeks to update a care plan with wound specific interventions. DON-B stated 3 weeks is not typical. R21's Wound NP-F note dated 11/19/25 documents in part: Wound is deteriorating. Upon assessment today, hematoma spontaneously dislodged requiring intervention. Wound debrided today without complications. Treatment plan updated. No new concerns . 5.5 x 5.5 x 0.3. Treatment recommendations: Adaptic covered with calcium alginate and border foam daily and as needed. R21's MD order dated 11/19/25 documents: Wound Care Left Leg: Cleanse with normal saline and pat dry, cover with an adaptic and calcium alginate. Then cover with bordered foam. Every day shift for wound care AND as needed. Surveyor reviewed R21's TAR and noted that facility staff entered orders for the new recommended treatment, but facility staff did not discontinue the first treatment order of skin prep to the hematoma. Surveyor noted facility documentation indicates R21's left leg was being treated with skin prep to an open wound 2 times a day as well as the new treatment order. On 6/9/26 at 9:40 AM, Surveyor interviewed Wound NP-F and asked if Wound NP-F ordered the skin prep 2 times a day to R21's hematoma. Wound NP-F stated skin prep to the hematoma was used for protection. Wound NP-F stated the top of the hematoma was very thin and superficial. Wound NP-F wanted to maintain the skin and have the hematoma absorb. When skin prep was put in place, the wound was not opened. Surveyor asked if R21 needed the skin prep 2 times a day after the wound opened. Wound NP-F stated R21 would not need it after it unroofed. Surveyor asked if Wound NP-F was aware facility staff continued to treat the wound 2 times a day with skin prep. Wound NP-F stated skin prep would not harm the wound if staff used it on the peri wound. Wound NP-F stated there would be nothing wrong with that. Surveyor asked if skin prep was placed on an open wound could that cause harm or cause bacteria to grow in the wound. Wound NP-F stated Wound NP-F did not think facility staff were putting the skin prep on the open wound. R21's Weekly Non-Pressure Wound Tracking note dated 11/26/25 documents in part: Left leg hematoma 5.5 x 5.5 x 0.3. Treatment ordered: Normal saline/pat dry/half strength Dakins moistened gauze/kerlix . Hematoma-90% granulation tissue, 10% slough. Moderate purulent exudate. No pain or discomfort . R21's progress note dated 11/26/25 at 2:36 PM, documents: Wound [NP-F] notified of purulent drainage of left leg wound. [NP-F] ordered wound culture. Wound culture collected. [NP-F] ordered Bactrim until wound culture results come back. New treatment orders received from [NP-F]. R21's MD order with a start date of 11/26/25 documents: Wound Care Left Leg: Cleanse with normal saline and pat dry, cover with Half strength Dakins moistened gauze. Cover with ABD (abdominal pad) and wrap with Kerlix/gauze roll. Every day shift for wound care AND as needed. R21's MD order with a start date of 11/26/25 documents: Bactrim DS oral tablet 800/160 mg (milligrams) . Give 1 tablet by mouth two times a day for wound infection for 7 days. R21's Wound culture results dated 11/30/25 documents a positive culture with the following organisms: Proteus Mirabilis, Klebsiella Pneumoniae, and Staphylococcus Aureus. R21's progress note dated 12/2/25 at 10:25 AM, documents: Ultrasound tech is here to place midline for IV (Intravenous) antibiotics for leg wound infection. R21's MD orders with a start date of 12/2/25 documents: Ertapenem Sodium Injection Solution Reconstituted (Ertapenem Sodium) Use 500 mg intravenously one time a day for Wound Infection for 10 Days. Cefazolin Sodium Intravenous Solution Reconstituted (Cefazolin Sodium). Use 2 gram intravenously one time only for Wound Infection for 1 Day AND Use 1 gram intravenously every 12 hours for Wound Infection for 10 Days. Surveyor noted R21 required 2 different IV antibiotics to treat R21's wound infection. R21's Wound NP-F note dated 12/3/25, documents, in part: Positive wound culture. Started on Dual IV antibiotic therapy . Hematoma to left leg remains the same as last visit. Treatment plan updated . Treatment Recommendations: Adaptic to wound bed, cover with Dakins-soaked gauze and bordered foam, change two times a day and as needed . R21's MD order with a start date of 12/3/25 documents: Wound Care Left Leg: Cleanse with normal saline and pat dry, cover with Adaptic then Half strength Dakins moistened gauze. Cover with bordered foam. Every day shift for wound care . Surveyor noted Wound NP-F ordered treatments be completed 2 times a day. Surveyor noted the treatment order placed by facility staff was entered as one time a day. Surveyor reviewed R21's TAR and noted facility staff continued to treat R21's left leg hematoma wound with skin prep 2 times a day. R21's Wound NP-F notes dated 12/9/25, 12/17/25 and 12/30/25 document in part: . Treatment plan maintained . Treatment Recommendations: Adaptic to wound bed, cover with Dakins soaked gauze and bordered foam, change two times a day and as needed . Surveyor noted Wound NP-F continued to recommend 2 times a day treatment to R21's left leg. Surveyor reviewed R21's TAR and noted facility staff continue to treat the wound one time a day, instead of 2 times a day with Dakins. In addition, facility staff continue to treat the wound two times a day with skin prep. Surveyor reviewed R21's Medication Administration Record (MAR) and noted R21 completed both IV antibiotics by 12/12/25. R21's Wound NP-F note dated 1/16/25 documents, in part: Hematoma to leg left has resolved . On 6/9/26 at 9:40 AM, Surveyor interviewed Wound NP-F. Surveyor asked if Wound NP-F was aware facility staff were only treating the wound daily instead of the 2 times a day that was recommended. Wound NP-F stated they did not specify that. Surveyor asked if Wound NP-F had any thoughts about how R21's wound became infected. Wound NP-F stated Wound NP-F did not have any thoughts on why it became infected. On 6/4/26 at 1:42 PM, Surveyor interviewed the facility Wound Nurse (WN)-E and asked who is responsible for entering orders after wound rounds take place. WN-E stated WN-E is responsible for entering treatment orders after wound rounds. On 6/9/26 at 11:02 AM, Surveyor interviewed Director of Nursing (DON)-B and asked when DON-B was made aware of R21's left leg injury. DON-B stated DON-B was aware the first day it happened. DON-B indicated DON-B went and looked at the injury but did not document an assessment. Surveyor informed DON-B of the concerns that after R21's injury, Wound NP-F ordered neurovascular assessments every shift and there is no evidence that the assessments were being completed by facility staff every shift. DON-B indicated DON-B would look into that. Surveyor informed DON-B of the concern R21's care plan was not updated timely with interventions to prevent worsening of the wound. Surveyor informed DON-B of the concern skin prep was not discontinued when Wound NP-F recommended a new treatment. Facility staff continued to treat R21's open wound with skin prep 2 times a day. DON-B stated, I see your point. In addition, Wound NP-F changed R21's treatment recommendation for Dakins to be done 2 times a day and facility staff continued to treat R21's wound one time a day. R21's leg wound needed to be debrided and became infected. R21 required 2 different IV antibiotics to treat the infected wound. On 6/9/26 at 11:28 AM, Surveyor informed Nursing Home Administrator (NHA)-A of the above concerns. 2.) R66 was admitted to the facility on [DATE] with diagnoses to include Parkinson's disease, Quadriplegia, Chronic Kidney disease, Neuromuscular dysfunction of the bladder, and Gastrostomy tube dependence. R66's Discharge Minimum Data Set (MDS) assessment dated [DATE] documents R66 is severely cognitively impaired. R66 is dependent on staff for all cares, mobility, and transfers. R66's progress note dated 2/15/26 with a service time of 5:38 AM documents in part: . [R66] developed respiratory congestion noticed by nursing staff tonight. [R66] is bedbound, and G-tube fed with continuous feeding. The congestion is described as chest congestion with rattly breath sounds . Oxygen saturation was found to be 85% on room air, which is abnormal for [R66] who is not normally on supplemental oxygen. The congestion represents an acute change from baseline respiratory status . This is an acute new problem. Condition is stable . PLAN: . Supplemental oxygen to maintain SpO2 [peripheral capillary oxygen saturation] > (greater than) 92%. DuoNeb x (times) 2. STAT (immediately) chest X-ray. Vital signs hourly x3 hours. Monitor O2 (oxygen) requirement and work of breathing; contact clinician if status worsens. Transfer to [Emergency Department (ED)] if SpO2 cannot be maintained >92% on 3 [Liters (L) Nasal Canula (NC)] or if persistent increased work of breathing. Disposition: Remain in facility with close monitoring; transfer to ED per above criteria . R66's MD (Medical Doctor) order with a start date of 2/15/26 at 7:32 AM, documents: Chest X-ray (2) views STAT to evaluate for pneumonia, pulmonary edema, or other pathology. On 6/4/26 at 8:29 AM, and on 6/8/26 at 9:09 AM, Surveyor attempted to reach Licensed Practical Nurse (LPN)-EEE, who was the nurse who initially called the MD on 2/15/26 early in the morning. LPN-EEE did not answer Surveyor's telephone call. Surveyor reviewed R66's medical record and noted R66 did not have a STAT chest x-ray completed anytime within the 12 hours after R66's MD ordered it to be completed. R66's MD order with a start date of 2/15/26 at 8 AM documents: Vital signs every hour for 3 hours one time only for low SpO2. Surveyor reviewed R66's vitals on 2/15/26 and noted no documentation indicating vitals were completed every hour for 3 hours after the MD ordered it to be completed. Surveyor reviewed R66's MD orders and noted after the MD ordered supplemental oxygen, DuoNeb x2 and monitoring of R66's O2 requirement, facility staff did not enter these as active orders in R66's electronic medical record. R66's progress note dated 2/15/26 with a service time of 7:29 PM, documents, in part: . [R66] with worsening shortness of breath. [R66] has coarse breath sound with [respiratory rate] >30. [Heart rate] >120. [R66] was seen . early this AM and DuoNebs, [chest x-ray (CXR)], frequent [vital signs (VS)] ordered. Nurse notes radiology never received order for CXR (chest x-ray) and does not appear that nebs or frequent vital signs were ever initiated. O2 sat (saturation) earlier was in 80s on RA (room air), but [R66] has been able to keep O2 sat >90 on supplemental oxygen. [R66] not usually on supplemental O2 . [R66 has a] low grade fever 99.1 . Condition is worsening . and has worsened throughout day. DuoNeb now. Transfer to hospital . Surveyor noted the time of the second MD consult on 2/15/26 was at 7:29 PM, almost 14 hours after the first MD consult was performed at 5:38 AM. R66's progress note dated 2/15/26 at 10:24 PM, documents, in part: Resident previously noted on prior shift to have low pulse oximetry reading . Nurse contacted on-call provider at that time. Provider recommended DuoNeb treatments, STAT chest x-ray, and vital signs every hour x 3. Per report, these orders were not initiated; resident was placed on oxygen only. Writer assessed resident at approximately 5 PM. Resident noted to be tachycardic with pulse oximetry reading of 93% on 2 l (liters) O2 via nasal cannula. Resident reassessed approximately 45 minutes later . Resident warm to touch. Full set of vital signs obtained. Low-grade fever noted. Resident observed using accessory muscles for breathing. Tachycardia persisted, along with elevated respiratory rate. On-call provider contacted regarding worsening condition. Provider informed that imaging company did not receive chest x-ray orders and that previously recommended order (DuoNeb treatments and [every 1 hour] vitals x 3) were not initiated. [Nurse Practitioner (NP)] recommended transfer to hospital for further evaluation and ordered DuoNeb treatment to be administered until transport arrival. Treatment completed prior to resident's departure . On 6/8/26 at 8:35 AM, Surveyor interviewed LPN-PP, who was the nurse who made the second call to the MD after R66 had worsening respiratory symptoms. LPN-PP stated R66 had oxygen on when LPN-PP first saw R66. LPN-PP indicated the x-ray, DuoNebs and vitals were not completed as first ordered. LPN-PP stated R66 was worsening, and they called the on-call doctor and got orders to do a DuoNeb treatment and to send R66 out to the hospital. LPN-PP stated R66 did not look good. R66 was transferred to the hospital and hospitalized from [DATE] until 2/20/26. R66's Hospital Discharge summary dated [DATE] documents the admission diagnosis of Multifocal Pneumonia, possible catheter-related urinary tract infection, Sepsis . [R66] brought to ER for evaluation of mild hypoxia along with cough and tachycardia. Upon EMS (Emergency Medical Services) arrival, patient's temperature 102.8 F . Required 4 L O2. (Chest x-ray) suspicious for multifocal pneumonia . R66's Hospital After Visit Summary dated 2/20/26 documents, in part: admission diagnosis: Hypoxia, Pneumonia due to infectious organism . Sepsis due to unspecified organism. On 6/4/26 at 8:23 AM, Surveyor interviewed LPN-CC and asked if oxygen should be entered as an MD order in the resident's medical record. LPN-CC stated it would be an MD order. Surveyor asked if DuoNeb treatments would be entered as an MD order. LPN-CC stated it would be an MD order, and the facility has supplies to complete the treatments right away. Surveyor asked if O2 is available at the facility. LPN-CC stated it would be an MD order, and the staff can go to central supply to get the supplies. O2 is available and is stored at the facility as well. Surveyor asked how long a STAT chest X-ray will take to be completed. LPN-CC stated it depends on the time of day. LPN-CC stated that if it is during the day, it typically takes 30 minutes to 2 hours. If off hours, it may take a little more time, but no more than 4 hours. On 6/8/26 at 11:12 AM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked if staff should enter MD orders into the resident's electronic medical record after they are given. DON-B stated yes. Surveyor asked if staff are expected to put in MD orders for oxygen, DuoNebs, and monitoring of O2 requirement if ordered by the Physician. DON-B stated yes, staff should follow through with whatever is ordered. Surveyor asked how long a STAT chest X-ray would take to be completed. DON-B stated it should be done the same day within a 4-to-6-hour window. On 6/8/26 at 9:17 AM, Surveyor interviewed MD-I, who is R66's Doctor and asked if staff should follow MD orders after a respiratory change of condition is identified in a resident. MD-I stated yes. MD-I stated they would expect facility staff to follow all the orders. Surveyor asked how long a STAT chest X-ray would take to be completed. MD-I stated they think it would not take longer than a couple hours to get a result. MD-I stated it shouldn't take longer than that. Surveyor noted according to facility staff, the orders recommended by the MD in the AM of 2/15/26 should have been entered into the medical record and completed. Surveyor noted according to facility staff the x-ray should have been completed between 2 to 6 hours after the order but was not done or resulted even 13 hours after the order was given. On 6/8/26 at 3:49 PM, Surveyor informed Nursing Home Administrator (NHA)-A, DON-B, and Assistant Director of Nursing (ADON)-C of the concern that R66 experienced a respiratory change of condition. The MD was made aware and put new orders in place. Some of these orders were not entered into R66's medical record and were not completed. R66's condition worsened and R66 required hospitalization for Pneumonia and sepsis. 3.) R109 was admitted to the facility on [DATE] with diagnoses to include hemiplegia affecting left nondominant side on the left side of the body and heart failure. R109's Medicare 5 day Minimum Data Set (MDS) with an assessment reference date of 3/30/2026, documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R109 is cognitively intact for decision making. The MDS documents R109 was assessed to have no behaviors exhibited during the look back period. The MDS documents R109 has one stage III pressure injury and five venous and arterial ulcers. R109's care plan documents R109 has actual impaired skin integrity to the Right Lower Leg (Vascular), Right Heel (Vascular), Right Back (Vascular), Right 2nd Toe (Vascular), Left 4th Toe (Vascular), Left 3rd Toe (Vascular), Left 5th toe (vascular) related to limited mobility, alterations in circulation, alterations in sensation, and fragile skin. Contributing factors include right lower extremity peripheral arterial disease with prior occlusion of the superficial femoral artery and dorsalis pedis artery requiring vascular intervention including stenting and angioplasty, hemiplegia affecting the left nondominant side, muscle wasting and atrophy, rheumatoid arthritis, osteoporosis, neuritis, and heart failure which may increase risk for impaired tissue perfusion, delayed wound healing, and skin breakdown. Resident is pleasant, cooperative with care, and able to make needs known. Date Initiated: 02/25/2026. Pertinent interventions include: Check, change, and reposition every 2 hours, offer and assist with toileting. Date Initiated: 02/25/2026 Elevate heels off the bed using pillows or pressure-relieving devices to prevent skin breakdown. Date Initiated: 02/25/2026 Encourage and assist resident to reposition every 2 hours while in bed. Date Initiated: 02/25/2026 Ensure air mattress is in place while resident is in bed. Date Initiated: 02/25/2026 Keep skin clean and dry; apply House Barrier Cream after each incontinence episode. Date Initiated: 02/25/2026 Surveyor noted R109 admitted to the facility with three pressure injuries on 1/9/2026 and the impaired skin integrity care plan was not initiated until 2/25/2026 and new interventions were not added after new wounds developed. R109's Weekly Wound Assessment dated 1/9/2026, the date of admission, documents three deep tissue injuries (DTI,) one on R109's right second toe measuring 0.3 x 0.3 x 0 cm, one on right heel, measuring 3.8 x 2.5 x 0 cm, and one on sacrum measuring 2.3 x 8 x 0 cm. On 1/20/2026, R109 developed two new wounds. The right buttock was assessed as a DTI. The right lower leg was assessed as vascular and measured 1.1 x 1.2 x 0.1 cm, it was documented as dark maroon and nonblanchable. On 1/26/2026, R109 developed 2 more wounds. The left fourth toe was assessed as an unstageable pressure injury measuring 0.5 x 0.7 x 0.2 cm, with 100% slough. The left third toe was assessed as an unstageable pressure measuring 0.7 x 1.1 x 0.2 cm with 100% slough. On 1/29/2026, R109's right buttock wound was reclassified as right back by the Wound Nurse Practitioner (NP)-F and was then assessed as a device associated pressure injury, unstageable with 100% eschar. Surveyor notes R109 had a life vest (a wearable cardioverter defibrillator that continuously monitors heart rhythms and automatically delivers a shock if in life threatening arrhythmia is detected) ordered. On 1/29/2026, a lab specimen was collected from R109's right heel wound. On 2/2/26, the results were reported as infected with methicillin resistant staphylococcus aureus, proteus mirabilis, and mixed skin flora. On 1/30/2026, R109 was admitted to the hospital due to no pedal pulses and diagnosed with a vascular occlusion. R109 returned to the facility on 2/12/2026. R109 returned with a physician order for doxycycline hyclate (antibiotic) 100 MG (milligrams) capsule. Take 1 capsule by mouth every 12 hours for wound infection for 5 days. On 2/18/2026, Wound NP-F ordered a 3 view Xray of left foot, toes and ankle to rule out osteomyelitis. On 2/19/2026, a lab specimen was collected from R109's toe wound (onset 1/26/2026). On 2/23/26, the results were reported as infected with enterococcus faecium and mixed skin flora. On 06/04/2026, at 7:44 AM, Surveyor asked Wound NP-F how R109 eventually developed osteomyelitis. Per Wound NP-F they were doing iodine to help with skin flora, but the wound progressed to the bone being exposed. Imaging was done and R109 had osteomyelitis. On 2/20/26, Wound NP-F assessed and changed R109's left fourth toe, left third toe, right second toe, right heel, and right back to being classified as vascular wounds. On 06/04/2026, at 7:44 AM, Surveyor interviewed Wound NP-F and asked why the pressure wounds were reclassified to vascular from pressure. Wound NP-F stated per communication with the collaborating physician, it was agreed the wounds should be classified as vascular given R109's history. On 2/23/2026, R109's progress note documents: Reported left toe wound culture results with sensitivities to Wound NP. New order received for Doxycycline for 14 days per culture results. NP also notified that right back wound culture remains pending at this time.&r

Based on observation, interview and record review, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 4 (R11, R33, R7 and R108) of 7 sampled residents reviewed for accidents. *On 3/27/26, at 6:15 AM, R11 sustained an unwitnessed fall that resulted in a right hip fracture requiring surgery. R11 was found lying on their fall mat next to their bed by facility staff. R11 was assessed as having difficulty with performing Range of Motion (ROM) with their right leg and increased pain. Facility staff used a mechanical lift to get R11 back into bed even though R11 had changes with their right leg ROM and increased pain. The facility did not complete a thorough fall investigations. *On 4/4/25, at 10:45 AM, R33 sustained a fall during cares. Certified Nursing Assistant (CNA)-LL transferred R33 independently with a Hoyer lift resulting in R33 falling and sustaining a head abrasion. R33 was assessed as requiring a hoyer lift with total assistance with 2 staff members for transferring. On 11/4/25, at 9:45 PM, R33 sustained an unwitnessed fall from bed. R33 was getting cleaned up at 8:30 PM with staff documenting R33 kept trying to roll towards the window and would get upset when staff tried to reposition R33. Staff left the room with R33 moving around restlessly in their bed. *R7 had a fall on 4/13/2026 that was not investigated thoroughly. R7 had a smoking assessment done on 5/12/2026. The assessment and the conclusion were contradictory. *On 11/10/25, at 3:30 PM, R108 was documented as having an unwitnessed fall and was found by staff on the floor. A Registered Nurse (RN) assessment was not completed; the facility did not complete a thorough fall investigation and the new intervention implemented was not consistent with the factors surrounding R108's fall. Findings include: The facility's policy titled Fall Prevention Program, dated 4/15/26, documents the following: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. When any resident experiences a fall, the facility will: Assess the resident. Complete a post fall assessment. Complete an incident report. Notify the Physician and family. Review the resident's care plan and update as indicated. Document all assessments and actions. Obtain witness statements in the case of injury. 1.) R11 was admitted to the facility on [DATE]. R11's diagnoses include right femur fracture, osteoarthritis, cataracts, left humerus fracture, anxiety, right tibia fracture and mild cognitive impairment. R11 was admitted to the facility on [DATE], due to a mechanical fall at home resulting in a right tibia fracture. R11 was admitted with a right lower extremity (RLE) immobilizer with orders to not bear weight on R11's right leg. Surveyor reviewed R11's admission Baseline Care Plan dated 3/11/26, that is documented on paper, which documents the following: (R11) is at risk for falls related to history of fall with fracture, cognitive impairment and NWB RLE. Interventions include: Complete a fall risk evaluation on admission. Place call light within easy reach. Cue for safety awareness. Assist with toileting and transfers. Anticipate needs. Keep environment clutter free/safe. (R11) has potential for behavioral problems related to cognitive impairment. Interventions include: Administer medications as ordered monitoring for side effects and effectiveness. Intervene as needed to protect the rights and safety if others; approach in a calm manner; divert attention; remove from situation/provide decreased stimulation. (R11) has impaired ADLs/mobility related to tibial plateau fracture and NWB RLE. Interventions include: NWB RLE. Maximum assistance is needed with bed mobility, transfers, bathing, ambulation, toileting, eating, dressing and hygiene until evaluation is completed. (R11) uses a walker. (R11) has a knee immobilizer and wears glasses. R11's care plan dated 3/11/26, documents the following: (R11) has an ADL self-care performance deficit and is at risk for falls related to activity intolerance, limited mobility, unaware of safety needs, Weight Bearing As Tolerated (WBAT) on Right Lower Extremity (RLE) and cognitive impairment. Date initiated 3/11/26, revised on 5/1/26. Interventions include: Anticipate and meet (R11's) needs. Date initiated 3/11/26. Be sure (R11's) call light is within reach and encourage (R11) to use it for assistance as needed. Date initiated 3/11/26. Ensure (R11) is wearing appropriate footwear. Date initiated 3/11/26. Bed mobility – Reposition every 2 hours as resident allows. Date initiated 3/11/26, revised on 3/13/26. Toilet use – Offer toileting assistance every 2 hours and as needed. Provide set-up assistance for toileting hygiene. Date initiated 3/11/26, revised on 3/13/26. Transfer – Discontinue Sara Steady lift. (R11) requires a gait belt, 2 wheeled walker and caregiver assist/stand by assist for all functional transfers in the room. WBAT on RLE. Must have on off-loading shoes when up and may require focus on heel weight bearing on Left Lower Extremity (LLE). Date initiated 3/11/26, revised 4/29/26. Review of R11's medical record indicated R11 sustained unwitnessed falls (UWF) on the following dates/times post admission: 3/11/26 at 11:05 PM UWF with no injury 3/19/26 at 9:30 PM UWF with no injury 3/24/26 at 7:25 AM UWF with no injury 3/27/26 at 7:25 AM UWF with hip fracture requiring surgical intervention (hemiarthroplasty) 4/9/26 at 6:15 PM UWF with no injury 4/17/26 at 9:39 AM UWF with no injury 4/18/26 at 7:05 PM UWF with no injury 5/28/26 at 5:03 AM UWF with no injury 6/1/26 at 5:00 AM UWF with no injury Surveyor reviewed R11's fall investigation for R11's unwitnessed fall on 3/11/26, at 11:05 PM, which documents the following: R11 was documented as being found crawling on the floor in their room calling out for help. R11 stated they put on the call light, and nobody answered R11's call light. R11 then went on to the floor and crawled across the room. R11 was assessed as having no change in pain, negative neurological exam and alert and oriented. R11 was transferred to a wheelchair and brought out to the nurse's station as the immediate safety intervention. R11's care plan was updated on 3/12/26 indicating - Sleep study, encourage to be in common areas when awake. Surveyor notes R11's fall investigation did not document an Registered Nurse (RN) assessment, when R11 was last checked or toileted, there was no staff statement to clarify if the call light was on or not as R11 stated and there was no call light audit to try to determine how long R11's call light was activated. There wasn't a comprehensive root cause analysis. R11's admission Minimum Data Set (MDS) completed on 3/16/26, documents R11 has difficulty focusing attention that fluctuates, verbal behaviors that occur 1-3 days a week and behaviors not directed towards others that occur 1-3 days a week. R11's behavioral symptoms are assessed as putting R11 at significant risk for physical illness and/or injury. R11's lower extremities have range of motion impairment to one side. R11 uses a walker and wheelchair. R11 requires supervision when rolling left to right, partial/moderate assistance with toileting hygiene, sit to lying position, lying to sitting position, sitting to standing, and chair/bed transfers. R11 requires substantial/maximal assistance with showering self and putting on footwear. R11 is dependent on staff for toileting transfers. R11 is frequently incontinent with bowel and bladder and was documented as having a fall with a fracture in the last 6 months prior to admission/entry. R11 was documented as having a Brief Interview for Mental Status (BIMS) score of 7, indicating R11 has severe cognitive impairment. R11's Care Area Assessment (CAA) documents the following: Cognitive CAA – (R11) was admitted for a short-term stay. (R11) has an Activated Power of Attorney (APOA) in place. (R11) scores indicate severe impairment on the BIMS with both orientation and recall deficits. (R11) is diagnosed with mild cognitive impairment and anxiety, and a care plan will be created. Functional Abilities CAA – was triggered related to assistance needed with Activities of Daily Living (ADL) tasks. (R11) was admitted status post (s/p) hospitalization following a fall at home with a fracture and multiple other diagnoses with a decline in functional ability. Staff assist (R11) with ADL tasks as necessary and encourage participation in rehab to reach their maximum level of function. Urinary Incontinence CAA – was triggered related to assistance needed with toileting and incontinence. Staff assist (R11) with toileting and incontinence cares as necessary, keeping (R11) clean and dry. (R11's) prompted/assisted toileting plan is in place. Refer to ADL functional CAA/care plan. Falls CAA – was triggered related to a fall prior to (R11's) admission as well as post admission. (R11) is at risk for further falls secondary to unsteady balance and use of antianxiety medications. Staff anticipate (R11's) needs and assist (R11) as necessary. Medications are given as ordered monitoring for side effects and effectiveness. Surveyor reviewed R11's fall investigation for R11's unwitnessed fall on 3/19/26, at 9:30 PM, which documented the following: R11 was noted to be sitting on the floor in R11's room on the left side of the bed when the Certified Nursing Assistant (CNA) answered R11's call light. R11 was noted to have gripper socks on and stated they were going to the bathroom and could not wait for assistance. The root cause for R11's fall was documented as R11 self-transferring trying to go to the bathroom. The immediate safety intervention was documented as, offer R11 to be toileted before going to bed. R11's care plan was updated on 3/20/26 indicating Staff to offer toileting before going to bed. Surveyor noted R11's fall investigation did not document if an RN assessment was completed, staff statements, when R11 was last checked or toileted and whether R11 was continent or not. There wasn't a review to try to determine how long R11's call light was activated before R11 self-transferred and staff responded to the call light. Surveyor reviewed R11's fall investigation for R11's unwitnessed fall on 3/24/26, at 7:25 AM, which documented the following: R11 was overheard calling out and noted to be sitting on the floor in front of R11's wheelchair with legs extended out next to R11's bed. R11 stated they wanted to go to the bathroom and get dressed. Range of Motion (ROM) and neurological checks were noted to be at baseline. R11 was assisted by 2 staff members back to their wheelchair and assisted with toileting. R11 was noted to be last seen at 7:00 AM in bed. The root cause of the fall was documented as R11 self-transferred to the toilet. R11's care plan was updated on 3/24/26 with the intervention: Upon getting (R11) up for the day, complete all ADLs including toileting and dressing. Surveyor noted R11's fall investigation did not document when R11 was last toileted and if an RN completed an assessment. R11's care plan was updated on 3/25/26, documenting (R11) has mixed bladder incontinence. Date initiated 3/25/26. Interventions included: Ensure (R11) has an unobstructed path to the bathroom. Date initiated 3/25/26. Surveyor reviewed R11's fall investigation for R11's unwitnessed fall on 3/27/26, at 6:15 AM, which documented the following: R11 was documented as being found lying flat on the floor next to their bed by the phlebotomist. R11 stated they wanted to get up, get dressed and use the bathroom, and fell. R11 was noted to have normal LLE (left lower extremity) ROM and neurological check. R11 was documented as having difficulty attempting to perform RLE (right lower extremity) ROM. R11 was documented as being hoyer lifted back to bed and documented as having increased pain rated as 7 out of 10. Staff contacted the on-call provider services and R11 was sent out to the emergency room (ER) for evaluation. Surveyor noted R11's fall investigation did not document when R11 was last observed by staff and offered to be toileted by staff. The investigation did not include a review to determine if care planned interventions were implemented or not. The investigation to not review whether R11's call light was within reach and/or activated to complete a comprehensive root cause analysis. R11 was documented as returning back to the facility on 3/31/26. R11's hospital records dated 3/31/26, documented R11 having the following imaging results: A displaced right femoral neck fracture requiring a right hip hemiarthroplasty performed on 3/28/26 and a large right knee effusion with possible hemarthrosis. R11's care plan was updated on 4/1/26 to include: Offer toileting before going to bed. On 6/8/26, at 9:24 AM, Surveyor left a message for Registered Nurse (RN)-MM who was present during R11's UWF with injury on 3/27/26. RN-MM did not return Surveyor's call. On 6/9/26, at 9:43 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-JJ about R11's falls. LPN-JJ stated staff are to perform an assessment on residents who experience a fall. LPN-JJ stated if a resident has a change with ROM and/or pain, staff are to contact the provider before trying to move the resident. LPN-JJ stated staff have the ability to video chat with the provider if a resident experiences a fall after hours. The provider will then provide direction/orders to contact Emergency Medical Services (EMS) or move the resident. LPN-JJ stated RN-MM was the night shift nurse for R11 on 3/27/26. LPN-JJ stated she was coming on shift to take over care for R11 when LPN-JJ was notified that R11 had a fall and RN-MM was working on getting R11 sent out for evaluation. LPN-JJ stated she does not recall seeing R11 prior to them being sent out. Surveyor asked LPN-JJ if she recalls if staff hoyer lifted R11 back to bed. LPN-JJ reviewed R11's EMR and stated it looks like they hoyer lifted R11 back to bed. LPN-JJ then stated she does not recall seeing R11 and this happened before LPN-JJ came on shift. R11's care plan was updated on 4/6/26 to include a new intervention of when (R11) is calling out, respond to (R11's) room and meet needs. Remind (R11) to use the call light. Provide positive reinforcement when using the call light appropriately. R11's care plan was further updated on 4/6/26 documenting, (R11) has a behavior problem related to anxiety, Obsessive Compulsive Disorder (OCD), Normal Pressure Hydrocephalus (NHP), mild cognitive impairment and Activated Power of Attorney (APOA) in place. (R11) yells out and/or calls out from room, verbal aggression with staff/family and (R11) will self-transfer, placing (R11) at risk for falling with an injury. Date initiated 4/6/26. Interventions include: When (R11) is calling out, respond to (R11's) room and meet needs and remind (R11) to use the call light. Provide positive reinforcement when using the call light appropriately. Date initiated 4/6/26. Surveyor reviewed R11's fall investigation for R11's unwitnessed fall on 4/9/26, at 6:09 PM, which documented the following: R11 was documented as found scooting across the floor by facility staff. R11 stated they were trying to scoot to the wheelchair. R11 was documented as having stable vital signs and assessment. R11's care plan was updated on 4/10/26, to include a new intervention to ask psychiatry to see (R11) earlier than 6 – 8 weeks. Surveyor noted R11's fall investigation does not document a comprehensive root cause, when R11 was last seen and toileted, staff statements, if R11's call light was within reach and/or activated and if fall interventions were in place. Surveyor reviewed R11's fall investigation for R11's unwitnessed fall on 4/17/26, at 7:30 AM, which documented the following: R11 was documented as being on the floor, on knees crawling to the door. Skin assessment and vital signs were completed and R11 was unable to relay to staff why they were on the floor. An RN assessment was performed and R11 was transferred back to the wheelchair. R11's care plan was updated on 4/20/26 with the intervention Re-educate (R11) to call for help and reeducate staff to get (R11) up out of bed if R11 is awake. Place a sign reminder to call for help using the call light. Surveyor noted R11's fall investigation does not document a comprehensive root cause, when R11 was last seen or toileted, staff statements, if R11's call light was activated or in reach, and if fall interventions were in place at the time of R11's fall. On 6/2/26, at 8:08 AM, Surveyor interviewed R11 in their room. R11 was sitting in their wheelchair with a cushion, dressed in personal clothes with laced shoes on. R11 stated they slept well and denied any concerns. Surveyor observed R11's room had a low bed in the lowest position with bilateral floor mats on the floor on each side of the bed. R11 is noted to independently, self-propel in wheelchair. Surveyor noted R11's care plan intervention dated 4/20/26, indicated R11 is to have a sign placed in R11's room reminding R11 to call for help by using the call light. Surveyor noted there are no signs in R11's room with reminders for R11 to use the call light for help. On 6/9/26, at 8:07 AM, Surveyor observed R11's room and noted R11's bed was in the lowest position, with a bolstered mattress, bilateral fall mats against the bed on the floor. Surveyor noted there are no signs in R11's room reminding them of safety interventions. R11 was observed self-propelling in the common television. R11's care plan was updated on 5/23/26to indicate- Distract (R11) from wandering by offering pleasant diversions, structured activities, food, conversation, television or book. (R11) prefers conversations and Television, including I love [NAME]. R11's care plan was updated on 5/27/26to indicate Move (R11) to room closer to nurses station. Surveyor reviewed R11's fall investigation for R11's unwitnessed fall on 5/28/26, at 3:35 AM, which documented the following: R11 was documented crawling on the floor by facility staff. R11 stated they crawled out of bed onto the floor mat and needed to get up now. R11 was last checked and asked to be toileted at 2:30 AM. An assessment was performed including neurological check, vital signs and skin check. The on-call provider was contacted and provided new orders for R11 was to follow up with their Primary Care Provider (PCP) later that day (5/28/26). R11 was assisted into the wheelchair and brought to the nursing station to talk with staff. Fall interventions were documented being in place at the time of R11's fall. Root cause was documented as R11 recently had an environment change from subacute to long-term care, which can take some adjustment to the unit. R11's care plan was updated on 5/28/26 to include a fall mat on floor beside the bed. Repeat a 3-day sleep study due to a change in environment. Do not wake up (R11) if sleeping for vital signs. Surveyor notes R11's fall investigation does not document if R11's call light was activated. Surveyor noted R11 did not follow up with R11's PCP per new order from the on-call provider. Surveyor reviewed R11's fall investigation for R11's unwitnessed fall on 6/1/26, at 5:00 AM, which documented the following: R11 was documented being found down on the fall mat next to the bed. Staff statement indicated R11's call light was noted to be activated at the time of the fall. Assessments included skin check, neurological check, vital signs, and ROM. R11 was continent of urine at the time of the fall and R11 stated they were trying to get up. The root cause was documented as the following: falls are going to be unavoidable for R11 due to cognitive impairment. R11 likes to lay on the floor mat and crawl around. The facility will try to keep R11 safe and free from injury. R11 loves to watch I Love [NAME], but I Love [NAME] is not on 24/7. R11's care plan was updated on 6/1/26 to include a Bolster mattress to define bed border. Surveyor noted R11's fall investigation does not document when R11 was last seen and toileted. On 6/4/26, at 8:04 AM, Surveyor interviewed Medication Technician (Med-Tech)-KK who stated R11 was previously on the subacute unit and recently moved to the Long-Term Care (LTC) unit. R11 is very anxious and needs things right away. R11 is known for crawling around on the floor in their room. Med-Tech-KK stated R11's call light would be activated and 10 second later, R11 would be crawling around the room. Med-Tech-KK stated R11 is more anxious on the LTC unit due to having a friend that resides on the subacute unit. Surveyor asked Med-Tech-KK how the facility prevents falls with R11. Med-Tech-KK stated they placed a regular mattress on the side of R11's bed facing the door that faces the center of the room and a fall mat in between R11's bed and window. Facility staff will often take R11 over to the subacute unit for R11 to eat with their friend. Med-Tech-KK stated R11 was noted to be looking for their daughter the other day and Med-Tech-KK took R11 outside as a distraction to look for R11's daughter. Med-Tech-KK stated they do lots of reminders for R11. On 6/4/26, at 12:51 PM, Surveyor asked Nursing Home Administrator (NHA)-A if there were any additional documents to go with R11's fall investigations that also included a root cause analysis of each fall. NHA-A stated the root cause analysis is at the bottom of the fall investigation sheet. On 6/8/26, at 9:51 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who stated if a resident falls, nursing staff will assess the resident, look for obvious things wrong, such as a leg that looks different or an injury. ADON-C stated the resident will be sent out for evaluation automatically if they hit their head. Staff will assess pain, notify the Medical Director (MD)-H, complete an incident report and document a progress note. ADON-C stated each tab in the fall incident report prompts the nurse on what to complete and what to do. Surveyor asked ADON-C what facility staff do if changes are noted with ROM or increased pain. ADON-C stated staff will notify the MD and send the resident to the hospital. ADON-C stated staff are not to move a resident back to bed if a leg injury is noted. ADON-C stated if the resident has ROM abnormalities and/or a change in pain, facility staff are to ask EMS or the MD what the recommendation is to see if they are okay to move the resident back to bed. ADON-C stated it's situational if staff move the resident. Fall incident reports are reviewed in morning meetings and they think about why the fall is happening and nail it on the head and try to figure out why, if repeated falls keep happening. Morning meetings are used to discuss root causes of falls. ADON-C stated NHA-A is the final person to close out fall investigations. Surveyor asked ADON-C about R11, and ADON-C stated R11 is very impulsive. R11 waxes and wanes with impulsivity and can become behavioral at times. ADON-C stated they keep R11 engaged. ADON-C stated a lot of falls happen in bed and we try to keep R11 out of bed and toileted. R11 likes to be engaged and if facility staff note R11 awake in the middle of the night, staff will offer R11 a snack and toilet them. ADON-C stated the facility talked with R11's family after multiple falls, and family indicated R11 has a variable sleep pattern where R11 will get up and down and up and down. Surveyor notified ADON-C of the following concerns: R11 sustained an UWF on 3/27/26, with documented ROM and pain changes. Facility staff hoyer lifted R11 back into bed prior to being sent out for an evaluation of the ROM and pain changes. R11 sustained a displaced right femoral neck fracture requiring a right hip hemiarthroplasty performed on 3/28/26. Surveyor observed no fall sign in R11's room on 6/2/26, at 8:08 AM and 6/9/26 at 8:07 AM, as indicated on the care plan. The facility did not complete a thorough fall investigation for each fall as noted above. The facility did not complete a thorough root cause analysis for R11's falls to help determine possible causes and develop interventions based on the possible root cause. R11 had a bolster mattress applied on 6/1/26, after R11 experienced 9 falls. Surveyor notified ADON-C of these concerns identified and requested additional information if available. 2.) R33 was admitted to the facility on [DATE]. R33's diagnoses include spondylosis, cognitive deficit, hearing loss, anxiety and Altered Mental Status (AMS). On 6/2/26, at 7:58 AM, Surveyor observed R33 lying in bed supine in a low bed with the bed in the lowest position. Surveyor observed R33's call light on the floor on left side of the bed out of reach. Bilateral fall mats were present on each side of the bed. On 6/2/26, at 1:09 PM, Surveyor observed R33 lying in bed supine with head of bed at approximately 45 degrees and call light hanging behind the bed on the floor out of reach from R33. The bed was in the lowest position with fall mats on each side of the bed. On 6/3/26, at 8:11 AM, Surveyor observed R33 lying in bed supine with bed in the lowest position and bilateral fall mats on each side of the bed. Surveyor observed a call light laying on the floor out of reach from R33. On 6/4/26, and 8:01 AM, Surveyor observed R33 lying in bed supine with the bed in the lowest position. Surveyor observed the right side of the bed with no fall mat present and one a fall mat on the left side of the bed. R33's call light was located out of reach on the floor. On 6/8/26, at 7:49 AM, Surveyor observed R33 lying in bed supine with the low bed in the lowest position, a fall mat on the left side of the bed and no fall mats present on the right side of bed. R33's Broda chair was observed pushed up to the right side of the bed with the feet of the chair touching the bed. R33's call light was laying on the floor behind the bed out of reach of R33. On 6/9/26, at 7:58 AM, Surveyor observed R33 lying in bed supine with head of bed approximately 15 degrees . R33's call light was observed laying on the floor behind the bed out of reach. Surveyor notes R33's call light appears to be in the same position as the previous day on 6/8/26 at 7:49 AM. Surveyor observed R33's Broda chair pushed up to the right side of the bed with the feet of the chair touching the bed and a fall mats on the left side of the bed only. On 6/4/26, at 8:04 AM, Surveyor interviewed Medication Technician (Med-Tech)-KK who stated R33 wiggles a lot. Med-Tech-KK stated R33's family requests R33 be up in the Broda chair throughout the day. R33's care plan documents the following: (R33) is at risk for falls related to deconditioning, dementia, balance problems and incontinence. Date initiated 7/4/21, revised on 12/1/25. Interventions include: Educate staff on bed positioning during cares. Date initiated 2/24/25. Bed is to be in lowest position. Date initiated 11/8/21, revised on 10/24/24. Offer (R33) to lay down for bed in between 8:00 PM and 9:00 PM. Date initiated 12/1/25. Anticipate and meet (R33's) needs. Date initiated 7/4/21, revised on 10/24/24. Neuro-checks to be completed per policy. Date initiated 7/4/21, revised on 10/24/24. Pharmacy consult to evaluate medications. Date initiated 7/4/21. Physical therapy evaluate and treat as ordered or as needed. Date initiated 7/4/21. Position (R33) in the center of the bed and two staff members for all cares. Date initiated 11/6/25. (R33) has bowel incontinence related to impaired mobility and dementia. Date initiated 7/4/21, revised on 1/21/22. Interventions include: Check (R33) every 2 hours and assist with check and change as needed. Date initiated 7/4/21, revised on 11/30/24. (R33) has an Activities of Daily Living (ADL) self-care performance deficit related to dementia and impaired balance. Date initiated 7/4/21, revised on 12/1/25. Interventions include: (R33) uses a Broda chair and is an assist of one. Date initiated 11/8/21, revised on 4/17/26. (R33) requires two staff members for assistance with bed mobility. Date initiated 10/24/23, revised on 10/24/24. Check and change every 2 hours and as needed. (R33) is incontinent of bowel and bladder. Provide Peri cares following episodes of incontinence. Date initiated 7/4/21, revised on 11/30/24. (R33) requires a Hoyer lift with total assistance of two staff members. Date initiated 7/4/21, revised on 5/24/23. Surveyor reviewed R33's Electronic Medical Record (EMR) which documents the Fall Risk Assessments: 9/11/25 – moderate risk 11/4/25 – moderate risk 11/28/25 – moderate risk Surveyor reviewed R33's fall investigation dated 11/4/25, which documents the following: On 11/4/25, at 9:45 PM, R33 was found lying on the floor mat next to their bed. R33 was lying on their left side naked with a blanket covering them. R33 was last checked and changed one hour prior to the fall. Neurological checks, skin assessment, pain assessment and vital signs were completed. R33's call light was noted to be within reach. Staff statement was documented as R33 was cleaned up at 8:30 PM. While staff provided cares, R33 kept trying to roll towards the window and would get upset when staff tried to reposition R33. When staff were leaving the room, R33 was noted to be moving around their bed. Root cause analysis documented, R33 was not centered properly in the bed. R33 rolled off the edge of the bed. New care plan intervention included position (R33) in the center of the bed and two staff members for all cares. Care plan was updated on 11/6/25. On 6/8/26, at 10:04 PM, Surveyor discussed with ADON-C the detail that R33 was noted by staff providing cares that R33 was upset and rolling within their bed on 11/4/25, at 8:30 PM, and R33 fell out of bed at 9:45 PM. Why did staff potentially leave R33 in an unsafe situation? ADON-C stated the big thing there (referring to R33's fall & the investigation details) is R33 was documented as moving a lot and R33 can't move a lot. ADON-C then stated I don't think R33 has the capability to move on their own and fall out of bed. R33 doesn't have the capability to reach over and turn and doesn't move a lot. There was a question of what really occurred. This was not further investigated by the facility. Surveyor reviewed R33's fall investigation dated 11/28/25, which documents the following: On 11/28/25, at 7:15 PM, R33 was found lying on the floor mat beside the bed. Neurological checks and Registered Nurse (RN) assessment were completed. Fall interventions were noted to be in place at the time of the fall. Surveyor noted the fall investigation does not include when R33 was last seen or toileted. Root cause analysis documented: (R33) is cognitively impaired and can't or won't call for assistance. Staff need to anticipate (R33's) needs. (R33's) family would like (R33) up as much as possible, but (R33) will normally go to bed between 6:00 PM and 7:00 PM. (R33) is still aroused at night. Further intervention is to put (R33) to bed later, to address the issue of (R33) still being aroused. R33's care plan was updated on 12/1/25 to include a new intervention to offer (R33) to l

Based on interview and record review, the facility did not ensure sufficient nursing staff was provided to all residents to maintain or attain their highest practicable physical, mental, and psychosocial well-being. Surveyor conducted a record review of the facility's nursing staff schedule and verified the facility is not providing staffing levels that meet the facility's identified staffing needs documented in the facility assessment for the night shift. The facility did not consistently designate a licensed nurse to serve as a charge nurse on each tour of duty. This deficient practice has the potential to affect all 83 residents residing at the facility. Findings include: The facility's policy titled, Nursing Services and Sufficient Staff and dated 4/21/25 under policy documents It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment. Under Policy Explanation and Compliance Guidelines include documentation of 2. The facility must designate a licensed nurse to serve as a charge nurse on each tour of duty (except when waived). On 6/8/26, at 11:24 a.m., surveyor reviewed the facility assessment last updated 5/30/26. Surveyor noted under the section staffing plan for direct care staff documents 1:9 to 16 ratio days, 1:9 to 16 ratio evenings and 1:8 to 10 ratio nights. Below the staffing ratio is documented Depends on the acute (sic) may be 3-4 Certified Nursing Assistants (CNAs) assigned to 1st and 2nd floor for days and PMs (evenings) and nights will have 2-3. Subacute will have 2 CNAs on all three shifts. Assistance with activities daily living (ADL) section in the facility assessment documented the number of residents who are independent for dressing is 2, require an assist of 1-2 staff is 39, and dependent upon staff is 38. For bathing 5 residents are independent, 53 require assistance of 1-2 staff and dependent is 31. For transfer 7 residents are independent, 58 require assistance of 1-2 staff, and 40 are dependent. For eating 31 residents are independent, 39 require assistance of 1-2 staff, and 11 are dependent. For toileting 4 residents are independent, 39 residents require assistance of 1-2 staff, and 11 are dependent. Surveyor reviewed the daily nursing schedules from 5/3/26 to 6/6/26 and noted the following: On 5/3/26 the census was 88. According to the facility assessment on the night shift there should be 8.8 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 6 CNAs working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/4/26 the census was 88. According to the facility assessment on the night shift there should be 8.8 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 6 CNAs and 1 med tech working as a CNA on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/5/26 the census was 91. According to the facility assessment on the night shift there should be 9.1 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 6 CNAs and 1 med tech working as a CNA on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/6/26 the census was 91. According to the facility assessment on the night shift there should be 9.1 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 6 CNAs working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/7/26 the census was 93. According to the facility assessment on the night shift there should be 9.3 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 8 CNAs, including 2 CNAs who were on orientation working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/8/26 the census was 93. According to the facility assessment on the night shift there should be 9.3 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 7 CNAs, including 2 CNAs who were on orientation working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/9/26 the census was 91. According to the facility assessment on the night shift there should be 9.1 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 7 CNAs, including 1 CNAs who were on orientation and one med tech working as a CNA for a total of 8 on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/10/26 the census was 89. According to the facility assessment on the night shift there should be 8.9 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 6 CNAs working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/12/26 the census was 87. According to the facility assessment on the night shift there should be 8.7 CNAs. Surveyor reviewed the nursing schedule and noted there were 8 CNAs, including 2 CNAs who were on orientation working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/13/26 the census was 88. According to the facility assessment on the night shift there should be 8.8 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 7 CNAs, including 2 CNAs who were on orientation working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/14/26 the census was 86. According to the facility assessment on the night shift there should be 8.6 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 8 CNAs, including 2 CNAs who were on orientation working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/15/26 the census was 86. According to the facility assessment on the night shift there should be 8.6 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 8 CNAs, including 1 CNA who was on orientation working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/16/26 the census was 86. According to the facility assessment on the night shift there should be 8.6 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 6 CNAs working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/17/26 the census was 82. According to the facility assessment on the night shift there should be 8.2 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 6 CNAs working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/18/26 the census was 83. According to the facility assessment on the night shift there should be 8.3 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 7 CNAs working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/19/26 the census was 83. According to the facility assessment on the night shift there should be 8.3 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 6 CNAs and 1 med tech working as a CNA who are on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/20/26 the census was 84. According to the facility assessment on the night shift there should be 8.4 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 6 CNAs working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/21/26 the census was 85. According to the facility assessment on the night shift there should be 8.5 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 6 CNAs working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/22/26 the census was 84. According to the facility assessment on the night shift there should be 8.4 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 6 CNAs working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/23/26 the census was 87. According to the facility assessment on the night shift there should be 8.7 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 4 CNAs and 1 med tech working as a CNA on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/24/26 the census was 85. According to the facility assessment on the night shift there should be 8.5 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 6 CNAs working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/25/26 the census was 85. According to the facility assessment on the night shift there should be 8.5 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 6 CNAs and 1 med tech working as a CNA on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/26/26 the census was 85. According to the facility assessment on the night shift there should be 8.5 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 5 CNAs and 2 med techs working as a CNA on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/27/26 the census was 86. According to the facility assessment on the night shift there should be 8.6 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 5 CNAs and 2 med tech who are working as CNAs working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/28/26 the census was 86. According to the facility assessment on the night shift there should be 8.6 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 5 CNAs and 2 med tech who are working as CNAs working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/29/26 the census was 86. According to the facility assessment on the night shift there should be 8.6 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 6 CNAs working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/30/26 the census was 86. According to the facility assessment on the night shift there should be 8.6 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 6 CNAs and 1 med tech who was working as a CNAs working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 5/31/26 the census was 83. According to the facility assessment on the night shift there should be 8.3 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 6 CNAs working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 6/1/26 the census was 83. According to the facility assessment on the night shift there should be 8.3 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 5 CNAs working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 6/2/26 the census was 84. According to the facility assessment, on the night shift there should be 8.4 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 6 CNAs, 1 orientee, and 1 med tech working as a CNA on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 6/3/26 the census was 83. According to the facility assessment on the night shift there should be 8.3 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 6 CNAs and 1 CNA orientee working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 6/5/26 the census was 83. According to the facility assessment on the night shift there should be 8.3 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 6 CNAs and 1 CNA orientee working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 6/6/26 the census was 84. According to the facility assessment on the night shift there should be 8.4 (Certified Nursing Assistant) CNAs. Surveyor reviewed the nursing schedule and noted there were 6 CNAs working on the night shift. The facility did not meet their staffing level identified in the facility assessment. On 6/9/26, at 11:02 a.m., Director of Nursing (DON)-B provided Surveyor the transfer assistance residents for the 83 residents who resided at the facility when the survey team entered on 6/1/26. Surveyor noted 44 residents required either contact guard or assistance of one staff member and 39 residents required assistance of 2 staff with a mechanical lift. For continence status 15 residents were identified as being continent and 68 residents were identified as being incontinent. Surveyor reviewed the daily nursing schedules from 5/3/26 to 6/6/26 and noted the following: On 5/3/26 there was not a designated charge nurse on the day, evening, & night shifts. On 5/4/26, 5/5/26, 5/6/26, & 5/7/26 there was not a designated charge nurse on the evening & night shifts. On 5/8/26, 5/9/26, 5/10/26, 5/11/26 there was not a designated charge nurse on the day, evening & night shifts. On 5/12/26 there was not a designated charge nurse on the evening shift. On 5/13/26 there was not a designated charge nurse on the day, evening, & night shifts. On 5/14/26 there was not a designated charge nurse on the day & evening shifts. On 5/15/26 there was not a designated charge nurse on the day, evening, & night shifts. On 5/16/26 there was not a designated charge nurse on the evening & night shifts. On 5/17/26 there was not a designated charge nurse on the day & evening shifts. On 5/18/26 there was not a designated charge nurse on the day, evening, & night shifts. On 5/19/26 there was not a designated charge nurse on the day & evening shifts. On 5/20/26, 5/21/26, 5/22/26, 5/23/26, 5/24/26, & 5/25/26 there was not a designated charge nurse on the day, evening, & night shifts. On 5/26/26 there was not a designated charge nurse on the day and evening shifts. On 5/27/26, 5/28/26, & 5/29/26 there was not a designated charge nurse on the day, evening and night shifts. On 5/30/26 & 5/31/26 there was not a designated charge nurse on the evening shifts. On 6/1/26 there was not a designated charge nurse on the day and evening shifts. On 6/2/26 there was not a designated charge nurse on the day, evening, and night shifts. On 6/3/26 there was not a designated charge nurse on the day shift. On 6/4/26 there was not a designated charge nurse on the day, evening, and night shifts. On 6/5/26 there was not a designated charge nurse on the day shift. On 6/6/26 there was not a designated charge nurse on the day, evening, and night shifts. On 6/9/26, at 8:12 a.m., Surveyor interviewed Scheduler-J to inquire how she determines to staff the facility. Scheduler-J informed surveyor it's based on acuity of the residents in the facility. Surveyor asked if there is a minimum number of Certified Nursing Assistants (CNAs) required. Scheduler-J informed surveyor she usually gets the number from Nursing Home Administrator (NHA)-A which fluctuates based on census. Surveyor asked Scheduler-J if she reviews the facility assessment to ensure they have the required number of staff based on the facility assessment. Scheduler-J informed surveyor that would be NHA-A. Surveyor informed Scheduler-J surveyor had reviewed the daily nursing schedule from 5/3/26 to 6/6/26 and didn't note where the facility designated a charge nurse each shift. Scheduler-J informed surveyor the charge nurse is their unit manager. Surveyor informed Scheduler-J there are days on the day shift when there are two-unit managers listed but there isn't a charge nurse designated. Scheduler-J informed surveyor there are shifts they don't have a charge nurse because they are constantly going through staff. On 6/9/26, at 9:12 a.m., Surveyor asked NHA-A how the facility determines the number of nursing staff required each shift. NHA-A replied how many residents we have and the acuity on that unit. Surveyor informed NHA-A surveyor noted based on the facility's assessment they meet their staff ratios for day and evening shift but not for the night shift. Surveyor informed NHA-A that the facility assessment indicates a ratio of one staff to eight to ten residents. Surveyor informed NHA-A surveyor had required the facility's staffing from 5/3/26 to 6/6/26 and noted on nights many days reviewed there are only six CNAs on the schedule for nights. NHA-A informed surveyor she thought the scheduler increased this referring to the number of CNAs on the night shift. On 6/4/26, Surveyor reviewed the facility's nursing staff daily schedules from September 2025 to November 2025. Surveyor noted the Facility was short-staffed on the following dates: On 9/15/25, the census was 82. On night shift the total CNAs working was 5. Based on the census and facility assessment, the lowest total number of CNAs required that shift would be 8. This shift only had 1 CNA staffed for the rehab unit, and the assessment stated the rehab unit should have 2 CNAs on all 3 shifts. On 9/20/25, the census was 84. On night shift there was not a nurse scheduled on the 1st floor, 5 CNAs scheduled total, and only 1 CNA working on the rehab unit. According to the census and facility assessment there should be at least 1 Nurse working night shift on the 1st floor, 8 CNAs total, and the rehab unit should have 2 CNAs scheduled. On 9/29/25, the census was 89. On night shift there were 6 CNAs scheduled total and on AM shift there were 3 Nurse and 1 orientee scheduled, with only 1 Nurse on the rehab unit. According to the census and facility assessment there should be at least 8 CNAs total. On AM shift there should be at least 4 Nurses scheduled. On 6/9/26, at 11:12 AM, Surveyor interviewed Scheduler-J regarding low staffing. Surveyor asked Scheduler-J about the staffing numbers for the dates 9/15/25, 9/20/25, and 9/29/25. Surveyor asked Scheduler-J if the facility was short staffed for the shifts on those dates. Scheduler-J reviewed the schedule and agreed the listed days were short staffed and the facility units did not have full coverage. Surveyor asked Scheduler-J if they knew why the facility was short staffed on those dates and if Scheduler-J knew if they attempted to cover the shifts with different staff. Scheduler-J indicated they did not know why they were short staffed and whether there was an attempt to cover the missing staff on those dates. On 6/9/26 at 11:45 AM, Surveyor shared the concern of short staffing on 9/15/25, 9/20/25, and 9/29/25 with Nursing Home Administrator (NHA)-A.

Based on interview and record review, the Facility did not ensure 4 (R2, R91, R4, & R5 ) of 5 sampled residents reviewed for unnecessary medications received psychotropic medications that were ordered properly, had appropriate indications for use, were monitored and care planned. * R2's as needed lorazepam medication used for anxiety did not have an end date. * R91 did not have an up to date Abnormal Involuntary Movement Scale (AIMS) assessment completed while receiving a psychotropic medication and as needed lorazepam medication did not have an end date. * R4 was receiving a psychotropic medication without an indication for use and no monitoring of behaviors. * R5 started a hypnotic medication for insomnia. The facility did not complete a sleep assessment. R5 did not have a care plan related to their insomnia. Findings include: The facility policy titled Use of Psychotropic Medication(s) implemented on 1/15/2026 documented: It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint.Policy Explanation and Compliance Guidelines: .2. Psychotropic medications are to be used only when a practitioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). 3. Other medications not classified as antipsychotic, antidepressant, antianxiety, or hypnotic medication but can affect brain activity should not be used as a substitution for another psychotropic medication unless prescribed with a documented clinical indication for use consistent with accepted clinical standards of practice.13. Residents who receive antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS) test performed on admission, quarterly, with a significant change in condition, change in antipsychotic medication, as needed (PRN) or as per facility policy. 14. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: .c. During Minimum Data Set (MDS) review (quarterly, annually .)d. In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care.16. a. PRN orders for psychotropic medications . shall be limited to no more than 14 days . 1.) R2 admitted to the facility on [DATE]. R2 has diagnoses that included anxiety disorder, and chronic respiratory failure with tracheostomy. R2's quarterly Minimum Data Set (MDS) dated [DATE] indicated R2 has severely impaired cognition with a Brief Interview for Mental Status score of 3. Surveyor reviewed R2's physician orders and noted an order for:-Lorazepam (anti-anxiety medication) oral tablet 1 mg- Give 1 tablet by mouth every 1 hour as needed for Anxiety. With an order date of: 1/27/2026 and no end date ordered. Surveyor noted there is not an end date for the as needed lorazepam. Surveyor also noted the order is for oral medication administration when R2 takes medications via percutaneous endoscopic gastrostomy (PEG tube). On 6/8/2026, at 3:41 PM surveyor interviewed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Assistant Director of Nursing (ADON)-C. NHA-A stated there should be a 14 day stop date on as needed orders for psychotropic medications and would look into getting an end date for R2's lorazepam medication. Surveyor confirmed R2 should have medications via PEG tube and not orally. NHA-A and DON-B agreed R2 should have medications via PEG tube and would look into R2's physician orders to ensure accuracy. 2.) R91 has diagnoses that included anxiety disorder, vascular dementia, and major depressive disorder. R91's quarterly Minimum Data Set (MDS) dated [DATE] indicated R91 has severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 0. Surveyor reviewed R91's physician orders and noted an order for:- Lorazepam (anti-anxiety medication) oral tablet 1 mg- Give 1 tablet by mouth every 1 hour as needed for Anxiety. With an order date of: 3/6/2026 and no end date ordered. Surveyor reviewed R91's assessments and noted the last documented Abnormal Involuntary Movement Scale (AIMS) assessment for R91 was on 11/10/2025. On 6/8/2026, at 3:41 PM surveyor interviewed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Assistant Director of Nursing (ADON)-C. NHA-A stated there should be a 14 day stop date on as needed orders for psychotropic medications and would look into getting an end date for R91's lorazepam medication. Surveyor shared concerns R91 did not have a recent AIMS assessment completed. ADON-C stated residents should have AIMS assessments completed on admission, change in status, medication adjustment if the resident is on a prescribed psychotropic medication. ADON-C stated any of the nursing staff and management can do an AIMS test on a resident however, the facility noted a problem with Point Click Care (PCC- electronic medical record system) that it was eliminating the reminders for some of the required assessments such as the AIMS assessment. ADON-C stated they are trying to catch up with the assessments that were due. NHA-A stated nursing is catching up to the required assessments. 3.) R4 admitted to the facility on [DATE] and had diagnoses that included Major Depressive Disorder, and dementia with agitation. R4's care plan documented: Uses psychotropic medications Buspar, Depakote and Quetiapine r/t (related to) depression - date Initiated 10/21/25. Interventions: Administer psychotropic medications as ordered by Physician. Monitor for side effects and effectiveness every shift. Monitor/document/report PRN (as needed) any adverse reactions of psychotropic medications: Unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Behavior problem r/t Dementia e/b (evidenced by) not recognizing limitations and safety concerns so will self-transfer/ambulate, resistive to staff redirection when doing so/staff assistance, wanders unit at times with attempts to enter other rooms when looking for her own - date Initiated 7/23/25. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Explain all procedures to the resident before starting. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Minimize potential for the resident's potential disruptive behaviors (wandering) by offering activities and tasks which divert attention such as (groups, 1:1s, TV, reading material, music etcetera). Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. R4's admission orders included an order for Quetiapine Fumarate oral Tablet 25 mg (milligrams) by mouth at bedtime for restlessness - dated 7/10/25. Surveyor noted the diagnosis for Quetiapine was changed to dementia with associated psychotic and/or agitated behaviors on 12/8/25. Surveyor noted Depakote Sprinkles delayed release 125 mg by mouth two times a day for dementia with agitation was ordered on 7/30/25. Surveyor noted Buspirone HCl (hydrochloride) 5 mg by mouth three times a day for anxiety was ordered on 7/17/25. The Buspirone was increased to 10 mg three times a day related to major depressive disorder on 7/30/25. R4 was followed by psychiatry. Progress note dated 4/30/26 at 1:30 PM documented: GDR (gradual dose reduction) of psychotropics not clinically indicated at this time. Resident continues to be followed by psych services for her anxiety and dementia. Surveyor reviewed R4's July 2025 Medication Administration Record (MAR) which documented: Enter the number that coincides with the behavior: 0-None, 1-Hitting, 2- Restlessness, 4-Withdrawal, 5-Combativeness, 6-Verbal outbursts, 8-Tearfulness, 9-Crying, 10-Paranoia, 11-Yelling, 12-Other (Describe) every shift for Behaviors. Surveyor noted that before Buspirone was ordered on 7/17/25, there was only 1 entry of 2 (restlessness) on 7/15/25 during the hours of 11 pm – 7 am. All other entries were 0. Surveyor noted before Depakote was ordered and Buspirone was increased on 7/30/25, there were only 4 entries of 2 (restlessness) on 7/19/25, 7/28/25 and 7/31/25 during the hours of 11 pm -7 am and on 7/29/25 during the hours of 7 am – 3 pm. All other entries were 0. There were no entries of agitation, hitting or combativeness. On 6/9/26 at 7:39 AM, Surveyor asked Nursing Home Administrator (NHA)-A why the Quetiapine and Buspirone diagnoses were changed. NHA-A reported R4 was initially seen by psychiatry and then the facility switched providers, who then changed the diagnoses. Surveyor asked why R4 was started on Buspirone and Depakote within a month after admission. Surveyor was unable to locate documentation of behaviors and told NHA-A there is no documentation of behaviors to support the use of the medications. NHA-A stated, There isn't any, I looked, the sheets are blank. But I can tell you she had behaviors, and she is much better now. Surveyor informed NHA-A of concern R4 was prescribed Buspirone for anxiety and major depressive disorder and Depakote for dementia with agitation within 1 month of admission and there is no evidence to support the clinical use of these medications, there was no specific behavior monitoring identified. No additional information was provided 4.) R5 was admitted to the facility on [DATE] with a diagnoses of obsessive-compulsive disorder, depression and anxiety. The admission physician orders included trazodone HCl (hydrochloride) Oral Tablet 150 MG. Give 150 mg orally at bedtime for Anxiety DepressionStarted on 1/13/2026 and discontinued on 3/4/2026. On 3/6/26 the trazadone was switched to Daridorexant HCl Oral Tablet 50 MG. Give 1 tablet by mouth at bedtime for Insomnia starting 3/6/26. This remains a current medication. On 3/4/26 a Psych Consult Assessment was completed. The assessment documented (R5's) sleep has been terrible. They receive trazadone at night and do not fall asleep for about 2 and 1/2 hours and then they often only sleep 3 or 4 hours at a time. Discussed risk and benefit of switching from Trazodone to Quviviq (Daridorexant). (R5) would like to try this. We'll begin weaning off Trazodone and start Quviviq tonight. R5's medical record did not include documentation of a sleep assessment and care plan for insomnia. The Quarterly Minimum Data Set (MDS) assessment completed on 5/14/26. Indicated a Hypnotic medication is administered daily. On 6/04/2026, at 10:46 AM, Surveyor requested additional information from Nursing Home Administrator-A. Nursing Home Administrator-A stated Director of Nurses (DON) -B does the sleep assessments and they are on paper. The Medical Record staff at the time was not scanning them in stating there are no paper charts. On 6/04/2026, at 11:40 AM. Surveyor interviewed Minimum Data Set Coordinator (MDSC)-M. MDSC reviewed the care plans for R5 and did not see a care plan for R5's insomnia or hypnotic medication. MDSC-M shared they typically complete them and it must have been missed. On 6/04/2026, at 11:51 AM, MDSC-M spoke with Surveyor. MDSC-M clarified a hypnotic medication would be addressed in the psych medication care plan. This would be because of the classification of the medication and not for what it is treating. MDSC-M did not have a care plan for insomnia. On 6/04/2026, at 12:46 PM, Medical Records (MK) -K supplied a Sleep Pattern for 1/14/26 - 1/15/26. There were no additional documents to address an assessment of R5's insomnia. On 6/08/2026, at 7:35 AM, Surveyor interviewed DON-B. DON-B stated the sleep assessment forms are a 3-day sleep diary. There are no additional sleep assessment documents. There was no care plan for insomnia developed based on a comprehensive sleep assessment.

Based on interview and record review, the facility did not ensure upon transfer or discharge of 6 (R105, R103, R13, R8, R14 and R66) of 7 sampled residents the resident was provided proper notices related to transfer and bed hold, and a process was established to ensure the Ombudsman was notified of the resident transfers and discharges in the facility. * R105 was discharged home 1/30/26. The facility did not notify the Ombudsman of this discharge. * R103 was discharged home 3/6/26. The facility did not notify the Ombudsman of this discharge. * R13 was transferred to the hospital on 5/31/26 and has not yet returned to the facility. The facility did not have documentation of providing bed-hold information, a transfer notice and notification to the Ombudsman regarding the transfer. * R8 did not receive a bed hold or transfer notice in writing from the facility when sent to the hospital on 2/26/26 and 3/18/26, the Ombudsman was not notified of the discharges. * R14was transferred to the hospital on [DATE] and 2/3/26. The facility did not have documentation that bed-hold information and transfer notice was provided to R14 or R14's representative. The facility did not notify the Ombudsman of R14's transfer. * R66 was transferred to the hospital on 5/13/25, 6/25/25, 7/18/25, 8/6/25, 12/23/25 and 2/15/26. The facility did not have documentation that bed-hold information and transfer notice was provided to R66 or R66's representative. The facility did not notify the Ombudsman of R66's transfer. Findings include: The facility policy titled, Transfer and Discharge, date implemented 4/15/26, documented, in part, . Policy: It is the policy of this facility to permit each resident to remain in the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source.Policy explanation and Compliance Guidelines: . 3. The facility's transfer/discharge notice will be provided to the resident and/or representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: The specific reason and basis for the transfer or discharge. The effective date of transfer or discharge. The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged . An explanation of the right to appeal the transfer or discharge to the State. The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests. Information on how to obtain an appeal form. Information on obtaining assistance in completing and submitting the appeal hearing request. The name, address (mailing and email), and phone number of the representative of the Office of the State Long-term Care Ombudsman. 5. The facility will maintain evidence that the notice was went to the Ombudsman. 1.) R105 was admitted to the facility on [DATE] and discharged on 1/30/26. R105's Progress Note, dated 1/30/26 at 15:30 (3:30 PM), documented, Health Status Note, Note Text: discharged home from facility. Left via private vehicle accompanied by son. Took discharge paperwork, remaining belongings, and remaining meds (medications) home. Alert and responsive skin warm and dry. Lungs clear, no complaints of sob (shortness of breath) or dyspnea. Abdomen soft non-tender with bowel sounds present x 4. No complaints of pain noted. On 06/09/26 at 8:37 AM, Surveyor asked Nursing Home Administrator (NHA)-A if NHA-A could provide evidence of Ombudsman notification for R105's discharge on [DATE]. NHA-A stated that Business Office Manager (BOM)-AA was responsible for Ombudsman notification and NHA-A discovered BOM-AA was not providing the notifications. Surveyor notified NHA-A of concern regarding no ombudsman notification for R105's discharge. 2.) On 2/26/2026, at 5:57PM, R8's progress note documents writer spoke with. R8 was admitted for Acute Respiratory Failure and is in ICU (Intensive Care Unit). Surveyor noted R8 returned to the facility on 3/4/2026 from the hospital. On 3/18/2026, at 06:32 AM, R8's progress note documents R8 continues to have hypotension and lethargy, difficult to arouse, new order to send to ER (emergency room) for eval/treat. Surveyor noted R8 returned to the facility on 3/27/2026 from the hospital. Surveyor reviewed R8's medical record. Surveyor noted the facility did not document that they provided R8 or R8's representative with bed-hold information or transfer notices for either of R8's hospitalizations. On 6/03/2026, at 3:13 PM, at the facility exit meeting with Nursing Home Administrator (NHA)-A, Director of Nursing-B and Assistant Director of Nursing-C, NHA-A stated the Ombudsman has not been notified monthly of discharges. The Business Office staff (Business Office Manager -BOM-AA) left and was not doing this task. On 6/8/26 at 9:44 AM, Surveyor interviewed NHA-A. Surveyor asked if R8 was provided bed-hold information or transfer notice when R8 was transferred to the hospital on 2/26/2026 and 3/18/2026. NHA-A stated that they did not have the bed-hold or transfer notices for R8. Surveyor asked if the Ombudsman was notified of R8's transfers to the hospital. NHA-A indicated the Ombudsman was not notified. 3.) R13's medical record was reviewed. R13 has resided in the facility since 8/19/20 and has an activated Power of Attorney for Healthcare (POAHC). R13 is currently on hospice services A Nurses Note on 5/31/26 documented R13 was sent to the hospital for a change in condition. This change in condition was discussed with the POAHC and Hospice. R13 was admitted to the hospital and has yet to return. R13's medical record did not include documentation of bed-hold information and transfer notice requirements. On 6/03/2026, at 12:48 PM, Surveyor requested additional information from Nursing Home Administrator (NHA)-A. NHA-A stated they don't have the paperwork. This includes the Bed-Hold and Transfer Form. On 6/03/2026, at 3:13 PM, at the facility exit meeting with Administrator-A, Director of Nurses (DON)-B and Assistant Director of Nurses (ADON)-C, Administrator-A stated the Ombudsman has not been notified monthly. The Business Office staff left and did not do this task. 4.) R103's medical record was reviewed. R103 had a planned discharge home on 3/6/26. Surveyor requested the Ombudsman notification related to R103's discharge from Nursing Home Administrator (NHA)-A. On 6/03/2026, at 3:13 PM, at the facility exit meeting with NHA-A, Director of Nurses (DON)-B and Assistant Director of Nurses (ADON)-C, NHA-A stated the Ombudsman was not notified of R105'w discharge. NHA-A stated the Business Office staff left and did not do this task. 5.) R14 was admitted to the facility on [DATE]. R14 experienced a change of condition on 12/16/25. R14 was transferred to the hospital and returned to the facility on [DATE]. R14 experienced a change of condition on 2/3/26. R14 was transferred to the hospital and returned to the facility on 2/6/26. Surveyor reviewed R14's medical record. Surveyor noted the facility did not document that they provided R14 or R14's representative with bed-hold information or transfer notices for either of R14's hospitalizations. On 6/3/26 at 3:22 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A. NHA-A informed Surveyor that the business office does not have a business office manager at the present time. On 6/8/26 at 9:44 AM, Surveyor returned to NHA-A. Surveyor asked if R14 was provided bed-hold information or transfer notice when R14 was transferred to the hospital on [DATE] and 2/6/26. NHA-A stated that they did not have the bed-hold or transfer notice for R14. Surveyor asked if the Ombudsman was notified of R14's transfers to the hospital. NHA-A indicated that the person in charge of the business office was not doing their job. The Ombudsman was not notified. 6.) R66 was admitted to the facility on [DATE]. R66 experienced a change of condition on 5/13/25. R66 was transferred to the hospital and returned to the facility on 5/22/25. R66 experienced a change of condition on 6/25/25. R66 was transferred to the hospital and returned to the facility on 7/2/25. R66 experienced a change of condition on 7/18/25. R66 was transferred to the hospital and returned to the facility on 7/28/25. R66 experienced a change of condition on 8/6/25. R66 was transferred to the hospital and returned to the facility on 8/11/25. R66 experienced a change of condition on 12/23/25. R66 was transferred to the hospital and returned to the facility on [DATE]. R66 experienced a change of condition on 2/15/26. R66 was transferred to the hospital and returned to the facility on 2/20/26. Surveyor reviewed R66's medical record. Surveyor noted that the facility did not document that they provided R66 or R66's representative with bed-hold information or transfer notices for any of R66's hospitalizations. On 6/3/26 at 3:22 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A. NHA-A informed Surveyor that the business office does not have a business office manager at the present time. Surveyor asked for evidence that the facility provided bed-hold information and transfer notices to R66 or R66's representative. NHA-A stated good luck with that. We do not have them. The previous person in charge of the business office was not doing their job. Surveyor asked if the Ombudsman was notified of R66's transfers. NHA-A indicated that the Ombudsman was not notified.

Based on interview and record review the facility did not ensure that 4 out of 5 Certified Nursing Assistants (CNAs) completed required dementia training annually. This has the potential to affect a pattern of the 83 residents residing in the facility who receive care from the 4 staff members.*CNA-Q, CNA-R, CNA-S, and CNA-V did not have documentation they had completed required dementia training.Findings include:The facility's policy titled, competency evaluation, dated 3/15/2026, documented it is the policy of this facility to evaluate each employee to assure they meet appropriate competencies and skills for performing their job. the knowledge and skills required among staff to meet residences needs are determined through the facility assessment process. Checklists are used to document training and competency evaluations. employee competency forms are maintained in the staff development coordinators office for current training year, then forwarded to the human resources director for placing into the employees personal file.The facility's Assessment, dated 5/30/26, in part 3 under staff training/education and competencies documented: .required in-service training for nurse aids in service training must: be sufficient to ensure the continuing competence of nurse aids, but must be no less than 12 hours per year.include dementia management training and resident abuse trainings.On 6/3/26, Surveyor requested and reviewed annual employee training for CNA-Q, CNA-R, CNA-S, and CNA-V. Surveyor noted the CNAs had not received the required annual training on dementia.On 6/3/26 at 8:19 AM, Surveyor interviewed Human Resources (HR) -D regarding staff training. HR-D stated they will do the initial orientation training courses that cover everything and to ensure staff have the required training courses yearly. HR-D stated they do not pick which trainings are done. HR-D stated Nursing Home Administrator (NHA) - A chooses the trainings based off the needs of the facility. HR-D was unable to locate training was completed by CNA-Q, CNA-R, CNA-S, and CNA-V. HR-D was not aware dementia training was required and stated the training will be implemented going forward.On 6/4/26, at 1:03 PM, Surveyor interviewed NHA-A regarding staff training. NHA-A stated there are mandatory training courses to be completed that NHA-A keeps a list of. NHA-A stated the Director of Nursing (DON)-B and Assistant Director of Nursing (ADON)-C will come up with a list of training based on weak areas in the facility. NHA-A will take the mandatory training and weak areas and make a training course to be completed for that year. Surveyor shared the concern of CNA-Q, CNA-R, CNA-S, and CNA-V not receiving annual dementia training. NHA-A stated they were unable to locate additional training records for those staff. NHA-A stated the facility plans to implement an in-depth dementia training going forward.

Based on interview and record review, the facility did not ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good grooming/hygiene for 1 (R31) of 19 sampled residents reviewed for bathing.*R31 did not consistently receive showers or bed baths. Findings include:The facility's Resident Showers implemented 4/15/26 documented:Policy:.It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice.Policy Explanation and Compliance Guidelines:.1.Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety.3.The Certified Nursing Assistant (CNA) will report skin changes to nursing staff while performing bathing and inform the nurse of any changes.R31 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction(complete paralysis on one side of body and partial/incomplete weakness on one side following stroke), Protein-Calorie Malnutrition Moderate(significant, but not severe, deficiency in nutrient intake), Chronic Pain Syndrome(a condition where pain persists for longer than 3-6 months and accompanied by emotional and physical symptoms like depression, anxiety, and sleep disturbance, Functional Quadriplegia(complete inability to move all four limbs due to severe disability or frailty), Type 2 Diabetes Mellitus(adult onset of trouble controlling blood sugar), Chronic Obstructive Pulmonary Disease(lung disease that block airflow and make it difficult to breathe), and Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities).R31's Quarterly Minimum Data Set (MDS) assessment, dated 4/2/26, indicated that R31's Brief Interview for Mental Status (BIMS) score was documented as 15, which indicated R31 was cognitively intact for daily decision making. R31's MDS also documented R31 had range of motion (ROM) impairment on both upper and lower extremity on one side and was dependent for dressing, mobility, and transfers. R31 was dependent on staff assistance for showers. R31's documented R31 had no depressive or behavioral symptoms. R31's comprehensive care plan documented:R31 had an activities of daily living (ADL) self-care performance/mobility deficit due to left-sided hemiplegia, impaired balanceInitiated 7/26/19Revised 3/29/22Interventions documented:-Bathing/Showering: R31 required assistance by 1 staff with bathing/showering every Friday nights(NOC), but required mechanical lift and total assist of 2 for transfer into shower chair/tubInitiated 7/30/19Revision 3/17/23-Bathing/Showering: Provide sponge bath when a full bath or shower cannot be toleratedInitiated 7/26/19Revision 3/17/23Surveyor noted there was no care plan that documented R31 refused any activities of daily living (ADL) assistance.Surveyor reviewed R31's electronic medical record (EMR). Under tasks the question: Was a bath given or a shower? Surveyor reviewed R31's record from December-June and noted the answer given stated Not Applicable. Surveyor noted showers are not documented as being provided to R31. On 6/4/2026, at 11:50 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-U. CNA-U stated that CNA-U does not work on R31's shower days so CNA-U would not know if R31refused. CNA-U stated that if a resident was to refuse, CNA-U would tell the nurse, that was what we are supposed to do.On 6/4/2026, at 11:01 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-Z. LPN-Z stated LPN-Z was the regular nurse working Monday-Friday and assigned to R31. LPN-Z explained that skin/body checks were done on shower days. If a resident refused a shower, then a bed bath needed to be given. LPN-Z stated that LPN-Z did not think LPN-Z could get R31 in the shower because R31 was set in R31's ways. On 6/4/2026, at 3:12 PM, Surveyor interviewed Wound Nurse (WN)-E. WE-E confirmed that a body check needs to be completed on every resident. WN-E gets updated information on a resident from nurse reports, completed body checks, 24-hour board, morning shift report and CNAs inform WN-E of any new skin issues with a resident. On 6/8/2026, at 10:25 AM, Surveyor interviewed Social Worker (SW)-L in regard to R31's preferences. SW-L stated R31 did not like to get out of bed and did not like to get into the shower room. This had been from R31's admission. SW-L confirmed that nursing staff should had been completing bed baths if R31 did not want a shower.On 6/8/2026, at 10:46 AM, Surveyor interviewed Unit Manager (UM)-BB. UM-BB informed Surveyor that if a resident did not want a shower, a bed bath should be offered. UM-BB confirmed that a body check should be completed. The body checks were completed by the regular nurse or by UM-BB and on the PM shift the supervisor would complete. UM-BB would monitor the body checks and notify WN-E. UM-BB was not aware of R31 refusing bed baths. On 6/9/2026, at 7:16 AM, Surveyor reviewed R31's completed body checks from December-June. December12/5, 12/12, 12/26Missed 12/19January 1/2/, 1/23, 1/30Missed 1/2, 1/16February2/13, 2/20, 2/27Missed 2/6March3/13, 3/27Missed 3/6, 3/20April4/3, 4/17Missed 4/10, 4/24The facility provided no documented completed body checks for May or June.On 6/9/26, at 9:21 AM, R31 informed Surveyor that R31 did not like to get out of bed because of the mechanical lift was needed to get into the shower room. R31 stated R31 will get a bed bath but it was not on a regular basis. R31stated R31 does not even know what R31's shower day was. R31 stated, of course I would like a regular bed bath since I don't get in the shower.On 6/9/2026, at 11:24 AM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that there was no documented completed bed baths provided to R31 on a consistent basis. The facility did not provide any additional information at this time in regard to R31 not receiving bed baths on a consistent basis.

Based on interviews and record review, the facility did not resolve a grievance as outlined in the facility policy for 1 (R105) of 2 residents reviewed for grievances.On 1/27/26 R105's family member sent an email correspondence to the Nursing Home Administrator (NHA)-A requesting that the content of the email regarding concerns with R105's discharge planning and a pressure injury be processed as a formal complaint.The facility did not have any evidence of R105's complaint being submitted as a grievance nor any resolution to the complaint.Findings include:The facility policy titled Resident and Family Grievances, date implemented 4/30/26, documents, in part, .Policy: It is the policy of this facility to support each resident's and family right to voice grievances, without discrimination, reprisal or fear of discrimination or reprisal.Definitions: Prompt efforts to resolve include facility acknowledgement of complaint/grievance and actively working toward resolution of that complaint/grievance.Policy Explanation and Compliance Guidelines:1. (Name and Title) (sic) has been designated as the Grievance Official and can be reached at (list contact information). (sic)2. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with the state and federal agencies as necessary in light of specific allegations.4. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their LTC (Long Term Care) facility stay.8. Grievances may be voiced in the following forums:Verbal complaint to a staff member or Grievance Official.Written complaint to a staff member or Grievance Official.Written complaint to an outside party.Verbal complaint during resident or family council meetings.Via the company toll free Customer Service Line (if applicable). 10. Procedure:This facility will not retaliate or discriminate against anyone who files a grievance or participates in the investigation of a grievance.The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form.Forward the grievance form to the Grievance Official as soon as practicable.The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form.The Grievance Official or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances.12. The facility will make prompt efforts to resolve grievances.R105 was admitted to the facility on [DATE] and discharged on 1/30/26 with diagnoses to include cerebral infarction (stroke), dementia with other behavioral disturbances, and hypertension. R105's comprehensive MDS, dated [DATE], documents R105 has a brief mental status (BIMS) score of 12, indicating moderate cognitive impairment.On 06/03/26 at 11:05 AM, Surveyor reviewed facility grievance log and there is no grievance documented on the grievance log for R105 on 1/27/26 or any date in January 26 or to date.On 6/03/26 at 11:09 AM, Surveyor asked Assistant Director of Nursing (ADON)-C if ADON-C ever received a grievance from R105 or R105's family. ADON-C stated ADON-C did not recall who R105 was and did not receive any grievances from R105 or R105's family.On 06/09/26 at 7:44 AM, Surveyor asked Director of Nursing (DON)-B if DON-B ever received a grievance from R105 or R105's family. DON-B stated they did not recall who R105 was and DON-B had not received any grievances from R105 or their family. DON-B stated if DON-B would have received a grievance DON-B would have submitted the concern on a grievance form.On 06/09/26 at 8:50 AM, Surveyor asked Social Worker (SW)-L if SW-L could find any evidence of a grievance filed by R105 or their family. SW-L could not find any evidence of a grievance being filed. Surveyor asked SW-L what the grievance process was. SW-L stated, anyone can come to SW-L to file a grievance and SW-L will follow up or have the appropriate staff member follow up. If the grievance is shared with another staff member, it is their responsibility to complete the grievance form and either the staff member follows up or submits to SW-L to follow up. Either way, the grievances are tracked and logged by SW-L. 06/09/26 8:55 AM Surveyor asked Nursing Home Administrator (NHA)-A if NHA-A ever received a grievance from R105 or their family. NHA-A stated NHA-A did not recall R105 but if NHA-A had received a grievance, NHA-A would have submitted a concern on a grievance form. Surveyor notified NHA-A that there is evidence of an email correspondence sent to NHA-A, dated 1/27/26, with the sender requesting sender's concerns regarding discharge planning and pressure injury concerns to be addressed as a formal complaint. NHA-A stated this email may have gone to NHA-A's junk folder as NHA-A never received an email. Surveyor notified NHA-A that NHA-A did reply to sender on 1/30/26 as evidenced by the email correspondence that documented by NHA-A, the sender can be assured this is considered a grievance from the family and will be investigated. NHA-A stated NHA-A did not recall receiving or responding to this email. Surveyor asked if NHA-A had access to her past emails and NHA-A stated NHA-A no longer has access to any emails prior to April of 2026.No further information was provided as to why the facility did not document a thorough investigation and did not resolve grievances as outlined in the facility policy.

Based on record review and staff interview, the facility did not ensure allegations of neglect, misappropriation of property, and injuries of unknown origin, were thoroughly investigated. This was observed with 3 (R106, R32 and R21) of 3 sampled residents. * R106 nurses notes included documentation on, 3/21/26 and 3/31/26, on care concerns provided by the facility. There is no further documentation of these concerns being investigated. * On 1/12/26 R32 reported his wallet containing $1000.00 was missing. The facility did not conduct a thorough investigation as the facility did not interview any ancillary staff such as housekeeping & activities who worked the floor from the time R32 went to the bank until R32's money was discovered missing. The facility does not have any evidence residents were interviewed to determine if there were any additional concerns regarding misappropriation of residents property. * R21 had an eye doctor appointment outside of the facility on 10/27/25. When R21 returned to the facility, R21 had an injury to the left lower leg. This injury of unknown origin was not fully investigated. Findings include: The facility policy and procedure Abuse, Neglect and Exploitation dated 1/8/2026. The Policy documents: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures. That prohibits and prevents abuse, neglect, exploitation and misappropriation of resident property.IV. Identification of Abuse, Neglect and Exploitation.B. Possible indicators of abuse include but are not limited to.1. Resident, staff or family report of abuse.2. Physical marks such as bruises or patterned appearances such as a handprint, belt or ring mark on a resident's body.3. Physical injury of a resident, of unknown source.4. Resident reports of theft of property, or missing property.V. Investigation of Alleged Abuse, Neglect and Exploitation.A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.B. Written procedures for investigations include:1. Identifying staff responsible for the investigation;2. Exercising caution in handling evidence that could be used in a criminal investigation;3. Investigating different types of alleged violations;4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator. Witnesses and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation and or mistreatment has occurred, the extent and cause; and6. Providing complete and thorough documentation of the investigation. 1.) R106 was admitted [DATE] with congestive heart failure and right foot wound with toe amputation. R106 was transferred to the hospital on 4/6/26 for a change in condition and has not returned to the facility. R106's medical record was reviewed. R106 is their own person. The admission Minimum Data Set (MDS) assessment completed 2/18/26; R106 requires assistance from staff for Activity of Daily Living (ADL). A Nurses Note dated: 3/21/2026 at 11:02 PM, documented by Licensed Practical Nurse (LPN) – DD indicated: Writer was informed by CNA (Certified Nursing Assistant) that a family member of noted resident called to the community to place a complaint. CNA stated that resident's family member made claims of photos being sent and noted resident not being cleaned after an incontinent (sic) episode. CNA stated the family member made claims to come up here to deal with the staff. At around 11:40 PM, one woman and one man entered the doors at subacute and walked past the nurse's station and headed to noted resident room. The nurse that was passing medications was present at time of entry into room (room number listed). After about 15 minutes both the man and women emerged from the room and exited the building. On 6/03/2026, at 9:57 AM, Surveyor interviewed Director of Nurses (DON)-B. DON-B stated they were not aware of any care concerns with R106. R106's family members were involved with direct care needs. DON-B stated they do not recall much about R106. DON-B indicated If they were aware of any concerns they would have written up a grievance. On 6/03/2026, at 2:31 PM, Surveyor interviewed the Assistant Director of Nurses (ADON)-C. ADON-C was not aware of any concerns with R106. ADON-C stated DON-B's number is posted everywhere for staff to call with any concerns. On 6/03/2026, at 3:13 PM, Surveyor requested any additional information related to the allegation referenced in the nurses note on 3/21/2026. Administrator-A stated they were not aware and did not have any further information. On 6/04/2026, at 10:57 AM, Surveyor interviewed LPN-DD via phone. LPN-DD stated R106's family had grievances with the facility that may have involved back and forth with DON-B and ADON-C. The family member did not feel R106 was being cared for properly. That evening R106 felt the CNA was taking too long. R106 can toilet themselves, but had c-diff (clostridium difficile) . R106 called their family member. The family member and a man came to the facility. They took pictures. The family member was very upset. LPN-DD told the supervisor about it. LPN-DD does not recall who was supervising that evening. A second Nurses Note dated: 3/31/2026 at 6:18 AM, by Agency Registered Nurse (RN) -P, documented: Resident could not be patient for a chance to attend to her towards close of shift amidst other duties (sic), (R106's) family member came into facility and writer calmed them down. Writer got (R106) cleaned. Family member furious with threat to report to state. On 6/03/2026, at 9:57 AM, Surveyor interviewed DON-B about the second allegation of care concerns. DON-B stated they were not aware of any care concerns with R106. R106's family members were involved with direct care needs. DON-B stated they do not recall much about R106. DON-B indicated If they were aware of any concerns they would have written up a grievance. On 6/03/2026, at 2:31 PM, Surveyor interviewed the Assistant Director of Nurses (ADON)-C. ADON-C was not aware of any concerns with R106. ADON-C stated the DON-B number is posted everywhere for staff to call with any concerns. On 06/04/2026, at 11:15 AM, Surveyor interviewed Agency RN-P via phone regarding the allegations of neglect from 3/31/26. RN-P could not recall any details and did not remember anything. 2.) R32 was discharged from the facility on 5/10/26. R32's quarterly MDS (minimum data set) with an assessment reference date of 1/8/26 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. On 1/12/26, R32 reported to Certified Nursing Assistant (CNA)-SS he was missing money. CNA-SS reported R32's missing money to Unit Manager (UM)-BB. On 1/12/26 UM-BB informed Social Worker (SW)-L R32 was missing his black wallet containing $1000.00. On 6/9/26, at 10:40 a.m., Nursing Home Administrator (NHA)-A provided surveyor with the facility's misappropriation investigation for R32's missing $1000. Surveyor asked NHA-A if this was the facility's complete investigation. NHA-A replied yes. On 6/9/26, at 10:59 a.m., surveyor reviewed the facility's misappropriation investigation. The investigation revealed R32 had gone to a bank on 1/9/26 wanting to withdraw $2000 but the bank would only allow R32 to withdraw $1000. Surveyor noted during the investigation the facility interviewed R32 & searched R32's room, interviewed R32's roommate, and some facility staff. Surveyor noted that the facility's investigation did not include interviews or statements from housekeeping and activities staff who worked on the unit after R32 went to the bank and R32's money was discovered missing. The investigation also did not include interviews with residents. On 6/9/26, at 11:36 a.m., Surveyor interviewed Social Worker (SW)-L regarding the facility's process when a resident voices an allegation of misappropriation. SW-L informed surveyor when there is an allegation of misappropriation she will go up to speak with the resident, get the specific information, inform Nursing Home Administrator (NHA)-A, do an online report and follow up with an investigation. Surveyor asked SW-L what their investigation consisted of. SW-L informed surveyor they pull schedules for the time frame, talk to staff that were on, interview other residents and if needed the police would be contacted. Surveyor inquired when the facility would contact the police. SW-L informed surveyor if there is misappropriation or abuse. Surveyor inquired about how they determine which staff to interview. SW-L informed surveyor it is based off the schedules for the time frame. Nursing and housekeeping are interviewed and depending on the allegation sometimes they could even be talking to therapy as well. On 6/9/26, at 11:40 a.m., surveyor informed SW-L surveyor reviewed the facility's investigation and noted during the investigation R32, R32's roommate, Receptionist-UU, and nursing staff were interviewed. Surveyor asked SW-L if she knew why she didn't interview any housekeeping or activities staff who worked on the unit after R32 withdrew $1000 from the bank until R32's money was discovered missing. SW-L replied I don't. Surveyor asked SW-L if she would normally interview housekeeping and/or activities. SW-L replied yes. Surveyor informed SW-L surveyor did not note any resident interviews in the facility's investigation. SW-L informed surveyor she only writes a resident interview if there is a concern. 3.) On 6/1/26 at 9:48 AM, Surveyor interviewed R21. R21 informed Surveyor that a few months ago, R21 obtained a large bruise on the way back from an eye appointment outside of the facility. R21 stated that R21 thinks the transport driver placed the bottle of oxygen on R21's legs and R21 got a large dark purple bruise. R21 stated that it took a while to heal. R21's progress note dated 10/27/25 at 8 AM, documented: Resident is being pick[ed] up via (name of transport company). R21's progress note entered by Licensed Practical Nurse (LPN) /Unit Manager (UM)-BB, dated 10/27/25 at 11:45 AM, documented, in part: Upon returned writer noted to [R21's] Left shin is bluish-purple to colored, oval in shape, skin is intact, skin is raised and pain to touch, updated [Assistant Director of Nursing (ADON)-C], [Director of Nursing (DON)-B] and administrator . Will have scheduler contact the transit (name of company) staff for statement. On 6/4/26, Surveyor requested all Facility Reported Incidents (FRI) for the month of October 2025. Surveyor noted the facility did not complete or document a thorough investigation into R21's injury that was first documented by facility staff on 10/27/25. On 6/4/26 at 9:28 AM, Surveyor interviewed UM-BB. Surveyor asked what happened to R21 on 10/27/25. UM-BB stated that R21 was injured during transport from an eye appointment outside of the facility. UM-BB stated that the transport company employee took an O2 tank and rested it on R21's leg. UM-BB stated that R21 got the injury from that. UM-BB stated that they thought that statements were collected from the transport company. UM-BB stated that UM-BB will check and get back to Surveyor. On 6/4/26 at 11:36, UM-BB returned to Surveyor and stated that UM-BB checked with Nursing Home Administrator (NHA)-A. NHA-A informed UM-BB that the transport company would not send any statements because they did not want to be sued. On 6/4/26 at 12:38 PM, Surveyor interviewed the transport service Office Manager (OM)-XX. Surveyor asked if there had ever been a break in the company providing transport services to the facility related to a resident injury. OM-XX indicated that there was not a break in service for a reason like that. Surveyor asked if OM-XX had heard that R21 had returned from an appointment with a transport employee and R21 had an injury to their lower left leg. OM-XX stated that they remembered the facility staff stated that a transport employee put an oxygen tank on R21's leg. OM-XX stated that they completed an incident report. OM-XX stated that they liked to get documentation right away when an accusation is made. OM-XX provided the written statements to Surveyor. Transport employee-ZZ's incident report statement dated 10/27/25 documented: Picked client up on 10/27/25. [R21] was lifted by Hoyer. Nurses at [Name of facility], placed client on cot. Placed oxygen machine on client's legs. On the return ride we put machine on stomach. Where the bruises [were] the machine wasn't even in that area. Nurses told us to, make sure y'all don't bruise [R21]. Transport employee-YY's incident report statement dated 10/27/25 documented: On [10/27/25 at] 8:00 AM, I and another driver picked up [R21] at [Name of facility]. While picking [R21] up, the ladies who work at facility used a Hoyer lift to lift [R21] up. [R21] didn't want that. [R21] said it hurts [their] leg. [R21] said bruises came from oxygen tank but oxygen was nowhere near where the bruises were. Injuries: Two bruises on legs which looked old black/blue. Surveyor noted different accounts by facility staff and transport employee staff of how [R21's] injury occurred. Surveyor noted OM-XX did have transport employee's completed statements and the facility did not obtain these statements. On 6/4/26 at 3:46 PM, Surveyor asked NHA-A if there was any investigation or report into what happened after R21 returned to the facility with an injury to R21's left leg. NHA-A stated that NHA-A would have to look into that and get back to Surveyor. NHA-A provided Surveyor with a form titled Other Skin Alteration, dated 10/27/25 at 11:30 AM completed by UM-BB. The form documented, in part. Resident states, during transportation, the driver placed portable oxygen tank on top of [R21's] left leg. [R21] told the driver [they] are experiencing pain to [their] leg, and the driver came and removed the portable oxygen tank. No statements found. People Notified: Administration [NHA-A], Physician [NP-G] and [DON-B]. Surveyor noted that the facility did not collect and document statements from any facility staff members that were with R21 before and after the outside eye appointment. Surveyor noted that the facility did not collect statements from other residents who use the same transport company to see if any other residents had concerns with transport drivers or facility staff. Surveyor noted that there was no education completed on how to prevent an injury like this from happening again. For example, if investigation proved that an oxygen tank caused the injury, education on placement or use of oxygen tanks during transportations. Surveyor concluded that there is not a thorough investigation documented by facility staff. On 6/9/25 at 11:28 AM, Surveyor interviewed ADON-C and NHA-A. Surveyor asked when they became aware of R21's leg injury. ADON-C stated that they were aware of the injury on the same day that it occurred. NHA-A stated that NHA-A was not told anything. Surveyor asked when NHA-A became aware of R21's leg injury. NHA-A indicated that they found out about it when Surveyor brought it to their attention. Surveyor shared the concern that this injury of unknown origin was not investigated or reported to the State Agency. ADON-C stated that the injury occurred from an oxygen tank during transfer. Surveyor asked if statements were collected and was told by NHA-A that Surveyor had everything. Surveyor asked how the facility could know exactly what happened without completing a thorough investigation. NHA-A stated that in the past NHA-A has had a hard time getting statements from the transport company because they do not want to be held liable. Surveyor shared continued concern that R21's injury was not thoroughly investigated. Statements were not obtained from facility staff, transport staff or residents. Education was not completed to prevent reoccurrence. No further information was provided.

Based on interview and record review, the facility did not ensure 3 (R108, R4, and R31) out of 19 sampled residents were provided and administered medications based upon physician orders and standards of practice for ensuring accurate administration of ordered medications. * R108 had multiple medications that were not administered from September to November of 2025 with notations that indicated the medications were not available to administer as ordered. * R4 had tooth pain and facial swelling. Chlorhexidine Gluconate solution was not administered as ordered by the physician. * R31 had multiple medications and treatments that were not documented as being administered or completed as ordered. Findings Include: The facility's policy titled, Medication Administration, dated 2/15/2026, documented Medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination more infection. Ensure that there are 6 rights of medication administration are followed: right resident, write drug, write dosage, right route, right time, and write documentation. Sign MAR after administered. correct any discrepancies and report to nurse manager. 1.) R108 is a [AGE] year-old resident who was admitted to the facility on [DATE]. R108's 5 day admission Minimum Data Set (MDS) completed on 9/29/25 documented R108 had a Brief Interview for Mental Status (BIMS) score of 11 (1-15), indicating that R108 had moderate cognitive impairment. On 6/2/26, Surveyor reviewed R108's Medication Administration Record (MAR) from September to November 2025. Surveyor noted the following missing medication administration notes in September 2025: * Loratadine 10 mg daily, ordered 2/26/25 – 11/21/25 was not administered on 9/28/25 and 9/30/25 and documented as 9 which means Other/See nurses notes. Surveyor reviewed R108's progress notes and both dates note Loratadine 10 mg to be on order. * Temazepam 22.5 mg given at bedtime, ordered 9/22/25 – 11/21/25 was not administered for the first 4 days the medication was ordered from 9/22/25 – 9/25/25. Surveyor reviewed R108's progress notes and the notes stated, med not yet delivered and awaiting pharmacy delivery. * Clonazepam 0.5 mg given 2 times a day, ordered 9/22/25 – 11/21/25 was not administered on 9/22/25-9/25/25 and the PM administration on 9/27/25. Surveyor reviewed R108's progress notes on those dates documented: med not yet delivered and med not available. Surveyor noted the following missing medication administration notes in October 2025: * Lidocaine cream 4% apply 4 times a day, ordered 9/22/25 – 11/26/25. Lidocaine was not administered: 10/1/25 at 12:00 AM and 6:00 AM; 10/2/25 at 12:00 AM, 12:00 PM, and 6:00 PM; 10/3/25 at 12:00 AM and 6:00 AM; 10/4/25 at 12:00 AM and 6:00 AM; 10/5/25 at 12:00 AM and 6:00 AM; 10/6/25 at 12:00 AM and 6:00 AM; and 10/7/25 at 12:00 AM and 6:00 AM. Surveyor reviewed R108's progress notes on those dates that documented na, on order, med not yet delivered, awaiting pharmacy delivery, or no note at all. * Clonazepam 0.5 mg given 2 times a day, ordered 9/22/25 – 11/21/25 was not administered 10/26/25 at 8:00 AM and 6:00 PM, 10/29/25 at 8:00 AM and 6:00 PM, 10/30/25 at 8:00 AM, and 10/31/25 at 8:00 AM and 6:00 PM. Surveyor reviewed R108's progress notes on those dates that documented waiting for pharmacy to send, medication not available, or no note at all. Surveyor noted the following missing medication administration notes in November 2025: * Temazepam 22.5 mg given at bedtime, ordered 9/22/25 – 11/21/25. This medication was not given 11/1/25, 11/3/25, 11/5/25, 11/6/25, and 11/9/25. Surveyor reviewed R108's progress notes on those dates that documented medication not in facility, reorder, pharmacy notified, med not available, missing medication, or no note at all. On 6/9/26, at 8:01 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-CC regarding medication availability and the process of ordering medications. LPN-CC stated when a resident is admitted , the medications are put into the system; they are automatically ordered, and pharmacy begins to process them. LPN-CC stated medications will arrive the next shift or the next morning. LPN-CC stated if a medication is needed sooner the nurse can either pull the medication from contingency if available, call pharmacy and have the medications sent STAT (immediately), or call the Physician and notify them of the medication unavailability and possibly have another medication ordered in its place. On 6/9/26, at 11:03 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-C regarding medication availability. ADON-C stated medications are to be reordered before running out, if the medication is not available staff are to pull the medication from contingency, and as a last resort the nurse is expected to call the pharmacy to get the medication STAT or document why the medication is not being sent. Surveyor questioned ADON-C why there were missing medication administrations for R108 from September 2025 – November 2025. ADON-C reviewed the dates in question and was unable to provide why the medications were not given. ADON-C stated the Nurses were not checking the manifest when medications would arrive to ensure the pharmacy delivery was complete and around that time a new pharmacy was being used and switching pharmacy providers caused issues with the reordering process. On 6/9/26 at 11:45 AM, Surveyor shared the concern of R108 not receiving medications on select dates from September 2025 to November 2025 with Nursing Home Administrator (NHA)-A. 2.) The facility policy titled Dental Services dated 12/1/25 documents (in part) . . It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the state plan) and emergency dental care. Emergency dental services includes services needed to treat an episode of acute pain in teeth, gums, or palate; broken or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist. The facility policy titled Pharmacy Services dated 2/15/26 documents (in part) . . It is the policy of this facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. 6. The facility will maintain a limited supply of medications for emergency or after hours situations in accordance with facility policy and applicable state laws. 8. The pharmacist, in collaboration with the facility and medical director, should include within its services to: f. Strive to assure that medications are requested, received, and administered in a timely manner as ordered by the authorized prescriber. R4 was admitted to the facility on [DATE] and had diagnoses of major depressive disorder, hypertension, paroxysmal atrial fibrillation, heart failure, cerebral infarction, type 2 diabetes mellitus, chronic kidney disease, myocardial infarction peripheral vascular disease and dementia. On 6/1/26 at 9:55 AM, Surveyor spoke with R4 in her room. Surveyor obserbed R4 had several missing and jagged teeth. R4 reported no concern with eating or chewing food but told Surveyor her teeth hurt sometimes. Facility progress notes documented: 12/3/25 at 10:50 AM, general nurses note: Resident has facial swelling that started last night, no symptoms or pain, vitals normal, Np (Nurse Practitioner) notified, told to hold Amlodipine x 2 days and to monitor swelling. Resident denies pain, trouble swallowing or SOB (shortness of breath). No swelling or redness in mouth or throat. 12/4/25 at 6:20 PM, general nurses note: Resident complained of left sided face pain and stated it was her tooth that's hurting. Left side of face appears swollen and third eye notified. New order received for Tramadol 50 mg (milligrams) q (every) 8 hours prn (as needed) for tooth pain and for PCP (primary care provider) to be contacted in am for possible CT (computerized tomography) scan. Will continue to monitor. 12/4/25 at 6:34 PM, third eye health note: Primary Chief Complaint: Oral Pain/SwellingHistory Present Illness: The patient is having pain in her mouth. This has been going on for several days and the PCP is aware. She has swelling on the left side of her face she only has Tylenol for pain. I cannot appreciate any cellulitis. Review of Systems Notes: Tooth pain. Condition is stable. Will order tramadol. Will need an outpatient CT. Surveyor noted a physician's order for Chlorhexidine Gluconate Solution 20%, place and dissolve 20 milliliters buccally three times a day for tooth pain for 7 Days oral rinse and spit start date 12/5/25. Surveyor review of facility progress notes documented: 12/5/25 at 10:38 PM, (L) (left) side facial swelling remains. Writer asked the resident was she in any pain and she stated no. Resident ate and drink without issue this shift. Awaiting swish and spit to arrive from the pharmacy. 12/6/25 at 2:21 PM, facial swelling has gone down, no complaints of any pain, prescribed mouthwash has not come in from pharmacy yet. 12/7/25 at 8:44 PM, facial swelling diminished. Resident eating and drinking without difficulty. Resident denies any pain at this x (time). Currently awaiting swish and spit to arrive from the pharmacy. 12/9/25 at 2:59 PM, facial swelling is down, medicated mouthwash should be coming tonight told to me by pharmacy. 12/10/25 at 1:59 PM, resident has no pain or facial swelling, I contacted pharmacy again about the medicated mouth wash. Pharmacy stated it will for sure be sent out tonight and that they are not sure why it was not sent out last night. 12/10/25 at 9:09 PM, minimal (L) and (R) (right) side facial swelling observed this shift. Patient denies pain. Patient eating and drinking without difficulty. T (temperature) 97.7. 12/12/25 9:57 AM, Chlorhexidine Gluconate Solution 20 % did not come from pharmacy. 12/13/25 at 8:20 PM, denies oral discomfort, no swelling to face noted. Denies any difficulty chewing or swallowing. Surveyor noted the last documentation regarding R4's tooth pain or facial swelling was on 12/13/25. Surveyor noted R4's facial swelling started on 12/3/25 accompanied by tooth pain that started on 12/4/25. Physician's orders for Chlorhexidine Gluconate Solution 20% three times a day for tooth pain for 7 Days starting 12/5/25 was not administered as ordered. On 6/8/26 at 11:37 AM, Surveyor told NHA-A of concern R4 had documented tooth pain and facial swelling and an order for Chlorhexidine solution, which was never administered. She reported she was not sure why the Chlorhexidine solution was not given because it is in contingency. NHA-A stated, I bet they didn't know that, and were just waiting for pharmacy to deliver it. No additional information was provided. (Cross reference F791). 3.) R31 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction, and chronic pain syndrome. R31's Quarterly Minimum Data Set (MDS) assessment, dated 4/2/26, indicated that R31's Brief Interview for Mental Status (BIMS) score was documented as 15, which indicated R31 did not have cognitive concerns. R31's MDS also assessed R31 had range of motion (ROM) impairment to both upper and lower extremity on one side and dependent for showers, dressing, mobility, and transfers. R31's MDS also documented R31 was receiving pain management. R31's current physician orders documented: 1. Monitor/document/report to MD signs/symptoms of Opioid complications: Constipation, Delirium, Over-sedation, Change in mental status, and reduced respirationsevery shift for Opioid MonitoringActive 4/21/2026 2. Tramadol HCl Oral Tablet 50 MG Give 50 mg by mouth two times a day for Pain ManagementActive 1/6/2026 3. Diclofenac Sodium External Gel 1 % 9 (Voltaren)Apply to Bilateral Knees/Shoulders topically two times a day for Pain Management: Arthralgia Upper Extremity: Apply 2g to each affected area. (Max Dose per joint is 8g/day). Lower Extremity: Apply 4g to each affected area. (Max dose per joint is 16g/day) MAX DAILY DOSE (ALL JOINTS): 32g/dayActive 12/16/2025 4. Apap (Acetaminophen) Oral Tablet 325 MG Give 2 tablet orally three times a day for painActive 4/20/2024 5. High Calorie Nutritional Supplement three times a day for weight loss Ensure Plus 1 bottle three times a day-nursing to provide Active 8/24/25 Surveyor reviewed R31s Medication Administration Records (MARS) for December 2025-June 2026 and noted multiple days with shifts that were blank. Surveyor noted there are days that R31 did not receive R31's medications as prescribed for the months of February-June 2026. February 2026 High Calorie Nutritional Supplement 3x a day 2/14/26, 2/28/26-missed administration at 6:00 AM Tramadol 50 mg 2/14/26, 2/15/26, 2/16/26, 2/28/26 missed administration at 6:00 AM 2/19/26 missed administration at 10:00 PM Acetaminophen Oral Tablet 325 mg 2/14/26, 2/28/26 missed administration at 6:00 AM Assessment of pain level 2/27/26 missed night assessment April 2026 High Calorie Nutritional Supplement 3 times a day 4/27/26 missed administration at 2:00 PM Acetaminophen Oral Tablet 325 mg 4/27/26 missed administration at 2:00 PM May 2026 High Calorie Nutritional Supplement 3 times a day 5/5/26 missed administration at 2:00 PM and 5/11/26, 5/23/26 missed administration at 6:00 AM Tramadol HCI 50 mg 5/1/26, 5/23/261 missed administration at 6:00 AM Acetaminophen Oral Tablet 325 mg 5/11/26, 5/23/26 missed administration at 6:00 AM Pain Level once a Shift 5/9/26, 5/10/26, 5/22/26 missed night assessments Surveyor noted there is no documentation as to why R31 had not received the medications. On 6/8/2026, at 10:46 AM, Surveyor interviewed Unit Manager (UM)-BB. UM-BB informed Surveyor that agency staff were a problem with medication administration. UM-BB was unaware there were shifts that R31 had not received physician ordered medications and R31's pain was not assessed. On 6/9/2026, at 8:18 AM, Surveyor interviewed R31 regarding R31's medications. Surveyor asked R31 if there was ever a time that R31 had not received medications. R31stated R31 had not received tramadol multiple times and did not know why. R31 informed Surveyor that tramadol was effective in managing R31's pain. On 6/9/2026, at 9:27 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-Z. Surveyor asked LPN-Z why R31 would have gone without prescribed medications. LPN-Z stated the reason would most likely be because R31 ran out. LPN-Z stated there was an instance where the contingency drawer would not open. LPN-Z stated there should never be an instance when R31 should go without medications. Just being honest, there has to be accountability. I am Monday-Friday on day shift; there needs to be accountability on other shifts. I heard R31 recently ran out of Tramadol. On 6/9/2026, at 10:21 AM, Surveyor interviewed Director of Nursing (DON)-B. DON-B stated DON-B was not aware of any days when R31 would have gone without medications. Surveyor shared the times when R31 had not been administered physician ordered medications. DON-B informed Surveyor there had been a period of time when medications were not being administrated to residents because of agency nursing staff. DON-B stated that ordered medications must be administered as prescribed and there was no exception. DON-B stated that the process would be to check the dashboard and for instance if there is 80% administration, it would need to be reviewed to see who did not get medications that day and it must not have been checked with (R31). On 6/9/2026, at 11:24 AM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that R31's MARS contained documented days with shifts that were blank with no documentation as to why R31did not receive physician prescribed medications.

Based on interview and record review, the facility did not ensure nurse staff posting information was accurate.Review of nursing schedules and the nurse staff posting from 5/3/26 through 6/6/26 revealed 17 of 35 days had discrepancies between the documents. This resulted in inaccuracies with the total number and actual hours worked for Certified Nursing Assistant (CNA) directly responsible for resident care each shift.This has the potential to affect 83 of 83 residents residing at the facility.Findings include:On 6/8/26 Surveyor reviewed the nursing schedules and staff posting from 5/3/26 through 6/6/26. Surveyor compared the actual nursing schedule with the nursing staff posting and noted the following discrepancies:On 5/3/26 the evening shift nursing schedule has 8 CNAs and the nursing staff posting documented 9 CNAs.On 5/7/26 the evening shift nursing schedule has 8 CNAs and the nurse staff posting documented 9 CNAs.On 5/9/26 the evening shift nursing schedule has 9 CNAs and the nurse staff posting documents 8 CNAs. The night shift nursing schedule has 6 CNAs and the nurse staff posting documented 5 CNAs.On 5/10/26 the evening shift nursing schedule has 7 CNAs and the nurse staff posting documented 9 CNAs. The night shift nursing schedule has 6 CNAs and the nurse staff posting documented 8 CNAs.On 5/11/26 the day shift nursing schedule has 10 CNAs and the nurse staff posting documented 9 CNAs.On 5/18/26 the day shift nursing schedule has 12 CNAs and the nurse staff posting documented 11 CNAs. The night shift nursing schedule has 7 CNAs and the nurse staff posting documented 8 CNAs.On 5/19/26 the night shift nursing schedule has 6 CNAs and the nurse staff posting documented 7 CNAs.On 5/22/26 the evening shift nursing schedule has 7 CNAs and the nurse staff posting documented 8 CNAs.On 5/23/26 the evening shift nursing schedule has 7 CNAs and the nurse staff posting documented 9 CNAs. The night shift nursing schedule has 4 CNAs and the nurse staff posting documents 5 CNAs.On 5/24/26 the evening shift nursing schedule has 7 CNAs and the nurse staff posting documented 10 CNAs.On 5/25/26 the day shift nursing schedule has 9 CNAs and the nurse staff posting documented 11 CNAs. The evening shift nursing schedule has 7 CNAs and the nurse staff posting documented 9 CNAs.On 5/26/26 the day shift nursing schedule has 9 CNAs and the nurse staff posting documented 8 CNAs. On 5/27/26 the evening shift nursing schedule has 9 CNAs and the nurse staff posting documented 8 CNAs.On 5/28/26 the evening shift nursing schedule has 9 CNAs and the nurse staff posting documented 8 CNAs.On 5/30/26 the night shift nursing schedule has 6 CNAs and the nurse staff posting documented 7 CNAs.On 5/31/26 the day shift nursing schedule has 8 CNAs and the nurse staff posting documented 10 CNAs. The evening shift nursing schedule has 7 CNAs and the nurse staff posting documented 8 CNAs.On 6/6/26 the day shift nursing schedule has 8 CNAs and the nurse staff posting documented 9 CNAs.On 6/9/26 at 8:20 a.m. surveyor asked Receptionist-J who is responsible for completing the nurse staff posting. Receptionist-J informed Surveyor Lead Receptionist (LR)-TT does this based on their schedules.On 6/9/26, at 8:27 a.m., surveyor asked Lead Receptionist (LR)-TT if she was responsible for completing the nurse staff postings. LR-TT informed Surveyor she was. LR-TT informed surveyor she already did today's and showed surveyor the nurse staff posting which is located to the right of the elevators opposite the receptionist area. LR-TT explained to surveyor she receives the schedule from the scheduler and whatever she sees on the schedule she writes on the nursing staffing hours form. If someone calls in, she does the changes the next day to correct the nursing staffing hour form. Surveyor inquired if CNAs who are on orientation are included in the staffing totals. LR-TT replied we do not count them explaining she writes them on the bottom of the form. Surveyor informed LR-TT surveyor compared the facility's daily nursing schedule with the nurse staff posting (nursing staffing hour) form and noted discrepancies on multiple days. LR-TT informed Surveyor she may not have been notified when something changed. As an example, surveyor showed LR-TT the discrepancy on 5/3/26. The evening shift nursing schedule has 8 CNAs and the nurse staff posting documented 9 CNAs. LR-TT reviewed the scheduling sheets she was provided for 5/3/26 and informed surveyor she wasn't given the right schedule and goes by what she is given.On 6/9/26, at 9:21 a.m., Surveyor informed Nursing Home Administrator (NHA)-A surveyor compared the daily nursing schedule with the nurse staff posting. Surveyor noted multiple days where there is a discrepancy between the two documents. NHA-A informed Surveyor LR-TT spoke to her and LR-TT thought she was doing it correctly.

Based on record review, interviews, and policy review, the facility failed to ensure residents were free from sexual abuse for 1 resident (R) of 3 residents reviewed for abuse (R2), R1 had a previous documented incident of trying to kiss another resident and there was a reported incident of R1 attempting to fondle the breasts of R2, a cognitively impaired resident. The facility failed to implement effective preventive measures after these incidents. R1 was later found by staff with his hand down R2's pants. Following this incident, not all caregivers were aware of the need to monitor the whereabouts of R1 or to keep R1 and R2 separated.The facility's failure to keep R2 free from sexual abuse created a finding of immediate jeopardy that began on 11/20/25. The Administrator, Director of Nursing (DON), and the Assistant Director of Nursing (ADON) were informed on the immediate jeopardy on 12/11/25 at 11:50 AM. The immediate jeopardy was removed on 12/13/25, however, the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include:Review of the facility's policy Abuse, Neglect and Exploitation, dated 03/25/25, indicated, .An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur . The facility will make efforts to ensure all residents are protected from physical and psychosocial harm as well as additional abuse. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs change as a result of an incident of abuse.1. Review of R1's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R1 was originally admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy and dementia.Review of R1's Psych Progress Note, dated 06/18/25, indicated, Chief Complaint: Staff requested follow up psych visit for inappropriately attempting to kiss another resident. Plan Staff educated to redirect patient to keep him away from other vulnerable patients.Review of R1's quarterly Minimum Data Set (MDS), located under the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 09/19/25, indicated R1 had a Brief Interview for Mental Status (BIMS) score of eight out of 15 which indicated R1 was moderately cognitively impaired. There was no documentation that R1 exhibited any behaviors during the seven day look back period. R1 self-propelled in a high back wheelchair.Review of R1's Care Plan, located under the Care Plan tab in the EMR, indicated R1 had not been care planned for behaviors until 11/20/25 when a Focus was initiated, [R1] requires frequent checks r/t [related to] physical inappropriateness with other resident. Interventions included: Encourage use of prescribed devices. Perform safety risk evaluation[s] on admission, as needed and upon changes in condition. Safety measures - including strategies to reduce the risk of infection, falls, injury initiated as appropriate. Place in common area visible to staff. Frequent check of [R1's] whereabouts. Keep [R1] separated from other female residents .2. Review of R2's undated Face Sheet located under the Profile tab in the EMR indicated R2 was admitted to the facility on [DATE] with diagnoses of [NAME]-[NAME] Syndrome, epilepsy, and developmental disorder.Review of R2's quarterly MDS, located under the MDS tab in the EMR with an ARD of 09/13/25, indicated R2 was severely cognitively impaired. R2 was dependent on staff for wheelchair mobility.Review of R2's Care Plan located under the Care Plan tab in the EMR indicated a Focus dated 09/21/22 for behavior problem r/t [related to] calling out/yelling out/screaming out/crying both during cares and at other times Interventions were to: Approach within view smiling and say 'Hello [R2]' to set positive tone of interaction. Caregivers to provide opportunity for positive interaction attention, stop and talk with her as passing by. If not calm during cares, withdraw and approach later. Review of R2's Care Plan did not indicate the care plan had been developed or revised after an incident with R1 on 11/20/25.R1 and R2 resided on the same hall of the facility in November 2025.Review of the facility's investigation revealed that on 11/20/25 at 12:30 PM in the East Lounge, R1 was witnessed with his hand down R2's pants. Certified Nursing Assistant (CNA) 1 immediately stopped the interaction and asked R2 what he was doing. CNA1 stated R1 said to R2, I told you we can't do this. CNA1 separated the residents. R1 was taken to his room. R2 remained in the East Lounge. The Administrator was notified, and R1 and R2 were assessed by the ADON. R2 was sent to the emergency room (ER) for a Sexual Assault Nursing Examiner (SANE) exam, a specialized medical exam for sexual assault survivors, with no injury or trauma noted. On 11/21/25, a nurse practitioner ordered sertraline (an antidepressant medication) 25 milligrams (mg) once a day for R1.During an interview on 12/09/25 at 12:07 PM, Certified Medication Aide (CMA) 1 was asked if R1 had inappropriate behavior prior to the incident on 11/20/25. CMA1 stated, He [R1] would try to touch her [R2's] breasts. He would try to be slick. Staff brought R1 to the front nurses' station and told him he could not touch people like that. When asked if this was reported to anyone, CMA1 stated, I'm not sure.During an interview on 12/09/25 at 1:30 PM, Unit Manager (UM) 1 stated, A couple of months ago I was told by another resident's family member that R1 and R2 should not be in the same area. The person told me that R1 liked to put his hands up R2's shirt and fondle her breasts. UM1 indicated they had not reported this allegation from another resident's family member to administration. UM1 denied knowledge of the 11/20/25 incident.Administration was not aware of these incidents and no plan was put in place to keep other residents safe.Further review of the facility's investigation of the 11/20/25 abuse incident revealed, staff to keep the residents separated. [R1] to be redirected from the East Lounge area where [R2] routinely sits. His whereabouts to be monitored and he's to be redirected to the common area by the nurses' station, to group activities with activity staff, or his room per his preference.During an interview on 12/09/25 at 1:01PM, CNA2 was asked if she ever took care of R1. CNA2 replied, I have never heard of him. CNA2 provided her assigned room numbers, which included R1's room. When notified that R1 was assigned to her, CNA2 stated, I don't remember anything about him except he doesn't want to be bothered. When asked what was given to her in report that morning when CNA2 accepted her assignment, CNA2 stated, They wrote down the people that like to get up, and that was all I got. When asked if there were any residents that R1 should not be around, CNA2 stated, I haven't been told anything about that.During an interview on 12/09/25 at 2:53 PM, CNA3 was asked how the staff monitor R1 and R2 to make sure they were not together since they were in the same unit and hallway. CNA3 stated, We try to keep them separated. When he [R1] is up and we are busy with other people, we may see him down that hallway; we will redirect him. I have heard that he has been down there to see [R2] or have seen him halfway down the hallway. We always keep an eye out for both of them.During an interview on 12/09/25 at 5:27 PM, the DON was asked if R1 had exhibited inappropriate behaviors prior to the incident on 11/20/25 with R2. The DON stated she was only aware of the 11/20/25 incident which occurred with R2. The DON confirmed a safety risk evaluation had not been completed on R1. When asked how the staff monitored R1 to make sure he did not get near R2, the DON stated, Frequent monitoring and rounding on both residents. This is done by all staff watching both residents. At first, we did frequent progress notes. The DON confirmed that there were no changes made in R1's plan of care to protect other residents until the incident on 11/20/25.During an interview on 12/10/25 at 8:50 AM, the Administrator reported she was unaware that another resident's family member told staff that R1 had fondled R2's breasts and that R1 needed to stay away from R2. When asked if this was something that should have been reported, she stated, Yes, most definitely so I could have investigated this.During an interview on 12/10/25 at 11:00 AM, CMA1 was again asked if she had reported R1 touching R2's breasts to anyone, and she stated, I believe that I reported this to the social worker.During an interview on 12/10/25 at 11:08 AM, the Social Services Director (SSD) stated, No, I was not notified of this. If I had been notified, I would have notified the Administrator and started an investigation.During an interview on 12/10/25 at 11:26 AM, the DON was asked if she had been notified of R1 attempting to kiss another resident on 06/18/25, according to the Psych Progress Note, and the DON denied having knowledge that this had taken place or having been notified of such an incident. The DON also denied having been notified of R1 fondling R2's breasts before the incident that occurred on 11/20/25.During an interview on 12/10/25 at 11:28 AM, the ADON was asked if he had been notified of the occurrence on 06/18/25 when R1 attempted to kiss another resident, and the ADON denied having knowledge of this incident or having been notified of such an incident that occurred with R1 fondling R2's breasts before the incident on 11/20/25.During an interview on 12/10/25 at 11:32 AM, the Administrator was asked if she had knowledge of R1 attempting to kiss another resident on 06/18/25, and the Administrator denied having knowledge of this incident.R2 is not able to verbalize how these incidents have affected her. Using the reasonable person concept, it is likely that a reasonable person would experience psychosocial and mental distress and feelings of not being safe in one's environment, reactions which would create a reasonable likelihood for serious harm. This led to the finding of immediate jeopardy, The facility removed the immediate jeopardy on 12/13/25, however, the deficient practice continues at a scope/severity level of D as the facility continues to implement the following action plan:~ The facility completed a root cause analysis of the facility practices and event to prevent reoccurrence and identified a failure to report the abuse to administration which led to further abuse.~ The facility assessed each resident and established a care plan and supervision for the residents. ~ Systems were established to monitor and document frequency of behaviors.~ Assessments were completed as indicated by psych services. ~ Facility staff were trained on facility practices and changes to any systems within the facility. ~ A system for auditing and monitoring along with QAPI was established by the facility.

Based on observations, record review, interviews, and policy review, the facility failed to maintain the cleanliness of a nebulizer mask for one of one resident (Resident (R) 7) reviewed for nebulizer use out of 17 sampled residents. This deficient practice increased the risk of infection for residents requiring nebulizer therapy.Findings include:Review of R7's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R7 was originally admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease.Review of R7's Physician Orders located under the Orders tab in the EMR indicated an order dated 09/10/24 for Budesonide Inhalation Suspension [an inhaled steroid] 0.5 mg [milligram]/ 2 ml [milliliter] inhalation . 2 ml inhale orally two times a day for SOB [shortness of breath] related to chronic obstructive pulmonary disease.Review of R7's annual Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 10/27/25 indicated R7 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R7 was cognitively intact. Review of R7's Care Plan located under the Care Plan tab in the EMR indicated R7 had a Focus, dated 01/10/22, [R7] has COPD [chronic obstructive pulmonary disease]/asthma/sleep apnea. Interventions included, . Give aerosol or bronchodilators as ordered . Observations conducted on 12/08/25 at 2:29 PM and on 12/12/25 at 9:00 AM revealed R7's nebulizer mask was sitting out on the bedside table, uncovered, and not in use. During an interview on 12/12/25 at 9:00 AM, Licensed Practical Nurse (LPN) 2 confirmed the nebulizer was on the bedside table and stated, The mask [nebulizer] should be in a plastic bag when not in use.During an interview on 12/13/25 at 1:00 PM, the Director of Nursing (DON) stated, The nebulizer mask is to be stored in a plastic bag when not in use.Review of the facility's policy Oxygen Administration, dated 02/01/25, indicated, . Keep delivery devices covered in plastic bag when not in use .

Based on record review, interviews, and policy review, the facility failed to maintain a complete and accurate medical record for one of 17 sampled residents (Resident (R) 5). This failure resulted in the medical record not accurately showing whether R5's medication was administered.Findings include:Review of R5's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R5 was admitted to the facility on [DATE] with diagnoses of fracture of the left femur and malignant neoplasm of the prostate with secondary neoplasm of the bone.Review of R5's Physician Orders located under the Orders tab in the EMR indicated an order dated 10/30/25 for apalutamide (a hormone blocker used to treat prostate cancer) 240 milligrams by mouth one time a day.Review of R5's Medication Administration Record (MAR), dated November 2025 and located under the Orders tab in the EMR, revealed that on 11/08/25 at 12:00 PM, the nurse documented code 9, which indicated that additional details should be referenced in the Progress Notes.Review of R5's Nursing Progress Notes located under the Progress Note tab in the EMR revealed there was no documentation regarding the administration of the apalutamide on 11/08/25.During an interview on 12/12/25 at 1:12 PM, Licensed Practical Nurse (LPN) 4 stated, I remember that day because I couldn't find it [cancer medication], and his family member told me where it was in the med [medication] cart, and I was able to go back and give it to him [R5]. When asked if she documented it as being given, LPN4 stated, I don't remember if I went back and charted that or not. LPN4 stated she should have documented it as given in the nurses' notes with an explanation of what happened since she documented a 9 on the MAR. During an interview on 12/13/25 at 1:10 PM, the Director of Nursing stated, The nurse should have clicked the medication as given or went to the nurses' note and explained this.Review of the facility's policy titled, Person-Centered Medication Administration, dated 02/02/25, indicated, . will document administration or refusal of medications as per facility policy .

Based on record review, interviews, and policy review, the facility failed to provide a fish-free meal to one resident (Resident (R) 13) with a documented fish allergy out of three residents reviewed for food allergies from a sample of 17 residents. This failure had the potential for R13 to experience a severe anaphylactic reaction.Findings include:Review of R13's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R13 was admitted to the facility on [DATE] with diagnoses of osteoarthritis and diabetes mellitus. R13's Face Sheet also included documentation of R13 having an allergy to . Fish Allergy, fish products . Review of R13's admission Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 10/09/25 indicated R13 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R13 was cognitively intact.Review of R13's Nursing Progress Notes located under the Progress Note tab in the EMR indicated a note dated 11/11/25 at 3:34 AM, Called to room resident states they had served Fish [sic] with supper, she [R13] did not eat any but just having it in her room made her itch all over, wants benadryl [sic] 50mg [milligram] prn [as needed] and hydrocortisone ointment to be kept at bedside so she can apply as needed to arms/hands/face/back and thighs. [Name of on call company] contacted.Review of Physician Orders located under the Orders tab in the EMR indicated an order dated 11/11/25 for Benadryl 50 mg by mouth every eight hours as needed for allergic reaction/ itching for 10 days and hydrocortisone 1% (percent) apply a thin layer to the affected skin twice a day for 10 days.Review of R13's Medication Administration Record, dated November 2025, indicated R13 received Benadryl 50 mg for itching on 11/11/25 at 4:21 AM, 11/16/25 at 9:35 AM, and 11/18/25 at 1:30 AM. It was documented that R13 received relief from itching after the administration of Benadryl on those dates and times. It was also documented that R13 was administrated hydrocortisone ointment on 11/15/25 at 2:44 AM and 11/18/25 at 1:32 AM. It was documented that R13 received relief from the use of the hydrocortisone ointment.During an interview on 12/13/25 at 12:30 PM, R13 stated, I got fish one day on my tray. I am allergic to fish and didn't eat it. I told them [staff] to never bring me fish again. R13 confirmed that she did not eat the fish that was brought to her on her tray.During an interview on 12/13/25 at 3:21 PM, Dietary Manager (DM) 1 stated, The line aide that served the fish that day was talked to, and I let her go home early that day. I explained to staff to look at the food allergies and highlight these so everyone can see the allergies of the residents so the residents will not get the food by mistake like what happened in this case. DM1 confirmed Fish allergy was on R13's tray card.During an interview on 12/13/25 at 3:30 PM, the Administrator stated, I expect the dietary staff to pay attention to the food allergies of each resident and not give the residents what they are allergic to.Review of the facility's policy titled Menus and Adequate Nutrition, dated 02/16/25, indicated, . Resident preferences, including likes and dislikes will be documented in the resident's chart, and shall be reviewed . It did not reflect documentation of the residents' food allergies.

Based on record review, interviews, and policy review, the facility failed to report allegations of abuse to the state agency for two of four residents (Resident (R) 1 and R2) reviewed for allegations of abuse out of 17 sampled residents. As a result of this deficient practice, the facility failed to investigate these incidents and implement interventions to prevent further occurrence, and R1 continued to touch R2 inappropriately. Cross Reference: F600 Freedom from Abuse. Findings include:1. Review of R1's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R1 was originally admitted to the facility on [DATE] with diagnoses of dementia and metabolic encephalopathy.Review of R1's Psych Progress Note, dated 06/18/25, indicated, Chief Complaint: Staff requested follow up psych visit for inappropriately attempting to kiss another resident . Plan . Staff educated to redirect patient . to keep him . away from other vulnerable patients . Review of R1's quarterly Minimum Data Set (MDS), located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 09/19/25, indicated R1 had a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated R1 was moderately cognitively impaired. There was no documentation that R1 exhibited any behaviors in the seven day look back period. R1 propelled independently in a wheelchair.Review of R1's Care Plan located under the Care Plan tab in the EMR indicated there was no care plan for sexual inappropriateness prior to 11/20/25.2. Review of R2's undated Face Sheet located under the Profile tab in the EMR indicated R2 was admitted to the facility on [DATE] with diagnoses of [NAME]-[NAME] syndrome, epilepsy, and developmental disorder.Review of R2's quarterly MDS, located under the MDS tab in the EMR with an ARD of 09/13/25, indicated R2 was coded as severely cognitively impaired.Review of R2's Care Plan, located under the Care Plan tab in the EMR and dated 02/14/17, indicated R2 had behaviors of screaming and swinging her arms if she did not want to do something or was upset or afraid. R2 was dependent on staff for wheelchair mobility.During an interview on 12/09/25 at 1:30 PM, Unit Manager (UM) 1 stated, A couple of months ago, I was told by another resident's family member that R1 and R2 should not be in the same area. The person told me that R1 likes to put his hands up R2's shirt and fondle her breasts . UM1 stated she did not report the allegation. During interviews on 12/09/25 at 12:07 PM and 12/10/25 at 11:00 AM, Certified Medication Aide (CMA) 1 stated, I was told by another resident's family member that R1 was holding R2's hand and would touch her breasts while they were in the east lounge area. CMA1 stated she had reported this to the social worker. During an interview on 12/10/25 at 11:08 AM, the Social Services Director (SSD) reported she had no knowledge of the family member's report or the incident the 06/18/25 Psych Progress Note referred to.During an interview on 12/10/25 at 11:26 AM, the Director of Nursing (DON) reported she had no knowledge of the family member's report or the incident the 06/18/25 Psych Progress Note referred to.During an interview on 12/10/25 at 11:28 AM, the Assistant Director of Nursing (ADON) reported he had no knowledge of the family member's report or the incident the 06/18/25 Psych Progress Note referred to.During an interview on 12/10/25 at 11:32 AM, the Administrator stated, If these had been reported to me, then I would have reported these to the State and done an investigation.Review of the facility's policy titled Abuse, Neglect and Exploitation, dated 03/25/25, revealed, . Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies [e.g., law enforcement when applicable] within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .

Based on interviews and record review, the facility did not resolve a grievance as outlined in the facility's grievance policy for 1 (R1) of 3 residents reviewed for grievances. R1's [family member] filed a grievance on 2/22/25 with concerns related to oxygen levels too high, staff not re-approaching R1 when R1 refuses to take medication or personal cares, R1 not getting out of bed due to refusals, broken laundry basket and two missing night gowns.The facility did not resolve R1's grievance related to the broken laundry basket or the two missing night gowns.Findings include:The facility policy titled Resident and Family Grievances, date implemented, 1/4/25, documents:Policy: It is the policy of this facility to support each resident's and family right to voice grievances, without discrimination, fear of reprisal or free of discrimination or reprisal. Definitions: Prompt efforts to resolve include facility acknowledgement of complaint/grievance and actively working toward resolution of that complaint/grievance.Policy Explanation and Compliance Guidelines:1. Social Services has been designated as the Grievance Official and can be reached at (list contact information). (sic)2. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with the state and federal agencies as necessary in light of specific allegations.10. Procedure:a. This facility will not retaliate or discriminate against anyone who files a grievance or participates in the investigation of a grievance.b. The staff member receiving the grievance will record the nature and specifics of the grievaqnce on the designated grievance form, or assit the resident or family member to complete the form.c. Forward the grievance form to the Grievance Official as soon as possible.d. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form.e. The Grievance Official or designee, will keep the resident appropriately apprised towards resolution of the grievances.12. The facility will make prompt efforts to resolve grievances.R1 was admitted to the facility on [DATE] with diagnoses that includes respiratory failure, dementia, type 2 diabetes, congestive heart failure, and reduced mobility.R1 has a Brief Interview of Mental Status (BIMS) score of 11, indicating mild cognitive impairment.R1's Progress Note, dated 2/12/25 at 15:18 (3:18 PM), author, Director of Nursing (DON)-B, documents, Late Entry: Note Text: Writer spoke with Activated-POA (Power of Attorney) [Family member]; regarding concerns she has for her mother [R1]. [Family member] states staff allows [R1] to make refusals, and that staff does not encourage her enough to be more compliant with her plan of care including medications and the use of her CPAP machine. [Family member] asked that [R1's] CO2 (oxygen) level be checked as she and her [Family member] feel this is why [R1] is refusing more often at this time vs (verses) her initial time following admission at this facility. [Family member] states staff often places facility linen in her personal laundry basket and loses [R1's] personal items by sending them to housekeeping. Writer asked for family assistance with [R1's] refusals as writer herself has attempted to assist with Medication and Insulin administration personally and multiple times. Writer educated [Family member] that although staff will make a stronger attempt at encouraging [R1], staff is required to respect resident Rights by Law. [Family member] also made aware that staff cannot force [R1]to do anything per [Family member's] request. Concerns about linen communicated with Social Services and Housekeeping. Order obtained for CO2 draw per [Nurse Practitioner]. [Lab] contacted by writer to arrange a timed draw on 2.13.25 so that staff, including writer who are familiar and who have a rapport with [R1] can be available to assist in obtaining specimen for CO2 level. Writer to ensure appropriate and visible signage is posted in resident room indicating family washes personal items. POC will be updated with this information as well. Staff will be instructed that any refusals of CPAP are to be reapproached after several minutes and by staff who [R1] is more compliant for or more familiar with given they are available. [Family member] requested multiple attempts be made by staff. Staff also informed they are to contact [family member] in the event is not successful in [R1's] refusals for her CPAP per [Family member's] request. [Family member] thanked writer for agreed changes to [R1's] plan of care.Surveyor reviewed the facility's grievance log. Surveyor noted a grievance filed by R1 on 2/12/25 which documents: Brief description of complaint: Oxygen level refusals Resolved: yes Date and Time resolved: 2/12/25 Customer/Family is satisfied: yes Interventions: up/down call fam (sic) c (with) refusals. Reportable: noOn 7/725 at 11:01 AM, Surveyor interviewed Social Worker (SW)-F and asked who follows up on grievances or concerns. SW-F stated sometimes grievances come directly to her. Surveyor asked SW-F what kind of grievances are directed to her and SW-F stated, it can be housekeeping, nursing, therapy, kitchen as they run the gamut. Surveyor asked SW-F if she can recall any grievances filed by R1 and she could not recall but would be getting back to me. On 7/7/25 at 11:51 AM, Surveyor interviewed R1. Surveyor asked R1 if family does her laundry and R1 stated yes, but R1 still has some clothing missing from the facility. R1 stated she could not recall now exactly what clothing items were missing because it was a while ago. Surveyor asked R1 if anyone has ever spoken to her about the missing clothing and R1 stated, no one has talked to me about it. Surveyor informed R1 that it would be reported to social services today.On 7/7/25 at 12:16 PM, Surveyor notified SW-F that R1 still has unresolved concerns regarding missing clothing. SW-F stated after she reviewed the progress notes, she did not recall anyone providing information to her regarding the broken hamper or missing night gowns but will now be addressing the issue. Surveyor notified SW-F this was a concern that no one followed up since 2/12/25 on these issues.On 7/8/25 at 8:30 AM, Surveyor interviewed Laundry Aide- H, who stated no one has ever reported to her any concerns regarding missing clothing items.Surveyor notes, DON-B stated in a progress note on 2/12/25 she reported broken hamper and missing night gowns to social services and housekeeping.On 7/8/25, Surveyor asked SW-F for the investigation into the grievance that R1 filed on 2/12/25. SW-F provided Surveyor the Service Recovery Form (SRC) for R1 and stated, after her review of the SRF, SW-F once again acknowledged, somehow the resolution regarding the broken hamper and two missing nightgowns was missed.Surveyor reviewed the SRC which documents on 2/12/25, in part, . staff broke the laundry basket and R1 is missing two, night gowns.Surveyor noted that the SRC does not document any resolution for the broken laundry basket or R1's missing night gowns. The other areas of the grievance were documented and resolved.On 7/8/25, at 11:00 AM, Surveyor notified, Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Assistant Director of Nursing (ADON)-C, regarding concerns related to components of the grievance filed on 2/12/25, were not addressed nor resolved to include broken hamper and two missing night gowns. NHA-A expressed understanding of concern.No additional information was provided as to why the facility did not document a thorough investigation and did not resolve grievances as outlined in the facility policy.

Based on interview and record review the facility did not ensure that 1 (R2) of 1 allegations of mistreatment involving residents were thoroughly investigated. * R2 reported allegations of retaliation from a staff member and the allegations were not reported to the Nursing Home Administrator (NHA)-A in a timely manner. Certified Nursing Assistant (CNA)-O continued to work in resident care the rest of the shift. Findings include: The facility's policy titled, [NAME] Lake healthcare at [NAME] Abuse, Neglect and Exploitation dated: 6/1/2024 documents under the policy: . V. Investigation of alleged abuse, neglect and exploitation. A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation of curb. VI. Protection of resident. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation. 1.) R2 was admitted to the facility on [DATE] with diagnoses that includes major depressive disorder, single episode, anxiety disorder, transient cerebral ischemic attack and repeated falls. R2's Quarterly Minimum Data Set (MDS), dated [DATE], documented a brief interview mental status (BIMS) score of 15, indicating that R2's cognition was intact. Section B, documents that R2 is understood and understands. R2's Behavioral care plan, dated 8/15/2024, with the target date of 4/17/2025, documents under the intervention section anticipate and meet the resident's needs, attempt to limit the assignment of new staff, encourage the resident to express feelings appropriately, explain all procedures to the resident before starting and as performing cares, if reasonable, discuss the resident's behavior. Interview necessary to protect the rights and safety of others monitor behavior episodes and attempt to determine underline because. Surveyor reviewed a complaint sent into the State Agency from R2, this complaint was regarding allegations of mistreatment or retaliation that had occurred at the facility in March of 2025. On 3/24/2025, at 9:50 AM, Surveyor interviewed R2, who indicated working with CNA-O on 3/6/2025. R2 indicated telling CNA-O that R2 wanted to use the toilet after being cleaned up from morning cares. R2 indicated that CNA-O used vulgar language and indicated that this was not going to happen after a complete bed bath was just done. R2 stated telling CNA-O that it is on R2's care plan to do it this way. R2 stated telling CNA-O that R2 will be calling the office and started to call. R2 indicated CNA-O then, bent down and unplugged the phone cord, R2 stated R2 started to yell out to CNA-O to plug the phone line back in. R2 stated that CNA-O then stated, my back hurts can't you see I'm in pain and then walked out of R2's room. R2 stated that R2 yelled out for help until another CNA came into R2's room to help, and that was CNA-F. R2 stated that CNA-O has not worked with R2 since the incident. R2 stated the only staff that R2 had a concern with is CNA-O. On 3/24/2025, at 12:30 PM, Surveyor interviewed CNA-O, who indicated working with R2 on 3/6/2025. CNA-O indicated remembering that CNA-O was about to use cream on R2 and that the cream fell under the bed. CNA-O stated having to move the bed to retrieve the cream and the phone getting unplugged at that time. CNA-O indicated that R2 was yelling and screaming, and that CNA-O went into the hall to get assistance from someone else related to R2's behaviors. CNA-O indicated being suspended on 3/10/2025 for the incident for the facility to investigate and returning to work on 3/17/2025. On 3/25/2025, at 9:30 AM, Surveyor interviewed CNA-F, who indicated working with R2 and CNA-O on 3/6/2025. CNA-F stated hearing R2 yelling out for help, and this was abnormal for R2, this is not a behavior that R2 has. CNA-F indicated that CNA-O was walking out of R2's room when she heard the yelling. CNA-O explained to CNA-F that the cream got dropped and when CNA-O moved the bed it must have unplugged the phone. CNA-F indicated remembering that R2's cares were switched to CNA-F for the rest of the shift, and this was the nurse's recommendations. CNA-F indicated that both CNA-F and CNA-O updated licensed practical nurse (LPN)-P right away. LPN-P is no longer employed at the facility. Surveyor reviewed the statement from the facility investigation from LPN-P. LPN-P indicated that LPN-P worked with R2 on 3/6/2025. LPN-P stated being informed of the allegation and that LPN-P changed the alleged CNA-O to not be assigned to R2 cares. LPN-P asked CNA-F to care for R2 for the remainder of the shift. R2's nurse didn't report allegation to NHA-A until the end of LPN-P's shift, causing the CNA-O to continue to work in resident care the rest of CNA-O's shift. On 3/26/2025, at 8:40 AM, Surveyor interviewed NHA-A, who indicated being updated about R2's incident at the end of LPN-P's shift. NHA-A stated that LPN-P is no longer employed here because LPN-P didn't notify NHA-A in a timely manner of what had occurred. NHA-A indicated that the facility just completed an in-service on reporting and LPN-P didn't report the allegation of potential retaliation in a timely manner. NHA-A indicated that as soon as NHA-A was aware of the allegation CNA-O was suspended. On 3/26/2025, at 9:26 AM, Surveyor interviewed Social Service Director (SSD)-M, who indicated not being informed of allegation of retaliation from R2 on 3/6/2025 until the end of LPN-P's shift. SSD-M stated that LPN-P should have updated SSD-M or NHA-A immediately. SSD-M stated that SSD-M immediately told HR (Human Resources) and scheduling that CNA-O was suspended. On 3/26/2025, at 9:45 AM, Surveyor interviewed Scheduler (SCHED)-S, who stated that CNA-O didn't work after 3/6/2025 and Surveyor observed the electronic schedule on (SCHED)-S computer and confirmed that CNA-O was not documented on the schedule. On 3/26/2025, at 10:55 AM, Surveyor informed NHA-A and Director of Nursing (DON)-B, of concern with CNA-O continuing to work on 3/6/2025 after the reported allegations of retaliation were made by R2. Surveyor informed concerns that LPN-P didn't report incident immediately. No additional information was provided.

Based on interview and record review the facility did not report 1(R2) of 2, reportable incidents reviewed, to the State survey agency and/or Law Enforcement within the required timeframe. *On 02/24/2025, The facility was made aware of R2's missing money. The facility did not notify the local Law Enforcement within the required timeframe. Findings include: The facility policy, titled [Facility Name] abuse, neglect and exploitation, dated 6/1/2024, documents, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the administrator, state agency, Adult Protective Services and to all other required agency (E.G., law enforcement when applicable. 1.) R2 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, single episode, anxiety disorder, transient cerebral ischemic attack, repeated falls. R2's Quarterly Minimum Data Set (MDS), dated [DATE], documented a brief interview mental status (BIMS) score of 15, indicating R2's cognition was intact. Section B documented that R2 is understood and understands. R2's Behavioral care plan, dated 8/15/2024, with the target date of 4/17/2025, documents under the intervention section anticipate and meet the resident's needs, attempt to limit the assignment of new staff, encourage the resident to express feelings appropriately, explain all procedures to the resident before starting and as performing cares, if reasonable, discuss the resident's behavior. Interview necessary to protect the rights and safety of others monitor behavior episodes and attempt to determine underline cause. Surveyor reviewed a complaint sent into the State Agency regarding allegations of misappropriation that had occurred at the facility in February of 2025. On 3/24/2025, at 10:15 AM, Surveyor interviewed R2, who indicated there was money in an envelope inside of R2's purse and that the envelope of money was missing. R2 indicated that Social Services Director (SSD)-J took statements and helped look for the missing money. R2 stated that the money was not found and that the police were never called. R2 indicated asking for the phone number for the police because she wanted her purse fingerprinted but then R2 just decided not to call after all. On 3/26/2025, at 8:40 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated that expectations for misappropriation allegations would be to contact local law enforcement. NHA-A indicated being on vacation during the time of the investigation of R2's missing money on 2/24/2025. NHA-A stated that Surveyor would need to speak with social service director (SSD)-J for further information. On 3/26/2025, at 9:26 AM, Surveyor interviewed SSD-J who stated that R2 didn't want SSD-J to contact the police. SSD-J stated that R2 had two different allegations, the first one when the police were called, as these where 2 separate occurrences and the current one where the money was found. The second reported incident, SSD-J wanted to call the police herself. SSD-J indicated not calling the police for this matter as R2 didn't want her to, and R2 wanted to call herself. On 3/26/2025, at 10:55 AM, Surveyor informed Director of Nursing (DON)-B and NHA-A, of the concern with R2's reported allegation of misappropriation on 2/24/2025 not being reported to local law enforcement. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure residents received adequate assistance devices to prevent accidents for 1 (R13) of 3 residents reviewed for accidents. *R13's At Risk for Falls Care Plan had the intervention of bilateral fall mats on the floor. Observations were made of R13 having one fall mat on the floor and not two fall mats. Findings include: 1.) R13 was admitted to the facility on [DATE] with diagnoses of osteoarthritis, malnutrition, anxiety, chronic kidney disease, and Alzheimer's disease. R13's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R13 was severely cognitively impaired per staff assessment. R13 has been receiving hospice services since admission on 1/27/2022 with a diagnosis of senile degeneration of the brain. R13 has an activated Power of Attorney. R13's Risk for Falls Care Plan was initiated on 1/28/2022 with the following interventions: -Anticipate and meet R13's needs. -Bed to be in lowest position and bilateral floor mats. -Educate R13/family/caregivers about safety reminders and what to do if a fall occurs. -Neuro checks per policy. -Vital signs per policy. No revisions were made to the Risk for Falls Care Plan since its initiation on 1/28/2022. R13 did not have any falls documented. On 7/13/2024 on the Fall Risk Evaluation form, nursing documented R13 was a moderate risk for falls with a score of 10. On 9/24/2024, at 10:57 AM, Surveyor observed R13 sitting in a Broda chair in the common area of the unit by the nurses' station. R13 appeared well groomed. Surveyor observed one fall mat in R13's room between the bed and the window. No second fall mat was observed on the floor or folded out of the way. On 9/24/2024, at 12:24 PM, Surveyor observed R13 lying in bed on the left side. The bed was in a low position. A fall mat was observed on the floor between the bed and the window. No fall mat was observed on the side of the bed between the bed and the door. In an interview on 9/25/2024, at 8:02 AM, Surveyor asked Licensed Practical Nurse (LPN)-G if R13 was supposed to have one or two floor mats. LPN-G looked in the computer charting system to find out. LPN-G stated LPN-G was not very familiar with the electronic charting system, so it took a little time to find information. LPN-G stated the Care Plan says R13 should have bilateral fall mats. Surveyor shared with LPN-G the observation of R13 having only one floor mat in the room. LPN-G stated LPN-G would get another fall mat placed in R13's room. On 9/25/2024, at 10:04 AM, Surveyor shared with Director of Nursing (DON)-B the observation of R13 having one fall mat on the floor when the At Risk for Falls Care Plan indicated there should be two fall mats. DON-B stated LPN-G had shared that information with DON-B earlier. No further information was provided at that time.

Based on observation, interview, and record review the facility did not ensure each resident receives adequate supervision or assistance devices to prevent accidents for 1 (R8) of 3 residents reviewed for accidents. *R8 was readmitted to the facility on [DATE] and had a significant change in R8's cognition and activities of daily living (ADL's) performance and enrolled onto Hospice services. R8 care plan and certified nursing (CNA) care Kardex was not revised to indicate R8's decline. R8 had a fall on 5/18/2024 that resulted in a dislocated finger with avulsion and 3 sutures for a laceration. Findings include: The facility policy, entitled Change in a Resident's Condition or Status, revised on 5/10/2024, documents: . 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . 5. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. The facility policy, entitled Care Plan Revisions, implemented on 6/14/2024, documents: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change, 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. The Interdisciplinary Team (IDT) will discuss the resident condition and collaborate on intervention options. b. The care plan will be updated with the new or modified interventions. c. Staff involved in the care of the resident will report resident response to new or modified interventions. d. Care plans will be modified as needed by the minimum data set (MDS) Coordinator or other designated staff member. R8 was initially admitted to the facility on [DATE] and R8 was readmitted to the facility on [DATE] and has diagnoses that include Chronic Obstructive Pulmonary Disease (COPD), Acute on Chronic Respiratory Failure with Hypercapnia and Hypoxia, Major Depressive Disorder, Anxiety Disorder, Metabolic Encephalopathy, history of alcohol abuse, muscle weakness, adult failure to thrive, and was dependent on supplemental oxygen. R8's quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated R8 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 and the facility assessed R8 to require minimal assist of 1 staff member for oral hygiene, toileting hygiene, repositioning and transferring and modified independent with set up with eating, bathing, upper and lower body dressing, and personal hygiene. R8 was able to propel self in a manual wheelchair with R8s lower legs for long distance and ambulate independently with a wheeled walker in R8's bedroom. R8 was occasionally incontinent of urine and frequently incontinent of bowel and wore adult briefs for protection. R8 was assessed on 5/17/2024 to be a moderate risk for falls with a fall risk score of 10.0. R8 was admitted on to Hospice care on 5/17/2024 for terminal COPD. R8's ADL (Activities of Daily Living) self-care care plan . care plan initiated on 1/21/2021 and last reviewed on 12/14/2023 had the following interventions in place: . - Locomotion: (R8) has a w/c (wheelchair) and is able to propel self and can ambulate independently in his room. (initiated: 5/5/2021, revision: 2/4/2022) - Bed Mobility: Independent (initiated: 1/21/2021, revision: 5/24/2023) - Toilet use: Independent, he is continent of bowel and bladder (initiated: 1/21/2021, revision: 5/24/2023) - Transfer: patient able to transfer in room to/from bed, w/c and toilet at MI (modified independent with use of grab bars for support. Able to ambulate in hallway with four wheeled walker and staff, requires supervision. When up ambulating with four wheeled walker, patient should have supervision for O2 (oxygen) tubing management and safety. (initiated:1/21/2024, revision: 5/2/2024) - Encourage resident to use bell to call for assistance (Initiated 5/5/2021) - Monitor/document/report PRN (as needed) any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function (initiated 5/5/20210) R8's risk for falls care plan . initiated on 1/27/2021 and last reviewed on 12/14/2023 had the following interventions in place: . - Be sure (R8's) call light is within reach and encourage (R8) to use it for assistance as needed. (initiated 1/27/2021, revision: 5/5/2021) - Ensure (R8) is wearing appropriate footwear when ambulating or mobilizing in w/c. (initiated 5/5/2021, revision: 11/3/2021) - Provide a reacher (initiated 2/26/2024) On 5/6/2024, R8 was admitted to the hospital with symptoms of shaking, tremors and elevated temperature. R8 underwent testing in the hospital, and it was documented that a lesion was found on R8's liver. R8's history indicated possible primary lung malignancy with metastasis to the liver. R8's power of attorney (POA) was activated and determined no further testing to be done due to R8's frailty and malignancy diagnosis. R8 and R8's POA decided to admit R8 into Hospice services. On 5/17/2024, at 18:30 (6:30 PM), in the progress notes nursing charted R8 arrival back to facility with Primary dx (diagnosis) documented as possible metastatic lung cancer versus chronic aspiration, Severe COPD On 5/17/2024, at 18:42 (6:42 PM), in the progress notes Assistant Director of Nursing (ADON)-N documented Nurse Practitioner (NP) aware of (R8) readmit to the facility and clarified medication orders with the NP. On 5/17/2023, at 21:37 (9:37 PM), in the progress notes nursing documented (R8) assessed by [Hospice company] and admitted to hospice care with diagnosis of terminal COPD. New orders noted for comfort medications. On 8/13/2024, Surveyor reviewed R8's hospital occupational therapy (OT) notes dated 5/17/2024 at 2:55 PM that documented: Cognitive Status: - (R8) confused and flat affect, oriented to person, disoriented to time, situation, and place. - overall status: impaired Sitting Balance: -Minimal assist required due to posterior lean when performing UE/LE (upper extremity/ lower extremity) exercise. Bed Mobility: - Repositioning in bed: 2 person, total assist-dependent (boost towards HOB (head of bed)) - Minimal assist for BLE (bilateral lower extremity) advancement and scooting towards end of bed. (R8) tolerated sitting up two minutes before returning back to lying. Assessment: - No functional improvements. - ADL's requiring support at discharge: transfers, dressing, grooming, bathing, toileting, and ambulation. - Staff assists. - Current self-care score-12 (score key indicates score of 9-12 requires maximal assist) - (R8) seen for occupational therapy session. (R8) wanting to sit at end of bed for session. (R8) confused with poor tolerance, quickly returning back to supine in bed. Plan for hospice at facility, poor activity tolerance, and limited progress made with therapy- will discharge 5/17/2024. End of Session: - (R8) in bed. - Safety measures: alarm system in place/re-engaged, lines intact and call light within reach. - Handoff therapist to nurse. Surveyor noted recommendations from OT regarding R8's ADL activity required maximal assist with all ADL's and R8 was documented to be more confused and have a flat affect. Surveyor also noted R8 required an alarm system when in the hospital. Surveyor noted there were no revisions made to R8's ADL or fall care plan with the recommendations from the hospital occupational therapist assessment of R8 on 5/17/2024. On 8/13/2024, Surveyor reviewed R8's CNA Kardex dated 5/17/2024 with the following care recommendations for R8: ADL: - Bed Mobility: Supervision, one person physical assist - Transfer: Independent, no setup or physical help from staff - Walk in room: Independent, setup help only - Walk in corridor: Independent, no setup or physical help from staff - Locomotion on unit: Independent, no setup or physical assist from staff - Locomotion off unit: Independent, no setup or physical help from staff - Dressing: Independent, setup help only - Eating: Supervision, setup help only - Toilet use: Supervision, one person physical assist - Personal hygiene, Supervision, one person physical assist - Bathing: Total dependence, One person physical assist. Not Steady during Transitions/ Walking for: - Moving from seated to standing - Walking - Turning around - Moving on and off toilet - Surface to surface transfers Surveyor noted the CNA Kardex was not revised to indicate the recommendations for R8 from the hospital regarding R8's ADL needs with the noted change in condition. On 5/18/2023, at 06:47 (6:47 AM), in the progress notes nursing documented (R8) alert and responsive. No s/s (signs/ symptoms) of pain or discomfort noted. Repositioning Q (every) 2 (two) hours and PRN (as needed) Surveyor noted the above intervention: Repositing every 2 hours and PRN was not added to R8's care plan or CNA Kardex. On 5/18/2024, at 22:21 (10:21 PM), in the progress notes Registered Nurse (RN)-L documented resident found on floor by staff. Unable to explain what made (R8) fall down. On assessment (R8) was lying on right side, had injury, right 4th finger was bleeding without stopping, pressure applied. Right elbow and right shoulder also had some bleeding. (R8) was transferred to [Hospital Name] for further evaluation On 5/19/2024, at 01:22 (1:22 AM), in the progress notes nursing documented R8 will be returning back to facility with diagnoses of dislocated finger. On 5/19/2024, at 06:30 (6:30 AM), in the progress notes nursing documented (R8) returned from emergency room . splint on right hand, fourth digit Surveyor reviewed R8's emergency room report that documented on physical exam: -Right wrist swelling (and ecchymosis (bruising) of ring finger), deformity (ring finger), laceration (pulp of ring finger), tenderness and bony tenderness present. Procedure: -Right ring finger, length: 2 cm, 3 sutures to area, tolerated well without complications. X-ray of right hand and right fingers: Impression: - Dislocation of the fourth phalanx (finger) with avulsion (when an injury causes a ligament or tendon to break off a small piece of bone that is attached to it). - Overlying soft tissue defect consistent with known laceration of the fourth digit. - Right fourth phalanx put into splint. Surveyor reviewed the fall investigation for R8's fall on 5/18/2024. RN-L documented R8 was incontinent at the time of fall and the resident stated, I was trying to go pee. The IDT (Interdisciplinary Team) reviewed the fall and documented R8 had a recent decline in health and now on Hospice services. R8 has lung cancer with metastasis. BIMS score of 9 with moderate impairment. R8 does not always call for assistance, R8 was independent prior to recent hospitalization , due to change in medical condition new intervention implemented is toileting every 2-3 hours as R8 will allow. On 8/13/2024, at 10:37 AM, Surveyor interviewed RN- L who stated RN-L is an agency nurse and moves around a lot and could not recall anything specific about R8 or a fall on 5/18/2024. Surveyor asked RN-L how RN-L would find information for a resident that RN-L was not familiar with to know what cares the resident needed. RN-L stated it would depend on what the facility policy is, but typically information would be gathered with shift change reporting from the previous nurse. RN-L also stated RN-L reviews the 24 hour board and will look at the care plan and what interventions are documented. Surveyor asked RN-L if RN-L recalls reviewing R8's care plan or revising the care plan after R8's fall on 5/18/2024. RN-L stated RN-L could not recall any detail regarding R8 or a fall on 5/18/2024. On 8/13/2024, at 11:27 AM, Surveyor interviewed Director of Nursing (DON)- B and ADON- N. Surveyor asked what staff is responsible for revising care plans. DON-B stated DON-B and ADON-N will do the initial care plan with appropriate interventions when able and any revisions to care plans are done as a team at weekly at risk meetings and as needed by other nursing staff. DON-B stated new admission, readmissions and changes of conditions are discussed with the IDT at weekly at risk meetings. DON-B stated any nursing staff is able to initiate a care plan and communicate it to management, put concerns on the 24 hour board, and make a note in progress notes. Surveyor asked what the process was when residents are readmitted to the facility and have a significant change to their previous plan of care. ADON- N stated the admitting nurse would update the care plan and manager. ADON- N stated the admitting nurse also fills out a readmit screener form and the form touches on the residents ADL function and if there are changes noted on the screener than from previous assessments of the resident then the care plan is updated and also should be noted on the 24 hour board and documented in the progress notes. Surveyor asked ADON- N if ADON- N recalled the readmission for R8 on 5/17/2024 and the changes documented from the hospital for R8. ADON- N stated ADON- N could not recall specific details about R8's readmission on 5/17/2024 or if she reviewed any of the admission paperwork. Surveyor informed ADON- N that ADON- N documented in the progress notes about contacting R8's NP regarding clarification orders for R8. ADON-N stated ADON- N did not recall the specifics or if ADON-N assisted with anything else from R8's readmission on 5/17/2024. Surveyor reviewed R8's re-admission screener form that was documented by RN-L on 5/17/2024, at 18:55 (6:55 PM). RN-L documented the following assessments for R8: BIMS-9, moderately impaired cognition ADLs - Eating, 5-set up or clean up assistance - Oral hygiene, 5- set up or clean up assistance - Toileting hygiene, 3- partial/moderate assistance - Sit to lying, 3- partial/moderate assistance - Lying to sitting on side of bed, 3-partial/moderate assistance - Sit to stand, 88- not attempted due to medical condition or safety concerns - Chair/bed to chair transfer, 88- not attempted due to medical condition or safety concerns - Toilet transfer, 88- not attempted due to medical condition or safety concerns - Walking, 88- not attempted due to medical condition or safety concerns Bladder: - Continent-No - How often is resident wet-once or more per shift - Resident is wet during-day and nighttime Bowel: - Continent-yes Mobility: -locomotion on unit (self-performance)-2, limited assistance Surveyor noted R8's assessed decline in ADL performance, toileting needs, mobility, and cognition did not get revised on R8's care plan or CNA kardex. Surveyor reviewed the 24 hour boards from 5/17/2024 and 5/18/2024. The 24 hour board had the following documentation on 5/17/2024: PM shift: -(R8) alert and oriented X3 (person, place, time), no respiratory distress noted, Assist of 1 with all cares and transfers, incontinent at times. NOC (night) shift: -(R8) no respiratory distress noted at this time, O2/ NC (nasal cannula) as ordered, scheduled breathing treatments, repositioning. The 24 hour board had the following documentation on 5/18/2024: AM shift: -No Issues PM shift: -(R8) fell with injury, out to hospital. On 8/13/2024, at 12:30 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A, DON-B and ADON-N that R8's care plan and CNA Kardex were not revised to indicate R8's change in condition regarding R8's decline in cognition, ADL needs when R8 was readmitted from the hospital on 5/17/2024 and R8 experienced a fall on 5/18/2024 that resulted in a right hand, 4th ring finger fracture with avulsion and required 3 sutures for a laceration. On 8/13/2024, at 1:24 PM, Surveyor interviewed RN unit Manager (RNUM)-D who stated R8 was independent with ADLs and then declined rather quickly once R8 was readmitting to the hospital after the new cancer diagnosis and was put on hospice. Surveyor asked RNUM- D how staff are made aware of significant changes or care concerns for residents. RNUM- D stated the concerns are reviewed in the morning stand up meetings with the IDT M-F, care plans are initiated and/or revised, education is provided to nursing, concerns are put on the 24 hour board and passed on in shift to shift reporting, and documenting in progress notes. Surveyor asked what happens if concerns should arise after hours or on a weekend. RNUM-D stated managers are always on call if nursing needs guidance, but care plans should still be updated, concerns put on 24 hour board, and documented in progress notes then the IDT reviews the next business day to make sure all the concerns were addressed and updated where needed. On 8/13/2024, at 1:33 PM, Surveyor interviewed CNA-M who stated CNA-M noted R8 to be more confused and antsy after returning from the hospital on 5/17/2024. CNA-M stated R8 was independent with most ADLs but when he came back from the hospital and put on Hospice R8 needed more redirection and assistance. CNA-M stated CNA-M was in R8's room frequently redirecting R8 and putting R8's oxygen tubing back on because R8 kept taking it off. CNA-M stated CNA-M last checked on R8 and noted R8 to be dry and sitting in R8's wheelchair watching TV. CNA-M stated CNA-M went to collect supper trays and another CNA notified CNA-M that R8 had fallen. Surveyor asked CNA-M how CNA-M was made aware of R8's new care concerns or where CNA-M would look to see what needs R8 required. CNA-M stated in shift report CNA-M was told R8 required more assistance and redirection. CNA-M stated CNA-M also looks at the resident's care kardex for direction of any care concerns or interventions a resident might have. Surveyor asked CNA-M if CNA-M communicated to the nurse that R8 was antsy and confused. CNA-M could not recall if CNA-M communicated that or not. CNA-M stated CNA-M and RN-L checked in on R8 frequently due to needing more assistance and redirection. No further information was provided to Surveyor at this time.

Based on observation, interview and record review, the Facility did not ensure that Residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 1 (R10) of 3 Residents reviewed for pressure injuries. R10 had a history of pressure injuries. R10 was admitted with a Stage 3 pressure injury on the right & left buttocks, an unstageable pressure injury on the right heel and a stage 3 pressure injury on the left heel. R10's right buttocks was identified as being healed on 5/28/24, the left buttocks pressure injury was healed on 6/11/24, the right heel was healed on 7/30/24, & the left heel was healed on 8/6/24. On 7/15/24, R10 developed three Stage 3 pressure injuries on the coccyx, left & right buttock. The Facility did not revise R10's care plan after development of these pressure injuries, R10's care plan does not include interventions of how often R10 should be repositioned and when incontinence cares should be provided for R10 who was identified as being a heavy wetter. Findings include: The facility's policy titled, Prevention of Pressure Ulcers and revised 1/16/24 under General Guidelines documents: 1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decreased of circulation (blood flow) to that area and subsequent destruction of tissue. 2. The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes. 3. Pressure can also come from splints, casts, bandages, and wrinkles in the bed linen. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected. 4. Pressure ulcers are often made worse by continued pressure, heat, moisture, irritating substances on the resident's skin (i.e., perspiration, feces, urine, wound discharge, soap residue, etc.), decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition. 5. Once a pressure ulcer develops, it an be extremely difficult to heal. Pressure ulcers are a serious skin condition for the resident. R10 was admitted to the facility on [DATE] with diagnoses which include major depressive disorder, diabetes mellitus, morbid obesity and altered mental status. R10 was admitted with a Stage 3 pressure injury on the right & left buttocks, an unstageable pressure injury on the right heel and a stage 3 pressure injury on the left heel. R10's right buttocks was identified as being healed on 5/28/24, the left buttocks pressure injury was healed on 6/11/24, the right heel was healed on 7/30/24, & the left heel was healed on 8/6/24. The potential/actual impairment to skin integrity care plan initiated 5/20/24 & revised 8/6/24 documents the following interventions: * Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Initiated & revised on 5/20/24. * Conduct weekly body audit. Initiated 5/20/24. * Follow facility protocols for treatment of injury. Initiated and revised on 5/20/24. * Identify/document potential causative factors and eliminate/resolve where possible. Initiated & revised on 5/20/24. * Keep skin clean and dry. Use lotion on dry skin. Do not apply on ANY WOUND. Initiated and revised on 5/20/24. * Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. to MD (medical doctor). Initiated & revised on 5/20/24. * The resident needs pressure relieving/reducing mattress, pillows, sheepskin padding etc to protect the skin while up in chair. Initiated and revised on 5/21/24. * Therapy as ordered by MD. Initiated 5/20/24. * Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Initiated & revised on 5/20/24. The CNA (Certified Nursing Assistant) kardex as of 8/13/24 under the skin section documents * Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. * Keep skin clean and dry. Use lotion on dry skin. Do not apply on any wound. * Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. * Wash feet daily with mild soap and water. Dry thoroughly. May use a light dusting powder or lotion. Do not apply lotion or powder between the toes. Under the Resident Care section documents: * All staff to converse with resident while providing care. * Explain all procedures to the resident before starting and throughout cares. * Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. * TRANSFER: Requires Hoyer A (assist) x (times) 2 for all transfers to/from bed and w/c (wheelchair). Surveyor noted the CNA kardex does not document how often R10 should be repositioned and when to provide incontinence cares. The admission MDS (minimum data set) with an assessment reference date of 5/27/24 has a BIMS (brief interview mental status score of 15 which indicates R10 is cognitively intact. R10 is assessed as not refusing cares. R10 is assessed as requiring substantial/maximal assistance for rolling left & right and is assessed as being dependent for toileting hygiene, chair/bed to chair transfer, & toilet transfer. R10 is always incontinent of bowel and bladder. R10 is assessed as being at risk for pressure injury development and has three Stage 3 pressure injuries which were present upon admission. The pressure injury CAA (care area assessment) dated 6/2/24 for nature of problem has not been completed & is blank. For existing pressure injury documents (Click here to add supporting documentation. Provide the basis/reason for items by clicking, including the location & date & source (if applicable), of that information). For extrinsic risk factors documents (Click here to add supporting documentation. Provide the basis/reason for items by clicking, including the location & date & source (if applicable), of that information). For intrinsic risk factors documents (Click here to add supporting documentation. Provide the basis/reason for items by clicking, including the location & date & source (if applicable), of that information). For medications that increase risk for pressure ulcer/injuries development documents (Click here to add supporting documentation. Provide the basis/reason for items by clicking, including the location & date & source (if applicable), of that information). Diagnosis & conditions that present complications or increase risk for pressure ulcer/injury is checked for diabetes, chronic or end stage renal, liver or heart disease, malnutrition, depression and pain. Treatments and other factors that cause complications or increase risk has newly admitted or readmitted checked. Resident and/or family representative and care plan considerations has not been completed and is blank. The Braden assessment dated [DATE] has a score of 17 which indicates low risk for pressure injury development. The nurses note dated 7/7/24, at 21:50 (9:50 p.m.), documents Resident monitored for low SPO2, increased pulse and low BS (blood sugar), BS 144 and O2 (oxygen) 95, Resident denies any pain, resident has had loose stools throughout the day x (times) 6, given PRN (as needed) loperamide. There is excoriation bilateral to buttocks, writer covered with bordered bandage. Resident states pain of 3/10 to buttocks area. Will continue to monitor. This nurses note was written by Nursing-R. Surveyor noted there is no notification to R10's physician regarding the excoriation and bordered bandage applied. The nurses note dated 7/9/24, at 04:05 (4:05 a.m.), includes documentation of Changed sacrum drsg (dressing) This nurses note was written by LPN-S. Surveyor noted there is not an order for a sacrum dressing nor any assessment for the sacrum. The nurses note dated 7/15/24, at 05:51 (5:51 a.m.), documents Resident resting throughout the night no s/s (signs/symptoms) of pain or discomfort noted Right and Left buttock open area noted resident provided peri care barrier cream applied. This nurses note was written by RN-T. Surveyor noted there is no notification to R10's physician regarding the open areas. The nurses note dated 7/15/24, at 12:31, documents Writer followed up r/t (related to) open areas to BIL (bilateral) buttocks. Writer assessed buttocks and cluster wound is noted to coccyx. 3 open areas observed with purple discoloration surrounding them. Documented as cluster DTI (deep tissue injury). Res (Resident) is already seen weekly by wound MD for BIL heel wounds, new wounds added to Wound MD roster. This nurses note was written by Wound Nurse/LPN-K. Surveyor noted there is no RN assessment of R10's pressure injuries. The nurses note dated 7/15/24, at 12:36, documents F/U (follow up) to add wound measurements. Wound measures 6.5 cm x 4.5 cm x 0.1 cm. This nurses note was written by Wound Nurse/LPN-K. The nurses note dated 7/16/24, at 15:43 (3:43 p.m.), documents Res seen by Wound MD this day and BIL heel wounds noted with improvement. Yesterday after reports of new wounds writer assessed res and measured 3 wounds to coccyx area as 1 cluster wound. MD has separated these wounds to be measured and treated separately d/t location of sites. New wounds to left and right buttock as well as coccyx are stage 3's. Writer phoned res RP(Responsible Party) [Name] but she is out of the office today. Writer left message for [Name] to return call for a wound update. Sharps debridement done at bedside per MD and res tolerated well. New tx (treatment) orders received and initiated for buttocks wounds. POC (plan of care) updated to reflect the above. This nurses note was written by Wound Nurse/LPN-K. The weekly wound assessment dated [DATE] documents for date of onset 7/15/24. Wound site is 32.) Left Buttocks. Type is Pressure. Length in cm (centimeters) is 3.7, width 1.8, and depth 0.1. Stage is Stage III (3). Summary documents res noted with new wound to left buttock on 7/15. Wound bed with 100% granulation. Light serosanguineous drainage. Wound edges well defined. Date of onset is 7/15/24. Wound site documents 23.) Coccyx. Type is Pressure. Length 1.6, width 1.1, and depth 0.1 Stage is Stage III (3). Under Summary documents res noted with new wound to coccyx on 7/15. wound bed with 100% granulation. Light serosanguineous drainage. Wound edges well defined. Date of onset is 7/15/24. Wound site documents 31.) Right Buttocks. Type is Pressure. Length 0.9, width 1.3, and depth 0.1. Stage is Stage III (3). Summary documents Res noted with new wound to right buttocks on 7/15. wound bed with 100% granulation. Light serosanguineous drainage. Wound edges well defined. Surveyor noted there were no revisions to R10's skin integrity care plan after R10 developed the three stage 3 pressure injuries. None of R10's care plans include interventions on how often R10 should be repositioned or when continence cares should be provided. The nurses note dated 7/18/24, at 23:29 (11:29 p.m.), documents Resident alert and responsive able to voice needs, treatment maintained to buttocks, resident repositioned as needed tolerated well bilat (bilateral) heels elevated in bed, This nurses note was written by Nursing-U. On 7/22/24 an intervention to the ADL (activities daily living) self care performance deficit care plan was added which documents Resident is resistive to cares, turning, and repositioning. This intervention was added 7 days after R10 developed 3 stage 3 pressure injuries. There is not a refusal of cares care plan. The weekly wound assessment dated [DATE] documents for date of onset 7/15/24. Wound site is 32) Left Buttocks. Type is Pressure. Length in cm (centimeters) is 2.9, width 1.7, and depth 0.1. Stage is Stage III (3). Summary documents Wound bed with 40% granulation and 60% slough. Light serosanguineous drainage. Wound edges well defined. No evidence of infection observed. Date of onset is 7/15/24. Wound site documents 23) Coccyx. Type is Pressure. Length 1.6, width 1.1, and depth 0.1 Stage is Stage III (3). Under Summary documents Wound bed with 100% granulation. Light serosanguineous drainage. Wound edges well defined. Date of onset is 7/15/24. Wound site documents 31) Right Buttocks. Type is Pressure. Length 0.9, width 0.8, and depth 0.1. Stage is Stage III (3). Summary documents Wound bed with 100% granulation. Light serosanguineous drainage. Wound edges well defined. No evidence of infection observed. The weekly wound assessment dated [DATE] documents for date of onset 7/15/24. Wound site is 32) Left Buttocks. Type is Pressure. Length in cm (centimeters) is 2.0, width 1.5, and depth 0.1. Stage is Stage III (3). Summary documents Wound bed with 100% granulation. Light serosanguineous drainage. Wound edges well defined. No evidence of infection observed. Date of onset is 7/15/24. Wound site documents 23) Coccyx. Type is Pressure. Length 1.6, width 1.0, and depth 0.1 Stage is Stage III (3). Under Summary documents Wound bed with 100% granulation. Light serosanguineous drainage. Wound edges well defined. Date of onset is 7/15/24. Wound site documents 31) Right Buttocks. Type is Pressure. Length 0.8, width 0.8, and depth 0.1. Stage is Stage III (3). Summary documents Wound bed with 100% granulation. Light serosanguineous drainage. Wound edges well defined. No evidence of infection observed. The weekly wound assessment dated [DATE] documents for date of onset 7/15/24. Wound site is 32) Left Buttocks. Type is Pressure. Length in cm (centimeters) is 3.5, width 0.8, and depth 0.1. Stage is Stage III (3). Summary documents Wound bed with 40% slough, 10% granulation, and 50% skin. Light serosanguineous drainage. Wound edges well defined. No evidence of infection observed. Date of onset is 7/15/24. Wound site documents 23) Coccyx. Type is Pressure. Length 1.1, width 0.8, and depth 0.1 Stage is Stage III (3). Under Summary documents Wound bed with 100% granulation. Light serosanguineous drainage. Wound edges well defined. Date of onset is 7/15/24. Wound site documents 31) Right Buttocks. Under summary documents wound is now healed. On 8/12/24, at 10:50 a.m., Surveyor observed R10 in bed on her back with her eyes closed, as oxygen via nasal cannula, and the head of the bed elevated. R10 is on an air mattress and is wearing blue pressure relieving boots. Surveyor noted the air mattress was provided on 5/21/24. On 8/12/24, at 12:21 p.m., Surveyor observed R10 continues to be in bed on her back with the head of the bed elevated. On 8/12/24, at 1:55 p.m., Surveyor observed R10 continues to be in bed on her back. Surveyor asked R10 what staff does for her. R10 replied they take care of what ever I need. Surveyor asked R10 if staff repositions her from side to side. R10 replied Usually I stay on my back. Surveyor asked R10 if staff asked her if she wanted to be repositioned on her side today. R10 replied no. Surveyor asked R10 if she has any pressure ulcers. R10 replied on my left heel. Surveyor asked R10 if she has anything on her bottom. R10 replied yes, two sores. Surveyor asked R10 has she developed the sores. R10 replied I don't know. On 8/13/24, at 8:19 a.m., Surveyor observed R10 in bed on her back with the head of the bed up high. R10 is on an air mattress and is wearing pressure relieving boots. On 8/13/24, at 9:41 a.m., Surveyor observed CNA-G & CNA-H enter R10's room. Surveyor asked CNA-G & CNA-H what they were going to do. CNA-G informed Surveyor they were going to change R10. Surveyor observed CNA-G & CNA-H were wear gloves. CNA-G lowered R10's head of the bed and raised the bed up. R10's blanket was removed and staff unfastened the incontinence product. Surveyor observed there is BM (bowel movement) up R10's frontal perineal area. CNA-G informed R10 she was going to clean her and washed R10's frontal perineal area to remove the BM. CNA-G informed R10 she was going to turn R10 towards the window. CNA-G pulled on the soaker pad to move R10 towards the left side of the mattress and CNA-G & CNA-H positioned R10 on the right side. CNA-G removed the dressing from R10's coccyx/left buttocks. Surveyor observed there is a Stage 3 pressure injury on R10's coccyx and left buttocks. CNA-G washed R10's rectal area & buttocks to remove the BM, applied barrier cream on R10's buttocks and an incontinence product was placed under R10 & fastened. CNA-G informed R10 the wound doctor would be here to change her patch. Surveyor asked CNA-G & CNA-H if Surveyor could look at R10's feet. CNA-G removed R10's blue pressure relieving boots. Surveyor did not observe any pressure injuries on R10's feet. CNA-G placed the pressure relieving boots back on R10 and R10 was positioned on the left side. On 8/13/24, at 9:54 a.m., Surveyor asked CNA-G how R10 developed the pressure injuries. CNA-G replied I'm not really sure. On 8/13/24, at 9:56 a.m., Surveyor asked CNA-H if she knew how R10 developed the pressure injuries. CNA-H informed Surveyor she usually works on the first floor or the other hallway explaining she gets moved around. Surveyor asked CNA-H if she did provided any cares to R10 prior to Surveyor's observation. CNA-H informed Surveyor she gave her ice water and changed her. CNA-H informed Surveyor R10 gets up after lunch depending on how she is. Surveyor asked CNA-H what time did she take care of R10. CNA-H informed Surveyor around 7:30 a.m. Surveyor asked CNA-H how often R10 should be repositioned CNA-H informed Surveyor probably every hour or so. On 8/13/24, at 9:59 a.m., Surveyor asked CNA-G how often R10 is repositioned. CNA-G replied every two hours. On 8/13/24, at 10:29 a.m., Surveyor asked Wound Nurse/LPN (Licensed Practical Nurse)-K how R10 developed the three Stage 3 pressure injuries on 7/15/24. Wound Nurse/LPN-K informed Surveyor it started as maceration, she's a heavy wetter, and has a history of wounds in the same area. Surveyor asked who revises skin impairment care plans. Wound Nurse/LPN-K replied typically me when we have wounds or is resolved. On 8/13/24, at 10:31 a.m., Surveyor observed wound rounds for R10 with Wound Nurse/LPN-K & Wound MD-Q. Wound MD-Q assessed R10's pressure injuries stating both are smaller today. Wound MD-Q assessed R10's coccyx Stage 3 pressure injury as having measurements of 0.7 cm (centimeters) x (times) 0.3 cm x 0.1. The wound bed 50% granulation and 50% slough. The left buttocks measurements are 0.5 cm x 0.3 cm x 0.1 cm. The wound bed is 100% granulation. After Wound MD-Q assessed R10's pressure injuries, Wound Nurse/LPN-K completed the treatment according to physician's orders. There were no concerns identified during this observation. On 8/13/24, at 10:49 a.m., Surveyor asked Wound MD-Q how R10 developed the Stage 3 pressure injuries on the left & right buttocks and coccyx on 7/15/24. Wound MD-Q informed Surveyor R10 is overweight and sometimes refuses positioning. Wound MD-Q informed Surveyor sitting in the same position you develop a pressure injury right away. Wound MD-Q stated now that R10 has the wounds she is listening more, before that not so much. On 8/13/24, at 10:51 a.m., Surveyor asked RN/UM (Registered Nurse/Unit Manager)-D how R10 developed the three Stage 3 pressure injuries on 7/15/24. RN/UM-D replied I don't know if I'm the right person. RN/UM-D informed Surveyor R10 was admitted with wounds. RN/UM-D informed Surveyor sometimes R10 can be non compliant with repositioning and doesn't always want to get out of bed which is their right to choose. Surveyor then read R10's nurses note dated 7/7/24 which includes there is excoriation bilateral to buttocks, writer covered with bordered bandage. Surveyor informed RN/UM-D Surveyor did not note where R10's physician was notified or any order for the excoriation. RN/UM-D informed Surveyor this may be an agency nurse. Surveyor then read R10's nurses note dated 7/9/24 which includes changed sacrum dressing. RN/UM-D informed Surveyor she didn't know anything and this was a third shift nurse. Surveyor read R10's note dated 7/15/24 which included noted right and left buttock open area noted resident provided peri care barrier cream applied. Surveyor informed RN/UM-D there is no physician notification and no assessment of the open areas. RN/UM-D informed Surveyor this nurse is no longer employed. Surveyor asked RN/UM-D who revises the care plans as Surveyor noted R10's care plan was not revised after development of the three pressure injuries. RN/UM-D replied our DON (Director of Nursing) or wound nurse does. On 8/13/24, at 11:41 a.m., Surveyor asked DON (Director of Nursing)-B and ADON (Assistant Director of Nursing)-N who revises care plans. DON-B replied we do that as a team. Surveyor asked when care plans are revised. DON-B informed Surveyor on admission, readmission, any changes that occur such as fall or new open area. Surveyor informed DON-B & ADON-N R10 developed 3 stage 3 pressure injuries on 7/15/24. There were no revisions after development of the pressure injuries to R10's care plan. Surveyor informed DON-B & ADON-N on 7/7/24 there is a nurses note regarding excoriation with a dressing being applied. Surveyor noted there was no physician notification or order for treatment. On 7/9/24 there is a nurses note which documented the sacrum dressing was changed. There is no order for a dressing or assessment of this area. On 7/15/24 there is a nurses note regarding left & right buttock open area with barrier cream being applied. The RN didn't assess this area and there is no notification to the physician. Surveyor informed DON-B and ADON-N R10's care plans do not have any interventions as to how often R10 should be repositioned and Surveyor was informed R10 is a heavy wetter but there are no interventions as to how often R10 should be checked and changed. Surveyor asked DON-B and ADON-N to provide any additional information Surveyor may have not reviewed. On 8/13/24, at 12:31 p.m., NHA (Nursing Home Administrator)-A, DON-B and ADON-N were informed of the above. No additional information was provided to Surveyor regarding the development of R10's three Stage 3 pressure injuries.

Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 3 (R16, R4, & R17) of 4 Residents reviewed for pressure injuries. * On 4/17/23, R16 developed an SDTI (suspected deep tissue injury) on the right medial heel. On 5/8 and 5/9/23, R16 was observed with the left thigh on top of the SDTI (right heel) and neither the left or right heel were offloaded. R16 was not wearing a Prevalon boot on the right foot. R16 did not have bilateral heel floaters while in bed as per physician's order dated 11/24/21. After R16 developed the SDTI on 4/17/23, the pressure injury care plan was not revised. During the weeks of 4/23/23 to 4/29/23 there was no RN assessment of R16's pressure injury. There were two different treatments for R16's right heel which were: 11/17/22 right medial heel cleanse with saline protect periwound with skin prep cover with foam change every Monday, Wednesday and Friday and 4/18/23 right heel cleanse with soap & water, pat dry, skin prep area followed by foam border on right heel daily and prn for preventative protection. Example 1 rises to a scope and severity level of G harm/isolated. * R4 was observed with non blanchable skin on the coccyx during continence cares. Barrier cream was not applied as R4 did not have any barrier cream. * R17 was observed having the feet directly on the Broda chair foot pedals and calf rests. The intervention of having a pillow between the legs was removed and the multiple observations that were made throughout the survey of R17 having the left leg crossed over the right leg where R17 has a wound to the right upper thigh. After R17's sacral pressure injury treatment was completed the head of the bed was elevated and R17 was positioned on the back. Findings include: The Prevention of Pressure Ulcer policy and procedure from 2001 Med-Pass Inc., (Revised October 2010) under general preventative measures documents: 2. For a person in bed: a. Change position at least every two hours or more frequently if needed. b. Determine if resident needs a special mattress. c. If a special mattress is needed use one that contains foam, air, gel or water as indicated; d. Raise the head of the bed as little and for as short a time as possible, and only as necessary for meals, treatments and medical necessity. 11. The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate. 1. R16's diagnoses include encephalopathy, hemiplegia and hemiparesis after cerebral vascular accident affecting right dominate side, chronic respiratory failure, contracture of right knee, anxiety disorder, and depressive disorder. The potential for pressure injury/ulcer development initiated 6/18/19 & revised 11/7/22 has the following interventions: * 1/15/22 weekly skin checks per policy. Initiated 1/18/22. * Administer treatments as ordered and monitor for effectiveness. Initiated 6/19/19. * Avoid positioning [R16's first name] on R (right) medial foot. Initiated 6/18/19 & revised 11/26/19. * Continue to encourage and educate [R16's first name] on the importance of floating her heels when in bed and to use prevalon boot to right foot. Initiated 8/21/20 & revised 8/6/22. * Daily foot checks by licensed staff. Initiated 8/27/19. * Education provided to [R16's first name] and family r/t (related to) appropriate positioning and skin protection. Initiated 5/31/22 & revised 8/6/22. * Ensure bedside table moved away from bed with all cares and repositioning. Initiated 3/25/22. * Inspect skin daily with cares-nursing assistant to report any concerns or changes to the nurse. Initiated 8/27/19. * Medacure APM mattress. Initiated 11/25/20. * Monitor nutritional status. Serve diet as ordered, monitor intake and record. Initiated 6/18/19. * Obtain and monitor lab/diagnostic work as ordered. Report results to MD (medical doctor) and follow up as indicated. Initiated 6/18/22. * Sheepskin palm guard on am (morning) off hs (hour sleep). Initiated 3/18/22. * Treatment as ordered to fungal rash R (right) hand. Initiated 3/18/22. * Turn and reposition every 2-3 hours while in bed and while up in chair, document refusals. Initiated 8/27/19 & revised 2/26/20. * Vitamin and protein supplements. Initiated 2/15/22. * W/C (wheelchair) cushion. Initiated 8/27/19 & revised 8/2/22. * Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, wound MD to follow. Initiated 6/18/19 & revised 12/14/21. The Braden assessment dated [DATE] has a score of 12 which indicates high risk. Surveyor was unable to locate another Braden assessment after 6/7/22. The CNA (Certified Nursing Assistant) Kardex as of 5/9/23 under the section monitors documents w/c (wheelchair) cushion. The other sections on this CNA Kardex are toileting, personal hygiene/oral care, eating/nutrition, dressing/splint care, and bathing. None of these sections address pressure relieving interventions including floating heels or repositioning. The quarterly MDS (minimum data set) with an assessment reference date of 3/5/23 documents a BIMS (brief interview mental status) score of 12 which indicates resident is moderately impaired. R16 is coded as not having any behavior including refusal of cares. R16 requires extensive assistance with two plus person physical assist for bed mobility & toilet use, is dependent with two plus person physical assist for transfer, and does not ambulate. R16 is always incontinent of urine and bowel. R16 is at risk for pressure injuries and is coded as not having any pressure injuries. Surveyor reviewed R16's physician orders and noted the orders include the following: * Bilateral heel floaters while in bed every shift with an order date of 11/24/21. * Right medial heel Cleanse with saline protect periwound with skin prep cover with foam change every Monday, Wednesday, Friday for treatment with an order date of 11/7/22. * Alternating air pressure mattress for prevention and wound tx. (treatment) every shift monitor for functioning with an order date 1/19/23. * Right heel Cleanse with soap & water, pat dry, skin prep area f/b (followed by) foam border dressing on right heel daily and prn for prevenative protection. Every day shift for wound care and as needed for preventative management (protection) every day shift for preventative care with an order date of 4/18/23. The late entry nurses note dated 4/17/23 & created on 4/18/23 documents: Writer notified that resident has an open area to the right heel. Right heel then washed with soap and water, dry skin removed. Observed small DTI (deep tissue injury). Assessment-Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration no epidermal separation revealing a dark wound bed (2.0 cm (centimeter) x (times) 0.9 cm). NP (nurse practitioner) notified & POA (power of attorney) [name] husband notified at 1333(1:33 p.m.) via phone call. TX (treatment) order placed. This nurses note was written by Former Wound Nurse/LPN (Licensed Practical Nurse)-M. The late entry nurses note dated 4/17/23 & created on 4/18/23 documents: Writer assessed new wound to right outer heel. Skin flaky, scaly skin. Area cleansed with normal saline and pat dry. Area is deep red not open measures 2cm x 1 cm. No s/s (signs/symptoms) pain with wash or measurement. Foam border placed on wound and change every 3 days and as needed. This nurses note was written by RN (Registered Nurse) Supervisor-H. The nurses note dated 4/19/23 documents: Resident had tears running down her cheek, when asked if she was having pain she put her thumb up which means yes. Resident pointing down to her foot, but can not verbalize where the pain exactly is. NP (Nurse Practitioner) [name] updated and new order for PRN (as needed) Tramadol ordered. If staff asked if she was having pain she can put her thumb up for yes or put her thumb down for no. Will continue to monitor pain and prn pain medication effectiveness. The weekly wound assessment dated [DATE] for date of onset 4/17/23 documents for wound site 49) right heel, type is pressure, and stage is Suspected Deep Tissue Injury. Measurements are length 2.0 and width 0.9. Treatment is wash with soap and water, pat dry, skin prep, f/b (followed by) foam border placed on wound and changed every 3 days and as needed. The summary section is blank. This assessment was completed Former Wound Nurse/LPN-M. There was no revision in R16's pressure injury care plan after R16 developed the suspected deep tissue injury. The weekly wound assessment dated [DATE] for date of onset 4/17/23 documents for wound site 49) right heel, type is pressure, and stage is Suspected Deep Tissue Injury. Measurements are length 2.0 and width 0.9. Treatment is wash with soap and water, pat dry, skin prep, f/b (followed by) foam border placed on wound and changed every 3 days and PRN. Preventative. The summary section documents Margin detail attached edges Wound bed assessment epithelialized Drain description none Periwound C/D/I (clean/dry/intact) This assessment was completed Former Wound Nurse/LPN-M. Surveyor noted there is no RN assessment. The weekly wound assessment dated [DATE] for date of onset 4/17/23 documents for wound site 49) right heel, type is pressure, and stage is Suspected Deep Tissue Injury. Measurements are length 1.0, width 1.0 and depth 0. Treatment is wash with soap and water, pat dry, skin prep, f/b (followed by) foam border placed on wound and changed every 3 days and PRN. Preventative. The summary section documents Margin detail attached edges Wound bed assessment epithelialized Drain description none Periwound C/D/I (clean/dry/intact) wound bed is 100% skin will monitor and may heal next assessment. On 5/8/23 at 10:25 a.m., Surveyor observed R16 in bed on her back, with the head of the bed elevated. R16 has an air mattress and R16's heels do not appear to being offloaded. Surveyor asked R16 if she was wearing pressure relieving boots? R16 gave Surveyor thumbs down. R16 communicates by thumbs up indicates yes & thumbs down is no. Surveyor asked R16 if she was wearing socks? R16 gave Surveyor thumbs up. Surveyor asked R16 if she has a pillow under her legs? R16 gave Surveyor thumbs down. On 5/8/23 at 11:31 a.m., Surveyor asked LPN (Licensed Practical Nurse)-F if she is responsible for completing resident's pressure injury treatments? LPN-F informed Surveyor she was. Surveyor inquired if any treatments have been done this morning? LPN-F informed Surveyor she hasn't done any residents' treatments yet and she usually waits until the end of her shift. Surveyor informed LPN-F Surveyor would like to observe R16's pressure injury treatment. On 5/8/23 at 12:39 p.m., Surveyor asked CNA (Certified Nursing Assistant)-D to accompany Surveyor to R16's room as Surveyor would like to look at R16's feet. CNA-D placed PPE (personal protective equipment) on and entered R16's room with Surveyor. Surveyor asked R16 permission to look at her feet with CNA-D. R16 gave Surveyor thumbs up. CNA-D removed R16's bedding. Surveyor observed there is a pillow under R16's left leg with her left heel resting directly on the pillow. R16's right knee is contracted and R16's right medial heel is resting under R16's left thigh and directly on the mattress. R16 is wearing yellow gripper socks on both feet and not wearing a prevalon boot on her right foot as per care plan dated 8/21/20 and 8/6/23. On 5/8/23 at 1:53 p.m., Surveyor observed the treatment for R16's SDTI with LPN (Licensed Practical Nurse)-F. LPN-F washed her hands, placed an isolation gown on, and informed R16 she was going to do her treatment. LPN-F gathered R16's treatment supplies, moved the over bed table from the right side of R16's bed to the left, and placed the treatment supplies directly on the over bed table. Surveyor observed R16 is in the same position as Surveyor's previous observation. R16's left heel is resting directly on the pillow and R16's right medial heel is under the left thigh. LPN-F placed gloves on, removed the bedding off R16, removed the dressing from R16's right medial heel, squirted normal saline on four by four gauze, and removed her gloves. LPN-F placed new gloves, dated the dressing, cleansed the SDTI with the normal saline, applied skin prep around the SDTI, and placed a border gauze dressing over the SDTI. LPN-F removed her gloves, washed her hands, and then removed her gown. On 5/8/23 at 2:02 p.m., Surveyor asked LPN-F how R16 developed the SDTI on her right medial heel? LPN-F replied, I honestly don't know. On 5/8/23 at 3:04 p.m., during the end of the day meeting with Administrator-A and DON (Director of Nursing)-B, Surveyor asked if the wound doctor assesses all residents with pressure injuries? Administrator-A replied yes, unless they are on hospice or refuse. On 5/8/23 at 3:10 p.m., Surveyor informed Administrator-A Surveyor isn't able to locate any wound doctor notes and asked for a copy of the wound doctor notes for R16's right heel. On 5/8/23 at 3:27 p.m., Surveyor observed R16 in bed in the same position as R16 was after LPN-F completed her treatment with R16's left heel resting directly on the pillow and her right heel positioned under the left thigh and directly on the mattress and without wearing a prevalon boot. Surveyor asked R16 if she ever gets out of bed? R16 shook her head no. On 5/9/23 at 7:21 a.m., Surveyor observed R16 in bed on her back with the head of the bed elevated. R16's left heel does not appear to be offloaded. On 5/9/23 at 9:22 a.m., Surveyor observed on R16's wall a blue sign which states: Also please make [R16's first name] keep the pillow under her leg so her heel is not resting against her leg. On 5/9/23 from 9:20 a.m. to 10:00 a.m., Surveyor observed morning cares including incontinence cares for R16 with CNA-D and CNA-N. During this observation at 9:27 a.m., the bedding was removed off R16. Surveyor observed there is a pillow under R16's left leg with R16's left heel resting directly on the pillow. R16's left heel is not being offloaded. R16's right medial heel is under R16's left thigh and directly on the mattress. Upon completion of R16's cares, a pillow was placed under R16's left lower leg. Surveyor observed R16's left heel is resting directly on the pillow and is not being offloaded. On 5/9/23 at 10:05 a.m., Surveyor asked CNA-D if R16 only wears gripper socks on her feet? CNA-D replied yes, she doesn't like her feet to be open to air. On 5/9/23 at 10:15 a.m., Administrator-A informed Surveyor the wound doctor's last note for R16's heel is dated 11/7/22. On 5/9/23 at 11:34 a.m., Surveyor asked LPN-F what staff was doing to promote healing of R16's right medial pressure injury & prevent further pressure injuries? LPN-F informed Surveyor they reposition R16 the best they can due to the position of R16's legs, they are taking care of the current wound and she receives prostat. Surveyor informed LPN-F of the observations of R16's left heel not being offloaded and the right heel under R16's left thigh and not offloaded. LPN-F informed Surveyor sometimes her leg is on top of the right heel. Surveyor informed LPN-F Surveyor is confused regarding R16's right heel treatment. Surveyor informed LPN-F there are currently two treatments for R16's right heel, one cleansing with soap & water and the other with saline followed by skin prep and covered with foam dressing. LPN-F informed Surveyor the CNAs are responsible for soap & water. Surveyor informed LPN-F they wouldn't apply skin prep & a dressing. LPN-F replied, now I'm confused. LPN-F informed Surveyor the wound nurse would be responsible for the treatments but they don't currently have a wound nurse. LPN-F informed Surveyor someone should have discontinued one of the orders and doesn't know why it wasn't discontinued. Surveyor informed LPN-F Surveyor noted a physician's order for bilateral heel floaters in bed and asked if these are currently being used? LPN-F replied, I don't believe so. On 5/9/23 at 1:43 p.m., Surveyor observed R16 in bed on her back with the head of the bed elevated. R16's right heel is resting directly on a pillow and is not being offloaded. On 5/9/23 at 3:20 p.m., Administrator-A and DON (Director of Nursing)-B were informed of the above. On 5/9/23 at 3:53 p.m., Surveyor met with RN/Supervisor-H regarding R16. Surveyor read RN/Supervisor-H R16's note dated 4/17/23 which she wrote. Surveyor asked how she became aware of R16's SDTI? RN/Supervisor-H informed Surveyor one of the CNAs told her. RN/Supervisor-H informed Surveyor at this time she was acting DON. RN/Supervisor-H informed Surveyor she notified the doctor, spoke with the family, and left a note under the wound nurse's door. Surveyor asked RN/Supervisor-H if Former Wound Nurse/LPN-M reviewed R16's pressure injury measurements and the information she collected with her? RN/Supervisor-H replied no, she didn't go over this with her. Surveyor inquired who revises the pressure injury care plans. RN/Supervisor-H replied the wound nurse. On 5/10/23 at 12:38 p.m., Surveyor asked Administrator-A if there is any additional information regarding R16's pressure injury or is there anyone else Surveyor should speak with? Administrator-A replied no. 2. R4's diagnoses includes diffuse traumatic brain injury, stroke with hemiplegia to dominate right side, hypertension, mixed receptive-expressive language disorder, aphasia, and vascular dementia. The at risk for falls care plan initiated 2/20/20 & revised 1/30/23 includes the intervention of * Check and change after meals. Initiated 12/1/22 & revised 1/30/23. The potential for pressure injury/ulcer care plan initiated 4/27/20 & revised 1/30/23 has the following interventions: * 9/2/21 encourage resident to sit with hands on the table not under to avoid skin tears. Initiated 9/3/21 & revised 11/30/21. * Administer treatments as ordered and monitor for effectiveness prn (as needed) per MD (medical doctor) orders. Initiated 5/13/20 & revised 9/1/20. * Assist with repositioning every 2-3 hours when in bed or w/c (wheelchair). Initiated 4/27/20. * Educate [R4's first name]/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. Initiated & revised 4/27/20. * Follow facility policies/protocols for the prevention/treatment of skin breakdown. Initiated & revised 4/27/20. * Inform the resident/family/caregivers of any new area of skin breakdown. Initiated 4/27/20. * Monitor nutritional status. Serve diet as ordered, monitor intake and record. Initiated 4/27/20. * Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length X (times) width X depth), stage. Initiated 4/27/20. * Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. Initiated 4/27/20. The quarterly MDS (minimum data set) with an assessment reference date of 2/22/23 documents R4 has short & long term memory problems and is severely impaired for cognitive skills for daily decision making. R4 requires extensive assistance with two plus person physical assist for bed mobility, & transfer, does not ambulate and requires extensive assistance with one person physical assist for toilet use. R4 is coded as being always incontinent of urine & frequently incontinent of bowel. R4 is at risk for pressure injury development and is coded as not having any pressure injuries. On 5/8/23 at 10:23 a.m. Surveyor observed R4 in bed on his back with the head of the bed up high. On 5/8/23 at 11:26 a.m. Surveyor observed R4 continues to be in bed on his back with his eyes closed. On 5/8/23 at 11:34 a.m. Surveyor observed CNA (Certified Nursing Assistant)-D place a gown & gloves on. Surveyor inquired what she was going to do. CNA-D informed Surveyor she was going to change and reposition R4. At 11:36 a.m. CNA-D informed R4 she was going to get him cleaned up for the day. At 11:39 a.m. CNA-D removed her PPE (personal protective equipment) stating she need to get R4 a brief as there is none in the room and left R4's room. At 11:41 a.m. CNA-D cleansed her hands, placed a gown on and entered R4's room. At 11:43 a.m. CNA-D informed R4 I'm back going to get you cleaned up. CNA-D placed water in a basin, cleansed her hands and placed gloves on. CNA-D informed Surveyor they don't have any face towels & she needs to use what they have. CNA-D then placed the end of a bath towel in the water basin. CNA-D raised the height of the bed and lowered R4's head of the bed down. CNA-D informed R4 she was going to do his face & top half. CNA-D then proceeded to wash R4's face and ears. CNA-D informed R4 she was going to uncross his legs and roll him towards the curtain. CNA-D then rolled R4 onto his left side. Surveyor observed the back of R4's incontinence product is saturated with urine. CNA-D then rolled R4 onto his right side to finish removing his shirt. At 11:52 a.m. Surveyor asked CNA-D if this was the first time today she has provided cares to R4. CNA-D replied yes. CNA-D explained when she got here she was the only CNA here along with [name of] Med Tech-E and a nurse. CNA-D informed Surveyor later another CNA came. CNA-D informed Surveyor she wanted to do R4 before lunch. CNA-D explained she started with the back half and was told there would only be two of them (CNA's) today. CNA-D washed R4' upper half. Surveyor observed the front portion of R4's incontinence product is saturated with urine. CNA-D placed deodorant and a shirt on R4. At 12:02 p.m. CNA-D informed R4 she was going to clean his lower area. CNA-D then informed R4 she needs to cover him back up, covered R4 with the bedspread, lowered the bed down and informed R4 she needed to get more towels and will be right back. CNA-D removed her PPE, went down the hallway, and washed her hands. At 12:05 p.m. CNA-D placed PPE on and entered R4's room with towels. CNA-D informed R4 she was back to finish him up. CNA-D raised the bed up, uncovered R4, folded the urine saturated product between R4's legs and washed R4's frontal area. At 12:10 p.m. CNA-D removed her gloves, cleansed her hands, placed gloves on and told R4 she was going to do the back area and was going to roll him towards the curtain. R4 was placed on his left side. CNA-D folded the saturated product under R4, washed R4's buttocks and rectal area to remove stool. After washing R4, CNA-D stated I don't have any cream, you need some cream. Surveyor observed there are no open areas but R4's coccyx area is pinkish-red in color. Surveyor informed CNA-D Surveyor can't touch Residents and asked CNA-D if she could press her finger where R4's skin is pinkish red. CNA-D pressed her finger approximately three times where R4's skin was pinkish red. Surveyor observed R4's skin stayed pinkish red. CNA-D informed Surveyor it's red and he needs some cream. CNA-D went to the left side of R4's bed informed R4 she was going to pull him towards her and roll him the other way. After rolling R4 onto his right side, CNA-D placed a clean draw sheet & product under R4. CNA-D fastened the left side of the product, positioned R4 on his other side to fasten product and straighten out the linen. CNA-D removed R4's gripper socks, Surveyor checked R4's heels and did not observe any open areas on R4's feet. CNA-D placed new gripper socks on R4, removed her gloves, cleansed her hands, and placed new gloves on. CNA-D informed Surveyor she needs to get help to boost R4 up, covered R4 with bed spread, lowered bed down, placed call light in reach, removed PPE and washed her hands. Surveyor noted during this observation CNA-D did not apply any cream on R4's pinkish-red area even though CNA-D stated R4 needs cream. On 5/9/23 at 3:20 p.m. Administrator-A and DON (Director of Nursing)-B were informed of the above. 38253 3. R17 was admitted to the facility on [DATE] with diagnoses of osteoarthritis of the right hip, malnutrition, anxiety, Alzheimer's, depression, and pemphigoid (an autoimmune disease that causes blisters to form on the arms, legs, and abdomen). R17's annual Minimum Data Set (MDS) assessment dated [DATE] indicated R17 was severely cognitively impaired per staff assessment and the facility assessed R17 as needing extensive assistance with bed mobility and dressing and total assistance with transfers, toilet use, hygiene, and bathing. R17 had an activated Power of Attorney (POA) and was on hospice services. R17's ADL (Activities of Daily Living) Care Plan was initiated on 2/5/2022 with the intervention for bed mobility: one staff assist to turn and reposition in bed every two to three hours as necessary. R17's Skin Integrity Care Plan was initiated on 2/15/2022 when R17 developed a Deep Tissue Pressure Injury to the left heel and had the following interventions: -Educate R17 and family of causative factors and measures to prevent skin injury. -Encourage good nutrition and hydration in order to promote healthier skin. -Follow facility protocols for treatment of injury. -Identify potential causative factors and eliminate/resolve when possible. -Keep skin clean and dry; use lotion on dry skin; do not apply at site of injury. -Monitor/document location, size and treatment of skin injury; report abnormalities, failure to heal, sign or symptoms of infection, maceration, etc. to the physician. -No bleached linens. -Provide pressure relieving/reducing mattress, Prevalon boots, pillow between thighs for pressure relief. -Treatment and supplements per physician order. R17's Skin Integrity Care Plan was resolved on 1/4/2023. R17's Actual Impairment to Skin Integrity Care Plan was initiated on 1/4/2023 due to bullous pemphigoid and unstageable pressure injuries to the sacrum and the left buttock with the interventions: -Avoid scratching and keep hands and body parts from excessive moisture; keep fingernails short. -Follow facility protocols for treatment or injury. -Geri sleeves to bilateral arms to provide comfort and protect skin. -Identify/document potential causative factors and eliminate/resolve where possible. -Monitor/document location, size, and treatment of skin injury; report abnormalities, failure to heal, signs or symptoms of infection, maceration, etc. to the physician. -Staff to assist in turning and repositioning; (R17) will refuse to lay on side frequently. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. R17's Pressure Injury Care Plan was initiated on 4/8/2023 with the interventions: -Apply barrier cream during periods of incontinence/toileting and as needed per physician orders to help prevent skin breakdown. -Assess, record, and monitor wound healing daily; measure length, width, and depth were possible; assess and document status of wound perimeter, wound bed, and healing progress; report improvements and declines to the physician. -Avoid positioning R17 on the sacrum. -R17 has specialty air mattress; use one disposable pad over lift sheet (no cloth pads); check to be sure pump/mattress is functioning correctly with care; manufacturer guidelines available in resident room. -R17 needs moisturizer applied frequently to skin; do not massage over bony prominence's and use mild cleansers for peri care and washing. -R17 requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. -R17 requires a pressure relieving reducing device on the bed and chair. -Complete every shift foot checks. -Follow facility policies and protocols for the prevention and treatment of skin breakdown. -Monitor R17's dressing daily to ensure it is intact and adhering; report loose dressing to treatment nurse. -Monitor, document, and report to wound physician or wound nurse as needed changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size, and stage. -Offload heels from mattress and wheelchair (Broda chair) pedals. -Reposition R17 side to side every 3 to 4 hours while in bed to minimize pressure to sacrum or coccyx -Wheelchair cushion. R17 was comprehensively assessed weekly by the wound physician and facility staff for pressure injuries that developed 7/18/2022 and open areas due to pemphigoid blisters that ruptured. On 5/5/2023 on the Weekly Wound assessment tool, nursing charted R17 had an Unstageable pressure injury to the sacrum that measured 3.8 cm x 1.5 cm x 0.5 cm with 76-100% granulation tissue. R17 had this pressure injury since 7/18/2022. Surveyor noted with the percentage of granulation tissue present, the wound was a Stage 3 pressure injury and not Unstageable as documented. No other pressure areas were present. On 5/8/2023 at 1:31 PM, Surveyor observed R17 sitting in a Broda chair in the resident room. Surveyor observed a bolstered alternating pressure air mattress on the bed. A Hoyer lift sling was observed to be underneath R17 in the chair and a cushion was in place under R17. A sign stating to please turn R17 side to side every two hours when in bed was noted to be on the wall at the head of the bed. R17 had the left leg crossed over the right leg with no pillow in between the legs and R17 had fluffy socks on with the feet resting on the foot pedals and on the calf rests of the Broda chair. Surveyor noted heel boots were on the top of the dresser. R17 had non-sensical talk and was unable to answer any questions. On 5/9/2023 at 11:16 AM, Surveyor observed R17 sitting in a Broda chair in the dining area across from the nurses' station. R17 had heel boots on. On 5/9/2023 at 1:54 PM, Surveyor observed R17 receiving wound care by Licensed Practical Nurse (LPN)-F and assisted by LPN-K who was in training. LPN-F provided wound care to the Unstageable pressure injury and when the treatment was completed, LPN-F and LPN-K positioned R17 on their back. LPN-F asked LPN-K to raise the head of the bed up slightly. Surveyor noted the positioning of R17 put direct pressure on the sacral pressure injury. LPN-F stated the wound nurse no longer worked at the facility as of a week ago so now the floor nurses have to do all the treatments. LPN-F stated they had been a nurse for only four months with this facility being the only place they had worked and they were learning as they go about how to do treatments and how to look at wounds. On 5/10/2023 at 1:15 PM, Surveyor met with Nursing Home Administrator (NHA)-A and shared the concerns with the observations of R17 having the feet directly on the Broda chair foot pedals and calf rests and how LPN-F positioned R17 after doing the wound care treatment to the sacral pressure injury. Surveyor shared with NHA-A that R17's intervention of having a pillow between the legs was removed on 1/4/23 when the skin integrity care plan was noted to be resolved. Surveyor shared with NHA-A multiple observations that were made throughout the survey of R17 having the left leg crossed over the right leg. Surveyor shared with NHA-A that R17 had a history of a wound to the right upper thigh where the left leg crossed over and would benefit from having protection to that area. (Documentation of the right upper thigh wound was originally documented as being from pressure but was then determined to be from pemphigus

Based on observations, record review, and interview, the facility did not ensure 2 of 6 Residents (R) reviewed for quality of care received treatment and care in accordance with standards of practice (R80 and R81.) The facility did not provide for the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . * R80 was admitted to the facility on [DATE]. On 5/17/22 R80's Braden Scale documented R80 was high risk for developing wounds. On 5/23/22, the wound care doctor documented an open area to the left buttock and requested a dermatology consult to rule out [CONDITION(S)] versus psoriasis. The dermatology consult was not followed up on by the facility. There is no documentation that skin evaluations and assessments including description, measurements, and characteristics were completed on R80's open areas. On 7/17/22, the nurse practitioner documented that R80 has an unstageable area to coccyx approximately 1cm x 1cm. On 8/28/22, a weekly skin evaluation documents there are multiple open areas to right and left back, hip, and buttocks. The documentation does not contain measurements, description, or characteristics. On 9/8/22, in R80's electronic medical record, it is documented that R80 has multiple areas that are now open and tissue is red in color. There is no documentation that the facility assessed R80's open areas further to include measurements, description, and characteristics. The wound doctor is aware and will see R80. The wound care doctor was in the facility on 9/13/22 and 9/20/22 and did not assess R80's open areas. *R81 had unwitnessed falls while at the facility and the facility did not perform completed neurological assessments of the resident post fall. R81 had an unwitnessed fall on 8/10/22. It was determined that R81 hit R81's head on the floor. R81 was sent to the emergency room and determined to have no injury as a result of the fall. Surveyor notes that neuro checks were not completed per facility policy and procedure. R81 had another unwitnessed fall on 9/10/22 and neuro checks were not completed per policy and procedure. Findings Include: Surveyor reviewed the facility's undated skin assessment policy and procedure and notes the following applicable: Policy: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 7. Documentation of skin assessment: a. Include date and time of the assessment, your name, and position title. b. Document observations(e.g. skin conditions, how the Resident tolerated the procedure, etc.) c. Document type of wound d. Describe wound(measurements, color, type of tissue in wound bed, drainage, odor, pain). e. Document if Resident refused assessment and why. f. Document other information as indicated or appropriate. 1. R80 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R80 has an activated health care power of attorney (HCPOA). Surveyor reviewed R80's hospital paperwork and notes on 5/12/22 it is documented that R80 has scattered shallow open areas, scratch marks, and eschars from picking and scratching. Recommend pressure injury prevention measures. R80 needs aggressive off-loading with low air loss mattress or equivalent, frequent turning/repositioning at least every 2 hours. Surveyor notes R80's Braden Scale dated 5/17/22 indicates R80 is at high risk for developing pressure areas. On 5/23/22, the wound care doctor assessed R80's left buttock and documents the open area to be 2.04 cm x 2.11 cm x .10 cm. Total area 3.24cm. Wound bed Assessment-Early/Partial granulation, moderate serous drain amount. The wound care doctor requested a dermatology consult to determine the etiology: [CONDITION(S)] versus psoriasis. Surveyor noted no dermatology consult per the 5/23/22 wound MD's request in R80's medical record. On 7/19/22, R80's nurse practitioner assessed R80. It is documented that R80's skin at this time had healing multiple scabbed wounds, scratch marks to upper extremities. Open unstageable area to coccyx approximately 1cm x 1cm, right lower extremity open area, bandage is in place, clean and dry. Surveyor noted there was no comprehensive assessment/description of the above referenced healing multiple scabbed wounds. Surveyor spoke to R80's nurse practitioner (NP F) on 9/23/22 at 2:05 pm, in regard to NP F's note dated 7/19/22. NP F stated that if NP F documented there are open areas, then they are there . I wouldn't have written it otherwise. NP F stated NP F did not do a physical head to toe assessment but wrote the note based on information provided by the floor nurse at the time. R80's record continues: R80's Quarterly Minimum Data Set (MDS) dated [DATE] documents R80's BIMS (Brief Interview for Mental Status) score to be an 8, indicating R80 demonstrates moderately impaired skills for daily decision making. R80's MDS also documents that R80 requires extensive assistance for bed mobility and hygiene. R80 requires total assistance for transfers and toileting. On 8/28/22 a weekly skin evaluation was completed for R80. The evaluation documents that R80 has multiple open areas red in color no drainage to right and left iliac crest and multiple areas red in color no drainage to the right and left buttock. [MEDICATION(S)] 0.05% applied to arms/legs/chest/back/buttocks. Surveyor noted there was no comprehensive assessment of the above referenced multiple open areas such as how many, size, etc. On 8/30/22, Surveyor notes that Allegra allergy oral tablet 60 mg 2 times a day for [CONDITION(S)]/allergic reaction for 2 weeks was ordered. Surveyor noted R80 was ordered a medication for [CONDITION(S)]/allergic reaction on 8/30/22 however the facility did not follow up with a dermatologist consult as requested by the physician on 5/23/22. On 9/24/22, the facility provided documentation of a progress note written by R80's physician and electronically signed on 9/23/22 at 11:46 PM. R80 was seen by R80's physician on 8/30/22 which documents that R80 is an elderly frail female with recurrent rash and [CONDITION(S)], multiple scratch marks and scab wounds at various stages of healing, also has increased itching and possibility of underlying chronic urticaria. Has been referred to dermatology and wound care team. Surveyor noted there was no comprehensive assessment of the scab wounds during R80's 8/30/22 physician visit and no follow up to the dermatology clinic or to the wound care team. On 9/7/22, R80's electronic medical record (EMR) contains documentation that R80 has been scratching excoriated areas to right buttock, which are large, and needs the wound physician to assess. R80's fingernails have been cut and filed. Writer was advised to place Tricimalone cream on areas and dressing to prevent further scratching. 9/8/22 at 6:34 AM, R80 is being monitored due to open areas on right buttock. 9/8/22 at 8:52 AM, R80 has areas to back, bilateral arms, and hips. R80 has an ongoing issue with itching to areas and a scheduled cream with an as needed cream. Areas are now open, and tissue is red in color. Wound physician is aware and will see R80 next week. Surveyor spoke to ADON D on 9/23/22 at 3:18 pm who confirmed that ADON D did not measure R80's open areas on 9/8/22 when assessing R80. Nursing Home Administrator (NHA A) confirmed during a conversation with Surveyor on 9/23/22 at 3:10 pm, that the wound care doctor was in the facility on 9/13/22 and 9/20/22 and did not assess R80. Surveyor noted there was still no comprehensive assessment of these wounds, no dermatology follow-up and R80 was not seen by the wound care team. On 9/23/22, Surveyor received a copy of R80's comprehensive care plan with revisions and notes the following: There is a focused problem indicating R80 has a mood problem due to anxiety, feeling depressed, having little energy, poor appetite, and feeling restless. Initiated 5/31/22 Revised 8/30/22 R80 has the potential for pressure injury/ulcer development due to impaired mobility, incontinence. 5/16/22 Readmit with stage II pressure left buttock (deemed open skin rather than pressure ulcer with new treatment order 5/23/22) 9/8/22 Excoriated areas to entire back, bilateral shoulders, bilateral buttocks, bilateral arms. Initiated 6/18/20, revised 9/8/22. Interventions: 5/23/22 dermatology consult 9/20/20 bilateral prevalon boots when in bed 8/31/21 Reposition at least every 2-3 hours when in bed or wheelchair 2/14/22 Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. 2/14/22 Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate Provide unbleached linens-initiated 4/28/21, revised 2/28/22 R80 requires an air mattress for pressure relieve-initiated 2/14/22, revised 2/28/22 9/8/22 R80 observed scratching lower extremities, keep nails trimmed. Surveyor noted according to R80's care plan initiated on 2/14/22 and revised on 2/28/22, R80 requires the use of an air mattress. A Surveyor from the Survey team requested to see R80's skin on 9/23/22 at 2:35 PM. Surveyor noted R80's bed does not have a pressure relieving air mattress in place. R80 is wearing pressure relieving heel boots to bilateral feet at this time. Surveyor noted R80's care planned identified the need for unbleached linens. Surveyor spoke to Laundry Supervisor (LS G) on 9/23/22 at 4:20 pm, who stated all the sheets and towel are washed together in bleach. LS G is unaware of any residents needing their towels and sheets washed in an unbleached condition. Surveyor interviewed Laundry Aide (LA H) on 9/24/22 at 7:13 am, who has worked at the facility for [AGE] years. LA H stated there are 2 residents, 1 of which is R80, who require their sheets, gown, towels to be washed in an unbleached condition. LA H stated there is spot in the laundry room with a note marked for these 2 residents, 1 of which is R80, require this special precaution. Further, these 2 Residents, 1 of which is R80, have special drawers marked indicating that these drawers contain unbleached items. Surveyor took a tour with LA H of the laundry room who confirmed that R80 was not posted as needing unbleached linen. Surveyor then conducted a tour with LA H of R80's drawers in R80's room. Surveyor notes at this time, R80's drawers are completely empty except for 1 washcloth. LA H stated that LA H needed to get R80 added to the list down in the laundry room for requiring unbleached linen and would need to get R80's drawers filled with unbleached linen. R80's medical record continues: On 9/10/22 R80 continues to have open areas, treatment completed, continues to monitor for new open areas. On 9/21/22, a weekly summary documents R80 is not currently receiving treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Surveyor reviewed R80's bedside Kardex report as of 9/23/22 which documents R80 was observed scratching R80's lower extremities by nursing. Staff to encourage R80 to avoid scratching. Keep nails trimmed short. Prevlon boots at all times. R80 requires air mattress for pressure relief. Provide unbleached linens. On 9/24/22, Surveyor was provided an updated comprehensive care plan for R80 and notes the following added for the focused problem for having the potential for pressure injury/ulcer development due to impaired mobility, incontinence. 9/23/22 Shallow open areas noted to bilateral back, bilateral buttocks, and bilateral hips. Revised 9/24/22 Interventions added: 9/23/22 Dermatology consult requested 9/23/22 Administer medications as ordered. Monitor/document for side effects and effectiveness 9/23/22 Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 9/24/22 Inform R80/family/caregivers of any new area of skin breakdown. 9/24/22 Obtain and monitor lab/diagnostic work as ordered. Report results to physician and follow-up as indicated. Surveyor notes that since re-admission to the facility on [DATE], subsequent assessment by wound physician on 5/23/22, the facility was only able to provide 1 weekly skin evaluation for R80. Further, the facility was unable to provide any documentation a weekly skin assessment was completed on the open areas which include measurements, description, color, drainage, pain, etc. for R80's open areas. On 9/23/22, the facility completed a Braden on R80 which documents that R80 is high risk for developing pressure areas. The facility also completed a weekly skin evaluation dated 9/23/22, which documents that R80 has shallow various sized open areas noted with distinct edges, red wound base, and scant amount of serosanginous drainage which appear to itch and be slightly painful to touch on the right and left buttock and right and left lower back. It is noted that neither document any measurements. On 9/23/22, R80's EMR contains documentation that there is no drainage or signs/symptoms of infection noted to multiple areas on buttock, back, legs, and arms. Mattress changed. Surveyor noted R80's mattress was changed back to an air mattress. On 9/23/22 at 10:56 AM, Surveyor interviewed Assistant Director of Nursing (ADON D) who confirmed ADON D has been the Registered Nurse (RN) monitoring and assessing the wounds in the facility. ADON D states that ADON D is wound care certified. ADON D informed Surveyor that ADON D spoke to the wound care physician about R80's open areas but that the wound care doctor would not assess because the doctor still maintained that R80 needed to be assessed by a dermatologist. ADON D confirmed at this time that R80 should be receiving unbleached sheets and towels and washcloths. On 9/23/22 at 11:40 AM, Surveyor interviewed ADON D again. ADON D confirmed there is not a lot of documentation regarding R80's open areas. ADON D confirmed that the expectation is that there should have been a documented assessment and weekly skin evaluations pertaining to R80's skin condition. ADON D stated that some staff are doing weekly skin evaluations in the Resident's EMR and some are doing the paper skin evaluations. ADON D stated that the nurse should be taking the CNA skin check and assessing the Resident on the weekly shower days and signing off on it. On 9/23/22 at 12:02 PM, ADON D confirmed that as of 9/23/22, a dermatologist consult originally ordered on 5/23/22 was not completed. On 9/23/22 at 2:35 PM, a Surveyor from the Survey team requested to see R80's skin. ADON D told Surveyor that R80 has a scattered rash that comes and goes on their body. ADON D showed Surveyor R80's back and buttocks. Surveyor noted a total of 6 open areas resembling ruptured blisters on R80's left buttock and 2 open areas on their left lower back resembling ruptured blisters. On R80's right buttock and right lower back there are 10 open areas resembling ruptured blisters. Surveyor notes R80's bed does not have a pressure relieving air mattress in place. R80 is wearing pressure relieving heel boots to bilateral feet at this time. Surveyors reviewed R80's medical record. Surveyors could not identify any weekly skin assessments referencing R80's current open areas to the bilateral buttocks and back. Surveyor spoke to ADON D on 9/23/22 at 3:18 pm, who stated she is not sure who took R80 off the wound board, because typically R80 should have remained on the board. ADON D was informed that R80 was itching more and recommended unbleached sheets. ADON D confirmed that there is no formal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON D confirmed that a Braden evaluation should be done on change of condition, re-admission, and every 3 months. ADON D stated that R80 should and needs to have had an air mattress and if that was an intervention for a fall (to remove the air mattress), they should have come up with another intervention. ADON D confirmed that skin checks should be completed weekly and documented in each Resident's EMR. On 9/23/22 at 3:30 PM, a Surveyor from the survey team conducted an interview with ADON D. ADON D is the facility's wound nurse and was hired by the facility on 9/1/22. ADON D told Surveyor that they assist the facility's wound MD with weekly wound rounds. Surveyor asked if residents at risk for pressure injury or those with current pressure injuries should have a pressure relieving air mattress on their bed. ADON D responded that any resident at risk or with current pressure injuries should have a pressure relieving air mattress on their bed. Surveyor asked ADON D how they would characterize the open areas to R80's bilateral buttocks and back. ADON D told Surveyor that these areas appear as if they were blisters at one time and have now popped open. ADON D told Surveyor that they would characterize these areas as stage 2 pressure injuries. Surveyor asked ADON D if they had been conducting weekly wound assessments to R80's open areas. ADON D told Surveyor that they were not aware that R80 had multiple open areas to R80's skin and that they believed that R80 just had a rash to their back and buttocks that was being treated with medicated topical treatments. ADON D told Surveyor that the facility had not conducted weekly wound assessments for R80's open areas and have not measured the areas. On 9/23/22 at 3:56 PM, Nursing Home Administrator (NHA A) stated that the expectation is for skin evaluations to be done weekly. NHA A stated that the facility would expect an evaluation to contain a description of all areas with measurements. On 9/23/22 at 4:30 PM, a Surveyor from the Survey team conducted an interview with DON B. Surveyor asked DON B if a resident has open areas or pressure injuries if the areas should be measured and comprehensively assessed on a weekly basis. DON B responded Yes. R80's medical record continues: On 9/24/22 at 5:02 AM, R80's EMR documents that the nurse practitioner was updated on R80's skin condition. R80 currently has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was continued, and dermatologist was called to schedule an appointment. On 9/24/22 at 7:45 AM, a Surveyor from the Survey team asked DON B if they had observed R80's current skin condition. DON B told Surveyor that she had seen R80's skin condition. Surveyor asked DON B what DON B's assessment of R80's open areas was? DON B told Surveyor that the areas appear to be blisters that are no longer intact and that they would say that the areas appear to be multiple stage 2 pressure injuries. On 9/24/22, the wound care physician came to the facility and assessed R80. Documentation does not include any measurements and states no wound detected with attached edges, early/partial granulation, small serous drainage. On 9/24/22, Surveyor notes that the facility added a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R80's Treatment Administration Record (TARS) from May 2022-September 2022 and notes that R80's Treatment Administration Record (TARS) indicate that a body check was to be completed every evening shift on Mondays. The facility was unable to provide documentation that this was completed. On 9/24/22 at 9:20 AM, Surveyors interviewed Wound Care Doctor (WCD E) who confirmed that WCD E assessed R80 today (9/24/22). Per WCD E's 9/24/22 assessment and documentation of R80, WCD E documented no wound detected. WCD E described R80's area as attached edges, early/partial granulation, small serous drainage with normal odor. Depth is 0.10. Surveyor asked WCD E if they had expected R80 to have had their dermatology consult that he had ordered 5/23/22 to have been completed by now. WCD E stated that it is a concern that the facility never had R80 seen by a dermatologist as WCD E ordered on 5/23/22. WCD E told Surveyors that the ball had been dropped and that R80's dermatology consult had not been followed up on in a timely fashion. WCD E also confirmed that the facility should have been assessing R80's open areas/blisters on a weekly basis including description, measurements, and characteristics of R80's open areas. WCD E confirmed that WCD E was not notified about R80's open areas until 9/7/22. WCD E told Surveyors he did not believe R80's open areas to be pressure injuries but a skin condition which was why he had previously given the facility an order for [MEDICAL RECORD OR PHYSICIAN ORDER] WCD E told Surveyors that he was planning on conducting a biopsy of R80's skin condition on 9/26/22 for further evaluation. On 9/24/22 at 11:57 AM, Surveyor shared with NHA A and DON B the concern that R80 did not get a dermatology consult completed as ordered on 5/23/22, weekly skin evaluations were not completed, and open area skin assessments were not completed including measurements, description, and characteristics for R80. After Surveyors exited from the facility on 9/24/22, NHA A provided Surveyors and Regional Field Operation Supervisors with the following additional information: Received from NHA A on 9/27/22, the results of a Dermatology appointment dated 9/26/22 by Advanced Practice Nurse Practitioner (APNP) J. The results indicate in part; The following areas were examined with significant findings as noted scalp/hair, head/face .scalp with excoriated [CONDITION(S)] frontal parietal regions, upper and lower back scars and excoriated .Picker nodules .trim nails short to limit trauma of skin when pt scratches propopic 0.1 oint (ment) BID back and scalp, possibly ruptured/unroofed blisters 3.5 pinch R hip R/O (rule out) [CONDITION(S)] .Aquaphor/[MEDICATION(S)] for now right hip and right ant (anterior) tubia . Received from NHA A 10/4/22 the results of a 10/3/22 Skin Biopsy report (from MD I) which states in part Conclusion: This pattern is most commonly observed in [CONDITION(S)]. It can, however, occur in other, less common conditions, including [CONDITION(S)] [NAME], anti-epiligrin cicatricial phemphigoid, and p200 pemphigoic . Miscroscopc Description: This lesion apparently was relatively old when sampled, because it reveals a shallow, reepithelizlising ulcer which extends across most of the specimen's width. At the edge of the ulcer is a narrow focus of dermoepidermal detachment. Many eosinophils are present within the ecleft and underlying dermis. These findings are consistent with pemphigoid but not entirely specific. Pathologic diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Regional Field Operations Supervisor noted, according to Mayo Clinic [CONDITION(S)] https://www.mayoclinic.org Bullouspemphigoid-symptoms and causes-Mayo clinic Overview Bullous pehphigoid is a rare skin condition that causes large, fluid-filled blisters. They develop on areas of skin that often flex-such as the lower abdomen, upper thighs or armpits. [CONDITION(S)] is most common in older adults. [CONDITION(S)] occurs when your immune system attacks a thin layer of tissue below your outer layer of skin. The reason for this abnormal immune response is unknown, although it sometimes can be triggered by taking certain medications. [CONDITION(S)] often goes away on its own in a few months, but may take as many as five years to resolve. Treatment usually helps heal the blisters and ease any itching. It may include corticoseroid medications, such as [MEDICATION(S)], and other drugs that suppress the immune system. Bullous pehphigoid can be life-threatening, especially for older people who are already in poor health. Symptoms The signs and symptoms of [CONDITION(S)] may include: Itching skin, weeks or months before blisters form Large blisters that don't easy rupture when touched, often along creases or folds in the skin Skin around the blisters that is normal, reddish or darker than normal [CONDITION(S)] or a hive-like rash Small blisters or sores in the mouth or other mucous membranes. When to see a doctor See your doctor if you develop: Unexplained blistering Blisters on your eyes Signs of infection . 2. Neurological Checks: Surveyor reviewed the Neurological Assessment policy and procedure revised October 2010 and notes the following: The purpose of this procedure is to provide guidelines for a neurological assessment: 1) when following an unwitnessed fall; 2) subsequent to a fall with a suspected head injury; or 3) when indicated by Resident condition. Neurological assessments are indicated: a. Following an unwitnessed fall b. Following a fall or other accident/injury involving head trauma; or when indicated by Resident's condition c. Any change in vital signs or/neurological status in a previously stable Resident should be reported to the physician immediately. Surveyor notes the facility protocol is for neuro-checks to completed every 15 minutes x 4, 30 minutes x 4, 1 hour x 4, 4 hours x 4, 8 hours x 6. R81 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R81 has an activated HCPOA. R81's Quarterly MDS (Minimum Data Set) dated 7/23/22 documents that R81 has both short and long term memory impairment and demonstrates severely impaired skills for daily decision making. R81's MDS also documents that R81 requires supervision for bed mobility and transfers, limited assistance for toileting, and extensive assistance for hygiene. R81's fall risk evaluations dated 4/19/22, 8/10/22, and 9/10/22 all indicate that R81 is at moderate risk for falls. R81's bedside Kardex as of 9/24/22 instructs staff to anticipate and meet R81's needs. The Kardex also documents to distract R81 from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Surveyor notes this is blank on the Kardex. Surveyor reviewed R81's comprehensive care plan and notes that on 2/1/22, a focused problem indicating R81 is at risk for falls due to dementia, fall history, gait/balance problems, vision problems, and unaware of safety needs was established. This focused problem was last revised on 9/12/22. Surveyor notes an intervention of neuro-checks per policy was initiated 2/2/22. Surveyor reviewed R81's fall report dated 8/10/22. R81 had an unwitnessed fall and was found in the middle of the floor. It was determined that R81 hit R81's head on the floor. R81 was sent to the emergency room and determined to have no injury as a result of the fall. Surveyor notes the physician and activated HCPOA were notified. Surveyor notes that neurochecks were not completed for the 8/10/22 fall per facility policy and procedure. R81 had another fall on 9/10/22 which was unwitnessed with no determined injury. R81 was found in another Resident's room, lying on the floor on her back. Surveyor notes the physician and activated HCPOA were notified. Surveyor notes that neurochecks were not completed per facility policy and procedure. Surveyor notes that R81 did not have neuro-checks completed per facility policy and procedure for each of their falls. On 9/24/22 at 9:12 AM, NHA A confirmed that the facility was unable to locate any neuro-checks completed for R81's falls. On 9/24/22 at 11:57 AM, Surveyor shared the concern that neuro-checks had not been completed for R81's unwitnessed falls per facility policy and procedure. No further information was provided by the facility at this time. Surveyor notes that on 9/23/22 and 9/24/22, facility nurses received an in-service training conducted by NHA A and discussed neuro-checks, open areas being reported, and follow-up appointments need to be completed/scheduled. On 10/4/22, the facility provided additional information in regards to R81's neuro-checks. The facility provided a LTC Neuro Assessment form with a date of 9/10/22 in regards to R81's unwitnessed fall. The LTC Neuro Assessment form has documented that R81 went to the hospital emergency room and returned on 9/10/22 at 1730 (5:30pm). Surveyor notes that per R81's EMR, the following is documented in regards to R81's 9/10/22 fall: 9/10/22 at 2:27 PM it is documented that R81 was found in another Resident's room on the floor on R81's back. R81 stated R81's head, back, and right arm was hurting. Nurse practitioner was updated and advised to monitor R81 and allow to eat and drink. At 2:30 PM, R81 stated R81 had no pain. R81 is sleepy and resting in bed. 9/10/22 at 10:13 PM, it is documented that R81 was sleeping as was upset by being woken up to obtain vitals. Surveyor notes that R81's EMR does not contain documentation that R81 was sent to the emergency roiagnom on [DATE] and as indicated on the 9/10/22 LTC Neuro Assessment form submitted on 10/4/22; but rather R81 remained in the facility and was monitored per nurse practitioner instructions. R81's 9/10/22 neuro checks that were listed on the LTC Neuro Assessment form submitted on 10/4/22 indicates upon R81's return from ER at 1730 (5:30 pm). The LTC Neuro Assessment form completed indicates the following dates and times when the neuro checks were completed: 9/10/22 1730, 1830, 9/11/22 0230, 1030, 1830, 9/12/22 0230 and 1030. Surveyor noted the neuro checks were not performed according to the instructions on the LTC Neuro Assessment form. Surveyor also notes, that neuro-checks for R81's fall on 8/10/22 have not been provided by the facility.

Based on observations, record review, and interview, the facility did not ensure 2 of 6 Residents (R) reviewed for quality of care received treatment and care in accordance with standards of practice (R80 and R81.) The facility did not provide for the care and treatment of a non-pressure wound for 1 of 1 (R80) sampled residents with non-pressure wounds and did not conduct adequate neurological checks for 1 of 3 (R81) residents reviewed for falls. * R80 was admitted to the facility on [DATE]. On 5/17/22 R80's Braden Scale documented R80 was high risk for developing wounds. On 5/23/22, the wound care doctor documented an open area to the left buttock and requested a dermatology consult to rule out eczema versus psoriasis. The dermatology consult was not followed up on by the facility. There is no documentation that skin evaluations and assessments including description, measurements, and characteristics were completed on R80's open areas. On 7/17/22, the nurse practitioner documented that R80 has an unstageable area to coccyx approximately 1cm x 1cm. On 8/28/22, a weekly skin evaluation documents there are multiple open areas to right and left back, hip, and buttocks. The documentation does not contain measurements, description, or characteristics. On 9/8/22, in R80's electronic medical record, it is documented that R80 has multiple areas that are now open and tissue is red in color. There is no documentation that the facility assessed R80's open areas further to include measurements, description, and characteristics. The wound doctor is aware and will see R80. The wound care doctor was in the facility on 9/13/22 and 9/20/22 and did not assess R80's open areas. *R81 had unwitnessed falls while at the facility and the facility did not perform completed neurological assessments of the resident post fall. R81 had an unwitnessed fall on 8/10/22. It was determined that R81 hit R81's head on the floor. R81 was sent to the emergency room and determined to have no injury as a result of the fall. Surveyor notes that neuro checks were not completed per facility policy and procedure. R81 had another unwitnessed fall on 9/10/22 and neuro checks were not completed per policy and procedure. Findings Include: Surveyor reviewed the facility's undated skin assessment policy and procedure and notes the following applicable: Policy: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 7. Documentation of skin assessment: a. Include date and time of the assessment, your name, and position title. b. Document observations(e.g. skin conditions, how the Resident tolerated the procedure, etc.) c. Document type of wound d. Describe wound(measurements, color, type of tissue in wound bed, drainage, odor, pain). e. Document if Resident refused assessment and why. f. Document other information as indicated or appropriate. 1. R80 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Morbid Obesity, Type 2 Diabetes Mellitus, Bilateral Primary Osteoarthritis of Hip, Other Specified Peripheral Vascular Diseases, Unspecified Dementia, Anxiety Disorder, and Major Depressive Disorder. R80 has an activated health care power of attorney (HCPOA). Surveyor reviewed R80's hospital paperwork and notes on 5/12/22 it is documented that R80 has scattered shallow open areas, scratch marks, and eschars from picking and scratching. Recommend pressure injury prevention measures. R80 needs aggressive off-loading with low air loss mattress or equivalent, frequent turning/repositioning at least every 2 hours. Surveyor notes R80's Braden Scale dated 5/17/22 indicates R80 is at high risk for developing pressure areas. On 5/23/22, the wound care doctor assessed R80's left buttock and documents the open area to be 2.04 cm x 2.11 cm x .10 cm. Total area 3.24cm. Wound bed Assessment-Early/Partial granulation, moderate serous drain amount. The wound care doctor requested a dermatology consult to determine the etiology: eczema versus psoriasis. Surveyor noted no dermatology consult per the 5/23/22 wound MD's request in R80's medical record. On 7/19/22, R80's nurse practitioner assessed R80. It is documented that R80's skin at this time had healing multiple scabbed wounds, scratch marks to upper extremities. Open unstageable area to coccyx approximately 1cm x 1cm, right lower extremity open area, bandage is in place, clean and dry. Surveyor noted there was no comprehensive assessment/description of the above referenced healing multiple scabbed wounds. Surveyor spoke to R80's nurse practitioner (NP F) on 9/23/22 at 2:05 pm, in regard to NP F's note dated 7/19/22. NP F stated that if NP F documented there are open areas, then they are there . I wouldn't have written it otherwise. NP F stated NP F did not do a physical head to toe assessment but wrote the note based on information provided by the floor nurse at the time. R80's record continues: R80's Quarterly Minimum Data Set (MDS) dated [DATE] documents R80's BIMS (Brief Interview for Mental Status) score to be an 8, indicating R80 demonstrates moderately impaired skills for daily decision making. R80's MDS also documents that R80 requires extensive assistance for bed mobility and hygiene. R80 requires total assistance for transfers and toileting. On 8/28/22 a weekly skin evaluation was completed for R80. The evaluation documents that R80 has multiple open areas red in color no drainage to right and left iliac crest and multiple areas red in color no drainage to the right and left buttock. Clobetasol Propionate Cream 0.05% applied to arms/legs/chest/back/buttocks. Surveyor noted there was no comprehensive assessment of the above referenced multiple open areas such as how many, size, etc. On 8/30/22, Surveyor notes that Allegra allergy oral tablet 60 mg 2 times a day for dermatitis/allergic reaction for 2 weeks was ordered. Surveyor noted R80 was ordered a medication for dermatitis/allergic reaction on 8/30/22 however the facility did not follow up with a dermatologist consult as requested by the physician on 5/23/22. On 9/24/22, the facility provided documentation of a progress note written by R80's physician and electronically signed on 9/23/22 at 11:46 PM. R80 was seen by R80's physician on 8/30/22 which documents that R80 is an elderly frail female with recurrent rash and dermatitis, multiple scratch marks and scab wounds at various stages of healing, also has increased itching and possibility of underlying chronic urticaria. Has been referred to dermatology and wound care team. Surveyor noted there was no comprehensive assessment of the scab wounds during R80's 8/30/22 physician visit and no follow up to the dermatology clinic or to the wound care team. On 9/7/22, R80's electronic medical record (EMR) contains documentation that R80 has been scratching excoriated areas to right buttock, which are large, and needs the wound physician to assess. R80's fingernails have been cut and filed. Writer was advised to place Tricimalone cream on areas and dressing to prevent further scratching. 9/8/22 at 6:34 AM, R80 is being monitored due to open areas on right buttock. 9/8/22 at 8:52 AM, R80 has areas to back, bilateral arms, and hips. R80 has an ongoing issue with itching to areas and a scheduled cream with an as needed cream. Areas are now open, and tissue is red in color. Wound physician is aware and will see R80 next week. Surveyor spoke to ADON D on 9/23/22 at 3:18 pm who confirmed that ADON D did not measure R80's open areas on 9/8/22 when assessing R80. Nursing Home Administrator (NHA A) confirmed during a conversation with Surveyor on 9/23/22 at 3:10 pm, that the wound care doctor was in the facility on 9/13/22 and 9/20/22 and did not assess R80. Surveyor noted there was still no comprehensive assessment of these wounds, no dermatology follow-up and R80 was not seen by the wound care team. On 9/23/22, Surveyor received a copy of R80's comprehensive care plan with revisions and notes the following: There is a focused problem indicating R80 has a mood problem due to anxiety, feeling depressed, having little energy, poor appetite, and feeling restless. Initiated 5/31/22 Revised 8/30/22 R80 has the potential for pressure injury/ulcer development due to impaired mobility, incontinence. 5/16/22 Readmit with stage II pressure left buttock (deemed open skin rather than pressure ulcer with new treatment order 5/23/22) 9/8/22 Excoriated areas to entire back, bilateral shoulders, bilateral buttocks, bilateral arms. Initiated 6/18/20, revised 9/8/22. Interventions: 5/23/22 dermatology consult 9/20/20 bilateral prevalon boots when in bed 8/31/21 Reposition at least every 2-3 hours when in bed or wheelchair 2/14/22 Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. 2/14/22 Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate Provide unbleached linens-initiated 4/28/21, revised 2/28/22 R80 requires an air mattress for pressure relieve-initiated 2/14/22, revised 2/28/22 9/8/22 R80 observed scratching lower extremities, keep nails trimmed. Surveyor noted according to R80's care plan initiated on 2/14/22 and revised on 2/28/22, R80 requires the use of an air mattress. A Surveyor from the Survey team requested to see R80's skin on 9/23/22 at 2:35 PM. Surveyor noted R80's bed does not have a pressure relieving air mattress in place. R80 is wearing pressure relieving heel boots to bilateral feet at this time. Surveyor noted R80's care planned identified the need for unbleached linens. Surveyor spoke to Laundry Supervisor (LS G) on 9/23/22 at 4:20 pm, who stated all the sheets and towel are washed together in bleach. LS G is unaware of any residents needing their towels and sheets washed in an unbleached condition. Surveyor interviewed Laundry Aide (LA H) on 9/24/22 at 7:13 am, who has worked at the facility for 16 years. LA H stated there are 2 residents, 1 of which is R80, who require their sheets, gown, towels to be washed in an unbleached condition. LA H stated there is spot in the laundry room with a note marked for these 2 residents, 1 of which is R80, require this special precaution. Further, these 2 Residents, 1 of which is R80, have special drawers marked indicating that these drawers contain unbleached items. Surveyor took a tour with LA H of the laundry room who confirmed that R80 was not posted as needing unbleached linen. Surveyor then conducted a tour with LA H of R80's drawers in R80's room. Surveyor notes at this time, R80's drawers are completely empty except for 1 washcloth. LA H stated that LA H needed to get R80 added to the list down in the laundry room for requiring unbleached linen and would need to get R80's drawers filled with unbleached linen. R80's medical record continues: On 9/10/22 R80 continues to have open areas, treatment completed, continues to monitor for new open areas. On 9/21/22, a weekly summary documents R80 is not currently receiving treatment for skin problems. Surveyor reviewed R80's bedside [NAME] report as of 9/23/22 which documents R80 was observed scratching R80's lower extremities by nursing. Staff to encourage R80 to avoid scratching. Keep nails trimmed short. Prevlon boots at all times. R80 requires air mattress for pressure relief. Provide unbleached linens. On 9/24/22, Surveyor was provided an updated comprehensive care plan for R80 and notes the following added for the focused problem for having the potential for pressure injury/ulcer development due to impaired mobility, incontinence. 9/23/22 Shallow open areas noted to bilateral back, bilateral buttocks, and bilateral hips. Revised 9/24/22 Interventions added: 9/23/22 Dermatology consult requested 9/23/22 Administer medications as ordered. Monitor/document for side effects and effectiveness 9/23/22 Follow facility policies/protocols for the prevention/treatment of skin breakdown. 9/24/22 Inform R80/family/caregivers of any new area of skin breakdown. 9/24/22 Obtain and monitor lab/diagnostic work as ordered. Report results to physician and follow-up as indicated. Surveyor notes that since re-admission to the facility on 5/16/22, subsequent assessment by wound physician on 5/23/22, the facility was only able to provide 1 weekly skin evaluation for R80. Further, the facility was unable to provide any documentation a weekly skin assessment was completed on the open areas which include measurements, description, color, drainage, pain, etc. for R80's open areas. On 9/23/22, the facility completed a Braden on R80 which documents that R80 is high risk for developing pressure areas. The facility also completed a weekly skin evaluation dated 9/23/22, which documents that R80 has shallow various sized open areas noted with distinct edges, red wound base, and scant amount of serosanginous drainage which appear to itch and be slightly painful to touch on the right and left buttock and right and left lower back. It is noted that neither document any measurements. On 9/23/22, R80's EMR contains documentation that there is no drainage or signs/symptoms of infection noted to multiple areas on buttock, back, legs, and arms. Mattress changed. Surveyor noted R80's mattress was changed back to an air mattress. On 9/23/22 at 10:56 AM, Surveyor interviewed Assistant Director of Nursing (ADON D) who confirmed ADON D has been the Registered Nurse (RN) monitoring and assessing the wounds in the facility. ADON D states that ADON D is wound care certified. ADON D informed Surveyor that ADON D spoke to the wound care physician about R80's open areas but that the wound care doctor would not assess because the doctor still maintained that R80 needed to be assessed by a dermatologist. ADON D confirmed at this time that R80 should be receiving unbleached sheets and towels and washcloths. On 9/23/22 at 11:40 AM, Surveyor interviewed ADON D again. ADON D confirmed there is not a lot of documentation regarding R80's open areas. ADON D confirmed that the expectation is that there should have been a documented assessment and weekly skin evaluations pertaining to R80's skin condition. ADON D stated that some staff are doing weekly skin evaluations in the Resident's EMR and some are doing the paper skin evaluations. ADON D stated that the nurse should be taking the CNA skin check and assessing the Resident on the weekly shower days and signing off on it. On 9/23/22 at 12:02 PM, ADON D confirmed that as of 9/23/22, a dermatologist consult originally ordered on 5/23/22 was not completed. On 9/23/22 at 2:35 PM, a Surveyor from the Survey team requested to see R80's skin. ADON D told Surveyor that R80 has a scattered rash that comes and goes on their body. ADON D showed Surveyor R80's back and buttocks. Surveyor noted a total of 6 open areas resembling ruptured blisters on R80's left buttock and 2 open areas on their left lower back resembling ruptured blisters. On R80's right buttock and right lower back there are 10 open areas resembling ruptured blisters. Surveyor notes R80's bed does not have a pressure relieving air mattress in place. R80 is wearing pressure relieving heel boots to bilateral feet at this time. Surveyors reviewed R80's medical record. Surveyors could not identify any weekly skin assessments referencing R80's current open areas to the bilateral buttocks and back. Surveyor spoke to ADON D on 9/23/22 at 3:18 pm, who stated she is not sure who took R80 off the wound board, because typically R80 should have remained on the board. ADON D was informed that R80 was itching more and recommended unbleached sheets. ADON D confirmed that there is no formal diagnosis for R80's skin condition at this time. ADON D confirmed that a Braden evaluation should be done on change of condition, re-admission, and every 3 months. ADON D stated that R80 should and needs to have had an air mattress and if that was an intervention for a fall (to remove the air mattress), they should have come up with another intervention. ADON D confirmed that skin checks should be completed weekly and documented in each Resident's EMR. On 9/23/22 at 3:30 PM, a Surveyor from the survey team conducted an interview with ADON D. ADON D is the facility's wound nurse and was hired by the facility on 9/1/22. ADON D told Surveyor that they assist the facility's wound MD with weekly wound rounds. Surveyor asked if residents at risk for pressure injury or those with current pressure injuries should have a pressure relieving air mattress on their bed. ADON D responded that any resident at risk or with current pressure injuries should have a pressure relieving air mattress on their bed. Surveyor asked ADON D how they would characterize the open areas to R80's bilateral buttocks and back. ADON D told Surveyor that these areas appear as if they were blisters at one time and have now popped open. ADON D told Surveyor that they would characterize these areas as stage 2 pressure injuries. Surveyor asked ADON D if they had been conducting weekly wound assessments to R80's open areas. ADON D told Surveyor that they were not aware that R80 had multiple open areas to R80's skin and that they believed that R80 just had a rash to their back and buttocks that was being treated with medicated topical treatments. ADON D told Surveyor that the facility had not conducted weekly wound assessments for R80's open areas and have not measured the areas. On 9/23/22 at 3:56 PM, Nursing Home Administrator (NHA A) stated that the expectation is for skin evaluations to be done weekly. NHA A stated that the facility would expect an evaluation to contain a description of all areas with measurements. On 9/23/22 at 4:30 PM, a Surveyor from the Survey team conducted an interview with DON B. Surveyor asked DON B if a resident has open areas or pressure injuries if the areas should be measured and comprehensively assessed on a weekly basis. DON B responded Yes. R80's medical record continues: On 9/24/22 at 5:02 AM, R80's EMR documents that the nurse practitioner was updated on R80's skin condition. R80 currently has an order for Clobetasol Propionate Cream 0.05% to be applied. This order was continued, and dermatologist was called to schedule an appointment. On 9/24/22 at 7:45 AM, a Surveyor from the Survey team asked DON B if they had observed R80's current skin condition. DON B told Surveyor that she had seen R80's skin condition. Surveyor asked DON B what DON B's assessment of R80's open areas was? DON B told Surveyor that the areas appear to be blisters that are no longer intact and that they would say that the areas appear to be multiple stage 2 pressure injuries. On 9/24/22, the wound care physician came to the facility and assessed R80. Documentation does not include any measurements and states no wound detected with attached edges, early/partial granulation, small serous drainage. On 9/24/22, Surveyor notes that the facility added a diagnosis to R80 of dermatitis, unspecified without a dermatology consult. Surveyor reviewed R80's Treatment Administration Record (TARS) from May 2022-September 2022 and notes that R80's Treatment Administration Record (TARS) indicate that a body check was to be completed every evening shift on Mondays. The facility was unable to provide documentation that this was completed. On 9/24/22 at 9:20 AM, Surveyors interviewed Wound Care Doctor (WCD E) who confirmed that WCD E assessed R80 today (9/24/22). Per WCD E's 9/24/22 assessment and documentation of R80, WCD E documented no wound detected. WCD E described R80's area as attached edges, early/partial granulation, small serous drainage with normal odor. Depth is 0.10. Surveyor asked WCD E if they had expected R80 to have had their dermatology consult that he had ordered 5/23/22 to have been completed by now. WCD E stated that it is a concern that the facility never had R80 seen by a dermatologist as WCD E ordered on 5/23/22. WCD E told Surveyors that the ball had been dropped and that R80's dermatology consult had not been followed up on in a timely fashion. WCD E also confirmed that the facility should have been assessing R80's open areas/blisters on a weekly basis including description, measurements, and characteristics of R80's open areas. WCD E confirmed that WCD E was not notified about R80's open areas until 9/7/22. WCD E told Surveyors he did not believe R80's open areas to be pressure injuries but a skin condition which was why he had previously given the facility an order for a dermatology consult for R80. WCD E told Surveyors that he was planning on conducting a biopsy of R80's skin condition on 9/26/22 for further evaluation. On 9/24/22 at 11:57 AM, Surveyor shared with NHA A and DON B the concern that R80 did not get a dermatology consult completed as ordered on 5/23/22, weekly skin evaluations were not completed, and open area skin assessments were not completed including measurements, description, and characteristics for R80. After Surveyors exited from the facility on 9/24/22, NHA A provided Surveyors and Regional Field Operation Supervisors with the following additional information: Received from NHA A on 9/27/22, the results of a Dermatology appointment dated 9/26/22 by Advanced Practice Nurse Practitioner (APNP) J. The results indicate in part; The following areas were examined with significant findings as noted scalp/hair, head/face .scalp with excoriated lesions frontal parietal regions, upper and lower back scars and excoriated .Picker nodules .trim nails short to limit trauma of skin when pt scratches propopic 0.1 oint (ment) BID back and scalp, possibly ruptured/unroofed blisters 3.5 pinch R hip R/O (rule out) bullous pemphigoid .Aquaphor/Telfa for now right hip and right ant (anterior) tubia . Received from NHA A 10/4/22 the results of a 10/3/22 Skin Biopsy report (from MD I) which states in part Conclusion: This pattern is most commonly observed in bullous pemphigoid. It can, however, occur in other, less common conditions, including epidermolysis bullosa [NAME], anti-epiligrin cicatricial phemphigoid, and p200 pemphigoic . Miscroscopc Description: This lesion apparently was relatively old when sampled, because it reveals a shallow, reepithelizlising ulcer which extends across most of the specimen's width. At the edge of the ulcer is a narrow focus of dermoepidermal detachment. Many eosinophils are present within the ecleft and underlying dermis. These findings are consistent with pemphigoid but not entirely specific. Pathologic Diagnosis skin, right hip, punch biopsy-consistent with pemphigoid. Regional Field Operations Supervisor noted, according to Mayo Clinic Bullous pemphigoid https://www.mayoclinic.org Bullouspemphigoid-symptoms and causes-Mayo clinic Overview Bullous pehphigoid is a rare skin condition that causes large, fluid-filled blisters. They develop on areas of skin that often flex-such as the lower abdomen, upper thighs or armpits. Bullous pemphigoid is most common in older adults. Bullous pemphigoid occurs when your immune system attacks a thin layer of tissue below your outer layer of skin. The reason for this abnormal immune response is unknown, although it sometimes can be triggered by taking certain medications. Bullous pemphigoid often goes away on its own in a few months, but may take as many as five years to resolve. Treatment usually helps heal the blisters and ease any itching. It may include corticoseroid medications, such as prednisone, and other drugs that suppress the immune system. Bullous pehphigoid can be life-threatening, especially for older people who are already in poor health. Symptoms The signs and symptoms of bullous pemphigoid may include: Itching skin, weeks or months before blisters form Large blisters that don't easy rupture when touched, often along creases or folds in the skin Skin around the blisters that is normal, reddish or darker than normal Eczema or a hive-like rash Small blisters or sores in the mouth or other mucous membranes. When to see a doctor See your doctor if you develop: Unexplained blistering Blisters on your eyes Signs of infection . 2. Neurological Checks: Surveyor reviewed the Neurological Assessment policy and procedure revised October 2010 and notes the following: The purpose of this procedure is to provide guidelines for a neurological assessment: 1) when following an unwitnessed fall; 2) subsequent to a fall with a suspected head injury; or 3) when indicated by Resident condition. Neurological assessments are indicated: a. Following an unwitnessed fall b. Following a fall or other accident/injury involving head trauma; or when indicated by Resident's condition c. Any change in vital signs or/neurological status in a previously stable Resident should be reported to the physician immediately. Surveyor notes the facility protocol is for neuro-checks to completed every 15 minutes x 4, 30 minutes x 4, 1 hour x 4, 4 hours x 4, 8 hours x 6. R81 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Hypothyroidism, Peripheral Vascular Disease, and Vascular Dementia. R81 has an activated HCPOA. R81's Quarterly MDS (Minimum Data Set) dated 7/23/22 documents that R81 has both short and long term memory impairment and demonstrates severely impaired skills for daily decision making. R81's MDS also documents that R81 requires supervision for bed mobility and transfers, limited assistance for toileting, and extensive assistance for hygiene. R81's fall risk evaluations dated 4/19/22, 8/10/22, and 9/10/22 all indicate that R81 is at moderate risk for falls. R81's bedside [NAME] as of 9/24/22 instructs staff to anticipate and meet R81's needs. The [NAME] also documents to distract R81 from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Surveyor notes this is blank on the [NAME]. Surveyor reviewed R81's comprehensive care plan and notes that on 2/1/22, a focused problem indicating R81 is at risk for falls due to dementia, fall history, gait/balance problems, vision problems, and unaware of safety needs was established. This focused problem was last revised on 9/12/22. Surveyor notes an intervention of neuro-checks per policy was initiated 2/2/22. Surveyor reviewed R81's fall report dated 8/10/22. R81 had an unwitnessed fall and was found in the middle of the floor. It was determined that R81 hit R81's head on the floor. R81 was sent to the emergency room and determined to have no injury as a result of the fall. Surveyor notes the physician and activated HCPOA were notified. Surveyor notes that neurochecks were not completed for the 8/10/22 fall per facility policy and procedure. R81 had another fall on 9/10/22 which was unwitnessed with no determined injury. R81 was found in another Resident's room, lying on the floor on her back. Surveyor notes the physician and activated HCPOA were notified. Surveyor notes that neurochecks were not completed per facility policy and procedure. Surveyor notes that R81 did not have neuro-checks completed per facility policy and procedure for each of their falls. On 9/24/22 at 9:12 AM, NHA A confirmed that the facility was unable to locate any neuro-checks completed for R81's falls. On 9/24/22 at 11:57 AM, Surveyor shared the concern that neuro-checks had not been completed for R81's unwitnessed falls per facility policy and procedure. No further information was provided by the facility at this time. Surveyor notes that on 9/23/22 and 9/24/22, facility nurses received an in-service training conducted by NHA A and discussed neuro-checks, open areas being reported, and follow-up appointments need to be completed/scheduled. On 10/4/22, the facility provided additional information in regards to R81's neuro-checks. The facility provided a LTC Neuro Assessment form with a date of 9/10/22 in regards to R81's unwitnessed fall. The LTC Neuro Assessment form has documented that R81 went to the hospital emergency room and returned on 9/10/22 at 1730 (5:30pm). Surveyor notes that per R81's EMR, the following is documented in regards to R81's 9/10/22 fall: 9/10/22 at 2:27 PM it is documented that R81 was found in another Resident's room on the floor on R81's back. R81 stated R81's head, back, and right arm was hurting. Nurse practitioner was updated and advised to monitor R81 and allow to eat and drink. At 2:30 PM, R81 stated R81 had no pain. R81 is sleepy and resting in bed. 9/10/22 at 10:13 PM, it is documented that R81 was sleeping as was upset by being woken up to obtain vitals. Surveyor notes that R81's EMR does not contain documentation that R81 was sent to the emergency room on 9/10/22 and as indicated on the 9/10/22 LTC Neuro Assessment form submitted on 10/4/22; but rather R81 remained in the facility and was monitored per nurse practitioner instructions. R81's 9/10/22 neuro checks that were listed on the LTC Neuro Assessment form submitted on 10/4/22 indicates upon R81's return from ER at 1730 (5:30 pm). The LTC Neuro Assessment form completed indicates the following dates and times when the neuro checks were completed: 9/10/22 1730, 1830, 9/11/22 0230, 1030, 1830, 9/12/22 0230 and 1030. Surveyor noted the neuro checks were not performed according to the instructions on the LTC Neuro Assessment form. Surveyor also notes, that neuro-checks for R81's fall on 8/10/22 have not been provided by the facility.

Based on observation, staff interviews and record review the facility did not ensure that they provided the necessary care and treatment to 2 of 2 (R10 and R47) residents reviewed with pressure ulcers to promote the healing and prevent new ulcers from developing. R10 was noted to have an open blister to the right heel that went without a comprehensive assessment until the area became worse. R10 was also observed to have an area to the left heel that went without an assessment and was observed to have a treatment in place without a physician order. R47 developed an intact blood filled blister to the right heel. The facility did not comprehensively assess the area to ensure that the proper treatment and interventions were in place to assist in healing the area. This is evidenced by: Review of the Facility's policy and procedure, Pressure Ulcer Treatment, last revised October 2010, documents: Purpose: The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. Definitions and Descriptions (includes) Stage #2 Pressure Ulcer: 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 blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape [CONDITION(S)], perineal [CONDITION(S)], maceration or excoriation. Bruising indicates suspected deep tissue injury. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and / or eschar(tan, brown or black) in the wound bed. Documentation: The following information should be recorded in the resident's medical record: 1. The type of treatment and resident response 2. The date and time the wound care was given. 3. The name and title of the individual performing the care. 4. Any change in the resident's condition. 5. All assessment data (i.e , color, size, pain, drainage, etc.) when inspecting the wound. 6. Resident tolerance of the procedure. 7. Any problems or complaints made by the resident related to the procedure. 8. Resident refusal of the treatment and reason(s) why. 9. The signature and title of the person recording the data. 1.) R10 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor conducted a review of the significant change MDS (Minimum Data Set), dated 4/18/22. R10 was assessed to have severely impaired cognitive skills for daily decision making. Extensive or total dependence on staff is needed for ADL's (activities of daily living) . R10 did not walk in corridor or walk in room. R10's locomotion on unit required total dependence and 1-person physical assist. No locomotion off unit occurred. R10 does not use a walker or cane. R10 is said to use a wheelchair. Yes- Resident (R10) has a pressure ulcer. Yes - R10 is at risk for developing pressure ulcers/ injuries. Yes- has 1 or more unhealed pressure ulcer. 1- Unstageable area with slough and/ or eschar. Nursing note dated 3/29/2022, at 10:54 p.m. states; This writer was called to resident's room (R10) re: blood on resident's right sock. When sock was removed noted an open area on right heel 5.5 cm in diameter. Wound base pink in color with flap of loose skin over wound. Area was washed with soap and water with dry dressing applied. Prevalon boots applied to both feet. R10 unable to state how wound was obtained due to confusion. Left message for Power of Attorney, NP (Nurse Practitioner)- C, DON (Director of Nursing) -B, and Wound RN- J. ( Note written by LPN- L) IDT (Interdisciplinary Team) note dated 3/31/22, states the Interdisciplinary Team reviewed open blister to right heel. Area noted clean dry intact 100% skin with skin flap noted. Treatment orders and Prevalon boots in place. Blister consistent with shoe rubbing back of foot. Plan of care was updated for R10 not to wear shoes until area resolved. A review of R10's individual plan of care which documented the following: R10 is at risk for pressure injury due to impaired mobility, bowel/bladder incontinence, at risk Braden score, Diabetes and peripheral vascular disease. On 3/30/22 open blister to posterior R heel - SDTI (Suspected deep tissue injury) 4/12/22 - Unstageable pressure ulcer- 4/18/22 The plan of care was initiated: 11/02/2021 and last revised on 5/3/2022. Interventions included the following: R10's remaining skin will be intact, free of redness, blisters or discoloration through review date; R10's Pressure injury/ulcer will show signs of healing and remain free from infection by/through review date; Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length X width X depth), stage; No shoe to right foot (open area). (Date Initiated: 04/01/2022); No shoes until posterior right heel blister resolved (Date Initiated: 03/30/2022); Prevalon Boots to both feet at all times. May remove for bathing. (Date Initiated: 04/12/2022) treatment per order. Nursing note dated 4/12/2022, at 11:21 a.m.; Writer noted during wound care to right heel is rounded with slight foul odor, with moderate sero-sang drainage noted with wound bed is 85% eschar. Prevalon boots intact. Wound RN (Registered Nurse)- J and DON (Director of Nursing)- B is here to assess. Skin/Wound note dated 4/12/2022, at 12:19 p.m. ; WCC (Wound Care Certified) RN -J called to room to assess open blister to R heel, area has worsened and formed SDTI (Suspected Deep Tissue Injury) at this time. R10 in bed, Prevalon boots in place per order, all skin protection orders in place. SDTI measures 5 x 3 cm (centimeters), dark purple at center, open blistering at edges with moderate serous drainage. NP-C updated and new treatment orders, MTV (multivitamin) and prostat orders obtained. Daughter called with updated, in agreement with TX (treatment) plan. Weekly Non- Pressure Wound Tracking, dated 4/12/22, documents that R10 had a right heel pressure area that is 5 cm in length by 3 cm in width. Suspected deep tissue injury. Onset date 3/30/22. Treatment ordered: normal saline, Iodosorb, foam border three times a week and as needed. Open blister to R heel noted 3/30/22 consistent with rubbing of shoe has worsened and formed SDTI at this time. R10 in bed, Prevalon boots in place per order, all skin protection orders in place. SDTI measures 5 x 3 cm, dark purple at center, open blistering at edges with moderate serous drainage no noted signs/symptoms infection. Edge defined and intact, surrounding skin warm/ dry/intact. R10 complain of pain during cleansing, pain ceases after. Further review of R10's medical record showed that the open blister (stage #2 pressure ulcer according to facility policy) had not been comprehensively assessed since the first date it was observed on 3/29/22. A treatment was obtained to wash open blister posterior right heel with soap and water, apply triple antibiotic ointment followed by border form. Change every other day and as needed for soilage or dislodgement. Weekly Wound Assessment, dated 4/18/22, right heel, pressure, onset 3/30/22 measures 2.84 cm by 2.49 cm, by 0.1. Unstageable. Nursing note dated 4/20/2022 at 10:42 a.m.; R10 seen by wound MD for right heel wound. Measurements: length 2.84 cm width 2.49 cm depth 0.10 cm margin detail attached edges wound bed assessment granulation 1-25% slough 51-75% drain amount moderate serous odor normal periwound edematous treatment: cleanse with 1/2 strength Dakin's solution, protect periwound with skin prep, apply [MEDICATION(S)] to wound bed, cover wound with bordered gauze change daily and PRN. Doppler study results pending. Weekly Wound assessment dated [DATE]. Right heel pressure, Unstageable measures 1.9 cm by 2.1 cm by 0.1. Unstageable pressure ulcer to right heel improved, notes 80 % well adhered eschar, 20 % pink moist granulation with noted moderate serous drainage. No noted odor, redness or signs of infection. Treatment orders changed this visit per Wound MD. Weekly Wound assessment dated [DATE]; right heel pressure area, unstageable. Measures 1.9 cm by 1.5 cm by 0.1. Unstageable pressure ulcer to right heel improved, noted to be 50% well adhered yellow slough, 50% pink moist granulation with noted moderate serous drainage. No noted odor. No s/s pain. Weekly Skin assessment dated [DATE]; Date of onset: 3/30/22 right heel - pressure area, measures 1.9 x 1.7 x 0.1 unstageable. Summary: Unstageable pressure ulcer to R heel debrided this assessment per Wound MD. Wound presents post debridement 60% well adhered yellow slough, 40% pink granulation. Moderate serous drainage noted pre debridement, no odor or s/s infection noted. Wound edges defined and intact, surrounding skin warm dry intact. No s/s pain or discomfort noted treatment: Cleanse with 1/2 strength Dakin's solution, protect periwound with skin prep. Apply Santyl to wound bed and cover with border gauze daily and PRN Facility conducted a Braden scale skin assessment on 5/10/22 stating R10 is at low risk for pressure ulcer development. On 5/11/22, at 2:25 p.m., Surveyor interviewed Wound RN- J regarding R10's open blister to the right heel that was initially identified on 3/29/22. RN- J stated that she was pretty sure risk management met and decided the original blister was from R10's from shoe. RN- J stated it was an intact blister at one time. Surveyor asked why there was not a comprehensive assessment, conducted by a Registered Nurse, of the area to the right heel until 4/12/22. RN- J stated that she did not assess the area until it became worse, she does not assess blisters and was not considering it as a pressure ulcer. RN- J stated that area in which the blister was kept changing. It was first like on the Achilles area of the right foot and moved down to heel. I thought it to be 1 area. RN- J stated that she believes the wound MD is still calling the right heel an unstageable SDTI. (Noted to be called pressure ulcer in MD assessment) RN- J stated again that the area was a clear fluid filled blister at 1 time. RN- J stated that they did obtain treatment initially for skin prep. RN- J stated that there should have been an assessment by one of the floor nurses at the time it was discovered. RN- J stated that R10 had the Prevalon boots in place when the blister was discovered. RN- J stated that somehow the area to R10's right heel got worse. Surveyor asked RN- J how she determined that R10 had a SDTI. RN- J responded based on what it looked like, I determined it to be a Deep Tissue Injury. On 05/11/22, 2:54 PM, RN- J provided Surveyor with the facility risk management IDT review of the open blister to right heel dated 3/31/22, which documented, area noted clean dry intact 100% skin with skin flap noted. Treatment orders and Prevalon boots in place. Blister consistent with shoe rubbing back of foot. POC updated for resident not to wear shoes until area resolved. RN - J stated she did not do a weekly comprehensive assessment of area until it became a Deep Tissue Injury. Verified area was open on 3/29/22. Surveyor asked RN- J why she did not assess area, RN stated well it was really only like a flap, like a deflated balloon. For a period of time, I was only following pressure ulcers. The Wound MD that I consult with has trained me that the trauma can't be staged and doesn't need assessing. Did not consider the flap to be a pressure ulcer. Surveyor verified facility policy with RN-J that a Stage #2 may also present as an intact or open/ruptured serum-filled blister. RN- J is agreeable per facility policy this meets the definition. On 05/12/22, at 8:35 AM , Surveyor made observations of Wound RN-J administering the treatment to R10's right heel. The following was observed: RN-J washed hands and applied gloves. Removed dressing to the R heel - small amount serous drainage on old dressing. RN-J wash hands and re-gloved; cleansed area with normal saline and gauze. RN-J had the cup up with gauze in it on table with barrier present; squirted pink bullets of normal saline onto gauze which was used to cleanse wound. Wound base appeared moist superficial area. No slough, necrosis or drainage noted. The area observed to be slightly larger than a 25 cent piece. No s/sx infection noted. No redness to surrounding skin. RN-J then washed her hands and re-gloved; skin prep applied to the surrounding skin; then applied Santyl with wood stick to wound bed; covered with clean dressing; replaced protective boot. Surveyor then asked to look at R10's L heel. Wound RN- J removed protective boot and sock. Surveyor observed dressing on L heel. RN- J stated: Oh! I wasn't aware she (R10) had something on that heel. Surveyor noted the dressing to be dated 4/28. Upon removal of dressing Surveyor noted large amount of yellow substance on dressing. Surveyor asked what the yellow substance was. Wound RN- J I don't think it's Iodosorb - it looks like maybe Iodine. Wound RN- J removed a piece of dried yellow matter, approximate size of a quarter, from the center of the old dressing and stated: This is some dried skin. Wound RN- J looked at heel and stated: I don't think anything is there, it just looks really dirty. I'm going to clean it up. Wound RN- J thoroughly cleansed heel with NS (Normal Saline) and gauze. Surveyor observed evidence of a previous (healed) blister; intact pink skin measuring 3 cm x 3 cm with surrounding peeling skin around edges. Wound RN- J palpated skin - reported it felt firm. stated: It's not open, I don't think there was a blister. Surveyor pointed out 3 x 3 cm area of healthy pink skin with surrounding peeling skin, and the evidence of the piece of skin in the old dressing. Wound RN- J stated: Maybe there was a blister there at one time, there's nothing there now. Wound RN- J applied skin prep to L heel. On 5/12/22, at 10:15 a.m., Surveyor interviewed Wound Care RN- J which stated R10's area started on the right Achilles from shoe rubbing. Surveyor asked if this would be considered pressure. Wound RN- J stated no, her shoes were too big for her. The Wound MD thought that the SDTI was actually a new area and told me I made a mistake. Wound RN- J- stated I thought the area had just moved down from Achilles to heel, it was the same area. Wound RN-J stated that on 4/12/22 she was made aware that R10 had an area to the right heel that was purple. I determined it was a SDTI. Wound RN- J stated that there should not be a concern with R10's skin assessments because a treatment was done the entire time. Surveyor asked Wound RN- J about the order from the Wound MD to use 1/2 strength Dakins solution to cleanse the wound prior to treatment. Wound RN- J stated that is a mistake, it is supposed to be normal saline solution, I had discussed this with the Wound MD last week. Surveyor verified with Wound RN- J that the last 3 weeks assessments indicated that 1/2 Dakins Solution was being used to cleanse the wound but the treatment order is for normal saline wash. This order was written on 4/27/22 to Apply Santayl to right heel topically one time a say for wound care. Normal Saline to right heel. Surveyor asked Wound RN- J about the observation in the morning on 5/12/22 that R10 had a dressing to the left heel dated 4/28/22. Wound RN- J stated she is not sure why this was there, maybe it was preventative. On 5/12/22, Surveyor conducted a review of R10's physician orders. It was noted that there was never an order obtained for a treatment to R10's left heel. The Treatment Administration Record for April, 2022 showed that on 4/28/22, Wound RN- J signed that she had completed a treatment to R10's right heel. This was also completed on 4/29/22 by Wound RN- J. R10 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, R10 had an order that staff are to Inspect Feet Daily. Document +/- (positive or negative) for findings. Document findings and implement interventions as needed every evening shift. The plan of care for R10 states that R10 has Diabetes Mellitus and a diabetic foot check is to be conducted every evening by licensed nurse, followed by lotion to bilateral lower extremities. Staff should have noticed that treatment gauze to R10's left foot was dated 4/28/22 when providing the nightly diabetic foot checks. Surveyor requested to view the weekly skin evaluations for R10. On 5/16/22, at 1:58 p.m., Director of Nursing- B stated that she could not provide any evidence that the weekly skin evaluations were completed and that she use to have a folder of the written evaluations but is not sure what happened to R10's. As of the time of exit, there was no further information provided as to why R10's open blister to her right heel (stage #2) was not comprehensively assessed until the area worsened on 4/12/22. R10's area continued to worsen, becoming unstageable and received a debridement treatment. In addition, there was concerns that the location of the area may have changed or even been 2 separate areas, although the assessment did not indicate this. The facility could not provide additional information as to how R10 ended up with a treatment gauze to the left heel, which was observed by the Surveyor and the area appeared to once have been a blister. 2.) R47 was originally admitted to the facility on [DATE] and was readmitted on [DATE] after a hospitalization . R47's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the significant change MDS (Minimum Data Set) dated 3/2/22, R47 had a BIMS (brief interview for mental status) score of 11, indicating moderate impairment for daily decision making. R47 needed extensive assistance of 2-person physical assist with bed mobility. R47 was assessed to be at risk for development of pressure ulcers and at the time of the assessment had no unhealed pressure ulcers. No DTI, (Deep Tissue Injury) no other wounds or skin problems noted. R47 is said to be non-verbal though able to communicate to a degree with nonverbal interaction. Nursing note dated 3/25/2022, at 12:08 p.m., documents: WCC (Wound Care Certified) RN- J called to room to assess darkened area to R47's medial right heel. NP (Nurse Practitioner)-C accompanied RN- J to room. Upon assessment, intact blood blister measuring 2 cm (centimeters) x 1 cm noted to medial right heel. R47 contracted, R leg under left and no noted skin to skin contact between heel and LLE noted. R47 questioned if skin was pinched and nods yes. Area assessed for items that may have pinched skin and consistent with skin being pinched between bed and bedside table. Plan of care updated to ensure bedside table moved away from bed during cares and repositioning. Skin prep orders obtained and processed. The facility obtained a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of individual plan of care for R47 documents the following concerns: R47 has potential for pressure injury/ulcer development r/t (related to) Impaired mobility, incontinence, decreased activity, contractures, [CONDITION(S)] (Cerbrovascular Accident) with right sided [CONDITION(S)] and [CONDITION(S)], hx (history) of pressure ulcer to right medial heel. readmitted [DATE] with unstagable to right elbow (resolved 1/27/22). 02/14/22 area of sheering to right lateral; lower leg (resolved 03/01/22); 3/18/22 fungal rash to R hand between thumb and 1st finger; 3/25/22 Intact blood blister medial R heel. (Date Initiated: 06/18/2019 Revision on: 03/25/2022) Interventions included: R47's skin will be intact, free of redness, blisters or discoloration by/through review date. (Date Initiated: 08/27/2019, Revision on: 03/16/2022, Target Date: 06/18/2022); 1/15/22 weekly skin checks per policy (Date Initiated: 01/18/2022); Avoid positioning R47 on R medial foot (Date Initiated: 06/18/2019 Revision on: 11/26/2019); Daily foot checks by licensed staff (Date Initiated: 08/27/2019); Ensure bedside table moved away from bed with all cares and repositioning (Date Initiated: 03/25/2022); Inspect skin daily with cares-nursing assistant to report any concerns or changes to the nurse (Date Initiated: 08/27/2019); Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, wound MD to follow (Date Initiated: 06/18/2019 Revision on: 12/14/2021). R47 was sent out to the hospital on 3/27/22 and returned to facility on 4/1/22. Review of the medical record did not show a re-admission skin assessment was completed upon R47's return to the facility. Nursing note dated 4/2/2022. at 8:07 p.m.; R47 A&O x's (Alert and oriented times) 3 and able to make needs known through hand signals. Resident resting quietly in bed this shift. Requires total assist with all cares and transfers. No s/sx (signs and symptoms) of pain or discomfort noted. Cares given every 2 and as needed. Peg tube in place and flushes well. Meds tolerated well. Tx (Treatment) continues to reddened areas and to right hand for fungus. Discoloration to right great toe and right heel remains with skin prep applied. Awaiting antibiotic to be delivered. Nursing note dated 4/3/2022, at 1:30 a.m., F/U (Follow Up) readmit. Alert & responsive. No s/s of pain & disc (discomfort). Color WNL (Within Normal Limits). Skin W&D (Warm and Dry). No cough or SOB (Shortness of Breath). HOB (Head of Bed) elevated. Tolerating TF (Tube Feeding) well. Oxygen continues @ 8L/min. (at 8 liters per minute) via [CONDITION(S)] mask. GT (Gastrostomy Tube) patent & intact. Abdominal soft. Non tender. Bowel sounds x4 (in all 4 quandrants), blister. Blood to R heel intact. Nursing note dated 4/4/2022, at 1:46 a.m.; F/u readmit. Alert & responsive. No c/o pain & disc. Color WNL. Skin W&D. No cough or SOB. HOB elevated. Tolerating TF well. Abdominal soft. Non tender. Bowel sounds x4. Continues ABT (antibiotic) for c-diff/[CONDITION(S)]. No adverse reaction. No loose stool noted @ present time. Blister R heel intact. TX (treatment) done. Surveyor noted though continued record review R47's medical record did not show any weekly pressure ulcer assessments to the areas to the right heel. Further review of the medical record did not show any evidence that the area to R47's right heel had been comprehensively assessed from 4/4/22- 4/29/22. Surveyor reviewed the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Skin intact with no residual noted. currently resting comfortably. Plan: Monitor for pressure points pressure offloading and repositioning as tolerated watch for recurrence of infection: For details please see orders in the chart. Nursing note dated 4/29/22, written by Wound RN- J, documented, in to review intact blood blister to R heel cause by pinched skin. Blister noted dry, intact no drainage, no opening in skin no s/s infection or pain. Skin prep treatment remains appropriate. Surveyor reviewed R47's plan of care which was not updated to include the new skin impairment concerns of the right heel blister or additional interventions put in place. On 05/11/22, at 2:19 PM , Surveyor conducted an interview with Wound RN- J in regards to R47's intact blister to the right heel. Surveyor asked Wound RN- J why R47's area to the right heel was not comprehensively assessed weekly and noted to be a Stage #2 pressure Ulcer per facility policy. Wound RN- J stated the area was deemed to be trauma and did not assess as a pressure ulcer. The staff determined R47's heel was pinched due to the bedside table. Wound RN- J stated she asked R47 if area was pinched and R47 shook head yes. New intervention was to keep side table away from her. Wound RN- J stated she probably did not follow- skin assessment. Wound RN- J stated per my wound doctor I consult with, he does not stage them (blisters), meaning does not stage trauma. Wound RN- J confirmed that R47 is not followed by the Wound MD she consults with but follows what he recommends. Wound RN- J was again asked if there was an assessment of the area and Wound- RN J stated she has not been doing this and the floor nurse should be doing this . Wound RN- J again stated that the area is identified as trauma on risk management notes. Surveyor confirmed that the care plan says blood blister. Wound RN- J stated that the facility did obtain treatment from MD. On 5/11/22, at 2:54 p.m., Surveyor interviewed Wound RN- J who reviewed the risk management notes dated 3/25/22, which documented: IDT (Interdisciplinary Team) reviewed intact blood blister to medial right heel. Intact blood blister measuring 2 x 1 cm noted to medial right heel. R47 contracted, right leg under left and no noted skin to skin contact between heel and lower left extremity noted. R47 questioned if skin was pinched, resident nodded yes. Area assessed for items that may have been pinched skin and consistent with skin being pinched between bed and bedside table. POC (Plan of Care) updated to ensure bedside table moved away from bed during cares and repositioning. Wound RN- J again stated that she has not been assessing this area weekly because it's just an intact blister and treated with skin prep. Wound RN-J stated area is now a dry blister. Surveyor refereed Wound RN- J to facility's wound policy which identifies a Stage #2 may also present as an intact or open/ ruptured serum filled blister. Wound RN- J stated that previously she was only following pressure ulcers, not trauma areas or surgical areas. As of the time of exit, no additional information was provided as to why the facility did not comprehensively assess, per the individual plan of care and facility policy, R47's blister to the right heel.

Based on observation, record review and interview, the facility did not ensure that 3 (146, R12, & R88) of 8 residents reviewed for accidents had adequate assistance devices and interventions in place to prevent accidents. * R146 was assessed to be at high risk for falls. R146 was assessed to require 2 staff assistant with bed mobility and toileting. On 3/24/22, cares were provided with 1 staff member and not 2 staff as assessed and as care planned for. On 3/24/22 during the cares provided, R146 fell out of bed sustaining a condyle fracture of lower end of R (right) femur. * R12 was observed to not have his fall interventions in place per his plan of care. R12 also sustained multiple falls (8 falls) that were not thoroughly investigated and did not include a root cause analysis to prevent future falls. * On 3/29/22, a Certified Nursing Assistant (CNA) provided cares to R88 by herself, rather than with the use of 2 staff members as indicated by R88's assessment and care plan. During the cares provided, R88 lifted her leg swinging it over causing R88 to fall out of bed and onto the floor striking her face. R88 was noted to have blood coming from her mouth. R88 was sent to the emergency department where R88 received 3 sutures for a laceration to her lower interior lip and 2 sutures to her lower exterior lip. Facility wide education was completed with all nursing staff on following the care plan however, during the survey, R88's fall preventive care planned interventions dated 1/2/20 was not followed. R88's bed was observed not to be in the lowest position and R88's call light was not within reach. Findings include: 1. R146 was readmitted to the facility on [DATE] with diagnoses that included Dementia with Behavioral Disturbance, Alzheimer's Disease with Late Onset and Chronic Obstructive Pulmonary Disease. R146's Quarterly MDS (Minimum Data Set) dated 2/22/22 documents that R146 has short and long term memory problems. Section C1000 (Cognitive Skills for Daily Decision Making) documents that R146 has severely impaired cognitive skills for daily decision making. Section G (Functional Status) documents that R146 has total dependence on staff and requires a two person physical assist for her bed mobility and toilet use needs. R146's Falls CAA (Care Area Assessment) dated 8/22/21 documents under the Care Plan Considerations section, R146 triggered the falls CAA because she has impaired balance and receives scheduled [CONDITION(S)] medications. R146's situation is complicated by her advanced Alzheimer's dementia with severe cognitive & communication impairment .The team agrees she continues to have risk for falls and risk for injury if falls occur. Staff will continue to provide assist with ADL's per c.n.a (Certified Nursing Assistant) care card and provide interventions to help reduce her risk for falls. R146's Falls Risk Evaluation assessment dated [DATE] documents a score of 16, indicating that R146 is at high risk for falls. R146's ADL (Activities of Daily Living) care plan dated as initiated on 11/20/17 documents under the Interventions section, TOILET USE: R146 is incontinent of both bowel and bladder and requires check and change q (every) 2-3 hours and prn (as needed) with total assist of 2. R146's nursing note dated 3/24/22 documents, General Nurses Note Text: Writer alerted by CNA (Certified Nursing Assistant) that during care resident rolled over and rolled out of bed and landed on the left side. Resident is unable to say she is in pain or not. [R146] is scream [sic] and yelling thru out the shift which is her baseline. Writer unable to straighten her legs out. Writer inform RN (Registered Nurse) on duty to assess. Updated NP (nurse practitioner) and left message for POA (power of attorney) to return call. R146's nursing note dated 3/24/22 documents, General Nurses Note Text: Res (Resident) returned to facility at 1332 (1:32 p.m.) from .hospital via ambulance .Res (Resident) returned with a condyle fracture of lower end of R (right) femur. R146's hospital discharge documentation dated 3/24/22 documents, Diagnosis: Displaced unspecified codyle fracture of lower end of right femur; Fall- initial encounter. R146's fall investigation dated 3/24/22 documents, R146 .admitted to the facility on [DATE] for long term placement that shows severe cognitive impairment and has a legal guardian in place. She has a history of falls. She has a history of calling out/yelling out when touched or moved. She does have some noted contractures of her lower extremities . On 3/24/2022 at approximately 07:15 (7:15 AM) nursing was notified by the CNA (Certified Nursing Assistant) that the resident rolled out of bed during cares. The resident was assessed by nursing with no obvious s/s (signs and symptoms) of injury noted. Resident was yelling/calling out during assessment. She was transported to the ED (emergency department) for evaluation. Notifications were made. While at the ED, she was diagnosed with a displaced unspecified condyle fracture of lower end of right femur . CNA (Certified Nursing Assistant)-M indicated that she was providing cares for the resident and rolled the resident onto her left side. She stated the resident became combative at that point. She stated she tried to continue with cares so she could roll the resident back, but the resident rolled off the bed. She stated she was performing cares by herself. Administration, DON (Director of Nursing) and Social Services spoke with the CNA in the Administrative office. She was asked how she rolled the resident, and she indicated she rolled the resident away from her. She was asked if she had referred to the resident's care card which indicates she requires 2 people for bed mobility. The CNA indicated she did not look at the care card. CNA was educated at that time to always check the care cards for the residents before doing cares. CNA was suspended pending investigation. The resident returned from the hospital at 13:32 (1:32 P.M.) and was assessed. Orders for ace wrap to right leg/femur fracture and pain medications processed. Education initiated with staff on following and checking care cards. Spot checks for fall interventions and care cards conducted. Involved CNA remained off the schedule during investigation. She admitted to providing cares by herself and not referring to the care card. Involved CNA's employment terminated. R146's fall investigation dated 3/24/22 includes a written statement from CNA-M which documents, I was in [R146's] room getting her dressed and cleaned and when I was cleaning [R146], I rolled her away from me and that's when she (R146) fell on the floor. Surveyor noted per the facility's investigation report, R146 fell during incontinence cares as a result of only having an assist of 1, not 2 as documented in R146's plan of care and R146's assessment. Due to CNA-M no longer being employed at the facility at the time of the survey, Surveyor was unable to interview CNA-M regarding R146's 3/24/22 fall. On 5/16/22 at 9:05 a.m., Surveyor informed NHA (Nursing Home Administrator)-A of the above findings. Surveyor asked NHA-A if R146 fell during incontinence cares as a result of only having an assist of 1, not 2 as documented in R146's plan of care. NHA-A informed Surveyor that R146 should have had an assist of 2 during incontinence cares instead of 1. No additional information was provided as to why R146 did not have adequate interventions in place to prevent accidents. 2. R12 was readmitted to the facility on [DATE] with diagnoses that included Traumatic Brain Injury, Dementia without Behavioral Disturbance, Cerebral Infraction and Monoplegia of Upper Limb. R12's Significant Change MDS (Minimum Data Set) dated 1/27/22 documents a BIMS (Brief Interview for Mental Status) score of 3, indicating that R12 is severely cognitively impaired. Section G (Functional Status) documents that R12 requires extensive assistance and a two person physical assist for his bed mobility and transfer needs. Section G0400 (Functional Limitation in Range of Motion) documents that R12 has impairment to one side of both his upper and lower extremities. R12's Falls CAA (Care Area Assessment) dated 1/27/22 documents under the Care Plan Considerations section, R12 triggered the falls CAA because he has has fallen since readmission, has a history of falls, has impaired balance, and received prn (as needed) antianxiety medication during [NAME]. His situation is further complicated by his impulsiveness and attempts at keeping as much independence as he is able to, when not too lethargic since readmission, he also has hospice orders and received prn narcotic during reference period. Staff completed a fall risk tool on 1/21 and 1/24/22 indicating high risk, see for details. The team agrees he continues to be at risk for falls and risk for injury if falls occur. R12's Falls Risk Evaluation assessments dated 5/8/21 documents a score of 14, indicating that R12 is at moderate risk for falls. A. Observations R12's Falls care plan dated as revised 9/21/20 documents under the Interventions section, Pillows to sides of resident when in bed to define bed parameters. On 5/9/22 at 3:16 p.m., Surveyor observed R12 laying supine in bed. Surveyor observed R12 not to have pillows to the sides of his bed as documented in R12's plan of care. On 5/10/22 at 8:03 a.m., Surveyor observed R12 attempting to get out out bed. Surveyor observed R12 not to have pillows to the sides of his bed as documented in R12's plan of care. On 5/11/22 at 8:11 a.m., Surveyor observed R12 laying supine in bed. Surveyor observed R12 not to have pillows to the sides of his bed as documented in R12's plan of care. On 5/16/22 at 9:05 a.m., Surveyor informed NHA (Nursing Home Administrator)-A of the above findings. No additional information was provided as to why R12 did not have his fall interventions in place to prevent accidents and falls. B. Fall Investigations On 5/11/22 at 8:57 a.m., Surveyor reviewed R12's falls. Fall #1; R12's nursing note dated 11/6/21 documents, General Nurses Note Text: Called to room by roommate that resident had fallen in the bathroom self transferring himself to the toilet. Resident assessed by DON. Vitals stable, ROM (Range of Motion) within baseline limits. Resident transferred to toilet with 2 assist and gait belt then assisted to wheelchair. DON (Director of Nursing), administrator, case manager RN (Registered Nurse), son all updated on fall. R12's fall investigation dated 11/6/21 documents, IDT (Interdisciplinary Team): Due to resident impulsivity, falls are unavoidable. Surveyor noted that R12's fall investigation did not include a root cause analysis, when R12 was last seen prior to his fall and what fall interventions were in place prior to R12's fall. Surveyor also noted R12's fall investigation did not have any new fall interventions put in place and R12's care plan was not updated to reflect R12's fall. Fall #2; R12's nursing note dated 11/7/21 documents, General Nurses Note Text: Writer was called to resident room, he was laying on the floor in the bathroom on his left side. He was yelling out that his left arm/elbow/wrist and hand are in severe pain. He would not allow staff to assess the left arm at all. He stated I fell NP (nurse practitioner) on call notified of above new order to send to (name of hospital) ER for evaluation. Bell ambulance notified of transport. Administration updated, Guardian message left to return call to update on above. Bell ambulance arrived at 1840 for transportation all paperwork is with ambulance driver. R12's fall investigation dated 11/7/21 documents, IDT (Interdisciplinary Team): Due to resident impulsivity, falls are unavoidable. Surveyor noted that R12's fall investigation did not include a root cause analysis, when R12 was last seen prior to his fall and what fall interventions were in place prior to R12's fall. Surveyor also noted that R12's fall investigation did not have any new fall interventions put in place and R12's care plan was not updated to reflect R12's fall. Fall #3; R12's nursing note dated 11/10/21 documents, General Nurses Note Text: Writer was alerted by patients roommate that patient was on the floor writer asses AROM (adequate range of motion), vitals and, checked skin for any indication of an injury. Patient had no c/o pain. Writer is a graduate RN who assessed under the supervision of DON. Patient Left extremities are at baseline patients Right extremities are unaffected by fall no trouble performing ROM exercises. Patient says he does not know what happened he was trying to get on the toilet and suddenly fell . R12's fall investigation dated 11/10/21 documents, IDT (Interdisciplinary Team): Due to resident impulsivity, falls are unavoidable. Surveyor noted that R12's fall investigation did not include a root cause analysis, when R12 was last seen prior to his fall and what fall interventions were in place prior to R12's fall. Surveyor also noted that R12's fall investigation did not have any new fall interventions put in place and R12's care plan was not updated to reflect R12's fall. Fall #4; R12's nursing note dated 11/18/21 documents, General Nurses Note Text: Per LPN (licensed practical nurse): Floor nurse discovered resident lying on the floor, in supine position in front of resident bathroom door, ROM (range of motion) WNL (within normal limit), denies pain and discomfort at this time, resident denies hitting his head. PERRLA (pupils equal and reactive to light), Resident states, I have to go pee, get me off this floor. Assisted resident to toilet he had a large BM. (bowel movement) Resident is dry, he did not use his call light. Encourage to use his call light for assistant. R12's fall investigation dated 11/18/21 documents, IDT (Interdisciplinary Team): Due to resident impulsivity, falls are unavoidable. Surveyor noted that R12's fall investigation did not include a root cause analysis, when R12 was last seen prior to his fall and what fall interventions were in place prior to R12's fall. Surveyor also noted that R12's fall investigation did not have any new fall interventions put in place and R12's care plan was not updated to reflect R12's fall. Fall #5; R12's nursing note dated 11/22/21 documents, Writer was made aware by CNA resident was in the bathroom on his back- Writer entered the bathroom where resident was laying on his back and his wheelchair was being him.[sic] No injuries. Surveyor noted that R12's fall investigation did not include a root cause analysis, when R12 was last seen prior to his fall and what fall interventions were in place prior to R12's fall. Surveyor also noted that R12's fall investigation did not have any new fall interventions put in place and R12's care plan was not updated to reflect R12's fall. Fall #6; R12's nursing note dated 11/23/21 documents, Patient could be heard yelling help from his room. Nurse entered room and saw patient in his bathroom alone on the floor. He did not have his shoes or left leg brace. Patient had a laceration to the left lateral orbital bone measuring 0.6 x 0.9 cm. Patient stated he was trying to go the bathroom, fell and his [sic] head on the sink. C/o (complains of ) headache. Transport to hospital. Surveyor noted that R12's fall investigation did not include a root cause analysis, when R12 was last seen prior to his fall and what fall interventions were in place prior to R12's fall. Surveyor also noted that R12's fall investigation did not have any new fall interventions put in place and R12's care plan was not updated to reflect R12's fall. Fall #7; R12's nursing note dated 1/21/22 documents, General Nurses Note Text: Called to room to assess resident. Resident was found on floor crawling toward the bathroom. Resident was admitted to hospice this AM. Resident is very confused at baseline. Resident unaware that he physically can not walk due to hx (history) of [CONDITION(S)] ([CONDITION(S)]) .No injuries noted at this time. Bed in low position, fall mats in place. R12's fall investigation dated 1/21/22 documents, Staff to begin 3 day bowel and bladder assessment to check for toileting needs Q (every) 2 hours. Surveyor was unable to locate a bowel and bladder assessment dated [DATE] in R12's medical record. Fall #8; R12's nursing note dated 2/6/22 documents, Health Status Note Text: Resident resting in bed quietly with no c/o pain or discomfort voiced. Neuro (neurological) check - and injuries noted from fall on 2/6/22 at 1000. Tolerated med pass well. Will continue to monitor. R12's fall investigation dated 2/6/22 documents, IDT (Interdisciplinary Team): Due to resident impulsivity, falls are unavoidable. Surveyor noted that R12's fall investigation did not include a root cause analysis, when R12 was last seen prior to his fall and what fall interventions were in place prior to R12's fall. Surveyor also noted that R12's fall investigation did not have any new fall interventions put in place and R12's care plan was not updated to reflect R12's fall. On 5/12/22 at 3:28 p.m., during the daily exit conference, Surveyor informed NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the above findings. NHA-A and DON-B directed Surveyor to speak with Wound RN (Registered Nurse)-J about R12's falls. On 5/16/22 at 8:46 a.m., Surveyor informed Wound RN-J of the above findings. Surveyor asked Wound RN-J if R12 had a bowel and bladder assessment completed on 1/21/22 as documented in R12's fall investigation, as Surveyor was unable to locate any in R12's medical record. Wound RN-J informed Surveyor that she also could not locate a bowel and bladder assessment dated [DATE] in R12's medical record. Surveyor asked Wound RN-J why R12's above fall investigations were not thoroughly investigated and or why they were missing a root cause analysis and new fall interventions for R12. Wound RN-J informed Surveyor that she could not provide any additional information regarding R12's above fall investigations as she was not employed at the facility at the time of R12's falls. No additional information was provided. 3. R88's Quarterly Minimum Data Set with an Annual Reference Date of 1/3/22 documents: Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture, as Extensive 2 person assist. R88's Care Plan (CP) Focus area initiated 1/2/20 documents: (R88) is at risk for falls r/t (related to) Fall history, impaired balance, [CONDITION(S)] medication use, behaviors, cognitive loss, fall risk tool score. Interventions include: (R88) needs a safe environment with: Adequate glare-free light; a working and reachable call light, handrails on walls in hallways and bathrooms, personal items within reach - Date Initiated: 1/2/20. Bed in lowest position - Date Initiated: 1/2/20 Anticipate and meet (R88)'s needs - Date Initiated: 1/2/20. Surveyor review of the Facility Reported Incident dated 3/29/22 which indicated R88 sustained a fall from the bed. The report documented: Certified Nursing Assistant (CNA) was providing cares for resident by herself and per CNA, resident lifted her leg swinging it over causing her to fall out of bed on the floor striking her face. Resident was noted to have blood coming from her mouth. She was sent to the ED (Emergency Department) for evaluation. She received sutures for a laceration to her lower lip. She was diagnosed with a [CONDITION(S)] (Urinary Tract Infection) and prescribed antibiotics. Imaging that was performed was negative for any fractures. Agency CNA told the DON (Director of Nursing) she had referenced the care card for the resident. The care card was reviewed and indicated resident is assist of 2 for bed mobility and dressing. When asked if she had someone in helping her, the CNA indicated that she did not. CNA was made a do not return to the facility. Her agency was notified by nursing. The ED note dated 3/29/22 documented: Laceration repair lower interior lip - 3 sutures. Laceration repair lower exterior lip - 2 sutures. On 5/9/22 at 3:23 PM Surveyor spoke with Nursing Home Administrator (NHA)-A. NHA-A reported the CNA admitted to her that she was getting the resident dressed when she fell out of bed, and she was alone when the CP indicated 2 person assist. NHA-A reported the CNA was fired after the incident. NHA-A reported facility wide education was completed after the incident and provided evidence of documentation. Surveyor noted the facility completed education with all nursing staff on following the Care Plan. On 5/9/22 at 11:20 AM Surveyor entered R88's room and observed R88 lying in bed, calling out Put some clothes on me. I want some pants on, I'm not wearing any pants, all I got on is my brief. R88 pointed to the closet and said: Clothes are in there. Surveyor noted R88's call light was not on. Surveyor asked R88 if she knew how to use her call light. R88 looked around, felt the bed with her right hand and said I don't know. Surveyor observed R88's call light on the floor near the right side of the head of he bed, not within reach of R88. On 5/9/22 at 2:14 PM Surveyor observed R88 lying in bed on her back, covered to her waist with a blanket. R88 was asleep and snoring. Surveyor observed R88's call light on the floor near the right side of the head of the bed, not within reach of R88. On 5/10/22 at 8:06 AM Surveyor observed R88 lying in bed on her back, with the head of the bed slightly elevated. Surveyor observed R88's call light on the floor, wrapped around the bed frame on the right side near the head of the bed, not within reach of R88. On 5/10/22 at 9:36 AM Surveyor observed R88 lying in bed, asleep, with the head of the bed elevated. R88's breakfast tray was on the table in front of her. Surveyor observed R88's call light was on the floor, wrapped around the bed frame on the right side near the head of the bed, not within reach of R88. On 5/10/22 at 11:15 AM Surveyor observed R88 lying in bed asleep. R88 woke when Surveyor entered room. Surveyor observed R88's call light remained on the floor, wrapped around the bed frame on the right side near the head of the bed, not within reach of R88. On 5/10/22 at 2:10 PM Surveyor observed R88 lying in bed asleep. R88's call light remained on the floor, wrapped around the bed frame on the right side of the bed, not within reach of R88. Surveyor noted R88's bed to be in a high position, at least 3 feet from the floor. No staff was in R88's room. On 5/10/22 at 3:28 PM Surveyor observed R88's call light remained on the floor wrapped around the right side of the bed frame on the right side of the bed, not within reach of R88. R88's bed remained in the high position at least 3 feet from the floor and no staff were in the room. On 5/11/22 at 11:04 AM Surveyor observed R88 lying in bed, which was now in the lowest position, with the call light attached to the left side of the bed within reach of R88. On 5/12/22 at 3:00 PM during the daily exit conference, Surveyor advised NHA-A that R88's Fall care planned P interventions included a working and reachable call light and bed in lowest position. Surveyor advised NHA-A of observations R88's call light not within reach and R88's bed in the high position without staff present in the room. No additional information was provided.

Based on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 1 (R70) residents reviewed. The facility was not monitoring NP-C's notes requesting lab orders starting on 1/13/22. Lab collections were not obtained timely with no follow through on results. The results of labs were not available in R70 medical record so that NP-C could monitor the results. NP-C ordered the labs because R70 was more confused, falling and declining. On 3/6/22, R70 was documented as having a fall. On 3/14/22, R70 had another fall, hitting her head and was sent to the emergency and hospitalized for an altered mental status and severe [CONDITION(S)]. This is evidenced by: The facility Policy titled: Lab (Laboratory) and Diagnostic Test Results - Clinical Protocol, revised October 2010 documents (in part) . 1. The physician will identify, and order diagnostic and lab testing based on diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. 3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. The facility policy titled: Physician/Licensed Prescriber Orders Queued in EMR (Electronic Medical Record), dated 1/2022 documents (in part) .Policy Statement Physician/Licensed orders shall be given by on a person duly licensed and authorized to prescribe such orders in this state. Policy Interpretation and Implementation . 2. All drug, diagnostic and biological orders shall be noted by a person lawfully authorized to give such an order. These orders will be inputted into the electronic medical record (EMR) by the licensed prescriber and queued. These queued orders will serve as a notification to the assigned licensed nurse to confirm in the EMR, which will place the order in an active status. 3. The Director of Nursing (DON) or designee will monitor and confirm any queued orders at the end of the scheduled shift. 4. The Administrator will check to confirm no outstanding queued orders to ensure timely activation of all Licensed Prescriber's orders. R70 admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R70's Brief Interview for Mental Status (BIMS) score dated 1/14/22 documents a score of 14 - indicating R70 was cognitively intact for daily decision making. R70's Quarterly Minimum Data Set assessment with an Assessment Reference Date of 3/2/22 documented a BIMS score of 13 - indicating R70 was cognitively intact for daily decision making. R70's readmission Minimum Data Set assessment BIMS score dated 3/25/22, documented a score of 7 indicating severe cognitive impairment for daily decision making. Surveyor reviewed the Nurse Practitioner (NP-C)'s progress notes related to R70, which documented: On 1/13/22, Labs as ordered: CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), TSH ([CONDITION(S)] Stimulating Hormone), Hemoglobin (Hg) A1C, lipid panel. The NP-C completed a laboratory order request for these labs including a CPK ([MEDICATION(S)] phosphokinase) dated 1/14/22. On 1/17/22, the NP-C documented: Labs ordered previous visit Not completed. On 1/18/22, (Medical Doctor note) documented: Labs as ordered - CBC, electrolytes, renal functions, Liver functions. Surveyor noted none of the above ordered lab results were in R70's medical record. On 1/21/22, NP-C documented: Lab request for CBC, CMP, TSH, Lipid profile, HgA1C. Surveyor noted lab test results dated 1/21/22, were not located in R70's medical record. Nursing Home Administrator (NHA)-A was able to provide this Surveyor with a copy of the lab results after the completion of survey. The lab results documented: CBC, Lipid panel, TSH, CBC, HgA1C as Cancelled. No specimen received. Surveyor was unable to find evidence NP-C was informed the ordered lab tests were cancelled due to no specimen being received. On 1/24/22, NP-C documented, Labs ordered but not resulted please obtain results and placed in chart. On 2/2/22, NP-C documented, Labs ordered but not completed. Labs ordered but not resulted please obtain results and placed in chart. On 2/4/22, NP-C documented, Labs ordered but not completed. Labs ordered but not resulted please obtain results and placed in chart. On 2/7/22, Surveyor noted the lab test results for the CBC, CMP, TSH, Lipid, Hga1C was collected. As of 5/16/22, the day of facility exit, these lab results were not in R70's medical record and was not available to staff includeing NP-C, or DON-B. (On 5/17/22, Surveyor was provided with the lab results that collected on 2/7/22 after the facility's exit on 5/16/22. There was no indication on these lab results that NP-C or the MD were ever notified of these lab results.) In the meantime, NP-C continued to order the labs which NP-C had not received. On 2/10/22, NP-C documented, Will get labs as ordered previously, monitor renal functions while on [MEDICATION(S)]. On 2/15/22, NP-C documented: Labs were ordered previously and drawn but not resulted - not available on PCC (Point Click Care). Bilateral 3 to 4+ pitting [CONDITION(S)], blistering, no calf tenderness. Start [MEDICATION(S)] 40 mg (milligrams) daily. Tubigrips lower extremities. Will get labs as ordered previously, monitor renal functions while on [MEDICATION(S)]. On 2/21/22, NP-C documented, Labs were ordered previously (initially ordered 1/13/22) and drawn but not resulted - not available on PCC. Bilateral 3 to 4+ pitting [CONDITION(S)], blistering, no calf tenderness. Continue [MEDICATION(S)] 40 mg in AM, and 1400 dose daily. Will get labs as ordered previously, monitor renal functions while on [MEDICATION(S)]. Surveyor noted these labs were again on collected on 2/21/22. During the survey with an exit of 5/16/22, the results of the labs (CBC, CMP, TSH) were not available in R70's medical record not available to staff. The R70's medical record continues to indicate no lab results, for the CBC, CMP, and TSH. On 2/23/22, R70's lab results document: Potassium this morning 3.2. Not currently supplemented. Labs were ordered previously and drawn but not resulted - not available on PCC. Bilateral 3+ pitting [CONDITION(S)], blistering, no calf tenderness. Potassium supplement today with 20 mEq (milliequivalents). Repeat BMP in 1 week. Will get labs as ordered previously, monitor renal functions while on [MEDICATION(S)]. On 2/24/22, NP-C documented, Bilateral 3+ pitting [CONDITION(S)], blistering, no calf tenderness. Repeat BMP not completed. Surveyor noted lab test results dated as collected on 2/25/22 for urine culture and sensitivity. Orders received on 2/28/22 indicated R70 received a 5-day course of [MEDICATION(S)] 100 mg (milligrams) twice daily for [CONDITION(S)] (urinary tract infection). On 2/28/22, NP-C documented, Bilateral 3+ pitting [CONDITION(S)], right ankle blistering, no calf tenderness. DC (discontinue) [MEDICATION(S)] patch, removed by myself. Start scheduled [MEDICATION(S)] every 4 hours while awake. Will get labs as ordered previously (CBC, CMP, TSH, HGa1, lipid), monitor renal functions while on [MEDICATION(S)]. Surveyor noted the only lab result in R70's medical record was a urine culture and sensitivity which was collected on 2/25/22. Orders received on 2/28/22, indicated R70 received a 5-day course of [MEDICATION(S)] 100 mg (milligrams) twice daily for [CONDITION(S)] (urinary tract infection). Surveyor noted no further lab results were in R70's medical record prior to hospitalization on [DATE]. R70's record continues to reflect; On 3/1/2022, at 11:12 PM, facility progress notes document: Resident was not herself. She was found multiple times hunched over on the side of the bed falling asleep and out of it. She was able to be re-alerted when her name was called. Resident was oriented but confused. She forgot that her dinner tray came and she did not eat. Her BS (blood sugar) was 90 and her insulin was held for dinner. HS (hour of sleep) her BS (Blood Sugar) was 92, her long-term insulin was held because resident did not want her meal and refused HS snack. Residents vital signs were within normal limits. This behavior has been observed for a couple of days. The NP-C was notified and ordered medication changes, but there has not been a change in this behavior at this time. Resident has +2 pitting [CONDITION(S)] to BL (bilateral) lower extremities. Supervisor was notified to remind day shift to place tubi-grip in the mornings. Resident did take all medications as ordered without any issues. Subsequent NP-C progress notes documented: On 3/2/22, NP-C documented, Bilateral 3+ pitting [CONDITION(S)], right ankle blistering, no calf tenderness. Labs were ordered previously and drawn but not resulted - not available on PCC. Check CBC and CMP Monday. On 3/7/22, NP-C documented, Bilateral 2+ [CONDITION(S)], resolving right ankle blistering, no calf tenderness. Check CBC, CMP Monday not done (in bold). On 3/11/22, NP-C documented, Resolved [CONDITION(S)], resolved right ankle blistering, no calf tenderness. DC [MEDICATION(S)], decrease [MEDICATION(S)] to once a day. Check CBC, BMP Monday not done (in bold). Surveyor noted none of the above ordered lab results (which were orginally ordered on 1/13/22) were in R70's medical record. On 3/6/22, R70 was documented to have had a fall. The fall investigation documented the resident reported she slid down from the bed. No injuries were documented, and the NP-C was notified. On 3/14/22, R70 was documented to have sustained a fall. The fall investigation documented: Resident calling out for help stating, I'm on the floor, get me off the floor. Nursing staff in to assist, resident found laying on back on floor between wall and nightstand under window. Resident continent at time of incident, denies need to use bathroom, barefoot. When asked what happened, resident states on the floor, over here, over there nonsensical answers to questions which is not resident's baseline. Assessed for injury, none noted. Resident unsure if she hit her head. Pupils equal and reactive. Sent to ED (emergency department) for evaluation due to uncertainty of head injury and AMS (altered mental status). R70 readmitted to the facility on [DATE]. The Hospital Discharge Summary documented: Primary Discharge Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/16/22, at 11:41 AM, Surveyor spoke with NP-C. Surveyor advised NP-C of review of R70's medical record revealed only the one urinalysis lab result. Surveyor asked NP-C if she had difficulty obtaining labs for R70. NP-C stated: Yes, I did have problems with her labs getting done. I was able to get only a few sent from the lab. The facility has PCC and I was told there would be no more paper orders, that I needed to put orders directly into PCC. NP-C stated: It (orders) would flag red pending confirmation and then staff would need to go in and confirm/sign them off, but that was not getting done, I'd come in and my orders would not be done. NP-C stated: I don't know if staff didn't know what to do or what, but now after I put my orders in, I have to send a list of the resident's names to the DON (Director of Nursing) so she can go in and sign them off. I don't understand why they just don't tell the nurses it's their job, and do it themselves - but now the DON does it all. Surveyor asked NP-C if she was aware of R70's cognition changes and falls prior to hospitalization on [DATE] and read the hospital discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . That's why I was ordering labs because she was more confused, falling and declining. On 5/16/22, at 10:22 AM, Surveyor advised NHA-A of concern that R70 did not have labs consistently completed as ordered since admission and most recently during the weeks prior to hospitalization on [DATE], following a fall with AMS. Surveyor advised NHA-A of R70's hospital discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . NHA-A reported I'm going to check right now to see if there were any more labs. No additional information provided at that time. NHA-A subsequently provided Surveyor additional lab results after the completion of survey. On 5/17/22, at 1:00 PM, (after survey completion) NHA-A called Surveyor to say she called the lab and has some lab results for Surveyor to review. Surveyor advised NHA-A that Surveyor would review the lab results the facility obtained. Surveyor reminded NHA-A of the concern labs were ordered on 3/2/22 but were not completed prior to R70's fall with AMS. This fall resulted in hospitalization of R70 and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . NHA-A stated, I understand. On 5/17/22, at 3:00 PM, (after survey completion) NHA-A advised Surveyor she looked in the computer and there was no order for a CBP, and CMP put in on 3/2/22. NHA-A reported the NP-C and doctors have to put their own orders in and I went in and looked and there was no order put in on 3/2/22, so we didn't know about the lab order. Surveyor advised NHA-A the NP-C progress notes on 3/2/22 documented the lab order and subsequent NP-C notes on 3/7/22 and 3/11/22 document (in bold) CBC/CMP not done. Surveyor asked NHA-A if anyone at the facility reviews the NP-C notes. NHA-A stated: I don't know, but I went into the computer, and she (NP-C) did not put an order in. Surveyor advised NHA-A the NP-C notes document patient and staff aware and understand. NHA-A stated: I see that she wrote that, but I'm saying she did not put an order in. Surveyor asked again if anyone at the facility reads or reviews NP-C or physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP and MD automatically scan them (progress notes) in (PCC) from their office, we don't even scan them in. On 5/17/22, at 4:55 PM, Surveyor advised NHA-A of concern the facility has no system in place to communicate with the NP or Physician prior to them leaving the facility regarding changes to the plan of care for the residents. Surveyor explained, NPs and Physicians are required to write progress notes, but there is no evidence the facility reviews the progress notes or communicates with the NP to ensure the plan of care and orders are followed. Surveyor advised NHA-A R70 experienced a change in cognition on 3/1/22 and NP-C's progress note on 3/2/22 indicated labs were to be ordered. Subsequent NP progress notes on 3/7/22 and 3/11/22 documented labs were not done (in bold letters). NHA-A stated: That's why I have to have a conversation with (NP-C-C) tomorrow. No additional information was provided.

Based on interview, observation and record review, the facility did not ensure 1 (R1) of 3 residents reviewed for wound care received quality of care with all treatments provided to facility residents. The facility did not ensure R1 received treatment and care in accordance with professional standards of practice. R1 was admitted to the facility with multiple surgical wounds. - The treatment ordered by the hospital was not put in place on admission to the facility on [DATE]. - R1's left groin surgical wound was not assessed on admission. - There was no care plan for the left groin incision. - The wound was found by a staff nurse to have drainage and excess moisture on 2/2/22. An InterDry order was put in place but was not appropriate for the wound. Facility stated they used a different fabric barrier and not InterDry but the MD was not updated and there was still no treatment in place. - When R1 went to the Vascular MD on 2/8/22 for a follow up visit, the left groin wound was found to be dehisced (a gap, cut, splitting or bursting open of a wound) and necrotic. - During survey, the wound was observed to be open with length, width and depth but there were no weekly assessments of the wound completed. Findings included: Surveyor reviewed the facility's Wound Care policy with a revision date of 12/21. Documented was: Purpose The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1. Verify there is a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Documentation The following information should be recorded in the resident's medical record: 4. Any changes in the resident's condition. 5. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound on a weekly basis . R1 was admitted to the facility 2/1/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R1's Hospital Discharge Summary with a discharge date of [DATE]. Documented under Discharge Milestones were instructions for left groin staples wound care: .[Chlorhexidine [MEDICATION(S)] (CHG)] and dry gauze to left groin incision at all times. Shower daily . Surveyor reviewed the MD orders and Treatment Administration Record (TAR) for R1 for February 2022. The Left groin incision treatment was not on the MD orders or TAR for R1 noting completion of daily wound care was not done. Surveyor reviewed bathing charting for R1 for February 2022. There was one shower given between 2/1/22 and 2/8/22 and no documentation noting daily showers completed as per the Hospital discharge instructions. Surveyor reviewed R1's Admit/Readmit Screen assessment with a date of 2/1/22. Documented under Section C. Skin Integrity by Director of Nursing (DON)-B were 4 surgical incisions, right arm bruising and a non-removable dressing on right ankle. There is no documentation of R1's left groin incision. Surveyor reviewed R1's Progress Notes. Documented on 2/1/22 at 10:30 PM by DON-B was during skin assessment: right arm has staples in place from top inner arm unable to count staples due to cast from right hand to right axilla which surgical incision continues in cast. Right hip has dressing which was not removed. Left upper arm had 11 sutures in place with no s/s infection, no drainage. [Abdomen (Abd)] has g-tube left upper quad patent with bolus tube feedings, abd. also has surgical incision which has 24 staples in place and steri strips between each staple. No [signs or symptoms (s/s)] infection no drainage. and bruise inner left ankle . There is no documentation of R1's left groin incision. Surveyor reviewed R1's Comprehensive Care Plan with an initiation date of 2/2/22. Documented was: Focus: Actual Alteration in skin integrity [related to (r/t)] admitted with surgical sites: skin graft site [right forearm], [right (R)] thigh, surgical incision to [left (L)] abdomen. 02/28/22 Returned from outside appt with skin tear to R hand (resolved). Goals: - There will be no complications r/t skin graft sites through the review date. - Educate resident/family/caregivers of causative factors and measures to prevent skin injury. - Encourage good nutrition and hydration in order to promote healthier skin. - Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] - Keep skin clean and dry. Use lotion on dry skin. Do not apply at site of injury. - Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. There was no care plan related to the left groin incision. Surveyor reviewed Nurse Practitioner (NP)-I's visit note from 2/2/22. Documented was .left groin incision well approximated . Surveyor interviewed NP-I on 3/23/22. Surveyor asked if she assessed the left groin incision on admission or during the 2/2/22 visit. NP-I stated no, she got the information from the floor nurses or wound care nurse. On 3/22/22 at 3:00 PM Surveyor interviewed RN-C responsible for wound care. Surveyor asked who monitors and assesses non-pressure wounds. RN-C stated she only does pressure injuries. Surgical wound treatments are done on second shift. Surveyor reviewed R1's Progress Notes. Documented on 2/2/22 at 10:38 PM by Registered Nurse (RN)-E was Monitoring [follow up (F/U)] new admission. Vitals stable. Incisions . to midline abdomen, staples and steri strips intact. Staples to left groin area are intact but moist surgical draining moderate serous colored fluid. An abdomen pad was placed in this area to absorb moisture. Graft site to right thigh has xeroform in and should not be removed. No s/s of infection to surgical areas . On 3/23/22 at 10:39 AM Surveyor interviewed RN-E. Surveyor asked about the left groin wound and what she observed on 2/2/22. RN-E stated the incision had yellow fluid around it and she was not sure if it was from the wound or urine. Surveyor asked if she reported it to anyone. RN-E stated she was not sure. Surveyor asked if the MD was notified. RN-E stated no because she was not sure that it was wound drainage. On 3/23/22 at 1:40 PM Surveyor interviewed RN-C. RN-C stated RN-E reported the moisture to her. Surveyor asked if she saw the incision. RN-E stated yes on 2/4/22, the incision was dehisced and open with clear drainage. RN-C stated she put in an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-C stated no, InterDry was a nursing order and was not a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Surveyor reviewed MD Orders for R1. Documented with a start date of 2/4/22 was InterDry to abdominal folds change daily and [as needed (PRN)] for soilage one time a day for protection AND as needed for soilage. Surveyor reviewed product information for InterDry. Documented was InterDry® Moisture Wicking Fabric with Antimicrobial Silver . Common areas where InterDry can be used: skin-to-skin: Manages skin damage in skin folds and/or skin-to-skin contact areas where [CONDITION(S)] is present or anticipated. Skin-to-device: Manages skin damage between any skin-to-device application where the skin is still intact. Should not be used on open wounds . On 3/23/22 at 1:44 PM and 2:20PM Surveyor interviewed RN-C. Surveyor asked if InterDry needed an MD order since it was medicated with silver in it. RN-C stated yes, but that was not the product they were using. At 3:00PM Surveyor was provided with a UltraSorbs Dry Sheet product sheet and RN-C stated that was their version of InterDry that did not have silver in it. Surveyor asked if that was an appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor asked if any treatment was put in place on 2/4/22. RN-C stated no. Surveyor reviewed the MD visit note from the Vascular Center dated 2/8/22. Documented was L groin incision noted to have skin necrosis and partial dehiscence due to excessive moisture . Surveyor reviewed Weekly Skin Evaluation assessments for R1. Documented on 2/18/22 was Surgical incisions abdomen and R arm. Documented on 2/25/22 was No new skin issues noted. Documented on 3/18/22 was Surgical incisions Left abdomen and R arm. R elbow wound. There were no other weekly skin assessments from 2/1/22 through survey on 3/23/22. There were no assessments of the left groin. On 3/23/22 at 12:35 PM Surveyor interviewed DON-B. Surveyor asked what was assessed for R1's admission skin assessment. DON-B stated she assessed R1's surgical sites which would include counting staples or sutures and assessing for signs and symptoms of infection. Surveyor asked why the left groin incision was not assessed. DON-B stated she must not have put it in the assessment. DON-B stated it should have been in the assessment and that was her mistake. Surveyor asked who would have put the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor asked why the left groin treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . DON-B was unsure but stated the orders should have been entered to include the Chlorhexidine [MEDICATION(S)] treatment and daily showers. DON-B stated the Chlorhexidine [MEDICATION(S)] treatment would not have been completed. DON-B stated about a month ago they instituted a new policy for 2 nurses to check the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON-B stated she needs to change the process again and she will be in charge of reviewing discharge summaries and double checking the orders are correct. Surveyor asked who assesses surgical wounds on a weekly basis. DON-B stated no one does, the nurses on second shift who perform the treatments update the MD if there are any changes. Surveyor asked what if a wound changes, such as dehisces or has drainage. DON-B stated she would expect to be informed, the MD informed or the staff to inform RN-C who does the pressure injury wound assessments. Surveyor asked if the surgical wound changes would it be assessed weekly. DON-B stated yes, it should be assessed if the wound opened. Surveyor asked if she ever saw the left groin wound. DON-B stated no. Surveyor noted on 3/23/22 at 8:15 AM Surveyor observed R1's left groin wound and it was approximately 7cm x 3cm x 1cm with a red wound base. DON-B stated someone should be assessing that but was unsure how often.

Based on interview and record review the facility did not ensure that 2 (R1 & R6) of 9 Residents reviewed received treatment and care in accordance with professional standards of practice. On [DATE] R1 experienced a change of condition as she was not yelling out per her norm, CNA (certified nursing assistant) -N elevated the head of the bed and left R1's breakfast tray in front of her as R1 could feed herself after set up. R1 did not eat any of her breakfast and R1 did not respond when CNA-N attempted to feed her breakfast. R1 did not respond when CNA-N provided personal cares and R1 did not assist with turning herself as she normally did during cares. CNA-N thought R1 was sleeping during her interactions with R1 and did not alert the nurse to the fact R1's behaviors had significantly changed. CNA-N had several opportunities in the morning to alert the nurse to the fact that R1's behavior had significantly changed. This did not occur. As a result, vital signs were not obtained and no information was gathered for R1 and the only Registered Nurse who was assigned to the Subacute unit was not summoned. When vital signs were obtained, R1 had an elevated respiratory rate, a below normal pulse oxygen level and her blood pressure reading was unobtainable. The failure to report a change of condition so that prompt assessment and intervention might occur created a finding of Immediate Jeopardy (IJ) that began on [DATE]. Administrator-A and DON (Director of Nursing-B were notified of the Immediate Jeopardy on [DATE] at 2:25 p.m. The Immediate Jeopardy was removed on [DATE]; however the deficient practice continues at a scope/severity level of G (harm/isolated) as the facility continues to implement its action plan and as evidenced by: R6's surgical wound declined on [DATE] as there is now an open area 3 x 0.5 cm on the lateral side and the eschar increased from 4 x 1.3 cm to 6 x 4.5 cm. The Facility called to move up R6's surgeon appointment but there is no evidence R6's primary physician was notified, the area was not assessed and the treatment was not changed until [DATE]. The April treatment administration record reveals R6's right foot surgical wound treatment was not completed on ,d+[DATE], ,d+[DATE] & [DATE]. On [DATE], R6's treatment change was not implemented and the antibiotic was not started for 3 days. RN Wound Nurse-W's [DATE] assessment does not include tunneling. Findings include: On [DATE] at 3:19 p.m. Surveyor asked DON (Director of Nursing)-B what a CNA should do if she notices a change in a Resident they are taking care of. DON-B informed Surveyor she would hope they would tell the nurse. DON-B also informed Surveyor there is a stop and watch form which is in PCC (point click care), the Facility's electronic medical record, and also on paper. On [DATE] at 7:33 a.m. DON-B informed Surveyor the stop and watch is only completed on paper. On [DATE] at 8:15 a.m. Surveyor was provided with a Stop and Watch Early Warning Tool. Administrator-A informed Surveyor they do not have a policy for the Stop & Watch and staff has been educated. Surveyor noted the Stop and Watch Early Warning Tool documents, If you have identified a change while caring for or observing a resident, please circle the change and notify a nurse. Either give the nurse a copy of this tool or review it with him/her as soon as you can. S Seems different than usual T Talks or communicates less O Overall needs more help P Pain - new or worsening; Participated less in activities a Ate less n No bowel movement in 3 days; or diarrhea d Drank less W Weight change A Agitated or nervous more than usual T Tired, weak, confused, or drowsy C Change in skin color or condition H Help with walking, transferring, toileting more than usual Surveyor reviewed R1's closed medical record. R1 was admitted to the Facility's rehab unit on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] & hemiparses following cerebral infarction, major depressive disorder, hypertension, opioid abuse in remission, heart failure, [CONDITION(S)] (chronic obstructive pulmonary disease), cerebral palsy, and anxiety disorder. R1's Power of Attorney for Health Care (POAHC) placed two calls to the facility to speak to R1 on [DATE] and was informed R1 was sleeping. Shortly after the second phone call R1's POAHC received a telephone call from the Facility informing her R1 was nonresponsive, cold & clammy but still breathing and was being sent out 911 to the hospital. RECORD REVIEW The admission MDS (Minimum Data Set) with an assessment reference date of [DATE] has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R1 requires extensive assistance with one person physical assist for bed mobility, transfer, & toilet use, ambulates in room with supervision and one person physical assist, eats with supervision and set up help only and is occasionally incontinent of urine and bowel. The nurses note dated [DATE] documents Resident resting comfortably at this x (time) prn (as needed) pain med (medication) effective to Rt (right) rib area. Bruising unchanged at this x. Alert and oriented, able to make needs know, lungs clear no s/s (sign symptom) of respiratory distress, HOB (head of bed) elevated. Beginning [DATE], R1's record indicates she frequently began yelling out. The nurses note dated [DATE] documents alert and oriented x 3, voiced c/o (complained of ) pain tp (to) rgt (right) side, pain rated ,d+[DATE], prn given and effective, was yelling out for staff multiple times throughout the shift, redirection attempted. Call light within reach, bed in lowest position, compliant with medications and treatments for pm (evening) shift, skin warm and dry, incontinent of bladder per staff, wears briefs, appetite good able to feed self in room, no sob (shortness of breath) or resp (respiratory) distress noted abd (abdomen) soft and nontender. The nurses note dated [DATE] documents .resident is yelling out for pain, PRN given and effective. Up to the bathroom with assist. Appetite is fair. The nurses note dated [DATE] documents . Resident was yelling out this morning decreased yelling out noted after scheduled medication given this morning .No s/s (signs/symptoms) noted after scheduled pain ed was given. The nurses note dated [DATE] documents Resident is calling out and yelling non-stop stating, I need to go to hospital for a stroke. She states, I'm having a stroke right now and my father died from a stroke, I have history stroke too. T (temperature) 97.7 75 18 ,d+[DATE] POX (pulse ox) 95% RA (room air). No facial drooping, no arm weakness noted. Writer ask how do she know its a stroke, she is complaining of a headache. She is requesting to go to hospital now. [APNP-H ] made aware and case worker left message. The hospital after visit summary printed at [DATE] 11:48 a.m. under diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Under medications given documents [MEDICATION(S)] (Haldol) last given at 10:30 a.m. The nurses note dated [DATE] documents 1745 (5:45 p.m.) resident is observed sitting on the floor in her bathroom with her back against the wall, no apparent injury noted, ROM WNL per resident. Resident did not put her call light on, resident is yelling out help, Resident is dry, assisted to toilet. The Facility implemented neuro checks following R1's fall. Instructions on the bottom of the LTC (long term care) neuro assessment sheet indicates neuro checks should be completed every 15 minutes times 4, 30 minutes times 4, 1 hour times 4, 4 hours times 4, 8 hours times 6. Surveyor noted neuro checks were not completed during the night shift & evening shift on [DATE] and night shift and day shift on [DATE]. The nurses note dated [DATE] documents Patient consistently yells out as well as self transfer. Follow up for a fall and patient denies any injury or pain. Cranial check is negative, ROM WNL, VS (vital signs) stable. Patient appears to have lots of anxiety throughout the shift . The APNP (Advance Practice Nurse Prescriber) note dated [DATE] under history of present illness documents Patient receiving [MEDICATION(S)] 1 mg (milligram) 3 times daily p.r.n. (as needed) for anxiety in behaviors, tolerating well. Staff reports no episodes of increased anxiety and yelling today. Patient is currently sleepy. Easily arousable. States she feels fine and has no pain. Patient has been moved from the subacute rehab area to the 1st floor to monitor closer. The nurses note dated [DATE] documents Resident witnessed by staff attempting to self transfer, crawl out of bed. Resident with low bed, and bed at lowest position with matt on each side of bed. The nurses note dated [DATE] documents Resident is being monitored for room transfer and post ER (emergency room )/fall. Resident is very agitated and restlessness already, complaining of pain, scheduled pain meds is given, redirected, provided distraction . The APNP (Advance Practice Nurse Prescriber) dated [DATE] under history of present illness documents .At this time her behaviors have been extremely disruptive, she has had to be moved in to a room closer to the nurses station on a different floor where she can be monitored closer. Medically she is intact, stable. Patient refuses to have discussion regarding the events of throwing herself on the floor and yelling at staff this morning. The nurses note dated [DATE] documents, Pt (patient) was dozing most of the morning. Pt has no noted respiratory distress, respirations were even and non labored. Pt took AM (morning) meds late morning. When doing noon meds went into see pt, noted this pt to be unresponsive to verbal/tactile stimuli and noted short rapid breaths. Pt was cool clammy accu check was taken 125, POX 95. Pt bed was in elevated position. O2 (oxygen) placed [APNP-H] was phoned and given report NOR (new order received) to send to .ER due to unresponsiveness. Phone 911, phoned .ER and gave report, phoned daughter [POA (power of attorney)-U] and left message for case manager RN (Registered Nurse)-[V]. Updated ADON (Assistant Director of Nursing) and DON (Director of Nursing). The nurses note dated [DATE] documents admitted to .Hospital for AMS (altered mental status), RF (renal failure), Dehydration and elevated troponin levels. INTERVIEWS On [DATE] at 1:56 p.m. Surveyor asked CNA (Certified Nursing Assistant)-N if she remembered R1. CNA-N informed Surveyor she did. Surveyor informed CNA-N Surveyor noted on the [DATE] schedule she (CNA-N) was working on the first floor and asked if she was assigned to R1. CNA-N replied yes. Surveyor inquired if she received any report from the night CNA. CNA-N replied no and explained the night nurse said she was restless. Surveyor asked CNA-N to explain what she did for R1 on [DATE], the day R1 went to the hospital. CNA-N informed Surveyor when she first came in she does rounds, looked inside the room and saw R1 was sleeping and breathing. CNA-N indicated she started to do cares on other Residents. CNA-N informed Surveyor the first time she went into R1's room was for breakfast. CNA-N informed Surveyor R1 could feed herself so she put the head of the bed up and left the tray for her. Surveyor asked CNA-N when she raised the head of the bed did R1 react. CNA-N replied no and explained it was just like R1 was sleeping. CNA-N informed Surveyor she came back to pick up the tray, R1 was sitting up, her eyes were closed and she was sleeping. CNA-N informed Surveyor she called R1's name and tried to offer R1 her food on a spoon. Surveyor asked if R1 responded when she put the spoon to R1's lips. CNA-N replied no, explained she put the lid on the breakfast and figured she was trying to sleep or whatever. Surveyor asked prior to [DATE] if R1 didn't want to eat would she tell you. CNA-N replied yes and explained R1 would say 'I don't want to eat.' CNA-N explained that day ([DATE]) R1 would not say anything, R1 was just different. Surveyor asked CNA-N after R1 didn't respond or eat any of her breakfast did she report this to the nurse. CNA-N replied no and explained she thought R1 was sleeping. CNA-N explained to Surveyor the next time she went into R1's room was around 9:00 or 9:30 a.m. when she went into to wash R1 up. CNA-N informed Surveyor when she went to wash R1 she was basically laying there, no gestures or anything, just laying there. Surveyor asked CNA-N when she turned R1 did she respond. CNA-N replied no. Surveyor asked if R1 could help turn herself and could R1 help take her gown off. CNA-N informed Surveyor R1 could help turn herself and could take off her gown off and even her depends. Surveyor asked CNA-N when she washed R1 up did R1 respond. CNA-N informed Surveyor R1 usually makes noise. R1 would communicate with you but she wasn't doing this that day. CNA-N informed Surveyor R1 was just like so sleepy couldn't get her to wake up, when she turned her there was no resistance like she was sleeping. CNA-N informed Surveyor usually when you touch someone when they are sleeping they would jump or something. CNA-N stated there was nothing. CNA-N informed Surveyor the room was hot, R1 was sweating so she turned off the heater. Surveyor inquired if she had taken care of R1 prior. CNA-N informed Surveyor she thinks she had her on [DATE]. Surveyor asked on ,d+[DATE] the day before R1 went to the hospital how was R1. CNA-N informed Surveyor R1 was like her normal self talking, yelling out but the day she went to the hospital she wasn't doing anything. CNA-N informed Surveyor when R1 yelled out you could hear her down the hallway. CNA-N informed Surveyor the day R1 went to the hospital it was like she was sleeping. Surveyor asked CNA-N after she washed R1 up and she wasn't responding did she report anything to the nurse. CNA-N replied no and explained she thought R1 was sleeping and didn't think anything different until lunch time when R1 was all crooked. Surveyor asked CNA-N to explained what she meant. CNA-N informed Surveyor R1 had slid down and was laying at an angle. Surveyor asked what time she came into R1's room. CNA-N informed Surveyor between 12:00 & 12:30 pm and explained she had to pass other trays and went into R1's after the 2nd feeder. CNA-N informed Surveyor there was a nurse in the room and the nurse asked CNA-N if R1 was usually like this as the nurse didn't know R1. CNA-N informed Surveyor R1 wasn't responding to her name, she kept shaking her until she finally got her to open her eyes. CNA-N informed Surveyor this was the first time R1 opened her eyes this day but her eyes were rolled up. CNA-N informed Surveyor this is when the nurse left R1's room and called 911. Surveyor asked who came into R1's room. CNA-N informed Surveyor a nurse with a crash cart, checked her pulse ox and placed oxygen on R1. CNA-N informed Surveyor she left R1's room after the nurse came in, checked her pulse ox and placed oxygen on her. On [DATE] at 2:33 p.m. Surveyor spoke to LPN (Licensed Practical Nurse)-O, who worked multiple days in the subacute unit, regarding R1. LPN-O informed Surveyor R1 would call out and her neighbors next door felt it was too much. LPN-O explained it was normal for R1 to yell out. On [DATE] at 3:24 p.m. Surveyor asked LPN-K if she was the nurse assigned to R1 on [DATE] when R1 went out to the hospital. LPN-K informed Surveyor the other nurse was taking care of R1. Surveyor inquired if she was involved with R1 on the day she went to the hospital. LPN-K explained she was coming back from break when the other nurse told her to get the crash cart and go to R1's room. LPN-K indicated the other nurse was going to look at the paper work for code status and call 911. LPN-K informed Surveyor when she got to R1's room with the crash cart there were 2 CNAs in the room. LPN-K informed Surveyor she took R1's vital signs and got a pulse so they didn't need the crash cart. LPN-K informed Surveyor she thinks R1's pulse ox was 78 to 80% and placed 2 liters of oxygen on her. LPN-K informed Surveyor they were unable to get a blood pressure either from the machine or manually, R1 was afebrile and the respirations were 36 and abnormal. LPN-K informed Surveyor the other nurse came in. LPN-K informed Surveyor she stayed in the room to see if the fire department could get a blood pressure which they couldn't get either. Surveyor asked how long did it take for the fire department to come. LPN-K informed Surveyor it was two or three minutes. On [DATE] at 8:57 a.m. Surveyor asked LPN-L if she remembered R1. LPN-L replied yes. LPN-L informed Surveyor she only worked with R1 one shift. LPN-L explained R1 came from another unit and she had been off a few days. Surveyor inquired if she received any report from the night nurse regarding R1. LPN-L informed Surveyor all she can remember is that R1 was a fall risk. LPN-L informed Surveyor on [DATE]st R1 was sleeping and she gave R1 her pills late in the morning. Surveyor asked LPN-L what time she gave R1 her medication. LPN-L informed Surveyor she thinking around 11:00 a.m. LPN-L informed Surveyor R1 was awake but very sleepy. Surveyor asked LPN-L why she gave R1 her morning medication so late. LPN-L informed Surveyor she was told R1 was a fall risk and let her sleep. LPN-L stated I don't know why, I imagine I saved her for last to let her rest. LPN-L indicated she really didn't know R1 too much at all. Surveyor asked LPN-L did she administered R1 her medication whole. LPN-L informed Surveyor she was told to crush them so she crushed them. LPN-L informed Surveyor she put the head of the bed up more than it was and told R1 she had her medication. Surveyor asked if R1 responded. LPN-L informed Surveyor R1 looked at her, doesn't want to say she was saying real words and took her medication. LPN-L informed Surveyor when she went in to give R1 her noon medication R1 was pretty droggy (sic) and sleepy. LPN-L informed Surveyor R1 sounded funny, sounded like she was in distress, not responding, didn't seem like she was well. Surveyor asked LPN-L if she spoke to the CNA. LPN-L replied oh ya, there's something wrong with her. LPN-L informed Surveyor no one reported in the morning R1 was in distress or reported anything to her about R1. LPN-L informed Surveyor she called 911, looked at the chart and called the doctor. Surveyor asked if there was an RN (Registered Nurse) in the building. LPN-L replied no. Surveyor had reviewed the Facility's nursing schedule for [DATE] and noted during the day shift there was a RN working on the subacute unit. On [DATE] at 9:21 a.m. Surveyor asked CNA-M if she cared for R1 on [DATE] the day R1 went to the hospital. CNA-M explained she worked on the far end and thought CNA-N had R1. CNA-M informed Surveyor she thinks CNA-N needed her to help boost R1. CNA-M informed Surveyor they walked into the room, R1's breathing was kind of funny and her eyes were moving side to side. Surveyor asked if a nurse was in the room. CNA-M replied no think they went to get the nurse. CNA-M informed Surveyor she brought an oxygen tank into R1's room and shortly after that the fire department came. Surveyor asked CNA-M if she helped with R1's morning cares that day. CNA-M replied, No, wasn't me. On [DATE] at 10:46 a.m. Surveyor spoke with APNP-H regarding R1. APNP-H informed Surveyor she was not in the building on [DATE] and did not assess R1 as she was not here. Surveyor asked APNP-H if anyone from the Facility contacted her. APNP-H informed Surveyor she was on call on the first, she wasn't texted but they may have called her. On [DATE] at 3:19 p.m. Surveyor asked DON (Director of Nursing)-B if on the weekend an LPN needs an assessment for a Resident what should they do. DON-B informed Surveyor if they need an assessment they will call the subacute unit and the RN will go to the unit and do an assessment and then they call herself or who ever is on call. On [DATE] at 7:33 a.m. DON-B informed Surveyor she followed up with the nurse and there was not a stop and watch done for R1 and when the nurse went in to do the noon medication this is when she found R1 unresponsive and sent her out. Surveyor informed DON-B of the concerns of CNA-N not reporting R1's change of condition to the nurse, R1's meal intake had decreased from eating 76 to 100% to not eating or eating less than 25% and neuro checks not completed following her fall on [DATE]. On [DATE] at 8:19 a.m. Surveyor asked LPN-L when she went in to give R1 her noon meds could she explain to Surveyor how R1 was again. LPN-L informed Surveyor she was kind of droggy. Surveyor asked if R1 talked to her. LPN-L informed Surveyor she was more of sounds. LPN-L informed Surveyor she did not see a care card for R1 or anything for her to look at, and she was new to her. Surveyor asked LPN-L if she was able to give R1 her noon medication. LPN-L replied, No, oh my gosh. Surveyor asked why were the noon meds checked as being administered. LPN-L replied, To be honest with you I was having trouble with the computer and explained she was trying to learn the computer and could not say why it was clicked. Surveyor asked about R1's pain level of zero on the morning of [DATE] and asked if R1 verbalized a zero. LPN-L replied no and explained she was resting so she entered a zero. According to First Aide for Unconsciousness, Unconsciousness is the state in which a person is unable to respond to stimuli and appears to be asleep. They may be unconscious for a few seconds - as in [CONDITION(S)] - or for longer periods of time. People who become unconscious don't respond to loud sounds or shaking. They may even stop breathing or their pulse may become faint. This calls for immediate emergency attention. The sooner the person receives emergency first aid, the better their outlook will be . Unconsciousness can be brought on by a major illness or injury, or complications from drug use or alcohol misuse .Common causes of unconsciousness include .severe blood loss, a blow to the chest or head, [the resident had had a fall three days earlier and was supposed to be on neuro checks], a drug overdose .low blood sugar, low blood pressure, [CONDITION(S)], or the loss of consciousness due to lack of blood flow to the brain, neurologic [CONDITION(S)], or the loss of consciousness caused by a [CONDITION(S)], stroke, or [CONDITION(S)] (TIA), dehydration, problems with the heart's rhythm, straining, hyperventilating .Potential complications of being unconscious for a long period of time include coma and brain damage .The outlook will depend on what caused the person to lose consciousness. However, the sooner they receive emergency treatment, the better their outlook will be. https://www.healthline.com/health/unconsciousness-first-aid#complications The facility's failure to recognize and report a change in condition prevented early assessment and delayed medical intervention for a potentially emergent situation. This created a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when the facility implemented the following; ~All clinical staff were educated on recognizing acute condition changes - clinical protocol policy. ~ Licensed Nurses were educated on the charting and documentation policy of a comprehensive assessment. ~Staff educated on Stop and Watch Form and proper CNA communication with nursing staff regarding changes in condition. ~Education to CNAs and agency staff on reporting changes of condition to nurses. ~Re-educate staff on Neurological Checks and Documentation. Following the implementation of their action plan, the deficient practice continues at a scope and severity level of G (harm/isolated) as evidenced by; 2. R6's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] & foot, diabetes mellitus, severe protein calorie malnutrition, [CONDITION(S)], and MRSA (methicillin resistant staphylococcus aureus). The quarterly MDS (Minimum Data Set) with an assessment reference date of [DATE] has a BIMS (brief interview mental status) score of 14 which indicates cognitively intact. R6 requires extensive assistance with one person physical assist for bed mobility, extensive assistance with two plus person physical assist for transfers, and does not ambulate. R6 is checked as having an indwelling catheter and ostomy. Yes is checked for surgical wound. Instructions from Surgeon-FF dated [DATE] documents, Your current Orthopedic problem we are working together to treat is: Transmetatarsal amputation of the right foot. The incision looks excellent. There is some dry eschar on the plant distal aspect but this is quite dry. There is no drainage. There is no purulence. There is no ischemia of the wound. Surveyor noted treatment to this area was Xeroform with dry sterile dressing over then Kerlix daily. The nurse's note dated [DATE] documents, F/U (follow up) oa (open area) coccyx rt. (right) foot dressing-alert responsive. skin warm and dry. dressing dry and intact. remains in isolation for MRSA rt. foot. receives IV abt. (antibiotic) per plan of care. no adverse reaction noted. receives oral [MEDICATION(S)] for pain which is effective. The weekly non pressure wound tracking assessment for R6's right foot dated [DATE] under progress of site one is unchanged. Under comments documents, Surgical incision. 16 sutures intact across incision. No active drainage. Area of eschar below incision on bottom of foot 3.5 x (times) 1.3 (cm). No open No drainage. Prevalon boots in place bilateral. On alternating pressure mattress. The nurses note dated [DATE] documents, Resident is being monitor ABT/IV for MRSA and Osteomyeltitis, [MEDICATION(S)] and Vanco is administered, he is complaining of stomach feeling queasy seen by NP-[H] new order to have Pepto-bismol for upset stomach. No adverse reaction noted. PICC line to right upper chest is intact and patent, no infiltration noted. Complaint of pain post therapy, PRN (as needed) given and effective. Dressing are intact. Boots in place and air mattress intact and function. The weekly non pressure wound tracking assessment for R6's right foot dated [DATE] progress of site one is unchanged. Under comments documents, Surgical incision. 16 sutures intact across incision. No active drainage. Area of eschar below incision on bottom of foot 4 x 1.3 (cm) Not open No drainage. Prevalon boots in place bilateral. On alternating pressure mattress. Seen at wound clinic on [DATE]. The weekly non pressure wound tracking assessment for R6's right foot dated [DATE] progress of site one is unchanged. Under comments documents, Surgical incision. 16 sutures intact cross incision. No active drainage. Area of eschar below incision on bottom of foot 4 x 1.5 (cm) Not open No drainage. Prevalon boots in place bilateral. On alternating pressure mattress. The weekly non pressure wound tracking assessment for R6's right foot dated [DATE] under progress of site one is worsened. Under comments documents, One suture remains on plantar area. Area is open 3 x 0.5 (cm) on lateral side of wound. Eschar on plantar foot 6 x 4.5 (cm) x un (unknown) Sm (small) serous drainage. [Surgeon-FF] called to move appointment up. Prevalon boots in place. Surveyor noted there is no physician notification, assessment or change in treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The weekly non pressure wound tracking assessment for R6's right foot dated [DATE] documents measurements of length 5.5 (cm), width 6.5 (cm), and depth 0.5. (cm) Under progress of site one is worsened. Under comments documents, Seen at wound clinic [DATE]. Measurements per wound clinic. Wound bed moist eschar. Area debrided at wound clinic. Small sero-sang drainage. 2 sutures removed at wound clinic. Prevalon boots in place. Surveyor noted there was a change in treatment from Xeroform with dry sterile dressing over then Kerlix daily to soap water wash, ,d+[DATE] Dakins moistened gauze packing, ABD (abdominal), Kerlix daily. Surveyor noted this treatment change was 6 days after R6's surgical wound decline. The weekly non pressure wound tracking assessment for R6's right foot dated [DATE] documents measurements of length 5.5, Width 7.8, Depth 0.5. Under progress of site one is unchanged. Under comments documents, Wound bed 25% slough 75% eschar. Periwound intact Small sero-san drainage. Prevalon boots in place. No complaints of pain. The nurse's note dated [DATE] documents Resident alert able to make needs known. C/O (complained of) general discomfort PRN pain pill provided. NO SOB (shortness of breath) or distress noted. Resident remains afebrile at this time. Dressing intact to sacrum wound. Resident completed IV and oral ABT for wound infection no adverse reaction noted. Call light within reach. The weekly non pressure wound tracking assessment for R6's right foot dated [DATE] documents measurements of length 5.5 (cm), Width 7.8 (cm), Depth 0.5 (cm). Under progress of site one is unchanged. Under comments documents, Wound bed 25% slough 75% eschar. Periwound intact Small sero-san drainage. Prevalon boots in place. No complaints of pain. Seen at [name of hospital] wound clinic on [DATE]. No new recommendations. APNP (Advanced Practice Nurse Prescriber)-H note dated [DATE] under history present illness documents .Nonhealing partial right foot amputation. Continues to see wound care frequently. Daily dressing changes. As appoint with [Physician-GG], for follow up with vascular surgery due to nonhealing. This is expected as patient has severe PVD ([CONDITION(S)]) below the knee bilaterally. Patient and family have extremely poor understanding of prognosis/denial severity disease. The nurse's note dated [DATE] documents [name of hospital] wound clinic called with new treatment orders for R (right) foot (TMA) (Transmetatarsal amputation). The physician telephone order dated [DATE] documents, Rec (recommendation) [name of hospital] wound clinic DC (discontinue) current treatment (R) (right) foot SWW (soap water wash) (R) foot F/B (followed by) [MEDICATION(S)] oint (ointment) 0.1% to wound bed F/B [MEDICATION(S)] (0.25%) moistened gauze cover with ABD & kerlix daily, PRN (as needed) check (check mark sign) placement q (every) shift. The weekly non pressure wound tracking assessment for R6's right foot dated [DATE] documents measurements of length 5.5, width 8, and depth 0.4. Under progress of site one documents unchanged. Under comments documents, Wound bed eschar. Mod (moderate) serous drainage. Peri wound soft and dark discoloration. Prevalon boots in place. No complaints pain Had ultrasound ABI (ankle-brachial index) on [DATE]. Surveyor noted the assessment reveals there is now a moderate amount of serous drainage and the peri wound is now soft and dark discoloration and there is no physician notification or assessment until [DATE]. The nurse's note dated [DATE] documents Pt (patient) transported via ambulance for MD (medical doctor) appointment. R6 was transported to Surgeon-FF. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . No deep tunneling. Daily or BID (twice daily) wet to dry on open area. [MEDICATION(S)] 100 mg (milligrams) po (by mouth) BID. Surveyor reviewed R6's April TAR (treatment administration record) and noted this new treatment order (wet to dry) was not started. In addition [MEDICATION(S)] 100 mg was not started until 3 days later on [DATE] during the evening shift. The [DATE] TAR on the 22nd, 24th, & 25th there are no initials to indicate the treatment was completed. The nurse's note dated [DATE] documents, stared (started) on ABT (antibiotic) [MEDICATION(S)] 100 mg (milligrams) for wound with no adverse reaction noted at this time. The nurse's [TRUNCATED]

Based on observation, record review and interview, the facility did not ensure that 4 (R61, R2, R35 & R80) of 10 residents reviewed for accidents had adequate assistance devices and interventions such as supervision in place to prevent accidents. * R61 experienced a fall with injury as a result of being left unsupervised by facility staff after staff found R61 in the shower room. R61 sustained a laceration to the back of the head that required 3 staples in the emergency room . * R2 was observed to not have his call light within reach per his falls plan of care. * R35 experienced 2 falls with her fall interventions not in place. * R80 was observed not to have her call light interventions in place per her plan of care. R61 is being cited at severity level 3 (actual harm). Findings include: 1.) R61 was admitted to the facility on [DATE] with diagnoses that included Dementia without Behavioral Disturbance, [CONDITION(S)] and Repeated Falls. R61's Significant Change MDS (Minimum Data Set) dated 2/5/21 documents that R61 has short and long term memory problems. Section C1000 (Cognitive Skills for Daily Decision Making) documents that R61 has severely impaired cognitive skills for daily decision making. Section G (Functional Status) documents that R61 requires limited assistance and one person physical assist for her bed mobility needs. Section G also documents that R61 requires extensive assistance and one person physical assist for her transfer needs. Section G0400 (Functional Limitation in Range of Motion) documents that R61 has no impairment to either side of both her upper and lower extremities. R61's Falls CAA (Care Area Assessment) dated 2/5/21 documents under the Care Plan Considerations section, R61 triggered the falls CAA because she has wandering type behavior, impaired balance at times, and has a history of falls. Her situation is further complicated by history of falls prior to admission, [CONDITION(S)], and Alzheimer's type dementia and R61 tries to maintain as much independence as able. Nursing completed a fall risk tool to help determine her risk for falls, see for details. The team agrees R61 has risk for falls and risk for injury if falls occur. Direct care staff to continue to provide interventions to help limit risk. Will continue to care plan. R61's Fall Risk assessment dated [DATE] documents a score of 17, indicating that R61 is at high risk for falls. A.) 12/27/20 Fall R61's Impaired Cognitive Function care plan dated as initiated on 8/15/19 documents under the Intervention section, Cue, reorient and supervise as needed. R61's Falls care plan dated as revised on 8/19/19 documents under the Intervention section, Provide frequent verbal cueing not to ambulate independently. R61's nursing note dated 12/27/20 documents, Health Status Note Text: Resident was observed lying on floor in bathroom behind nursing bleeding from the back of her head. Resident stated that she was cleaning the bathroom and slipped and fell . Laceration noted to the back of her head, pressure was held x (times) 15 minutes. Bleeding did slow, and resident stated she had pain in her head, this writer called 911 and give (sic) report. Fire Dept (Department) arrived and took over. Pressure bandage applied to head, BP (blood pressure) 110/68, 76 (pulse), 97.9 (temperature), 20 (Respirations) 96% RA (Peripheral Oxygen Saturation-Level Room Air). FD (Fire Department) captain called for ambulance. Resident was loaded into his (sic) w/c (wheelchair) and FD (Fire Department) took (R61) to lobby to wait for the ambulance. R61's nursing note dated 12/27/20 documents, Unwitnessed Fall: Date, time, location of fall, position of resident and (all residents) statement of what happened: 12/27/20, bathroom behind nursing station, lying on her back, Resident stated she was cleaning her bathroom and slipped and fell and hit her head. Location of resident prior to fall (bed, w/c etc) and time of last void-(CNA (Certified Nursing Assistant assigned): In bathroom, unsure, resident toilets self .Range of Motion Functional Limits: WNL (within normal limits) C/O (complains of) pain or discomfort (offer pain medicine and document refusal if applicable): Pain in back of her head, 911 called; Describe Injuries Noted-including skin check (orders implemented if needed): Laceration noted in the back of her head .What new intervention is being implemented?: Monitor resident more closely. R61's nursing note dated 12/27/20 documents, Health Status Note Text: Resident returned to facility via stretcher with (name of ambulance company) ambulance. 2 assist to 110. 3 staples noted to back of head and site open to air. Resident assisted to bed. VS (vital signs) 98/58 (blood pressure), 72 (pulse), 18 (respirations), 95% (Peripheral Oxygen Saturation) 98.1 (temperature). R61's Hospital Discharge Summary dated 12/27/20 documents, Date of Visit: 12/27/20; Diagnosis: Laceration of Scalp; No [CONDITION(S)] Seen; Follow up: Staple Removal. R61's Fall Incident Report Investigation dated 12/27/20 documents, Date of Incident: 12/27/20; Time of Incident: 6:45 PM; Location of Incident: Bathroom behind nursing station; Description of Incident: Resident noted laying on floor in bathroom on her back with blood coming from back of head; First Aide Provide: Pressure dressing applied. New Interventions: Staff education; offer diversional activities in common area prior to evening meal. R61's facility self-report submitted to the state agency on 12/27/20 documents, Describe the Incident Resident was found in the shower room behind the nurses' station laying on her back on the floor. She stated she was cleaning the bathroom and slipped and fell . She was found by the sink and scale and there was water noted on the floor; Describe the Effect: The resident received a laceration to the back of her; Explain: Nursing assessed the resident and located the laceration on the back of her head. Pressure was applied which did slow the bleeding. 911 was called and the resident was sent out to the hospital for evaluation and treatment where she received staples to the laceration. Investigation was completed. It was determined that the nurse was aware the resident had been in the shower room and left her alone. The nurse did receive counseling regarding never leaving high risk resident alone. In addition, the resident was care planned to offer diversional activities in common areas prior to the evening meal to keep her and within viewing distance. R61's facility self-report also documents, (R61) Fall Investigation: On 12/27/2020 at approximately 18:45 (6:45 PM) the resident had a fall in the bathroom located behind the nurses' stations. The resident stated that she was cleaning the bathroom and fell . She did hit her head received a laceration to the back of her head. She was assessed by nursing and sent to the hospital for evaluation and treatment. She returned to the facility at approximately 22:34 (10:34 PM) after receiving staples to the laceration on the back of her head. (MT (Medication Technician)-Y) stated that she was assisting in passing out meal trays on the resident's hallway. She indicated that she was looking for the resident so she could give her supper to her, but the resident not in her room or in the common area. She stated that the nurse told her she had last seen (R61) by the door to the shower room behind the nurses' station. (MT-Y) indicated she went to the shower room and opened the door to look inside. That is when she saw (R61) on the floor by the sink and scale in the shower room. She stated that she called the nurse who came to assess the resident. She the nurse indicated that (R61) must have went in the room after she saw her by the door. (MT-Y) did indicate that the nurse sent the resident out because she had hit her head and was bleeding. (CNA-X) indicated that she had seen the resident earlier the shift walking the hallway from room to room. She stated that she was passing trays on the other hallway and was not involved in the fall at all and had no knowledge that the resident was in the bathroom behind the nurses' station. (RN-W) indicated that approximately 10 minutes before the fall, the resident was in the shower room behind the nurses' station washing her hands. (RN-W's) statement indicates that she was attempting to get the resident out of the bathroom, but the resident was resistive so she went to get help. She stated then (MT-Y) went to the bathroom and found the resident on the floor. (RN-W) indicated that there was blood coming from the resident's head. She stated the resident told her she was cleaning the bathroom and she slipped and fell . (RN-W) stated the floor was wet. She noted the laceration to the back of her head and she applied pressure which did slow the bleeding. She indicated that she called 911 and the resident was sent out to the ER (emergency room ) for evaluation and treatment. She indicated the resident returned to the facility with staples to the laceration. Review of the information shows that the nurse on was aware that the resident was in the bathroom being resistive to leaving, so she left her alone to ask for help. It is not clear if she did ask for help as she is indicating she did, but the CNAs (Certified Nursing Assistants) are stating they were not aware the resident had been in the bathroom and was being resistive to leaving. She was found by (MT-Y) after the nurse told her where she had last seen her. The nurse received a counseling for failure to prevent resident from injury as she left a resident who is a falls risk alone unsupervised. She was educated on never leaving a high fall risk resident alone, and that she should instead use a call light or call out for assistance instead, In addition, the resident's care plan was updated to offer diversional activities in the common areas prior to evening meals. Surveyor reviewed MT-Y, CNA-X and RN-W's statements which were attached to the facility's self-report for R61's fall on 12/27/20 and confirmed the above findings. On 3/1/21 at 3:52 p.m., Surveyor completed a walk-through of the shower room where R61 fell on [DATE]. During the walk-through, Surveyor observed a total of 5 call lights available for staff to pull to call for assistance. On 3/4/21 at 9:25 a.m., Surveyor informed ADON (Assistant Director of Nursing)-C of the above findings. Surveyor asked ADON-C to confirm the above findings and asked if R61's fall on 12/27/20 was a result of R61 being left unsupervised by RN-W. ADON-B confirmed the above findings and investigation and informed Surveyor that R61's fall on 12/27/20 was a result of R61 being left unsupervised by RN-W. No additional information was provided as to why the facility did not ensure that R61 received adequate supervision to prevent her fall on 12/27/20. B.) Fall Interventions Not in Place R61's Falls care plan dated as revised on 8/19/19 documents under the Intervention section, Be sure (R61's) call light is within reach and encourage her to use it for assistance as needed. On 3/1/21 at 11:25 a.m., Surveyor observed R61 supine in bed with the call light hanging off the headboard of the bed and not in reach of R61 per R61's falls plan of care. On 3/1/21 at 3:49 p.m., Surveyor observed R61 supine in bed with the call light hanging off the headboard of the bed and not in reach of R61 per R61's falls plan of care. On 3/2/21 at 7:19 a.m., Surveyor observed R61 supine in bed with the call light on floor and not in reach of R61 per R61's falls plan of care. On 3/2/21 at 8:23 a.m., Surveyor observed R61 supine in bed with the call light on floor and not in reach of R61 per R61's falls plan of care. On 3/2/21 at 1:47 p.m., Surveyor observed R61 supine in bed with the call light on floor and not in reach of R61 per R61's falls plan of care. On 3/3/21 at 8:23 a.m., Surveyor observed R61 supine in bed with the call light hanging off the headboard of the bed and not in reach of R61 per R61's falls plan of care. On 3/3/21 at 10:24 a.m., Surveyor observed R61 supine in bed with the call light hanging off the headboard of the bed and not in reach of R61 per R61's falls plan of care. On 3/3/21 at 12:36 p.m., Surveyor observed R61 supine in bed with the call light hanging off the headboard of the bed and not in reach of R61 per R61's falls plan of care. On 3/4/21 at 8:15 a.m., Surveyor observed R61 supine in bed with the call light on floor and not in reach of R61 per R61's falls plan of care. On 3/4/21 at 9:25 a.m., Surveyor informed ADON (Assistant Director of Nursing)-C of the above findings. Surveyor asked ADON-C if R61 is able to use her call light and if it should be in reach per R61's plan of care. ADON-B informed Surveyor that R61 is able to use her call light and at times moves it away from her (R61). No additional information was provided as to why the facility did not ensure that R61's fall interventions were in place to prevent future accidents and falls. 2.) R2 was admitted to the facility on [DATE] with a diagnosis that includes Dysphagia, [CONDITION(S)] and [CONDITION(S)], Dementia without Behavioral Disturbance and [CONDITION(S)]. R2's Annual MDS (Minimum Data Set) dated 2/1/21 documents a BIMS (Brief Interview for Mental Status) score 11, indicating that R2 is moderately cognitively impaired. Section B1000 (Vision) documents that R2 has severely impaired vision. Section G (Functional Status) documents that R2 requires extensive assistance and a one person physical assist for his bed mobility needs. Section G also documents that R2 requires extensive assistance and a two person physical assist for his transfer needs. R2's Falls CAA (Care Area Assessment) dated 2/4/21 documents under the Care Plan Considerations section, The team has determined that (R2) continues to be at risk for falls related to his visual impairment, history of CVA (cerebrovascular accident) with left sided weakness, B&B (bowel and bladder) incontinence . impaired balance/mobility, and use of [CONDITION(S)] medication . Direct care staff to continue to provide interventions to help limit fall risk. The team agrees he remains at risk for falls and injury if falls occur. Will continue to care plan. R2's Fall Risk Evaluation dated 11/25/20 documents a score of 18, indicating that R2 is at high risk for falls. R2's Falls care plan dated as revised on 4/10/18 documents under the Interventions section, Be sure (R2's) call light is within reach and encourage him to use it for assistance as needed. On 3/1/21 at 3:50 p.m., Surveyor observed R2 supine in bed with the call light clipped to the curtain divider at the foot of R2's bed. Surveyor noted that R2's call light was not in reach of R2 per R2's falls plan of care. On 3/2/21 at 7:35 a.m., Surveyor observed R2 supine in bed with the call light clipped to the curtain divider at the foot of R2's bed. Surveyor noted that R2's call light was not in reach of R2 per R2's falls plan of care. On 3/2/21 at 8:23 a.m., Surveyor observed R2 supine in bed with the call light clipped to the curtain divider at the foot of R2's bed. Surveyor noted that R2's call light was not in reach of R2 per R2's falls plan of care. On 3/3/21 at 8:24 a.m., Surveyor observed R2 supine in bed with the call light clipped to the curtain divider at the foot of R2's bed. Surveyor noted that R2's call light was not in reach of R2 per R2's falls plan of care. On 3/4/21 at 8:16 a.m., Surveyor observed R2 supine in bed with the call light clipped to the curtain divider at the foot of R2's bed. Surveyor noted that R2's call light was not in reach of R2 per R2's falls plan of care. On 3/4/21 at 9:25 a.m., Surveyor informed ADON (Assistant Director of Nursing)-C of the above findings. No additional information was provided as to why the facility did not ensure that R2's fall interventions were in place to prevent future accidents and falls. 3.) R35 was admitted to the facility on [DATE] with a diagnosis that includes Alzheimer's Disease, Dementia with Behavioral Disturbance, Cognitive Communication Deficit and Anxiety. R35's Annual MDS (Minimum Data Set) dated 12/18/20 documents that R35 has short and long term memory problems. Section C1000 (Cognitive Skills for Daily Decision Making) documents that R35 has severely impaired cognitive skills for daily decision making. Section G (Functional Status) documents that R35 requires extensive assistance and a two person physical assist for her bed mobility needs. Section G also documents that R35 has total dependence and requires a two person physical assist for her transfer needs. Section G0400 (Functional Limitation in Range of Motion) documents that R35 has impairment to both sides of her lower extremities. R35's Falls CAA (Care Area Assessment) dated 12/18/20 documents under the Care Plan Considerations section, (R35) triggered the falls CAA because she has impaired balance, has fallen this past quarter without injury, and receives scheduled [CONDITION(S)] medications. R35's situation is complicated by her advanced Alzheimer's dementia with severe cognitive & communication impairment, chronic pain with use of scheduled [MEDICATION(S)] use, [CONDITION(S)], and incontinence. (R35) has Hx (history) of falls. The team agrees she continues to have risk for falls and risk for injury if falls occur. Staff will continue to provide assist with ADL's (activities of daily living) per c.n.a (Certified Nursing Assistant) care card and provide interventions to help reduce her risk for falls. R35's Falls care plan dated as initiated on 11/23/18 documents under the Interventions section, Body pillow to both sides of bed when in bed. R35's nursing note dated 10/31/20 documents, Unwitnessed Fall Date, time, location of fall, position of resident and (all residents) statement of what happened: 10/31/2020 2000 (8 PM) In resident's room lying on R (right) side of mat next to bed. Unable to state what happened; Location of resident prior to fall (bed, w/c etc) and time of last void-(CNA assigned): In bed; Vital Signs obtained for all residents even if not on O2 (oxygen) or diabetic: T 97.9 (temperature) P84 (pulse) R20 (respirations) B/P 92/63 (blood pressure); Orthostatic BP check (all residents-laying and sitting if unable to stand)-laying, sitting, standing: 122/56; Range of Motion Functional Limits: WNL (within normal limits) C/O (complains of) pain or discomfort (offer pain medicine and document refusal if applicable): no complaints; Describe Injuries Noted-including skin check (orders implemented if needed): no visible injuries; New Orders Received and transcribed: Monitor LLE for swelling; What is the current fall intervention and is it in place and functioning? Bed in low position mats on floor; What new intervention is being implemented?: Pillows on both sides when in bed. R35's nursing note dated 10/31/20 documents, Health Status Note Text: Called to room by CNA at 2000 (8 PM) stating resident was on floor. Bed was in low position and resident was lying on mat on L (left) side of bed on her back. RN (registered nurse) supervisor assessed resident ROM (range of motion) WNL (within normal limits) neuro (neurological) check negative no visible injuries. R35's nursing note dated 10/31/20 documents, Health Status Note Text: Writer notified by agency nurse that resident had fall. Upon entering resident's room, bed was in low position, resident was found lying on floor mat on her right side. Initial neuro check negative, ROM (range of motion) WNL (within normal limit), no visible injuries noted, and resident unable to communicate what happened due to cognitive delays. No s/sx (signs or symptoms) of pain or discomfort. Instructed agency nurse to notify doctor and family. And to complete fall report with neuro checks. R35's falls Incident Report dated 10/31/20 documents, Found resident on mat next to bed lying on her back. Bed was in low position; what did you do to prevent another fall: Implement using pillows on both sides. Surveyor noted that R35's Fall Incident Report dated 10/31/20 did not document that R35 had body pillows in place prior to her fall on 10/31/20. R35's nursing note dated 1/7/21 documents, Health Status Note Text: Following resident for right ankle and foot swelling. An x-ray was done and is negative. She appears comfortable. R35's nursing note dated 1/7/21 documents, Unwitnessed Fall Date, time, location of fall, position of resident and (all residents) statement of what happened: Today at 1000 (AM) resident rolled out of her bed and was found laying on her right side next to the bed. The bed was in the low position and the body pillow was still in the bed; Location of resident prior to fall (bed, w/c etc) and time of last void-(CNA assigned): Resident was in bed. Her last void is unknown because she is always incontinent; Vital Signs obtained for all residents even if not on O2 or diabetic: 97.7 (temperature) - 80 (pulse) - 16 (respirations) - 142/85 (blood pressure); Orthostatic BP check (all residents-laying and sitting if unable to stand)-laying, sitting, standing: Laying: 142/85; Range of Motion Functional Limits: Range of motion normal in all extremities; C/O (complains of) pain or discomfort (offer pain medicine and document refusal if applicable): She was given Tylenol 650 mg because she was rubbing her right shoulder. Describe Injuries Noted-including skin check (orders implemented if needed): No apparent injury noted; What is the current fall intervention and is it in place and functioning? Body pillows in her bed and floor mat. R35's falls Incident Report dated 1/7/21 documents, Writer called to resident's room by CNA and found her laying on the floor on her right side next to her bed. The body pillow was still in her bed. Writer assessed resident and found no apparent injury. R35's falls Incident Report dated 1/7/21 included a statement from CNA-Z that documented, I was on [MEDICATION(S)] to (R35's) room because I had to get her weight with the Hoyer. I head like a slap noise and I walked in her room and (R35) was on the floor. Surveyor noted that per R35's Incident Report dated 1/7/21, CNA-Z left R35 unattended in bed when she left to get the Hoyer. Surveyor noted that R35 did not have adequate supervision in place to prevent her fall on 1/7/21. On 3/4/21 at 9:25 a.m., Surveyor informed ADON (Assistant Director of Nursing)-C of the above findings. Surveyor asked ADON-C to confirm the above findings regarding R35's falls on 10/31/20 and 1/7/21. ADON-C confirmed the above findings regarding R35's falls on 10/31/20 and 1/7/21. No additional information was provided as to why the facility did not ensure that R2's fall interventions were in place and or why R35 did not have adequate supervision to prevent her falls on 10/31/20 and 1/7/21. 4.) R80 was admitted to the facility on [DATE] with diagnoses which includes dementia without behavioral disturbances, hypertension, and right humerus fracture. The CNA (Certified Nursing Assistant) care card located on the back of R80's door & dated 1/28/21 under the section safety needs documents bed in lowest position, call light in reach, gripper socks in bed, 1/28 Dycem to wheelchair. The admission MDS (minimum data set) with an assessment reference date of 2/2/21 documents a BIMS (brief interview mental status) score of 3 which indicates severe impairment. R80 requires extensive assistance with one person physical assist for bed mobility & toilet use, extensive assistance with two plus person physical assist for transfers, and does not ambulate. Yes is checked for the questions did resident have a fall any time in the last month prior to admission, did the resident have a fall any time in the last 2-6 months prior to admission and did the resident have any fracture related to a fall in the 6 months prior to admission. Yes is checked for any falls since admission with one no injury being coded. The fall CAA (care area assessment) dated 2/4/21 under care plan considerations documents R80 has impaired balance and has a history of falls, which makes her at risk for falls. R80's situation is complicated by her right elbow fracture & [CONDITION(S)], refer to d/c (discharge) summary. Staff used a fall risk eval (evaluation) tool to help determine her risk, see for details. Staff will provide assist with ADL's (activities of daily living) and will provide interventions to help reduce her risk for future falls. MD (medical doctor) updated of any falls. Therapy referred for strengthening. On 3/2/21 at 1:44 p.m. Surveyor observed R80 in bed on her back. Surveyor observed there are gray mats on each side of R80's bed but R80's bed is not at the lowest position. On 3/2/21 at 2:18 p.m. Surveyor observed R80 continues to be in bed on her back. R80's bed continues not to be at the lowest position. On 3/2/21 at 3:36 p.m. Surveyor observed R80 continues to be in bed on her back. R80's bed continues not to be at the lowest position. On 3/3/21 at 8:03 a.m. Surveyor observed R80 in bed on her right side. Surveyor observed there are two gray mats on side of R80's bed but R80's bed is not at the lowest position. On 3/3/21 at 12:15 p.m. Surveyor asked CNA (Certified Nursing Assistant)-IQ what position should R80's bed be in. CNA-Q informed Surveyor it's suppose to be down as low as it can go. On 3/03/21 at 2:42 p.m. Administrator-A and DON (Director of Nursing)-B were informed of the above.

Based on observation, record review, and interview, the facility did not thoroughly assess and provide services consistent with professional standards of practice to prevent development or worsening of pressure injuries for 5 (R75, R38, R196, R80, and R73) of 7 residents reviewed for pressure injuries. *R75 was readmitted to the facility with pressure injuries that were not comprehensively assessed for two days. R75 had pressure injuries on readmission 1/12/2021 to the coccyx and the left buttock; the wounds had measurements, but no wound descriptions or staging. The left buttock wound was not documented on after 1/12/2021. On 1/13/2021, the coccyx wound was not staged but described as granulation tissue. On 1/14/2021 the wound was unstageable with 70% slough. The following week, 1/21/2021, the wound had progressed to a Stage 4 with 20% bone and needing an antibiotic for wound infection. *R38 was readmitted to the facility on [DATE] with pressure injuries that were not comprehensively assessed until 2/24/2021, five days later. On 2/22/2021, the left buttock Stage 2 wound's etiology was not accurately identify, pressure versus trauma, and mislabeled the area as being on the left buttock when it was the right buttock that had the wound. The description of the wound base of the buttock said dermis which means skin and would indicate the area is not open. The measurements of the left buttock were greatly different from 2/19/2021 to 2/22/2021 leading to the question if the areas identified were the same areas being assessed. The Stage 4 sacral wound was not staged, measured, or described until 2/24/2021. The sacral wound was a Stage 4 prior to hospitalization . *R196 was admitted to the facility with a pressure injury that was not comprehensively assessed for six days. *R80 was observed with the heels not off-loaded per plan of care. *R73 was observed with the heels not off-loaded per plan of care. R38 is being cited at severity level 3 (actual harm). Findings include: The facility policy and procedure entitled Prevention of Pressure Ulcers dated 10/2010 states: Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. General Preventive Measures: 1. Identify risk factors for pressure ulcer development. 2. For a person in bed: a. Change position at least every two hours or more frequently if needed; b. Determine if resident needs a special mattress; c. If a special mattress is needed, use one that contains foam, air, gel, or water, as indicated; d. Raise the head of the bed as little and for as short a time as possible, and only as necessary for meals, treatments and medical necessity. 5. Risk Factor - Immobility: . b. Use pillows or wedges to keep bony prominences such as knees or ankles from touching each other. Do not massage bony prominences. c. When in bed, every attempt should be made to 'float heels' (keep heels off of the bed) by placing a pillow from knee to ankle or with other devices as recommended by therapist and prescribed by the physician. 1.) R75 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R75's quarterly Minimum Data Set (MDS) assessment dated [DATE] coded R75 as needing extensive assistance with bed mobility and total assistance with activities of daily living. R75 receives nutrition through a gastrostomy tube four times daily and needs to have the head of the bed elevated at those times putting pressure to the coccyx. R75 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R75's Pressure Injury Care Plan was initiated on 5/10/2018 with the following interventions: -a brand-specific air mattress -administer medications as ordered. Monitor/document for side effects and effectiveness. -Administer treatments as ordered and monitor for effectiveness. -Assess/record/monitor wound healing weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician. -Educate to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during mobility, good nutrition and frequent repositioning. -Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Inform family/caregivers of any new area of skin breakdown. -Reposition at least every 2 hours and as needed when in bed or Broda chair. -Monitor for nutritional status. Serve diet as ordered, monitor intake and record. -Monitor/document/report any changes in skin status: appearance, color, wound healing, sign or symptoms of infection, wound size, stage. -Obtain and monitor lab/diagnostic work as ordered. -Brand-specific cushion to Broda. -vascular consult as ordered. -Wound care physician to follow and treat. Surveyor noted there is no intervention addressing added pressure placed on R75's coccyx related to gastrostomy tube feeding needs requiring the head of R75's bed to be elevated despite history of previous coccyx pressure injuries. On 1/12/2021, R75 was readmitted to the facility after hospitalization for a urinary tract infection and septic shock. On 1/12/2021 on the Admit/Readmit Screener form, nursing charted R75 had a pressure injury to the coccyx measuring 2.0 cm x 1.7 cm x 1.5 cm and a pressure injury to the left buttock measuring 1.7 cm x 0.5 cm. Discharge orders from the hospital included: [MEDICATION(S)] to the buttocks every shift and as needed, and soap and water wash to the sacrum, pack with [MEDICATION(S)] gauze followed by a foam border gauze with skin prep to the peri wound daily and as needed. The pressure injuries were not staged and did not have any descriptions of the wound bases. The pressure injury to the left buttock was not documented on after the initial charting on 1/12/2021. Surveyor noted there is no indication R75's care plan was reviewed or revised upon admission back to the facility despite the presence of two pressure injuries. On 1/13/2021 at 12:29 PM in the progress notes, Registered Nurse (RN)-L charted a skin assessment was completed related to R75's readmission. RN-L charted R75 had an open area to the coccyx measuring 1.5 cm x 1.0 cm x 2.0 cm with granulation tissue in the wound bed. The wound was not staged and the etiology of the wound was not documented. Surveyor noted there were no revisions to R75's pressure injury care plan. On 1/14/2021, R75 was seen by the wound physician. The wound physician documented the coccyx wound was an unstageable pressure injury measuring 1.5 cm x 1.0 cm x 2.0 cm with undermining of 2.0 cm at 12 o'clock. The wound base was 70% slough and 30% granulation tissue. The treatment was changed at that time. This was the first time the coccyx pressure injury was comprehensively assessed since readmission on 1/12/2021. Surveyor noted no changes were made to R75's pressure injury care plan despite presence of an unstageable pressure injury with undermining. On 1/21/2021 in the wound physician notes, the unstageable coccyx pressure injury measured 2.0 cm x 1.0 cm x 2.0 cm with 2.0 cm undermining at 12 o'clock. The wound base was 50% slough, 30% granulation tissue, and 20% bone. The wound had deteriorated and an x-ray was ordered to rule out [CONDITION(S)]. Antibiotics were started. The x-ray came back with no [CONDITION(S)] detected. The pressure injury was a Stage 4 per the wound physician and documented as likely unavoidable as patient has multiple comorbidities and history of wounds to sacrum. The treatment was changed at that time. Surveyor noted no changes were made to R75's pressure injury care plan despite presence of a deteriorating pressure injury. On 1/28/2021 in the wound physician notes, the Stage 4 coccyx pressure injury measured 2.0 cm x 1.0 cm x 2.0 cm with undermining of 2.0 cm at 12 o'clock. The wound base was 30% slough, 50% granulation tissue, and 20% bone. Improvement was noted with a decrease in the amount of slough. On 2/4/2021 in the wound physician notes, the Stage 4 coccyx pressure injury measured 2.0 cm x 1.0 cm x 2.0 cm with undermining of 2.0 cm at 12 o'clock. The wound base was 20% slough, 60% granulation tissue, and 20% bone. Improvement was noted with a decrease in the amount of slough. R75's Pressure Injury Care Plan was revised on 2/4/2021 with the following intervention: bone culture and biopsy ordered. R75's Pressure Injury Care plan was revised on 2/5/2021 with the following intervention: Monitor for signs and symptoms of a urinary tract infection. On 2/11/2021 in the wound physician notes, the Stage 4 coccyx pressure injury measured 1.5 cm x 1.5 cm x 2.0 cm with undermining of 2.0 cm at 12 o'clock. The wound base was 10% slough and 90% granulation. Improvement was noted with a decrease in slough and no bone showing. On 2/18/2021 in the wound physician notes, the Stage 4 coccyx pressure injury measured 1.0 cm x 1.0 cm x 1.8 cm with undermining of 2.0 cm at 12 o'clock. The wound base was 10% slough and 90% granulation tissue. Improvement was noted with a decrease in size of the wound with no signs of infection. On 2/25/2021 in the wound physician notes, the Stage 4 coccyx pressure injury measured 1.5 cm x 1.5 cm x 1.5 cm with undermining of 1.5 cm at 12 o'clock. The wound base was 10% slough and 90% granulation tissue. Improvement was noted with a decrease in undermining. On 3/3/2021 at 8:30 AM, Surveyor observed the wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R75 was on an air-loss mattress. The wound treatment was completed by RN-L. In an interview on 3/3/2021 at 3:05 PM, Surveyor asked RN-L what the process was for a new admission or a readmission skin assessment. RN-L stated the nurse on the floor does the initial skin check when the resident arrives at the facility and then RN-L would do a complete assessment the next working day. Surveyor shared R75's Admit/Readmit Screener form that was completed on 1/12/2021 indicating there were two pressure wounds: the coccyx and the left buttock. RN-L stated when R75 was assessed by RN-L on 1/13/2021, R75 did not have any open area to the left buttock and that's why it wasn't documented by RN-L. Surveyor asked if RN-L looks at the admitting nurse's documentation to see what areas were found on admission. RN-L stated, no, the readmit assessment isn't always looked at. RN-L agreed the documentation written by RN-L should have included the left buttock of not having any wounds. Surveyor asked RN-L if a pressure injury should be staged when assessed. RN-L stated yes, the coccyx wound should have been staged. In an interview on 3/4/2021 at 1:21 PM, Surveyor shared with Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A concerns of R75 returning to the facility on [DATE] and the coccyx wound not being comprehensively assessed until 1/14/2021. On 1/12/2021 on the Admit/Readmit Screener form for R75 was a wound to the coccyx and the left buttock; the wounds had measurements, but no wound descriptions or staging, no revisions to the care plan. On 1/13/2021 when RN-L assessed R75's skin, the left buttock was not documented on and the coccyx wound was not staged but described as granulation tissue. On 1/14/2021 when the coccyx wound was assessed by the wound physician, the wound was 70% slough and unstageable. Surveyor noted there still were no changes to the care plan. The wound progressed quickly from granulation to slough and the following week, 1/21/2021, the wound had progressed to 20% bone and needing an antibiotic for wound infection. DON-B agreed the documentation should have been more thorough when R75 was readmitted on [DATE]. No further information was provided at that time. 2.) R38 was admitted to the facility on [DATE] with a Stage 4 pressure injury to the sacrum, [CONDITION(S)] disease requiring a [CONDITION(S)], diabetes, dementia, and peripheral vascular disease. R38's Pressure Injury to the Sacrum Care Plan was initiated on 8/22/2019. R38 was readmitted to the facility on [DATE] after hospitalization for partial amputation of the right foot due to ulceration. The foot wound had [CONDITION(S)] and R38 was on intravenous antibiotics to treat that infection. R38 was readmitted with two pressure areas: the sacrum and the left buttock. The Stage 4 sacrum pressure injury had been present prior to hospitalization . The sacral pressure injury had MRSA (Methicillin Resistant Staphylococcus Aureus) and R38 was receiving intravenous antibiotics to treat the infection. The Stage 2 left buttock pressure injury was not present prior to hospitalization . SACRUM On 2/19/2021 on the Admit/Readmit Screener form, nursing charted R38 had a Stage 4 pressure injury to the coccyx measuring 11.0 cm x 3.0 cm x 3.5 cm. The wound base was not described. The hospital discharge orders included a treatment to the sacrum: clean with soap and water, pat dry, and pack wound with Dakins' moistened gauze followed by border gauze daily. R38's Pressure Injury Care Plan was revised on 2/20/2021 to include intravenous antibiotics via a Peripheral Intravenous Central Catheter (PICC) line and the care of the PICC line. The Pressure Injury Care Plan was revised on 2/21/2021 to include isolation procedures due to the MRSA infection in the sacral wound. On 2/22/2021 at 1:34 PM in the progress notes, Registered Nurse (RN)-L charted the coccyx wound measured 8.0 cm x 2.0 cm x 2.0 cm with undermining of 1.5 cm at 3-5 o'clock. The wound bed had granulation tissue present. The wound was not staged. On 2/24/2021 on the Weekly Wound Assessment form, the Stage 4 sacral pressure injury measured 8.0 cm x 2.0 cm x 2.0 cm with undermining of 1.5 cm at 3-5 o'clock. The wound bed had granulation tissue. The sacral pressure injury was not comprehensively assessed until 2/24/2021, five days after readmission to the facility. LEFT BUTTOCK On 2/19/2021 on the Admit/Readmit Screener form, nursing charted R38 had a Stage 2 wound to the left buttock measuring 1.0 cm x 1.0 cm x 0.1 cm from dressing tape. The wound base was not described. The hospital discharge orders included [MEDICATION(S)] to left buttocks every shift and as needed. On 2/22/2021 at 1:34 PM in the progress notes, Registered Nurse (RN)-L charted R38 had an area on the left buttocks that measured 8.0 cm x 0.7 cm and [MEDICATION(S)] was applied. The etiology of the wound was not given with no staging or wound base description. The wound measurements from 2/19/2021 and 2/22/2021 are vastly different in size. On 2/24/2021 on the Weekly Wound Assessment form, nursing charted R38 had a Stage 2 pressure injury to the left buttock measuring 8.0 cm x 0.7 cm x 0.1 cm and the wound bed is dermis. (Dermis means the skin.) On 3/3/2021 at 8:51 AM, Surveyor observed RN-L do wound care to R38's sacral Stage 4 pressure injury and left buttock Stage 2 pressure injury. RN-L gathered the supplies needed to perform the dressing changes. The sacral wound appeared as documented on 2/24/2021. The left buttock wound measuring 8.0 cm x 0.7 cm x 0.1 cm was on the right buttock. In an interview on 3/3/2021 at 2:57 PM, Surveyor shared with RN-L the observation of the wound documented to be on the left buttock was on the right buttock. RN-L agreed the wound was in fact on the right buttock. Surveyor asked how the wound developed since it was documented as a Stage 2 pressure injury. RN-L guessed the wound occurred when removing tape from the sacral wound dressing. Surveyor questioned RN-L if the wound was from pressure or trauma. RN-L stated it is most likely from trauma and the documentation was inaccurate. Surveyor asked RN-L why R38 was not comprehensively assessed on readmission to the facility on [DATE]. RN-L stated RN-L does all the comprehensive assessments on new admissions and readmissions and RN-L does the assessment the next working day after the admission. RN-L stated if a resident comes into the facility on Friday, then the resident is assessed on the following Monday. Surveyor asked RN-L if the readmission screener form had been reviewed before doing R38's initial assessment by RN-L on 2/22/2021. RN-L stated RN-L seldom looks at the readmission screener form. Surveyor shared the concern the left buttock Stage 2 pressure injury the nurse noted on admission had a very different measurement on 2/19/2021 compared to what RN-L documented on 2/22/2021. The measurement went from 1.0 cm x 1.0 cm x 0.1 cm to 8.0 cm x 0.7 cm x 0.1 cm in three days. RN-L stated the area that was measured on 2/22/2021 was the right buttock area and RN-L stated there were no additional open areas when R38's skin was assessed by RN-L on 2/22/2021. RN-L agreed the area on R38's right buttock should not have been documented as pressure. In an interview on 3/4/2021 at 11:17 AM, Surveyor shared with Director of Nursing (DON)-B the concerns with documentation and assessments related to R38. When R38 returned from the hospital on 2/19/2021, R38's skin was not comprehensively assessed until the weekly wound assessment completed on 2/24/2021. RN-L looked at R38 on 2/22/2021, but did not accurately identify the etiology of the right buttock wound and mislabeled the area as being on the left buttock. The description of the wound base of the buttock said dermis which means skin and would indicate the area is not open. The measurements of the left buttocks were greatly different leading to the question, were the same areas being assessed. The sacral wound was not staged, measured, or described until 2/24/2021. RN-L is not available 24 hours a day to do assessments and there does not appear to be anyone else in the facility that is responsible to perform a comprehensive skin assessment. DON-B agreed R38's wound documentation was confusing and lacked a comprehensive assessment on readmission to the facility. No further information was provided at that time. 3.) R73's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The potential for pressure injury/ulcer development care plan initiated 1/20/21 & revised on 2/15/21 includes an intervention dated 2/9/21 of float heels in bed. The admission MDS (minimum data set) with an assessment reference date of 1/22/21 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R73 requires extensive assistance with one person physical assist for bed mobility & toilet use, doesn't ambulate and is always incontinent of bowel & bladder. R73 is at risk for pressure injury development and is coded as not having any pressure injuries. The pressure injury CAA (care area assessment) dated 2/1/21 under care plan considerations documents R73 requires extensive assist with ADL's (activities daily living) such as bed mobility and is incontinent of bladder and bowel, which makes her at risk for pressure ulcers. Staff used a Braden Scale to help determine her risk for pressure ulcers, see for details. Staff will provide assist with ADL's and will monitor her skin for any alterations in skin integrity. MD (medical doctor) updated as needed. Therapy referred for strengthening. On 3/1/21 at 11:23 a.m. Surveyor observed R73 in bed on her back with the head of the bed up reading a book. Surveyor observed R73's heels were resting directly on the mattress and were not being offloaded. On 3/1/21 at 2:07 p.m. Surveyor observed R73 in bed on her back with the head of the bed elevated and her eyes closed. Surveyor observed R73's heels are not being offloaded. On 3/2/21 at 8:05 a.m. during morning cares for R73 with CNA (Certified Nursing Assistant)-R, Surveyor observed there is a pillow under R73's lower legs but R73 heels are resting directly on the mattress and are not being offloaded. On 3/2/21 at 1:39 p.m. Surveyor observed R73 in bed on her back with the head of the bed elevated and R73 was reading a book. Surveyor observed R73's heels are not being offloaded. On 3/2/21 at 2:16 p.m. Surveyor observed R73 continues to be in bed with the head of the bed elevated and R73's eyes are closed. Surveyor observed R73's heels are still not being offloaded. On 3/2/21 at 3:38 p.m. Surveyor observed R73 continues to be in bed on her back. R73's heels are still not being offloaded. On 3/3/21 at 7:43 a.m. Surveyor observed R73 in bed on her back with the head of the bed elevated reading a book. Surveyor observed R73's bare feet are resting directly on the mattress. On 3/3/21 at 9:35 a.m. Surveyor observed R73 continues to be in bed on her back. Surveyor observed R73's heels are still not being offloaded. On 3/3/21 at 12:13 p.m. Surveyor asked CNA-Q if R73's heels are suppose to be floated while she is in bed. CNA-Q informed Surveyor R73 has a pillow under her legs so yes her heels are suppose to be floated off the mattress. On 3/3/21 at 3:13 p.m. Surveyor asked RN (Registered Nurse)-L, who is the Facility's wound nurse, how staff floats R73's heels. RN-L informed Surveyor R73 said the boots were too hot so the staff uses pillows to offload R73's heels. Surveyor informed RN-L of the observations of R73's heels not being offloaded. On 3/4/21 at 7:52 a.m. Surveyor observed R73 in bed on her back with the head of the bed elevated reading a book. Surveyor observed R73's heels are being offloaded. On 3/4/21 at 12:30 p.m. Administrator-A and DON (Director of Nursing)-B were informed of the above. 4.) R80's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The CNA (Certified Nursing Assistant) care plan located on the back of R80's door & dated 1/28/21 under the positioning section documents reposition every 2 when in bed, 2/11/21 float heels, special equipment apm (alternating pressure mattress) mattress bed. The admission MDS (minimum data set) with an assessment reference date of 2/2/21 documents a BIMS (brief interview mental status) score of 3 which indicates severe impairment. R80 requires extensive assistance with one person physical assist for bed mobility & toilet use, requires extensive assistance with two plus person physical assist for transfer, does not ambulate, is checked for an indwelling catheter and is frequently incontinent of bowel. R80 is at risk for pressure injury development and is coded as having one Stage 2 pressure injury which was present upon admission. The pressure injury CAA (care area assessment) dated 2/4/21 under care plan considerations documents R80 admitted with a stage 2, refer to chart. R80's situation is complicated by her decline in ADL (activities daily living) functioning & bowel incontinence, refer to charting. Staff used a Braden Scale to help determine her risk, see for details. Staff will monitor and provide treatment to the area, per MD (medical doctor) orders. MD updated as needed. Wound team to follow till area is healed. Surveyor noted R80's left buttock pressure injury healed on 2/11/21. On 3/1/21 at 2:08 p.m. Surveyor observed R80 in bed on her back. Surveyor observed R80's heels are not being offloaded. On 3/2/21 at 7:27 a.m. Surveyor observed R80 in bed on her back with the head of the bed elevated. Surveyor observed R80's heels are not being offloaded. On 3/2/21 at 1:44 p.m. Surveyor observed R80 in bed on her back with a pillow under her lower legs. Surveyor observed R80's heels are resting directly on the mattress and are not being offloaded. R80 asked Surveyor to give her a drink of milk. Surveyor explained Surveyor is unable to give her the milk but would let nursing staff know of her request. On 3/2/21 at 2:18 p.m. Surveyor observed R80 continues to be in bed on her back with her heels not being offloaded. On 3/2/21 at 3:36 p.m. Surveyor observed R80 continues to be in bed on her back with her heels not being offloaded. On 3/3/21 at 10:31 a.m. Surveyor entered R80's room with LPN (Licensed Practical Nurse)-S and CNA-Q. CNA-Q washed her hands & placed gloves on. LPN-S placed gloves on. Surveyor observed R80 was on her right side, there was a pillow under R80's left side and under her lower legs. Surveyor observed R80 has gripper socks on and her heels are resting directly on the mattress. CNA-Q unfastened R80's incontinence product and R80 was positioned on her side. LPN-S informed Surveyor R80 came in with a pressure injury which RN-L healed. Surveyor did not observe any pressure injuries on R80's buttocks. A new incontinence product was placed on R80 & fastened. LPN-S & CNA-Q positioned R80 up in bed. LPN-S asked R80 if they could put boots on which R80 replied no. A pillow was placed under R80's right side and under R80's lower legs. Surveyor observed R80's heels were not floating and were resting directly on the mattress. LPN-S & CNA-Q covered R80 with bedding, the call light was placed within reach, the head of the bed was raised, and the bed was lowered down. On 3/3/21 at 12:13 p.m. Surveyor asked CNA-Q if R80's heels are suppose to be floated while she is in bed. CNA-Q informed Surveyor R80 has a pillow under her legs and her heels are suppose to be floated off the mattress. CNA-Q informed Surveyor R80 is up now. On 3/3/21 at 3:12 p.m. Surveyor asked RN (Registered Nurse)-L if R80's heels should be offloaded. RN-L informed Surveyor staff uses a pillow as R80 hates the boots. Surveyor informed RN-L of the observations of R80's heels not being offloaded. On 3/4/21 at 12:30 p.m. Administrator-A and DON (Director of Nursing)-B were informed of the above. 5.) R196's admission note dated 2/19/21 documents Resident arrived via ambulance, he is A/Ox3 (alert orientated times three) able to make his needs known, post hospital for complaint of right LE (left extremity) pain from wound PAD (peripheral artery disease), dressing intact, that nurse from St. [NAME] change today at 1300 (1:00) pm. It is due to be change Q (every) Tues (Tuesday) and Friday. wound bed is has [MEDICATION(S)] and 4x4 gauze and co-flex wrap, resident kept hitting his head with his hand stating, I ' m not going to stop hitting my head til you stop messing with my leg. Left buttock open area 2x1cm 100% granulation, apply [MEDICATION(S)] to area, and off-loading. Left BKA (below knee amputation), FR (French) 16 with 5cc (cubic centimeter), foley is intact and patent draining yellow to color, foley was inserted due to urinary retention, it was inserted today 2/19/21, in 2 weeks may try to do voiding trial. (3/5/21). LCTA (lungs clear to auscultation), abdomen is rounded and soft, LBM (last bowel movement) is today per resident. Resident has no teeth and no denture present. Resident denies pain and discomfort at this time. boot to right foot intact. Medication is very (verified) by NP (nurse practitioner)-T. This note is written by a LPN (Licensed Practical Nurse). The Braden scale assessment dated [DATE] documents a score of 17 which low risk. The nurses note dated 2/20/21 documents resident alert and responsive, denies pain when asked, drsing (dressing) to coccyx soiled, area cleaned/dry, new drsing applied, no s/s (signs/symptoms) infection, skin warm and dry, no s/s hypo/[CONDITION(S)]. appetite fair able to feed self in room with set up assistance, foley patent with straw colored urine noted in drainage bag, BS (bowel sounds) x (times) 4, BLCTA (bilateral lungs clear to auscultation), no resp (respiratory) distress or sob (shortness of breath) noted. skin warm and dry, fluids at bedside. VSS (vital signs stable). The nurses note dated 2/22/21 documents Skin assessment completed r/t (related to) new admission. Incontinent of bowel function. Has foley catheter patent and draining yellow urine. Bruises noted on L (left) arm. L BKA (below knee amputation). Scar R (right) knee. Vascular areas on R lower leg upper area 6.8 x 3.5 Wound bed 50% eschar 50% granulation. Sm (small) sero-sang drainage drainage. lower area 3 x 1.5. Wound bed 25% granulation 75% eschar. Sm sero-sang drainage. Areas cleansed and treatment completed. L buttock 1 x 2 x 0.1. Sm serous drainage. Prevalon boot in place R foot. Consent form signed to see wound care MD(medical doctor). Surveyor noted this note was written by RN (Registered Nurse)-L who is the Facility's wound nurse. Surveyor also noted this is 3 days after R196 was admitted , does not include a stage for R196's left buttocks pressure injury and does not describe the wound bed. The weekly wound assessment dated [DATE] documents for wound site 32) left buttocks, length 1, width 1.5, depth 0.1, and stage 4) Stage III (3). Under summary documents Seen by wound care MD. Wound bed 100% granulation tissue. Moderate serous drainage. On alternating pressure mattress. Gel cushion in w/c (wheel chair). Wears Prevalon boot. Incontinent bowel and bladder functions. On 3/2/21 at 1:13 p.m. Surveyor asked RN-L, who is the Facility's wound nurse, who is responsible for assessing a new/readmission Resident's skin. RN-L informed Surveyor there are various different people. RN-L indicated staff nurses complete a body check and if the Resident is admitted during the day & she is here she may go with the staff nurse. RN-L informed Surveyor if she is unable to go with the staff nurse then the next morning she will assess their skin. RN-L informed Surveyor if a Resident is admitted on a Friday she does the assessment on Monday. RN-L informed Surveyor if there are multiple admissions, she can't always get to all of them but states she does her best. Surveyor asked RN-L if there was anyone that helps her. RN-L informed Surveyor the staff nurse will be the one doing the assessment. Surveyor asked what happens if the staff nurse is a LPN (Licensed Practical Nurse). RN-L informed Surveyor if a LPN is on the floor there is another RN they can get to help and DON (Director of Nursing)-B and ADON (Assistant Director of Nursing)-C will help. On 3/3/21 at 7:06 a.m. Surveyor observed R196's treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no concerns identified with RN-L treatment technique or hand hygiene during this observation. On 3/3/21 at 3:15 p.m. Surveyor asked RN-L why R196's pressure injury wasn't assessed until 3 days after R196 was admitted . RN-L informed Surveyor she thought the nurse did an original skin assessment. Surveyor informed RN-L the admission note was completed by LPN-S. RN-L informed Surveyor she doesn't know. On 3/4/21 at 12:30 p.m. Administrator-A and DON (Director of Nursing)-B were informed of the above.

Based on record review and interviews, the facility did not ensure a resident with a pressure injury was comprehensively assessed upon readmission into the facility. This was observed with 1 (R1) of 8 residents reviewed with pressure injuries. * R1 was readmitted on [DATE] with an open area that was not comprehensively assessed until 8/13/20 as a stage 3 pressure injury on the sacrum. This resulted in actual harm to R1's sacrum area, which progressed from an open area on 8/7/20 to a wound measuring 3.5 x 4 x 0.1 cm on 8/10/20 to a stage 3 pressure injury measuring 9 x 4 x 0.1 cm on 8/13/20. The facility did not implement interventions until 8/13/20. Findings include: The facility's Pressure Ulcer Risk Assessment, revised 10/2010, was reviewed. It indicates under Assessment: Because a resident at risk can develop a pressure ulcer within 2 - 6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions promptly to attempt to prevent pressure ulcers. The admission evaluation helps define these initial care approaches. R1's medical record was reviewed as a result of complaint concerns registered with the Division of Quality Assurance. R1 was discharged from the facility on 10/3/20 and did not return. R1 was reviewed as a closed record review. R1 was readmitted into the facility on [DATE]. The hospital discharge summary, dated 8/7/20, does not indicate any wounds. The admission skin assessment indicates an open area to the iliac crest. There was no further assessment information documented. There is no evidence that the facility implemented a care plan to address skin issues on this date. The Progress Note dated 8/10/20 indicates a skin assessment was completed related to admission. The assessment indicates R1 has multiple bruises. The assessment also indicates R1 has an open area on coccyx/buttocks measuring 3.5 cm (centimeters) by 4 cm by 0.1 cm. The area was cleaned and a treatment applied. There is no documentation of the type of open area, including staging of the area for a pressure injury. The next wound assessment was completed on 8/13/20. This assessment indicates the sacrum is a stage 3 pressure injury measuring 9 cm by 4 cm by 0.1 cm. R1 was also seen by the wound physician on this date with the same assessment. The pressure injury had increased in size, from 3.5 cm to 9 cm since 8/10/20. R1's 5-day MDS (minimum data set) assessment completed on 8/13/20 indicates a stage 3 pressure injury was noted upon admission on 8/7/20. The MDS indicates pressure reduction devices in a chair and bed. The postioning intervention is not checked. R1's plan of care for skin impairment, revised 9/22/20, was reviewed. The plan of care indicates on 8/13/20 a stage 3 pressure injury to the sacrum. There was no intervention revision related to this new pressure injury upon readmission on 8/7/20. The interventions after 8/7/20 include: - 9/22/20 a ROHO cushion - 9/11/20 may be up just prior to lunch on and down after lunch on Tues/Thurs/Sat and up util after dinner on Sun/Mon/Wed/Fri. - 9/21/20 praise R1 for compliance with Prevalon boots - 8/24/20 Prevalon boots - 9/11/20 reposition R1 every 2 hours in the bed and chair On 1/6/21 at 11:42 AM Surveyor spoke with the wound RN (Registered Nurse)-C. RN-C indicated R1 was admitted on a Friday (8/7/20) and they assessed the resident on Monday (8/10/20). RN-C indicated residents should have a complete skin assessment upon admission. RN-C did not know why this was not completed. RN-C did not have any further information. RN-C did not have a further assessment on 8/10/20. RN-C did not conduct the skin assessment on 8/7/20. On 1/6/21 at 2:01 PM Surveyor spoke with DON-B (Director of Nurses). DON-B indicated residents should have complete skin assessments upon admission. DON-B did not have further information why this was not completed for R1 on admission. The LPN (Licensed Practical Nurse) that completed the admission skin assessment on 8/7/20 was not available for interview. There is not a documented comprehensive assessment by an RN until 8/13/20.

Based on observation, record review and interview, the facility did not ensure that 3 (R1, R2 & R6) of 6 resident's reviewed for falls and accidents, had adequate assistance devices and interventions in place to prevent accidents and falls. * R1 was not transferred with a Hoyer lift per R1's plan of care resulting in a fracture to R1's left tibia. * R2 was not provided with bed mobility by two staff members per R2's plan of care, resulting in R2 falling and suffering a subdural hematoma. * On 12/3/19, R6 was observed in bed and did not have her bed in the low boy bed position to prevent falls and accidents per her falls plan of care and Visual/ Bedside Kardex Report. Findings include: 1. R1 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R1's Quarterly MDS (Minimum Data Set) dated 9/19/19 documents that R1 has short and long term memory problems with severely impaired cognitive skills for daily decision making. Section G (Functional Status) documents that R1 requires extensive assistance and a two person physical assist for her bed mobility needs. Section G also documents that R1 has total dependence on staff and requires a two person physical assist for her transfer needs. R1's Falls CAA (Care Area Assessment) dated 12/17/18 documents under the Care Plan Considerations section,R1 triggered the falls CAA (Care Area Assessment) because she has impaired balance and receives scheduled [MEDICAL CONDITION] medications. R1's situation is complicated by her advanced Alzheimer's dementia with severe cognitive/communication impairment, both acute/chronic pain with use of scheduled narcotic/[MEDICATION NAME] use. R1 has recent Hx (history) of falls. The team agrees she continues to have risk for falls and risk for injury if falls occur. Staff will continue to provide assist with ADL's (activities of daily living) per CNA (Certified Nursing Assistant) care card and provide interventions to help reduce her risk for falls. MD (medical doctor) and fall team update if indicated. Will continue to care plan. R1's Fall Risk assessment dated [DATE] documents a score of 18, indicating she is at high risk for falls. R1's ADL (Activities of Daily Living) care plan dated as initiated on 11/20/17 documents under the Interventions section, TRANSFER: R requires Mechanical Lift-Hoyer with 2 total staff assistance for transfers. She uses medium sling size. R1's nursing note dated 10/21/19 documents, Health Status Note Text: Writer assessed resident at this time d/t (due to) reports of resident having pain to LLE (left lower extremity). Resident unable to extend LLE, RLE (right lower extremity) unable to straighten out completely but has more range of motion than left. LLE bent up shorter than the right. Dark red discolored area noted to L (left) inner knee, resident has R (right) knee resting on the left. Pillow placed in between knees for support and to relieve pressure. Resident unable to describe pain d/t (due to) cognitive deficits. Resident yells out upon palpation of LLE. Resident medicated with prn (as needed) [MEDICATION NAME] by med tech at this time. DR (doctor) called and updated. NOR (new orders received) for stat X-ray of the L knee and uric acid level. Orders read back to writer. AM nurse updated on above. R1's Final Laboratory Report dated 10/21/19 documents a Uric Acid level of 3.9, indicating that R1's Uric Acid levels are normal and within limits. R1's Radiology Report dated 10/21/19 documents, Examination: Knee Exam 3 V (views); Results: No acute fracture or dislocation. The osseous structures appear intact. Joint spaces are narrow. Conclusion: No acute osseous abnormality. [MEDICAL CONDITION] changes. R1's nursing note dated 10/21/19 documents, Health Status Note Text: X-ray resulted and uric acid. Faxed to Dr. (doctor) awaiting for respond. R1's nursing note dated 10/22/19 documents, Left foot swollen and resident yelling out . given scheduled [MEDICATION NAME] and [MEDICATION NAME] which was effective. Resident guarding the left knee and leg. R1's nursing note dated 10/23/19 documents, Resident continues to cry out with pain to LLE (knee and ankle) pain and swelling. Called out to DR (doctor) new order to send resident to St. Luke's ER (emergency room ) for evaluate and treat .Ambulance is called. R1's nursing note dated 10/23/19 documents, Health Status Note Late Entry: Called SLMC (St. Luke's Medical Center) ER (emergency room ) for update. RN (Registered Nurse) stated that resident would be discharged back to the facility. DX (diagnosis) of re-[MEDICAL CONDITION] leg. Resident will have an immobilizer and pain med (medication). R1's emergency room After Visit Summary dated 10/23/19 documents, Patient arrived to ED (emergency department) .with complaints of left pain for two days. Discharge Diagnosis: [REDACTED]. Follow up with orthopedics, discharged with soft splint. R1's Orthopedic Office Visit, dated 10/28/19 documents, Impression/Diagnosis: [REDACTED]. Plan: Recommend conservative treatment with non-weight bearing. Placed in a posterior splint. Unwrapped daily for skin checks. Follow up in 6 weeks for 2 view left leg X-rays. The facility self-reported the above incident, as an injury of unknown origin, to the State Agency on 10/23/18 after R1 was found to have a left tibia fracture. The facility's self-reported investigation documents, On (MONTH) 21, 2019 at PM shift, RN (Registered Nurse) Manager-G heard resident yelling out, she opened the door to find the resident (R1) was receiving H.S. (hour of sleep) cares from CNA (Certified Nursing Assistant)-I. He was the only one with the resident. RN Manager-G didn't notice a Hoyer lift in the room at this time. On (MONTH) 21, 2019 at PM shift, CNA-I stated that he put resident to bed, she was screaming that her leg was hurting. He informed the supervisor that her (R1) was hurting. R1 was treated for [REDACTED].Conclusion: Interviews and statements revealed that a CNA (CNA-I) did not followed the resident's care card for transferred during the time frame of 10/21/19 to 10/22/19. It appears that these transfers cause the injury, which overtime, became more symptomatic with movement during cares. RN-Manager-G's statement, included in the facility's investigation, dated 10/21/19 documents, I heard resident screaming out and opened the door to her room and saw he (CNA-I) was undressing resident (HS (hour of sleep) cares) over her blanket. Noticed he was the only on with her. No Hoyer was present. I went to the unit nurse to inform her of the situation and she confirmed that resident (R1) was a Hoyer transfer. CNA-I's statement, included in the facility's investigation, dated 10/23/19 documents, I had the resident and put her in the bed. And she was screaming but her leg was hurting. I told the supervisor her knee was hurt again. Then she (R1) went to sleep. Surveyor noted that per the facility's self-report investigation, on or around 10/21/19, R1 was injured by CNA-I when CNA-I transferred R1 into bed without the use of a Hoyer lift. On 12/2/19 at 12:06 p.m., Surveyor informed Administrator-A and DON (Director of Nursing)-B of the above findings. Surveyor asked Administrator-A how the facility was able to confirm that R1's fracture on 10/23/19 was caused by CNA-I. Administrator-A and DON-B informed Surveyor that during the facility's investigation, CNA-I admitted to Administrator-A and DON-B that he (CNA-I) had transferred R1 by himself without the use of a Hoyer lift. Administrator-A and DON-B informed and confirmed to Surveyor the above findings. No additional information was provided as to why R1 was not transferred with a Hoyer lift to prevent falls and or accidents. 2. R2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R2 was discharged from the facility to the hospital on [DATE] and has not returned to the facility. R2's quarterly MDS (Minimum Data Set) dated 9/30/19 documents a BIMS (Brief Interview for Mental Status) score of 10, indicating that R2 was moderately cognitively impaired. Section G (Functional Status) documents that R2 required extensive assistance and a two person physical assist for her bed mobility needs. Section G also documented that R2 has total dependence and required a two person physical assist for her transfer needs. Section G also documents impairment to one side of both R2's upper and lower extremities. R2's ADL (Activities of Daily Living) CAA (Care Area Assessment) dated 12/28/18 documents under the Care Plan Considerations section, R2 triggered the ADL CAA because she . requires extensive-total assist with most ADL's such as bed mobility, transferring and toileting, and is noted with impaired balance, refer to CNA charting. Her situation is complicated by her Dx (diagnosis) of late effects [MEDICAL CONDITION] of left sided [MEDICAL CONDITION] .The team agrees her current functional status places her at risk for complications such as falls .Direct care staff to assist (Resident) per CNA care card and provide interventions to help limit risk for complications of functional status. Will continue to care plan. R2's Falls CAA dated 12/28/18 documents under the Care Plan Considerations section, (R2) triggered the Falls CAA because she requires total assist with transfers (a Hoyer lift) .The team agrees (R2) has risk for falls and risk for injury if falls occur. Direct care staff to continue to provide interventions to help limit risk for falls and follow CNA care card for transfers/mobility. R2's Falls Risk Evaluation/assessment dated [DATE] documents a score of 10, indicating she is at moderate risk for falls. R2's ADL care plan dated 10/21/19 documents under the Interventions section, Cares in pairs. R2's ADL care plan dated 7/12/19 documents under the Interventions section, BED MOBILITY: requires assistance by 2 staff to turn and reposition in bed. R2's nursing note dated 11/12/19 documents, Health Status Note Text: Writer on unit at 1215 (12:15 pm) and called to residents room d/t (due to) fall. CNA reported that she was performing hygiene on resident in bed and resident rolled out of bed on side of bed toward window. Resident lying on back next to window with head toward headboard when writer entered room. Resident alert, oriented per baseline. Large hematoma noted to L (left) side of forehead. L (left) side of face reddened. Staff nurse applied ice to L (left) forehead. LUE (left upper extremity) and LLE (left lower extremity) are weak per baseline. RUE (right upper extremity) and RLE (right lower extremity) able to move freely on command. LLE with slight inward rotation. RLE no inward or outward rotation. Pillow placed under resident's head, sheet placed under resident until ambulance arrives to assist resident off floor. Resident c/o (complains of) pain to nose, neck, and R (right) hip. Rates 10/10 .Report called to SLMC (St. Luke's Medical Center) ER (emergency room ) RN on resident transfer to ER (emergency room ) for eval (evaluation) and treatment. R2's nursing noted dated 11/12/19 documents, Resident is being admitted to SLMC (St. Luke's Medical Center) for subdural hematoma. On 11/18/19, a complaint was called into the Southeastern Regional Office alleging that (R2) was transferred by one CNA instead of two per R2's care plan. The above incident was also self-reported to the State Agency by the facility on 11/12/19. The facility's investigation documents, On 11/12/19 at approximately 12:00/noon a CNA (CNA-H) was providing cares for the resident in bed (washing her up and dressing her) in preparation for the resident to go out .During the cares, the CNA rolled the resident onto her left side away from her, and the resident continued to roll of the bed onto the floor. The CNA indicated that she attempted to stop the resident from rolling off the bed, but she was not able to. The DON (Director of Nursing) was on the unit and was called to the resident' room. She noted the resident was on the floor in the room on the side of the bed near the window .She had a large hematoma noted to the left side of her forehead and the left side of her face was reddened Administration and DON met with CNA involved and obtained statement. The CNA was providing cares herself. The resident's care card indicates the resident is a 2 person for bed mobility. The CNA indicated that she was not aware the resident required 2 for bed mobility, and informed the Administrator and DON that she did not reference the care card which was placed behind the resident's door On 11/13/19 additional staff were interviewed. The LPN (Licensed Practical Nurse) on the unit indicated that the CNA called her to the room. Upon entering, she stated she noted the resident on the floor and the bed in the high position .The LPN stated that the CNA did not ask her for any assistance with the resident prior to calling her to the room for the fall. The other CNAs on the unit indicated that they were not present for the incident and were involved in cares with other residents on the unit at the time (of the fall). On 11/13/19, the facility received paperwork from the hospital regarding the resident's evaluation. She was diagnosed with [REDACTED]. No fractures noted. CNA-H's statement included in the above self-report investigation documents, At noon on 11/12/19, I was washing (R2) up getting her ready to depart from the facility by 1 PM and as I turned her on her left side to wash behind she slipped away, I tried to grab her but my hand was slippery. R2's Hospital Critical Care/Admission Consult notes dated 11/12/19 documents, Presented to the ER (emergency room ) on 11/12/19 after a fall at nursing home. Active Diagnosis: [REDACTED].The patient IS expected to require a two midnight stay in the hospital. Surveyor noted that per the facility's self-report investigation, on 11/12/19, R2 suffered a preventable fall due to CNA-H not following R2's plan of care, resulting in R2 suffering a subdural hematoma and being placed in the Intensive Care Unit at the hospital. On 12/2/19 at 12:13 p.m., Surveyor informed Administrator-A and DON (Director of Nursing)-B of the above findings. Surveyor asked Administrator-A and DON-B if they had confirmed the above findings through the investigation reported to the State Agency on 11/12/19. Administrator-A and DON-B informed Surveyor that they had confirmed the above findings and noted that (R2's) fall was caused by CNA-H not following R2's plan of care, resulting in R2 suffering a subdural hematoma. No additional information was provided as to why R2 was not provided with bed mobility by two staff members instead of one to prevent accidents and falls. 3. R6 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R6's Significant Change in Status MDS (Minimum Data Set) dated 9/18/19, documents short and long term memory problems for R6. Section G (Functional Status) documents that R6 has total dependence on staff and requires a two person physical assist for her transfer and bed mobility needs. R6's Falls CAA (Care Area Assessment) documents under the Care Plan Considerations section, R6 has other fall risk factors, including her dx (diagnosis) of Down's Syndrome with cognitive/communication impairment .[MEDICAL CONDITION] disorder. The team agrees has continued risk for falls and risk for injury if they occur. Direct care staff to continue to provide interventions to help limit risk for falls. R6's Falls Risk assessment dated [DATE] documents a score of 12, indicating that R6 is at moderate risk for falls. R6's Falls care plan documents under the Interventions sections, Low boy bed with scoop mattress and floor matt to window side of bed. On 12/3/19 at approximately 12:08 pm, Surveyor observed R6 laying supine in bed with her bed not in the low position per R6's falls plan of care. On 12/3/19 at approximately 2:30 pm, Surveyor observed R6 in bed. R6 was non-interviewable and did not respond to Surveyors attempt to interact with her. Surveyor observed floor mats on each side of R6's bed. Surveyor observed on R6's bed an air mattress control device called Dynarex which was located on the bed frame at the foot of R6's bed. Surveyor observed R6's bed was not in a low position but rather was at medium (thigh level) height position. On 12/3/19, Surveyor reviewed R6's care card which the facility labels as the Visual/ Bedside Kardex Report located on the inside of R6's room door. The Visual/Bedside Kardex Report documented as of 11/26/19 the following instructions in part; Under Safety * Low boy bed with scoop mattress and floor matt to window side of bed * [MEDICAL CONDITION] Precautions if indicated; do not leave (R6) alone during a [MEDICAL CONDITION], Protect from injury, if she is out of bed, help to the floor to prevent injury, remove or loosen tight clothing. Don't attempt to restrain her during a [MEDICAL CONDITION], Protect from onlookers, draw curtain, etc. Under Resident Care * Anticipate and meet (R) needs, * She is non-verbal, but still speak to her when doing cares and with interactions. Under Mobility * Bed Mobility: (R6) requires 2 staff for repositioning and turning in bed and when in Broda chair every 2-3 hours. * Transfer: (R6) requires mechanical lift with 2 total staff assistance for transfers. Under Personal Hygiene/Oral * Dressing: (6) is totally dependent on 2 staff for dressing . * Personal Hygiene/Oral Care: (R6) is totally dependent on 1 staff for personal hygiene and oral care. Under Eating/Nutrition * (R) is depend is NPO (nothing by mouth). Even though R6's Visual/ Bedside Kardex Report with a date of 11/26/19 indicated the need for R6 to have a Low boy bed with scoop mattress . Surveyor did not observe R6's bed to be in a low position while R6 was in the bed on 12/3/19. On 12/3/19 at 2:35 pm, Certified Nursing Assistant (CNA) D and Registered Nurse (RN) [NAME] entered R6's room. CNA D stated she was assigned to R6 today. Surveyor asked CNA D if she thought R6's bed was in low position. CNA D stated the bed was not in its lowest position and it can go lower. CNA D stated that the air mattress machine was stopping the bed from going lower. Surveyor asked what the term Low boy bed meant which was documented on R6's Visual Bedside Kardex Report. RN [NAME] stated, A low boy bed is when the bed can go lower than normal all the way down. RN [NAME] reported there was no foot board on R6's bed as it broke a day or so ago and maintenance was now fixing it. RN [NAME] stated, Can't move the bed low due to the air mattress machine being in the way (air mattress machine was on the bed frame) and then stated can put the air mattress machine on the ground, (so that the bed could go lower). RN [NAME] stated, I will call maintenance to see how much longer. Surveyor understood RN [NAME] and CNA D to indicate the air mattress machine was originally placed on the foot board of the bed and when the foot board broke, the air mattress machine was placed either on the floor or onto the bed frame. When placed onto the bed frame, the air mattress machine prevented the bed from being lowered into the low boy bed position. Surveyor interviewed CNA D who indicated she received training a few weeks ago on following care cards while in a conference room in the lower level. CNA D stated they (facility staff) came up (to the unit) and demonstrated pivot transfers, all transfers. CNA D stated the resident care cards are on the back of the resident room doors and are in a blue binder at the nurse's station. CNA D informed Surveyor she has worked with R6 before and that the bed was lower than this in the past (referring to the bed being at a medium height.) At 2:55 pm, upon the completion of cares, Surveyor observed RN [NAME] place the air mattress machine onto the floor and lowered R6's bed. At 3:00 pm, Surveyor interviewed RN [NAME] who stated R6's foot board broke a day or 2 ago and that maintenance took it (foot board) 2 days ago. RN [NAME] stated she came on shift and it (foot board) was off so maybe it was Friday (11/29/19). RN [NAME] stated she made out a Maintenance slip who took it Monday (12/2/19). RN [NAME] stated, I'll call to see where they are at with it. Additionally RN [NAME] stated she received training on following care cards at a mandatory meeting but could not recall the exact date. Surveyor asked RN [NAME] how she ensures CNAs are following Resident care cards. RN [NAME] stated, I do rounds on shift, I start rounds at 6:30 a.m., and then I check during med pass. I spot check when assisting with transfers and Hoyer lifts, I help. Surveyor questioned RN [NAME] as to why she had not noticed R6's bed not being in a low position, prior to Surveyor's observation of this. RN [NAME] stated, When I came in (referring to when she came on duty) it (the bed) was in the low position with the air mattress machine being on the floor in the morning. RN [NAME] stated she was not sure if cares were provided after this observation was made. On 12/3/19 at approximately 12:08 pm and at 2:30 pm, Surveyors observed R6's Visual/Bedside Kardex Report had not been followed as R6's bed was observed not to be in the low boy bed position as indicated on the Visual/Bedside Kardex Report, but instead was observed at a medium height while R6 was in bed. On 12/3/19 at 3:20 pm, Surveyor interviewed Maintenance Director F who stated that the foot board to (R6's) bed was knocked off with a Hoyer Lift and that he was just coming down the steps after fixing the foot board. Maintenance Director F stated the foot board is now on the bed. On 12/3/19, Surveyor observed the Maintenance work order slip dated 12/3/19 from the nursing department which indicated the foot board to resident's bed was broken. On 12/3/19 at 3:49 pm, Surveyor asked CNA D why R6's bed was not in the low position when observed earlier in the day. CNA D informed Surveyor that at approximately 11 am, she was lowering R6's bed into the low position and accidentally crushed the air mattress machine, causing the footboard to come off. CNA D informed Surveyor that because of this, she did not leave R6's bed in the low position. On 12/3/19 at 4:00 pm, Surveyor shared the above information with Director of Nursing B. On 12/3/19 at 5:00 pm, Surveyor shared the above observation of R6's with Administrator A and Director of Nursing B. No additional information was provided as to why R6 was observed to not have her bed in the low position to prevent falls and accidents per her falls plan of care.

Based on record review and interviews, the facility did not immediately consult with the physician when a significant change of condition in the resident's physical and mental status occurred for 1 (R1) of 1 sampled residents reviewed for change of condition. On 1/8/18 at approximately 6:00 pm R1's family complained to facility nursing staff that R1 was experiencing a change in condition including staring to the left side, non-verbal, left hand grasp weak and right arm and hand flaccid. A Licensed Practical Nurse (LPN) assessed R1 and noted the changes in a progress note dated 1/8/18 at 6:41 pm. There is no indication that a Registered Nurse (RN) assessed R1 following the LPN's findings. There is no indication that R1's attending physician was contacted and consulted with regarding the changes in R1's condition. At the continued insistence of the family members, at approximately 9:00 pm, R1's physician was contacted and consulted with regarding R1's ongoing change in condition. At the time of contact with the physician R1 was now unresponsive. The physician gave orders to send R1 to the emergency department however, R1 was not transferred to the hospital until approximately 10:15 pm. Once at the hospital, it was determined R1 had sustained a stroke. The hospital record states: (R1) was brought to the emergency room with a window period of more than 4 and 0.5 hours, felt not a candidate of tPA (tissue plasminogen activator). R1 passed away on 1/14/18. The facility's failure to promptly consult with R1's physician at 6:00 pm when R1 first experienced a change in condition created a situation of immediate jeopardy for R1. The facility Nursing Home Administrator (NHA)-A and Director of Nurses (DON)-B were notified of the immediate jeopardy at approximately 9:50 am on 6/14/18. The immediate jeopardy started on 1/8/18 and was removed on 6/18/18. The deficient practice continues at a scope and severity of a D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: R1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. On 6/12/18 at 12:20 pm Surveyor spoke with OT (Occupation Therapist)-E to get a sense of R1's baseline arm/hand function. Surveyor reviewed the OT plan of care and confirmed the start of care date 12/30/17 which documented: Fine motor control LUE (Left upper extremity) and RUE (right upper extremity) minimally impaired. OT-E reported fine motor skills would be grasping utensils to feed himself or picking something up. OT-E stated R1 was able to reach out 25% like a Tyrannosaurus Rex and he was able to use both hands and arms for utensils and feeding himself. Reported R1 was not able to dress himself, but wanted to shave himself and would try. Progress notes dated 1/8/18 at 6:41 pm by LPN (Licensed Practical Nurse)-C.documented: Resident staring to left side while sitting up in w/c (wheelchair). Alert, non verbal. Moving feet while sitting in w/c. Hand grasp on left side weak. Right arm and hand flaccid. Spouse reported resident ate a good supper and all of a sudden became very weak and sleeping. Did wake up with much physical stimuli. (T) Temperature 98, (P) pulse 56, (B/P) blood pressure 120/58 (po) pulse oximetry 95%. Surveyor noted there was no indication or documentation the physician was notified and consulted with regarding these findings. Progress notes dated 1/8/18 at 9:00 pm documented: Resident assisted into bed per hoyer lift. Non responsive. Family at bedside, requested MD (Medical Doctor) be called and sent to the hospital. T 98.2 P 88 R (respirations) 18 B/P 148/80 po 95%. Documentation was entered by LPN-C. Progress notes dated 1/8/18 at 10:15 pm documented: Transferred to Wheaton St. Francis per ambulance. Documentation was entered by LPN-C. Progress notes dated 1/9/18 at 12:08 am documented: Resident appeared drowsy after meal tonight, being reported by wife/poa (Power of Attorney). VSS (Vital Signs Stable) and was arrousable with min (minimal) stimuli. Spoke with wife who thought that patient might merely be tired or not want to be bothered. At approximately 9 pm I received a call from nurse (LPN-C) that family was increasingly concerned. Assessed patient had declined somewhat from earlier assessment. Resident was thus sent to St. Francis for AMS (Altered Mental Status) and order was received from (MD-H) for this. Patient was admitted at St. Francis for AMS. Documentation was entered by RN-D. Surveyor noted this is the first indication that an RN had been involved in R1's change of condition. Surveyor noted the note did not include assessment details and was a reflective note. On 6/12/18 at 1:15 pm Surveyor spoke with Family Member-G who stated he was in to visit R1 at supper time. He stated: He was fine, eating dinner, feeding himself. He reported his Mom stayed after he left (not sure of the time; it was after supper). He stated: She (Mom) called me to tell me that around 6:30 pm he (R1) slumped over in the chair and she called the nurse. She told me he didn't look good and was not responding and that they weren't doing anything about it. Reported he came in around 8:30-9:00 after his Mom called him. He stated: She (Mom) told me the nurse said he was probably tired. I could tell immediately he was not right. A nurse did come in after I had to demand it. She took some vital signs. We said we wanted him to go the hospital. He didn't get sent out until (I think) almost 10:30 pm. Family Member-G added: I don't understand it. (LPN-C) has been his nurse all time time, you'd think she'd know something was wrong. The aide was there and she kept saying he's not right, they need to do something. He was admitted to the hospital and they told us he had a stroke. He ended up dying less than a week later. On 6/18/18 at 1:30 pm Surveyor spoke with Spouse-I who stated (R1) ate dinner around 5:00 pm. Her son had just left and around 6:00 pm (R1) finished a piece of cake she brought in for him. She stated: He turned around to look at me and slumped over. The nurse came in and tried to give him his pills and they were just running out of his mouth. I knew immediately something was wrong. He was slumped over and was not speaking or responding to me. She stated the nurse said she was going to call the supervisor. Reported the supervisor came around 6:30 pm. Surveyor asked if the supervisor did an assessment? Spouse-I stated: No, all she said was: Maybe we should put him to bed. Reported the supervisor left and the CNA's (Certified Nursing Assistants) came in around 7:00 pm (she thinks it was after Wheel of Fortune) and laid R1 down in bed. She stated: I knew something was wrong, he was not speaking, just staring. I asked if the supervisor would come back. Reported the supervisor did come back a short time later (not sure of the time) and she told her something was wrong. Reported the supervisor said: I'm new, I don't know what his condition is, we'll wait awhile. Maybe we should wait until morning and see what happens. Spouse-I stated: I asked her: Do you think he had a stroke? She said: We don't treat [MEDICAL CONDITION] here (were her exact words). I said: I'm not asking you to treat him, I'm asking if you think he had a stroke. She said: I'm new here, I don't know your husband. I said: Well I'm telling you this is not him. Reported she told the supervisor she wanted R1 hospitalized and the supervisor said: I can't admit him without a doctors order, medicare won't pay for it and you will have to pay. Reported the supervisor left and Spouse-I called her son and he came in. Reported around 9:00 pm they told the nurse supervisor they wanted R1 hospitalized . Reports the supervisor said she was trying to get hold of MD-H. Reported the supervisor told her again that insurance won't pay for it without a doctors order. Reported she said: I don't care. Reported the supervisor said they were going to call an ambulance and it took another hour or so before the ambulance came. On 6/12/18 at 3:15 pm Surveyor spoke with LPN-C and reviewed the progress notes LPN-C documented on 1/8/18. LPN-C stated she remembered the situation. She stated: He was fine at supper, I gave him his pills. All of a sudden he was slumped over. I'm sure I notified (RN-D). I'm sure we probably put him to bed. I'm sure (RN-D) came down pretty quick, she usually comes right away. LPN-C stated she is not sure if RN-D assessed R1. Surveyor reviewed the time R1 was sent to the ER with LPN-C. She stated: I can't believe we would have waited that long, it looks like he was having a stroke. On 6/12/18 at 3:30 pm Surveyor spoke with RN-D who stated she was not sure if she remembered the resident. Surveyor reviewed the progress notes dated 1/8/18 with RN-D and she stated: Oh yeah, I remember him now. Surveyor reviewed the progress notes documented by LPN-C with RN-D. She stated: I'm sure I came down to assess him, I would have come down right away. Surveyor asked RN-D why there was no charting until after midnight? RN-D stated: There must have been other stuff going on that night, I'm usually never here past 11:00 pm. RN-D stated: I was supervisor that night. When I assessed him, I didn't have a baseline to go by, I was new here then. I spoke to the family, they thought he was close to baseline and was maybe just being stubborn. Surveyor asked RN-D why there was not an assessment charted? RN-D stated: I did an assessment, but must not have charted it. RN-D confirmed there was no other place an assessment would be documented except for the progress notes. RN-D stated: I think I originally assessed him around 7:00 pm, but I'm not exactly sure of the time, it might have been earlier, because I would have come right down when (LPN-C) called me. When I assessed him, I wasn't seeing the same things she did. He responded to me. RN-D stated R1's wife was present both times she assessed him. Surveyor asked why R1 was transferred to the hospital so much later than the original assessment by LPN-C? RN-D stated: He probably went out by Paratech ambulance, I don't think it was 911. I probably reported to Paratech a change in mental status, I can't remember specifically what I told them. He (referring to R1) may have not been responding at that point. Surveyor review of the facility's 24 hour report documented: PM assessment: 6:00 pm - staring to left side. T 98 P 56 R 20 B/P 120/58. 9:00 pm - Non responsive 10:15 pm - Sent to Wheaton St. Francis N[NAME] (night) assessment: Called St. Francis Hospital ER (emergency room ) - Resident being admitted with [DIAGNOSES REDACTED].>Hospital AMS/(Stroke?) s/s (signs/symptoms) Physician's Telephone Order dated 1/8/18 and signed by LPN-C documented: Transport to SFH (St. Francis Hospital) for eval (evaluation) and tx (treatment). Surveyor noted there was no time documented on the telephone order. On 6/13/18 at 12:05 pm Surveyor spoke with MD-H who stated he remembered the resident. Surveyor read the documentation of LPN-C at 6:41 pm. MD-H stated: I would expect a call based on that assessment. If he (R1) was staring to the left and had arm weakness or an arm that was flaccid, I absolutely would expect a call. It sounded like a change of condition, I would have had him sent to the ER. MD-H stated he did not recall receiving a call from the facility regarding the LPN assessment/note before the call to transfer him to the ER. Surveyor read the LPN documentation at 9 pm of R1 being non-responsive. Surveyor asked MD-H if he remembered what time the facility called and he provided the telephone order to send R1 to the ER? MD-H stated: I receive so many calls. To be honest, I don't remember what time they called. ED (Emergency Department) provider notes dated 1/8/18 at 10:31 pm documented: [AGE] year old male with multiple medical problems presents to the ED with chief complaint of altered mental status. History seems to suggest that the symptoms began approximately 4 and 0.5 hours ago. Our nurse called the patient's nurse at (the facility) who states that the patient seemed to become progressively worse. At baseline, is reported to be alert and oriented x 2. Patient is unable to give any additional history at this time. He is essentially nonverbal. Physician Discharge Summary dated 1/14/18 at 4:22 am documented: Hospital course: [AGE] year old thin built gentlemen currently nursing home resident was noted to have altered mental status, gradually worsening as per nursing report, was brought to the emergency room with a window period of more than 4 and 0.5 hours, felt not a candidate of tPA (tissue plasminogen activator). During the workup patient had MRI (magnetic resonance imaging) done which showed large left frontal ischemic stroke without hemorrhage transformation. Patient did have persistent [MEDICAL CONDITION] and after having detailed discussion with the family, they decided to get a PEG (percutaneous endoscopic gastrostomy) tube and to monitor closely and reassess in 6-8 weeks if does not show any improvement applying to go for comfort measures at the nursing home. In the meantime patient developed back episode of severe [MEDICAL CONDITION] and cardio respiratory arrest and because of his DNR (do not resuscitate) status, no aggressive interventions were suggested and eventually on the early morning of (MONTH) 14th he was found to have no cardiac respiratory activity and was pronounced dead. Discharge Diagnoses: [REDACTED]. Large acute left frontal ischemic stroke, no hemorrhagic transformation. Dysphagia secondary to large acute left frontal ischemic stroke, status [REDACTED]. The facility's failure to promptly consult with R1's physician at the time of a change in condition created a situation of immediate jeopardy that started on 1/8/18. The facility removed the immediate jeopardy on 6/18/18 when it implemented the following action plan. The deficient practice continues at a scope and severity of a D - potential for for more than harm/isolated. By 6/18/18 the facility implemented the following: ~ The facility's change in condition and physician notification policies and procedures were reviewed and approved by the facility's new Medical Director that started on 6/14/18. ~ The facility developed and initiated training on physician notification and assessment for change in condition for all nursing staff ensuring all staff are trained prior to initiating next tour of duty. ~ Facility nursing staff were trained on the roles of LPN and RN including education that LPN to collect data and observation of the resident report then to the RN on duty. RN then will complete an assessment. RN will notify MD based on assessment. ~ Training was initiated with the licensed nurses on the sign and symptoms of a stroke. ~ The facility established an audit process to monitor physician consultation and response to changes in conditions. ~ The facility established a QAPI (Quality Assessment Improvement Plan) to assist in reestablishing and maintaining compliance.

Based on record review and interviews, the facility did not complete a comprehensive assessment of the resident when a change of condition in the resident's physical and mental status occurred for 1 (R1) of 1 sampled residents reviewed for change of condition. R1 had a change of condition that occurred on 1/8/18 between the hours of 6:00 pm and 6:41 pm that included staring to the left side, non-verbal, left hand grasp weak and right arm and hand flaccid. The was noted by a Licensed Practical Nurse (LPN). There is no contemporaneous documentation that an RN competed an assessment at this time. There is no indication facility staff consulted with R1's attending physician regarding the change in condition (Cross-reference F580). At 9:00 pm it was documented the resident was non-responsive and the family demanded the resident be sent to the hospital. The nurse did not call 911 for immediate transfer. At 10:15 pm it was documented the resident was transferred to the hospital. Documentation was completed by an LPN (Licensed Practical Nurse). There was no indication or documentation that a comprehensive RN assessment was completed. The RN progress note on 1/9/18 at 12:08 am did not include documentation of a comprehensive assessment. RI was transferred to the hospital where he was admitted with a chief complaint of altered mental status that began 4.5 hours ago, that had become progressively worse. MRI (magnetic resonance imaging) showed a large left frontal ischemic stroke without hemorrhage transformation. With a window period of more than 4.5 hours, he was not a candidate of tPA (tissue plasminogen activator). During his hospital stay, R1 developed back episode of severe [MEDICAL CONDITION] and cardio respiratory arrest and because of his DNR (do not resuscitate) status, no aggressive interventions were suggested and eventually on the early morning of (MONTH) 14th he was found to have no cardiac respiratory activity and was pronounced dead. The facility's failure to ensure a comprehensive RN assessment at 6:00 pm when R1 first experienced a change and its failure to respond appropriately to this signficant change in condition created a situation of immediate jeopardy for R1. The facility Nursing Home Administrator (NHA)-A and Director of Nurses (DON)-B were notified of the immediate jeopardy at approximately 9:50 am on 6/14/18. The immediate jeopardy started on 1/8/18 and was removed on 6/18/18. The deficient practice continues at a scope and severity of a D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: R1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. On 6/12/18 at 12:20 pm Surveyor spoke with OT (Occupation Therapist)-E to get a sense of R1's baseline arm/hand function. Surveyor reviewed the OT plan of care and confirmed the start of care date 12/30/17 which documented: Fine motor control LUE (Left upper extremity) and RUE (right upper extremity) minimally impaired. OT-E reported fine motor skills would be grasping utensils to feed himself or picking something up. OT-E stated R1 was able to reach out 25% like a Tyrannosaurus Rex and he was able to use both hands and arms for utensils and feeding himself. Reported R1 was not able to dress himself, but wanted to shave himself and would try. Progress notes dated 1/8/18 at 6:41 pm documented: Resident staring to left side while sitting up in w/c (wheelchair). Alert, non verbal. Moving feet while sitting in w/c. Hand grasp on left side weak. Right arm and hand flaccid. Spouse reported resident ate a good supper and all of a sudden became very weak and sleeping. Did wake up with much physical stimuli. (T) Temperature 98, (P) pulse 56, (B/P) blood pressure 120/58 (po) pulse oximetry 95%. Documentation was entered by LPN (Licensed Practical Nurse)-C. Surveyor noted there was no contemporaneous documentation that a comprehensive RN assessment was completed or that R1's physician was consulted with. Progress notes dated 1/8/18 at 9:00 pm documented: Resident assisted into bed per hoyer lift. Non responsive. Family at bedside, requested MD (Medical Doctor) be called and sent to the hospital. T 98.2 P 88 R (respirations) 18 B/P 148/80 po 95%. Documentation was entered by LPN-C. Progress notes dated 1/8/18 at 10:15 pm documented: Transferred to Wheaton St. Francis per ambulance. Documentation was entered by LPN-C. Progress notes dated 1/9/18 at 12:08 am by RN-D documented: Resident appeared drowsy after meal tonight, being reported by wife/poa (Power of Attorney). VSS (Vital Signs Stable) and was arrousable with min (minimal) stimuli. Spoke with wife who thought that patient might merely be tired or not want to be bothered. At approximately 9 pm I received a call from nurse (LPN-C) that family was increasingly concerned. Assessed patient had declined somewhat from earlier assessment. Resident was thus sent to St. Francis for AMS (Altered Mental Status) and order was received from (MD-H) for this. Patient was admitted at St. Francis for AMS. Surveyor noted there was no documentation of a comprehensive assessment completed. Surveyor noted this is the first indication that an RN had been involved in R1's change of condition. Surveyor noted the note did not include assessment details and was a reflective note. On 6/12/18 at 1:15 pm Surveyor spoke with Family Member-G who stated he was in to visit R1 at supper time. He stated: He was fine, eating dinner, feeding himself. He reported his Mom stayed after he left (not sure of the time; it was after supper). He stated: She (Mom) called me to tell me that around 6:30 pm he (R1) slumped over in the chair and she called the nurse. She told me he didn't look good and was not responding and that they weren't doing anything about it. Reported he came in around 8:30-9:00 after his Mom called him. He stated: She (Mom) told me the nurse said he was probably tired. I could tell immediately he was not right. A nurse did come in after I had to demand it. She took some vital signs. We said we wanted him to go the hospital. He didn't get sent out until (I think) almost 10:30 pm. Family Member-G added: I don't understand it. (LPN-C) has been his nurse all time time, you'd think she'd know something was wrong. The aide was there and she kept saying he's not right, they need to do something. He was admitted to the hospital and they told us he had a stroke. He ended up dying less than a week later. On 6/18/18 at 1:30 pm Surveyor spoke with Spouse-I who stated R1 ate dinner around 5:00 pm. Her son had just left and around 6:00 pm R1 finished a piece of cake she brought in for him. She stated: He turned around to look at me and slumped over. The nurse came in and tried to give him his pills and they were just running out of his mouth. I knew immediately something was wrong. He was slumped over and was not speaking or responding to me. She stated the nurse said she was going to call the supervisor. Reported the supervisor came around 6:30 pm. Surveyor asked if the supervisor did an assessment? Spouse-I stated: No, all she said was: Maybe we should put him to bed. Reported the supervisor left and the CNAs (Certified Nursing Assistants) came in around 7:00 pm (she thinks it was after Wheel of Fortune) and laid R1 down in bed. She stated: I knew something was wrong, he was not speaking, just staring. I asked if the supervisor would come back. Reported the supervisor did come back a short time later (not sure of the time) and she told her something was wrong. Reported the supervisor said: I'm new, I don't know what his condition is, we'll wait awhile. Maybe we should wait until morning and see what happens. Spouse-I stated: I asked her: Do you think he had a stroke? She said: We don't treat [MEDICAL CONDITION] here (were her exact words). I said: I'm not asking you to treat him, I'm asking if you think he had a stroke. She said: I'm new here, I don't know your husband. I said: Well I'm telling you this is not him. Reported she told the supervisor she wanted R1 hospitalized and the supervisor said: I can't admit him without a doctors order, medicare won't pay for it and you will have to pay. Reported the supervisor left and Spouse-I called her son and he came in. Reported around 9:00 pm they told the nurse supervisor they wanted R1 hospitalized . Reports the supervisor said she was trying to get ahold of MD-H. Reported the supervisor told her again that insurance won't pay for it without a doctors order. Reported she said: I don't care. Reported the supervisor said they were going to call an ambulance and it took another hour or so before the ambulance came. On 6/12/18 at 3:15 pm Surveyor spoke with LPN-C and reviewed the progress notes LPN-C documented on 1/8/18. LPN-C stated she remembered the situation. She stated: He was fine at supper, I gave him his pills. All of a sudden he was slumped over. I'm sure I notified (RN-D). I'm sure we probably put him to bed. I'm sure (RN-D) came down pretty quick, she usually comes right away. LPN-C stated she is not sure if RN-D assessed R1. Surveyor reviewed the time R1 was sent to the ER with LPN-C. She stated: I can't believe we would have waited that long, it looks like he was having a stroke. On 6/12/18 at 3:30 pm Surveyor spoke with RN-D who stated she was not sure if she remembered the resident. Surveyor reviewed the progress notes dated 1/8/18 with RN-D and she stated: Oh yeah, I remember him now. Surveyor reviewed the progress notes documented by LPN-C with RN-D. She stated: I'm sure I came down to assess him, I would have come down right away. Surveyor asked RN-D why there was no charting until after midnight? RN-D stated: There must have been other stuff going on that night, I'm usually never here past 11:00 pm. RN-D stated: I was supervisor that night. When I assessed him, I didn't have a baseline to go by, I was new here then. I spoke to the family, they thought he was close to baseline and was maybe just being stubborn. Surveyor asked RN-D why there was not an assessment charted? RN-D stated: I did an assessment, but must not have charted it. RN-D confirmed there was no other place an assessment would be documented except for the progress notes. RN-D stated: I think I originally assessed him around 7:00 pm, but I'm not exactly sure of the time, it might have been earlier, because I would have come right down when (LPN-C) called me. When I assessed him, I wasn't seeing the same things she did. He responded to me. RN-D stated R1's wife was present both times she assessed him. Surveyor asked why R1 was transferred to the hospital so much later than the original assessment by LPN-C? RN-D stated: He probably went out by Paratech ambulance, I don't think it was 911. I probably reported to Paratech a change in mental status, I can't remember specifically what I told them. He (referring to R1) may have not been responding at that point. On 6/13/18 at 8:30 am Surveyor spoke with CNA (Certified Nursing Assistant)-F who was assigned to R1 on the date in question, and reviewed the events of 1/8/18 with her. CNA-F reported she worked for the facility here and there and does not remember the resident or the situation on 1/8/18. Surveyor review of the facility's 24 hour report documented: PM assessment: 6:00 pm - staring to left side. T 98 P 56 R 20 B/P 120/58. 9:00 pm - Non responsive 10:15 pm - Sent to Wheaton St. Francis N[NAME] (night) assessment: Called St. Francis Hospital ER (emergency room ) - Resident being admitted with [DIAGNOSES REDACTED].>Hospital AMS/(Stroke?) s/s (signs/symptoms) Physician's Telephone Order dated 1/8/18 and signed by LPN-C documented: Transport to SFH (St. Francis Hospital) for eval (evaluation) and tx (treatment). Surveyor noted there was no time documented on the telephone order. On 6/13/18 at 12:05 pm Surveyor spoke with MD-H who stated he remembered the resident. Surveyor read the documentation of LPN-C at 6:41 pm. MD-H stated: I would expect a call based on that assessment. If he (R1) was staring to the left and had arm weakness or an arm that was flaccid, I absolutely would expect a call. It sounded like a change of condition, I would have had him sent to the ER. MD-H stated he did not recall receiving a call from the facility regarding the LPN assessment/note or before the call to transfer him to the ER. Surveyor read the LPN documentation at 9 pm of R1 non-responsive. Surveyor asked MD-H if he remembered what time the facility called and he provided the telephone order to send R1 to the ER? MD-H stated: I receive so many calls. To be honest, I don't remember what time they called. ED (Emergency Department) provider notes dated 1/8/18 at 10:31 pm documented: [AGE] year old male with multiple medical problems presents to the ED with chief complaint of altered mental status. History seems to suggest that the symptoms began approximately 4 and 0.5 hours ago. Our nurse called the patient's nurse at (the facility) who states that the patient seemed to become progressively worse. At baseline, is reported to be alert and oriented x 2. Patient is unable to give any additional history at this time. He is essentially nonverbal. Physician Discharge Summary dated 1/14/18 at 4:22 am documented: Hospital course: [AGE] year old thin built gentlemen currently nursing home resident was noted to have altered mental status, gradually worsening as per nursing report, was brought to the emergency room with a window period of more than 4 and 0.5 hours, felt not a candidate of tPA (tissue plasminogen activator). During the workup patient had MRI (magnetic resonance imaging) done which showed large left frontal ischemic stroke without hemorrhage transformation. Patient did have persistent [MEDICAL CONDITION] and after having detailed discussion with the family, they decided to get a PEG (percutaneous endoscopic gastrostomy) tube and to monitor closely and reassess in 6-8 weeks if does not show any improvement applying to go for comfort measures at the nursing home. The meantime patient developed back episode of severe [MEDICAL CONDITION] and cardio respiratory arrest and because of his DNR (do not resuscitate) status, no aggressive interventions were suggested and eventually on the early morning of (MONTH) 14th he was found to have no cardiac respiratory activity and was pronounced dead. Discharge Diagnoses: [REDACTED]. Large acute left frontal ischemic stroke, no hemorrhagic transformation. Dysphagia secondary to large acute left frontal ischemic stroke, status [REDACTED]. The facility's failure to respond to R1's change in condition created a situation of immediate jeopardy that started on 1/8/18. The facility removed the immediate jeopardy on 6/18/18 when it implemented the following action plan. The deficient practice continues at a scope and severity of a D - potential for more than minimal harm/isolated. By 6/18/18 the facility implemented the following: ~ The facility's change in condition and physician notification policies and procedures were reviewed and approved by the facility's new Medical Director that started on 6/14/18. ~ The facility developed and initiated training on physician notification and assessment for change in condition for all nursing staff ensuring all staff are trained prior to initiating next tour of duty. ~ Facility nursing staff were trained on the roles of LPN and RN including education that LPN to collect data and observation of the resident report then to the RN on duty. RN then will complete an assessment. RN will notify MD based on assessment. ~ Training was initiated with the licensed nurses on the sign and symptoms of a stroke. ~ The facility established an audit process to monitor physician consultation and response to changes in conditions. ~ The facility established a QAPI (Quality Assessment Improvement Plan) to assist in reestablishing and maintaining compliance.

Based on observation, interview, and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infection. The facility's infection control program failed to prevent the spread of an acute respiratory illness when the facility: -Failed to identify and put measures in place to prevent and contain an acute respiratory illness outbreak starting on 9/16/17 when 3 residents (R15, R32, and R33) on the 1-West unit, 2 residents on the 1-East unit (R34 and R35), and 1 resident (R13) on the 2-East unit were noted to have an acute respiratory illness. -Failed to demonstrate housekeeping, nursing, and therapy staff using appropriate use of transmission-based precautions for residents observed on droplet and contact precautions. -Failed to appropriately disinfect patient care equipment between residents with an acute respiratory illness and well residents. -Failed to consistently demonstrate appropriate hand hygiene. A total of 15 (R15, R32, R33, R34, R35, R13, R30, R22, R38, R14, R24, R2, R12, R31, and R9) residents developed signs or symptoms of an acute respiratory illness. A total of 6 (R15, R34, R13, R30, R14, and R12) residents went to the hospital after experiencing signs or symptoms of an acute respiratory illness. The facility's failure to put measures in place to prevent the spread of infection had the potential to affect 87 of 87 residents residing at the facility. The facility's failure to identify, contain, and prevent the spread of an acute respiratory illness outbreak created a finding of immediate jeopardy beginning on 9/16/17. Administrator-A and DON (Director of Nursing)-B were informed of the immediate Jeopardy on 10/4/17 at 2:35 p.m. The Immediate Jeopardy was removed on 10/4/17 when the facility implemented their action plan; however, the deficient practice continues at a scope and severity level of an E (potential for harm/pattern) as the facility has not fully implemented its removal plan and based on the following examples: -Staff did not wash their hands after each direct resident contact for which handwashing is indicated by accepted professional practice during observations of care for R14, R15, and R4. -A barrier was not placed on the floor when staff emptied R3 and R4's urinary collection bags. Findings include: 1.) On 9/28/17 at 9:05 a.m. the surveyor interviewed ADON (Assistant Director of Nursing)-R. ADON-R serves as the facility's infection control preventionist. During the interview ADON-R informed the surveyor the facility utilizes the State of Wisconsin Department of Health Services November 14, 2016 memo for Reporting, prevention, and control of acute respiratory illness outbreaks in long-term care facilities for their policy and procedure to prevent and control an acute respiratory illness. The memo, in part, states A respiratory disease outbreak in a LTCF (long term care facility) is defined by DPH (Department of Public Health) as three or more residents and/or staff from the same unit with illness onsets within 72 hours of each other and who have: Pneumonia, or ARI (acute respiratory illness) or Laboratory-confirmed viral or bacterial infection including influenza). The memo also defines an acute respiratory illness as an illness characterized by any two (2) of the following: Fever, Cough (new or worsening, productive or nonproductive) Rhinorrhea (runny nose) or nasal congestion, sore throat, myalgia (muscle aches) greater than the resident's norm. The memo also states Caregivers and visitors should adhere to the appropriate precautions when in the presence of a resident with suspected or confirmed respiratory illness. Until the causes(s) of an ARI outbreak is determined, both droplet and contact precautions should be initiated in addition to standard precautions. 4.1 Droplet Precautions are intended to prevent transmission of pathogens spread though close respiratory of mucous membrane contact with respiratory secretions. In contrast to contact transmission, respiratory droplets carry and transmit infectious pathogens when they travel directly from the respiratory tract of the infectious individual to susceptible mucosal surface of the recipient, generally over short distances. 4.1.1 Health care personal should wear a mask (a respirator is not necessary) for close contact with an ill resident. The mask is generally donned immediately prior to room entry. 4.1.2 Residents on droplet precautions who must be transported outside of their room should wear a mask if tolerated and practice respiratory hygiene/cough etiquette. 4.2 Contact Precautions apply when the presence of discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission. 4.2.1 Health care staff should wear a gown and gloves for all interactions that may involve direct contact with the resident or potentially contaminated areas in the environment. 4.2.2 Donning PPE (personal protection equipment) immediately prior to room and entry and discarding before exiting the room to contain pathogens implicated in direct transmission or indirect transmission through environmental contamination. On 9/28/17 at 9:05 a.m. the surveyor interviewed ADON-R. The surveyor asked if the cause of the respiratory outbreak was determined. ADON-R stated no. The surveyor asked ADON-R what type of precautions were in place for symptomatic residents. ADON-R stated respiratory and standard. The surveyor asked ADON-R to clarify respiratory isolation. ADON-R clarified respiratory to mean droplet precautions. The surveyor asked what was the expectation of staff to follow for a resident on droplet precautions. ADON-R stated staff should wear a mask. On 9/14/17, 1 resident (R15) on the 1-West unit was noted on report for cough, nasal congestion, and fever. The surveyor reviewed R15's progress notes and was unable to find documentation that R15 was immediately placed in contact and droplet precautions. On 9/15/17, 2 residents (R15 and R32) on the 1-West unit, 2 residents on 1-East (R34 and R35), and 1 resident on 2-East (R13) were now noted to have an acute respiratory illness. R32 was noted to have a fever, cough, and nasal congestion. R34 was noted to have a fever, cough, and nasal congestion. R35 was noted to have a cough and nasal congestion. R13 was noted to have a cough and nasal congestion. The surveyor reviewed R32, R34, R35, and R13's medical record and was unable to find documentation that they were immediately placed in contact and droplet precautions. On 9/16/17, 3 residents (R15, R32, and R33) on the 1-West unit, 2 residents on the 1-East unit (R34 and R35), and 1 resident on the 2-East (R13) unit were noted to have an acute respiratory illness. R33 was noted to have a cough and nasal congestion. The facility failed to recognize on 9/16/17 that the 1-West unit now met their definition of an outbreak, with 3 residents (R15, R32, R33) meeting the definition of an acute respiratory illness. Per the facility's Respiratory Outbreak timeline received on 9/28/17 on 9/16/17 All symptomatic residents placed (on) isolation. An updated timeline received 10/3/17 states on 9/16/17 All symptomatic residents placed (on) isolation droplet and contact. DON (Director of Nursing)-B and ADON-R were not notified of the outbreak on 9/16/17. Aggressive measures were not put into place to prevent the outbreak from spreading on 9/16/17. On 9/16/17, R32 was started on antibiotics for a lung infiltrate. On 9/16/17- 9/24/17, R34 was hospitalized with a discharge [DIAGNOSES REDACTED]. On 9/17/17, R30 was noted to have a cough and congestion. R30 was sent to the hospital and hospitalized from [DATE]-9/28/17 with discharge [DIAGNOSES REDACTED]. Additional information on R30's infectious process indicates: R30 had a history of [REDACTED]. R30 was most recently re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The readmission nursing note on 9/14/17, at 11:45 A.M., stated the following assessment of R30's lungs, HRR regular (heart rate regular), lungs clear. No sob (shortness of breath) noted. This note was signed by Registered Nurse (RN) Manager-N. On 9/15/17, at 5:59A.M., the nursing progress note stated, .resident has non productive cough noted on shift lungs congested . On 9/15/17, at 2:13P.M., the nursing progress note stated, .lungs remain congested. No SOB or resp distress On 9/15/17, at 10:43P.M., the nursing progress note stated, .remains on abt(antibiotic)-no adverse reaction. Lung sounds congested. On 9/16/17, at 6:12A.M., the nursing progress note stated, .resident has dry non productive cough noted with much congestion RN supervisor notified and came over to assess. Resident denies any SOB or trouble breathing. On 9/16/17, at 6:28A.M., the nursing progress note stated, .Denies having any breathing difficulty, but some audible wheezes noted, and rhonchi auscultated t/o lung fields . On 9/16/17, at 10:31A.M., the nursing progress note stated, .Lung sounds coarse in upper lobes, coughing and deep breathing exercises completed with resident/tolerated well. Breathing even and non-labored NO SOB or respiratory distress noted. On 9/16/17, at 11:17P.M., the nursing progress note stated, Lungs remain congested. On 9/17/17, at 6:34A.M., the nursing progress note stated, resident has congestion and edema in ble's (bilateral lower extremities). Prevalon boots on. Resident denies sob or difficulty breathing .abdomen soft non tender resident states he feels fine and has zero issues breathing. On 9/17/17, at 10:52A.M., the nursing progress note stated, .lungs congested but clear with coughing and deep breathing exercises., no sob or respiratory distress noted, breathing even and non-labored . On 9/17/17, 1:22P.M., the nursing progress note stated, Pt noted to have increased congestion/cough in the afternoon. Lungs coarse/Pt noted to gave (sic) decreased appetite. Vitals bp 144/76 P-78 RR-20 Temp 98.4 Spo2-97% RA The facility contacted R30's primary care physician and R30 was sent to the hospital on [DATE]. There is no evidence the facility placed R30 into isolation. R30's nursing progress note from 9/17/17 at 11:23P.M. stated, Resident admitted to (hospital) with [DIAGNOSES REDACTED]. R30's Hospital History and Physical (H&P) dated 9/18/17 stated, (R30) is a [AGE] year old male with a PMH (past medical history) of quadriplegia, post c1-c4 mechanical fractures, ESRD s/p transplant, CAD who presented with a complaint of raspy cough. He is a nursing home patient as a result of his quadriplegia. A chest x-ray reveals left mid to lower lung hazy airspace opacities concerning for pneumonitis. He was transferred to MRICU for further management. He denies feeling ill, nausea, chills, fever. He says I've just had this cough for I think 2 weeks. He denies dyspnea and hemoptysis. His cough is congested but nonproductive. It just doesn't come up. He says he has been eating and drinking without issue and having bowel movements. The History and Physical lists the following Active Problems: -Healthcare Acquired Pneumonia -Respiratory acidosis -Quadriplegia -Immuno-suppression s/p renal transplant. The baseline hospital pulmonary assessment on the H&P stated, On 4L (Liters) NC (nasal cannula), appears comfortable. Sats 100%. Possible HAP (healthcare acquired pneumonia), resides in nursing home. CXR (chest x-ray) with left mid to lower lung hazy airspace opacities. Rhonchi to bases. Questionable aspiration pneumonitis? Was recently seen in ER for AMS (altered mental status), may have aspirated R30 was discharged from the hospital after 12 days, and was readmitted to the facility on [DATE]. R30's facility Nursing Admission Evaluation dated, 9/28/17, indicated R30's admission [DIAGNOSES REDACTED]. Upon admission on 9/28/17, R30's lung sounds were checked as normal. Additional Resident's admitted to the Hospital or with symptoms: On 9/17/17, R15 was admitted to the hospital until 9/21/17. R15 had [DIAGNOSES REDACTED]. On 9/17/17, R33 had a chest x-ray ordered that was positive for pneumonia. On 9/17/17, R13 was admitted to the hospital until 9/21/17. R13 had discharge [DIAGNOSES REDACTED]. On 9/17/17, R22, who resides on the 2-East unit, progress notes document C(NAME) (change of condition)/COUGHING/CONGESTION/TEMPERATURE: T (temperature) 99.7 BP(blood pressure) 129/90 (pulse) 80 (respirations) 20 SPO2 (pulse oximetry) 94%. On 9/3/17, before R22 was noted to have respiratory symptoms, R22's vitals were noted to be Temperature-97.6, Blood pressure-104/56, Pulse-80, Respirations-20, Pulse Oximetry- 95% on room air. Per the facility's Respiratory Outbreak timeline, the only measure that was put into place on 9/17/17 to prevent the outbreak from spreading was Sign placed in front lobby alerting visitor of increase in respiratory illness on units. On 9/28/17 at 9:05 a.m. the surveyor interviewed ADON-R. ADON-R informed the surveyor that the facility was currently experiencing a respiratory outbreak. The surveyor asked when the outbreak was considered as present. ADON-R informed the surveyor on 9/18/17 we (the facility) called the outbreak. The surveyor asked why an outbreak was not considered on 9/16/17 when 3 three residents on the 1- West unit were ill within 72 hours. ADON-R stated that she did not know, that she was not made aware until when she came in on Monday 9/18/17. ADON-R confirmed that the outbreak would have begun on 9/16/17. The surveyor asked who monitors on weekends (for potential outbreaks). ADON-R stated the supervisor. ADON-R informed the surveyor that a checklist is kept on the units to inform supervisors of what to do in the event of any outbreak. The surveyor asked if they (ADON-R), as the facility's infection preventionist, should be notified of any outbreak. ADON-R stated yes. ADON-R confirmed that she was not made aware of the outbreak until Monday 9/18/17. ADON-R provided the surveyor with a copy of the Suspected Outbreak Checklist. The surveyor observed the checklist instructions included to 1. Isolate residents from each other by keeping them to their rooms. 2. Notify Activites of ill resident. Discontinue group activities between ill and well residents. 3. Notify Dietary of ill residents. Have ill residents eat their meals in their room. 4. Notify Housekeeping of ill residents. Increase cleaning schedule to these areas. 5. Notify Maintenance of ill resident rooms. 6. Notify Therapy of ill resident 7. Place a sign on the entrance to alert visitors of the outbreak. 8. Notify Infection Prevention/designee 9. Notify on Call/ designee of outbreak policy implemented. 10. Notify the City of Milwaukee Health Department 11. Notify medical director. On 9/27/17 at 3:18 p.m. the surveyor interviewed Director of Nursing (DON)-B. The surveyor asked when DON-B was informed of the respiratory outbreak. DON-B stated Sunday, September 17th. The surveyor asked what was done when she was notified. DON-B stated she asked (staff) to do an assessment, to keep staff from floating, start a line listing, isolation was started, place a sign by the front door, make sure masks were available at the front desk, and by that time it was 2 in the morning and she would be in in a couple of hours (Monday morning). On 9/18/17, per the facility's Respiratory Outbreak timelines, at 0900 (9am) an outbreak was called due to above stated residents exhibiting respiratory symptoms. Housekeeping, Laundry, Activities, therapy, admissions, central supply and dietary notified. All sick residents to remain in their rooms, not to attend social dining or activities. Sick residents to eat in their rooms. Sick residents to receive therapy in their rooms. Housekeeping will increase the cleaning of sick rooms. 1140 (11:40 a.m.) Milwaukee Health Department .called .medical director notified. On 9/28/17 at 2:32 p.m. the surveyor interviewed Environmental Service Director-SS. The surveyor asked Environmental Service Director when she was first notified of the outbreak. Environmental Services director stated last Monday (9/18/17). On 9/28/17 at 1:46 p.m. the surveyor interviewed Activity Director-G. The surveyor asked Activity Director-G when she was first notified of the outbreak. Activity Director-G stated she believed it was (September) the 18th. On 9/18/17, R38, who resides on the 1-East unit, developed symptoms of an acute respiratory illness including fever and cough. On 9/19/17, R14, who resides on the 1-West unit, developed symptoms of an acute respiratory illness including fever and cough. R14 was hospitalized from [DATE]-9/21/17 with a discharge [DIAGNOSES REDACTED]. On 9/19/17, R24, who residents on the 1-East unit, developed symptoms of an acute respiratory illness, including cough, myalgia, and nasal congestion. On 9/19/17, R2, who resides on the 1-West unit, developed symptoms of an acute respiratory illness, including fever and cough. A chest x-ray was ordered, was positive for a lung infiltrate, and R2 was started on antibiotics. On 9/19/17, R12, who resides on the 1-East unit, developed a cough. R12 went out to the hospital on [DATE] with chest pain, was hospitalized through 9/26/17. R12's discharge [DIAGNOSES REDACTED]. On 9/21/17, R31, who resides on the 1-West unit, developed symptoms of an acute respiratory illness including a fever and a cough. R31 was started on antibiotics. Observations of staff not following recommended precautions or infection prevention measures: On 9/26/17 at 11:06 a.m. the surveyor observed LPN (licensed practical nurse)-JJ giving R35 medications. The surveyor observed a white signs on R35's door stating Please see the nurse before entering. The surveyor observed that LPN-JJ was not wearing gloves, a mask, or a gown. The surveyor observed that LPN-JJ was within 3 feet of R35. The surveyor observed LPN-JJ give R35 a glass of water, place his call light within reach, exit the room and use hand sanitizer on her cart. On 9/26/17 at 11:20 a.m. the surveyor observed CNA (certified nursing assistant)-FF enter R24's room. The surveyor observed a white sign on R24's door stating Please see the nurse before entering. The surveyor observed CNA-FF did not have on gloves, a gown, or a mask. CNA-FF went within 3 feet of R24. The surveyor observed CNA-FF exit R24's room without washing her hands. CNA-FF then went into room [ROOM NUMBER] and closed the door. On 9/27/16 at 7:48 a.m. the surveyor observed RN (registered nurse)-I enter R2's room. The surveyor observed a white sign on R2's door stating Please see the nurse before entering. The surveyor observed RN-I had gloves, but no mask or gown on. The surveyor observed RN-I look at R2's feet. RN-I used hand sanitizer, exited the room, went to the medication room, and returned with ostomy supplies. RN-I reapplied gloves and re-entered the room. RN-I did not don a mask or a gown. RN-I assisted to change R2's ostomy appliances. RN-I was near R2's head of bed. The surveyor observed R2 coughing while RN-I was in close proximity to R2. The surveyor observed RN-I exit the room and use hand sanitizer. On 9/27/17 at 7:53 a.m. the surveyor observed Restorative Aide-QQ pushing R14 out of her bathroom. Restorative Aide-QQ did not have a gown, mask, or gloves on. The surveyor observed a white sign on R14's door stating Please see the nurse before entering. On 9/27/17 at 7:54 a.m. the surveyor observed RN-I re-enter R2's room with no gown, gloves, or mask on. The surveyor observed R2 cough as RN-I was within 2 feet of R2's head of bed. The surveyor observed RN-I lower R2's head of bed and exit the room and use sanitizer. On 9/27/17 at 8:09 a.m. the surveyor observed CNA-W pushing R14 in her wheelchair out of her room. CNA-W stated to R14 that first she had to put a mask on. CNA-W assisted R14 to place a mask on. CNA-W did not have on gloves, a gown, or a mask. CNA-W did not wash his hands after assisting R14 to put the mask on. The surveyor observed CNA-W assist R-14 to the unit bathroom. The surveyor observed CNA-W open the bathroom door with his hand. The surveyor observed CNA-W had not washed his hands since assisting R14 to place her mask on. The surveyor observed CNA-W and R14 then exit the bathroom, and return to her room. CNA-W remained without gloves, a mask, or a gown. The surveyor observed Housekeeping-X in R14's room. The surveyor observed the white sign stating Please see the nurse before entering remained on R14's door. The surveyor observed Housekeeping-X sweeping and cleaning R14's room. The surveyor observed Housekeeping-X within 2-3 feet of R14. The surveyor observed Housekeeping-X did not have on a gown, mask, or gloves. The surveyor observed Housekeeping-X exit R14's room and enter room [ROOM NUMBER]. Housekeeping-X did not wash her hands after leaving R14's room and entering room [ROOM NUMBER]. On 9/27/17 at 7:45 a.m. Surveyor observed Med Tech-T in R13's room without any PPE (personal protective equipment) on. Med Tech-T was standing next to R13 asking him if he needed more Kleenex. On 9/27/17 at 7:48 a.m. Surveyor asked Med Tech-T why there's a sign on R13's door. Med Tech-T informed Surveyor R13 came back with pneumonia. Surveyor inquired when R13 came back from the hospital. Med Tech-T informed Surveyor about 3 days ago. On 9/27/17 at 8:33 a.m. Surveyor observed a therapy staff member talking with R13 in his room. Surveyor observed the therapy staff member was not wearing any PPE. On 9/27/17 at 8:29 a.m. the surveyor observed CNA-PP enter R34's room. The surveyor observed a white sign on R34's door stating Please see the nurse before entering. The surveyor observed CNA-PP stand right next to R34's wheelchair and answer a question R34 had. The surveyor observed CNA-PP did not have on gloves, a gown, or a mask. On 9/27/17 at 8:40 a.m. the surveyor observed LPN-U enter R12's room. The surveyor observed a white sign on R12's door stating Please see nurse before entering. The surveyor observed LPN-U had gloves on, but not a mask or a gown. The surveyor observed LPN-U give R12 medicine and water. The surveyor observed LPN-U was within 3 feet of the resident. The surveyor observed LPN-U take R12's temperature orally. LPN-U remained without a gown or a mask on. On 9/27/17 at 8:45 a.m. the surveyor observed LPN-U enter R35's room. The surveyor observed a white sign on the door stating Please see nurse before entering. The surveyor observed LPN-U go to speak with R35. The surveyor observed LPN-U was within 3 feet of R35. The surveyor observed LPN-U had no gown, gloves, or mask on. On 9/27/17 at 8:52 a.m. the surveyor observed LPN-U re-enter R35's room. The surveyor observed LPN-U give R35 his medication. The surveyor observed LPN-U was within 3 feet of R35. The surveyor observed LPN-U did not have on a gown or a mask. The surveyor observed LPN-U state Cough syrup for that cough. and hand R35 a medication cup. The surveyor observed R35 drink the medication from the med cup. The surveyor observed LPN-U had no gown, gloves, or mask on. The surveyor observed LPN-U take the med cup from R35 after he was finished with no gloves on. On 9/27/17 at 9:14 a.m. the surveyor observed CNA-S enter R2's room and place a clothing protector around R2's neck. The surveyor observed CNA-S had no gown, gloves, or mask on. On 9/27/17 at 9:37 a.m. the surveyor observed Speech Therapist-V in R12's room. The surveyor noted a white sign on the door stating Please see nurse before entering. The surveyor observed Speech Therapist-V in front of R12 within 3 feet of R12. The surveyor observed Speech Therapist had no gown, gloves, or mask on. At 9:44 a.m. the surveyor observed Speech Therapist-V remained in front of R12, and within 3 feet of R12 with no gown, gloves, or mask on. On 10/3/17 at 10:56 a.m. the surveyor interviewed Speech Therapist-V. The surveyor asked how Speech Therapist-V knowns if a resident is in isolation. Speech Therapist-V stated that if he saw a sign on the door (A Please see nurse before entering sign) he would check with the nurse manager on what he should do. On 9/27/17 at 12:05 p.m. the surveyor observed Med Tech-T in R2's room taking R2 vital signs with a thermometer, blood pressure cuff and pulse oximetry meter. The surveyor observed Med Tech-T did not have on a gown or a mask. The surveyor noted a white sign on the door stating Please see nurse before entering. The surveyor observed Med Tech-T exit the room with the vital sign equipment. The surveyor observed Med Tech-T wipe down the vital equipment with PDI Sani-Hands wipes. The surveyor reviewed the manufactures information for the PDI Sani-Hands wipes. The surveyor noted Sani-Hands wipes are a hand hygiene product, and that the manufacturer's information did not indicate the wipes are intended or effective to be used to clean equipment. At 12:12 p.m. the surveyor observed Med Tech-T enter room [ROOM NUMBER], and take a resident that was in bed vital signs, with the same vitals equipment used to take R2's vitals that had not been disinfected with a proper product. The surveyor noted that room [ROOM NUMBER] did not have a sign on the door indicating that R2 was on isolation precautions. On 9/27/17 at 10:17 a.m. the surveyor interviewed ADON-R. The surveyor asked what should be used to clean patient care equipment between residents. ADON-R stated bleach wipes. The surveyor asked if the PDI Sani-Hands wipes should be used. ADON-R stated they are used for hands, have never used for equipment, we have Clorox bleach wipes for equipment. On 9/28/17 at 7:20 a.m. Surveyor observed CNA (Certified Nursing Assistant)-BB enter R13's room and close the door behind her. Surveyor observed CNA-BB was not wearing any PPE. Surveyor observed the there is still a sign on R13's door indicating to please see the nurse before entering. On 9/28/17 at 8:11 a.m. Surveyor observed SW (Social Worker)-K talking with R13 in his room. Surveyor observed SW-K is not wearing any PPE. R12 was hospitalized from [DATE] to 9/26/17. Hospital discharge [DIAGNOSES REDACTED]. On 9/28/17 at 2:20 p.m., Surveyor passed R12's room and noticed a sign on his door stating, Please see nurse before entering. Both A and B bed were occupied at this time. The privacy curtain was pulled closed between both beds. On 9/28/17 at 2:22 p.m., Surveyor asked RN (Registered Nurse) Manager-C why R12's door had a sign on it. RN Manager-C informed Surveyor it was for isolation precautions both contact and respiratory. Surveyor asked if the precautions were for one or both residents in the room. RN Manager-C informed Surveyor it was for R12 only and that is why the privacy curtain is pulled closed between the two residents. Surveyor asked RN Manager-C what type of PPE (Personal Protective Equipment) was needed to enter the room. RN Manager-C informed Surveyor that gloves and a mask were needed. Surveyor asked RN Manager-C where the required PPE was located as there was no isolation cart outside of R12's room. RN Manager-C assisted Surveyor in searching the 1 East wing for PPE/Isolation cart. One could not be located. RN Manager-C called floor assistance in locating the PPE/Isolation cart. RN Manager-C informed Surveyor that 1 East wing PPE/Isolation cart had been removed at it was believed that all residents on that unit were clear and out of isolation. A PPE/Isolation cart was going to be delivered to the unit shortly by Facility staff per RN Manager-C. On 9/29/17 at 5:35 p.m., Surveyor observed CNA (Certified Nursing Assistant)-HH enter R2's room without wearing a mask, gloves or a gown. Surveyor noted that there was a sign outside of R2's room door that informed visitors and staff to please see the nurse prior to entering R2's room. Surveyor observed CNA-HH provide R2 with a water mug, fix R2's bedside table and then proceed to exit R2's room. Surveyor noted that CNA-HH did not wash her hands after exiting R2's room. On 9/29/17 at 5:37 p.m., Surveyor observed CNA-HH walk from R2's room to R16's room and provide R16 with a water mug and and an oatmeal cookie. Surveyor noted that CNA-HH did not wash her hands after exiting R2's room and before entering R16's room. On 9/29/17 at 5:39 p.m., Surveyor asked LPN (Licensed Practical Nurse)-Y why there was a sign outside of R2's room door that informed visitors and staff to please see the nurse prior to entering R2's room. LPN-Y informed Surveyor that R2 is currently on isolation due to R2's pneumonia. Surveyor asked LPN-Y what facility staff should be wearing prior to entering R2's room. LPN-Y informed Surveyor that R2 facility staff should be wearing a gown, mask and gloves prior to entering R2's room. Surveyor asked LPN-Y if facility staff should be washing their hands after leaving R2's room and prior to entering another resident's room. LPN-Y informed Surveyor that facility staff should be washing their hands after leaving R2's room and prior to entering another resident's room. On 10/2/17 at approximately 2:20 p.m. the surveyor observed Activity Director-G ask residents on the first floor, including R14, if they would like to go to BINGO on the 2nd floor. On 10/3/17 at 10:13 a.m., Surveyor informed RN (Registered Nurse) Manager-C of the above findings. Surveyor asked RN Manager-C if CNA-HH should be wearing a gown, gloves and mask prior to entering R2's room. RN Manager-C informed Surveyor that CNA-HH should be wearing a gown, gloves and mask prior to entering R2's room. Surveyor asked RN Manager-C if CNA-HH should be washing her hands after leaving R2's room and prior to entering another resident's room. RN-Manager-C informed Surveyor that CNA-HH should be washing her hands after leaving R2's room and prior to entering another resident's room. On 10/3/17 at 1:32 p.m. the surveyor interviewed ADON-R. ADON-R confirmed that residents during the above observations with white Please see nurse before entering signs should be on droplet and contact precautions. The surveyor asked ADON-R to clarify how staff is expected to follow those precautions. ADON-R stated staff are required to wear a mask when entering the residents rooms. The surveyor asked how staff are expected to follow contact precautions. ADON-R stated it was her understanding that staff should follow contact precautions if someone is actively coughing or if touching something, for example, with phlegm. The surveyor asked if there was an expectation for staff to wear a gown. ADON-R stated she did not believe so, just a mask. The surveyor noted that per the State of Wisconsin Department of Health Services November 14, 2016 memo for Reporting, prevention, and control of acute respiratory illness outbreaks in long-term care facilities that the facility utilizes for its policy and procedure Until the causes(s) of an ARI outbreak is determined, both droplet and contact precautions should be initiated in addition to standard precautions .4.2 Contact Precautions apply when the presence of discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission. 4.2.1 Health care staff should wear a gown and gloves for all interactions that may involve direct contact with the resident or potentially contaminated areas in the environment. On 9/28/17 at 2:32 p.m. the surveyor interviewed Environmental Service Director-SS. The surveyor asked Environmental Service Director-SS how do housekeeping staff known if a resident is on isolation. Environmental Service Director-SS stated that she tells them, and also the see nurse sign is on the (TRUNCATED)

Based on observation, interview and record review the facility did not provide adequate supervision and assistive devices to prevent accidents for 10 (R10, R5, R13, R14, R15, R4, R12, R6, R7 and R8) of 15 sampled residents and 1 (R24) supplemental resident identified by the facility at risk for falls. * R10 sustained 17 falls during the period of 1/21/17 to 9/7/17. On 3/13/17 R10 fell in the doorway of her room. Prior to the fall R10 had been observed pushing her wheelchair backwards down the hall like the chair was a walker. The fall investigation indicates staff redirected R10 however, there is no indication increased supervision was implemented. R10's 3/13/17 fall resulted in R10 sustaining a fracture to her right Humerus that would required surgical intervention to repair however, R10's family declined surgery. On 8/19/17 R10 sustained a fall in the main dining room of the facility. This was R10's second fall in the dining room in two days. R10 sustained a fracture to her right shoulder that again would have required surgical intervention to repair however, R10's family declined surgical repair and opted for non-weight bearing status and an immobilizer. During the survey R10 was observed unsafely maneuvering around the unit and transferring herself without staff present and alarm interventions not sounding properly. * R5 was observed to not have fall mats in place per his falls plan of care. * R13 was observed attached to a Hoyer lift in a sling suspended over a high bed with no staff present. * R14 was observed without safety devices in place and was incorrectly transferred by staff per her falls plan of care. * R15 was observed without safety devices in place per her falls plan of care. * R4 suffered a fall from a sling on 9/18/17 due to the sling not being correctly connected and was observed to be given thin liquids despite orders for thickened liquids causing a potential for choking. * R12 was provided thin liquids despite orders for thickened liquids causing a potential for choking. * R7 was observed not to have her call light within reach per her falls plan of care. * R8 was observed not to have his fall interventions in place and be improperly transferred by facility staff without a gait belt per R8's fall plan of care. * R6 was not provided the proper food consistency per his dietary plan of care causing a potential for a choking. * R24 was provided thin liquids despite orders for thickened liquids causing a potential for choking. Example 1 regarding R10 rises to a scope and severity level of G (harm/isolated). Findings include: 1.) Surveyor reviewed R10's medical record from 9/26/17 to 10/3/17. R10 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R10's annual MDS (Minimum Data Set) dated 9/1/17 indicates R10 has long and short term memory problems and is severely cognitively impaired/never/rarely makes decisions. Section E0900 (Behavior/Wandering) indicates that R10 exhibits wandering behavior 4 to 6 days a week and R10's wandering behavior significantly intrudes on the privacy or activities of others. The MDS indicates R10's behavior symptoms have become worse compared to prior assessments. R10 also requires extensive assistance and two persons physical assist for transfers. R10's Cognitive Loss/Dementia CAA (Care Area Assessment) with assessment reference date of 9/1/17 documents, R10 demonstrates severe cognitive impairment. R10 has an activated Health Care Power of Attorney. R10 has expressive aphasia and garbled speech and is unable to make herself understood. Staff assessment shows short and long term memory loss and severely impaired decision making skills. R10 is diagnosed with [REDACTED]. R10's Behavior CAA with assessment reference date of 9/1/17 documents, R10 can be resistive to cares as well as to attempts at redirecting wandering behaviors. R10 does wander the unit-does not exit seek-but attempts to enter other resident rooms. R10 can become aggressive with redirection attempts. R10 is not able to process personal space and will often attempt to approach other residents and touch them, pick up their belongings. R10's Falls CAA with assessment reference date of 9/1/17 documents, R10 is noted to have poor balance, has fallen in the last month, one which resulted in a right Humerus fracture with non weight bearing status and decline in mobility/activities of daily living. The team agrees R10 is at risk for falls and injury. Direct care staff to provide interventions to help limit risk of falls and risk for injury. R10's Fall/Injury Risk care plan initiated 6/7/16 indicates R10 is at risk for falls due to Osteoporosis/Osteopenia, fall history, impaired vision, impaired mobility, Medication: antidepressant, impaired safety judgement related to dementia and increase risk for bruises/skin tears related to osteoporosis. Goals with target dates of 9/16 and 12/16 indicate: resident will sustain no fall related injury will decrease incidents of falling and will sustain no serious bruises or skin tears. The target date is 2/19/17. Approaches/Interventions include: Assess medications for side effects such as: impaired balance, hypotension, lethargy, dizziness, fatigue; instruct resident to ask for assist prior to attempts to stand, walk, transfer; restorative program: ambulation LE (lower extremity) exercise; place call light and frequently used items within easy reach; encourage participation in ambulation or strengthening program - resident is currently on restorative; keep environment free of hazards, walkways clear, maintain adequate lighting, including at night; use mobility alarm as ordered: bed, chair; encourage participation in structured activity program; transfer resident using 1 staff; use gait belt and proper transfer techniques; lock wheelchair and bed during transfers; remove or rotate leg rests to side during transfers; ensure use of glasses PRN (as needed); toilet resident per schedule (see continence care plan); do not leave unsupervised in bathroom; monitor for signs of infection; assure resident is wearing proper footwear; review fall risk factors every 3 months and PRN; monitor for abnormal laboratory results; low bed; mat on floor; protect dependent extremities during transfer and repositioning; provide emotional support for coping with mobility limitations. Handwritten and undated is: keep in common area for observation redirect to falls group when needed. The care plan includes a handwritten/undated intervention of keep in common area for observation, redirect to falls group when needed. On 10/6/16 UI program with therapy along with anti-rollback brakes on wheelchair. On 11/29/16 staff assist to toilet prior to lunch was added. On 1/23/17 gripper socks in bed was added to the care plan. Since 1/21/17 R10 has had 17 falls, 2 resulted in injuries one on 3/13/17 resulting in a right humerus fracture and again on 8/19/17 resulting in a right shoulder fracture. Surveyor reviewed R10's fall investigation dated 1/21/17. R10's Fall Assessment documents, fall occurred at 1:30 a.m. No injuries noted. CNA (Certified Nursing Assistant) walked passed resident's room; hear bed alarm sounding and resident standing by her bed and then R10 fell to the floor. Fall Assessment documents R10 was assisted to the bathroom at 12:30 a.m., call light was in reach and bed in safe position. Falls Assessment documents measures put into place to prevent future falls: gripper socks on in bed. This intervention was noted on R10's plan of care and CNA care card dated 1/23/17. Surveyor reviewed R10's fall investigation dated 2/9/17. R10's Fall Assessment documents, fall occurred at 22:25 (10:25 p.m.) R10 was found sitting on the bathroom floor in a puddle of urine attempting to get up by herself. Bed alarm was noted to be unplugged. The report indicates R10 has a history of unplugging her alarm. R10 was seen one hour prior to fall walking with walker. Assistance with cares provided at 8:00 p.m. No injuries noted. Falls Assessment documents measures taken to prevent future falls: bathroom light on at night. Surveyor noted despite indication R10 unplugged her alarm and it was not sounding, there is no indication the facility assessed the use of alarms. Surveyor could not locate any documentation indicating that the intervention of, Bathroom light will be on at night was implemented on R10's plan of care or CNA care card to prevent future falls. Surveyor reviewed R10's fall investigation dated 2/10/17. R10's Fall Assessment documents that the fall occurred at 5:30 a.m. R10 was found on the floor by CNA half way to the bathroom by the foot of her bed. Bed alarm not sounding. Bed alarm checked and was replaced due to not functioning. Resident was last seen by nursing staff at 04:25 a.m. when vitals were taken as follow up from the fall the prior evening. R10 was noted to have two unresponsive episodes starting at 8:30 a.m. R10 was sent to the hospital for evaluation. R10 was diagnosed with [REDACTED]. Indicating that the intervention of: bathroom light being on at night will be implemented for this fall as well. Surveyor could not locate any documentation indicating that the intervention of, Bathroom light will be on at night was implemented on R10's plan of care or CNA care card to prevent future falls. Surveyor also noted there is again no indication the facility reviewed R10's use of alarms. On 2/15/17 a new falls care plan was initiated for R10. The care plan included: indicates R10 is at risk for falls due to Osteoporosis/Osteopenia, fall history, impaired vision, impaired mobility, Medication: antidepressant, impaired safety judgement related to dementia and increase risk for bruises/skin tears related to osteoporosis. Goals with target dates of 9/16 and 12/16 indicate: resident will sustain no fall related injury will decrease incidents of falling and will sustain no serious bruises or skin tears. Target date is 2/19/17. Approaches/Interventions include: Assess medications for side effects such as: impaired balance, hypotension, increased confusion, lethargy, dizziness, fatigue and lightheadedness; instruct resident to ask for assist prior to attempts to stand, walk, transfer; therapy to evaluate and treat as warranted: gait, balance; restorative program: ambulation, ADL's (activities of daily living), LE (lower extremity) exercise; place call light and frequently used items within easy reach; encourage participation in ambulation or strengthening program - resident is currently on restorative PT/OT (physical therapy/occupational therapy); keep environment free of hazards, walkways clear, maintain adequate lighting, including at night; encourage participation in structured activity program; transfer resident using 1 staff; use gait belt and proper transfer techniques; lock wheelchair and bed during transfers; remove or rotate leg rests to side during transfers; ensure use of glasses PRN (as needed); toilet resident per schedule (see continence care plan); do not leave unsupervised in bathroom; monitor for signs of infection; assure resident is wearing proper footwear; review fall risk factors every 3 months and PRN; check blood pressure lying, sitting and standing q (each) month; protect dependent extremities during transfer and repositioning; provide emotional support for coping with mobility limitations; pain medications. Handwritten and undated is: keep in common area for observation redirect to falls group when needed. The care plan includes a handwritten/undated intervention of anti-rollback brakes on (unreadable word); staff to assist to toilet prior to bed, gripper socks in bed; keep in common area for observation, redirect to falls group when needed. Surveyor noted the care plan no longer includes safety measures such as a low bed or mat or used of bed or wheelchair alarms. Surveyor reviewed R10's fall investigation dated 3/13/17. Fall Assessment documents the fall occurred at 22:30 (10:30 p.m.) R10 was calling out and was found on the floor in the doorway of her room on her right side with her wheel chair tipped over, complaints of severe pain in right shoulder. R10 was continent of bowel and bladder. R10 complained of pain to right shoulder. The report indicates R10 was seen an hour prior to the fall pushing her wheelchair backwards using it as a walker. Redirection was provided to R10 by staff for correct use of the wheelchair. R10 was sent to the hospital for evaluation. R10 was diagnosed with [REDACTED]. R10 returned to facility with non weight bearing status of the right arm and right arm sling. Fall Assessment documents measures to prevent future falls: anti roll back breaks removed from wheelchair: speech therapy to assess cognitive status; therapy to assess transfer status and toileting assistance within 45 minutes of the evening meal. Surveyor reviewed R10's fall investigation dated 3/18/17. Fall Assessment documents the fall occurred at 16:05 (4:05 p.m.). Fall was unwitnessed. R10 was found kneeling over bed on fall mat. R10 attempted to use her right arm with fracture and non-weight bearing status to stand. R10 complaining of pain in right arm, grimacing and guarding her right arm. Fall Assessment documents measures to prevent future falls: 5 day pain review to be completed due to right arm and shoulder pain. Surveyor noted pain medications were adjusted after the 5 day review was completed. Surveyor noted this intervention would not necessarily prevent future falls. Surveyor also noted the care plan dated 2/15/17 does not include the use of mats next to the bed. Surveyor reviewed R10's fall investigation dated 3/19/17. Fall Assessment documents the fall occurred at 13:30 (1:30 p.m.) R10 was found on the floor in her room. R10 was attempting to transfer into her wheelchair. Concern for non-weight bearing on right arm and ability to transfer may have caused the fall. Fall Assessment documents intervention of therapy to assess environment for maximal space and mobility. Surveyor noted a therapy assessment was completed with no noted concerns for her environment. Surveyor reviewed R10's fall investigation dated 4/18/17. Fall Assessment documents the fall occurred at 18:45 (6:45 p.m.) Staff heard R10 yelling, Help me. R10 found on floor on right side complaining of pain. Nursing noted concern for R10's right hip due to complaint of pain. R10 sent to hospital for evaluation. No injuries noted. R10 was diagnosed with [REDACTED]. Surveyor noted assessment was complete with recommendations of making sure R10's call light and frequently used items are in reach. Surveyor noted these are interventions that were already included in R10's plan of care prior to this fall. Surveyor reviewed R10's fall investigation dated 5/9/17. Fall Assessment documents the fall occurred at 22:05 (10:05 p.m.) R10 was found lying on the floor of her room between the bed and bathroom. R10 was continent of bowel and bladder. R10 was taken to the bathroom and voided. R10 was last toileted sometime after dinner but not specified. Fall Assessment documents measures put into place to prevent future falls: motion sensor alarm in room. Surveyor noted intervention was documented on R10's plan of care and CNA care card and motion sensor noted in R10's room. Surveyor reviewed R10's fall investigation dated 5/12/17. Fall assessment documents the fall occurred at 14:40 (2:40 p.m.) R10 was heard yelling and was found on the floor on her right side between the bed and walker attempting to transfer into the bed. X-rays were taken of her right hip and right arm due to pain. No injuries were documented. Fall Assessment documents measures put into place to prevent future falls: signs in room with colorful tape to remind resident to call for help and colorful tape on hand rails in bathroom. During the survey, Surveyor noted signs and colorful tape in R10 room and bathroom. Surveyor reviewed R10's fall investigation dated 6/5/17. Fall Assessment documents the fall occurred at 15:05 (3:05 p.m.) R10 was found on the floor next to the bed in a room that wasn't assigned to her. Fall Assessment documents measures put into place to prevent future falls: Behavioral Solutions evaluation. Surveyor noted that Behavioral Solutions did evaluate resident on 7/10/17. Documentation notes a failed dose reduction of Lexapro and Depakote after increased crying/tearfulness along with restlessness, invading peers personal space and difficulty redirecting behaviors was noted. Behavior appeared to improve with higher dose of medication. Medication adjustment made by R10's doctor. Surveyor noted that while the facility requested a behavioral evaluation there is no indication the facility assessed for increased supervision given R10 was found in other resident's room and fell . Surveyor reviewed R10's fall investigation dated 6/11/17. Fall Assessment documents the fall occurred at 19:10 (7:10 p.m.). The investigation indicates a CNA was assisting R10 with toileting needs in the resident room when the CNA left the room to get linen to assist resident with evening ADLs (Activities of Daily Living.) When the CNA returned to the room R10 was found on the floor at the foot of the bed. The fall assessment documents measures put into place to prevent future falls: establish regular toileting routine of offering toileting and check and change every 2-3 hours and as needed. Surveyor noted the fall appeared to be due to a lack of supervision and did not appear to be related specifically to a toileting routine however, the determined intervention to prevent future falls did not address supervision or safety should staff have to step away from the resident during cares. On 6/21/17 a Fall/Injury resident care plan was initiated indicating R10 was at risk for falls due to osteoporosis/osteopenia, fall history, impaired vision, impaired mobility, impaired safety judgement related to dementia, CVA (cerebrovascular accident) and depression, the care plan indicates all needs anticipated. Goals include sustain no fall related injury or no serious bruises/skin tears with a goal date of 9/2017. Interventions include: Assess medications for side effects such as: impaired balance, hypotension, increased confusion, lethargy, dizziness, fatigue and lightheadedness; instruct resident to ask for assist prior to attempts to stand, walk, transfer; therapy to evaluate and treat as warranted: seating, gait, balance; position devices in chair; place call light and frequently used items within easy reach; keep environment free of hazards, walkways clear. Maintain adequate lighting including at night; use mobility alarm as ordered - bed, chair; encourage participation in structured activity program; transfer resident using 2 staff; use gait belt and proper transfer techniques; lock wheelchair and bed during transfers; ensure use of eyeglasses PRN; do not leave unsupervised in bathroom; monitor for signs of infection; assure resident is wearing proper footwear; review fall risk factors every 3 months and PRN; check blood pressure monthly; monitor for abnormal laboratory results; protect dependent extremities during transfer and repositioning; meds for bone porosity: calcium; provide emotional support for coping with mobility limitation; pain medication: see MAR (medication administration record). Interventions handwritten and undated include: sensor alarm in room; staff to toilet within 45 minutes after dinner; staff to toilet before bed; gripper socks in bed. On 7/3/17 added handwritten interventions were added including: keep resident arms-length away from other residents; keep resident out of peer's personal space; assist to redirect from (not readable on copy). Surveyor reviewed R10's fall investigation dated 7/17/17. Fall Assessment documents the fall occurred at 16:27 (4:27 p.m.) R10's fall was witnessed by staff. R10 slipped forward out of wheelchair attempting to wheel into the Nurse Manager's office. Fall Assessment documents measures taken to prevent future falls: Dycem to wheelchair seat. Surveyor could not locate any documentation indicating that the intervention of, Dycem to wheelchair seat was implemented on R10's plan of care to prevent future falls. Surveyor reviewed R10's fall investigation dated 8/5/17. Fall Assessment document the fall occurred at 17:30 (5:30 p.m.) R10 was found in a peer's room by the B bed, near the window. R10 was lying on her right side with her wheelchair alarm unplugged. Fall Assessment documents measures taken to prevent future falls: keep in common area when up for observation. Surveyor noted on 7/3/17 the intervention to keep R10 arms-length away from peers and out of their personal space was added to the plan of care. Surveyor noted R10's actual need for supervision is not assessed and the plans of care do not specify how staff is to carry out keeping R10 an arms-length away from peers or out of their personal space despite the care plan indicating all of R10's needs are to be anticipated. Surveyor could not locate any documentation indicating that the intervention of, Common areas when up for observation from R10's 2/15/17 care plan was implemented. Surveyor reviewed R10's fall investigation dated 8/16/17. Fall Assessment documents the fall occurred at 14:45 (2:45 p.m.) R10 was found on the floor in room 110-B by the air vent. R10 had pulled open the door on the vent and taken the filter out. The report indicates the alarm on her chair was disconnected. The report indicates R10 was seen 15 minutes prior to the fall in the hallway and was assisted to the bathroom 25 minutes before the fall. Fall Assessment documents measures taken to prevent future falls as: use interventions presently in place and goal is to keep resident free from injury. Surveyor reviewed R10's fall investigation dated 8/18/17. Fall Assessment documents the fall occurred at 21:00 (9:00 p.m.) R10 was found on her left side next to her wheelchair in the main dining room. R10 reached forward and fell out of her wheelchair. Fall Assessment documents measures taken to prevent future falls: decrease dose of Ativan. Surveyor noted that R10's Ativan was changed from 0.5 mg (Milligrams) BID (two times daily) to 0.5 mg PRN (as needed). Surveyor noted there is no indication if R10's alarm was functioning at the time of the fall, whether staff had anticipated her needs, and whether staff had followed the plan of care by ensuring items were easily within reach for R10. Although R10 was noted to have falled in the main dining room (common area) there is no indication of the type of observation resident was being provided with when she fell on [DATE], as per 2/25/17 care plan fall prevention which stated to keep in common area for observation. Surveyor reviewed R10's fall investigation dated 8/19/17. Fall Assessment documents the fall occurred at 16:30 (4:30 pm) R10 was found on the floor in the main dining room laying on the right side. Injury noted to her right shoulder. R10 was sent to the hospital for evaluation. R10 was diagnosed with [REDACTED]. R10's family decided against surgical intervention and R10's shoulder was immobilized and she was placed in a sling. Fall Assessment documents measures put into place to prevent future falls: Activity staff to assess for leisure activities. Surveyor noted Activity Assessment completed 8/28/17 listing leisure activities to redirect resident's attention noting mood and activity tolerance fluctuates due to dementia. Surveyor noted R10's plan of care already included interventions to encourage R10 to participate in structured activities. Although R10 was noted to have falled in the main dining room (common area) there is no indication of the type of observation resident was being provided with when she fell on [DATE], as per 2/25/17 care plan fall prevention which stated to keep in common area for observation. Surveyor reviewed R10's fall investigation dated 9/7/17. Fall Assessment documents the fall occurred at 13:55 (1:55 p.m.) R10 was found on the floor in the main dining room. R10 tipped her wheelchair backwards falling backwards and her head landed on the wheelchair cushion. Fall Assessment documents measures put into place to prevent future falls: anti tip bars to wheelchair. During the survey, Surveyor observed anti tip bars on R10's wheelchair. Surveyor noted this is now the third fall that occurred in the main dining room however there is no indication the facility evaluated the dining room and possible need for increased supervision. Observations of R10: On 9/26/17 at 12:23 p.m., Surveyor observed R10 in the day room at the end of the hall without staff supervision. R10 was repeatedly bumping her wheelchair into the corner of the room unable to turn herself around. On 9/26/17 at 12:30 p.m., Surveyor observed R10 wheeling self into unoccupied room 109. At 12:36 p.m., R10 was observed transferring self into a bed in room 109. Surveyor did not observe any staff in the area. R10's chair alarm did not sound until R10 was laying supine in bed. Bed alarm then sounded for a short time then stopped without R10's or staff's assistance. At 12:44 p.m., staff did walk past room 109 and observe R10 in bed in room 109. Staff assisted R10 out of bed and took her to her assigned room and assisted her to bed. On 9/27/17 at 8:24 a.m., Surveyor observed R10 propelling self from her room to the unit main dining room. R10 was propelling extremely close to peers in the dining room then proceed propelling down another hallway unsupervised. On 9/27/17 at 8:35 a.m., Surveyor observe staff redirecting R10 towards the Falls dining room as R10 had been propelling about the unit unsupervised. At 8:37 a.m., Surveyor observed R10 enter room 122 occupied by a peer. At 8:45 a.m., Surveyor observed staff removing R10 from room 122 and physically assisting her to the dining room and seating her at a table. On 10/3/17 at 10:56 a.m., Surveyor informed RN (Registered Nurse) Manager-C of the above findings. Surveyor ask RN Manager-C if the intervention from R10's fall investigation dated 2/9/17 recommending that, Bathroom light be on at night should be on R10's fall plan of care and CNA care card. RN Manager-C informed Surveyor the intervention of the bathroom light being on at night should be on R10's falls plan of care and CNA care card. Surveyor asked RN Manager-C if the intervention of the bathroom light being on at night would be helpful for facility staff in providing care to R10. RN Manager-C informed Surveyor yes it was and she would update R10's plan of care and CNA care card to reflect the intervention of the bathroom light on at night. Surveyor asked RN Manager-C if the intervention from R10's fall investigation dated 7/17/17 recommending that, Dycem to wheelchair seat, be on R10's falls plan of care. RN Manager-C informed Surveyor the fall intervention of Dycem to the wheelchair seat should be in R10's falls plan of care. Surveyor asked RN Manager-C if the intervention of dycem on the wheelchair seat would be helpful for facility staff in providing care to R10. RN Manager-C informed Surveyor yes it was and she would update R10's plan of care to reflect the falls' intervention of dycem on wheelchair seat. Surveyor asked RN Manager-C if the intervention from R10's fall investigation dated 8/5/17 recommending, R10 stay in the common areas for observation be on R10's falls plan of care and CNA care card. RN Manager-C informed Surveyor the intervention of keep in common areas for observation should be on R10's falls plan of care and CNA care card. Surveyor asked RN Manager-C if the intervention of keep in common areas for observation would be helpful for facility staff in providing care to R10. RN Manager-C informed Surveyor yes it is and she would update R10's plan of care and CNA care card to reflect the intervention of keeping in common areas for observation. On 10/3/17 at 4:05 p.m., Surveyor informed Administrator-A and Director of Nursing (DON)-B of the above findings. No further information was provided as to why the facility did not implement fall interventions to prevent future falls and accidents. 2.) Surveyor reviewed R4's medical record on 9/26/17 to 10/3/17. The CNA (Certified Nursing Assistant) Care Card dated 5/10/17 under transfers is checked for Hoyer 2. The quarterly MDS (minimum data set) with an assessment reference date of 8/4/17 and signed as complete on 8/18/17 documents a BIMS (brief interview mental status) score of 7 which indicates severe impairment. R4 requires extensive assistance with two plus person physical assist for bed mobility, is dependent with two plus person physical assist for transfers, land does not ambulate. R4 is coded as not having any falls since prior assessment. The nurses note dated 9/18/17 documents This RN (Registered Nurse) was called to resident's room due to a fall. Two staff members were transferring resident from her bed to the wheelchair in the Hoyer lift. Resident slipped out of the sling and the two staff members guided her to the floor. She bumped her head on the Hoyer leg, no injury noted. Vital signs stable, afebrile. Denies pain. ROM (range of motion) at baseline for resident. Neuro checks wnl (within normal limits). Physician, Family Care worker, and son/emergency contact were notified. Will be monitored by neuro checks and on the 24 hour board. No new orders from physician. CNA (Certified Nursing Assistant)-AA witness investigation form dated 9/18/17 documents while transferring R4 in the Hoyer lift near her bed, one strap slipped off of Hoyer causing her to slide onto floor in between the bed & her wheelchair. CNA/US (Certified Nursing Assistant/Unit Secretary)-KK witness investigation form dated 9/18/17 documents The other aid put the sling on R4 and we began to lift her to put her in the chair as we was turning her she fell out. The IDT (interdisciplinary team)falls/incident review note dated 9/19/17 documents Resident was being transferred by 2 CNA's (Certified Nursing Assistant) and a Hoyer lift from bed to her wheelchair when she slid out from the top of the lift sling and was guided by staff to the floor. She did bump her head on the Hoyer lift leg but no injury was sustained due to guiding resident down. No injuries were noted. Physician family and Family Care worker notified. No new orders. Neuro checks to be done per protocol. On 24 hour board for additional monitoring. No c/o (complaints of) or s/s (signs/symptoms) of pain or injury from resident. Hoyer lift safety and review of proper sling placement was reviewed with staff involved. Both did demonstrate proper techniques prior to education. On 10/3/17 at 9:59 a.m. Surveyor spoke with RN (Registered Nurse) Manager-N regarding R4's fall from the Hoyer lift on 9/18/17. Surveyor informed RN Manager-N while reviewing this fall Surveyor noted one of the straps came off the Hoyer lift and inquired if staff should check the straps prior to raising a Resident off the bed or wheelchair. RN Manager-N replied yes and explained that the CNA's are suppose to tug on all four sides. RN Manager-N informed Surveyor she provided education to the two CNA's involved. On 10/3/17 at 3:23 p.m. during the daily exit conference Administrator-A and DON-B were informed of the above. 3.) Surveyor reviewed R15's medical record on 9/28/17 to 10/3/17. The falls care plan dated 5/4/17 under approaches/interventions is checked for Use mobility alarm as ordere (TRUNCATED)

Based on observation, record review and interview, the Facility did not ensure 3 (R4, R3, & R16) of 8 Residents at risk for development of pressure injury received consistent measures to prevent the development of pressure injuries. * R4 is at risk for pressure injury and CNA (Certified Nursing Assistant)-CC was observed sheering R4 * R3 who is at risk for pressure injuries was observed without her heels being offloaded. * R16 was observed without her prevalon boots to offload her heels. Findings include: 1.) Surveyor reviewed R4's medical record on 9/26/17 to 10/3/17. The CNA (Certified Nursing Assistant) Care Card dated 5/10/17 documents 2 caregivers for ADL's (activities daily living) when in bed. The Braden assessment dated [DATE] has a score of 14. A score of 13-14 indicates moderate risk for pressure injury development. The quarterly MDS (minimum data set) with an assessment reference date of 8/4/17 documents a BIMS (brief interview mental status) score of 7 which indicates severe impairment. R4 requires extensive assistance with two plus person physical assist for bed mobility, does not ambulate, is checked as having an indwelling catheter and is always incontinent of bowel. R4 is coded as being 64 inches tall and weight of 184 pounds. R4 is at risk for pressure injuries and is coded as not having any pressure injuries. On 9/27/17 at 8:34 a.m. Surveyor observed CNA (Certified Nursing Assistant)-CC enter R4's room, place gloves on and remove clothing from the closet. CNA-CC filled a wash basin, raised the height of the bed and lowered the head of the bed down. CNA-CC handed R4 a wash cloth and R4 washed her face. CNA-CC informed R4 she was going to slide her and pulled on the sheet to move R4 towards the right side of the bed. CNA-CC removed the gown washed R4's upper body and then placed a shirt on R4. CNA-CC informed R4 she was going to wash her bottom and washed R4's frontal perineal area. CNA-CC stated she needed to get another towel, removed her gloves, and left R4's room. CNA-CC returned with towels, washed her hand and placed gloves on. CNA-CC informed R4 she was going to turn her so she could wipe her bottom, pulled on the sheet to move R4 who was on her back towards the right and positioned R4 on her left side. Pulling on the sheet and not lifting causes shearing of the buttocks. On May 20, 2016, the National Pressure Ulcer Advisory Panel (NPUAP) updated pressure ulcer terminology and stages. Within the update, the NPUAP explicitly states, (A pressure injury) occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. On 10/3/17 at 9:48 a.m. Surveyor met with RN (Registered Nurse) Manager-N to discuss R4. Surveyor asked if two CNA are required for R4's ADL's (activities daily living). RN Manager-N replied yes when in bed. Surveyor informed RN Manager-N of the observation of only CNA-CC providing morning cares and CNA-CC pulling on the sheet which causes shearing to reposition R4. On 10/3/17 at 3:23 p.m. during the daily exit conference Administrator-A and DON-B were informed of the above. 2.) Surveyor reviewed R3's medical record on 9/26/17 to 10/2/17. The CNA (Certified Nursing Assistant) Care Card dated 8/10/17 under positioning is checked for float heels with a hand written notation of heels off in bed. The skin integrity care plan dated 8/11/17 includes an intervention not dated of Elevate heels off the bed with heels off. The significant change MDS (minimum data set) with an assessment reference date of 8/17/17 and signed as complete on 8/30/17. R3 has short & long term memory problems and is severely impaired for daily decision making. R3 requires extensive assistance with two plus person physical assist for bed mobility, and does not ambulate. R3 is at risk for developing pressure injuries and is coded as not having any pressure injuries. The pressure ulcer CAA (care area assessment) dated 8/30/17 under care plan considerations documents R3 triggered the pressure ulcer CAA because she requires staff assist with bed mobility, has bowel incontinence, wt (weight) loss, and an at risk Braden score of 11 per nursing staff on 8/17/17. R3 also has Hx (history) of scar tissue to bilateral buttocks. She remains at risk for skin breakdown/alterations in skin integrity related to impaired mobility and weakness due to recent hospitalization with return to facility with dx (diagnosis) [MEDICAL CONDITION] and placed on hospice care with Allay for same. Other contributing risk factors include but not limited to chronic low back pain, cognitive deficit secondary to her dementia, chronic arthritis, hypertension, Hx [MEDICAL CONDITIONS], depression, DM (diabetes mellitus), [MEDICAL CONDITIONS], resolved ulcers in past (also just after reference period-see TAR (treatment administration record) and nursing documentation). Care plan will address to avoid complications and minimize risk and maintain skin integrity. Staff will continue to encourage and assist turning and repositioning regularly. MD/hospice nurse updated if indicated, wound team following weekly at this time. The physician orders [REDACTED]. On 9/26/17 at 1:10 p.m Surveyor observed R3 in bed on her back with her heels resting directly on the mattress. R3's heels were not being offloaded. On 9/26/17 at 2:14 p.m. Surveyor observed R3 continues to be in bed on her back, with a pillow under her calves and R3's heels resting directly on the mattress. R3's heels were not being offloaded. On 9/27/17 at 9:24 a.m. Surveyor observed R3 in bed on her back. Surveyor observed there is a pillow between R3's legs and a heels up pad under R3's calves. R3's heels are not being offloaded as R3's left heel is resting directly on the heels up pad and her right heel is resting directly on the mattress. On 9/27/17 at 9:55 a.m. Surveyor observed morning cares for R3 with CNA (Certified Nursing Assistant)-MM & CNA-DD. At 10:14 a.m. when staff positioned R3 on her right side to wash her buttocks Surveyor observed there are no open areas on R3's buttocks but on the bottom of R3's right heel Surveyor observed a reddened area approximately the size of a dime. On 9/27/17 at 10:27 a.m. after CNA-MM and CNA-DD completed morning cares for R3, CNA-MM placed the heels up pad under R3's calves and a small green pillow between her legs. Surveyor observed R3's heels are not being offloaded as they are resting directly on the heels up pad. After placing the heels up pad under R3's calves, CNA-MM covered R3 with a sheet, raised the head of the bed, lowered the bed down, and placed the call light within reach. On 9/27/17 at 3:51 p.m. Surveyor observed R3 in bed on her right side. Surveyor observed there is a heels up pad under R3's calves but R3's heels are resting directly on the mattress and are not being offloaded. On 9/28/17 at 7:12 a.m. Surveyor observed R3 in bed on her back. Surveyor observed there is a pillow under R3's calves and R3's heels are resting directly on the mattress. Surveyor observed the heels up pad is on the floor near R3's broda chair. On 9/28/17 at 8:09 a.m. Surveyor observed R3 continues to be in bed on her back. R3's heels continue to be resting directly on the mattress and are not being offloaded. R3's heels up pad continues to be on the floor near the broda chair. On 9/28/17 at 9:18 a.m. Surveyor observed R3 continues to be in bed on her back. There is a pillow under R3's calves but R3's heels continue to be resting directly on the mattress and re not being offloaded. On 9/28/17 at 10:54 a.m. Surveyor observed R3 in bed on her back with a pillow under R3's calves. Surveyor observed R3's heels are not being offloaded and are resting directly on the mattress. On 9/28/17 at 1:27 p.m. Surveyor observed R3 in bed on her right side with her heels resting directly on the mattress. R3 informed Surveyor her butt hurts. On 9/28/17 at 2:20 p.m. Surveyor asked RN (Registered Nurse) Manager-N if she could accompany Surveyor to R3's room as R3 had told Surveyor her bottom was hurting. Surveyor and RN Manager-N went to R3's room where RN Manager-N informed R3 she was going to look at her bottom as R3 had stated her bottom hurts. R3 replied it still is. RN Manager-N placed the call light on stating she would need help. Surveyor asked to look at R3's heels. Surveyor showed RN Manager-N the area on R3's right heel and informed RN Manager-N Surveyor had noted this area yesterday which appears to be a little larger today. Surveyor informed RN Manager-N Surveyor has multiple observations of R3's heels not being offloaded. RN Manager-N informed Surveyor she was going to call ADON (Assistant Director of Nursing)-R who is wound certified to look at this area. Surveyor asked RN Manager-N if the CNA's (Certified Nursing Assistants) should be looking at Resident's feet. RN Manager-N replied they usually do, they should be. At 2:29 p.m. Surveyor observed R3's buttocks with RN Manager-N. R3's buttocks was red, blanchable and her skin was intact. ADON-R's note dated 9/28/17 documents called to check area on R (right) heel. Noted to have a 1.5 x (times) 1.5 light brown/yellow callous type area. Non tender to touch. Has heel floated on heels off. L (left) heel slightly resting on heels off due to contracture. Resident asked if she would like to try boots instead and agrees. Central supply called for prevalon boots. On 10/3/17 at 3:23 p.m. during the daily exit conference Administrator-A and DON-B were informed of the above. 3.) Surveyor reviewed R16's medical record from 9/28/17 to 10/4/17. R16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R16's admission MDS (Minimum Data Set) dated 7/26/17 documents a BIMS (Brief Interview for Mental Status) score of 7, indicating that R16 is severely cognitively impaired. Section G (Functional Status) documents that R16 requires extensive assist and requires a two person physical assist for her bed mobility and transferring needs. Section G0400 (Functional Range of Motion) documents that R16 has impairment to one side of her upper extremities. Section M (Skin Conditions) documents that R16 is at risk for the development of pressure ulcers and has currently one stage 2 pressure injury that was present on R16's admission the facility. R16's Pressure Ulcer CAA (Care Area Assessment) dated 8/1/17 documents under the Care Plan Considerations section, R16 triggered the pressure ulcer CAA because she requires extensive assist with ADL's (activities of daily living) such as bed mobility, is frequently incontinent of bowel and bladder, staff used a Braden Scale to help determine her risk for pressure ulcers on 7/26/16, she (R16) scored a 12 indicating high risk. She was admitted with existing sites .Direct care staff to provide interventions to help maintain the rest of her skin integrity and treat current sites per MD (medical doctor) orders. R16's Skin Integrity Care Plan dated 7/19/17 documents under the Interventions section,Elevate heels off the bed with prevalon boots. R16's CNA (Certified Nursing Assistant) Care Card documents under the Positioning section, Prevalon Boots. On 9/28/17 at 2:26 p.m., Surveyor observed R16 laying supine in bed with both heels resting directly on mattress. Surveyor noted that R16 was not wearing prevalon boots to offload her heels to relieve pressure per R16's plan of care. On 9/28/17 at 2:54 p.m., Surveyor observed R16 laying supine in bed with both heels resting directly on mattress. Surveyor noted that R16 was not wearing prevalon boots to offload her heels to relieve pressure per R16's plan of care. On 10/3/17 at 10:13 a.m., Surveyor informed RN (Registered Nurse) Manager-C of the above findings. Surveyor asked RN Manager-C if R16 should have her heels offloaded to relieve pressure per R16's plan of care. RN Manager-C informed Surveyor that at times R16 refuses to have her heels offloaded but that R16 should have her heels offloaded to relieve pressure per R16's plan of care. On 10/3/17 at 4:11 p.m., Surveyor informed Administrator-A and DON (Director of Nursing)-B of the above findings. No further information was provided as to why the facility did not provide R16 with care, consistent with the professional standards of practice, to prevent new pressure injuries and promote healing.

Based on observation, interview, and record review the facility did not promote the prevention of pressure injuries for 1 (R2) of 2 sampled residents at risk of pressure injuries. R2 developed an avoidable deep tissue injury on 1/30/17 that was first noted when Surveyor requested to see R2's foot. The facility did not provide interventions to prevent the development of a pressure injury to R2's foot despite R2 being at risk for the development of pressure injuries. R2 was also observed with a crow boot on, a potential origin of pressure, not in accordance with physician's orders [REDACTED]. Findings include: The facility's POLICY AND PROCEDURE FOR THE TREATMENT AND PREVENTION OF SKIN BREAKDOWN revised 4/27/16 states, Pressure is the primary cause of pressure injury. An effective turning and repositioning schedule can help reduce the risk of developing a pressure injury. Everyone's tissue tolerance (ability of the skin and it's supporting structures to endure the effects of pressure without breakdown), is different. Therefore, it is importance to individualize each resident's turning and repositioning schedule. The facility's PRESSURE INJURY PREVENTION AND TREATMENT INTERVENTIONS AND GUIDELINES revised 4/27/16 under Decreased Mobility, Activity, or Sensory Perception states to Elevate heels off bed as indicated. R2 has [DIAGNOSES REDACTED]. R2's Care Area Analysis (CAA) signed 9/6/16 for pressure injuries states, (R2) is at risk for skin breakdown related to impaired mobility related to R BKA (right [MEDICAL CONDITION]) with right leg prosthesis as evidence by needing extensive assistance with bed mobility and frequently incontinent of bowel and bladder. (R2's) skin is intact with this assessment. Goal is to be free from skin breakdown. Care plan will address interventions to avoid complications and minimize risk and maintain skin integrity. Staff will continue to assess skin condition with ADL (activities of daily living) cares daily and report any abnormalities. (R2) would be at risk for poor wound healing and infection if pressure ulcers would develop r/t (related to) his dx (diagnosis) of IDDM (insulin dependent diabetes mellitus) and [MEDICAL CONDITIONS] MD update if indicated. R2's most recent Minimum Data Set (MDS) assessment with an assessment reference date of 11/23/16 documents that R2 is mildly cognitively impaired, did not have behaviors of rejecting care, required extensive assistance of one person's physical assistance for bed mobility, has impairment in range of motion on 1 side of his lower extremity, and is at risk for the development of pressure injuries. R2's Braden scale dated 11/26/16 for predicting pressure injury risk indicates that R2 is at risk for the development of pressure injuries. R2's CNA care card dated 8/23/16 and in R2's room on 1/30/17 did not include interventions to offload R2's heels of pressure or assist R2 to reposition despite documentation that R2 needs extensive assistance of staff for bed mobility. R2's current Care Plan with a goal date of February 2017, including his Care Plan for Skin Integrity rewritten 8/23/16, did not include interventions to offload R2's heels of pressure or interventions on how often to assist R2 to reposition despite documentation that R2 needs extensive assistance of staff for bed mobility. R2's physician's orders [REDACTED]. R2's Care Plan documents, Crow boot for wt (weight) bearing and amb (ambulation) to LLE (left lower extremity). On 1/26/17 throughout the day including at 9:36 a.m, 10:32 a.m., 11:15 a.m., and at 12:30 p.m.-1:36 p.m. Surveyor observed R2 in his wheelchair, with both of his legs resting on foot pedals, and with a black crow boot on his left foot. R2 was not bearing weight or ambulating. On 1/26/17 at 1:37 p.m., Surveyor observed Restorative Aid-D assist R2 to stand up from his wheelchair, bear weight, and ambulate with a walker and the black crow boot in place on his left leg. R2 uses a prosthesis on his right leg. Surveyor observed Restorative Aid-D assist R2 to ambulate throughout the unit until 1:55 p.m. Surveyor observed Restorative Aid-D assist R2 back into his wheelchair, observed Restorative Aid-D apply the foot pedals back on to R2's wheelchair and assist in placing R2's legs on to the foot pedals. Surveyor observed that following R2 being ambulated he was not assisted in removing the crow boot despite no longer bearing weight or ambulating. Surveyor observed R2 in his wheelchair with the foot pedals in place until 2: 42 p.m., at which point Surveyor left the unit. No attempts were observed to assist R2 to remove the black crow boot. On 1/30/17 at 7:33 a.m., Surveyor observed R2 in the dining room in his wheelchair, with his legs resting on the foot pedal, with the crow boot in place despite R2 not ambulating or bearing weight at that time. On 1/30/17 at 12:00 p.m., Surveyor and LPN (licensed practical nurse)-G went to observe R2's skin. Upon assessment Surveyor observed that R2 had a black circular pressure injury on his heel. Surveyor noted that the location of the area was consistent with the point of pressure of the heel resting on the bed. LPN-G stated that the area was new and that it would have to be measured. R2 stated that the heel is painful. On 1/30/17 at 12:12 p.m. RN (Registered Nurse) Manager-F entered the room to observe R2's heel. When RN Manager-F pressed against the area and asked if it hurt, R2 stated, Yes. RN Manager questioned aloud if R2's boot was rubbing against his foot wrong. Surveyor then reviewed R2's physician orders [REDACTED]. RN Manager-F confirmed that the physician's orders [REDACTED]. RN Manager-F confirmed there was no previous documentation of the area. On 1/30/17 the area to R2's left heel was documented as a pressure condition. The area is documented to be a deep tissue injury (DTI) measuring 3cm x 3cm, new, and dark. On 1/30/17 at 1:47 p.m., Surveyor interviewed DON (Director of Nursing)-A. Surveyor asked if a resident required extensive assistance of staff with bed mobility should heels be off-loaded of pressure? DON-A confirmed that R2 should have an intervention to have his heels offloaded if he required extensive assistance with bed mobility. Surveyor informed DON-A of R2 wearing the black crow boot on his left foot while not weight bearing or ambulating, which was contrary to R2's physician's orders [REDACTED]. Surveyor asked for any additional information. No further information was provided.

Based on observation, interview and record review, the facility did not ensure that 3 out of 9 sample residents who were receiving mechanically altered diets received foods prepared in a form designed to meet their individual needs. Resident # 1, who has an identified swallowing problem, [MEDICAL CONDITION] and a dental problem that prevents proper chewing of food, received a meal on 12/24/15 that was not prepared in a form designed to meet her needs. Resident #1 choked on a piece of turkey from an open-faced turkey sandwich that was not cut small enough and which lodged in her throat/windpipe, creating a near death experience of being without breath or pulse. Resident #1 was given the [MEDICATION NAME] Maneuver following being found unresponsive while eating her meal. Resident was then found without breath or pulse and CPR was administered. Emergency personnel were called to the facility and paramedics were able to remove a large piece of turkey from her windpipe using forceps and a larygnoscope. Resident was transported to the hospital and admitted . Resident #1 had orders to receive a mechanical soft diet. The meal ticket instructions do not include instructions on cutting of meat. Dietary instructions indicated dietary staff should cut the entree of an open-faced turkey sandwich into pieces, but did not specify how fine the pieces were to be cut. There is no evidence the facility investigated the practice of how dietary staff were to cut meat to meet the needs of a resident on a mechanically altered diet so it can be consumed safely. There is no evidence the person who served the entree to Resident #1 had training as to how to prepare a mechanically altered diet according to acceptable dietary standards. Resident #8, identified as having a swallowing problem and also identified as having no upper teeth and a poor to hopeless prognosis of lower teeth was observed on 1/13/16 to receive 2 strips of crisp bacon in whole pieces along with his mechanically altered diet that included other ground meat. Resident #8 was again observed to receive 2 pieces of limp, not crisp, bacon on 1/14/16 for his breakfast along side other mechanically altered entree items. Resident #8 has had no assessment of eating limp bacon safely with his current swallowing and dental condition. Dietary staff were unable to show evidence as to why Resident #8 was served bacon on 2 days in a row when it was not indicated to be okay on his dietary slip. Resident #7 was served food that was not prepared in a form designed to meet the resident's individual needs. Resident#7 was served a sausage patty that was not ground as required by physician orders [REDACTED]. This deficient practice has the potential to affect 21 residents who are receiving mechanically altered diets. The failure of the facility to ensure that 3 out of 9 residents sampled, who were receiving mechanically altered diets, received foods prepared in a form designed to meet their individual needs created a finding of Immediate Jeopardy that began on 12/24/15 and continued until 1/14/16. The deficient practice continues at a scope/severity of E (potential for harm that is not immediate jeopardy/pattern) as the facility continues to implement its action plan. Findings include: 1) Resident #1's clinical record was reviewed during a complaint investigation by Surveyor . Resident #1 was initially admitted to the facility on [DATE]. Admission paperwork found in Resident #1's medical record dated 11/6/15 indicates the following information: .seen by orofacial surgery and X-rays done and recommended extraction and full edentulous intubation of maxillary and mandibular teeth under general anesthesia which was done on 11/4/15. .11/6/15 Mechanical Soft diet effective now. A plan of care, dated 11/14/15, was established by the facility that indicated a problem of difficulty chewing related to recent dental surgery as evidenced by Resident edentulous (arrow up and down symbols) since 11/4 and wears no plates; does not tolerate food textures of general diet. The goal established on this plan of care indicates will tolerate least restrictive food texture in diet without increased chewing difficulties. The intervention specified indicates resident is to receive a mech(anical) soft with double entrees all meals diet per MD order. On 12/10/15, Resident #1 was readmitted to the hospital until 12/23/15 for low blood pressure and an [MEDICAL TREATMENT] AV fistula malfunction and [MEDICAL CONDITION]. This hospital visit included surgery to repair Resident #1's [MEDICAL TREATMENT] fistula. The hospital record paperwork returned to the facility on [DATE] had the following information in it: .12/22/15, swallow study .slow and incomplete mastication (chewing), excessive mastication, piece meal swallow .resident continued on puree/thin .primary medical history (PMH), dysphagia (difficulty swallowing) with silent aspiration, last video March 2015 with PEG (feeding) tube, pneumonia .medications could affect swallow and/or cognition. On 12/24/15, the evening meal served was an open-faced turkey sandwich, cream of mushroom soup, green beans, pumpkin pie with an alternate of a tuna pasta salad. A copy of the Week 2 Thursday Diet Spreadsheet/FW was requested by Surveyor . This Spreadsheet indicated a column listed titled Mech Soft (mechanical soft). On this column, next to the open-faced turkey sandwich, it specifies to cut in pieces and no crust for the pumpkin pie. All other food items were marked with an X. Nursing Progress Notes, dated 12/24/15 at 1630 (4:30 PM), indicate writer called to unit STAT (immediately). Resident choking at dinner. [MEDICATION NAME] maneuver performed currently .1730 (5:30 PM) Resident had choking episode [MEDICATION NAME] performed without success. Assisted to room and into bed, continued with abdominal thrusts, able to visualize food substance in oral cavity. Not breathing, unable to feel pulse. CPR (cardiopulmonary resuscitation) was started and 911 called. Fire dept arrived and were able to dislodge food from throat. She is breathing on her own, but not responsive .transfer to (hospital name). 2300 (11:00 PM), Resident admitted to (hospital name) with [DIAGNOSES REDACTED]. The facility did conduct an investigation into this event and shared the investigation with the State survey team on 1/13/16. Assistant Director of Nursing (ADON)-H was interviewed regarding the events of 12/24/15. ADON-H told the surveyor that she reviewed the event that occurred with Resident #1 on 12/24/15. ADON-H indicated her review was to ascertain whether CPR, the dining policy and the response to choking was handled appropriately. ADON-H indicated that the investigation did not include whether the meal was served appropriately to prevent a choking incident. ADON-H indicated the different staff she spoke with who witnessed the incident. ADON-H indicated she did not know what dietary staff member served the tray to Resident #1, but that she spoke with the Certified Dietary Manager (CDM) - D about the meal served who was going to speak with her staff. ADON-H told the surveyor that she was informed of the meal served to be an open-faced turkey sandwich and was told by CDM-D that if it could be easily mashed with a fork, it was permissible. Surveyor interviewed CDM-D on 1/13/16 at 10:55 AM. CDM-D told the surveyor that she was aware of the event with Resident #1 on 12/24/15 and found out after the incident occurred in report the next day. CDM-D knew who the two dietary servers were for that meal and indicated which employee served the meal to Resident #1. CDM-D indicated that Dietary Aide - I told her that he served the open face turkey sandwich to Resident #1 and he did cut it up. He also indicated there was gravy on it and described it as one slice of bread with 2 slices of deli style turkey and gravy over the top of that. CDM-D indicated it was Dietary Aide - J who served the plate to Resident #1 and she indicated to CDM-D that there was a lot of gravy on it and it was cut up. CDM-D indicated that Registered Dietician (RD) - F indicated this was permissible to serve for a mechanically altered diet as long as the meat was cut up. CDM-D indicated she brought both of her staff in for interviews following this incident and they went over the spread sheets together. CDM-D indicated she questioned them on how to prepare and determine if they needed any additional training. The surveyor asked CDM-D if she knew what the size of the pieces were that Dietary Aide - I cut up for Resident #1 and she indicated she did not know that. The surveyor asked CDM-D for training given to Dietary Aide - I on how to prepare mechanically altered diets. The CDM indicated this is done on hire, but was not able to show the surveyor training given to Dietary Aide - I on how to prepare mechanically altered diets. Surveyor reviewed the dietary ticket with CDM-D for Resident #1 for the meal served. The texture specified on this ticket is mechanical soft, however, there is no instruction to staff to cut meat and no instructions on how small to cut the meat. The spread sheet also indicates to cut in pieces, but does not specify how big or small to cut the pieces. CDM-D also showed Surveyor the orientation training and competency guide used with new dietary employees. Point #5 on this checklist indicates, 5. Verbalizes understanding of all diets, has been provided a list of all diets used. The check list also included a description of all diets offered in the facility. The Mechanical Soft diet is defined as Texture of food is altered: No breads, softened cereals, no raw vegetables or fruits, ground meats. Minimal chew diet. The Indications for use indicate decreased chewing or swallowing ability, poor fitting dentures, missing teeth or edentulous (without any teeth). CDM-D indicated these diet descriptions are approximately [AGE] years old and residents on mechanical soft diets can now have bread unless there is special instructions not to give bread. Surveyor interviewed Speech Therapist (SLP)-E on 1/13/16 from 12:35 PM to 12: 54 PM. SLP-E told the surveyor that he did conduct the evaluation of Resident #1 after his admission to the facility. SLP-E indicated Resident #1 was on caseload for less than 1 week and then was rehospitalized . Resident #1 indicated he spent more time with the cognitive part of her problems and saw her at the end of her meals. SLP-E told the surveyor that when he heard Resident #1 had choked on an open-faced turkey sandwich, he was concerned as turkey is a tough texture and does not flake apart easily, such as meatloaf, hamburger, flakable fish. SLP-E indicated all other meats would have to be chopped for Resident #1. Surveyor interviewed Registered Dietician (RD)-F by telephone on 1/14/16 at 11:37 AM- 12:00 PM. RD-F told the surveyor that she refers to the internet website titled Eat Right from the American Dietetic Association for guidance and resource if she has questions. The surveyor asked RD-F about Resident #1's choking episode. RD-F indicated that the open-faced turkey sandwich was to be cut into bite size pieces. RD-F indicated she did not get involved in that investigation and RD-F does not get involved with hands-on training of dietary staff. RD-F indicated she has answered questions of dietary staff such as actual and grinding of puree diets and the proper use of the Robo Coupe, used for processing foods. The surveyor asked RD-F about her instruction to the CDM that if foods can be easily mashed with a fork, they can be mechanical soft. RD-F indicated this was asked of her when it came to food items such as bananas and usually mashable foods are fruits or vegetables. RD-F indicated meat will not mash with a fork. Surveyor reviewed the hospital record for Resident #1, admitted through the emergency roiagnom on [DATE]. The hospital record indicates pt. (patient) admitted after needing [MEDICATION NAME] then CPR after choking episode of turkey. Recent video 12/22 showed penetration with thin, recommended puree/thin. At NH (nursing home), diet was mech(anical) soft/thin. Pt (patient) eating turkey breast during choking episode, large piece removed from trachea using forceps under direct laryngoscopy-post pharyngeal (throat) wall is still [DIAGNOSES REDACTED]tic. The American Dietetic Association published a chart to assist health care providers and patients on standards for food items for people who require mechanically altered diets. This chart was adapted from the National Dysphagia Diet: Standardization for Optimal Care, 2002. This chart indicates a Level 2 Dysphagia Mechanically Altered diet is one that consists of foods that are moist, soft-textured and easily formed into a bolus. Meats and other select foods may be ground or minced into small pieces no larger than 1/4 inch. All food items should be easy to chew. As indicated in the emergency room hospital record of 12/24/15, A large piece of turkey (large enough to obstruct the airway) removed from the windpipe of Resident #1, using forceps and a laryngoscope, would be larger than 1/4 inch. 2) Resident #8 was reviewed by Surveyor . The medical record indicates Resident #8 to have progress notes from the dentist, on 12/22/15, that state Pt. (patient) is edentulous (without teeth) upper arch and doesn't wear dentures; poor to hopeless prognosis lower natural teeth; Pt. (patient) satisfied, doesn't want tx (treatment). On 11/3/15, a new diet order was observed in the chart that indicates to D/C (discontinue) Puree diet, mechanical soft diet with fortified foods with nectar thick liquids. On 11/4/15, Registered Dietician (RD)- F documented difficulty swallowing r/t (related to) dysphagia as e/b (exhibited by) resident does not tolerate food textures of General diet and thin/liq(uid) consistency. Resident #8 was reviewed by Surveyor . Resident #8 was observed in the supervised dining room on the east area of the second floor on 1/13/16 at 8:30 AM to be at a table feeding himself breakfast. Resident #8's dietary slip on his meal tray indicated he was on a general, mechanical soft, nectar thick liquid diet. Resident was observed to be served an English muffin, ground sausage patty, scrambled eggs, crushed pineapple, thickened juice, thickened milk, oatmeal and 2 strips of crisp bacon. Resident #8 was observed to eat one slice of the bacon without any obvious signs or symptoms of swallowing problems. On 1/13/16 at 10:12 AM, Surveyor interviewed Speech Therapist (SLP) - G regarding Resident #8 receiving bacon along with all of his mechanically altered diet and thickened liquids. SLP-G told the surveyor that she had worked with Resident #8 in the past and he had a swallow study that allowed him to be upgraded to mechanical soft. SLP-G indicated Resident #8 would be able to handle a piece of bacon, but ideally it should be cut into smaller pieces. On 1/13/16 at 10:55 AM, Surveyor interviewed CDM-D regarding the observation made and the bacon served to Resident #8. CDM-D indicated that she was told that as long as the bacon is crisp, the dietician said it would be okay, but if it is not crisp, then the bacon would have to be mechanically altered with a Robo Coupe (food processor) before serving it. CDM-D showed Surveyor the spreadsheet dated 1/13/16. The Column for Mechanical Soft diets indicate all items that are to be served. Bacon is not listed on this spreadsheet anywhere. CDM-D indicated she was not sure why resident was served bacon, other than personal preference, but may be because he has double portions written on the diet card. On 1/14/16 at 8:45 AM, Resident #8 was observed during another breakfast meal in the second floor supervised dining room. Resident #8 was observed to have 2 slices of limp bacon that were whole, not cut up, ground or minced. The dietary card did not indicate resident to have bacon. On 1/14/16 at 11:37 AM, RD-F was interviewed by telephone regarding the mechanically altered diets in the facility. RD-F told the surveyor that she had given approval for crisp bacon because she had been told by other professional speech therapists and dieticians in the past that if crisp bacon could be chewed in the mouth, it would break down into little bits that could be easily swallowed. RD-F indicated she thought she did get permission from a SLP for Resident #8 to have bacon. RD-F told the surveyor that Resident #8 should not have limp bacon. The American Dietetic Association published a chart to assist health care providers and patients on standards for food items for people who require mechanically altered diets. This chart was adapted from the National Dysphagia Diet: Standardization for Optimal Care, 2002. This chart indicates a Level 2 Dysphagia Mechanically Altered diet is one that consists of foods that are moist, soft-textured and easily formed into a bolus. Meats and other select foods may be ground or minced into small pieces no larger than 1/4 inch. All food items should be easy to chew. This chart also indicates foods to avoid would be dried meats, tough meats such as bacon, sausage, hot dogs and bratwurst. 3) On 1/12/16 Surveyor # began review of medical record for Resident #7 who was admitted on [DATE] with [DIAGNOSES REDACTED]. According to Annual and Quarterly Minimum data set assessments ((MDS) dated [DATE] and 11/7/15, Resident #7 was able to eat independently with no setup up required. Surveyor # also reviewed Dietary assessments started in December 2014 and completed quarterly through 2015 that indicated that Resident #7 was to have a general diet but required all meat to be ground. Surveyor # reviewed meal tickets on 1/12/15 and 1/13/15 that also indicated that Resident #7 was to have ground meat. On 1/13/16 at 8:48am Surveyor # observed Resident #7 with a plate of breakfast, eating scrambled eggs at this time. Present on the plate was a medium sized sausage patty that was not ground. Surveyor # asked CNA staff who was present in the dining room if Resident #7 had any special diet restrictions and she replied, No, she is a general diet. Surveyor # then interviewed RN manager-C who indicated that Resident #7 is on a general diet but is to have ground meats. RN manager-C went over to Resident #7 and immediately removed her plate and took it back to dietary staff. RN manager- C retrieved a new plate of food from the dietary staff that now included ground sausage. RN manager- C indicated that dietary staff not following the meal ticket has been an issue for a while now and she feels that the dietary manager may need to be present on the unit during meal times. RN manager- C also indicated that it is also the responsibility of her staff to double check the tickets before giving food to the resident so she will be re-educating them on this protocol. At 10:53am Surveyor # interviewed Dietary manager-D who indicated that the staff should be reviewing the meal ticket prior to plating the food to ensure they are serving the proper diet and consistency. Dietary manager-D indicated that she had received no previous complaints regarding this concern and was unaware that her staff was not following the serving protocols. Dietary manager-D indicated that she was not sure why her staff person did not check the meal ticket prior to plating the food. The facility staff did not follow the physician ordered diet plan that was established for Resident #7 to meet her individual needs. The facility was notified of these concerns upon daily exit on 1/13/16. The failure to serve food that was modified in a form to meet individual needs created a finding of immediate jeopardy. The jeopardy was removed on 1/14/16 by which time the facility had begun implementing the following: All dietary and nursing staff were educated on food delivery and monitoring of the dining room to include monitoring meal tickets for accuracy. Dietary staff were educated on tray card accuracy and delivery including texture and sizing of mechanically altered diets. Speech therapy began reviewing residents with mechanically altered diets. Dining room service policy reviewed and revised.

Based on observation, interview and record review the Facility did not ensure 4 out of 20 sampled residents received the necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. 1 (Resident #9) of 20 sampled Residents with pain did not receive the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being in accordance with their comprehensive assessment and plan of care. Resident #9 was observed on 6/2/15 during morning cares to be crying out in pain. The CNA indicated that Resident #9 usually cries out in pain and that she tries to soothe her and on the way to the falls group will stop at the nurses station for pain medication. The Facility did not comprehensively assess the Resident's pain. 1 (Resident #6) of 20 residents reviewed experienced a decline in bowel continence without a comprehensive assessment. Resident #6 was continent of bowel then sustained a [MEDICAL CONDITION] and bowel continence declined occurred. A comprehensive assessment was not conducted and Resident #6 continues to be always incontinent of bowel. Resident #6 was not receiving the necessary services to prevent a decline in or to restore bowel continence 1 (Resident #12) of 1 resident needing a device after an arm fracture was not provided with the necessary services to aid in healing and provide comfort to the fractured arm. Resident #12 sustained an arm fracture on 5/4/15 and had an order for [REDACTED]. * 1 (Resident #19) of 1 residents reviewed needing follow up consultation after an emergency room visit did not receive physician orders [REDACTED]. Resident #19 was seen in the Emergency Department on 5/5/15, for a chronic cough with a recent episode of bloody sputum. The recommendations from the Emergency Department included the need to get an order from the primary physician for a pulmonology consult. The facility did not address the pulmonology consult recommendation with the primary physician. Resident #19 was transferred to the hospital for a non-related medical condition on 6/1/15. Example 1 rises to a G actual harm that is not immediate jeopardy. Findings include: 1. Surveyor # reviewed Resident #9's medical record on 6/1/15 & 6/2/15. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/18/15 Resident #9 was admitted to Hospice. The pain care plan dated 3/24/15 documents pain site of (R) (right) shoulder/hand. Approaches checked are routinely monitor temperature, pulse, respiration, B/P (blood pressure)-notify physician and guardian/family when abnormal, Evaluate hydration/observe fluid & food intake. Observe oral mucosa and skin tugor of forehead for signs of dehydration. Report abnormality to physician and guardian/family, Assess resident's mood, behavior, level of consciousness, cognitive status and report abnormality to physician and guardian/family, Assess for decline in physical functioning and report abnormality to physician and guardian/family, Assist resident to meet needs and maintain safety: keep call light in reach, keep personal effects in easy reach, remind to avoid sudden position changes that may increase pain, Evaluate and treat as indicated PT (physical therapy), OT (occupational therapy), SLP (speech language pathologist), Rehab program based on assessment, Keep as active as possible, Monitor tolerance of activity and report changes to physician and guardian/family, Administer medication per MD order for pain management, Monitor for constipation laxative as ordered to decrease constipation risk, Monitor opiod side effects: sedation, [MEDICAL CONDITIONS], pruritis, Encourage the resident/family/guardian to verbalize feelings, concerns. Answer questions and concerns from resident carefully and accurately. Explain procedures/interventions to motivate resident's cooperation. Give reassurance, promote positive feedback. Education about pain and its management. Use non-medication interventions: relaxation, distraction, Position to support the painful area: elevate (R) hand and Use sling when up. The admission MDS (minimum data set) signed as complete on 4/4/15 documents a BIMS (brief interview mental status) score of 4, which indicates severe cognitive impairment. Resident #9 does not ambulate, requires extensive assistance with two plus persons physical assist for bed mobility & transfer. The pain assessment interview documents yes for have you had pain or hurting any time over the last 5 days? For the question How much of the time have you experienced pain or hurting over the last 5 days? Occasionally is documented. The pain is rated at 7 on a scale of 0 to 10. The pain CAA (care area assessment) dated 4/4/15 under pain team assessment and analysis documents, Pain related to R (right) arm pain with swelling and R hip contusion 2nd to fall as evidence by pain rating at 7/10. Goal is to be free from pain or acceptable pain management limits. Care plan will attempt to maintain current level of functioning and to avoid complications. Staff will continue to monitor pain and administer [MEDICATION NAME] as needed. The significant change pain management plan dated 5/26/15 documents for results from 3 day pain data collection, Res. (Resident) started on 12 mcg (micrograms) Fentyl patch with prn (as needed) [MEDICATION NAME] effective to manage break thru pain. Resident #9 has scheduled pain medication of [MEDICATION NAME] 12 mcg every 72 hours. As needed medication includes [MEDICATION NAME] 650 mg suppository every 4 hours prn (as needed), [MEDICATION NAME] sulfate concentrate 10 mg every 2 hours prn, [MEDICATION NAME] 1000 mg every 6 hours prn and [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg every 6 hours prn. Resident #9's prn (as needed) MAR (medication administration record) reveals Resident #9 received [MEDICATION NAME] 5/325 mg on 5/8/15 at 1:30 a.m., 5/18/15 at 10:45 a.m., 5/28/15 at 10:00 p.m., and 5/29/15 at 4:30 p.m. There are no other prn pain medications documented as being given during the month of May and June 1, 2015. On 6/2/15 at 8:14 a.m. Surveyor # entered Resident #9's room with CNA (Certified Nursing Assistant)-C to observe morning cares. CNA-C washed her hands and placed gloves on. Resident #9 stated, Oh it hurts. CNA-C asked Resident #9, What hurts? Resident #9 replied, My shoulder. Resident #9 stated, I'm afraid. CNA-C replied, I'm here you don't have to be afraid. CNA-C removed the covers and the heels up pad under Resident #9's calves. CNA-C then handed Resident #9 a wash cloth and asked Resident #9 if she could wash her face. Resident #9 replied no and CNA-C washed Resident #9's face. CNA-C informed Resident #9 she was going to remove her gown. As CNA-C was removing the gown from Resident #9's left shoulder, Resident #9 cried out ow. CNA-C stated, I'll ask the nurse for a pain pill. Resident #9 replied, Can you ask her? CNA-C replied, Can I just get you dressed then I'll ask her. You have to trust me. CNA-C stated, Let me raise your arm. Resident #9 cried out ow and Surveyor # noted that she was grimacing. CNA-C then informed Resident #9 that she would just clean under her breasts. As CNA-C was washing Resident #9's left upper chest and shoulder area Resident #9 was grimacing and stated, That hurts. CNA-C replied, I'm going to make sure I get you that pain pill. You are doing amazing. Can you turn? CNA-C washed Resident #9's frontal perineal area and then attempted to position Resident #9 on her left side. Resident #9 stated, I can't. CNA-C asked Resident #9, Will you be comfortable rolling the other way? Resident #9 replied, It hurts. CNA-C replied, I know just for a little while, ok? Resident #9 replied, Please let me go. CNA-C positioned Resident #9 on her right side. Resident #9 cried out, Ow that hurts, that hurts. CNA-C replied, Ok now you can go back. Going to turn for a second to get the pad. Resident #9 stated, I can't, I can't. CNA-C stated, Let's just try. CNA-C positioned Resident #9 slightly on her left side to remove the pad. While removing the pad Resident #9 was grimacing and calling out, Ow, ow, ow. CNA-C placed a product along side Resident #9. CNA-C asked Resident #9 if she could check her bottom. At 8:23 a.m. CNA-F and CNA-I entered Resident #9's room. CNA-F asked Resident #9 how she was doing. CNA-C informed CNA-F, She's just in a lot of pain. CNA-C asked Resident #9, Can you lift your bottom? Resident #9 was able to raise her buttocks up slightly. CNA-C wiped Resident #9's buttocks with the wash cloth and placed the product under Resident #9. CNA-C placed socks and pants asking Resident #9 to raise her buttocks so she could pull her pants up. While CNA-C placed Resident #9's left arm thru her sweater, Resident #9 cried out ow. After placing the sweater on Resident #9, CNA-C told Resident #9, You did amazing. CNA-C and CNA-F sat Resident #9 up in bed, CNA-C placed a gait belt around Resident #9 and CNA-C and CNA-I transferred Resident #9 into the broda chair. CNA-C combed Resident #9's hair and then staff removed their gloves and washed their hands. At 8:31 a.m., Resident #9 stated, My shoulder hurts. CNA-F stated that she will take Resident #9 down to the falls group. CNA-C asked CNA-F to ask the nurse for a pain pill for Resident #9. On 6/2/15 at 8:35 a.m., Surveyor # asked CNA-C if Resident #9 usually complains of pain during morning cares and was this usually how Resident #9 is. CNA-C replied, Yes and explained that her shoulder and arm hurts and that Resident #9 told her she was in an accident once. CNA-C informed Surveyor # that she tries to soothe Resident #9. Surveyor # asked CNA-C why she didn't stop doing cares and ask the nurse to give her pain medication. CNA-C informed Surveyor # that Resident #9 cries out when doing cares every day so she tries to soothe her and when going to the falls group will stop at the nurses station. On 6/2/15 at 8:39 a.m., Surveyor # asked LPN (Licensed Practical Nurse)-G if the CNA asked her to give Resident #9 a pain pill. LPN-G replied She did, about five minutes ago. Surveyor # asked LPN-G if she gave Resident #9 any pain medication. LPN-G replied, No and explained that she was in the process of preparing medication for another Resident. Surveyor # asked LPN-G if Resident #9 has any scheduled pain medication. LPN-G informed Surveyor # that Resident #9 has a [MEDICATION NAME] scheduled that was placed on June 1st and the other pain medication is prn. On 6/2/15 at 8:47 a.m. Surveyor # observed LPN-G giving Resident #9 medication in pudding. Surveyor # asked LPN-G what she gave Resident #9. LPN-G indicated her morning medication and [MEDICATION NAME]. On 6/2/15 at 10:14 a.m., Surveyor # met with RN (Registered Nurse) Manager-D regarding Resident #9. Surveyor # informed RN Manager-D during Resident #9's record review Surveyor # had noted a significant change pain management plan dated 5/26/15 and inquired what prompted this assessment to be completed. RN Manager-D informed Surveyor # that the assessment was completed because Resident #9 went on hospice. Surveyor # asked RN Manager-D if she spoke to the CNA's about how Resident #9 is during cares when completing this assessment. RN Manager-D informed Surveyor # that she watches her staff do cares, treatments, & showers so she knows what is going on. RN Manager-D informed Surveyor # that when staff get Resident #9 dressed her upper arm bothers her and most of the time it's Resident #9's right upper extremity. RN Manager-D informed Surveyor # that the CNA's will tell her if Resident #9 is having discomfort. Surveyor # asked again if RN Manager-D asked the CNA's how Resident #9 is during cares. RN Manager-D replied, I don't recall if I spoke to any CNA's. I know I watched cares. We do a number of pain assessments every week. Surveyor # informed RN Manager-D of the observation of Resident #9 being in pain during morning cares. RN Manager-D informed Surveyor # that she would look into this and contact hospice. On 6/2/15 at 11:48 a.m. the Administrator and Director of Nursing were informed of the above. 2. On 6/2/15, Surveyor # reviewed Resident #6's medical record. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS (minimum data set) dated 1/23/15 indicates Resident #6 has a BIMS score of 14/15 (cognitively intact) and was independent for transfers, ambulation, and eating. Resident #6 was continent of bowel. The nurses note dated 4/1/15 indicates Resident #6 fell while ambulating to the bathroom. Resident #6 complained of pain and was sent to the hospital. Resident #6 sustained a right [MEDICAL CONDITION] and then had surgery. On 4/6/15 Resident #6 returned to the facility with therapy to regain function. The significant change MDS dated [DATE] indicates Resident #6 has a BIMS score of 8/15 (moderately impaired cognitively) and now is dependent for one staff assist for bed mobility, dressing, hygiene and eating and extensive assistance with two staff assistance for transfers. It also indicates Resident #6 is now always incontinent of bowel. The CAA (care area assessment) for urinary incontinence dated 5/15/15 indicates Resident #6 is incontinent of bowel. Staff will continue to monitor and report any changes with resident's bowel and bladder pattern. Resident has [DIAGNOSES REDACTED], [MEDICAL CONDITION] disease,[MEDICAL CONDITION](hypertension) psych disorders, [MEDICAL CONDITIONS] and now ORIF (open reduction and internal fixation) of right hip after fracture. He is now a total assist for cares and does not have the mental alertness as before the fracture. He is now incontinent for B/B (bowel and bladder) and requires the staff to check and change every 2-3 hours as needed. The alteration in bowel elimination care plan dated 4/8/15 indicates bowel incontinence secondary to [MEDICAL CONDITION] and Resident #6 is to use briefs and soaker pads on the bed. The 3/12/15 bowel assessment indicates Resident #6 can identify the urge to void/defecate. It also indicates Resident #6 is generally continent of bowel. The 4/8/15 bowel assessment after Resident #6 returned to the facility from the right hip surgery was reviewed. This assessment indicates Resident #6 can identify the urge to void/defecate some of the time. It also indicates Resident #6 is occasionally incontinent of bowel. The treatment plan to keep Resident #6's continence status from declining was not completed. A 3 day bowel and bladder screening was done on 5/9/15-5/12/15. The screening is not completed, there are areas that were not completed to get an accurate picture of Resident #6's bowel pattern. A comprehensive bowel assessment was not conducted. On 6/3/15 at 2:10 p.m., Surveyor # spoke with CNA NN regarding Resident #6's incontinence status. CNA NN stated Resident #6 at times can say when he has to use the bathroom. Resident #6 will at times use a urinal. CNA NN states she doesn't think he sits on the toilet. On 6/3/15 at 2:25 p.m., Surveyor # spoke with RN Manager J regarding Resident #6's incontinence status. RN Manager J stated Resident #6 has had a decline in his cognitive status and mobility since the 4/1/15 fracture and often times can't tell the staff when he has to use the bathroom. RN Manager J states Resident #6 is a check and change. On 6/4/15 at 10:00 a.m., Surveyor # observed Resident #6 moving around in bed and yelling out toilet several times. RN OO was nearby and went in Resident's #6 room to assist. RN OO stated Resident #6 was incontinent and went to get a CNA to assist with cleaning Resident #6. Surveyor # asked RN OO if Resident #6 sits on the toilet and RN OO stated I don't believe he does. RN OO states Resident #6 doesn't usually make his needs known. On 6/4/15 at 3:00 p.m. during the daily exit meeting with the facility, Surveyor # explained the concern with Resident's #6 bowel decline and a comprehensive assessment was not completed to determine Resident #6 level of continence and if Resident #6 is appropriate for a toileting schedule. Surveyor # also shared with administrative staff that Surveyor # received different answers from nursing staff as to Resident #6 continence status and toileting abilities. As of 6/9/15 at 3:00 p.m. the facility had no additional information. 3. Surveyor # began review of record for Resident #12 on 6/2/15. Resident #12 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #12 has been coded on the Minimum Data Set (MDS) assessment as being cognitively impaired with a score of 6. According to her Care Area Assessment (CAA) Resident #12 was at high risk for falls due to impaired mobility, arthritis, and [MEDICAL CONDITION] disorder. According to the record Resident #12 sustained falls on 2/2/15, 3/7/15, 5/4/15, and 6/1/15. The fall sustained on 5/4/15 resulted in an elbow and pelvic fracture. Resident #12 was discharged from the hospital after surgical procedure to repair fracture on 5/6/15. Per hospital documentation the Resident was discharged with aftercare instructions that the Resident is to wear an arm splint and ace wrap on left arm at all times for rehabilitation of her fractured elbow. The order also stated that Resident is to be non-weight bearing with her left arm. Resident #12 attended a follow up appointment with the orthopedic physician who ordered that the Resident was to have sling on as tolerated and remove for Occupational Therapy. On 6/2/15 at 9:28am, Resident #12 was observed sitting at the dining room table with no sling or ace wrap present on arm. Resident #12 was observed attempting to self-transfer by pushing up on both handles of her chair using both arms. Resident #12 was redirected by housekeeping staff. At 1:50pm, Surveyor # interviewed CNA- TT who stated that Resident #12 is required to wear an arm sling daily. When asked if Resident #12 is compliant when she attempts to place the sling on, CNA-TT replied yes, she lets me put it on with no problem. At 1:53 p.m. Surveyor # interviewed RN-OO who stated that Resident #12 is ordered to wear the arm sling daily but therapy came up that morning to discontinue the use of the sling to promote better range of motion. On 6/3/15 at 9:11am, Resident #12 was being wheeled out of her room into the dining room with arm sling present at this time. At 10:13am, Surveyor # interviewed Therapy Director-T who stated that the Resident had an elbow fracture that was repaired with staples and a cast at the beginning of May. Therapy Director-T stated that the Resident was initially ordered to wear a sling but that this order had been discontinued last week. Surveyor # requested documentation related to the physician discontinuing the use of the arm sling and Therapy Director-T provided an aftercare report from the Physician dated 5/28/15 that stated the Resident is to have sling on as tolerated and removed for therapy. Therapy Director-T stated that she must have gotten the order confused as the sling was not discontinued but the facility staff has not been using it because she doesn't tolerate it. Surveyor # asked if there was any documentation stating that staff encouraged the use of the sling and resident refused or would not tolerate them applying it. Therapy Director-T replied, no, I wouldn't think that we would do that if the doctor order says as tolerated. Surveyor # asked Therapy Director-T if she was aware of her staff informing the unit that the sling had been discontinued on the morning of 6/2/15, she stated that they had not. The facility did not follow the Physicians order related to therapy interventions for Resident #12 after she fractured her elbow and was recovering from a surgical procedure related to this injury. The facility was notified of these findings upon daily exit. 4. Surveyor # reviewed Resident #19's record on 6/8-6/9/15. Nurses' note documentation on 5/5/15, states Resident #19 reported that on 5/4/15, Resident #19 felt a pop when coughing and then coughed up bloody sputum. Resident #19 was assessed to have intermittent cough with wheezing throughout the bilateral upper lung field, with decreased breath sounds to the bilateral lower lung fields. Resident #19 was noted to be bracing her right side while coughing. The findings were reported to the physician who gave the facility an order to send Resident #19 to the Emergency Department (ED). Resident #19 was sent to the (ED) on 5/5/15 and returned to the facility the same day. A review of the ED report, located in Resident #19's medical record, reveals a progress note that summarized her ED visit. Within the progress note is the following statement, No evidence for PE (pulmonary embolism), [MEDICAL CONDITIONS], and unlikely acute pneumonia. Hemoptysis (coughing up blood) several days ago concerning for possible malignancy. Will treat for [MEDICAL CONDITION], but definitely needs pulmonologist follow-up for persistent chronic cough. After the section of the ED report which listed discharge medications, there is a section titled: Additional Instructions. This section included the statement, Have Dr. ---- arrange for you to see a lung specialist to arrange further evaluation of your chronic cough of 9 months and bringing up bloody phlegm. You should see the lung specialist as soon as possible. On 5/6/15, the nurses' progress notes state NOR (new orders received) from hospital transcribed. Family Care and guardian aware. A review of the physician's orders [REDACTED]. On 6/9/15 at noon, Surveyor # spoke with Registered Nurse (RN) Manager-J regarding the pulmonologist recommendation in the ED report to 5/5/15. RN Manager-J stated she was not in the facility when Resident #19 returned from the hospital and was unaware of the recommendation for a pulmonology consult. RN Manager-J stated the nurse who obtained the orders from the primary physician should have read the discharge summary and been aware of the need to obtain the pulmonology referral. Resident #19 was discharged to the hospital for a non-related medical issue on 6/1/15.

Based on observation, interview and record review the facility did not ensure 1 (Resident #6) of 20 resident received a comprehensive bladder assessment to prevent a decline in continence status. Resident #6 was continent of bladder then sustained a [MEDICAL CONDITION] and bladder continence declined. A comprehensive assessment was not conducted and Resident #6 continues to be always incontinent of bladder. Findings include: On 6/2/15, Surveyor # reviewed Resident #6 medical record. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS (minimum data set) dated 1/23/15 indicates Resident #6 has a BIMS score of 14/15 (cognitively intact) and was independent for transfers, ambulation, and eating. Resident #6 was continent of bladder. The nurses note dated 4/1/15 indicates Resident #6 fell while ambulating to the bathroom. Resident #6 complained of pain and was sent to the hospital. Resident #6 sustained a right [MEDICAL CONDITION] and then had surgery. On 4/6/15 Resident #6 returned to the facility with therapy to regain function. The significant change MDS dated [DATE] indicates Resident #6 has a BIMS score of 8/15 (Moderately cognitively impaired) and now is dependent for one staff assist for bed mobility, dressing, hygiene and eating and extensive assistance with two staff assistance for transfers. It also indicates Resident #6 is now always incontinent of bladder. The CAA (care area assessment) for urinary incontinence dated 5/15/15 indicates Resident #6 is incontinent of .bladder. Staff will continue to monitor and report any changes with resident's bowel and bladder pattern. Resident has [DIAGNOSES REDACTED], [MEDICAL CONDITION] disease,[MEDICAL CONDITION](hypertension) psych disorders, [MEDICAL CONDITIONS] and now ORIF (open reduction and internal fixation) of right hip after fracture. He is now a total assist for cares and does not have the mental alertness as before the fracture. He is now incontinent for B/B (bowel and bladder) and requires the staff to check and change every 2-3 hours as needed. The urinary incontinence care plan not dated indicates Resident #6 cannot reach the toilet quickly enough due to mobility. It also indicates Resident #6 is a check and change 2-3 hours and wears adult briefs and incontinent pad in bed. The care plan does not indicate the type of incontinence Resident #6 has. The 3/12/15 bladder assessment indicates Resident #6 can identify the urge to void/defecate. It also indicates Resident #6 is generally continent of bladder. The 4/8/15 bladder assessment after Resident #6 returned to the facility from the right hip surgery was reviewed. This assessment indicates Resident #6 can identify the urge to void/defecate some of the time. It also indicates Resident #6 is occasionally incontinent of bladder and voids when assisted with urinal. The treatment plan to keep Resident #6 continence status from declining was not completed. A 3 day bladder screening was done on 5/9/15-5/12/15. The screening is not completed, there are areas that were not completed to get an accurate picture of Resident #6's bladder pattern. A comprehensive bladder assessment was not conducted. On 6/3/15 at 2:10 p.m. Surveyor # spoke with CNA NN regarding Resident #6 incontinence status. CNA NN stated Resident #6 at times can say when he has to use the bathroom. Resident #6 will at times use a urinal. CNA NN states she doesn't think he sits on the toilet. On 6/3/15 at 2:25 p.m. Surveyor # spoke with RN Manager J regarding Resident #6 incontinence status. RN Manager J stated Resident #6 has a decline in his cognitive status and mobility since the 4/1/15 fracture and often times can't tell the staff when he has to use the bathroom. RN Manager J states Resident #6 is a check and change. On 6/4/15 at 10:00 a.m. Surveyor # observed Resident #6 moving around in bed and yelling out toilet several times. RN OO was nearby and went in Resident's #6 room to assist. RN OO stated Resident #6 was incontinent and went to get a CNA to assist with cleaning Resident #6. Surveyor # asked RN OO if Resident #6 sits on the toilet and RN OO stated I don't believe he does. RN OO states Resident #6 doesn't usually make his needs know. On 6/4/15 at 3:00 p.m. during the daily exit meeting with the facility, Surveyor # explained the concern with Resident's #6 bladder decline and a comprehensive assessment was not completed to determine Resident #6's level of continence and if Resident #6 is appropriate for a toileting schedule. Additionally Surveyor # shared with administrative staff that Surveyor received different answers from nursing staff as to Resident #6 continence status and toileting abilities. As of 6/9/15 at 3:00 p.m. the facility had no additional information.

Based on observation, staff interview, and record review the Facility did not ensure that Residents at risk for falls had identified safety devices in place and followed the care plan to prevent falls for 1 (Resident #29) of 5 Residents reviewed for falls. On [DATE], Resident #29 was transferred without a gait belt and 2 staff assistance as per his plan of care and this resulted in a humerus fracture. No surgery was indicated as a result of the fracture. On [DATE], Resident #29 was observed in bed without a bed alarm on according to his plan of care. The bed alarm would alert staff if Resident #29 was exiting the bed. Findings include: 1. On [DATE], Surveyor # reviewed the facility's self report regarding Resident #29's fall on [DATE]. The facility's investigation into the [DATE] fall concluded that Certified Nursing Assistant (CNA) KK transferred Resident #29 from his bed to his wheelchair alone and did not have a gait belt on the resident nor have another staff member to assist with the transfer. Resident #29 fell on to the floor. Resident #29 complained of pain to the shoulder and the facility received an order to send the resident to the hospital for evaluation. Resident #29's CNA care card indicates as of [DATE], Resident #29 needs extensive assistance of 2 to transfer. Resident #29's Fall/Injury Risk care plan dated [DATE] indicates Resident is at high risk for falls with a fall history. Approaches/interventions include Transfer using 2 staff ([DATE]) and use of gait belt for proper transfer techniques. On [DATE] at 9:15 p.m., the medical record indicates Resident #29 returned to the facility with a sling to his left arm. The hospital record indicates Resident #29 had a left humerus fracture (left shoulder). The hospital record indicates Resident #29 had an X- ray of his elbow, shoulder, wrist and CT of his head. The only definitive results were Resident #29 had a humerus fracture. The medical record indicates Resident #29 was being monitored throughout the evening and night and had no change in his status. The medical record indicates on [DATE] at 8:45 a.m., Resident #29 experienced a change in condition. The nurses note indicate the resident was difficult to arouse, had labored breathing, pulse oxygen level was 63 with oxygen flowing via nasal cannula, blood pressure ,[DATE], temperature 97.3 and pulse 80. MD JJ was in the facility and assessed the resident. MD JJ ordered for the resident to be sent back to the hospital. The ambulance was called to transport Resident #29 to the hospital. The nurses note indicate when the ambulance arrived Resident #29 was deceased and his death was pronounced at 9:31 a.m. The medical record indicates Resident #29 had a no code status and so resuscitation methods were not started. The medical record indicates the medical examiner was notified of Resident #29's death and the fall of the previous day. The medical examiner report indicates Resident #29's son did not find the death suspicious and did not want an autopsy performed. The report also indicates the medical examiner called MD JJ and MD JJ stated he didn't feel the humerus fracture was significant to death of Resident #29 and the CT of the head done in the ER (emergency room ) was negative for trauma. The report indicates Resident #29 had a history of [REDACTED]. The report indicates on [DATE] Resident #29's body was released to the funeral home. On [DATE] at 10:48 a.m., Surveyor # spoke with Director of Nursing (DON) B. DON B stated the result of Resident #29's fall on [DATE] was due to CNA KK not following the care plan and transferring the resident without a gait belt and without assistance. DON B states inservices were done with direct care staff regarding transfers and resident care plans. 2. Surveyor # reviewed Resident #29's medical record on [DATE]. Resident #29 has a [DIAGNOSES REDACTED]. Resident #29's last fall is dated [DATE] when he fell from the bed. The falls care plan dated [DATE] includes an intervention of "Use mobility alarm as ordered: bed." There is a handwritten notation ",[DATE] changed (triangle symbol) to tab alarm." The quarterly MDS (Minimum Data Set) signed as completed on [DATE] documents a BIMS (brief interview mental status) score of "7" which indicates severe impairment. Resident #29 does not ambulate, requires extensive assistance with one person physical assist for transfers, and is incontinent of bowel and bladder. Resident #29 has fallen twice with no injury since the prior assessment. The CNA (Certified Nursing Assistant) care cared reviewed [DATE] documents under safety needs is checked for bed alarm with a handwritten notation ",[DATE] tab alarm given", bed in lowest posit. (position), mats on floor, call light in reach. Under other documents "scoop mattress with extra wide bed ,[DATE]" and ",[DATE] falls group when OOB (out of bed)." On [DATE] at 1:47 p.m., Surveyor # observed Resident #29 in bed on his left side. Surveyor # noted that the bed was in the low position and there was a mat on the floor on the left side. Surveyor # did not observe a bed alarm. On [DATE] at 2:00 p.m., Surveyor # observed that Resident #29 continues to be on his left side in bed. Surveyor # did not observe a bed alarm. On [DATE] at 2:18 p.m., Surveyor # observed CNA-II enter Resident #29's room, check on Resident #29 who was in bed, and then left the room. Surveyor # did not observe a bed alarm. On [DATE] at 2:32 p.m., Surveyor # observed that Resident #29 continues to be in bed without a bed alarm. On [DATE] at 2:49 p.m., Surveyor # observed that Resident #29 continues to be in bed without a bed alarm. On [DATE] at 2:51 p.m., Surveyor # asked CNA-II if she placed Resident #29 in bed. CNA-II replied "yes." Surveyor # informed CNA-II that Surveyor # did not see a bed alarm on Resident #29's bed. CNA-II informed Surveyor # that she didn't see a bed alarm on Resident #29's bed, didn't know he had one, and if she saw an alarm she would have put it on. Surveyor # asked CNA-II if she checks the CNA care cards. CNA-II replied "yes." Surveyor # informed CNA-II that the CNA-II care card indicates that Resident #29 should have a bed alarm on. On [DATE] at 2:54 p.m., Surveyor # showed RN (Registered Nurse) Manager-Q Resident #29's CNA care card and asked if these were current interventions for Resident #29. RN Manager-Q replied "yes." Surveyor # informed RN Manager-Q that Surveyor # observed Resident #29 in bed without a bed alarm. RN Manager-Q informed Surveyor # that sometimes Resident #29 hides the bed alarm. Surveyor # informed RN Manager-Q that CNA-II didn't know that Resident #29 was suppose to have a bed alarm. RN Manager-Q replied, "then she didn't read the care card." Surveyor # accompanied RN Manager-Q to Resident #29 where RN Manager-Q looked on Resident #29's bed for the bed alarm. RN Manager-Q informed Surveyor # that it wasn't on the bed. RN Manager-Q informed Surveyor # that if CNA-II didn't see the alarm then she should have told someone. RN Manager-Q informed Surveyor # that this morning the night shift told her there wasn't an alarm and one was placed on. RN Manager-Q indicated that they had found four alarms. RN Manager-Q informed Surveyor # that they would put one on right away. On [DATE] at 3:01 p.m., Surveyor # asked RN Manager-Q how often should staff check the CNA care cards. RN Manager-Q replied, "daily, things could change over night." Surveyor # asked how staff would know this. RN Manager-Q replied "Common sense. I don't do orientation so I don't know what they are taught." On [DATE] at 3:12 p.m., Surveyor # asked the DON (Director of Nursing) how are staff made aware of checking the care cards. The DON informed Surveyor # they are informed during orientation, during meetings, and the nurses review the care cards with staff on the floor for any changes. Surveyor # asked how often should a CNA check the care cards. The DON indicated that they are on the back of the door in the rooms so they can check them daily. Surveyor # informed the DON of the observation of Resident #29 being in bed without his bed alarm.

Based on record review, observation, and staff interview the facility did not ensure that 2 of 13 residents with pressure ulcers received the necessary treatment and services to promote healing and prevent new ulcers from developing. * Resident #1 has was admitted to the facility with a stage 2 pressure ulcer on the right buttocks and has a facility acquired, stage 2 pressure ulcer on the right lower coccyx. On 3/24/14 and 3/25/14, Resident #1 was observed in bed with the bottom of both feet pressing directly on the hard surface of the footboard of the bed. On 3/25/14, Resident #1 developed an avoidable suspected deep tissue injury to the bottom of the right foot. (Cross Reference F246) * Resident #4 was admitted to the facility with a pressure ulcer on the heel and on the coccyx. Resident #4 did not have pressure redistribution boots on during 2 days of the survey, did not have a dressing on the heel pressure ulcer, and did not have the treatment to the pressure ulcers completed according to the physician's orders [REDACTED].#4's pressure ulcers were progressing toward healing. Example 1 involving Resident #1 is determined to be an example at a s/s (scope and severity) of "G" actual harm/isolated. The remaining example #2 is determined to be severity level of potential harm. Findings include: 1. On 3/24/14, Surveyor # reviewed Resident #1's medical record. The record indicates Resident #1 was admitted to the facility on [DATE]. The Comprehensive Risk Data Collection Form, dated 3/01/14, and the Tissue Management Weekly Progress Report, dated 3/01/14, indicates Resident #1 was admitted with a pressure ulcer to the right buttocks. The plan of care for skin integrity, dated 3/02/14, includes interventions to provide pressure reduction to heels and to elevate heels off the bed with a body pillow. The admission Minimal Data Set (MDS), dated [DATE], indicates Resident #1 has a Brief Interview for Mental Status score of 13 (cognitively intact), requires extensive staff assistance for bed mobility, is dependent on staff for transfers, is at risk for pressure ulcers, and has one stage 2 pressure ulcer. The Tissue Management Weekly Progress Report, dated 3/17/14, indicates Resident #1 developed an in-house pressure ulcer to the right lower coccyx. The record review indicates Resident #1 is noncompliant with repositioning. The record review indicates the facility developed a plan of care for Noncompliance with getting out of bed and with repositioning. The plan of care included pressure ulcer preventative interventions, which were based on the comprehensive assessment. On 3/24/14 at 11:00 a.m., Surveyor # observed Resident #1 in bed. Resident #1 had a pillow under his calves to elevate his heels off the mattress; however the bottom of both feet were positioned directly on the hard surfaced footboard of the bed. On 3/24/14 at 11:00 a.m., Surveyor # spoke with Resident #1 who indicated he was too tall for his bed. Resident #1 indicated he is 6 feet 5 inches tall and when lying in bed his feet press against the footboard of the bed. On 3/24/14 at 12:40 p.m. and 1:05 p.m., Surveyor # observed Resident #1 in bed. Resident #1 had a pillow under his calves to elevate his heels off the mattress; however the bottom of both feet were positioned directly on the hard surfaced footboard of the bed. On 3/25/14 at 7:45 a.m. and 9:20 a.m., Surveyor # observed Resident #1 in bed. Resident #1 had a pillow under his calves to elevate his heels off the mattress; however the bottom of both feet were positioned directly on the hard surfaced footboard of the bed. On 3/25/14 at 11:45 a.m., Surveyor # and Licensed Practical Nurses (LPN)-F and G observed Resident #1 in bed. LPN-F and G verified Resident #1 had a pillow under his calves to elevate his heels off the mattress; however, the bottom of both feet were positioned directly on the hard surfaced footboard of the bed. Surveyor # and LPN-F and G observed the bottom of Resident #1's feet and noted a dark maroon area to the bottom of the right foot just below the 5th toe. LPN-F and G notified Registered Nurse-H of the development of the area to the bottom of the right foot. The Nursing Note, dated 3/25/14 at 12:25 p.m., indicates RN-H assessed the bottom of Resident #1's foot, below the 5th toe. The note indicates Resident #1 has a 3.2 centimeter (cm) by 2.7 cm suspected deep tissue injury, with 80% of the wound bed dark maroon and upper inner edge red. The note indicates the physician was notified of the suspected deep tissue injury and skin prep was ordered to the area every shift. On 3/25/14 at 1:30 p.m., Surveyor # spoke with Registered Nurse/Nurse Manager-D who indicated Resident #1's bed would be re-evaluated to ensure a proper size for the Resident, and to ensure the resident's feet do not press on the footboard. On 3/26/14 at 7:50 a.m., Surveyor # observed Resident #1 in bed. Resident #1 had no footboard on his bed and had pressure redistribution boots on both feet. 2. Surveyor # reviewed Resident #4's medical record on 3/24 to 3/27/14. Resident #4 was admitted to the facility on [DATE] with multiple pressure ulcers including a Stage 3 pressure ulcer to her left heel and a deep tissue injury to her left heel. Resident #4 is dependent upon staff for her ADL's (activities of daily living). The skin integrity plan of care dated 12/14/13 includes an intervention of "Elevate heels off the bed with prevalon boots bilat. (bilateral) @ (at) all x's (times)." The CNA (Certified Nursing Assistant) care card reviewed 1/14/14 documents, "Prevalon boots @ (at) all times." The follow up wound clinic dated 3/12/14 under recommendation and MD findings documents, "1. continue santyl to coccyx apply edge to edge & nickel thick daily followed by dakins moist gauze. 2. Start [MEDICATION NAME] flex to (L) (left) heel, change dsg. (dressing) 3x(times)/week." The physician telephone order dated 3/12/14 for the treatment to Resident #4's left heel is normal saline wash followed by [MEDICATION NAME] flex to wound bed, skin prep around periwound, followed by dry sterile dressing and kerlix. Change on Monday, Wednesday, Friday, and prn (as needed). On 3/24/14 at 11:04 a.m., Surveyor # observed Resident #4 in bed on her left side. Surveyor # observed prevalon boots on the dresser next to Resident #4's bed. On 3/24/14 at 12:03 p.m., Surveyor # observed RN (Registered Nurse) Manager-D and CNA -X reposition Resident #4 in bed. Surveyor # observed that Resident #4 was not wearing prevalon boots and observed the prevalon boots on the dresser next to Resident #4's bed. After Resident #4 was repositioned RN Manager-D informed CNA-X to place the prevalon boots on Resident #4. On 3/24/14 at 2:56 p.m., Surveyor # observed Resident #4 in bed on her left side. Surveyor # observed that Resident #4 was not wearing the prevalon boots and observed the prevalon boots in a chair. On 3/24/14 at 3:48 p.m., Surveyor # observed Resident #4 in bed. Surveyor # observed that Resident #4 has a pillow under her calves but her heels are resting directly on the mattress and Resident #4 was not wearing the prevalon boots. Surveyor # observed the prevalon boots were in a chair. On 3/25/14 at 7:23 a.m., Surveyor # observed Resident #4 in bed on her back. Surveyor # observed the right prevalon boot is on and the left prevalon boot off. LPN (Licensed Practical Nurse)-EE washed his hands and put gloves on. Surveyor # observed Resident #4's left heel was resting directly on the mattress without a dressing. Surveyor # asked LPN-EE if he had removed the dressing. LPN-EE informed Surveyor # that he had. LPN-EE applied skin prep around the pressure ulcer, cut a piece of [MEDICATION NAME] flex, placed the [MEDICATION NAME] on a four by four, placed the [MEDICATION NAME] with the four by four over the left heel pressure ulcer and wrapped with kerlix. Surveyor # observed that while LPN-EE was wrapping the left foot, the four by four gauze moved towards the left of the heel so that only the [MEDICATION NAME] was over the pressure ulcer. In addition, when LPN-EE was wrapping Resident #4's left foot he did not wrap the kerlix over the heel where the [MEDICATION NAME] was placed. After LPN-EE was finished with the kerlix he placed the prevalon boot on Resident #4's left foot. On 3/25/14 at 8:46 a.m., Surveyor # observed morning cares for Resident #4 with CNA (Certified Nursing Assistant)-HH. At 8:52 a.m. CNA-GG entered Resident #4's room to assist CNA-HH. CNA-HH washed Resident #4's upper body, placed lotion on her arms & hands, and removed the prevalon boots. CNA-HH washed Resident #4's frontal perineal area and cleansed the tubing of the catheter. At 9:06 a.m., Surveyor # observed the [MEDICATION NAME] dressing was off Resident #4's left heel and was on the mattress. CNA-HH washed Resident #4's buttocks and placed an incontinence product on Resident #4. CNA-HH and CNA-GG placed pants on Resident #4. CNA-HH picked up the [MEDICATION NAME] flex dressing off the mattress, placed the dressing on the over bed table, and then threw it away in the garbage. Gripper socks and prevalon boots were placed on Resident #4. Surveyor # noted the gripper sock on the left foot was not pulled up over the back portion of the heel. Resident #4 does not have a dressing on the left heel pressure ulcer. On 3/25/14 at 1:45 p.m., Surveyor # observed CNA-HH and CNA-GG transfer Resident #4 from the wheelchair into bed using a Hoyer lift. Staff removed the sling from under Resident #4, removed the prevalon boots and pants. CNA-HH provided incontinence care for Resident #4. After providing incontinence care CNA-HH stated that they have to put the boots back on Resident #4. Surveyor # observed prior to staff placing the prevalon boots on, there is still not a dressing over the pressure ulcer on Resident #4's left heel. On 3/25/14 at 2:07 p.m., Surveyor # informed CNA-HH that during morning cares Surveyor # observed her pick up a black piece of material (the [MEDICATION NAME] flex dressing) and threw it away. Surveyor # asked CNA-HH if she knew what it was. CNA-HH replied, "No I don't know what it was." On 3/25/14 at 2:15 p.m., Surveyor # informed RN (Registered Nurse) Manager-D of Surveyor # treatment observation with LPN-EE, inquired why LPN-EE did the treatment when it wasn't due, and the subsequent observations of Resident #4 not having a dressing on the left heel pressure ulcer. Surveyor # accompanied RN Manager-D to Resident #4's room, RN Manager-D removed the left prevalon boot and confirmed there was not a dressing on the pressure ulcer. On 3/26/14 at 7:21 a.m., Surveyor # asked RN Manager-D if she had any information as to why LPN-EE did the treatment on Tuesday. RN Manager-D replied "no" and that they asked him but LPN-EE didn't give them a reason. On 3/26/14, Surveyor # reviewed Resident #4's treatment record and noted the left heel prior treatment of [REDACTED]. The treatment to Resident #4's left heel which was ordered on [DATE] was not started until 3/25/14. Review of the weekly wound sheets does not indicate that Resident #4's left heel pressure ulcer deteriorated during this time period. On 3/26/14 at 2:00 p.m., Surveyor # asked RN (Registered Nurse) Manager-D why the treatment for [REDACTED]. until 3/25/14. RN Manager-D informed Surveyor # that it was her fault as she wrote the telephone order but didn't transcribe it onto the treatment sheet. On 3/27/14 at 9:01 a.m., Surveyor # asked LPN-EE why he changed the dressing on Resident #4's left heel on Tuesday, March 25th when it was ordered on Monday, Wednesday, & Fridays. LPN-EE informed Surveyor # that he didn't see the Monday, Wednesday, Friday written on the treatment sheet and thought it was daily. LPN-EE stated that they usually box out the days when the treatment should be done and he didn't see that on the sheet. On 3/26/14 at 3:06 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above.

Based on record review and staff interview the facility did not establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The facility did not establish an Infection Control Program under which it (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. Upon review of the facility's Infection Control program, Surveyor # noted the facility had an outbreak of a GI (gastrointestinal illness) in November 2011 and December 2011. Faced with the onset of a GI outbreak among residents beginning 11/17/11, the facility did not: ? Recognize that an outbreak had occurred ? Isolate residents who were ill. Ill residents and non-ill (exposed but asymptomatic) residents were allowed to commingle and to eat in the central dining room and to attend activities. ? Increase scheduled cleaning and ensure that housekeeping staff was cleaning with a product that was effective against noro virus ? Ensure that all staff consistently used personal protective equipment when caring for residents who were ill. ? Ensure that staff who was ill did not report back to work until 48 hours after being asymptomatic. The facility allowed staff to report back to work within 24 hours of being well and, in some cases, on the same day they reported being well. ? Prevent staff from floating between units ? Call the local public health department to inform them that an outbreak had occurred and to get guidance from them on how to control it ? Call the medical director to inform him that an outbreak had occurred. Staff did call the medical director, individually, when his patients became ill but never apprised him of the extent to which the outbreak had spread. ? Curtail admissions This situation created a finding of immediate jeopardy that began on 11/17/11. On 1/24/12 at 3:00 p.m., the Administration and Director of Nursing -A was informed of the immediate jeopardy. The immediate jeopardy was removed on 1/25/12. The deficient practice continues at a scope and severity level of an F ( no actual harm with potential for more than minimal harm that is not immediate jeopardy/widespread) as the facility must continue with staff training on Infection Control specifically Outbreak policy and procedures. The facility will increase its use of outside resources for educational purposes and program development. The facility's Quality Assurance Program will continue to monitor the facility's progress in this area. Findings include: 1. The Division of Quality Assurance (DQA) Memo 10-033 dated 11/2/10, "Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in Wisconsin Long-Term Care Facilities" Revised 10/20/09 states: "Facilities should immediately institute aggressive infection control measures anytime an outbreak is suspected " and that "When appropriate prevention and control measures are not implemented immediately, outbreaks can continue for weeks causing many illnesses, some hospitalization s and the occasional death from dehydration and other complications of vomiting and diarrhea. " The WDPH (Wisconsin Division of Public Health) "Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in Wisconsin Long-Term Care Facilities", revised 10/20/09, indicates an outbreak of viral gastroenteritis should be suspected when two or more residents and/or staff develop new onset of vomiting and/or diarrhea within one to two days. The recommendations direct the facility to notify the local Health Department of any suspected or confirmed outbreak. The recommendations further direct the facility to post signage that the facility is experiencing an increase in gastrointestinal illness, and visits to symptomatic residents should be discouraged. On 1/24/12 at 11:05 a.m., Surveyor # interviewed Registered Nurse (RN)-B who is in charge of Infection Control in the facility. It was during this time that Surveyor # reviewed the outline of infections "Infection Prevention Weekly Notes" in which RN-B uses as a tool for herself. These notes contained the following: November 11-19: 5 residents with GI symptoms on the 1st floor; 8 residents with GI symptoms on the 2nd floor. November 20-26: 2 residents with GI symptoms on the 1st floor; 2 residents with GI symptoms on the 2nd floor. November 27-30: 2 staff with GI symptoms; 0 residents with GI symptoms. December 1-3: No GI symptoms December 11-17: 7 residents with GI symptoms 1st floor; 3 residents with GI symptoms 2nd floor, 1 staff The Norovirus Log for residents indicates the following: November 2011: 1st floor: 5 residents; 2nd floor: 12 residents Date of onset on the 1st floor was 11/14/11 Date of onset: On 11/11- 1st resident became ill. On 11/13 - a second resident became ill. On 11/16 - a third became ill with a well date of 11/19. On 11/17- a fourth resident became ill with a well date of 11/19. On 11/18- four additional residents became ill on the 2nd floor. December 2011: 1st floor: 23 residents 2nd floor: 8 residents These residents displayed some or all of GI symptoms including fever, loose stool, and nausea/vomiting. Last documented case of a resident with GI symptoms was 12/27/11, but no well date was documented for that resident. Staff did not consistently document well dates on the logs for residents. RN-B indicated that staff were not very good at documenting on the forms and some residents were missed who were sick. RN-B further indicated that the forms were changed to make it easier for staff to document but it didn't really help. RN-B was uncertain how consistent the documentation was or how thorough. The Surveyor # asked RN-B what constitutes an outbreak? RN-B indicated she was not aware of what constituted an outbreak, she would have to look in her binder. Early identification of an infection is necessary to help prevent its spread. 2. The WDPH recommendations indicate a facility should cancel or postpone group activities for at least forty-eight hours after the last identified case. Facilities are directed to minimize movement of residents. Asymptomatic, exposed residents should not be moved from an affected to an unaffected resident unit. Additionally, the recommendations indicate a facility should consider discontinuing use of common dining areas and instituting in-room dining. Surveyor # asked RN-B on 1/24/12 at 11:05 a.m. if any type of isolation took place during this time of GI illness? RN-B indicated that no resident was isolated. Residents traveled from floor to floor, ate in the dining rooms, went to activities and therapy. The Health Department was not notified of this GI outbreak. RN-B indicated that no cultures were taken on either staff nor resident. 3. The WDPH guidelines state, "Staff assignments a. Maintain the same staff to resident assignments, if possible. b. Limit staff from moving between affected and unaffected units. c. Discontinue " floating " staff from affected units and other facilities to food service." RN-B further indicated on 1/24/12 at 11:05 a.m. that residents and staff were allowed to continue with normal daily life activity, routine housekeeping was continued, the medical director was not informed of an outbreak status and the facility continued with admissions. Staff were not designated to work on isolated units. 3. The WDPH guidelines state that "A staff illness policy outlining the duty to inform requirements for exclusion and the circumstances for returning to work (48 hours) should be developed and implemented and all employees should be educated about the policy." On 1/24/12, at approximately 12:50 p.m., RN-B provided Surveyor # with a log in which staff illness was documented. Surveyor # noted that staff returned on the same day in which they reported to be well. RN-B indicated that no protocol was put in place for staff, they were encouraged to stay home, but it wasn't enforced. Staff Line List includes the following information: 1st staff member became ill on 10/5/11 well date of 10/7/11 and returned to work on 10/7/11. 2nd staff member became ill on 10/11/11 well date of 10/12/11 and returned to work on 10/12. Staff continued to be sick through November and December 2011. A total of 14 staff members were documented sick with GI illness during the dates of 10/5/11 thru 12/27/11. During this recertification survey, the facility's currents census is 97 residents with residents residing on two floors. Some residents from 1st and 2nd floor co-mingle in the ground floor dining room for meals. According to RN-B, this dining room was also kept open during the GI illness. The failure of the facility to implement a program in which the facility promptly recognized an outbreak and took appropriate action to prevent the spread of an infection created a finding of immediate jeopardy. The facility removed the finding of immediate jeopardy on 1/25/12 when the facility implemented the following: * Investigate all incidents of GI issues/symptoms * Residents exhibiting symptoms will be placed on the 24 hour board and the flu/norovirus long until they are symptom free for 48 hours. * Guidelines/recommendations to prevent the spread of infection have been posted at the nurses station. * The facility has established a policy as to what constitutes an outbreak and will inservice the staff on infection control procedures and prevention of spread. * The facility has established procedures to follow in regards to the prevention and spread of infection, such as notifying all departments when there is an outbreak, isolation of symptomatic residents, the use of bleach for cleaning rooms, discouraging visitors with posted signs, staff assignment to unit, notification of the medical director, consultants, and public health. * On 1/25/12 inservicing on infection control including but not limited to GI symptoms was held every hour beginning beginning at 6:30 a.m. by the Director of Nursing/Infection Control Nurse/designee. Fifty percent of all licensed nursing and direct care staff was inserviced on 1/25/2012. The remaining fifty percent of the staff will be inserviced by 2/1/12. * The facility contacted an outside consultant agency to assist with the education. * The Medical Director has been notified. The deficient practice continues at a scope and severity level of an F (no actual harm with potential for more than minimal harm that is not immediate jeopardy/widespread) because the facility needs to continue inservicing all of their staff on infection control including the facility's policies and procedures for infection control including outbreak standards. The facility has contacted an outside consultant agency to assist with the education.

Based on observations, record reviews and interviews, the facility did not ensure that 3 of 8 residents with pressure ulcers (Residents #4, #16 & #21) received the necessary treatment and services to promote healing, prevent infections and prevent new ulcers from developing. * Resident #4 has a facility acquired pressure ulcer on the coccyx. The pressure ulcer was first noted on 4/1/11, and has progressed into a Stage 4 pressure ulcer as of 1/4/12. Resident #4 is being followed by the wound clinic, with the last consultation completed on 1/3/12. The facility did not complete a treatment, (1/8 strength of Dakins solution), as recommended by the wound clinic on 1/20/12. Resident #4 was not repositioned from side to side while in bed on 1/19 & 1/20/12 as per the plan of care, and was up in her wheelchair for lunch in excess of 2 hours on 1/20/12. Resident #4's treatment was changed on 1/20/12, to include calcium alginate. On 1/23/12, during a treatment observation, there was no evidence that the calcium alginate had been used the previous day. The facility's failure to provide appropriate treatment for [REDACTED]. The Administrator was notified of this finding on 1/24/12, at 9:40 a.m. The facility removed the immediate jeopardy on 1/25/12, and the deficient practice continues at a scope/severity level of G (actual harm/isolated) based on the following findings. * Resident #16 was readmitted to the facility after a hospitalization on [DATE]. The facility noted a blister on Resident #16's left heel on 1/19/12. The facility wound nurse recommended skin prep and a dressing be applied daily. A physician's orders [REDACTED]. Resident #16 had orders upon readmission to float her heels. On 1/23/12, Resident #16 was observed with her heels resting on the mattress for 1 hour and 55 minutes. According to facility assessments of the blister, the blister measured 1.7cm x 0.5cm on 1/19/12, and 2.5cm x 2.5cm on 1/24/12. * There was no evidence that regular weekly skin assessments by licensed nurses were conducted prior to Resident #21 developing what is described as a Stage 2 pressure ulcer to the back of his left heel of the foot, open blister, 2.4 cm X 4 cm X 0.1 cm which was first noticed on 10/14/11. Daily documentation by nursing assistants did not indicate that daily skin checks or foot checks were being done, as directed by facility policy for pressure ulcer prevention. Findings include: 1. Surveyor # reviewed Resident #4's record on 1/19 - 1/25/12. Resident #4 was admitted to the facility on [DATE]. Her most recent readmission was on 3/28/09. Resident #4 has [DIAGNOSES REDACTED]. According to a Minimum Data Set ((MDS) dated [DATE], Resident #4 requires extensive assistance for bed mobility, is at risk for the development of pressure ulcers, and currently has 1- Stage 4 pressure ulcer. According to the Care Area Assessment (CAA) for pressure ulcers dated 1/10/12, Resident #4 is at risk for skin breakdown related to impaired mobility and bowel incontinence. A review of Resident #4's Resident Life Plan dated 8/3/11, which is a form kept in the resident's room to provide care information for direct care staff, addresses positioning needs. The positioning section was updated 10/10/11, and instructs staff to position Resident #4 from side to side, every 2 hours while in bed, and every 1 hour while up in her chair. Positions to avoid, updated 10/10/11, is on her back. Additional interventions listed on the Resident Life Plan included a Panacea air mattress for the bed, and a roho cushion in her chair. A Braden/Bergstrom Scale for Predicting Pressure Ulcer Risk completed 1/11/12, indicates Resident #4 is at high risk for skin break down. A physician's progress note dated 11/4/11 indicates Resident #4 is followed up by the wound clinic regarding her decubitus ulcer which is chronically infected. Resident #4 experienced an 8 pound weight loss between December 2011 and January 2012. Nutritional interventions are in place. Resident #4's appetite remains poor according to meal intake documentation in December 2011 and January 2012. Resident #4's pressure ulcer is being monitored weekly by the Assistant Director of Nursing (ADON)-B, who is a wound certified nurse. The pressure ulcer was assessed as a Stage 3 from 12/6/11 until the week of 1/4/12, when it was assessed as a Stage 4 pressure ulcer. On 1/9/12, the pressure ulcer measured 2.5cm x 2 cm x 1.2cm, with 3.8cm of undermining (where the skin is separating from the underlying tissue). There was a small amount of drainage. On 1/17/12, the pressure ulcer measured 3.5cm x 2 cm x 1.2cm, with a large amount of drainage. A culture was obtained. There was increased undermining along more areas of the pressure ulcer. The progress of the pressure ulcer was assessed as deteriorated. On 1/24/12, the pressure ulcer measured 3cm x 2cm x 1cm., with a moderate amount of drainage. Two small areas of bone were exposed. Resident #4 has most recently been evaluated in the wound clinic on 1/3/12. physician's orders [REDACTED]. The new treatment order as written in the physician's orders [REDACTED]. Gently pack with gauze and cover with DSD (dry sterile dressing). Change daily and PRN (as necessary)." A review of the recommended treatment change as written on the consult form from the wound clinic on 1/3/12, was: Change sacral wound orders to: Cleanse with 1/8 strength Dakins solution. Apply Santyl to wound. Gently pack with gauze and cover with dry dressing. Change daily and as necessary. (When Surveyor # reviewed Resident #4's record on 1/20/12, the clinical record contained a clinic appointment form which indicated the appointment was on 1/3/12, and there was a note on the form to "see note and orders." The notes from the wound clinic which included the recommended treatment changes were not in the clinical record. Surveyor # obtained the notes on 1/23/12. The notes were in ADON-B's office.) Surveyor # observed Resident #4 either sitting up in her wheelchair or lying on her back in bed on 1/19 & 1/20/12. On 1/19/12, Resident was observed sitting up in her wheelchair in the dining room at 11:35a.m, 12:18p.m., 12:43p.m., 12:50p.m. and 12:58p.m. On 1/19/12 at 1:40p.m., Surveyor # entered Resident #4's room. Certified Nursing Assistant (CNA) - J was finishing incontinence cares and stated she had just layed Resident #4 down in bed. Surveyor # asked how long Resident #4 usually stays up in her wheelchair. CNA-J stated Resident #4 is usually up for about an hour or so. CNA-J stated that she had gotten Resident #4 up at 11:00a.m. today. That meant Resident #4 had been sitting up in her chair for approximately 2 1/2 hours. According to current standards of practice per the Eurpopean and National Pressure Ulcer Advisory Pannel (EPUP and NPUAP), "Pressure Ulcer Treatment: Quick Reference Guide" dated 2009 states, "If sitting in a chair is necessary for individuals with pressure ulcers on the sacrum/coccyx or ischia, limit sitting to three times a day in periods of 60 minutes or less. Consult a seating specialist to prescribe an appropriate seating surface and/or positioning techniques to avoid or minimize pressure on the ulcer." CNA-J left Resident #4 positioned on her back in bed after finishing incontinence cares at 1:50p.m. Surveyor # observed Resident #4 laying in bed on her back, with the head of the bed at approximately 30 degrees, at 2:30p.m. and 3:15p.m. This was contrary to her care needs as identified in the plan of care. On 1/20/12, Surveyor # observed Resident #4 positioned on her back in bed at the following times, again contrary to her care needs as identified in the plan of care: At 7:50p.m., lying in bed, with the head of the bed lowered. At 9:15p.m., CNA-F was assisting Resident #4 with her breakfast. The head of the bed was raised to approximately 60 degrees for breakfast. CNA-F stated Resident #4 would stay in bed until around 11:30, then she was going to give her a shower. At 9:45a.m., Resident #4 was done with breakfast. She remained on her back with the head of the bed at approximately 60 degrees. She was observed in the same position at 10:17a.m. and 10:45a.m. At 11:15a.m., Resident #4 was taken for her shower. The dressing from the coccyx pressure ulcer was removed by LPN-D. The dressing was saturated with sereosanguinous drainage. On 1/20/12 at 11:45a.m., Resident #4 returned to her room from her shower. LPN-D stated she could not complete the treatment to the pressure ulcer because she was out of Santyl. LPN-D stated she had ordered more from pharmacy several days ago, but it still had not arrived. LPN-D stated she had ordered the Santyl again. LPN-D stated she would cleanse the pressure area and apply a dry dressing until the Santyl arrived. Surveyor # observed LPN-D cleanse the pressure ulcer with Dakins solution half strength (0.25%), then apply skin prep to the peri wound area, followed by a dry dressing taped in place. On 1/20/12 at 1:30p.m., Surveyor # spoke with ADON-B, who confirmed that Resident #4 was not to be positioned on her back, she was to be positioned side to side while in bed. Surveyor # asked ADON-B if the Panacea air mattress was a type of mattress that negated the need for repositioning. ADON-B stated the Panacea air mattress is a Stage 4 mattress, but Resident #4 should still be kept positioned off of her back. On 1/20/12 at 2:30p.m., Resident #4 was positioned on her left side in bed. LPN-D completed the treatment to the coccyx. The dressing LPN-D had placed over the pressure ulcer at 11:50a.m., was saturated with serosanguinous drainage. LPN-D cleansed the pressure ulcer with Dakins solution half strength (0.25%), then applied a gauze impregnated with Santyl into the pressure ulcer. The gauze packing was then covered with gauze and taped in place. A review of Resident #4's record on 1/23/12, revealed the treatment for [REDACTED]. The new order stated : Wash with Dakins solution FB skin prep to the periwound area, pack with silver alginate and cover with a sterile ABD pad. Change daily and as necessary. On 1/23/12 at 2:05p.m., Surveyor # observed LPN-D complete the treatment for [REDACTED]. The old dressing was 1/2 saturated with drainage. As LPN-D removed the dressing, Surveyor # observed that there was no silver alginate in the dressing or in the pressure ulcer. It was verified by LPN-D that there was no silver alginate present as specified by the physician's orders [REDACTED]. The area was then covered with an ABD dressing. Surveyor # asked LPN-D if the silver alginate had been available on 1/22/12, for the dressing change. LPN-D stated the silver alginate is a stock item, so should have been available. LPN-D did not know why the treatment had not been completed as ordered. On 1/25/12 at 1:10p.m., Surveyor # spoke with RN-E regarding the order for Dakins solution for wound cleansing. RN-E and Surveyor # verified that the Dakins solution in the treatment cart was half strength (0.25%). Surveyor # showed RN-E a copy of the wound clinic recommendations for Dakins 1/8 strength. RN-E stated she had not seen the consult. She had been given a note from ADON-B regarding the wound clinic recommendations, and had obtained physician's orders [REDACTED]. The failure to provide the necessary repositioning and treatment orders for the treatment of [REDACTED]. The facility removed the immediate jeopardy on 1/25/12 at 3:00p.m., by which time it had: * Established a plan to monitor Resident #4's positioning and treatment needs utilizing a positioning audit tool and a wound audit tool. * Verified treatment orders for all residents with pressure ulcers. * Care plans for all residents with pressure ulcers have been reviewed and staff will be monitored for implementation of the care plans with the audit tools. The Team leader will monitor positioning and treatments. The shift supervisor will review the audit tools each shift for completion. The wound car nurse/designee will monitor the audit tools daily and report to DON. * Inservicing on pressure ulcer treatment and monitoring had been completed for 55% of nursing staff. Remainder of staff will receive inservicing prior to working with residents, with all staff to be inserviced by 2/1/12. * Pathways will assist in continuing education efforts. * The Medical Director is aware of the situation. Deficient practice continues at a scope severity level of G, actual harm/isolated, as the facility continues to inservice staff and monitor staff compliance with pressure ulcer management and by the following examples: 2. Surveyor # reviewed Resident #16's record on 1/23 - 1/25/12. Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Since that admission she had experienced a cardiovascular accident in 2009, and was most recently admitted to the hospital on [DATE] - 1/16/12 for [MEDICAL CONDITION] (low amount of oxygen in blood) related to a worsening of her [MEDICAL CONDITIONS]. A Change of Condition MDS was completed on 12/14/11. Resident #16 requires total assistance with bed mobility. She was assessed to be at risk for pressure ulcers. At the time of the 12/14/11 MDS, the resident had no current pressure ulcers. The CAA noted that a Stage 3 pressure ulcer of the coccyx was healed. The admission nursing assessment on 1/16/12, noted a Stage 2 pressure ulcer on the coccyx, and a Stage 2 pressure ulcer on the right ankle. The admission physician's orders [REDACTED]. On 1/23/12 at 9:30a.m., Surveyor # observed Resident #16 lying in her bed. She was positioned on her back, with the head of the bed raised approximately 45 - 50 degrees. There was a pillow placed under her calves, but the pillow was not thick enough to float her heels. Her heels were observed resting on the mattress. On 1/23/12, Resident #16 was observed lying on her back with her heels resting on the mattress, at 9:55a.m., 10:30a.m., and 11:15a.m. At 11:25a.m., CNA-G entered the room to complete morning cares with Resident #16. Surveyor # had LPN-D check the positioning of Resident #16's heels before Resident #16 was moved. LPN-D stated that the pillow was not positioned correctly as the heels were not being floated. LPN-D stated the left heel was reddened and felt soft. (There was no dressing on the left heel). On 1/24/12 at 7:45a.m., Surveyor # observed a dressing on Resident #16's left heel. On 1/24/12, Surveyor # reviewed the nurse's note documentation for Resident #16 and noted that on 1/19/12, ADON-B had assessed Resident #16's skin and noted an intact blister on the left heel measuring 1.7cm x 0.5cm. The surrounding skin was noted to be reddened. The nurses' note indicated ADON-B recommended skin prep and cover the left heel with a dry dressing every shift. On 1/24/12, Surveyor # reviewed the physician's orders [REDACTED]. A review of the treatment administration record (TAR) for January 2012, revealed the TAR did not contain a treatment for [REDACTED]. On 1/24/12 at 2:00p.m., Surveyor # spoke with RN-E. RN-E is responsible for obtaining physician's orders [REDACTED]. RN-E was not aware of the recommendation for the treatment of [REDACTED]. RN-E checked the faxes sent to physicians but did not find one related to Resident #16's left heel. RN-E explained that after wound rounds ADON-B gives written recommendations and RN-E will then contact the physician for orders. On 1/24/12 at 2:05p.m., Surveyor # spoke with LPN-H, who had applied the dressing the morning of 1/24/12. LPN-H stated she was responsible for wound treatments after ADON-B had assessed the pressure ulcers. LPN-H stated she had been with ADON-B earlier in the morning and had applied skin prep and a dressing after the area had been assessed. LPN-H indicated that ADON-B had stated the treatment for [REDACTED]. On 1/25/12, Surveyor # reviewed the documentation on the Tissue Management Weekly Progress Report, which is the facility from used to document weekly assessments of pressure ulcers. Resident #16's left heel was assessed on 1/24/12. The blister had increased in size from 1.7cm x 0.5cm on 1/19/12, to 2.5cm x 2.5cm on 1/24/12. The treatment recommendation remained unchanged. 3. Resident # 21's closed medical record and hospital medical record were reviewed by Surveyor # on 1/25/12. Resident #21 was admitted to the facility on [DATE] following hospitalization . Resident #21 [DIAGNOSES REDACTED]. Resident #21 had a history of [REDACTED]. On 8/29/11, the comprehensive risk data collection document indicated "Resident skin in fair condition, has scabbed areas in healing stages, but needs to be monitored closely due to DM (diabetes mellitus)." The Minimum Data Set (MDS), dated [DATE] indicated Resident #21 is "at risk for pressure ulcers." Section M1040 of this form indicates, "Foot problems: [MEDICAL CONDITION], not checked, other open lesion on the foot, not checked." The Pressure Ulcer CAA (care assessment) completed on 9/9/11 and signed by Registered Nurse (RN)-J indicated Resident #21 is "at risk for skin breakdown related to impaired mobility due to osteoporotic compression fractures....as exhibited by extensive assist with bed mobility and frequent incontinence for both bowel and bladder. Resident admitted with right lower extremity skin breakdown with treatment. Goal is to free from skin breakdown. Care plan will address to avoid complications and minimize risk and improve skin integrity. Staff will continue to assess skin condition with Activities of Daily Living cares daily and report any abnormalities. Staff will continue to encourage and assist turning and repositioning regularly." On 8/30/11, a plan of care was developed for Skin integrity. This plan of care indicates the resident is at risk for alteration of skin integrity due to being chair fast, low [MEDICATION NAME] and pre-[MEDICATION NAME] level, [MEDICAL CONDITION] drug use and [DIAGNOSES REDACTED]. One of the interventions for risk factors not on the Braden scale identifies interventions of weekly skin assessment by licensed nurses. Surveyor # did not see evidence that regular weekly skin assessments by licensed nurses were conducted prior to Resident #21 developing what is described as a Stage 2 pressure ulcer to the back of his left heel of the foot, open blister, 2.4 cm X 4 cm X 0.1 cm which was first noticed on 10/14/11. Evidence of weekly skin assessments by licensed nurses of the heels was conducted on 9/7/11, 9/11/11 and 9/20/11. Resident body audit, dated 8/30, 9/23, and 9/30/11 was also conducted that did not indicate any problems with Resident #21's feet or heels. There is no evidence that weekly skin assessments by licensed nurses was conducted after 9/30/11, until 10/14/11 when the stage 2 open blister to the back of the heel was discovered. The facility policy and procedure for the treatment and prevention of skin breakdown, reviewed on 12/7/10, indicates that as part of the prevention plan of pressure ulcers, the facility will conduct ongoing monitoring of skin integrity, that includes weekly skin audits on the bath/shower day performed by the team leaders. This prevention policy also indicates that skin is to be observed daily with cares by the nursing assistant and if any skin concerns are noted, they are to be reported immediately to the team leader. The CNA care card titled, "Cameo Care Center, Resident Life Plan," has a section on "positioning" for nurse aide caregivers. This section does indicate the use of zero G boots (established once the pressure ulcer on the left heel was discovered on 10/14/11), but it does not indicate approaches to "float heels" or provide instruction to check heels every day for this diabetic resident who is at risk for pressure ulcers. The daily documentation done by the nurse aides does not indicate that daily skin checks or foot checks are being provided, as indicated in the facility policy for pressure ulcer prevention. Surveyor interviewed Director of Nursing (DON)- B on 1/25/12 regarding monitoring of Resident #21's feet/heels in October of 2011, and the DON could not locate evidence or documentation that this was being done as specified in the plan of care.

Based on record reviews, observations and interviews the facility did not ensure that 1 of 7 residents (#8) who entered the facility without pressure ulcers, did not develop pressure ulcers, and did not ensure that 4 of 7 residents (#4, #6, #8 & #7) received the necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. Resident #8 was admitted to the facility on [DATE], after sustaining a right [MEDICAL CONDITION]. On 8/22/10, facility staff noted a Stage 2 pressure ulcer on Resident #8's right heel. There was no evidence that aggressive off loading interventions were instituted on admission to prevent the development of the right heel pressure ulcer. Observations during the survey revealed that despite a physician's orders [REDACTED].#8 wear his sandals on 11/10/10. Resident #4 was admitted to the facility on [DATE], with 2 unstageable pressure ulcers on the right foot. The hospital wound clinic had recommended the use of a Stage 4 pressure reduction mattress. The facility assessed Resident #4 to be at very high risk for the development of pressure ulcers. On 8/17/10, Resident #4 was noted to have Stage 2 pressure ulcers on the left buttock and left gluteal fold. On 9/14/10, additional Stage 2 pressure ulcers were noted on the left gluteal fold and coccyx. On 9/18/10, a Stage 2 pressure ulcer of the left shin was noted. On 9/20/10, a deep tissue injury of the right hip was noted. On 9/21/10, Resident #4 was noted with a Stage 2 pressure ulcer of the right inner knee. On 9/21/10, the facility placed Resident #4 on a Stage 4 pressure reduction mattress when the facility wound nurse assessed the wounds and noted the gluteal and coccyx pressure ulcers had worsened and had become Stage 3 pressure ulcers. Resident #6 has Stage 2 pressure ulcers of the coccyx and right buttock. During observations of the treatment on 11/11/10, Licensed Practical Nurse (LPN)-C treated both areas simultaneously, rather than completing the treatment for one area before doing the other, thereby increasing the risk of cross contaminating the wounds. Resident #8 has an unstageable pressure ulcer of the right heel. During observations of the treatment on 11/11/10, Licensed Practical Nurse (LPN)-D did not follow proper aseptic techniques, when she did not wash her hands after removing the old dressing. LPN-D removed the soiled gloves and regloved without washing her hands. Resident #7 has a Stage 2 pressure ulcer of the left heel. Resident #7 has a physician's orders [REDACTED]. The pillow was not in place during observations made on 11/10 & 11/11/10. On 11/11/10, Resident #7 was observed lying in her bed for 45 minutes without her boots being in place. Her heels were resting directly on the mattress. Findings include: 1. Surveyor # reviewed Resident #8's medical record on 11/10-11/15/10. Resident #8 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Admission documentation indicated Resident #8's right heel skin was intact upon admission. A Nurses' Note entry dated 08/22/10 indicated, "(Resident #8) noted with 2.5 X 2.5 c.m. open area right heel. Scant amount serous drainage..." Review of a Tissue Management Weekly Progress Report dated 08/22/10, indicated Resident #8 had an in-house acquired pressure ulcer on his right heel measuring 2.5 X 2.5 X 0.1 c.m. On 11/16/10 at approximately 7:00 a.m., Surveyor # spoke with Registered Nurse (RN)-A, regarding pressure reducing interventions at the time Resident #8 was admitted to the facility with a [MEDICAL CONDITION]. RN-A indicated that on admission, nursing staff were floating Resident #8's heels and were utilizing an A-Frame, due to his [MEDICAL CONDITION]. RN-A also indicated Resident #8 moved his legs around a lot when in bed. On 11/16/10 at approximately 7:15 a.m., Surveyor spoke to Assistant Director of Nursing (ADON)-B, who is also the facility's wound nurse. The ADON indicated that Zero-G boots were implemented on 08/22/10, after Resident #8 had developed the pressure ulcer on his right heel. The ADON also indicated nursing staff had difficulty applying the Zero-G boots due to the use of the A-Frame and that they were not an effective intervention. Resident #8 was hospitalized and returned to the facility on [DATE]. Review of Resident #8's Tissue Management Progress Report dated 10/19/10, indicated the pressure ulcer on Resident #8's right heel measured 4 X 5 X 0 c.m. Review of Resident #8's Tissue Management Progress Report dated 11/09/10, after his return from the hospital, indicated the pressure ulcer on Resident #8's right heel measured 4.8 X 5.8 c.m. Review of Resident #8's physician's orders [REDACTED]. Review of Resident #8's plan of care dated 11/09/10, indicated a problem of at risk for alteration in skin integrity with an intervention of Prevalon boots. On 11/10/10, Surveyor # made the following observations of Resident #8: At approximately 9:25 a.m., Resident #8 was observed in his wheelchair attending the falls group. (Residents identified to be a high risk for falls requiring close staff supervision). At this observation Resident #8 was observed to be wearing white socks and sandals rather than his Prevalon boots. At approximately 10:00 a.m., Resident #8 was observed in his wheelchair attending the falls group. At this observation, Resident #8 was observed to be wearing white socks and sandals rather than his Prevalon boots. At approximately 10:30 a.m., Resident #8 was observed in his wheelchair attending the falls group. At this observation, Resident #8 was observed to be wearing white socks and sandals rather than his Prevalon boots. At approximately 11:00 a.m., Resident #8 was observed in his wheelchair in his bedroom. At this observation, Resident #8 was observed to be wearing white socks and sandals rather than his Prevalon boots. At approximately 12:00 p.m., Resident #8 was observed in his wheelchair eating lunch with the falls group. At this observation, Resident #8 was observed to be wearing white socks and sandals rather than his Prevalon boots. At approximately 2:12 p.m., Resident #8 was observed in his wheelchair in his bedroom. At this observation, Resident #8 was observed to be wearing white socks and sandals rather than his Prevalon boots. At approximately 2:40 p.m., Resident #8 was observed in his wheelchair attending the falls group. At this observation, Resident #8 was observed to be wearing white socks and sandals rather than his Prevalon boots. At approximately 4:30 p.m., Resident #8 was observed in his wheelchair attending the falls group. At this observation, Resident #8 was observed to be wearing white socks and sandals rather than his Prevalon boots. At approximately 5:00 p.m., Resident #8 was observed in his wheelchair at dinner. At this observation, Resident #8 was observed to be wearing white socks and sandals rather than his Prevalon boots. Review of Resident #8's Certified Nursing Assistant (CNA) Care Card located in his room, indicated the use of the Prevalon boots but did not specify "at all times." On 11/11/10 at approximately 10:30 a.m., Surveyor # spoke with Certified Nursing Assistant (CNA)-J who was assigned to care for Resident #8 on 11/10/10. CNA-J was asked whether she was aware Resident #8 was to wear Prevalon boots at all times. CNA-J indicated she was not aware Resident #8 was to wear Prevalon boots at all times. CNA-J indicated she does not usually work on Resident #8's unit. CNA-J also indicated she had read Resident #8's CNA care card prior to caring for him. 2. Surveyor # reviewed Resident #4's record on 11/9 - 11/15/10. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #4 was admitted with 2 unstageable pressure ulcers. One ulcer was located on her left heel, and the other was on the left lateral foot, at the base of the 5th toe. While hospitalized prior to admission, Resident #4 had been treated through the hospital wound clinic. According to the Wound Assessment documentation provided to the facility at the time of admission, Resident #4 had been seen by the hospital wound nurse on 7/7/10. The wound nurse documented, "Dry black eschars persist on left lateral foot and left heel. ... Buttocks reddened and blanchable but not open. Recommend: Stage IV mattress." The facility completed weekly Braden/Bergstom Scale for Predicting Pressure Ulcer Risk assessments during the month of July 2010. Resident #4's score on the Braden Scale was 9, which indicates she was at "very high risk" for pressure ulcer development. When interviewed by Surveyor # on 11/15/10 at 10:25 a.m., the Assistant Director of Nursing (ADON)/Wound Nurse-B stated that when Resident #4 was admitted she was placed on a Stage 2 pressure reduction mattress, given a gel cushion for her wheelchair, and was to a wear a Prevalon boot at all times for the left foot ulcers. On 8/17/10, Resident #4 was noted to have Stage 2 pressure ulcers on the left buttock and left gluteal fold. According to the Tissue Management Weekly Progress Report, the Stage 2 pressure ulcer on the left gluteal fold measured 0.5 centimeter (cm) x 1.5 cm x 0.1 cm and the Stage 2 left buttock pressure ulcer measured 0.4cm x 0.6cm x 0.1cm. The physician was notified, and treatments were ordered. On 9/14/10, additional Stage 2 pressure ulcers were noted on the left gluteal fold. According to the Tissue Management Weekly Progress Report there was a Stage 2 pressure ulcer on the upper left gluteal fold measuring 0.7cm x 0.5cm x 0.1cm.; a Stage 2 pressure ulcer on the lower gluteal fold measuring 0.6cm x 0.6cm x 0.1cm and a Stage 2 pressure ulcer in the mid gluteal area measuring 0.0cm x 0.8cm x 0.1cm. By 9/20/10, the three gluteal areas had merged into one large area determined to be a Stage 3 pressure ulcer measuring 5.5cm x 6.0cm x 0.1cm. According to the Tissue Management Weekly Progress Report of 9/14/10, a Stage 2 pressure ulcer of the coccyx was noted which measured 2.5cm x 0.1cm x 0.1cm. By 9/20/10, the coccyx pressure ulcer was assessed as a Stage 3 pressure ulcer measuring 3.6cm x 4.5cm x 0.1cm. According to the Tissue Management Weekly Progress Report, on 9/18/10, a Stage 2 pressure ulcer of the left ischium measuring 5.2cm x 1.5cm x 0.1cm was noted. According to the Tissue Management Weekly Progress Report, on 9/20/10, a deep tissue injury of the right hip measuring 5cm x 4cm was noted. According to the Tissue Management Weekly Progress Report, on 9/21/10, Resident #4 was noted with a Stage 2 pressure ulcer of the right inner knee. The physician had been notified of all pressure ulcers and treatments had been initiated. On 9/21/10, the facility placed Resident #4 on a Stage 4 pressure reduction mattress when ADON/Wound Nurse -B nurse assessed the wounds and noted the gluteal and coccyx pressure ulcers had worsened and had become Stage 3 pressure ulcers. ADON/Wound Nurse-B was interviewed by Surveyor # on 11/15/10 at 10:25 a.m. ADON/Wound Nurse-B verified that Resident #4 had been assessed to be at very high risk for pressure ulcer development. Resident #4 had a poor appetite and had been evaluated by the dietitian. ADON/Wound Nurse-B stated she did not initiate a Stage 4 mattress on admission because the pressure areas were on the foot and a Prevalon boot was ordered for pressure relief. ADON/Wound Nurse-B stated she would not recommend a Stage 3/4 pressure reduction mattress unless the resident actually had a Stage 3 or 4 pressure ulcer. Surveyor # interviewed Registered Nurse (RN) Supervisor-A on 11/15/10 at 11:00 a.m., regarding pressure relief interventions for Resident #4. RN-Supervisor-A stated that ADON-Wound Nurse-B makes decisions regarding choice of pressure reduction devices. RN-Supervisor-B stated Resident #4 liked to lie on her left side and would frequently reposition herself to that side. 3. According to documentation in Resident #6's record, the resident has 2 pressure ulcer areas being treated. The area on the coccyx has a pinpoint area that is not yet healed. The pressure ulcer on the left buttock was measured on 11/8/10, as 1.4cm x 1.3cm x 0.1cm. Resident #6's record indicates a Foley catheter is utilized for pressure ulcer management. On 11/11/10 at 10:10 a.m., Surveyor # accompanied Licensed Practical Nurse (LPN)-C to Resident #6's room to observe a pressure ulcer treatment. When LPN-C lowered the bedsheet, Surveyor # observed the draw sheet under Resident #6 was wet with urine. LPN-C stated she would have a nursing assistant clean and change the bedding before doing the pressure ulcer treatment. Surveyor # returned to observe Resident #6's pressure ulcer treatment on 11/11/10 at 10:42 a.m. LPN-C stated that she had gotten the Foley catheter flowing again and that the tubing had been kinked in Resident #6's brief. Surveyor # made the following observation of the treatment of Resident #6's pressure ulcers on 11/11/10 at 10:42 a.m. Prior to the observation, the dressing to Resident #6's coccyx had been removed during incontinence care. Surveyor # observed LPN-C remove the dressing to the left buttock, remove her gloves, wash her hands and reglove. LPN-C then cleansed both areas with normal saline, removed her gloves, washed her hands and regloved. LPN-C then applied skin prep to the skin surrounding the coccyx and buttock pressure ulcer areas, applied Iodosorb to the coccyx and buttock pressure ulcers, and covered both pressure ulcers with [MEDICATION NAME]. LPN-C treated both areas simultaneously, rather than completing the treatment for one area before doing the other, thereby increasing the risk of cross contaminating the wounds. 4. Resident #8 has an unstageable pressure ulcer of the right heel. Surveyor # observed Licensed Practical Nurse (LPN)-D complete the treatment of Resident #8's pressure ulcer on 11/11/10 at 10:25 a.m. LPN-D washed her hands, donned gloves and removed the dressing from Resident #8's right heel. LPN-D then cleansed the pressure ulcer with normal saline. LPN-D removed the gloves, and donned clean gloves without washing her hands. LPN-D did not follow proper aseptic techniques, when she did not wash her hands after removing the old dressing. LPN-D removed the soiled gloves and regloved without washing her hands. 5. Surveyor # initiated a medical record review for Resident #7 on 11/10/10. It was noted that on 10/21/10 the facility conducted the "Braden/ Bergstorm Scale for Predicating Pressure Ulcer Risk" assessment, and determined that Resident #7 was a score of 16- at risk for pressure ulcer development. According to the "Tissue Management" wound assessment documentation, Resident # 7 has a pressure ulcer on her left heel which developed on 10/5/10. On 11/8/10, which was the most current assessment of Resident #7's pressure ulcer on her left foot, the wound assessment states that there is a Stage # 2 pressure ulcer that measures 1.4 centimeters by 0.9 centimeters (cm), wound bed is brown and has shown improved progress. The treatment was to have the left heel cleansed with normal saline, followed by skin prep to the peri-wound, followed by Mepelix heel cup, change every 3 days, check placement each shift. The individual plan of care for Resident #7 dated 8/21/10, states that Resident # 7 is to have Zero- G boots on while in bed. A review of the November, 2010 physician orders [REDACTED]. The Treatment Administration Record for November, 2010 shows that Resident #7 is to have her heels floated on a pillow, which was signed out each shift from 11/1/10 to 11/11/10. A review of the Certified Nursing Assistant (CNA) Care Card in Resident #7's room states that Resident #7 is to have her heels floated on a pillow and have Zero- G boots on while in bed. On 11/10/10 at 9:55 a.m., Surveyor # made observations of Resident #7 lying in bed. It was noted that Resident #7 had the Zero- G boots on both of her feet, but there was not a pillow in place as per the physician orders [REDACTED]. On 11/10/10 at 10:40 a.m., Surveyor # made observations of Resident # 7 lying in bed. Resident # 7 had the Zero- G boots on both feet, but there was no pillow in place to free float her heels. On 11/11/10 at 7:20 a.m., Surveyor # made observations of Resident # 7 lying in bed with the Zero- G boots on, but there was no pillow in place to free float her heels. On 11/11/10 at 11:25 a.m., Surveyor # made observations of Resident # 7 lying in her bed. At this time Certified Nursing Assistant (CNA)- G stated that she had attempted to get Resident #7 up, but she was refusing to get up so she would return later to try again. It was noted that CNA- G then left the room and Resident # 7 was lying in her bed on her back. Resident # 7 did not have the Zero- G boots on either feet nor did she have a pillow in place. Surveyor # made continuous observations of Resident #7 lying on her back with out the boots or pillows in place until 12:15 p.m. when nursing staff went into the room and placed both the boots on Resident #7's feet and placed a pillow under her heels. On 11/11/10 at 3:00 p.m., Surveyor # shared the above observations with the Administrative staff , and no additional information had been provided at this time.

Based on record reviews, observations and staff interviews, the facility did not implement interventions and assistive devices to prevent accidents for 2 of 6 residents (#7 & #10), identified by the facility as being at a risk for falls. Resident #7 is a confused resident who is at risk for falls due to poor safety awareness. Resident #7 usually walks with a walker with stand by assistance from facility staff. On 7/9/10, Resident #7 was ambulating to the lunch meal when she began to trip on her pants, which were too long. Facility staff were instructed to take Resident #7 back to her room and change pants, but instead the Certified Nursing Assistance (CNA) placed Resident #7 in a wheelchair and brought her to the dining room and left Resident #7 seated in the wheelchair. Resident #7 is not used to sitting in a wheelchair and stood from the chair, falling over the side of the chair and hitting her face on the floor. Resident #7 fractured her nose as a result of the fall. Resident #10 is identified by the facility as being at risk for falls and has a recent history of falls while trying to self-transfer. After a fall on 11/05/10, which required treatment at the emergency room , the facility re-implemented the use of a bed sensor pad alarm and initiated a new intervention to remove Resident #10's wheelchair from her room when not in use. On 11/11/10, Resident #10 was observed lying in bed with her wheelchair remaining in her room; after Resident #10 had been assisted from bed, there was no sensor pad alarm on her bed. Findings include: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual "Safety Risk Data Collection" assessment, dated 4/6/10, states that Resident # 7 has Dementia, a history of falls and unsteady gait at times. The summary states that Resident #7 is at risk for falls due to the history of falls, medications, cognitive impairment, poor judgement, etc. Resident #7 is extensive assist with transfers and limited assist with ambulation with a wheeled walker. According to the significant change, full Minimum Data Set ( MDS), dated [DATE], Resident #7 has long and short- term memory impairment and is moderately impaired in cognitive skills for daily decision making. The MDS also states that Resident #7 is able to walk in her room and the corridor with supervision and 1 person physical assistance. The locomotion on the unit is limited assistance with 1 person physical assistance. The MDS states that Resident #7's mode of locomotion is using a cane/ walker/crutch. According to the individual plan of care dated 4/1/2009 for Resident #7, she has a self-care deficit related to her [DIAGNOSES REDACTED]. Listed interventions included ambulation with wheeled walker with supervision. Resident #7's plan of care also states that she has a potential for injury related to her [DIAGNOSES REDACTED]. Listed interventions included to keep the environment free of hazards and walkways clear. Also to provide supervision with ambulation while using the wheeled walker. Nurse's note dated 7/9/10 at 12:35 p.m., states that writer was called to the dining room because Resident #7 had fallen from the wheelchair. Resident #7 attempted to stand herself out of wheelchair and fell over side of wheelchair and hit her face on floor. Resident #7 has lacerations to bridge of nose and right nare. The physician was notified of the incident and an order was received to send Resident #7 to the emergency room for treatment. Resident #7 returned to the facility on [DATE] at 7:00 p.m., with a fracture to the right maxillary and nasal bone fracture. Also, Resident #7 suffered a fracture to her right, third finger joint. The falls assessment dated [DATE], states that Resident #7 was trying to get out of wheelchair which she usually does not sit in. The immediate intervention put in place to prevent further falls was to have Resident #7 use a wheeled walker and sit in regular table chairs. According to the facility's investigation into the fall involving Resident #7 on 7/9/10, Licensed Practical Nurse (LPN)- M stated that she had instructed Certified Nurse Assistant (CNA)-E to get up Resident #7 and take her to the dining room. LPN- M stated she observed Resident #7 walking out of her room with CNA- E and that Resident #7 was tripping over her pants. LPN- M stated that Resident #7's pants were too long and and CNA- E stated that all of Resident #7's pants were too long. LPN- M stated that she then instructed CNA- E to cuff Resident #7's pants. LPN- E stated that as she was coming down the hallway past Resident #7's room she observed that CNA- E had placed Resident #7 into a wheelchair and then she pushed her into the dining area. The facility's investigation continued to state that the use of the wheelchair was not appropriate seating as Resident #7 is not typically aware of safety issues. Surveyor # interviewed the Director of Nursing ( DON) on 11/11/10 at approximately 3:00 p.m. The DON stated that the facility had conducted an investigation into Resident #7's fall. 2. Surveyor # reviewed Resident #10's medical record on 11/10-11/15/10. Resident #10 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of a fall risk assessment dated [DATE] indicated Resident #10 was assessed as a high risk for falls. Nurses' Notes documentation revealed the following: An entry dated 08/24/10 at 1:15 p.m. indicated Resident #10's bed and chair alarms were discontinued. Documentation on 09/05/10 at 10:20 p.m., indicated Resident #10 was noted lying on the floor by her wheelchair. Resident #10 stated she got up from bed and had lowered herself to the floor. An entry dated 09/16/10 at 7:30 a.m., indicated Resident #10 was noted sitting on the floor next to her bed. A subsequent entry on 09/16/10 at 10:00 p.m., indicated Resident #10 slid out of her bed because she wanted to close the door. An entry dated 11/05/10 at 1:50 p.m. indicated Resident #10 was found on her floor next to her bed and the resident was attempting to self transfer when the incident occurred. A Patient Transfer Form dated 11/05/10, indicated, "fell in room striking R (right) side of head on floor...Lg (large) hematoma R eyebrow. Send to ER (emergency room ) for evaluation. A Nurses' Note entry, dated 11/08/10 at 10:25 a.m., indicated the facility falls committee met to review Resident #10's fall on 11/05/10 and her self transferring. The falls committee recommended re-initiating the use of bed and chair alarms and keeping Resident #10's wheelchair out of her room when not in use. On 11/11/10 at approximately 7:40 a.m., Surveyor # reviewed Resident #10's Certified Nursing Assistant (CNA) Care Card located on her bedroom door and her plan of care dated 11/23/09 and located in her medical record. The intervention of removing Resident #10's wheelchair from her room had not been added to either. On 11/11/10 at approximately 7:35 a.m., Surveyor # observed Resident #10 in bed asleep. Resident #10's wheelchair was in her room by her closet, approximately 4-5' from Resident #10's bed. Surveyor # informed Nurse Supervisor-A that Resident #10's wheelchair was in her room. Nurse Supervisor-A indicated she was aware Resident #10's wheelchair should not be in her room and she would remove it right away. On 11/11/10 at approximately 10:00 a.m., after Resident #10 was out of bed, Surveyor # checked Resident #10's bed to ensure a sensor pad alarm was on the bed. At this observation, there was no alarm on the bed. On 11/11/10, at approximately 10:05 a.m., Surveyor # informed Nurse Supervisor-A that there was no sensor alarm pad on Resident #10's bed. Nurse Supervisor-A indicated she was aware there should be a sensor alarm pad on Resident #10's bed as recommended. Surveyor # spoke with Registered Nurse (RN)-A on 11/11/10, at approximately 8:05 a.m. RN-A indicated it is the responsibility of the team leader (nurse assigned to each wing of the floor), or herself to update residents' care plans and CNA Care cards with new interventions. On 11/11/10 at approximately 1:25 p.m., Surveyor # informed the facility Director of Nursing of the above observations regarding Resident #10's wheelchair being in her room while she was in bed and the lack of a bed sensor alarm pad on her bed. At that time, the Director of Nursing presented Surveyor # with a statement from CNA-L, dated 11/11/10 at 12:35 p.m., indicating when she got Resident #10 up in the morning she did not have a bed alarm on her bed.