Every finding on record at Avina of Milwaukee

Based on record review, interviews and review of facility policy, the facility failed to provide supervision to prevent accidents for one of three residents reviewed for quality of care (Resident (R) 7). R7 was assessed and care planned to require supervision during meals, meals should be eaten in a dining area, and liquids should be in a cup with a handle and lid. R7 spilled coffee in her lap while eating breakfast in her room without supervision or proper equipment. This failure resulted in R7 sustaining a partial thickness (second-degree) burn to her left thigh. Findings include: Review of R7's admission Record under the Profile tab in the EMR revealed R7 was initially admitted to the facility on [DATE] with diagnoses including dementia (mental decline and memory loss) and type two diabetes mellitus (disease causing elevated blood sugar.) Review of the admission Record under the Profile tab in the EMR revealed R7 was readmitted on [DATE] with new diagnoses which included cerebral infarction (stroke) and epilepsy (neurological disorder causing seizure.) Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/07/26 revealed R7 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating moderate cognitive impairment. R7 was independent for eating and required moderate assistance to move from sitting to lying. The assessment indicated R7 had diabetes, lack of coordination, dementia, and a cognitive communication deficit. Review of the hospital Discharge summary dated [DATE] under the Misc tab in the EMR revealed R7 was hospitalized for a stroke and seizures from 06/15/26 to 06/25/26. Review of the OT [occupational therapy] Evaluation & Plan of Treatment dated 06/26/26 provided by the facility revealed, . Functional Skills Assessment – Activities of Daily Living (ADLs) & Instrumental ADLs . Eating = Supervision or touching assistance . Review of R7's Care Plan Report under the Care Plan tab in the EMR revealed, The resident has an ADL [activities of daily living] self-care performance deficit r/t [related to] weakness, left sided neglect/hemiplegia, seizure, antidepressant use. Date Initiated: 06/25/2026 . Interventions . EATING: The resident is supervision assist for eating. In dining area for meals. Mug with handle and lid . Date Initiated: 06/26/2026 . A skin issues report dated 6/29/26 at 19:09 (7:09 PM) documented for notes: CNA reported to the nurse that the resident had a wound on the left thigh. Upon assessment, the nurse noted a blister present on the resident's left thigh. The NP and POA were notified. Treatment was initiated per providers orders, and the wound nurse was notified for further evaluation and follow-up. During the investigation, OT reported that around breakfast time the resident appeared to have spilled coffee in her lap. OT heard the resident state help me, it's hot. OT immediately notified the floor nurse. The nurse assessed the resident's skin at that time and no redness, blistering, or other injuries were noted. Later, a blister was identified on the resident's left thigh and reported to nursing staff. Additional notes documented: The incident was investigated, appropriate notifications were completed, and treatment measures were initiated. Care planned for the resident to be out of bed and supervised for meals and a lid provided for hot liquids. The resident will continue to be monitored for changes in skin integrity and response to treatment. Resident refused to use coffee cup with cover lid. Resident stats I'm not a baby. Hot liquid temps audits will be completed. Surveyor noted R7's care plan had been updated on 6/26/26 to already include supervision with meals, in dining area, and mug with handle and lid; this was not implemented at the time of the spill of hot liquids. Review of the Progress Notes under the Progress Notes tab in the EMR revealed a nurses note dated 06/29/26 at 8:03 PM indicating, . Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were . Skin Status Evaluation: Blister . Nursing observations, evaluation, and recommendations are: CNA [certified nurse aide] called writer to check skin blister to left thigh . skin prep cover with foam dressing . Primary Care Provider responded with the following feedback . Recommendations: skin prep cover with foam dressing . referral to wound team and PMD [primary medical doctor]/PNP [primary nurse practitioner] . Further review of the Progress Notes revealed a nurses note dated 06/29/26 at 8:32 PM revealed, NP notified. Fluid-filled blister to left outer lower thigh measures 10.0 cm x 4.5 cm. Applied skin prep for now, covered with foam dressing avoid pressing the blister . Referral to wound care team . Review of the Progress Notes revealed a note by the Wound Care (WC) APNP (advanced practice nurse practitioner) (WCAPNP) dated 07/02/26 at 9:45 AM indicating, Wound Care Initial Evaluation . Chief Complaint . Wound to left thigh . Patient . states that she woke up 1 [one] time and it was there she does not know how it occurred . Physical Examination . Left thigh-blister . Partial-thickness wound measuring 9.0 cm x 8.5 cm x 0.1 cm. The base is pink and there is a moderate amount of serosanguineous drainage . Assessment and Plan . Blister (nonthermal [not a heat burn], left thigh . Review of the Progress Notes revealed a note by the WCAPNP dated 07/16/26 revealed, . Chief Complaint . Wound to left thigh . Patient has stated to staff that she had spilled coffee on her thigh . Physical Examination . Left thigh-burn . Assessment . Burn of unspecified degree of left thigh . Review of the nursing document titled, Skin Impairment/Wound Eval [evaluation] dated 07/16/26, under the Forms tab in the EMR revealed, . Type of Skin Alteration . Burn(s) (second or third degree . Location . L [left] thigh . Measurement . 7.4 cm x 6.1 cm x 0.1 cm . During an interview on 08/12/26 at 10:42 AM, Occupational Therapist (OT) 1 stated she was walking past R7's room and she heard her calling out and she noticed R7 Spilled coffee all over herself. OT1 stated, I took off the wet blankets and gown . I saw her skin, but I didn't notice anything. OT1 stated she saw R7's legs and abdomen and regarding the presence of any redness, she stated, Not that I can remember. OT1 stated she went and told R7's nurse (Former Nurse (FN)) and they returned to the resident's room together and She didn't see anything. OT1 stated R7 was saying, It's burning me. OT1 stated there was a large Styrofoam cup on R7's overbed table with a couple drops of coffee left. OT1 stated she had just evaluated R7 a couple of days prior and recommended supervision with meals just for safety. During an interview on 08/12/26 at 10:22 AM, Certified Nurse Aide (CNA) 7 stated on the day R7 spilled coffee on herself, she was temporarily assigned to another hall until around 10:00 AM. CNA7 stated, I noticed her clothes and bedding was wet. CNA7 stated R7 told her, I spilled some coffee on myself. CNA7 stated, I noticed it was red on her stomach and on her leg. CNA7 stated she reported it to R7's FN. CNA7 stated, The nurse said she already assessed her, so I went back and got her cleaned up. CNA7 stated there was no blister on either of R7's thighs or abdomen. During an interview on 08/12/26 at 11:37 AM, Nursing Supervisor (NS) 1 stated she Wasn't aware of the incident when it happened. She stated R7's FN, didn't report the accident to her. RN1 stated, At the point that it happened, it should have been reported for the simple fact that . had we known, someone could have been monitoring it. During an interview on 08/12/26 at 1:40 PM, the WCAPNP stated she didn't know it was a burn when she first saw R7, but about three weeks later, R7 said, I spilled coffee on myself. The WCAPNP stated if she would have been notified immediately, I would have said just monitor it, maybe ice for the comfort unless you see something. There was no documentation in R7's record when she spilled coffee on herself. The nurse (FN) did not report the accident to the nursing supervisor. The nurse (FN) did not document an incident report or an assessment. The staff treating R7's wound did not know for approximately three weeks that the wound was a burn wound as a result of R7 spilling coffee on herself. Additionally, there wasn't a timely investigation at the time of the possible spill/burn to understand why R7 received a hot liquid without supervision and in a Styrofoam cup vs. the mug with handle R7 was care-planned to use. Review of the facility policy titled, Incidents and Accidents, dated January 2026 revealed, It is the policy of this facility for staff to utilize PCC [Point Click Care – EMR] risk management to report, investigate, and review any accidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Definitions: 'Accident' refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. Following this incident the facility implemented an action plan to address supervision, safety of hot beverages, and training of facility staff with audits to sustain compliance.

Based on record reviews, interviews, and review of facility policy, the facility failed to provide personal care hygiene for two of four residents reviewed for activities of daily living (ADLs) (Resident (R) 7, and R2) when personal hygiene and showers/baths were not provided according to the plan of care. These failures had the potential to cause skin integrity issues and a decline in mental health and well-being for R7 and R2. Findings include: 1. Review of R7's admission Record under the Profile tab in the EMR revealed R7 was admitted to the facility on [DATE] with diagnoses including dementia (mental decline and memory loss) and type two diabetes mellitus (disease causing elevated blood sugar), fall, periprosthetic fracture around internal prosthetic right knee joint. R7 was readmitted on [DATE] with diagnoses including cerebral infarction (stroke), epilepsy (neurological disorder causing seizures), muscle wasting and atrophy, unsteadiness on feet. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/07/26 revealed R7 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating moderate cognitive impairment. R7 required set-up assistance for personal hygiene, moderate assistance for toileting hygiene, and maximal assistance for showering/bathing. R7 was totally dependent for transfer on and off the toilet or commode. Review of the Care Plan Report under the Care Plan tab in the EMR revealed, Focus . The resident has bladder & [and] bowel incontinence r/t [related to] Dementia, Impaired Mobility, weakness . Date Initiated . 06/26/2026 . Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date . Date Initiated: 06/26/26 . Interventions . Clean peri-area with each incontinence episode . Date Initiated: 06/26/26 . Focus . The resident has an ADL self-care performance deficit r/t weakness, left sided neglect/hemiplegia [paralysis on one side of the body], seizure, antidepressant use, B&B [bowel and bladder] incontinence . Date Initiated: 06/25/26 . Interventions . BATHING/SHOWERING: The resident requires (Max [maximum] assistance) by (2) [two] staff with (showering) (Wed [Wednesday & Fri [Friday] AM [morning] and PRN [as needed]) and as necessary . Date Initiated: 06/26/26 . PERSONAL HYGIENE/ORAL CARE: The resident is Mod [moderate] A [assistance] on (1) staff for personal hygiene and oral care . Date Initiated: 06/29/26 . TOILET USE: The resident requires (Mas assistance) by (2) staff for toileting hygiene . Date Initiated: 06/26/26 . Review of the Documentation Survey Report for the month of July 2026, revealed no documented evidence R7 was assisted with the task BLADDER FUNCTION, which was blank on one shift each day for five days; blank on two shifts each day for ten days; and blank on all three shift for four days. Review of the Documentation Survey Report for the month of July 2026, revealed there was no documented evidence R7 was assisted with the task Personal Hygiene . The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face, and hands (excludes baths, showers, and oral hygiene) . Review of the Documentation Survey Report for the month of July 2026 revealed there was no documented evidence R7 received assistance with the task Shower/Bathe . The ability to bathe self, including washing, rinsing, and drying self (excluding washing of back and hair) . The documentation indicated no shower or bath was provided on 19 of 24 days R7 was in the facility. Review of the Documentation Survey Report for the month of July 2026, revealed there was no documented evidence that R7 received assistance with the task SKIN CARE/MONITORING. The documentation indicated no skin care/monitoring was provided on one shift for four days; on two shifts for ten days; and on all three shifts (an entire 24 hour period) for four days. During an interview with Nursing Supervisor (NS) 1 on 08/11/26 at 12:07 PM, she reviewed the Documentation Survey Reports for R7 and confirmed there were many shifts and days without any documented evidence of bladder (urination), personal hygiene, shower/bath, or skin care. NS1 stated this documentation is how they know if it was done or if it happened. During an interview with certified nurse aide (CNA) 10 on 08/11/26 at 4:20 PM, he stated dependent incontinent residents were checked and changed every two hours. CNA10 stated if residents don't urinate for an entire shift, the CNA's select the option indicating not applicable for the bladder task on their documentation in the computer. CNA10 stated all residents should be documented on all assigned tasks every shift. During an interview with CNA4 on 08/11/26 at 1:00 PM, she stated for incontinent dependent residents, they are checked and changed every two hours. She stated CNA's document on all assigned tasks every shift. During an interview with CNA7 on 08/12/26 at 10:22 AM, she stated that all assigned tasks should be documented on every shift. CNA7 confirmed R7's Documentation Survey Report for the month of July 2026 had no documented evidence of bladder function (urination), personal hygiene care, showers/baths, or skin care on multiple shifts on multiple days. CNA7 stated, If it's blank, it's like you didn't do it. During an interview with the Director of Nursing (DON), on 08/12/26 at 6:12 PM, he confirmed there was no documented evidence of bladder function (urination), personal hygiene, shower/bath, and skin care on many shifts and days in the month of July 2026. He stated regarding the documentation, It's a way of us knowing what care was performed. 2. On 05/12/26, the facility investigated an incident involving Resident (R2), who alleged that on the evening of 05/10/26, Certified Nursing Assistant (CNA) 1 responded to the resident's call light by turning the call light off and leaving the room without providing requested toileting assistance or incontinence care. Review of the facility's investigation dated 05/12/26, R2 reported she activated her call light after soiling her brief and requested assistance. According to the resident, CNA 1 entered the room, turned off the call light, stated she would return, and left the room. The resident stated she eventually received care but waited longer than desired. During the same investigation, CNA1 acknowledged turning off the resident's call light after informing the resident she was on break and would attempt to locate another staff member or return to assist the resident. Review of the EMR, under profile tab, revealed R2 was originally admitted to the facility on [DATE] with diagnoses that included hyperkalemia, stage 5 chronic kidney disease with heart failure, type 2 diabetes mellitus, and history of stroke affecting left, non-dominant side. The EMR also revealed the most recent quarterly MDS, located under the MDS tab, with an ARD of 06/23/26. The MDS indicated that R2 has a BIMS of 15 out of 15, indicating no significant evidence of cognitive impairment. The MDS further indicates that R2 is always incontinent of bladder. During an interview with R2 on 08/12/26 at 2:12 PM, regarding the incident that occurred on 05/10/26, she stated that she activated her call light requesting assistance with toileting and placement on a bedpan, as she preferred not to remain in a wet brief. R2 reported that CNA 1 entered the room, turned off the call light, and left without assisting her to a bedpan. R2 stated the staff member returned approximately 30 minutes later and provided incontinence care, during which time she reported remaining in a wet brief. The resident further reported this was not an isolated occurrence and stated CNA1 frequently encouraged the use of an incontinence brief rather than assisting with bedpan use. Review of R2's care plan indicated the resident required total assistance of one staff member for toileting due to impaired mobility related to a stroke. The care plan directed staff to encourage call light use for assistance requests, provide toileting and incontinence care as needed, and monitor, document, and report care provided according to facility standards. A review of the CNA documentation for the month of May, located in the Task tab of the EMR, did not indicate incontinence care was provided on any shift on 05/12/26. The day shift (06:30AM - 02:30PM) did not record providing incontinence care from 05/03/26 through 05/28/26. The overnight shift (10:30PM – 06:30AM) recorded providing incontinence care once during the month of May (05/02/26). Staff interviews revealed CNA staff consistently stated that care provided should be documented and that undocumented care could not be verified. During an interview on 08/12/26 at 10:35 AM, CNA 7 stated staff should document either services provided or not applicable when no services were rendered. During an interview on 08/12/26 at 12:55 PM, CNA 4 stated the expectation was to document care each shift. During an interview with the DON on 08/12/26 at 5:30 PM, stated that he does not believe that the residents were not receiving some care but agreed that it should be documented, and the documentation does not indicate the appropriate level of care. Review of the facility's Activities of Daily Living Policy, implemented January 2026, stated the facility would ensure residents receive assistance with ADLs based on assessed needs and resident choices and would support maintaining resident abilities unless decline was unavoidable.

Based on record reviews and interviews, the facility failed to assess the skin for pressure injuries for two of three residents reviewed for pressure ulcers (Resident (R) 6 and R7) when skin assessments were not done according to the care plan. These failures had the potential for nursing staff not to be aware of developing pressure injury wounds, which could cause a delay in treatment and potential worsening of the wounds. Findings include: 1. Review of R6's admission Record under the Profile tab in the electronic medical record (EMR) revealed R6 was readmitted to the facility on [DATE] with diagnoses including unspecified dementia (mental decline and memory loss), moderate protein-calorie malnutrition (energy and protein intake are inadequate to meet the body's needs), chronic venous hypertension (causes blood to pool in the legs) with ulcer (wound) left lower extremity (leg), and peripheral vascular disease (causes decreased blood flow in the legs.) Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/15/26 revealed R6 had a Brief Interview for Mental Status (BIMS) of 3 out of 15, indicating severe cognitive impairment. R6 was dependent on rolling left and right; was always incontinent of bowel and bladder and indicated R6 was at risk for developing pressure ulcers. Review of the Care Plan Report under the Care Plan tab in the EMR revealed, The resident has actual impairment to skin integrity r/t [related to] stage 4 [four] PI [pressure injury] coccyx . Date Initiated: 09/30/2025 . Interventions . Document Skin observation during ADL [activities of daily living] care – report abnormal findings to the Nurse . CNA [certified nurse aide] . NSG [nursing] . Date Initiated: 10/08/2025 . Review of the last Braden Scale, dated 12/25/25, under the Forms tab in the EMR revealed R6 scored 14 of 23, indicating she was at moderate risk for pressure injuries. Review of the Skin Observation notes under the Forms tab in the EMR revealed Skin Observation notes dated 02/03/26, 02/17/26, 02/24/26, 03/10/26, 04/21/26, 05/07/26, and 05/14/26 indicated the resident's skin was not intact, but did not identify the location or any observation/assessment information. During an interview on 08/12/26 at 12:07 PM, the Nursing Supervisor (NS) 1 confirmed weekly skin assessments were not done in February, March, April, and May of 2026 for R6. NS1 stated, Skin should be assessed at least once a week. NS1 confirmed the nurses were supposed to document the assessments on the Skin Observation forms in the EMR. NS1 also confirmed the Skin Observation notes (identified above) were not complete. During an interview on 08/12/26 at 4:18 PM, Registered Nurse (RN) 1 stated the protocol for skin assessments is weekly. He stated the Skin Observation notes are where the staff were supposed to document the skin assessments. He confirmed that weekly skin assessments were not completed for R6 in the months of February, March, April, and May 2026. 2. Review of R7's admission Record under the Profile tab in the EMR revealed R7 was admitted to the facility on [DATE] with diagnoses including dementia (mental decline and memory loss) and type two diabetes mellitus (disease causing elevated blood sugar), fall, periprosthetic fracture around internal prosthetic right knee joint. Review of the admission MDS with an ARD of 04/07/26 revealed R7 had a BIMS score of 8 out of 15, indicating moderate cognitive impairment. R7 required moderate assistance to roll left and right and to change from a sitting position on the edge of the bed to a lying position or from a lying position to a sitting position on the edge of the bed. R7 was totally dependent to stand. Review of the admission Record revealed R7 was readmitted on [DATE] with diagnoses including cerebral infarction (stroke), epilepsy (neurological disorder causing seizures), muscle wasting and atrophy. Review of the Care Plan Report under the Care Plan tab in the EMR revealed, The resident has potential impairment to skin integrity r/t [related to] weakness, impaired mobility, B&B [bowel and bladder] incontinence, diagnosis of DM [diabetes mellitus], left sided neglect/hemiplegia . Date Initiated: 06/25/2026 . Interventions . Document Skin observation during ADL care – report abnormal findings to the Nurse . CNA . NSG . Date Initiated: 06/26/2026 . Review of the Skin Observation notes under the Forms tab revealed notes dated 06/28/26, 06/29/26 and 07/18/26. Skin assessments were not done weekly in the months of June and July 2026. During an interview on 08/12/26 at 12:07 PM, Nursing Supervisor (NS) 1 confirmed skin assessments were not done for the months of June and July 2026. NS1 stated, Skin should be assessed at least once a week, and documented on the Skin Observation forms in the EMR. During an interview on 08/12/26 at 6:12 PM, the Director of Nursing (DON) stated the facility policy was, Body checks at least weekly with every shower. Review of the facility policy titled, Skin Observation for licensed nurses, revised July 2026 revealed, A full body, or head to toe, skin observation will be conducted by a licensed or registered nurse upon admission/re-admission, PRN [as needed] and weekly thereafter . Document observations (e.g. skin conditions . ) . Document any identified wound(s), as discovered, to include type of wound, wound measurements, color, type of tissue in wound bed, drainage, odor, pain, etc. Thorough documentation of identified wounds should be performed at least weekly thereafter to note current status and/or changes in wound characteristics .

Based on interviews and record review, the facility failed to protect the resident's right to be free from neglect, including the failure to provide timely incontinence care by staff, resulted in the deprivation of necessary services, prolonged exposure to urine, compromised dignity, and caused mental anguish and emotional distress for 1 (R105) of 2 residents reviewed. *R105 informed Surveyor that 2 or 3 months ago, an unknown facility Certified Nursing Assistant (CNA), CNA-Q, left R105 in urine-soaked bed linens and incontinence brief. R105 went the entire day shift without incontinence cares despite R105 asking CNA-Q to change and clean R105. R105 tearfully informed Surveyor that this made R105 feel like garbage and useless and R105 felt like R105 had been physically abused. CNA-G informed Surveyor that when CNA-G went into R105's room on second shift that same day, CNA-G noted that R105's bed linens and incontinence brief were soaked with urine. CNA-G helped get R105 clean and dry. R105 informed CNA-G that R105 had not been changed since 3rd shift. CNA-G informed Surveyor that R105 was in tears and upset. CNA-G reported this incident to Assistant Director of Nursing (ADON)-E and Social Worker (SW)-R. ADON-E informed Surveyor that R105 was crying and needed consoling when talking about this allegation of neglect. ADON-E initiated a grievance and gave the grievance to the facility Social Workers (SW). Neither SW-R nor SW-P had documentation of the allegation of neglect. Nursing Home Administrator (NHA)-A informed Surveyor that NHA-A was not aware of this allegation of neglect. This allegation of neglect was known by multiple facility staff members and was not immediately reported to NHA-A.Approximately 2 months after the incident, R105 continued to have persistent mental anguish and emotional distress, vividly describing the incidentand becoming tearful and emotional when being interviewed about the incident. Findings include:The facility policy with a last reviewed date of 2/25/26 and titled, Abuse, Neglect and Exploitation, 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 prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will have written procedures to assist staff in identifying the different types of abuse- mental/verbal abuse, sexual abuse, physical abuse, and deprivation by an individual of goods and services. Possible indicators of abuse include, but are not limited to: Resident, staff or family report of abuse.Verbal abuse of a resident overheard, Physical abuse of a resident observed, Psychological abuse of a resident observed, Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning and positioning. 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, during and after the investigation. The facility will have written procedures that include: 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. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: Analyzing the occurrence (s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences. Defining how care provision will be changed and/or improved to protect residents receiving services. Training of staff. Identification of staff responsible for implementation of corrective actions. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.1.) R105 was admitted to the facility on [DATE] with diagnosis that include Polyneuropathy (multiple nerves throughout the body malfunction causing weakness, numbness and burning pain), Type 2 Diabetes, Chronic obstructive pulmonary disease (progressive, long-term lung condition that damages airways making it difficult to breathe), Heart failure, and Osteoarthritis (degenerative joint disease that causes pain, stiffness and joint damage). R105's Annual Minimum Data Set (MDS) assessment dated [DATE] documents R105 can express ideas and wants and is able to understand others. The MDS documents: R105 is cognitively intact; R105 does not exhibit physical or verbal behaviors directed towards others; R105 requires substantial/maximal assistance for toileting hygiene, bathing, and transfers; R105 is frequently incontinent of urine. R105's bladder incontinence care plan initiated on 8/21/25 documents the following intervention: Clean peri-area with each incontinence episode.Surveyor reviewed R105's comprehensive care plan and noted there is no mood or psychosocial concerns. Surveyor noted R105 does have a care plan related to resisting cares (like weights, activities of daily living cares, therapy) but no other behavior concerns are care planned. On 4/14/26 at 9:58 AM, Surveyor interviewed R105. R105 explained an incident that occurred at the facility with an unknown CNA, CNA-Q. R105 stated that it happened about 2 or 3 months ago and thinks it was January or February. R105 stated that R105 could not remember the name of CNA-Q and described CNA-Q as African American, small and shorter. R105 stated that R105 had overslept and was jostled awake by CNA-Q. R105 groaned and was groggy. R105 stated that CNA-Q told R105 that R105 had an attitude and that R105 was rude. R105 stated that CNA-Q had a chip on her shoulder and was in a bad mood. R105 stated that CNA-Q left R105's room. R105 informed Surveyor that R105 wears an incontinence brief and first-shift staff typically change R105's brief after breakfast, and around 1:30 -2 PM. R105 stated that CNA-Q did not change R105's incontinence brief after breakfast. R105 stated that CNA-Q did return to R105's room at lunch time. R105 stated that R105 told CNA-Q that R105 really needed to be changed. CNA-Q did not respond to R105. R105 stated that CNA-Q threw R105's lunch tray down on the bedside table and did not speak to R105. R105 stated that R105 begged CNA-Q to be changed. R105 stated that CNA-Q did not say a word and walked out of R105's room. R105 remembers falling asleep for a little bit after lunch. R105 stated that it was around 2:30 in the afternoon and R105 was upset that R105 had not been changed all day. R105 stated that R105 felt like garbage and felt useless. R105 got tearful with Surveyor and stated that the whole situation made R105 feel awful. R105 stated that R105 was cold because R105's incontinence brief and bed sheets were soaked with urine. R105 stated that R105 was wet and dirty and itchy where a lady shouldn't be itchy. R105 indicated that R105 tries to be a lady but that day R105 couldn't be a lady. R105 stated when second shift started, CNA-G came to R105's room. CNA-G looked at R105 and asked, what happened to you? R105 explained the events of the day. R105 stated that CNA-G stripped R105's bed, cleaned the mattress and remade the bed. CNA-G gave R105 a full bed bath and changed R105's incontinence brief for the first time that day after 3 pm. R105 stated CNA-G got R105 all clean and comfortable again. R105 stated, God bless CNA-G. R105 stated that CNA-G went to Assistant Director of Nursing (ADON)-E to inform ADON-E of the situation. R105 stated that one or two days later, Social Worker (SW)-R came to talk to R105 about the incident. R105 stated that R105 told both ADON-E and SW-R of the whole situation. R105 stated that after that, R105 never saw CNA-Q again.As Surveyor was leaving R105's room, R105 stated that R105 can understand someone having a bad day, but R105 stated I was physically abused. Severely abused.Surveyor noted that according to the definition of neglect documented in the facility abuse policy, neglect is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Surveyor noted R105 described an allegation of neglect to Surveyor.Surveyor noted R105 informed CNA-G, ADON-E and SW-R of the allegation of neglect.Surveyor reviewed R105's progress notes for documentation of the incident. No progress notes were found.On 4/13/26, Surveyor asked Nursing Home Administrator (NHA)-A for all facility self-reports from January 2026 to present. Surveyor reviewed the self-reports and noted the facility did not have a self-report regarding R105 and CNA-Q.On 4/14/26, Surveyor reviewed the grievance log from January 2026 to present. Surveyor noted the facility did not have a grievance filed regarding R105 and CNA-Q.On 4/14/26 at 12:19 PM, Surveyor interviewed CNA-G. Surveyor asked if CNA-G recalled an incident regarding R105 and the fact that R105 was not changed for an entire shift. CNA-G stated that CNA-G remembered the day. CNA-G stated that while getting shift-to-shift report from CNA-Q, CNA-Q told CNA-G that when CNA-Q went into R105's room, R105 kept asking to be changed. CNA-Q would tell R105 that CNA-Q would be back and did not go back to the room. CNA-G indicated that CNA-G wanted to go to R105's room to help R105. CNA-G stated that R105 told CNA-G about what had happened. CNA-G stated that R105 was in tears. CNA-G stated that R105's incontinence brief and bed were wet with urine. CNA-G stated that CNA-G got R105 all clean and dry. CNA-G stated that ADON-E and SW-R were made aware of the incident. CNA-G stated that SW-R went to speak with R105, but CNA-G does not know what happened after that. Surveyor asked for the name of CNA-Q. CNA-G stated that CNA-G does not know who CNA-Q was and can't remember what CNA-Q looked like. Surveyor asked when this incident occurred. CNA-G stated that it happened in January or February but could not remember the exact date.Surveyor noted that CNA-G described an allegation of neglect that had R105 in tears. Surveyor noted that CNA-G indicated that ADON-E and SW-R were made aware of the allegation of neglect.On 4/14/26 at 11:45 AM, Surveyor interviewed ADON-E. Surveyor asked if ADON-E recalled an incident where R105 reported that R105 did not have R105's incontinence brief changed for an entire shift. ADON-E indicated yes. ADON-E stated R105 needed R105's incontinence brief changed. A CNA came into R105's room and never went back to help R105. ADON-E stated that this happened about 3-4 months ago. ADON-E stated that a grievance was filled out and given to the Social Workers. Surveyor asked if R105 informed ADON-E how R105 felt. ADON-E stated that ADON-E remembers that R105 was crying. ADON-E had to hug and console R105. ADON-E stated that the accused CNA (CNA-Q) does not work at the facility anymore but did not give Surveyor the name of the former employee.Surveyor noted ADON-E described an allegation of neglect that had R105 in tears. Surveyor noted that ADON-E stated that ADON-E gave a grievance to the facility Social Workers (SW-R or SW-P).On 4/14/26 at 12:03 PM, Surveyor interviewed SW-R. SW-R informed Surveyor that there are 2 facility Social Workers, SW-R and SW-P. Surveyor asked if SW-R could speak about the incident that occurred with R105 and a facility CNA and an allegation that the CNA did not change R105's incontinence brief for an entire shift. SW-R stated that R105 has a lot of things going on. SW-R stated that nothing was jumping in SW-R's head. SW-R stated, let me look and SW-R will get back to Surveyor. At 12:57 PM, SW-R returned to Surveyor. SW-R stated SW-R looked through the records and did not find anything for the last 3 months regarding R105. SW-R stated again that SW-R does not remember anything. Surveyor asked what SW-R would do if a resident tearfully reported to SW-R of a time that staff refused to change an incontinence brief. SW-R stated that SW-R would consider that a reportable event and tell NHA-A. SW-R stated that SW-R looked though grievances and did not find a grievance related to R105 in the last months. Surveyor informed SW-R that SW-R was mentioned by R105 and 2 other facility staff members as having knowledge of R105's concern. SW-R stated that SW-R does not remember anything and stated it was a long time ago.On 4/14/26 at 1:30 PM, Surveyor interviewed SW-P. Surveyor asked if SW-P had received a grievance or report about R105 and a concern that R105 did not have R105's brief change for an entire shift. SW-P indicated that SW-P was not notified of that and did not get a report about an incident like that.Surveyor noted that SW-R and SW-P reported to Surveyor that they were not aware of R105's concern and there was no grievance for R105's neglect allegation.On 4/13/26 at 4:56 PM, Surveyor interviewed Medication Technician (MT)-F. Surveyor asked what MT-F would do if a resident reported a concern (like not being changed or being rough) about a different facility CNA. MT-F stated that MT-F would inform the Unit nurse and Unit manager right away. MT-F stated MT-F would have to report that. MT-F stated that MT-F would not sleep at night if MT-F did not report that.On 4/14/26 at 9:14 AM, Surveyor interviewed CNA-X. Surveyor asked what CNA-X would do if a resident reported a concern (like not being changed or being rough) about a different facility CNA. CNA-X stated that CNA-X would tell the unit nurse and a supervisor. On 4/14/26 at 11:01 AM, Surveyor interviewed CNA-H. Surveyor asked what CNA-H would do if a resident reported a concern (like not being changed or being rough) about a different facility CNA. CNA-H stated that CNA-H would report it to NHA-A immediately.Surveyor noted one out of the 3 facility staff interviewed stated that they would report an allegation of possible abuse or neglect to NHA-A. On 4/14/26 at 2:28 PM, Surveyor interviewed NHA-A. Surveyor asked what the expectation is for facility staff if an allegation of abuse or neglect is made by a resident against a CNA or other staff member. NHA-A stated that staff should call NHA-A. NHA-A has NHA-A's phone number posted all over the facility, so staff have access to get a hold of NHA-A for concerns like that. NHA-A stated NHA-A should be notified so an investigation can start. Surveyor asked if a resident reported that a CNA refused to change the resident's incontinence pad for an entire shift, would NHA-A consider that an allegation of abuse or neglect. NHA-A stated yes. Surveyor reviewed R105's allegation of neglect with NHA-A. Surveyor asked if NHA-A was aware of this allegation. NHA-A first stated I don't believe that I have heard of this. NHA-A then stated, I have not heard this. Surveyor shared the following concerns with NHA-A: R105 informed Surveyor that about 2 to 3 months ago (during January or February), an unknown CNA, CNA-Q, told R105 that R105 had an attitude and was rude. After that interaction in the morning, CNA-Q would not help R105 with all R105's needs for the rest of CNA-Q's shift. CNA-Q delivered R105's lunch and R105 asked to be changed. CNA-Q ignored R105's request. R105 went the entire shift with out any incontinence cares from CNA-Q. R105 informed Surveyor that this made R105 feel like garbage and useless. R105 got tearful with Surveyor while talking about this and stated that the whole situation made R105 feel awful. R105 informed Surveyor that R105 was cold because R105's incontinence pad and bed sheets were soaked with urine. R105 stated that R105 was wet, dirty and itchy where a lady shouldn't be itchy. CNA-G came to work on 2nd shift that day. CNA-G informed Surveyor that R105 was tearful and upset about the events of the day. CNA-G indicated that R105's bed sheets and incontinence brief were soaked with urine and CNA-G got R105 clean and dry as soon as CNA-G started work. CNA-G and R105 informed Surveyor that ADON-E and SW-R were made aware of the situation. ADON-E confirmed to Surveyor that R105 did communicate that R105 was not changed for an entire shift and was tearful during the interaction and needed consoling. ADON-E stated a grievance was initiated and given to facility social workers. SW-R stated that SW-R did not remember and did not have documentation of the incident. SW-P told Surveyor that SW-P was not informed of this incident.Surveyor noted that the facility failed to protect the resident from abuse and neglect by not intervening to stop the deprivation of care, not ensuring timely incontinence care, and not implementing measures to prevent recurrence, resulting in ongoing risk for physical harm, compromised dignity, and psychosocial harm fpr R105.On 4/14/26 at 3:17 PM, NHA-A, Director of Nursing (DON)-B, Director of Operations-C and Nurse Consultant-D were made aware of the above concerns. Surveyor asked if there were any questions. DON-B did not ask a question. Surveyor stated that if there is any additional information to please let Surveyor know. DON-B did not offer any verbal additional information about the above concern.On 4/16/26 at 12:24 PM, Surveyor received additional information from the facility. The additional information summary documented, in part: We would like to provide evidence to show that [R105] has a pre-existing condition that needs to be considered when determining if this single event caused [R105] harm. Grievance regarding the situation with [R105] was found. We have a timestamped email of when the grievance was scanned in, indicating that there was a grievance written at the time of the event. See attachment 1. Statement from [CNA-G] indicating she was the one who provided cares on 2nd shift and that other than being happy to see [CNA-G], [R105] displayed no other emotions. See attachment 2Statement from [DON-B]. See attachment 3Statement from [ADON-E]. See attachment 4[R105] was seen by psychiatry on 12/30/25 and [R105] appeared with irritable affect, variable eye contact, defensive statements, somatic complaints, and partially cooperative behavior [R105] also endorsed depression in this visit. See attachment 5[R105] was then seen by psychiatry on 1/30/2026 shortly after the grievance. At that visit, [R105] denied symptoms of anxiety, feels her sleep is adequate, and complains about food choices but appetite is overall adequate. Regarding depression [R105] stated not anymore. See attachment 6. [R105] had a medical appointment outside the facility on 1/20/26, the day after the grievance, attached note indicated that [R105] was pleasant and had no complaints. See attachment 7. [Nurse consultant-D] interviewed [R105] on 4/15/26. [Nurse consultant-D] had not had any previous interactions with [R105]. See attachment 8. PHQ-9 assessments from before and after the event improved mood. See attachment 9.1. Surveyor reviewed the grievance form dated 1/20/26 and completed by SW-R, which documents, in part: Resident name: [R105]. Person making complaint and relationship to resident: Self. Detail of complaint/grievance: [CNA-Q] was asked by [R105] to be changed following breakfast on 1/19/26. [CNA-Q] picked up tray and [R105] asked to use commode and be changed. [CNA-Q] said I'll get to you soon. [R105] stated she then put light on after 1pm as [R105] was never changed or used commode. Another CNA came in to answer light and stated [they] would get [CNA-Q]. [R105] shared [CNA-Q] turned light off. [R105] put light on, and 2nd shift, [CNA-G] answered light [at] 2:40 pm. [CNA-G] asked [R105] if [R105] was changed 1st shift and [R105] stated no. [R105] shared [CNA-Q] has been rude from start with [R105]. [R105] praised [CNA-G] as an excellent CNA. [CNA-G] changed sheets, assisted to commode and changed [R105's] clothing and cleaned up. [R105] asked that [CNA-Q] not provide cares on [R105] moving forward. What shift did the complaint/grievance occur: 6-2. Person investigating complaint/grievance: BLANK. Grievance official follow-up: BLANK. Grievance official's signature: BLANK. Date Resolved: BLANK. Documented: BLANK.Surveyor noted that this grievance was not listed on the facility grievance log requested by Surveyor on 4/13/26 at the start of Survey. Surveyor noted that this grievance form was not the same as the other resident grievance forms given to Surveyors during the Survey process. Surveyor noted that this is a handwritten grievance form as opposed to an electronic form that was given to Surveyors during the Survey process. Surveyor noted that SW-R filled out the grievance form on 1/20/26 but did not recall the grievance and was unable to provide the grievance to Surveyor when requested on Survey. Surveyor noted the grievance was not documented as investigated. Surveyor noted that there was no follow up to the grievance. Surveyor noted that there was no resolution to the grievance.Surveyor noted that R105's grievance documented that R105 asked multiple times during CNA-Q's shift to be changed and toileted, CNA-Q was aware and did not help R105 with R105's needs. Surveyor noted that according to the grievance, R105 needed R105's sheets and clothing changed, and needed to be cleaned up. Surveyor noted that R105's basic needs were refused by CNA-Q.Surveyor noted that the refusal to provide requested toileting and hygiene assistance constituted neglect and abuse, as it involved the willful deprivation of services necessary to maintain the resident's physical health, personal hygiene, dignity, and psychosocial well-being. 2. [NHA-A] phone conversation with [CNA-G] dated 4/15/26 at 12:53PM documents: Before when [Surveyor] asked me, I couldn't think of who it was, and then I thought about it more and it was [first name of CNA-Q] I think it was in January or February, I'm not sure. [CNA-Q] came up to me when I got there and said that [R105] wanted to get on the commode. So, I went in to go and help [R105] and [R105] said that every time [CNA-Q] went in there, [CNA-Q] would say [CNA-Q] was busy or would make an excuse and say [CNA-Q] would come back. So, [CNA-Q] procrastinated until the start of my shift. I went and told [SW-R] about it. [SW-R] said that [SW-R] would go and talk to [R105]. I told [SW-R] to wait a little bit because I wanted to clean [R105] up. When I got [R105] on the commode, [R105] had urine in [R105's] brief but didn't have a bowel movement on the commode. [R105] wasn't distraught, [R105] wasn't crying, [R105] was just happy to see me.Surveyor noted that this interview happened after the Survey process had concluded. Surveyor noted that CNA-G confirmed that CNA-Q was aware of R105's need for toileting and CNA-Q did not meet R105's basic needs. Surveyor noted that CNA-G stated again in this statement, that CNA-G informed SW-R the same day. Surveyor noted SW-R was told of this incident on 1/19/26 and did not visit with R105 until the next day on 1/20/26 when SW-R filled out the grievance. Surveyor noted that CNA-G informed Surveyor on 4/14/26 that R105 was in tears but when CNA-G spoke to NHA-A on 4/15/26 CNA-G stated that R105 was not distraught or crying.3. Director of Nursing (DON)-B statement dated 4/16/26 documents: [CNA-Q] came to me on 1/19/26 to say that [R105] was refusing to be toileted when [R105] offered. DON-B went towards the room. [DON-B] heard [CNA-Q] offering to toilet [R105], but then [R105] declined at that time. [CNA-Q] came to get me sometimes when [CNA-Q] was going to go into [R105]'s room so I could hear. Each time [CNA-Q] offered when I was there, [R105] declined. This happened a few times throughout the day. I never heard [R105] ask to be taken to the commode or changed when I was outside the room. One of the times [CNA-Q] asked, [R105] said 'I do not feel like getting up right now'.Surveyor reviewed R105's progress notes from January to 4/14/26, Surveyor noted that R4 did refuse medications at times. Surveyor did not locate documentation from mid-January to mid-February documenting refusals of toileting or bathing in the progress notes. Surveyor noted with the additional information, facility did not provide documentation of refusals of toileting. Surveyor noted DON-B did not communicate these incidents of listening outside the room when speaking to NHA-A, DON-B, Director of Operations-C or Nurse Consultant-D during the exit meeting on 4/14/26. Surveyor noted that according to R105's grievance form, R105 did not tell CNA-G, or SW-R that R105 declined help from CNA-Q. Surveyor noted that during an interview with CNA-G on 4/14/26, CNA-G stated that while getting shift-to-shift report from CNA-Q, CNA-Q told CNA-G that when CNA-Q went in to R105's room, R105 kept asking to be changed. CNA-Q would tell R105 that CNA-Q would be back and CNA-Q did not go back to the room. 4. [ADON-E]. Statement taken by [NHA-A] on 4/16/26 regarding event in January. I don't remember what day it specifically was but I think that [R105] requested to see me. I think the event happened the day before. [R105] was upset that the day before [R105 didn't have to go to the bathroom when toileting was offered. When [R105] did request to go, [CNA-Q] said that [CNA-Q] didn't have time then, that [CNA-Q] would come back. Then [CNA-Q] never came back. [R105] said that the next shift changed [R105].Surveyor noted that ADON-E informed Surveyor on 4/14/26 at 11:45 AM, that R105 needed R105's incontinence brief changed. A CNA came into R105's room and never went back to help R105. ADON-E stated that ADON-E remembers that R105 was crying. ADON-E had to hug and console R105. Surveyor noted that during this interview with ADON-E, 2 days prior to this statement, ADON-E did not include that toileting was offered but only stated that R105 needed to be toileted, A CNA came into R105's room and never went back to help R105.5 and 6: R105's initial psychiatry evaluation dated 12/30/25 documents, in part: .[R105 is seen by writer for depression and [R105] does not take psychotropic medication. [R105] appears with irritable affect, variable eye contact, defensive statements, somatic complaints, and partially cooperative behavior. [R105 endorses frequent nausea for the last week, denies emesis, but is refusing meals and medication due to nausea. [R105] describes [R105's] sleep as off and on. [R105] endorses depression and states, yeah that's why they called you to see me because look, this place is a trash pit. [R105] is referring to [R105's] belongings in the room. [R105] moved to SNF about 4 weeks ago, per [R105] and is still settling in. [R105] refuses antidepressant therapy due to nausea but is open to starting sertraline in the future. Staff report irritability, but no other concerns about mood, behavior or cognition. Assessment/plan: Major depressive disorder, recurrent, mild.Stable, primarily depressed about living situation, elements of childhood abuse as well. We discussed starting [medication] will wait until nausea resolves .Surveyor noted that R105 was assessed to have mild depression- primarily depressed about living situation after a recent move to the facility 4 weeks prior. Medication was recommended to be started.R105's Follow up Psychiatric evaluation dated 1/30/26 documents, in part: . [R105] appears with irritable affect, obese but well-groomed, with good eye contact and has a variety of complaints about current living situation. Regarding depression [R105] states, not anymore. Assessment/plan: Major depressive disorder, recurrent, mild. [R105] is very irritable today. We discussed starting [medication], [R105] refused, continue to suggest in future.Surveyor noted the follow up visit documented that R105 was very irritable and starting medication was recommended and discussed but ultimately refused by R105. Surveyor noted that both psychiatry visits listed that the plan was to start medication indicating that at both times, the doctor thought it was necessary, but R105 refused.Surveyor reviewed R105's comprehensive care plan with revisions and noted that R105 did not have a care plan regarding depression, mood or psychosocial concerns at any point while being admitted at the facility during this admission.7. R105's Hematology and Oncology visit note dated 1/20/26 documents, in part: [R105] is a pleasant [patient] here today for follow-up. On presentation today [R105] reports felling generally well, under the circumstances. [R105] continues to struggle with a number of chronic health problems.Surveyor noted that the facility provided Surveyor with only the first page of the Hematology visit note. Surveyor noted that facility stated that R105 did not have any complaints, but the note provided to Surveyor did not document that statement.8. Interview with [R105] completed by Nurse consultant-D, dated 4/15/26. During the conversation [R105] was tangential and laughing. Talking about the wasp that was flying outside [R105's] window. Talking about [R105's] sons and father and the mementos [ R105 keeps in [R105] little box on the windowsill. [R105] was alert and very interactive and very upbeat. [R105 denied having any issues since that unspecified day. [R105] was hard to keep on track. I had a hard time ending the interview because [R105] was so talkative and had lots to talk about. Disappointed [R105] cannot return to the assisted living. Talking about [R105's] upcoming surgery. Summary of [R105's] statement. I think it was maybe a couple months ago, but I don't remember exactly. It was during the day. I don't remember the CNAs name, but she was black, short, maybe 5'3 and had [their] hair pinned up. [CNA-Q] came in that morning. I overslept. [CNA-Q] startled me when [CNA-Q] woke me up and I mumbled something at [CNA-Q]. [CNA-Q] told me not to be so rude. [CNA-Q] came back for my breakfast tray, and I said I usually use commode after breakfast, [CNA-Q] told me [CNA-Q] would be back. [CNA-Q] came back around lunch time with my lunch tray. I asked [CNA-Q] when I could be changed. [CNA-Q] stated when I was done with lunch. Then [CNA-Q] never came back. I turned on my call light maybe around 1:30. Then [CNA-G] came in when [CNA-G] shift started and I was happy to see [CNA-G] I really like [CNA-G]. You know I like [ADON-E] a lot too. They are no nonsense. [CNA-G] cleaned me up. I didn't want [CNA-Q] fired. I just wanted her to be re-instructed. [R105] stated [R105] did talk to [ADON-E] and [SW-R]. [R105 was asked if anyone else came into the room during the day. [R105] said probably the med tech or nurse, but [R105] couldn't remember.Surveyor noted that again R105 described letting CNA-Q know multiple times for help toileting and CNA-Q did not help R105 with R105's basic needs.9. R105's PHQ9 (a resident mood interview assessment) dated 10/31/25 documents a score of 2 indicating minimal or no depression.R105's PHQ9 dated 1/30/26 documents a score of 1 indicating minimal or no depression.Surveyor reviewed all additional information. Surveyor noted that R105 described to Surveyor on 4/14/26 an allegation of neglect. R105 described how that allegation made R105 feel. R105 was tearfully explaining that R105 felt like garbage, useless and felt like R105 had been abused. CNA-G stated to Surveyor that R105 was in tears after the allegation of neglect occurred. ADON-E stated to Surveyor that R105 was crying when talking to ADON-E about the alleged neglect. ADON-E had to hug and console R105. Surveyor noted that after a grievance was filed, there was no follow-up, investigation or resolution. Surveyor determined that the facility's failure to investigate, resolve, and implement corrective actions allowed the effects of the abuse and neglect to remain unaddressed and place

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse or neglect were reported to the Administrator and the State Agency within the required reporting timeframe for 2 (R105 and R108) of 2 residents reviewed with an allegation of abuse. *R105 informed Surveyor that 2 or 3 months ago, an unknown facility Certified Nursing Assistant (CNA), CNA-Q, left R105 in urine-soaked bed linens and incontinence brief. R105 went the entire day shift without incontinence cares despite R105 asking CNA-Q to change and clean R105. R105 tearfully informed Surveyor that this made R105 feel like garbage and useless and R105 felt like R105 had been physically abused. CNA-G informed Surveyor that when CNA-G went into R105's room on second shift that same day, CNA-G noted that R105's bed linens and incontinence brief were soaked with urine. CNA-G helped get R105 clean and dry. R105 informed CNA-G that R105 had not been changed since 3rd shift. CNA-G informed Surveyor that R105 was in tears and upset. CNA-G reported this incident to Assistant Director of Nursing (ADON)-E and Social Worker (SW)-R. ADON-E informed Surveyor that R105 was crying and needed consoling when talking about this allegation of neglect. ADON-E initiated a grievance and gave the grievance to the facility Social Workers (SW). Neither SW-R nor SW-P had documentation of the allegation of neglect. Nursing Home Administrator (NHA)-A informed Surveyor that NHA-A was not aware of this allegation of neglect. This allegation of neglect was known by multiple facility staff members and was not immediately reported to NHA-A and was not reported to the State Agency. *R108 reported to Surveyor an allegation of abuse that was not immediately reported to Nursing Home Administrator (NHA)-A and was not reported to the State Agency. Findings include: The facility policy with a last reviewed date of 2/25/26 and titled, Abuse, Neglect and Exploitation, 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 prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will have written procedures to assist staff in identifying the different types of abuse- mental/verbal abuse, sexual abuse, physical abuse, and deprivation by an individual of goods and services. Possible indicators of abuse include, but are not limited to: Resident, staff or family report of abuse.Verbal abuse of a resident overheard, Physical abuse of a resident observed, Psychological abuse of a resident observed, Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning and positioning. 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, during and after the investigation. The facility will have written procedures that include: 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. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: Analyzing the occurrence (s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences. Defining how care provision will be changed and/or improved to protect residents receiving services. Training of staff. Identification of staff responsible for implementation of corrective actions. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. 1.) R105 was admitted to the facility on [DATE] with diagnosis that include Polyneuropathy (multiple nerves throughout the body malfunction causing weakness, numbness and burning pain), Type 2 Diabetes, Chronic obstructive pulmonary disease (progressive, long-term lung condition that damages airways making it difficult to breathe), Heart failure, and Osteoarthritis (degenerative joint disease that causes pain, stiffness and joint damage). R105's Annual Minimum Data Set (MDS) assessment dated [DATE] documents R105 can express ideas and wants and is able to understand others. The MDS documents: R105 is cognitively intact; R105 does not exhibit physical or verbal behaviors directed towards others; R105 requires substantial/maximal assistance for toileting hygiene, bathing, and transfers; R105 is frequently incontinent of urine. R105's bladder incontinence care plan initiated on 8/21/25 documents the following intervention: Clean peri-area with each incontinence episode. Surveyor reviewed R105's comprehensive care plan and noted there is no mood or psychosocial concerns. Surveyor noted R105 does have a care plan related to resisting cares (like weights, activities of daily living cares, therapy) but no other behavior concerns are care planned. On 4/14/26 at 9:58 AM, Surveyor interviewed R105. R105 explained an incident that occurred at the facility with an unknown CNA, CNA-Q. R105 stated that it happened about 2 or 3 months ago and thinks it was January or February. R105 stated that R105 could not remember the name of CNA-Q and described CNA-Q as African American, small and shorter. R105 stated that R105 had overslept and was jostled awake by CNA-Q. R105 groaned and was groggy. R105 stated that CNA-Q told R105 that R105 had an attitude and that R105 was rude. R105 stated that CNA-Q had a chip on her shoulder and was in a bad mood. R105 stated that CNA-Q left R105's room. R105 informed Surveyor that R105 wears an incontinence brief and first-shift staff typically change R105's brief after breakfast, and around 1:30 -2 PM. R105 stated that CNA-Q did not change R105's incontinence brief after breakfast. R105 stated that CNA-Q did return to R105's room at lunch time. R105 stated that R105 told CNA-Q that R105 really needed to be changed. CNA-Q did not respond to R105. R105 stated that CNA-Q threw R105's lunch tray down on the bedside table and did not speak to R105. R105 stated that R105 begged CNA-Q to be changed. R105 stated that CNA-Q did not say a word and walked out of R105's room. R105 remembers falling asleep for a little bit after lunch. R105 stated that it was around 2:30 in the afternoon and R105 was upset that R105 had not been changed all day. R105 stated that R105 felt like garbage and felt useless. R105 got tearful with Surveyor and stated that the whole situation made R105 feel awful. R105 stated that R105 was cold because R105's incontinence brief and bed sheets were soaked with urine. R105 stated that R105 was wet and dirty and itchy where a lady shouldn't be itchy. R105 indicated that R105 tries to be a lady but that day R105 couldn't be a lady. R105 stated when second shift started, CNA-G came to R105's room. CNA-G looked at R105 and asked, what happened to you? R105 explained the events of the day. R105 stated that CNA-G stripped R105's bed, cleaned the mattress and remade the bed. CNA-G gave R105 a full bed bath and changed R105's incontinence brief for the first time that day after 3 pm. R105 stated CNA-G got R105 all clean and comfortable again. R105 stated, God bless CNA-G. R105 stated that CNA-G went to Assistant Director of Nursing (ADON)-E to inform ADON-E of the situation. R105 stated that one or two days later, Social Worker (SW)-R came to talk to R105 about the incident. R105 stated that R105 told both ADON-E and SW-R of the whole situation. R105 stated that after that, R105 never saw CNA-Q again. As Surveyor was leaving R105's room, R105 stated that R105 can understand someone having a bad day, but R105 stated I was physically abused. Severely abused. Surveyor noted that according to the definition of neglect documented in the facility abuse policy, neglect is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Surveyor noted R105 described an allegation of neglect to Surveyor. Surveyor noted R105 informed CNA-G, ADON-E and SW-R of the allegation of neglect. Surveyor reviewed R105's progress notes for documentation of the incident. No progress notes were found. On 4/13/26, Surveyor asked Nursing Home Administrator (NHA)-A for all facility self-reports from January 2026 to present. Surveyor reviewed the self-reports and noted the facility did not have a self-report regarding R105 and CNA-Q. On 4/14/26, Surveyor reviewed the grievance log from January 2026 to present. Surveyor noted the facility did not have a grievance filed regarding R105 and CNA-Q. On 4/14/26 at 12:19 PM, Surveyor interviewed CNA-G. Surveyor asked if CNA-G recalled an incident regarding R105 and the fact that R105 was not changed for an entire shift. CNA-G stated that CNA-G remembered the day. CNA-G stated that while getting shift-to-shift report from CNA-Q, CNA-Q told CNA-G that when CNA-Q went into R105's room, R105 kept asking to be changed. CNA-Q would tell R105 that CNA-Q would be back and did not go back to the room. CNA-G indicated that CNA-G wanted to go to R105's room to help R105. CNA-G stated that R105 told CNA-G about what had happened. CNA-G stated that R105 was in tears. CNA-G stated that R105's incontinence brief and bed were wet with urine. CNA-G stated that CNA-G got R105 all clean and dry. CNA-G stated that ADON-E and SW-R were made aware of the incident. CNA-G stated that SW-R went to speak with R105, but CNA-G does not know what happened after that. Surveyor asked for the name of CNA-Q. CNA-G stated that CNA-G does not know who CNA-Q was and can't remember what CNA-Q looked like. Surveyor asked when this incident occurred. CNA-G stated that it happened in January or February but could not remember the exact date. Surveyor noted that CNA-G described an allegation of neglect that had R105 in tears. Surveyor noted that CNA-G indicated that ADON-E and SW-R were made aware of the allegation of neglect. On 4/14/26 at 11:45 AM, Surveyor interviewed ADON-E. Surveyor asked if ADON-E recalled an incident where R105 reported that R105 did not have R105's incontinence brief changed for an entire shift. ADON-E indicated yes. ADON-E stated R105 needed R105's incontinence brief changed. A CNA came into R105's room and never went back to help R105. ADON-E stated that this happened about 3-4 months ago. ADON-E stated that a grievance was filled out and given to the Social Workers. Surveyor asked if R105 informed ADON-E how R105 felt. ADON-E stated that ADON-E remembers that R105 was crying. ADON-E had to hug and console R105. ADON-E stated that the accused CNA (CNA-Q) does not work at the facility anymore but did not give Surveyor the name of the former employee. Surveyor noted ADON-E described an allegation of neglect that had R105 in tears. Surveyor noted that ADON-E stated that ADON-E gave a grievance to the facility Social Workers (SW-R or SW-P). On 4/14/26 at 12:03 PM, Surveyor interviewed SW-R. SW-R informed Surveyor that there are 2 facility Social Workers, SW-R and SW-P. Surveyor asked if SW-R could speak about the incident that occurred with R105 and a facility CNA and an allegation that the CNA did not change R105's incontinence brief for an entire shift. SW-R stated that R105 has a lot of things going on. SW-R stated that nothing was jumping in SW-R's head. SW-R stated, let me look and SW-R will get back to Surveyor. At 12:57 PM, SW-R returned to Surveyor. SW-R stated SW-R looked through the records and did not find anything for the last 3 months regarding R105. SW-R stated again that SW-R does not remember anything. Surveyor asked what SW-R would do if a resident tearfully reported to SW-R of a time that staff refused to change an incontinence brief. SW-R stated that SW-R would consider that a reportable event and tell NHA-A. SW-R stated that SW-R looked though grievances and did not find a grievance related to R105 in the last months. Surveyor informed SW-R that SW-R was mentioned by R105 and 2 other facility staff members as having knowledge of R105's concern. SW-R stated that SW-R does not remember anything and stated it was a long time ago. On 4/14/26 at 1:30 PM, Surveyor interviewed SW-P. Surveyor asked if SW-P had received a grievance or report about R105 and a concern that R105 did not have R105's brief change for an entire shift. SW-P indicated that SW-P was not notified of that and did not get a report about an incident like that. Surveyor noted that SW-R and SW-P reported to Surveyor that they were not aware of R105's concern and there was no grievance for R105's neglect allegation. On 4/13/26 at 4:56 PM, Surveyor interviewed Medication Technician (MT)-F. Surveyor asked what MT-F would do if a resident reported a concern (like not being changed or being rough) about a different facility CNA. MT-F stated that MT-F would inform the Unit nurse and Unit manager right away. MT-F stated MT-F would have to report that. MT-F stated that MT-F would not sleep at night if MT-F did not report that. On 4/14/26 at 9:14 AM, Surveyor interviewed CNA-X. Surveyor asked what CNA-X would do if a resident reported a concern (like not being changed or being rough) about a different facility CNA. CNA-X stated that CNA-X would tell the unit nurse and a supervisor. On 4/14/26 at 11:01 AM, Surveyor interviewed CNA-H. Surveyor asked what CNA-H would do if a resident reported a concern (like not being changed or being rough) about a different facility CNA. CNA-H stated that CNA-H would report it to NHA-A immediately. Surveyor noted one out of the 3 facility staff interviewed stated that they would report an allegation of possible abuse or neglect to NHA-A. On 4/14/26 at 2:28 PM, Surveyor interviewed NHA-A. Surveyor asked what the expectation is for facility staff if an allegation of abuse or neglect is made by a resident against a CNA or other staff member. NHA-A stated that staff should call NHA-A. NHA-A has NHA-A's phone number posted all over the facility, so staff have access to get a hold of NHA-A for concerns like that. NHA-A stated NHA-A should be notified so an investigation can start. Surveyor asked if a resident reported that a CNA refused to change the resident's incontinence pad for an entire shift, would NHA-A consider that an allegation of abuse or neglect. NHA-A stated yes. Surveyor reviewed R105's allegation of neglect with NHA-A. Surveyor asked if NHA-A was aware of this allegation. NHA-A first stated I don't believe that I have heard of this. NHA-A then stated, I have not heard this. Surveyor shared the following concerns with NHA-A: R105 informed Surveyor that about 2 to 3 months ago (during January or February), an unknown CNA, CNA-Q, told R105 that R105 had an attitude and was rude. After that interaction in the morning, CNA-Q would not help R105 with all R105's needs for the rest of CNA-Q's shift. CNA-Q delivered R105's lunch and R105 asked to be changed. CNA-Q ignored R105's request. R105 went the entire shift with out any incontinence cares from CNA-Q. R105 informed Surveyor that this made R105 feel like garbage and useless. R105 got tearful with Surveyor while talking about this and stated that the whole situation made R105 feel awful. R105 informed Surveyor that R105 was cold because R105's incontinence pad and bed sheets were soaked with urine. R105 stated that R105 was wet, dirty and itchy where a lady shouldn't be itchy. CNA-G came to work on 2nd shift that day. CNA-G informed Surveyor that R105 was tearful and upset about the events of the day. CNA-G indicated that R105's bed sheets and incontinence brief were soaked with urine and CNA-G got R105 clean and dry as soon as CNA-G started work. CNA-G and R105 informed Surveyor that ADON-E and SW-R were made aware of the situation. ADON-E confirmed to Surveyor that R105 did communicate that R105 was not changed for an entire shift and was tearful during the interaction and needed consoling. ADON-E stated a grievance was initiated and given to facility social workers. SW-R stated that SW-R did not remember and did not have documentation of the incident. SW-P told Surveyor that SW-P was not informed of this incident. Surveyor noted that facility staff were aware of an allegation of neglect and NHA-A was not notified and the allegation of neglect was not reported to the State Agency. On 4/14/26 at 3:17 PM, NHA-A, Director of Nursing (DON)-B, Director of Operations-C and Nurse Consultant-D were made aware of the above concerns. Surveyor asked if there were any questions. DON-B did not ask a question. Surveyor stated that if there is any additional information to please let Surveyor know. DON-B did not offer any verbal additional information about the above concern. On 4/16/26 at 12:24 PM, Surveyor received additional information from the facility. The additional information summary documented, in part: We would like to provide evidence to show that [R105] has a pre-existing condition that needs to be considered when determining if this single event caused [R105] harm. Grievance regarding the situation with [R105] was found. We have a timestamped email of when the grievance was scanned in, indicating that there was a grievance written at the time of the event. See attachment 1. Statement from [CNA-G] indicating she was the one who provided cares on 2nd shift and that other than being happy to see [CNA-G], [R105] displayed no other emotions. See attachment 2 Statement from [DON-B]. See attachment 3 Statement from [ADON-E]. See attachment 4 [R105] was seen by psychiatry on 12/30/25 and [R105] appeared with irritable affect, variable eye contact, defensive statements, somatic complaints, and partially cooperative behavior [R105] also endorsed depression in this visit. See attachment 5 [R105] was then seen by psychiatry on 1/30/2026 shortly after the grievance. At that visit, [R105] denied symptoms of anxiety, feels her sleep is adequate, and complains about food choices but appetite is overall adequate. Regarding depression [R105] stated not anymore. See attachment 6. [R105] had a medical appointment outside the facility on 1/20/26, the day after the grievance, attached note indicated that [R105] was pleasant and had no complaints. See attachment 7. [Nurse consultant-D] interviewed [R105] on 4/15/26. [Nurse consultant-D] had not had any previous interactions with [R105]. See attachment 8. PHQ-9 assessments from before and after the event improved mood. See attachment 9. 1. Surveyor reviewed the grievance form dated 1/20/26 and completed by SW-R, which documents, in part: Resident name: [R105]. Person making complaint and relationship to resident: Self. Detail of complaint/grievance: [CNA-Q] was asked by [R105] to be changed following breakfast on 1/19/26. [CNA-Q] picked up tray and [NAME] asked to use commode and be changed. [CNA-Q] said I'll get to you soon. [R105] stated she then put light on after 1pm as [R105] was never changed or used commode. Another CNA came in to answer light and stated [they] would get [CNA-Q]. [R105] shared [CNA-Q] turned light off. [R105] put light on, and 2nd shift, [CNA-G] answered light [at] 2:40 pm. [CNA-G] asked [R105] if [R105] was changed 1st shift and [R105] stated no. [R105] shared [CNA-Q] has been rude from start with [R105]. [R105] praised [CNA-G] as an excellent CNA. [CNA-G] changed sheets, assisted to commode and changed [R105's] clothing and cleaned up. [R105] asked that [CNA-Q] not provide cares on [R105] moving forward. What shift did the complaint/grievance occur: 6-2. Person investigating complaint/grievance: BLANK. Grievance official follow-up: BLANK. Grievance official's signature: BLANK. Date Resolved: BLANK. Documented: BLANK. Surveyor noted that this grievance was not listed on the facility grievance log requested by Surveyor on 4/13/26 at the start of Survey. Surveyor noted that this grievance form was not the same as the other resident grievance forms given to Surveyors during the Survey process. Surveyor noted that this is a handwritten grievance form as opposed to an electronic form that was given to Surveyors during the Survey process. Surveyor noted that SW-R filled out the grievance form on 1/20/26 but did not recall the grievance and was unable to provide the grievance to Surveyor when requested on Survey. Surveyor noted the grievance was not documented as investigated. Surveyor noted that there was no follow up to the grievance. Surveyor noted that there was no resolution to the grievance. Surveyor noted that R105's grievance documented that R105 asked multiple times during CNA-Q's shift to be changed and toileted, CNA-Q was aware and did not help R105 with R105's needs. Surveyor noted that according to the grievance, R105 needed R105's sheets and clothing changed, and needed to be cleaned up. Surveyor noted that R105's basic needs were refused by CNA-Q. 2. [NHA-A] phone conversation with [CNA-G] dated 4/15/26 at 12:53PM documents: Before when [Surveyor] asked me, I couldn't think of who it was, and then I thought about it more and it was [first name of CNA-Q] I think it was in January or February, I'm not sure. [CNA-Q] came up to me when I got there and said that [R105] wanted to get on the commode. So, I went in to go and help [R105] and [R105] said that every time [CNA-Q] went in there, [CNA-Q] would say [CNA-Q] was busy or would make an excuse and say [CNA-Q] would come back. So, [CNA-Q] procrastinated until the start of my shift. I went and told [SW-R] about it. [SW-R] said that [SW-R] would go and talk to [R105]. I told [SW-R] to wait a little bit because I wanted to clean [R105] up. When I got [R105] on the commode, [R105] had urine in [R105's] brief but didn't have a bowel movement on the commode. [R105] wasn't distraught, [R105] wasn't crying, [R105] was just happy to see me. Surveyor noted that this interview happened after the Survey process had concluded. Surveyor noted that CNA-G confirmed that CNA-Q was aware of R105's need for toileting and CNA-Q did not meet R105's basic needs. Surveyor noted that CNA-G stated again in this statement, that CNA-G informed SW-R the same day. Surveyor noted SW-R was told of this incident on 1/19/26 and did not visit with R105 until the next day on 1/20/26 when SW-R filled out the grievance. Surveyor noted that CNA-G informed Surveyor on 4/14/26 that R105 was in tears but when CNA-G spoke to NHA-A on 4/15/26 CNA-G stated that R105 was not distraught or crying. 3. Director of Nursing (DON)-B statement dated 4/16/26 documents: [CNA-Q] came to me on 1/19/26 to say that [R105] was refusing to be toileted when [R105] offered. DON-B went towards the room. [DON-B] heard [CNA-Q] offering to toilet [R105], but then [R105] declined at that time. [CNA-Q] came to get me sometimes when [CNA-Q] was going to go into [R105]'s room so I could hear. Each time [CNA-Q] offered when I was there, [R105] declined. This happened a few times throughout the day. I never heard [R105] ask to be taken to the commode or changed when I was outside the room. One of the times [CNA-Q] asked, [R105] said 'I do not feel like getting up right now'. Surveyor reviewed R105's progress notes from January to 4/14/26, Surveyor noted that R4 did refuse medications at times. Surveyor did not locate documentation from mid-January to mid-February documenting refusals of toileting or bathing in the progress notes. Surveyor noted with the additional information, facility did not provide documentation of refusals of toileting. Surveyor noted DON-B did not communicate these incidents of listening outside the room when speaking to NHA-A, DON-B, Director of Operations-C or Nurse Consultant-D during the exit meeting on 4/14/26. Surveyor noted that according to R105's grievance form, R105 did not tell CNA-G, or SW-R that R105 declined help from CNA-Q. Surveyor noted that during an interview with CNA-G on 4/14/26, CNA-G stated that while getting shift-to-shift report from CNA-Q, CNA-Q told CNA-G that when CNA-Q went in to R105's room, R105 kept asking to be changed. CNA-Q would tell R105 that CNA-Q would be back and CNA-Q did not go back to the room. 4. [ADON-E]. Statement taken by [NHA-A] on 4/16/26 regarding event in January. I don't remember what day it specifically was but I think that [R105] requested to see me. I think the event happened the day before. [R105] was upset that the day before [R105 didn't have to go to the bathroom when toileting was offered. When [R105] did request to go, [CNA-Q] said that [CNA-Q] didn't have time then, that [CNA-Q] would come back. Then [CNA-Q] never came back. [R105] said that the next shift changed [R105]. Surveyor noted that ADON-E informed Surveyor on 4/14/26 at 11:45 AM, that R105 needed R105's incontinence brief changed. A CNA came into R105's room and never went back to help R105. ADON-E stated that ADON-E remembers that R105 was crying. ADON-E had to hug and console R105. Surveyor noted that during this interview with ADON-E, 2 days prior to this statement, ADON-E did not include that toileting was offered but only stated that R105 needed to be toileted, A CNA came into R105's room and never went back to help R105. 5 and 6: R105's initial psychiatry evaluation dated 12/30/25 documents, in part: .[R105 is seen by writer for depression and [R105] does not take psychotropic medication. [R105] appears with irritable affect, variable eye contact, defensive statements, somatic complaints, and partially cooperative behavior. [R105 endorses frequent nausea for the last week, denies emesis, but is refusing meals and medication due to nausea. [R105] describes [R105's] sleep as off and on. [R105] endorses depression and states, yeah that's why they called you to see me because look, this place is a trash pit. [R105] is referring to [R105's] belongings in the room. [R105] moved to SNF about 4 weeks ago, per [R105] and is still settling in. [R105] refuses antidepressant therapy due to nausea but is open to starting sertraline in the future. Staff report irritability, but no other concerns about mood, behavior or cognition. Assessment/plan: Major depressive disorder, recurrent, mild.Stable, primarily depressed about living situation, elements of childhood abuse as well. We discussed starting [medication] will wait until nausea resolves . Surveyor noted that R105 was assessed to have mild depression- primarily depressed about living situation after a recent move to the facility 4 weeks prior. Medication was recommended to be started. R105's Follow up Psychiatric evaluation dated 1/30/26 documents, in part: . [R105] appears with irritable affect, obese but well-groomed, with good eye contact and has a variety of complaints about current living situation. Regarding depression [R105] states, not anymore. Assessment/plan: Major depressive disorder, recurrent, mild. [R105] is very irritable today. We discussed starting [medication], [R105] refused, continue to suggest in future. Surveyor noted the follow up visit documented that R105 was very irritable and starting medication was recommended and discussed but ultimately refused by R105. Surveyor noted that both psychiatry visits listed that the plan was to start medication indicating that at both times, the doctor thought it was necessary, but R105 refused. Surveyor reviewed R105's comprehensive care plan with revisions and noted that R105 did not have a care plan regarding depression, mood or psychosocial concerns at any point while being admitted at the facility during this admission. 7. R105's Hematology and Oncology visit note dated 1/20/26 documents, in part: [R105] is a pleasant [patient] here today for follow-up. On presentation today [R105] reports felling generally well, under the circumstances. [R105] continues to struggle with a number of chronic health problems. Surveyor noted that the facility provided Surveyor with only the first page of the Hematology visit note. Surveyor noted that facility stated that R105 did not have any complaints, but the note provided to Surveyor did not document that statement. 8. Interview with [R105] completed by Nurse consultant-D, dated 4/15/26. During the conversation [R105] was tangential and laughing. Talking about the wasp that was flying outside [R105's] window. Talking about [R105's] sons and father and the mementos [ R105 keeps in [R105] little box on the windowsill. [R105] was alert and very interactive and very upbeat. [R105 denied having any issues since that unspecified day. [R105] was hard to keep on track. I had a hard time ending the interview because [R105] was so talkative and had lots to talk about. Disappointed [R105] cannot return to the assisted living. Talking about [R105's] upcoming surgery. Summary of [R105's] statement. I think it was maybe a couple months ago, but I don't remember exactly. It was during the day. I don't remember the CNAs name, but she was black, short, maybe 5'3 and had [their] hair pinned up. [CNA-Q] came in that morning. I overslept. [CNA-Q] startled me when [CNA-Q] woke me up and I mumbled something at [CNA-Q]. [CNA-Q] told me not to be so rude. [CNA-Q] came back for my breakfast tray, and I said I usually use commode after breakfast, [CNA-Q] told me [CNA-Q] would be back. [CNA-Q] came back around lunch time with my lunch tray. I asked [CNA-Q] when I could be changed. [CNA-Q] stated when I was done with lunch. Then [CNA-Q] never came back. I turned on my call light maybe around 1:30. Then [CNA-G] came in when [CNA-G] shift started and I was happy to see [CNA-G] I really like [CNA-G]. You know I like [ADON-E] a lot too. They are no nonsense. [CNA-G] cleaned me up. I didn't want [CNA-Q] fired. I just wanted her to be re-instructed. [R105] stated [R105] did talk to [ADON-E] and [SW-R]. [R105 was asked if anyone else came into the room during the day. [R105] said probably the med tech or nurse, but [R105] couldn't remember. Surveyor noted that again R105 described letting CNA-Q know multiple times for help toileting and CNA-Q did not help R105 with R105's basic needs. 9. R105's PHQ9 (a resident mood interview assessment) dated 10/31/25 documents a score of 2 indicating minimal or no depression. R105's PHQ9 dated 1/30/26 documents a score of 1 indicating minimal or no depression. Surveyor reviewed all additional information. Surveyor noted that R105 described to Surveyor on 4/14/26 an allegation of neglect. R105 described how that allegation made R105 feel. R105 was tearful

Based on interviews and record review, the facility did not ensure all allegations of abuse or neglect were thoroughly investigated for 2 (R105 and R108) of 2 residents reviewed for an allegation of abuse. *R105 informed Surveyor of an allegation of neglect. R105 told Surveyor that after the incident occurred, R105 spoke to Certified Nursing Assistant (CNA)-G, Assistant Director of Nursing (ADON)-E and Social Worker (SW)-R of the allegation of neglect. This allegation was not immediately reported to Nursing Home Administrator (NHA)-A and an investigation into the allegation of neglect was not completed. *R108 reported to Surveyor an allegation of abuse that was not thoroughly investigated by facility staff. Findings include: The facility policy with a last reviewed date of 2/25/26 and titled, Abuse, Neglect and Exploitation, 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 prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will have written procedures to assist staff in identifying the different types of abuse- mental/verbal abuse, sexual abuse, physical abuse, and deprivation by an individual of goods and services. Possible indicators of abuse include, but are not limited to: Resident, staff or family report of abuse.Verbal abuse of a resident overheard, Physical abuse of a resident observed, Psychological abuse of a resident observed, Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning and positioning. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: Identifying staff responsible for the investigation. Investigating different types of alleged violations. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations. Focusing the investigation on determining if abuse neglect, exploitation, and/or mistreatment has occurred, the extent, and the cause. Providing complete and thorough documentation of the investigation. 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: Responding immediately to protect the alleged victim and integrity of the investigation. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed. Increased supervision of the alleged victim and residents. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. Providing emotional support and counseling to the resident during and after the investigation, as needed. 1.) R105 was admitted to the facility on [DATE] with diagnosis that include Polyneuropathy (multiple nerves throughout the body malfunction causing weakness, numbness and burning pain), Type 2 Diabetes, Chronic obstructive pulmonary disease (progressive, long-term lung condition that damages airways making it difficult to breathe), Heart failure, and Osteoarthritis (degenerative joint disease that causes pain, stiffness and joint damage). R105's Annual Minimum Data Set (MDS) assessment dated [DATE] documents R105 can express ideas and wants and is able to understand others. The MDS documents: R105 is cognitively intact; R105 does not exhibit physical or verbal behaviors directed towards others; R105 requires substantial/maximal assistance for toileting hygiene, bathing, and transfers; R105 is frequently incontinent of urine. R105's bladder incontinence care plan initiated on 8/21/25 documents the following intervention: Clean peri-area with each incontinence episode. Surveyor reviewed R105's comprehensive care plan and noted there is no mood or psychosocial concerns. Surveyor noted that R105 does have a care plan related to resisting cares (like weights, activities of daily living cares, therapy) but no other behavior concerns are care planned. On 4/14/26 at 9:58 AM, Surveyor interviewed R105. R105 explained an incident that occurred at the facility with an unknown CNA (Certified Nursing Assistant), whom was later determined to be CNA-Q. R105 stated that it happened about 2 or 3 months ago and thinks it was January or February 2026. R105 stated that R105 could not remember the name of CNA-Q and described CNA-Q as African American, small and shorter. R105 stated that R105 had overslept and was jostled awake by CNA-Q. R105 groaned and was groggy. R105 stated that CNA-Q told R105 that R105 had an attitude and that R105 was rude. R105 stated that CNA-Q had a chip on her shoulder and was in a bad mood. R105 stated that CNA-Q left R105's room. R105 informed Surveyor that R105 wears an incontinence brief and first-shift staff typically change R105's brief after breakfast, and around 1:30 -2 PM. R105 stated that CNA-Q did not change R105's incontinence brief after breakfast. R105 stated that CNA-Q did return to R105's room at lunch time. R105 stated that R105 told CNA-Q that R105 really needed to be changed. CNA-Q did not respond to R105. R105 stated that CNA-Q threw R105's lunch tray down on the bedside table and did not speak to R105. R105 stated that R105 begged CNA-Q to be changed. R105 stated that CNA-Q did not say a word and walked out of R105's room. R105 remembers falling asleep for a little bit after lunch. R105 stated that it was around 2:30 in the afternoon and R105 was upset that R105 had not been changed all day. R105 stated that R105 felt like garbage and felt useless. R105 got tearful with Surveyor and stated that the whole situation made R105 feel awful. R105 stated that R105 was cold because R105's incontinence brief and bed sheets were soaked with urine. R105 stated that R105 was wet and dirty and itchy where a lady shouldn't be itchy. R105 indicated that R105 tries to be a lady but that day R105 couldn't be a lady. R105 stated when second shift started, CNA-G came to R105's room. CNA-G looked at R105 and asked, what happened to you? R105 explained the events of the day. R105 stated that CNA-G stripped R105's bed, cleaned the mattress and remade the bed. CNA-G gave R105 a full bed bath and changed R105's incontinence brief for the first time that day after 3 pm. R105 stated CNA-G got R105 all clean and comfortable again. R105 stated, God bless CNA-G. R105 stated that CNA-G went to Assistant Director of Nursing (ADON)-E to inform ADON-E of the situation. R105 stated that one or two days later, Social Worker (SW)-R came to talk to R105 about the incident. R105 stated that R105 told both ADON-E and SW-R of the whole situation. R105 stated that after that, R105 never saw CNA-Q again. As Surveyor was leaving R105's room, R105 stated that R105 can understand someone having a bad day, but R105 stated I was physically abused. Severely abused. Surveyor noted that according to the definition of neglect documented in the facility abuse policy, neglect is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Surveyor noted R105 described an allegation of neglect to Surveyor. Surveyor noted R105 informed CNA-G, ADON-E and SW-R of the allegation of neglect. Surveyor reviewed R105's progress notes for documentation of the incident. No progress notes were found. On 4/13/26, Surveyor asked Nursing Home Administrator (NHA)-A for all facility self-reports from January 2026 to present. Surveyor reviewed the self-reports and noted the facility did not have a self-report regarding R105 and CNA-Q. On 4/14/26, Surveyor reviewed the grievance log from January 2026 to present. Surveyor noted the facility did not have a grievance filed regarding R105 and CNA-Q. On 4/14/26 at 12:19 PM, Surveyor interviewed CNA-G. Surveyor asked if CNA-G recalled an incident regarding R105 and the fact that R105 was not changed for an entire shift. CNA-G stated that CNA-G remembered the day. CNA-G stated that R105 told CNA-G about what had happened. CNA-G stated that R105 was in tears. CNA-G stated that R105's incontinence brief and bed were wet with urine. CNA-G stated that CNA-G got R105 all clean and dry. CNA-G stated that ADON-E and SW-R were made aware of the incident. CNA-G stated that SW-R went to speak with R105, but CNA-G does not know what happened after that. Surveyor noted that CNA-G described an allegation of neglect. Surveyor noted that CNA-G indicated that ADON-E and SW-R were made aware of the allegation of neglect. Surveyor noted that CNA-G did not make NHA-A aware of the allegation of neglect so that a thorough investigation could be completed. On 4/14/26 at 11:45 AM, Surveyor interviewed ADON-E. Surveyor asked if ADON-E recalled an incident where R105 reported that R105 did not have R105's incontinence brief changed for an entire shift. ADON-E indicated yes. ADON-E stated R105 needed R105's incontinence brief changed. A CNA came into R105's room and never went back to help R105. ADON-E stated that the accused CNA (CNA-Q) does not work at the facility anymore but did not give Surveyor the name of the former employee. ADON-E stated that a grievance was filled out and given to the Social Workers. Surveyor noted ADON-E described an allegation of neglect. Surveyor noted that ADON-E stated that ADON-E gave a grievance to the facility Social Workers (SW-R or SW-P). Surveyor noted ADON-E did not make NHA-A aware of the allegation of abuse so that a thorough investigation could be completed. On 4/14/26 at 12:03 PM, Surveyor interviewed SW-R. SW-R informed Surveyor that there are 2 facility Social Workers, SW-R and SW-P. Surveyor asked if SW-R could speak about the incident that occurred with R105 and a facility CNA and an allegation that the CNA did not change R105's incontinence brief for an entire shift. SW-R stated that R105 has a lot of things going on. SW-R stated that nothing was jumping in SW-R's head. SW-R stated, let me look and SW-R will get back to Surveyor. At 12:57 PM, SW-R returned to Surveyor. SW-R stated SW-R looked through the records and did not find anything for the last 3 months regarding R105. SW-R stated again that SW-R does not remember anything. Surveyor asked what SW-R would do if a resident tearfully reported to SW-R of a time that staff refused to change an incontinence brief. SW-R stated that SW-R would consider that a reportable event and tell NHA-A. SW-R stated that SW-R looked though grievances and did not find a grievance related to R105 in the last months. Surveyor informed SW-R that SW-R was mentioned by R105 and 2 other facility staff members as having knowledge of R105's concern. SW-R stated that SW-R does not remember anything and stated it was a long time ago. On 4/14/26 at 1:30 PM, Surveyor interviewed SW-P. Surveyor asked if SW-P had received a grievance or report about R105 and a concern that R105 did not have R105's brief change for an entire shift. SW-P indicated that SW-P was not notified of that and did not get a report about an incident like that. Surveyor noted that SW-R and SW-P reported to Surveyor that they were not aware of R105's concern and there was no grievance for R105's neglect allegation. On 4/14/26 at 9:14 AM, Surveyor interviewed CNA-X. Surveyor asked what CNA-X would do if a resident reported a concern (like not being changed or being rough) about a different facility CNA. CNA-X stated that CNA-X would tell the unit nurse and a supervisor. On 4/14/26 at 11:01 AM, Surveyor interviewed CNA-H. Surveyor asked what CNA-H would do if a resident reported a concerns (like not being changed or being rough) about a different facility CNA. CNA-H stated that CNA-H would report it to NHA-A immediately. On 4/14/26 at 2:28 PM, Surveyor interviewed NHA-A. Surveyor asked what the expectation is for facility staff if an allegation of abuse or neglect is made by a resident against a CNA or other staff member. NHA-A stated that staff should call NHA-A. NHA-A has NHA-A's phone number posted all over the facility, so staff have access to get a hold of NHA-A for concerns like that. NHA-A stated NHA-A should be notified so an investigation can start. Surveyor asked if a resident reported that a CNA refused to change the resident's incontinence pad for an entire shift, would NHA-A consider that an allegation of abuse or neglect. NHA-A stated yes. Surveyor reviewed R105's allegation of neglect with NHA-A. Surveyor asked if NHA-A was aware of this allegation. NHA-A first stated I don't believe that I have heard of this. NHA-A then stated, I have not heard this. Surveyor shared the following concerns with NHA-A: R105 informed Surveyor that R105 reported an allegation of neglect to CNA-G, ADON-E and SW-R. Multiple staff were aware of this allegation and did not inform NHA-A so a thorough investigation could be completed. On 4/16/26 at 12:24 PM, Surveyor received additional information from the facility. The facility was able to locate the grievance form for R105. Surveyor reviewed the grievance form dated 1/20/26 and completed by SW-R, which documents, in part: Resident name: [R105]. Person making complaint and relationship to resident: Self. Detail of complaint/grievance: [CNA-Q] was asked by [R105] to be changed following breakfast on 1/19/26. [CNA-Q] picked up tray and [NAME] asked to use commode and be changed. [CNA-Q] said I'll get to you soon. [R105] stated she then put light on after 1pm as [R105] was never changed or used commode. Another CNA came in to answer light and stated [they] would get [CNA-Q]. [R105] shared [CNA-Q] turned light off. [R105] put light on, and 2nd shift, [CNA-G] answered light [at] 2:40 pm. [CNA-G] asked [R105] if [R105] was changed 1st shift and [R105] stated no. [R105] shared [CNA-Q] has been rude from start with [R105]. [R105] praised [CNA-G] as an excellent CNA. [CNA-G] changed sheets, assisted to commode and changed [R105's] clothing and cleaned up. [R105] asked that [CNA-Q] not provide cares on [R105] moving forward. What shift did the complaint/grievance occur: 6-2. Person investigating complaint/grievance: BLANK. Grievance official follow-up: BLANK. Grievance official's signature: BLANK. Date Resolved: BLANK. Documented: BLANK. Surveyor noted that this grievance was not listed on the facility grievance log requested by Surveyor on 4/13/26 at the start of Survey. Surveyor noted that this grievance form was not the same as the other resident grievance forms given to Surveyors during the Survey process. Surveyor noted that this is a handwritten grievance form as opposed to an electronic form that was given to Surveyors during the Survey process. Surveyor noted that SW-R filled out the grievance form on 1/20/26 but did not recall the grievance and was unable to provide the grievance to Surveyor when requested on Survey. Surveyor noted the grievance was not documented as investigated. Surveyor noted that there was no follow up to the grievance. Surveyor noted that there was no resolution to the grievance. Surveyor noted that R105's grievance documented that R105 asked multiple times during CNA-Q's shift to be changed and toileted, CNA-Q was aware and did not help R105 with R105's needs. Surveyor noted that according to the grievance, R105 needed R105's sheets and clothing changed, and needed to be cleaned up. Surveyor noted that R105's basic needs were refused by CNA-Q. No additional information was provided as to why the facility did not complete a thorough investigation of R105's allegations of potential neglect. 2.) R108 was admitted to the facility on [DATE] with diagnoses of Intracerebral Hemorrhage(life threatening type of stroke caused by ruptured blood vessel bleeding into the brain tissue), Type 2 Diabetes Mellitus(adult onset of trouble controlling blood sugar), Hyperlipidemia(high levels of fat particles in blood), Metabolic Encephalopathy(brain dysfunction resulting from underlying condition that disrupts the metabolic processes), Depression(mood disorder that causes persistent feelings of sadness and loss of interest), Alzheimer's(progressive disease that destroys memory and other important mental functions), and Vascular Dementia(brain damage caused by multiple strokes). R108's Quarterly Minimum Data Set (MDS) completed 3/3/26 documents R108's Brief Interview for Mental Status (BIMS) score to be 12, indicating moderately impaired skills for daily decision making. Surveyor reviewed R108's comprehensive care plan and noted there is no mood, behavior, or psychosocial concerns. On 4/13/26, at 11:47 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-W. CNA-W shared that R108 had reported that R108 was afraid of CNA-V. R108 had communicated that CNA-V was mean and aggressive towards R108. CNA-W shared that CNA-V had thrown a breakfast tray at R108. CNA-W reported that R108 was upset with CNA-T the next day because R108 assumed that CNA-T had reported the incident and was not protecting R108 because CNA-V was still being aggressive towards R108. CNA-W shared that CNA-V approached CNA-T in the dining room and started yelling at CNA-T in regard to the concern. CNA-W also shared that R108 was very upset with CNA-T the next day stating: I reported her to you, you didn't protect me. On 4/13/26, at 1:53 PM, Surveyor interviewed CNA-T. CNA-T explained that on Sunday, March 22,2026, R108 had expressed that CNA-V was very rough with cares and felt abused. R108 also reported to CNA-T that CNA-V threw R108's breakfast tray at her. CNA-T stated that CNA-T reported the allegation to Licensed Practical Nurse (LPN)-U on 3/22/26. CNA-T shared that R108 did not feel safe on that day. On 3/23/26, CNA-T wanted to make sure the allegation was followed up on so CNA-T communicated with Social Worker (SW)-P the allegations of CNA-V being rough with morning cares, making R108 get up and throwing the breakfast tray at R108. CNA-T shared to Surveyor that on that date, R108 was very afraid of CNA-V and that R108 is still currently afraid of CNA-V. Surveyor observed CNA-T go directly to SW-P and observed both in conversation. On 4/14/26, at 9:15 AM, Surveyor interviewed R108. R108 confirmed that there was an incident where CNA-V threw the breakfast tray at R108. R108 recalls saying something and then CNA-V stated, then don't eat it. R108 stated it was the tone of CNA-V's voice. CNA-V was not speaking to R108 right, it was in a mean way. R108 states that no one came to talk to R108 about the incident. R108 does not recall having any issues with cares. On 4/14/26, at 9:56 AM, Surveyor interviewed SW-P in regard to R108's allegation. SW-P does recall that CNA-T informed SW-P on March 23,2026 about the incident involving CNA-V and R108. SW-P recalled it was communicated that CNA-V ripped the covers off. SW-P informed Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A. SW-P also recalls putting in a grievance. SW-P explained after that, SW-P does not get involved in the investigation process. Surveyor asked if SW-P knew about the breakfast tray being thrown at R108. SW-P stated SW-P was not aware of that incident, only that CNA-V had been aggressive with R108. SW-P recalls CNA-T being upset about the incident with CNA-V and R108 as R108 was upset with CNA-T the next day. SW-P did not write out a statement after interviewing R108 about the incident on March 23,2026. SW-P informed Surveyor that SW-P learned about the incident of the breakfast tray being thrown at R108 after discussing with CNA-T the conversation CNA-T had with Surveyor yesterday. SW-P informed Surveyor that SW-P did not report the incident of the tray being thrown at R108 to either NHA-A or DON-B. SW-P stated SW-P would normally report something like that but did not because there was a lot going on and there was no morning meeting. On 4/14/26, at 11:49 AM, Surveyor spoke with NHA (Nursing Home Administrator)-A. NHA-A confirmed that NHA-A is the grievance officer and handles the investigations of abuse and neglect. NHA-A will delegate to the social workers to interview the residents. NHA-A does not recall being told about an allegation of abuse involving R108. NHA-A stated, there was so much going on in March with the survey, I don't remember much. Surveyor shared the concern that R108's allegation that CNA-V was rough with morning cares and threw the breakfast tray at R108 was reported to CNA-T who reported it LPN-U. CNA-T again reported the incident to SW-P. Surveyor shared the concern that both incidents were not investigated thoroughly. Surveyor shared that SW-P indicated a grievance had been completed in regard to CNA-V being rough with R108, but the facility grievance log does not document any grievance for R108 on March 23, 2026. Surveyor shared that CNA-V has been allowed to provide cares to residents with no investigation of the allegations of abuse involving R108. NHA-A confirmed that a thorough investigation should have started on 3/22/26, the day of the incident when CNA-T reported it to LPN-U. On 4/14/26, at 1:01 PM, Surveyor was not able to interview LPN-U. On 4/14/26, at 2:40 PM, NHA-A informed Surveyor that any sort of abuse or neglect concerns should be reported right away and agreed there was not follow-up with the incidents involving R108. NHA-A again confirmed that a thorough investigation should have been completed back when the incident occurred on March 22,2026. NHA-A stated the facility submitted an initial alleged misconduct report involving R108 and CNA-V has been removed from resident care areas. No additional information was provided as to why the facility did not complete a thorough investigation of R108's allegations of abuse as reported on March 22,2026.

Based on interview and record review, the facility did not ensure 2 (R102 and R109) of 4 residents reviewed for grievances had their grievances resolved.*A grievance filed for R102 on 11/13/25 documents R102 was not provided incontinence cares on day shift of 11/12/25. There is no documentation that the grievance was investigated and that steps were taken to investigate the grievance, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued and/or communicated to the resident and/or representative filing the grievance.* A grievance filed for R109 on 3/31/26 documents R109 was served a lunch tray with a fly on it and was not receiving a salad with lunch. There is no documentation that the grievance was investigated and the steps were taken to investigate the grievance, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued and/or communicated to the resident and/or representative filing the grievance.Findings Include:The facility's Grievance Policy implemented 10/1/25 documents: Policy: It is the policy of the facility to provide a system whereby residents, and/or their significant others or representatives, can voice concerns about the quality of services received at the facility.The facility will designate a Grievance Officer who 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; taking immediate action, as necessary, to prevent further potential violations of any resident right while the alleged violation is being investigated; immediate reporting of all alleged violations involving neglect, abuse, injuries of unknown source, misappropriation of resident property and/or exploitation; and taking appropriate corrective action in accordance with State law when indicated.Procedure:The Grievance Officer will route the grievance to the appropriate department head related to the grievance filed, and an investigation of the grievance will be conducted. Based on the nature of grievance, the Grievance Officer will initiate any additional interventions that are indicated at that time. The resident and/or resident's representative may be interviewed for additional information as needed. The Department Head or Grievance Officer may also question other members of the healthcare team that have been involved in the care of the residents. After thorough research has been conducted, the Department Head and/or Grievance Officer will work in tandem with staff identified as key individuals critical to problem resolution for the specific identified concern. All efforts will be made to effectively and expeditiously resolve the grievance.All grievances receive immediate priority and must be investigated with efforts made toward resolution within 7 days by either the facility Administrator or Director of Nursing (DON).The resident will be provided with a verbal or written print out of the concern from facility metrics Grievance log showing the follow up to their grievance including the following information:The name of the Department head who conducted the follow up/investigationThe steps taken to investigate and resolve the grievanceThe outcome of the grievance.1.) R102 was admitted to the facility on [DATE] with diagnoses of Unspecified Protein-Calorie Malnutrition, Severe (deficiency of both protein and energy), Hypoglycemia (blood sugar drops below normal levels), Adult Failure to Thrive(decline in overall health in older adults), Hypothyroidism (underactive thyroid), Thrombocytopenia(low number of platelets in the blood), Gastro-Esophageal Reflux Disease(stomach contents leak backward from stomach into the esophagus(food pipe), Chronic Kidney Disease(progressive damage and loss of function in the kidneys), and Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life).R102 discharged from the facility on 3/23/26. R102's significant change Minimum Data Set (MDS) completed 2/6/26 documents a Brief Interview for Mental Status (BIMS) score to be 15, indicating R102 is cognitively intact daily decision-making skills. The MDS documents that R102 was assessed for: R102 had no range of motion impairment; R102 was independent with eating, required set-up for showers and dressing, and required supervision for mobility and transfers.Surveyor reviewed all facility grievances from October 2025 to present. Surveyor noted that R102's representative filed a grievance on 11/13/25 documenting that R102 received no incontinence cares on day shift of 11/12/25. Documentation states that DON-B went and observed R102 and documented R102 was dry. There is no other documentation that the grievance was investigated including interviewing R102 and staff assigned to R102 on day shift of 11/12/25. Surveyor noted that the documented grievance states the grievance was reported on 11/13/25, but the resolved date is 11/12/25, one day prior to the grievance being reported. DON-B document that R102 was dry and comfortable on 1/5/26. Surveyor noted there is conflicting dates documented on the grievance form. There is no documentation of R102 and representative being informed of resolution and actions taken to prevent further concerns or grievances. On 04/14/26, at 11:55 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding the grievance process. NHA-A confirmed that NHA-A is the grievance officer. NHA-A explained that grievances are reviewed as an interdisciplinary team (IDT). NHA-A stated that if the department manager states the grievance was addressed and everything is good, then NHA-A will not complete any further review. Surveyor shared the concern that R102's grievances have no documentation that an investigation was completed, resolution was achieved, and steps taken to prevent further occurrences. Surveyor also shared that R102 and R102's representative were not notified of any resolution.No additional information was provided. 2.) R109 was admitted to the facility on [DATE] with diagnoses of Unspecified Protein-Calorie Malnutrition(deficiency of both protein and energy), Type 2 Diabetes Mellitus(adult onset of trouble controlling blood sugar), Hemiplegia and Hemiparesis Following Cerebral Infarction(complete paralysis on one side of body and partial/incomplete weakness on one side following stroke), Parkinson's Disease(disorder of the central nervous system that affects movement, often including tremors), Peripheral Vascular Disease(circulatory condition in which narrowed blood vessels reduce blood flow to limbs), and Atherosclerotic Heart Disease of the Native Coronary Artery(plaque buildup narrows the arteries that supply blood to the heart). R109 discharged from the facility on 4/8/26.R109's admission MDS completed 4/2/26 documents R109's BIMS (Brief Interview for Mental Status) score to be a 14, indicating R109 is cognitively intact for daily decision making. R109 had no range of motion impairment. R109's MDS also documents that R109 was independent for eating and required partial/moderate assistance for mobility and transfers.Surveyor reviewed all facility grievances from October 2025 to present. Surveyor noted there was grievance filed on 3/31/26 by R109 documenting that R109 received a lunch tray with a fly on it and not receiving a salad at lunch. The grievance documents that Dietary Manager (DM)-K discussed with R109 the concern and will receive a salad at lunch. There is no documentation that DM-K addressed the concern of the fly. On 4/13/26, at 2:43 PM, Surveyor interviewed DM-K regarding fly grievances. DM-K stated that DM-K was unable to speak with R109 because R109 was discharged the next day. DM-K stated that DM-K has not seen a fly herself but stated there may be flies because the steam table on the second floor is located right next to a door.DM-K provided documentation that stated: Received a concern from Social Worker (SW)-P that R109 had a fly in R109's food. The following day when DM-K was going to visit R109, R109 was discharged . I did, however, talk to my staff and informed them of the situation and told them to be more observant as we prepare food, especially because our location is in very close proximity to an outside entrance.Surveyor noted that R109 filed the grievance on 3/31/26, but was not discharged the next day on 4/1/26, but rather R109 was discharged on 4/8/26.On 4/14/26, at 11:19 AM, Surveyor interviewed Maintenance Director (MD)- N. MD-N stated that no one had informed the maintenance department that there was a fly issue. MD-N stated that pest control comes in monthly and when notified, will also address specific concerns.On 11/14/26, at 11:55 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding the grievance process. NHA-A confirmed that NHA-A is the grievance officer. NHA-A explained that grievances are reviewed as an interdisciplinary team (IDT). NHA-A stated that if the department manager states the grievance was addressed and everything is good, then NHA-A will not complete any further review. Surveyor shared the concern that R109's grievances have no documentation that an investigation was completed, resolution was achieved, and steps taken to prevent further occurrences. Surveyor also shared that R109 was not notified of any resolution.No additional information was provided.

Based on observation, interview, and record review the facility did not ensure that food was palatable, attractive and at a safe and appetizing temperature. This has the potential to affect 2 (R102 and R109) out of 5 residents receiving meals by the facility kitchen.*R102 was served peaches that appeared to be moldy and had a fly on R102's meal.*R109 filed a grievance documenting R109 received a lunch tray with a fly on it.Findings Include:The facility's undated Food Storage policy and procedure documents: Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. 1.) R102 was admitted to the facility on [DATE] with diagnoses of Unspecified Protein-Calorie Malnutrition, Severe (deficiency of both protein and energy), Hypoglycemia (blood sugar drops below normal levels), Adult Failure to Thrive(decline in overall health in older adults), Hypothyroidism (underactive thyroid), Thrombocytopenia(low number of platelets in the blood), Gastro-Esophageal Reflux Disease(stomach contents leak backward from stomach into the esophagus(food pipe), Chronic Kidney Disease(progressive damage and loss of function in the kidneys), and Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life). R102 discharged from the facility on 3/23/26. R102's significant change Minimum Data Set (MDS) completed 2/6/26 documents a Brief Interview for Mental Status (BIMS) score to be 15, indicating R102 demonstrated cognitively intact daily decision-making skills. R102's MDS also documents R102 was independent with eating.On 4/13/26, at 3:15 PM, Surveyor reviewed photographs of R102's food trays provided by Anonymous (AN)-L. Surveyor observed a picture of a bowl of peaches with what appeared to be white fuzzy mold on the peaches. Another picture shows a fly sitting on top of the mixed vegetables served on the plate. On 4/13/26, at 3:34 PM, Surveyor spoke with AN-L via telephone about the pictures. Surveyor asked AN-L how the pictures were obtained. AN-L stated that R102 took pictures of every meal and would send the pictures daily to AN-L. AN-L shared that Licensed Practical Nurse (LPN)-M found the mold on the peaches and informed R102 that R102 could not eat the peaches.On 4/14/26, at 11:37 AM, Surveyor interviewed LPN-M via telephone. LPN-M verified that LPN-M was in R102's room when R102's lunch tray was delivered. LPN-M observed what appeared to be white fuzzy mold on the peaches and observed some areas of green fungi mold on the peaches. LPN-M removed the peaches off of R102's tray right away and told R102, R102 could not eat the peaches. LPN-M stated, that is horrible to put something like that on a resident's tray.On 4/14/26, at 11:55 AM, Surveyor spoke with Nursing Home Administrator (NHA)-A in regard to the concern about potential mold on R102's peaches and the concern about R102 having flies on their food. NHA-A does not recall being informed about mold or a fly concern. NHA-A shared that the facility has been working a lot on dietary and service. Surveyor shared that R102 was served food that was not attractive and palatable. No additional information was provided. 2.) R109 was admitted to the facility on [DATE] with diagnoses of Unspecified Protein-Calorie Malnutrition(deficiency of both protein and energy), Type 2 Diabetes Mellitus(adult onset of trouble controlling blood sugar), Hemiplegia and Hemiparesis Following Cerebral Infarction(complete paralysis on one side of body and partial/incomplete weakness on one side following stroke), Parkinson's Disease(disorder of the central nervous system that affects movement, often including tremors), Peripheral Vascular Disease(circulatory condition in which narrowed blood vessels reduce blood flow to limbs), and Atherosclerotic Heart Disease of the Native Coronary Artery(plaque buildup narrows the arteries that supply blood to the heart). R109 discharged from the facility on 4/8/26. R109's admission MDS completed 4/2/26 documents R109's BIMS score to be a 14, indicating R109 is cognitively intact for daily decision making. Surveyor reviewed all facility grievances from October 2025 to present. Surveyor noted that there was grievance filed on 3/31/26 by R109 documenting that R109 received a lunch tray with a fly on it. The grievance documents that Dietary Manager (DM)-K discussed with R109 the concern. There is no documentation that DM-K addressed the concern of the fly. On 4/13/26, at 2:43 PM, Surveyor interviewed DM-K in regards the concern about the fly. DM-K stated that DM-K was unable to speak with R109 because R109 was discharged the next day. DM-K stated that DM-K has not seen a fly herself but stated there may be flies because the steam table on the second floor is located right next to a door. DM-K provided documentation that stated: Received a concern from Social Worker (SW)-P that R109 had a fly in R109's food. The following day when I was going to visit R109, R109 was discharged . I did however, talk to my staff and informed them of the situation and told them to be more observant as we prepare food, especially because our location is in very close proximity to an outside entrance.Surveyor noted that R109 filed the grievance on 3/31/26, but was not discharged the next day on 4/1/26, but rather R109 was discharged on 4/8/26.On 4/14/26, at 11:19 AM, Surveyor interviewed Maintenance Director (MD)- N. MD-N stated that no one had informed the maintenance department that there was a fly issue. MD-N stated that pest control comes in monthly and when notified, will also address specific concerns.On 4/14/26, at 11:55 AM, Surveyor spoke with Nursing Home Administrator (NHA)-A regarding R109 having flies on their food. NHA-A does not recall being informed about a fly concern. NHA-A shared that the facility has been working a lot on dietary and service. Surveyor shared that R109 was served food that was not attractive and palatable. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure the accurate and safe administration of medication for 1 (R68) of 7 residents reviewed for medication administration.*Surveyor observed Medication Technician (MT)-J deliver R68 an afternoon medication. MT-J left the medication on R68's bedside table and exited R68's room. R68 did not have a self-administration of medication assessment completed, did not have a physician's order to self-administer medication and did not have a care plan regarding self-administration of medication.Findings include:The facility's policy dated 1/1/26 and titled, Medication Administration, documents: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice. Review [Medication Administration Record (MAR)] to identify medications to be administered. Remove medication from source. Administer medication as ordered in accordance with manufacturer specifications. Crush medications as ordered. Observe resident consumption of medication unless otherwise specified in order.R68 was admitted to the facility on [DATE] with diagnosis that includes Diabetes, Autoimmune thyroiditis (Chronic condition where the immune system attacks the thyroid gland), Hypertension (high blood pressure), Chronic kidney disease, Dementia, and Depression.R68's admission Minimum Data Set (MDS) assessment dated [DATE] documents R68 is cognitively intact.R68's physician order with a start date of 2/14/26 documents: Cholecalciferol Tablet 1000 UNIT. Give 1 tablet by mouth in the evening for [chronic kidney disease] supplement.On 4/13/26 at 2:38 PM, Surveyor observed MT-J administering medications. MT-J started to prepare R68's medication. MT-J put R68's Cholecalciferol tablet in a medication cup. MT-J informed Surveyor that R68 prefers medications crushed and in applesauce. MT-J crushed R68's medication, put applesauce in a small medication cup and mixed in R68's Cholecalciferol.On 4/13/26 at 2:42 PM, MT-J entered R68's room. MT-J informed R68 that MT-J had R68's medication. MT-J placed a glass of water and the small medication cup with applesauce and Cholecalciferol on R68's bedside table. MT-J then exited R68's room. Surveyor asked MT-J if it is ok to leave R68's medication on the bedside table. MT-J stated that R68 can take it by R68's self. MT-J stated if you stay until the medication is gone, residents will start talking and you will not be able to leave. If a resident is not with it, MT-J will stay until the medication is gone, but MT-J stated again that R68 can do it themselves.On 4/13/26 t 2:54 PM and at 3:01 PM, Surveyor observed R68's applesauce and Cholecalciferol still sitting on R68's bedside table and not consumed.On 4/13/26 at 11:40 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-O. Surveyor asked if facility staff leave medications on resident's bedside table. LPN-O stated that there are residents who have been assessed to self-administer medications. LPN-O stated that they have permission from the physician to self-administer, and if it is in the resident's care plan. LPN-O stated that other than that, staff should not leave medications on bedside table. LPN-O indicated that it is the facility policy to be in the resident's room and watch until the medication is consumed.Surveyor reviewed R68's medical record and did not find a physician order, an assessment or a care plan regarding self-administration of medication.On 4/14/26 at 11:55 AM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked if R68 can self-administer medication. DON-B stated that DON-B would check. Surveyor asked what facility staff need to complete for residents to self-administer medications. DON-B stated that the residents need a self-administration assessment and care plan that would document what medications can be self-administered. Surveyor asked if facility staff are allowed to leave medications on resident's bedside table. DON-B stated if they have a physician order for that, staff can leave it, but if there is no physician order they should not leave it on the bedside table. DON-B informed Surveyor that DON-B did not see an order or documentation that R68 can self-administer medications. Surveyor informed DON-B of the concern that MT-J was observed leaving R68's applesauce and crushed Cholecalciferol on R68's bedside table during MT-J's medication pass. In addition, MT-J informed Surveyor that R68 can take it by R68's self. On 4/14/26 at 3:17 PM, Surveyor informed Nursing Home Administrator (NHA)-A, DON-B, Director of Operations-C and Regional Nurse-D of the above concern. No additional information was provided.

Based on observation, interview and record review, the facility did not ensure 2 (R96 & R19) of 6 sampled residents had adequate supervision to prevent accidents. *R96 had an unwitnessed fall on 10/19/25 and was diagnosed with a right hip fracture. R96 had care plan interventions to wear hip protectors and to be in high traffic areas in line of sight of nursing staff to prevent falls. The facility did not provide any evidence that these interventions were in place at the time of R96's fall on 10/19/25. The facility did not conduct thorough investigations of R96's falls on 9/22/25, 10/4/25, 10/18/25, and 10/19/25. *R19 is a smoker, the facility lacked ongoing smoking supervision and assessments. Findings include: The facility policy titled Fall Policy with implemented date 2/11/25 and reviewed/revised date 1/2/26 documents: .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. an individualized care plan will be implemented according to the risk factors identified on the fall assessment tool. interventions will be monitored for effectiveness and reviewed/revised following a fall event, quarterly, annually and with significant change or as needed. potential fall interventions . purposeful staff rounding . proper seating if in wheelchair – feet flat on the floor, lowering the back of the seat, etc. ensure proper footwear . hip protectors . helmets if applicable . increased observation . room closer to nursing station . toileting program: scheduled, cueing . increased activities . 1:1 supervision . provide high back chairs . hourly rounding for the 4 P's: Pain, Potty, Personal Items, Positioning . When any resident experiences a fall, the following will result: . complete a post-fall investigation which may include witness statements as applicable. complete an incident report. document all assessments and actions. complete a root cause analysis (RCA) with IDT (interdisciplinary team) Team and update the plan of care based on RCA. R96 was admitted to facility on 5/27/25 with diagnoses including nontraumatic subarachnoid hemorrhage (bleeding in the fluid-filled space surrounding the brain), seizures, cognitive communication deficit, difficulty in walking, weakness, and unspecified lack of coordination, generalized anxiety. R96's admission Minimum Data Set (MDS) dated [DATE] documents R96 has short- and long-term memory problems, fluctuating inattention behavior, fluctuating altered level of consciousness, and R96 is dependent with bed mobility and transfers. The MDS documents R96 had a fall in the last month prior to admission and R96 had a fall in the last 2-6 months prior to admission. R96's falls Care Area Assessment (CAA) was triggered, but no rationale regarding care planning was documented in the CAA. R96's risk for falls assessment dated [DATE] documents a score of 14, indicating R96 is at high risk for falls. On 3/10/26 at 3:05 PM, Nursing Home Administrator (NHA)-A stated the facility changed electronic health records (EHR) systems on 8/1/25, and the facility does not have access to any documentation prior to 8/1/25. R96's risk for falls care plan was initiated 8/1/25 with the following interventions: -bed in lowest position (initiated 8/1/25)-bolster mattress (initiated 8/1/25)-fall mats on both sides of bed (initiated 8/1/25)-keep commonly used items within reach (initiated 8/1/25)-soft touch call light (initiated 8/1/25)-encourage resident to be in high traffic areas when awake (initiated 8/17/25)-room move to third floor (initiated 9/2/25)-high back reclining wheelchair (initiated 9/3/25) R96's care plan for activities of daily living (ADL) self-care performance documents the following interventions initiated 8/2/25:-bed mobility: the resident is maximum assistance of 1 staff for repositioning and turning in bed and as necessary-toilet use: the resident requires maximum assistance by 1 staff for toileting-transfer: the resident is maximum assistance of 1 staff for transferring R96's care plan for delirium documents the following intervention initiated 8/5/25:-provide appropriate level of supervision or surveillance to monitor resident and allow for therapeutic actions as needed A nurse's note in R96's EHR dated 9/11/25 at 11:50 PM documents [R96] had a witnessed fall at 7:30 PM in front of the dining room next to the medication cart. [R96] is highly anxious and confused, continuously attempting to get out of the wheelchair. [R96] would benefit from 1:1 (one on one) staff. A progress note in R96's EHR dated 9/22/25 at 2:35 PM documents [R96] yelling for help in bedroom. Upon entering bedroom, [R96] was found lying on right side on the floor mat. [R96] complained of pain to right hip and lower back. NP updated, new order received to send [R96] out to the hospital. [R96] was transported to the hospital at approximately 9:00 AM. A progress note in R96's EHR dated 9/22/25 at 3:57 PM documents [R96] returned to the facility from the emergency room (ER) without any evidence of findings. No new injury noted. The notes section of the fall investigation for 9/22/25 documents IDT (Interdisciplinary Team) met and reviewed the fall incident. [R96] stated [R96] was trying to self-transfer and [R96] was found lying on the floor mat with a blanket. Surveyor notes there is no documentation regarding the last time R96 was rounded on by staff or offered toileting or why R96 was not in a high traffic area per R96's care plan. R96's risk for falls care plan documents the following interventions initiated 9/22/25:-offer toileting upon rising, before and after meals, and at bedtime, and NOC (night shift) rounding times-prompted and purposeful rounding (pain, potty, positioning, and possessions) A progress note in R96's EHR dated 10/4/25 at 3:17 PM documents [R96] laying on hallway floor in prone (on stomach) position. Hematoma noted on right side of the frontal lobe. New order received to send R96 to the hospital. Surveyor notes there is no documentation regarding the last time R96 was rounded on by staff, offered toileting or who was observing in the high traffic area. A progress note in R96's EHR dated 10/4/25 at 5:54 PM documents [R96] returned from ER, no changes. A progress note written by NP-Y dated 10/6/25 at 8:45 AM documents [R96] had another fall over the weekend, fortunately without injuries. Memory retention remains limited, requires frequent redirection throughout the day. continues to require close monitoring for safety due to cognitive impairment and fall risk. Generalized Anxiety Disorder: continue non-pharmacological interventions including redirection and environmental modifications to reduce anxiety triggers. Repeated falls: multifactorial fall risk continues with cognitive impairment, medication side effects, and generalized weakness. Maintaining fall precautions including Broda chair for positioning. On 3/11/26 at 2:00 PM, Surveyor placed a phone call to NP-Y but was unable to leave a voicemail to return Surveyor's phone call. On 3/12/26 at 8:57 AM, Surveyor placed a phone call to NP-Y and left a voicemail to return Surveyor's call. At the time of this write up, Surveyor did not receive a return phone call from NP-Y. R96's care plan for focus area The resident has a behavior problem (specify behavior; yells/calling out, anxious, impulsive) . was initiated on 10/6/25 with the following interventions:-administer medications as ordered. Monitor/document for side effects and effectiveness -anticipate and meet the resident's needs-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-monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes-provide interventions to redirect triggered behavior such as 1 on 1, encourage to attend activities, return to room, toilet, offer food/snack(s), offer fluids, change position, adjust room temperature, offer back rub to aid comfort R96's risk for falls care plan documents the following interventions:-resident to wear helmet at all times (initiated 10/10/25)-resident to wear hip protectors (initiated 10/13/25) R96's care plan for focus area The resident is resistive to care (refuses to wear helmet) . was initiated 10/13/25 with the following interventions:-allow the resident to make decisions about treatment regime to provide sense of control-give clear explanation of all care activities prior to and as they occur during each contact-if resident refuses, reassure resident, leave and return 5-10 minutes later and try again-praise the resident when behavior is appropriate R96's Treatment Administration Record (TAR) for dates 10/1/25-10/31/25 documents resident to wear helmet at all times, every shift, start date 10/10/25. The TAR documents a checkmark for day, evening, night shift on all dates 10/10/25-10/18/25 and day shift 10/19/25. A checkmark on the TAR is to mean the treatment was administered. Surveyor notes no documentation on the October TAR that R96 refused to wear the helmet. Surveyor notes there is no care plan regarding R96 refusing to wear hip protectors. Surveyor notes between the dates of 9/1/25-10/13/25, R96 had 10 falls which did not result in major injury. A progress note in R96's EHR dated 10/16/25 at 12:34 AM documents [R96] yelling, screaming out, attempts to redirect resident unsuccessful. At about midnight, [R96] became aggressive, hitting staff, very agitated, tried throwing self to the floor. Staff lowered [R96] to the floor after multiple attempts of redirection. Obtained order to send to ER for evaluation. The fall investigation dated 10/16/25 documents no injuries observed at the time of incident or after the incident, and R96 had no pain. The notes section in the fall investigation dated 10/16/25 documents [R96] impulsive and goal is to prevent major injury. [R96] returned to facility with UTI (Urinary Tract Infection) diagnosis. Surveyor notes the fall investigation dated 10/16/25 does not document if R96 was wearing a helmet and hip protectors at the time of the fall per R96's care plan. R96's risk for falls assessment dated [DATE] documents a score of 16, indicating R96 is at high risk for falls. A post-fall investigation form dated 10/18/25 documents R96 had a witnessed fall on 10/18/25 at 10:04 AM. The witness statement documents went to change resident, went to grab towels, came back and resident was on floor. Surveyor was unable to locate a progress note in R96's EHR regarding this fall on 10/18/25. Surveyor notes the post-fall investigation form dated 10/18/25 does not document if R96 sustained any injuries or complained of any pain after the fall, or if R96 was wearing a helmet and hip protectors at the time of the fall per R96's care plan. Surveyor was unable to locate IDT notes documenting a root cause analysis or assessment of appropriateness of fall interventions. A progress note in R96's EHR dated 10/19/25 at 6:55 AM documents [R96] complaining of pain at right hip/bottom area while in dining room. NP was updated and order obtained for an x-ray on the right hip. A progress note in R96's EHR dated 10/19/25 at 11:56 AM documents [R96] had a fall in the dining room, complained of pain and discomfort, facial grimacing noted. [R96] became tachycardic (fast heart beat) and wished to be sent to the hospital as [R96] became more anxious. [R96's] right hip/leg is the area of concern; however, nurse could not conduct a proper evaluation of the extent of the injury. Primary physician contacted and agreed resident should be sent to the hospital for further evaluation. Surveyor notes the fall on 10/19/25 occurred prior to the facility obtaining an x-ray on R96's right hip. The hospital history and physical (H&P) dated 10/19/25 documents under the assessment section [R96] was sent to the hospital from [nursing facility] after mechanical fall. Per the nursing home [R96] had an unwitnessed fall in the dining room. X-ray of the hip was notable for right impacted subcaptial fracture (a stable hip fracture where the ball of the hip joint is broken and forced into the neck of the thigh bone). [R96] is being admitted to hospital for further management. The hospital Discharge summary dated [DATE] documents right subcapital fracture: evaluated by orthopedics and palliative care. No plans for operative intervention. Continue pain control . goals of care were discussed, and plan is for comfort focused care. [R96] will return to [nursing facility] with hospice later today. Condition at discharge: stable. Surveyor was unable to locate a fall investigation regarding the fall in the dining room on 10/19/25 in R96's EHR. On 3/12/26 at 11:11 AM, NHA-A, Director of Nursing (DON)-B, Director of Operations-C, and Regional Nurse Consultant-D informed Surveyor that the facility did not have a fall investigation for R96's fall on 10/19/25. NHA-A, DON-B, Director of Operations-C and Regional Nurse Consultant-D confirmed no additional information is available regarding the last time R96 was rounded on or offered toileting prior to the fall. Director of Operations-C stated no documentation can be found if R96 was wearing hip protectors per R96's care plan at the time of the fall. Surveyor asked if R96 was in a high back wheelchair or Broda chair on 10/19/25, and NHA-A stated NHA-A will look into it. On 3/12/26 at 12:16 PM, NHA-A and DON-B informed Surveyor R96 was in a high back wheelchair at the time of the fall on 10/19/25. NHA-A and DON-B stated since R96 was in the dining room prior to lunch, R96's wheelchair would have been in an upright position and there is no indication the high back wheelchair would have been tilted back. Surveyor requested the manufacturer guidelines for R96's high back wheelchair, and NHA-A and DON-B stated they would try to locate it. On 3/12/26 at 12:25 PM, Surveyor interviewed Director of Rehabilitation (DOR)-W who stated therapy staff assists the facility to assess if a resident would be appropriate for a high back wheelchair. DOR-W stated a high back wheelchair would typically be indicated for a resident with poor trunk support or for pressure relief. Surveyor asked DOR-W if it would be possible for a resident to fall out of a high back wheelchair if the wheelchair were in an upright position, and DOR-W responded yes. On 3/12/26 at 1:32 PM, NHA-A informed Surveyor that manufacturer guidelines for the high back wheelchair R96 was using at the time of R96's fall on 10/19/25 were unable to be located. A progress note in R96's EHR dated 10/21/25 at 7:41 PM documents [R96] readmitted to the facility at 4:00 PM with diagnosis of hip fracture. [R96] admitted on to hospice services. Surveyor notes between the dates of 10/21/25-12/18/25, R96 had an additional 6 falls that did not result in major injury or hospitalization. R96 passed away on hospice services on 2/10/26. On 3/11/26 at 3:18 PM, Surveyor interviewed certified nursing assistant (CNA)-AA who has worked in the facility since September 2025. CNA-AA recalled working with R96 and stated R96 needed a lot of assistance for ADLs (Activities of Daily Living) and transfers and was a fall risk. CNA-AA stated R96 had fall mats in place and wore a helmet, and staff tried to keep R96 in supervised areas. CNA-AA stated R96 was not very cooperative and was difficult to redirect, R96 would try to get up independently and fall. CNA-AA stated R96 needed to be supervised 24/7 but the facility was not able to do that. On 3/12/26 at 9:06 AM, Surveyor interviewed licensed practical nurse (LPN) supervisor-I who recalled working with R96. LPN supervisor-I stated R96 never seemed comfortable at the facility and would get up out of the wheelchair even if a staff member was right next to R96. LPN supervisor-I stated the facility did talk about having 1 on 1 supervision for R96 but it was never implemented because the facility did not have the staff availability to do that. LPN supervisor-I stated the nursing staff tried to supervise R96 throughout the day as much as possible, but nursing staff gets pulled in many different directions throughout the day, so that was not always able to be provided. In an interview on 3/12/26 at 10:03 AM, DON-B stated R96 was not safe to walk and used a wheelchair, was easily agitated, and impulsive. DON-B stated a care plan was in place for R96 to be in high traffic areas in line of sight, and nurses would take turns watching R96 throughout their shifts. Surveyor shared concern with NHA-A, DON-B, Director of Operations-C and Regional Nurse Consultant-D that R96 sustained an unwitnessed fall on 10/19/25 and was found to have a right hip fracture when R96 was admitted to the hospital. NHA-A, DON-B, Director of Operations-C and Regional Nurse Consultant-D did not provide any additional information regarding if R96 was in the line of sight of nursing staff at the time of the fall per R96's fall care plan or if 1 on 1 assistance was provided at the time of the fall to redirect R96's triggered behaviors of anxiousness and impulsiveness per R96's behavior care plan. Surveyor shared concern with NHA-A, DON-B, Director of Operations-C and Regional Nurse Consultant-D regarding incomplete fall investigations on 9/22/25, 10/4/25, 10/18/25, and 10/19/25. No additional information was provided. 2.) The facility's policy and procedure titled, (name of facility) Resident Smoking, implemented 2/1/26 documents in part: Policy: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and nonsmoking residents. Policy Explanation and Compliance Guidelines: 7. Residents will be asked about tobacco use during the admission process, and during each quarterly comprehensive MDS assessment process and on an as needed basis. 8. Residents who smoke will be further assessed, using the Smoking Assessment, to determine whether resident is safe to smoke at all. 10. Any resident who is deemed safe to smoke will be allowed to smoke in designated smoking areas (weather permitting) and in accordance with his/her care plan. 11. If a resident who smokes experiences any decline in condition or cognition, he/she will be reassessed by the clinical team for the ability to smoke independently and/or to evaluate whether any additional safety measures are indicated. 12. If residents are found to be unsafe with smoking/vaping/chewing materials then smoking/vaping/chewing privileges will be evaluated by clinical team. 13. If a resident demonstrates noncompliance with this policy, he/she will receive re-direction and counseling interventions. Noncompliance may result in the discharge from the facility (30 Day discharge). Conduct that threatens and/or offends the health, safety, and welfare of others and/or interferes with the professional management of the facility will jeopardize the resident's placement at this health care facility and may result in an immediate discharge. 14. The following actions that will be considered unsafe practice by residents who smoke are.: h. Any reasonable action that would be deemed unsafe to self or others by a reasonable process. On the last page of the policy is the statement I have read and agree with all components and consequences outlined in this document. Followed by lines to be completed for Resident Name/Date, Resident Signature, Witness Signature/Date. R19 was admitted to the facility on [DATE]. with pertinent diagnoses that include delirium (an acute, fluctuating disturbance in attention, awareness, and cognition that develops rapidly (hours to days), often caused by underlying medical conditions, infections, or medication side effects), dementia (a syndrome that can be caused by a number of diseases which over time destroy nerve cells and damage the brain, typically leading to deterioration in cognitive function (i.e. the ability to process thought) beyond what might be expected from the usual consequences of biological ageing), and cognitive communication deficit (difficulty with communication that stems from impaired thinking skills, such as memory, attention, and problem-solving, rather than from physical speech problems). R19's Medicare 5 day Minimum Data Set (MDS) with an assessment reference date of 1/8/26 documented R19 had a Brief Interview for Mental Status score of 10 (moderate cognitive impairment). R19 has an activated Power of Attorney. R19 is documented to be understood and understands others. During the look back period of the MDS no behaviors were exhibited by R19. R19's care plan tobacco use initiated on 1/12/2026, has the following interventions: Conduct smoking safety evaluation on admission and PRN (as needed). Date Initiated: 1/12/2026 Educate resident/responsible party on the facility's tobacco/smoking policy(s). Date Initiated: 1/12/2026 Monitor resident's oral hygiene. Date Initiated: 1/12/2026 R19's care plan the resident is a smoker/vapes initiated on 1/12/2026, has the following interventions: Declines a smoking cessation patch. Date Initiated: 1/25/2026 Instruct resident about smoking/vaping risks and hazards and about smoking cessation aids that are available. Date Initiated: 1/12/2026 Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Date Initiated: 1/12/2026 Observe clothing and skin for signs of cigarette burns. Date Initiated: 1/12/2026 R19's care plan the resident has a behavior problem (noncompliant with smoking policy) initiated on 1/25/2026, has the following interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 1/25/2026 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. Date Initiated: 1/25/2026 Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Date Initiated: 1/25/2026 Surveyor noted the tobacco use and the resident is a smoker/vapes care plans were initiated on 1/12/26. Neither address R19's ability to smoke independently or where smoking materials will be stored. On 1/12/26, the form Smoking Evaluation was completed for R19. Under the Planning and Interventions section: -Intervention: The resident can smoke UNSUPERVISED -Intervention: The resident is able to: (SPECIFY light own cigarette, keep lighter at bedside .) -Intervention: The resident's smoking supplies are stored (SPECIFY). Surveyor noted two of the interventions were not completed to reflect the plan of care for R19. R19's progress note written on 1/25/2026, at 07:52 AM, documents Upon entering resident's room this AM, room heavily smelled of cigarette smoke. Asked resident if he had been smoking in his room, resident denied smoking in his room. Cigarette smell wafted down B hallway. Staff attempted to spray air freshener in the hallway with no success in removing smell. R19's progress note written on 1/25/2026, at 10:17 AM, documents Reeducated resident on importance of only smoking outside as oxygen is in use in the area and could cause an explosion and a fire could start. Educated resident that there are resident's with asthma and lung issues that are intolerant to the smoke as his window does not open to allow ventilation. Writer offered to talk to the doctor about getting a nicotine patch for resident, if the cold was the reason he began to smoke in his room. Resident stated, I don't know about that. I just love smoking so much. Writer was able to convince resident to go outside to smoke for safety. R19's progress note written on 1/25/2026, at 11:17 AM, documents Per Assistant Director of Nursing (ADON)-G, started physical paper of safety checks every 30 minutes during day shift and 15 minutes NOC (night shift). Paper at nurses station to be placed under DON (Director of Nursing) office door upon shift completion. Facility provided document regarding the 1/25/26 smoking in room issue. The Incident Description documents Per (name of), started physical paper of safety checks every 30 minutes during day shift and 15 minutes NOC. Paper at nurses station to be placed under DON office door upon shift completion. Reeducated resident on importance of only smoking outside as oxygen is in use in the area and could cause an explosion and a fire could start. Educated resident that there are resident's with asthma and lung issues that are intolerant to the smoke as his window does not open to allow ventilation. Writer offered to talk to the doctor about getting a nicotine patch for resident, if the cold was the reason he began to smoke in his room. Resident stated, I don't know about that. I just love smoking so much. Writer was able to convince resident to go outside to smoke for safety. The Resident Description documents Resident denied smoking. Denied having lighter or smoking materials. The Immediate Action Taken documents Reeducated resident on smoking policy, completed smoking assessment, MDS Coordinator met with resident same day reeducated on smoking rules and asked if we could keep smoking materials in med cart. Resident denied having any smoking materials. Offered nicotine patch. Safety checks initiated when resident returned to building. The notes section documents on 1/26/26, IDT (interdisciplinary team) met to review incident regarding alleged smoking in resident room. Resident was not witnessed smoking in room nor does he have his own smoking materials. Staff completed smoking assessment deeming safe to smoke 1/25. Resident reeducated on smoking policy. Social Services met with resident 1/26 to review smoking policy. Safety checks were initiated to ensure resident compliant with smoking policy. Resident went out with sister after incident and safety checks initiated around 1900 (7pm) when resident returned. Doctor met with resident, resident denied smoking in room, Doctor offered nicotine patch and resident declined. Surveyor noted the Immediate Action Taken documents Reeducated resident on smoking policy, the smoking policy has a signature section on the last page and this was not provided as documentation that the policy had been reviewed with R19. Surveyor noted on 1/25/26, R19 allegedly smoked in room, the the resident has a behavior problem (noncompliant with smoking policy) care plan was added. No interventions directly related to smoking or materials were added. On the the resident is a smoker/vapes care plan an intervention was added declines a smoking cessation patch. On 1/25/26, the form Smoking Evaluation was completed again, after R19 allegedly smoked in room. The Smoking Related Incidents section documents Is the resident free of smoking/e-cigarette/vaping related incidents? No is selected. The next question If no: the reason Smoking in unauthorized areas is selected. The Instructions section documents A response of no to any of the questions above indicates the need for implementation of interventions to safely accommodate the resident's desire to smoke. Surveyor noted no new interventions were selected. The same were selected as on the 1/12/26 evaluation. R19's progress note written on 1/29/2026, at 3:48 PM, documents Staff CNA (Certified Nursing Assistant) reported to writer that resident is smoking in the room. Writer went to resident room and found resident sitting near the window with smoke ash all over the room floor, the room and hallway smell cigarette smoke. Writer sent for ADON-G, and he came in to the room immediately and asked the resident if he was smoking? Resident answer No. ADON-G asked again do you have a lighter? Resident answer Yes. ADON-G asked again how many lighters? Resident answer Two. ADON-G pleaded with resident if he can have the lighter back. Resident finally gave the lighters to ADON-G. R19's progress note written on 1/29/2026, at 5:21 PM, documents During a routine 30-minute safety check, writer was called to the resident's room due to a strong odor of smoke that was noticeable both inside the room and lingering in the hallway. Upon initial inquiry, the resident denied smoking. Following further discussion, the resident did surrender two lighters to the writer these items along with the cigarettes (which were already in staff possession), were secured in the locked medication cart. It remains unclear how the resident obtained the additional lighter or the cigarette used during the incident Education was provided to the resident regarding facility policy emphasizing that smoking is strictly prohibited on the premises and represents a significant fire and safety hazard. The resident voiced understanding and stated he agreed with the safety requirements. Social Services has been notified of the incident. Safety checks will continue as scheduled to ensure ongoing compliance and a safe environment. Surveyor noted no care plan intervention was initiated for storing R19's smoking materials, this was the second time R19 allegedly smoked in room. This time it was documented that smoke ash was all over the room floor. R19's progress note written on 1/29/2026, at 5:44 PM, documents Writer spoke with POA (Power of Attorney) and shared that it was believed that R19 was smoking in his room. POA shared she would most certainly speak to her dad and apologized. Facility provided document regarding the 1/29/26 smoking in room issue. The Incident Description documents During a routine 30-minute safety check, writer was called to the resident's room due to a strong odor of smoke that was noticeable both inside the room and lingering in the hallway. Upon initial inquiry, the resident denied smoking. Following further discussion, the resident did surrender two lighters to the writer these items along with the cigarettes (which were already in staff possession), were secured in the locked medication cart. It remains unclear how the resident obtained the additional lighter or the cigarette used during the incident. Education was provided to the resident regarding facility policy emphasizing that smoking is strictly prohibited on the premises and represents a significant fire and safety hazard. The resident voiced understanding and stated he agreed with the safety requirements. Social Services has been notified of the incident. Safety checks will continue as scheduled to ensure ongoing compliance and a safe environment. The Resident Descri

Based on observation and interview, the facility did not ensure food was stored, prepared and served in a sanitary manner in accordance with professional standards for food safety requirements. *Dietary staff was observed with no a hair net or beard/mustache guard in food preparation areas. *Observations of no labeling, dating or use by date for opened food items located in the cooler and freezer. *An ice scoop was observed resting inside of the ice bucket touching the ice on the third-floor dining area. This deficient practice has the potential to affect residents residing on the third floor of the facility who receive ice in their water. This deficient practice has the potential to affect 87 out of 88 residents whom receive food from the main kitchen in the facility. Findings include: The Facility Policy titled, Nutrition Care, updated 11/06/25, documents: 4.3 Label and Dating. Policy: All RTE (Ready to Eat) and TCS (Time/Temperature Control for Safety) foods stored greater than 24 hours must be labeled and date-marked per FDA (Federal Drug Administration) Food Code 3-501.17 and Wisconsin Food Code. Purpose: To prevent the use of expired, spoiled, or contaminated product from being used, thus, preventing the potential of hazardous food going into circulation. Procedure: 1. Label with product name, open/prep date or discard date and initials. 2. Day 1 is day prepared/opened. 3. Discard date must be on product. Consult storage chart for shelf life. 3 days for prepped items, 7 days from open for dairy and premade products, and single day for anything on units or down hallways. 4. Manufacturer use-by cannot be exceeded. 5. Responsibility: Dietary staff; oversight by FSD (Food Service Director). Documentation: Date-marking logs. Documentation: Date and covered refrigerator log. 4.4 Hair Restraints and Staff attire. Policy: Staff must wear hairnets/hair restraints, clean uniforms, non-slip shoes, and minimize jewelry. Purpose: Prevent contamination and comply with hygiene standards. Procedure: Hair fully covered; beard guards as needed; clean apron; no artificial nails in prep areas. Responsibility: Dietary staff and manager. Documentation: Hygiene audits. Documentation: Daily Quality Walkthrough done by management or leadership team.Infection Prevention and Emergency Preparedness. 5.1 Food Service: Infection Control: Policy: Food service operations follow infection control practices aligned with CMS F812/F880. Purpose: to prevent cross-contamination and infection transmission. Procedure: Follow hand hygiene, PPE use for isolation trays, sanitize surfaces, avoid bare-hand contact with RTE foods, Date and label food, report any incidents to your manager, and completing annual and item specific educations staying up to date. Documentation: Daily Quality Walkthrough done by management and leadership team. 1.) On 3/9/26 at 8:20 AM, Surveyor completed an initial tour of the kitchen. Surveyor observed the following: Dishwasher-Q was walking through food preparation area pushing a cart without a hair net or beard/mustache guard. Dishwasher-Q donned a hairnet at 8:27 AM but no beard guard. Dietary Aide-R was observed prepping food and not wearing a mustache guard. Surveyor noted that Dishwasher-Q and Dietary Aide-R have facial hair and both were observed not wearing beard/mustache guards while in food preparation areas. On 3/9/26 at 8:31 AM, Surveyor observed the following in the produce cooler: sweet potatoes, green peppers, cucumbers, carrots, green cabbage, romaine lettuce, bread, coleslaw dressing and milk were opened and not labeled with a use by date. Surveyor observed the following in the freezer: Chicken quarters, cut chicken, hot dogs, naan bread and tortilla shells were opened and not labeled with a use by date. On 3/9/26 at 8:37 AM, Surveyor asked Kitchen Supervisor-S if the facility's practice is to label all food items if not already labeled by supplier. Kitchen Supervisor-S stated yes. Surveyor asked if the product is open, if it is the facility's practice to date the container or box. Kitchen Supervisor-S stated yes. Kitchen Supervisor-S acknowledged many food items were either not dated, initialed or sealed after opening and Kitchen Supervisor-S stated dating, labeling and sealing will occur immediately. Surveyor asked Kitchen Supervisor-S if it's the facility's policy to cover hair, including facial hair while in the kitchen. Kitchen Supervisor-S stated, all people in kitchen need to wear hair nets or facial hair restraints. On 3/12/26 at 9:38 AM, Surveyor notified Nursing Home Administrator (NHA)-A, Director of Operations (Director of Ops)-C, and Nurse Consultant-D of observations made of cooler and freezer items not dated or initialed once opened and observations of two dietary staff members not wearing the appropriate hair nets and/or beard/mustache guards while in food preparation areas. No additional information was provided. 2.) The Wisconsin Food Code, dated November 2024, documents: In-Use Utensils, Between-Use Storage . during pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: . in a clean, protected location if the utensils, such as ice scoops, are used only with a food that is not time/temperature control for safety food; On 3/10/26 at 9:00 AM, Surveyor observed a bucket of ice resting on a counter in the third-floor dining area with the ice scoop resting inside of the ice bucket touching the ice. On 3/10/26 at 12:50 PM, Surveyor observed a bucket of ice resting on a counter in the third-floor dining area with the ice scoop resting inside of the ice bucket touching the ice. On 3/11/26 at 9:30 AM, Surveyor observed a bucket of ice resting on a counter in the third-floor dining area with the ice scoop resting inside of the ice bucket touching the ice. On 3/11/26 at 9:36 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-M regarding what the ice in the dining area is used for. CNA-M stated it is used for filling up resident water cups. CNA-M stated the kitchen staff brings up the ice bucket daily for nursing staff to utilize. CNA-M stated the ice scoop is always inside of the ice bucket. On 3/11/26 at 9:40 AM, Surveyor interviewed Regional Culinary Manager-N. Regional Culinary Manager-N stated the facility follows the Wisconsin Food Code. Regional Culinary Manager-N stated ice is brought to the third-floor dining area from the main kitchen daily for nursing staff to utilize for resident drinks. Surveyor shared the concern with Regional Culinary Manager-N of several observations of the ice scoop resting inside of the ice bucket touching the ice in the third-floor dining area. On 3/11/26 at 3:05 PM, Surveyor shared concern with NHA-A, Director of Nursing (DON)-B, Regional Nurse Consultant-D, and Director of Operations-C regarding several observations of the ice scoop resting inside of the ice bucket touching the ice on the third-floor dining area. No additional information was provided.

Based on interview and record review, the Facility did not ensure the medical record contained signed advanced directive election forms for 4 (R4, R8, R60, and R82) of 18 residents reviewed. R4's medical record showed no evidence of being offered the option to formulate an advance directive. R8's medical record showed no evidence of being offered the option to formulate an advance directive. R60's medical record showed no evidence of being offered the option to formulate an advance directive. R82's medical record showed no evidence of being offered the option to formulate an advance directive. Findings include: The Facility Policy titled Communication of Code Status implemented [DATE] documents (in part): Policy:It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information. Policy Explanation and Compliance Guidelines:1. The facility will meet with resident/resident decision makers to determine code status upon admission. Code status will be reviewed quarterly and as needed.3. In the absence of an Advance Directive or further direction from the physician, the default direction will be Full Code.1.) R4 was admitted to the facility on [DATE] with pertinent diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a serious neurological condition characterized by paralysis (hemiplegia) or weakness (hemiparesis) on the left side of the body, with the left hemisphere of the brain being nondominant), severe protein-calorie malnutrition (a life-threatening condition caused by inadequate intake or absorption of protein and energy), cerebellar stroke syndrome (occurs when blood flow to the cerebellum is blocked (ischemic) or a vessel bursts (hemorrhagic), causing sudden vertigo, severe nausea, vomiting, and acute loss of balance or coordination (ataxia)), dysphagia (difficulty swallowing), and type 1 diabetes mellitus (a chronic autoimmune condition where the immune system destroys insulin-producing beta cells in the pancreas, leading to little or no insulin production and high blood sugar).R4's Annual Minimum Data Set (MDS) with an assessment reference date of [DATE] documented R4 had a Brief Interview for Mental Status score of 06 (severe cognitive impairment). R4 has an activated Power of Attorney. R4 is documented to be sometimes understood and sometimes understands others. Surveyor reviewed R4's electronic medical record (EMR) and was unable to locate a signed advanced directive form indicating whether CPR (cardiopulmonary resuscitation) should be performed or not. On [DATE], at 3:15pm, during the end of day meeting with facility, Nurse Consultant-D stated a couple weeks ago they discovered that there were no CPR election forms on file for residents and started an action plan to fix. On [DATE], at 8:57am, Surveyor was waiting in the hall to talk to the social worker and overheard a phone call with a family member regarding whether a resident's advance directive status paperwork should be emailed or mailed out. On [DATE], at 1:58 PM, Surveyor informed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Nurse Consultant-D and Director of Operations-C of the concern that R4 did not have a CPR election form completed notating right to choose. No additional information was provided regarding R4 being offered the option to formulate an advance directive. 2.) R8 was admitted to the facility on [DATE] with pertinent diagnoses that include orthopedic aftercare following surgical amputation, osteomyelitis right ankle and foot (a serious bone infection), metabolic encephalopathy (a group of conditions that cause brain dysfunction. Brain dysfunction can appear as confusion, memory loss, personality changes and/or coma in the most severe form), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a serious neurological condition characterized by paralysis (hemiplegia) or weakness (hemiparesis) on the left side of the body, with the left hemisphere of the brain being nondominant), and cognitive communication deficit (difficulty with communication that stems from impaired thinking skills, such as memory, attention, and problem-solving, rather than from physical speech problems). R8's Medicare 5 day Minimum Data Set (MDS) with an assessment reference date of [DATE] documented R8 had a Brief Interview for Mental Status score of 15 (cognitively intact). R8 is documented to be understood and understand others. Surveyor reviewed R8's electronic medical record (EMR) and was unable to locate a signed advanced directive form indicating whether CPR (cardiopulmonary resuscitation) should be performed or not. On [DATE], at 3:15pm, during the end of day meeting with facility, Nurse Consultant-D stated a couple weeks ago they discovered that there were no CPR election forms on file for residents and started an action plan to fix. On [DATE], at 8:57am, Surveyor was waiting in the hall to talk to social worker and overheard a phone call with a family member regarding a resident's advance directive status paperwork should be emailed or mailed out. On [DATE], at 1:58 PM, Surveyor informed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Nurse Consultant-D and Director of Operations-C of the concern that R8 did not have a CPR election form completed notating right to choose. No additional information was provided regarding R8 being offered the option to formulate an advance directive. 3.) R60 was admitted to the facility on [DATE] with pertinent diagnoses that include palliative care (specialized medical care for people living with a serious illness), dementia (a syndrome that can be caused by a number of diseases which over time destroy nerve cells and damage the brain, typically leading to deterioration in cognitive function (i.e. the ability to process thought) beyond what might be expected from the usual consequences of biological ageing), dysphagia (difficulty swallowing), and adult failure to thrive (a syndrome of decline marked by unintended weight loss, malnutrition, cognitive impairment, and functional decline). R60's Quarterly Minimum Data Set (MDS) with an assessment reference date of [DATE] does not document a Brief Interview for Mental Status (BIMS) assessment. R60 has an activated Power of Attorney. R60 is documented to rarely/never be understood and rarely/never understand others. Surveyor reviewed R60's electronic medical record (EMR) and was unable to locate a signed advanced directive form indicating whether CPR (cardiopulmonary resuscitation) should be performed or not. Surveyor reviewed a progress note indicting even though R60 is hospice the family elects CPR. On [DATE], at 3:15pm, during the end of day meeting with facility, Nurse Consultant-D stated a couple weeks ago they discovered that there were no CPR election forms on file for residents and started an action plan to fix. On [DATE], at 8:57am, Surveyor was waiting in the hall to talk to social worker and overheard a phone call with a family member regarding a resident's advance directive status paperwork should be emailed or mailed out. On [DATE], at 9:07am, Surveyor reviewed the hospice communication binder for R60. A tab for Advanced Directive was in the binder, however no documentation of the advance directive choice was included. On [DATE], the form CPR Cardiopulmonary Resuscitation Consent was provided to Surveyor for R60. Resuscitation was the desire chosen. A note at the bottom of the form indicated this was verbal (sic) obtained from POA (Power of Attorney) on [DATE]. Surveyor noted this form was completed after Surveyor brought the issue to the Facility's attention. 4.) R82 was admitted to the facility on [DATE] with pertinent diagnoses that include hypertensive chronic kidney disease with stage 5 chronic kidney disease (kidney damage caused by long-term high blood pressure (hypertension), type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), and dependence on renal dialysis (refers to the mandatory, long-term reliance on artificial blood filtration-hemodialysis or peritoneal dialysis-because the kidneys have permanently failed, usually due to end-stage renal disease). R82's Quarterly Minimum Data Set (MDS) with an assessment reference date of [DATE] documented R82 had a Brief Interview for Mental Status score of 12 (moderate cognitive impairment). R82 is documented to be understood and understand others. Surveyor reviewed R82's electronic medical record (EMR) and was unable to locate a signed advanced directive form indicating whether CPR (cardiopulmonary resuscitation) should be performed or not. On [DATE], at 3:15pm, during the end of day meeting with facility, Nurse Consultant-D stated a couple weeks ago they discovered that there were no CPR election forms on file for residents and started an action plan to fix. On [DATE], at 8:57am, Surveyor was waiting in the hall to talk to social worker and overheard a phone call with a family member regarding a resident's advance directive status paperwork should be emailed or mailed out. On [DATE], at 1:58 PM, Surveyor informed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Nurse Consultant-D and Director of Operations-C of the concern that R82 did not have a CPR election form completed notating right to choose. No additional information was provided regarding R82 being offered the option to formulate an advance directive.

Based on interview and record review, the facility did not consistently provide or offer a substantial evening snack to residents within a timeframe greater than 14 hours between evening supper meal and breakfast. *R67 is not offered a substantial snack routinely between meals as care planned which created a gap of more than 14 hours between the supper and breakfast meals. *The facility failed to provide a nourishing snack at bedtime to residents between the dinner meal and breakfast the following day. This resulted in a 14.5 hour time-lapse in meals for second floor residents and a 15.5 hour time-lapse in meals for third floor residents. This deficient practice has the potential to affect 87 out of the 88 residents residing at the facility. Findings include: The State Operating Manual documents, 483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. The facility could not provide a snack timing policy. 1.) R67 was admitted to the facility on [DATE] with a diagnoses that include hemiplegia (severe or complete paralysis of one side of the body) and hemiparesis (neurological condition characterized by mild to moderate weakness or reduced control of one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side, chronic obstructive pulmonary disease, mild protein-calorie malnutrition, heart failure and vascular dementia. R67's Minimum Data Set (MDS) dated [DATE] documents R67 has a Brief Interview for Mental Status (BIMS) of 3, indicating severe cognitive impairment. R67's MDS assessment indicates that it is very important for snacks to be available between meals for R67. R67's Care Plan initiated 9/22/25, documents: Resident with the potential for altered nutritional status related to diagnoses/history of cerebral infarct, COPD , mild protein-calorie malnutrition, vascular dementia, and HLD. The goal for R67 is the resident will maintain adequate nutritional status with diet and/or supplement tolerance. Interventions include; Monitor intake of food/fluids, Monitor weight trends, Offer Ensure supplements BID (twice a day), Offer snacks between meals, Provide and serve diet as ordered (general diet, regular texture, regular/thin liquids), Weigh as directed. Notify MD (Medical Doctor), RD (Registered Dietician) of significant weight changes. Surveyor located mealtimes in the facility survey binder that was provided by Nursing Home Administrator (NHA)-A. The mealtimes for the third floor are documented as breakfast from 8:30-9:30 AM, lunch from 12:30-1:30 PM, and dinner from 4:00-5:00 PM. Surveyor noted R67 resides on the third floor and there is a 15.5-hour time lapse between dinner ending at 5:00 PM and breakfast starting at 8:30 AM for residents on the third floor. On 03/10/26 at 12:08 PM, Surveyor interviewed Dietary Aide-O who stated she delivers snacks to kitchen areas on floor 2 and 3 every morning and checks to see if there is more snacks needed throughout her shift. Dietary Aide-O stated she does not pass out the snacks to residents and the staff on the unit do this. On 03/10/26 at 12:15 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-P. LPN-P stated she does not pass out snacks but if a resident asks for snacks, she will get a snack from the unit kitchen for them. LPN-P stated that snacks are based upon request and not passed out. Surveyor asked if residents have access to the kitchen and LPN-P stated, no, just the staff. On 03/10/26 at 12:23 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-G who stated, there is no structure for snacks. If a resident asks for a snack, it is provided to them. ADON-G stated, dietary staff used to pass out the snacks but now rely on the unit staff to do this. ADON-G stated dietary staff stopped providing snacks directly to the residents at least a few weeks ago and there is no current structured plan to distribute. On 03/11/26 at 9: 38 AM, Surveyor notified NHA-A, Director of Operations (Director of Ops)-C, and Nurse Consultant-D of concerns relating to R67 not being offered or provided nourishing evening snack with approximately 15.5 hours in between dinner and breakfast. Director of Ops -C, stated, I am not sure if it is true that residents are not provided snacks. Surveyor stated, the dietary staff, unit staff and residents have been interviewed and verified the practice of providing evening snacks stopped several weeks ago. Director of Ops-C could not validate this information. No additional information was provided. 2.) R44 admitted to the facility 9/17/25. R44's quarterly Minimum Data Set (MDS) dated [DATE] documents R44 has a Brief Interview for Mental Status (BIMS) score of 04 indicating severe cognitive impairment. R51 admitted to the facility on [DATE]. R51's admission MDS dated [DATE] documents R51 has a BIMS score of 12 indicating moderate cognitive impairment. R65 admitted to the facility 2/18/24. R65's quarterly MDS dated [DATE] documents R65 has a BIMS score of 15 indicating intact cognition. On 3/10/26 at 11:03 AM, Surveyor conducted resident council at the facility with R44, R51, and R65 in attendance. R65 stated the facility used to come to resident rooms twice a day with a snack cart, but since the facility was bought by a new owner this has stopped. R51 stated the only time residents get an extra snack is during Bingo. R44, R51, and R65 stated the facility does not offer snacks at bedtime. Surveyor located mealtimes in the facility survey binder that was provided by Nursing Home Administrator (NHA)-A. The mealtimes for second floor are documented as breakfast from 8:00-9:00 AM, lunch from 12:00-1:00 PM, and dinner from 4:30-5:30 PM. Surveyor notes there is a 14.5-hour time lapse between dinner ending at 5:30 pm and breakfast starting at 8:00 AM for residents on the second floor. The mealtimes for the third floor are documented as breakfast from 8:30-9:30 AM, lunch from 12:30-1:30 PM, and dinner from 4:00-5:00 PM. Surveyor notes there is a 15.5-hour time lapse between dinner ending at 5:00 PM and breakfast starting at 8:30 AM for residents on the third floor. In an interview on 3/10/26 at 12:08 PM, Dietary Aide (DA)-O stated the kitchen staff deliver snacks to the kitchen area on the second floor and snacks are restored as needed. DA-O stated kitchen staff do not pass out snacks to residents and nursing staff is responsible for that. In an interview on 3/10/26 at 12:15 PM, Licensed Practical Nurse (LPN)-P stated LPN-P does not pass out snacks to residents, but if a resident requests a snack, LPN-P would get a snack from the second-floor kitchen. LPN-P stated snacks are based upon request and not passed out throughout the day or at bedtime. In an interview on 3/10/26 at 12:23 PM, Assistant Director of Nursing (ADON)-G stated there is no structure for snacks. ADON-G stated if a resident asks for a snack, it is provided to them, or if there is a physician order for a snack, a resident would be provided with one, otherwise the residents must ask for a snack. In an interview on 3/11/26 at 9:40 AM, Regional Culinary Manager-N confirmed dinner ends at 5:30 PM and breakfast starts at 8:00 AM on the second floor, and dinner ends at 5:00 PM and breakfast starts at 8:30 AM on the third floor. Regional Culinary Manager-N stated residents can request snacks during business hours, and a nighttime snack is stocked in the second-floor kitchen nightly. Regional Culinary Manager-N stated the nursing staff is responsible for providing the residents with snacks and kitchen staff does not supply snacks directly to residents. Surveyor shared the concern with Regional Culinary Manager-N a nourishing snack is not served to residents at bedtime between the evening meal and breakfast the following day, which has a 14.5-hour time lapse for second floor residents and a 15.5-hour time lapse for third floor residents. On 3/11/26 at 3:05 PM, Surveyor shared concern with NHA-A, Director of Nursing (DON)-B, Regional Nurse Consultant-D, and Director of Operations-C that a nourishing snack is not served to residents at bedtime between the evening meal and breakfast the following day, which has a 14.5-hour time lapse for second floor residents and a 15.5-hour time lapse for third floor residents. No additional information was provided.

Based on observation, interview and record review the facility did not ensure 1 (R12) of 1 residents at risk for diabetic wounds received the necessary services to prevent diabetic wounds. R12 was admitted to the facility on [DATE]. On 1/22/26 diabetic wounds were identified to R12's bilateral heels. There are no documented interventions that were in place to prevent diabetic wounds from developing despite R12 having a diagnosis of diabetes type 2. Findings include:The facility's Skin Integrity-Foot Care dated 2/2/26 documents: 2. Assessment of Riskb. The comprehensive assessment process will be utilized for identifying additional risk factors or conditions that increase risk for impaired skin integrity of the foot. Examples include, but are not limited to: diabetes, peripheral vascular disease, peripheral arterial disease, venous insufficiency, peripheral neuropathy and lack of sensation in feet.3. Interventions for Prevention and to Promote Healinga. Interventions will be based on specific factors identified in the risk assessment, skin assessment and assessment of any foot ulcers (e.g. impaired sensation, immobility, foot deformity, wound characteristics).ii. Appropriate offloading or orthopedic devices, diabetic shoes, or pressure relieving devices will be utilized as indicated.R12 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes, Alzheimer's disease and anxiety. The admission Minimum Data Set (MDS) dated [DATE] documents R12 is moderately cognitively impaired and R12 needs moderate assistance to move in bed. It also documents R12 did not have any diabetic wound upon admission.The admission assessment dated [DATE] documents R12 was admitted with a pressure injury to the sacrum area but does not indicate any skin integrity concerns with the feet.Wound Advanced Practical Nurse Practitioner (APNP)-J assessment note dated 1/22/26 documents R12 having a diabetic wound to the right heel, deep purple area measuring 3.5 cm by 1.0 cm with intact skin no drainage, periwound pink and blanchable. No signs or symptoms of infection. Status: new. Plan: Betadine daily, heel offloading boots at all times when in bed. R12 also had a diabetic wound to the left posterior heel, dry eschar measuring 1.0 cm by 1.0 cm, intact skin no drainage. No signs or symptoms of infection. Status: New. Plan: betadine daily heel offloading boots at all times.The potential/actual impairment to skin integrity care plan dated 1/12/26 documents turn and position as necessary as one of the interventions. There is no documentation in the care plan that addresses offloading of the feet. Wound APNP-J's assessment note dated 3/5/26 documents the diabetic wound to the right heel as a full thickness wound measuring 1.6 cm by 3.0 cm by 0.1 cm with 90% slough and 10% granular. Light serosanguineous drainage with periwound pink and blanchable. No signs or symptoms of infection. Status: stable. Plan: medihoney on border gauze change three times a week. The diabetic wound to the left posterior heel with dry eschar measuring 4.0 cm by 2.5 cm 100% eschar. Intact with no drainage and no signs or symptoms of infection. Status: stable. Plan Betadine daily heel offloading boots at all times. (R12) is not very compliant with position changing (sic) and utilizing heel offloading boots. (R12) is very resistant and verbally unpleasant using swear words and stating leave me alone. She can be resistant to utilizing offloading measures.The previous wound assessments document R12 non compliance with offloading and repositioning. The care plan does not address R12's offloading devices or R12 being not compliant with interventions. On 3/9/26 at 2:14 pm Surveyor observed R12 in bed with air mattress on. Surveyor observed R12's feet offloaded. On 3/12/26 at 8:44 a.m. Surveyor observed Wound APNP-J assess R12's wounds and apply the treatment as ordered. Wound APNP-J stated she has been seeing R12 since admission. Wound APNP-J stated she thought R12 heel wounds were present upon admission [DATE]). Surveyor explained Wound APNP-J documented the heel wounds were first discovered on 1/22/26. Wound APNP-J clarified her answer and agreed with Surveyor that was the case. Wound APNP-J stated R12 is not complaint with interventions like repositioning and offloading. Wound APNP-J stated R12's heel wounds are stable.On 3/11/26 at 1:03 p.m. Surveyor interviewed Assistant Director of Nursing (ADON)-G. Surveyor asked ADON-G when it was discovered that R12 developed heel wounds. ADON-G stated it was discovered on 1/22/26 by Wound APNP-J. Surveyor asked ADON-G when were heel offloading interventions implemented for R12. ADON-G stated after the heel wounds were discovered. Surveyor explained the heel wounds and intervention of offloading are not on the care plan. ADON-G stated he was not aware and will adjust the care plan. ADON-G stated he's not sure why offloading was not implemented prior to 1/22/26. ADON-G agreed R12 was at risk for skin impairments due to her diagnoses.On 3/11/26 at 3:10 p.m. during the daily exit meeting with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B, Surveyor explained the concern R12 developed diabetic heel wounds and there's no documented evidence R12 had any offloading device used prior to the development of the wounds. Surveyor also explained that the care plan does not address the heel wounds or offloading devices. The care plan also does not address R12's non compliance with interventions.

Based on interview and record review the facility did not ensure 1 (R43) of 6 residents had necessary interventions to monitor weight.R43's physician order dated 1/27/26 documents that R43 is to be weighed Monday, Wednesday and Friday for two weeks and then weekly thereafter. R43's medical record reveals R43 has a documented weight on 1/21/26, 2/2/26 and 2/3/26. Weights were not obtained per physician orders.Findings include:R43 was admitted to the facility on [DATE] with diagnoses of dementia, congestive heart failure, chronic obstructive pulmonary disease and cardiomyopathy. R43 was discharged home during the survey on 3/11/25.R43's admission Minimum Data Set (MDS) dated [DATE] documents that R43 is cognitively intact, needs maximum assistance with toileting and moderate assistance with dressing.R43's care plan for potential for altered nutritional status related to diagnoses/history of cardiomyopathy, adult failure to thrive, congestive heart failure (CHF), cardiovascular accident (CVA), chronic obstructive pulmonary disease (COPD), hyperlipidemia (HLD), dementia and coronary artery disease (CAD) dated 1/12/26 documents under the Interventions section: Monitor weight trends.weigh as directed. Notify Medical Doctor (MD), Registered Dietician (RD) of significant weight changes.R43's physician order dated 1/27/26 documents R43 to be weighed Monday, Wednesday and Friday for two weeks and then weekly thereafter due to history of heart failure.R43's medical record documents weights on 1/21/26 of 143.2 lbs., 2/2/26 historical weight data of143 lbs. and 2/3/26 of 137.6 lbs. No other weights were documented in R43's medical record.On 3/10/26 at 3:00 p.m. during the daily exit meeting, Surveyor asked to see R43 weight data. On 3/11/26 at 12:47 p.m. Nursing Home Administrator (NHA)-A informed Surveyor that there are no other weights obtained for R43. On 3/11/26 p.m. Surveyor interviewed Assistant Director of Nursing (ADON)-G. Surveyor explained R43 had an order for weekly weights, and it wasn't obtained. ADON-G Stated this was missed and had no other information as to why the weights were not obtained as ordered.

Based on interview and record review, the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, including the ongoing communication with the dialysis center before and after dialysis treatments, for 1 (R82) of 2 residents reviewed for dialysis. R82 has a physician order for dialysis on Monday, Wednesday and Friday. Communication between the facility and the dialysis center was not being shared with each dialysis visit.Findings include:The Facility Policy titled Hemodialysis implemented 1/31/2026 documents: Policy- This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis.Purpose:The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include:-The ongoing assessment of the resident's condition and observing for complications before and after dialysis treatments received at a certified dialysis facility.-Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices: and-Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.5. The licensed nurse will communicate to the dialysis facility via dialysis communication form or other form, that will include, but not limit itself to:a. Changes and/or declines in condition unrelated to dialysis.b. The occurrence or risk of falls and any concerns related to transportation to and from the dialysis facility.c. Dialysis treatment outcomes as indicated may include pre-post weights and pre-post vital signs.d. Changes in orders.R82 was admitted to the facility on [DATE] with pertinent diagnoses that include hypertensive chronic kidney disease with stage 5 chronic kidney disease (kidney damage caused by long-term high blood pressure (hypertension), type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), and dependence on renal dialysis (refers to the mandatory, long-term reliance on artificial blood filtration-hemodialysis or peritoneal dialysis-because the kidneys have permanently failed, usually due to end-stage renal disease).R82's Quarterly Minimum Data Set (MDS) with an assessment reference date of 2/25/26 documented R82 had a Brief Interview for Mental Status score of 12 (moderate cognitive impairment). R82 is documented to be understood and understand others and not to have behaviors exhibited during the MDS assessment period. R82's care plan documents The resident goes to [name] dialysis (SPECIFY type hemo) Tue-Thur-Sat revision on 8/21/2025.Interventions include: Check and change dressing daily at access site. Document. Date initiated: 8/19/2025 Do not draw blood or take B/P (blood pressure) in arm with dialysis site. Date initiated: 3/2/2026 Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis (). Revision on: 12/11/2025 Monitor labs and report to doctor as needed. Date initiated: 3/2/2026 Monitor VITAL SIGNS, per orders. Notify MD (medical doctor) of significant abnormalities. Revision on: 3/2/2026 Monitor/document report to MD s/sx (signs and symptoms) of depression. Obtain order for mental health consult if needed. Date initiated: 3/2/2026 Monitor/document/report PRN any s/sx of infection to access site: Redness, Swelling, warmth or drainage. Date initiated: 3/2/2026 Monitor/document/report PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Date initiated: 3/2/2026 Monitor/document/report PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. Date initiated: 3/2/2026 Monitor/document/report PRN new/worsening peripheral edema. Date initiated: 3/2/2026 Surveyor noted the wrong dialysis days for R82 were indicated on R82's care plan.R82's physician order documents: Fill out bottom of dialysis communication sheet, then place in medical records at bedtime every Mon, Wed, Fri.Surveyor reviewed the last 3 full months that R82 was scheduled for dialysis for the communication forms being uploaded to R82's medical record. Surveyor noted: 12/1 None12/3 completed12/5 None12/8 upon return section not completed 12/10 completed12/12 completed12/15 None12/17 upon return section not completed 12/19 completed12/22 None12/24 None12/26 None12/29 None12/31 completedFor December, seven dialysis communication forms were unable to be located and 2 more forms were not completed by staff after R82 returned from dialysis.1/2 upon return section not completed1/5 None1/7 None1/9 None1/12 completed1/14 None1/16 None1/19 None1/21 completed1/23 None1/26 completed1/28 None1/30 completedFor January, eight dialysis communication forms were not accounted for, with 1 more not completed by staff after R82 returned from dialysis.2/2 None2/4 completed2/6 upon return section not completedR82's progress note dated 2/9/2026, at 10:05 PM, documents Resident is alert and oriented. Went to dialysis clinic today. The resident was not given the dialysis form to bring back to the facility. No issues noted, denies pain or discomfort.2/11 upon return section not completed2/13 None2/16 upon return section not completedR82's progress note dated 2/18/2026, at 10:20 PM, documents Resident came back from dialysis without but her dialysis form b/p 166/81 hr/89 resident ate dinner and received her medication tolerated well.2/20 upon return section not completed2/23 None2/25 upon return section not completed2/27 NoneFor February, four dialysis forms were unable to be located, two were not returned and 5 more were not completed by staff after R82 returned from dialysis.3/2 None3/4 None3/6 completed3/9 NoneFor March, three dialysis communication forms were unable to be located. On 03/11/2026, at 8:55 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E regarding when R82 goes to dialysis. Per LPN-E, R82 is given an envelope with a paper in that that the nurse has put vital signs and an assessment on. R82 is supposed to give the envelope to dialysis center staff and have them complete a section. R82 then brings back the form to the facility and gives to a nurse who puts it in a file.On 03/11/2026, at 9:24 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-G and asked about the dialysis communication form and was told when a resident comes back from dialysis the form goes to medical records to be put into their medical record. Surveyor let ADON-G know several of R82's were missing and was told ADON-G will look into.On 03/11/2026, at 1:58 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Nurse Consultant-D and Director of Operations-C about the concern regarding R82's dialysis communication forms missing from R82's medical record. On 03/12/2026, at 9:45 AM, Surveyor interviewed R82 about the dialysis communication forms. Per R82, facility staff provide an envelope that R82 takes to dialysis. The dialysis facility staff fill out the form and R82 brings it back to the facility. R82 feels this works out as R82 keeps the enveloped in her purse with a blanket and headphones that R82 takes with to appointments.No additional information was provided regarding R82's missing dialysis communication forms.

Based on observation, interview and record review the facility did not ensure its medication error rate was not 5 percent or greater. The medication error rate was 14.81%.Findings include:The facility policy titled Medication Administration dated 1/1/26 documents: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.10. Ensure that the six rights of medication administration are followed:a. Right residentb. Right drugc. Right dosaged. Right routee. Right timef. Right documentationOn 3/10/26 at 7:45 AM, Surveyor observed Medication Technician (MT)-H prepare medications for R7. While preparing the medications, MT-H stated he did not have a 6 mg (milligram) tablet of Austedo and went to talk to nurse. After talking to the nurse, MT-H reported the medication cannot be broken in half because it is not scored, and pharmacy would deliver the medication this afternoon.Surveyor verified the number of tablets with MT-H. R7 was observed to swallow the tablets whole with water. On 3/10/26 at 8:00 AM, Surveyor reconciled R7's medications ordered. Surveyor noted MT-H signed out the following medications as administered:Duloxetine HCl (Hydrochloride) capsule Delayed Release Particles 30 MG. Give 1 capsule by mouth two times a day for depression/pain related to Major Depressive Disorder.Austedo Oral Tablet 12 MG (Deutetrabenazine). Give 1 tablet by mouth two times a day for tardive dyskinesia along with 6 mg tablet for total dose of 18 mg BID (twice daily).Advair Diskus Inhalation Aerosol Powder Breath Activated 250-50 MCG (micrograms)/ACT (Fluticasone Salmeterol). 1 puff inhale orally every 12 hours related to Chronic Obstructive Pulmonary Disease.Surveyor noted Duloxetine HCL and Advair inhaler were signed out as administered, but neither were observed given and Austedo 18 mg was signed out as administered, but only 12 mg was given. On 3/10/26 at 8:45 AM, Surveyor informed MT-H of the above medications signed out as administered but were not given. Surveyor and MT-H viewed R7's Medication Administration Record (MAR) together. MT-H viewed R7's medication cards and was not able to find a card for Duloxetine. MT-H stated, How did I miss that? I don't know why I signed that out. While viewing R7's MAR, MT-H stated, Oops, I signed out that other medication too, the Austedo. I don't know why I did that; I'll have to change it. MT-H searched the medication cart for the Advair inhaler and stated, I don't know why I signed that out, didn't I give it? Surveyor advised the Advair inhaler was not given during observation of medication pass. On 3/10/26 at 8:50 AM, MT-H approached Surveyor and reported he gave R7 her inhaler after Surveyor left medication pass observation. On 3/10/26 at 8:53 AM, Surveyor asked R7 (who has a Brief Interview for Mental Status score of 15, indicating no cognitive impairment) if she got her Advair inhaler this morning. R7 stated, No, not yet. On 3/11/26 at 8:23 AM, Surveyor observed Registered Nurse (RN)-F prepare medications for R4. Surveyor verified the number of tablets with RN-F. RN-F crushed all the tablets and administered them through R4's G-tube (gastrostomy tube). Surveyor reconciled R4's medications and noted Calcium with vitamin D 600 mg /5mcg was observed given, however R4's physicians order reads: Vitamin D-3 Tablet (Cholecalciferol) Give 1 tablet enterally one time a day for prophylactic Vitamin D3 with Calcium 500-5mg-mcg via GT. On 3/11/26 at 10:29 AM, DON-B was advised of the above concerns and the medication error rate. No additional information was provided.

Based on observation and interview, the facility did not ensure that drugs and biologicals used in the facility were stored under proper temperature controls, were labeled in accordance with currently accepted professional principles, and include the expiration date when applicable for 1 of 2 medication rooms and 2 of 6 medication carts observed.Insulin was not dated when opened and/or was expired and the medication refrigerator temperature was above the recommended temperature.Findings include:The facility policy titled Storage of Medication Requiring Refrigeration dated [DATE] documents (in part): It is the policy of this facility to assure proper and safe storage of medications requiring refrigeration and to prevent the potential alteration of medication by exposure to improper temperature controls.2. The facility will ensure that all drugs and biologicals used will be labeled in accordance with professional standards, including expiration dates (when applicable).3. The facility will ensure that all medications and biologicals will be stored at proper temperatures and other appropriate environmental controls according to manufacturers' recommendations to preserve their integrity.4. Refrigerators used for the storage of medications and biologicals:c. Temperature should be maintained between 36 - 46 degrees F (Fahrenheit).The facility provided a form which was not titled or dated. The form documents:Insulins:Most insulins should have an expiration date of 28 days after opening. According to manufacturer different insulins have different times before they expire; only if the medication is maintained according to manufacturer instructions. Practice O's and X's. O = open date, X = expiration date. Nurses must write on the product the open and expire dates. On [DATE] at 7:45 AM, Surveyor observed the 3rd floor C medication cart. In the top drawer of the cart, Surveyor located a Glargine insulin vial belonging to R5 opened [DATE].On [DATE] at 10:20 AM, Surveyor observed the 2nd floor medication room refrigerator which contained medications, including insulin. Surveyor noted the refrigerator temperature was 54 degrees. The log sheet on top of the refrigerator documented the temperature is to be between 32 - 40 degrees. On [DATE] at 8:03 AM, Surveyor noted the refrigerator temperature read 48 degrees.On [DATE] at 8:17 AM, Surveyor advised Director of Nursing (DON)-B of the temperature and viewed together. The temperature was 58 degrees. DON-B reported she wanted to wait 15 minutes and recheck the temperature.On [DATE] at 8:46 AM, Surveyor and Licensed Practical Nurse (LPN) Supervisor-I observed the refrigerator temperature which was 48 degrees. LPN Supervisor-I stated, What is it supposed to be? She looked at the log which documented 32-40 degrees. LPN Supervisor-I stated, I'm not sure how we fix that. Surveyor advised LPN-Supervisor-I would inform DON-B. On [DATE] at 8:07 AM, Surveyor observed the 2nd floor treatment cart. On top of the cart was a plastic bin containing: A Glargine insulin vial and 2 Lispro insulin vials belonging to R68 which were open and used but not dated when opened.A Glargine insulin pen which was not labeled with a resident name. The insulin pen was open and used but not dated when opened.A Lispro insulin Kwik pen with a name written in black marker (which was not legible) dated opened [DATE] expired [DATE]. On [DATE] at 10:29 AM, Surveyor advised DON-B of concern insulins were not dated when opened and/or were expired and the refrigerator temperature was above the recommended temperature. No additional information was provided.

Based on interview and record review, the facility did not ensure that a resident continued to receive specialized rehabilitative services for 1(R67) of 1 residents reviewed for rehabilitation services.R67 was discharged from Occupational Therapy services on 3/3/26 when goals were not met and R67 was cooperative in participation.Findings include:R67 was admitted to the facility on [DATE] with diagnoses that include hemiplegia (severe or complete paralysis of one side of the body) and hemiparesis (neurological condition characterized by mild to moderate weakness or reduced control of one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side, chronic obstructive pulmonary disease, mild protein-calorie malnutrition, heart failure and vascular dementia.R67's Minimum Data Set (MDS) assessment, dated 3/28/25, documents R67 has a Brief Interview for Mental Status (BIMS) of 3, indicating severe cognitive impairment. The MDS documents the following assessments: R67 has no upper and lower extremity functional limitation in range of motion and uses a wheelchair; R67 needs partial to moderate assistance with upper and lower body dressing, showering/bathing, personal and oral hygiene and putting on footwear; R67 partial to moderate assistance with the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed and with the ability to move from lying on the back to sitting on the side of the bed and with no back support.R67's Care Plan, date initiated 3/9/25, documents: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) impaired mobility, dementia, and antidepressant use. The goal for R67 is to maintain current level of function through review date. Interventions include; resident has personal refrigerator, check nail length and trim and clean on bath day and as necessary, Report any changes to the nurse, . BED MOBILITY: The resident uses 2 grab bars to maximize independence with turning and repositioning in bed, EATING: The resident is able to: setup assist, staff to remind her to eat, TRANSFER: The resident is stand pivot of 1 staff for transferring.R67's Physician Orders, date initiated 7/29/25, documents, THERAPY - PT (Physical Therapy) eval and treat. No directions specified for order. OtherActive7/29/2025, THERAPY - OT (Occupational Therapy) eval and treat. No directions specified for order. OtherActive7/29/2025R67's progress note, dated 2/5/26 at11:05 AM, written by Nurse Practitioner (NP)-X, documents: Health Status Note.rehabilitation evaluation after a functional decline. She has been working with the OT team at the facility since 1/31/2026 on functional goals including improved balance, increased trunk and bilateral upper extremity strength, safe wheelchair mobility, and increased participation in her ADLs such as dressing, hygiene, and self-feeding. She previously received PT and OT in 2025, and after discharge from therapy she remained wheelchair dependent, required maximal assistance for all ADLs, required supervision for wheelchair mobility, and was able to stand-pivot transfer with moderate assistance. Currently at the facility, she remains wheelchair dependent and requires substantial assistance with all ADLs.R67's progress note, dated 2/19/26 at 11:10 AM, written by NP-X, documents: Health Status Note.rehabilitation follow-up.R67 states OT is going well, but it is unclear if she remembers her recent sessions. She denies pain and states she has a good appetite. She remains pleasantly confused, stating that she is going back to work at [NAME] hospital and needs to find someone to keep the baby while I'm gone. Per therapy notes, she tolerated wheelchair mobility training during her last OT session on 2/18 this week.Prior level of function: after previous course of PT/OT in 2025: wheelchair dependent, maximum assist for all ADLs, required supervision for wheelchair mobility, required moderate assist with stand-pivot-transfer. Current level of function: requires substantial-total assistance with transfers, mobility, toileting, hygiene, and clothing management. Uses a wheelchair for mobility.continue OT plan of care to increase participation in activity tolerance, strength, coordination, and ADLs.R67's Occupational Therapy Discharge summary, dated [DATE], documents: Short term goal not met, patient will improve ability to safely and efficiently perform UB dressing with Supervision or Touching Assistance with the use of no adaptive equipment in order to be able to return to prior level of living and facilitate ability to live in environment with least amount of supervision and assistance. Discharge evaluation: Partial/moderate assistance.Short term goal not met, patient will increase trunk strength to 4+/5 in order to increase performance of ADL/self care tasks, increase flexibility for functional activity performance, achieve and maintain upright posture, facilitate reaching during ADL/mobility tasks and increase core strength for mobility tasks. Discharge evaluation: 4/5. Long term goal not met, patient will increase BUE strength to 4+/5 for increased safety and IND with self-cares and ADL tasks. Discharge evaluation: 4/5.Assessment and Summary of Skilled Services: Patient Progress, Progress and response to treatment: patient has improved strength generally, some of her goals are met.R67's Progress Note, dated 3/5/2026 at 10:20 AM, written by NP-X, documents: Health Status Note.rehabilitation follow-up.I encountered [R67] sitting in her wheelchair in no distress at her baseline mental status. She denies pain and states she has a good appetite. She does not recall how she transferred out of bed this morning or other details of her day. Per her OT re-evaluation on 2/28, she continues to require partial assistance with clothing, hygiene, and reaching/balance tasks. She requires supervision assistance with wheelchair mobility and is noted to be self-propelling with her bilateral feet in her room and the hallways at the facility.prior level of function: after previous course of PT/OT in 2025: wheelchair dependent, maximum assist for all ADLs, required supervision for wheelchair mobility, required moderate assist with stand-pivot-transfer. Current level of function: requires continued assistance with transfers, mobility, toileting, hygiene, and clothing management. Uses a wheelchair for mobility. Continue OT plan of care to increase participation in activity tolerance, strength, coordination, and ADLs.On 03/11/26 at 8:15 AM, Surveyor interviewed Director of Rehabilitation (Director of Rehab)-W. Surveyor asked why was R67 discharged from OT. Director of Rehab-W stated, R67 was seen for OT from 1/31/26 to 3/3/26 and Director of Rehab-W stated Director of Rehab-W believes R67 was discharged from OT because R67 achieved R67's highest potential and R67 was not cooperating or engaging in therapy. Surveyor asked for the therapy progress notes.On 03/11/26 at 8:32 AM, Director of Rehab-W provided Surveyor R67's progress notes. Director of Rehab-W stated, there must have been a mistake with discharging R67. Director of Rehab-W stated that Director of Rehab-W was told by Certified Occupational Therapist Assistant- (COTA)-Z that R67 had reached highest practical potential and R67 was not cooperative, therefore Director of Rehab-W discharged R67. Director of Rehab-W stated that after just reviewing the progress notes, Director of Rehab-W realized there was a mistake and R67 had not reach highest practical potential and R67 is willing to participate in therapy. Director of Rehab-W will now begin the process to get R67 reestablished with therapy services.On 03/11/26 at 2:23 PM, Surveyor asked Director of Rehab-W for R67's OT care plan. Surveyor asked Director of Rehab-W if R67 has an active order to evaluate and treat for PT (physical therapy), why did R67 only have OT services provided. Director of Rehab-W stated she would review and let Surveyor know. Surveyor asked Director of Rehab-W how Director of Rehab-W feels the mistake may have occurred regarding the discharge of R67 from OT services. Director of Rehab-W stated COTA-Z told Director of Rehab-W that in COTA- Z's opinion, R67 had reached full potential and was also not cooperative, but after Director of Rehab-W reviewed progress notes today, Director of Rehab-W realized R67 had not reached goals and was willing to cooperate.On 03/12/26 at12:46 PM, Surveyor met with Director of Rehab-W. Director of Rehab-W informed Surveyor at the time R67 was having OT, there was not a need for additional PT services and as of yesterday, Director of Rehab-W is screening/initiating PT services. Surveyor asked why Director of Rehab-W switched from OT to PT for resumption of therapy services. Director of Rehab-W stated that OT was not able to address R67 issues adequately and now with resumption of therapy, PT will be able to progress R67's needs more efficiently to a point of safety. Director of Rehab-W stated there is no need for R67 to have both OT and PT.On 03/11/2026 at 3:38 PM, Surveyor notified NHA-A, Director of Operations-C, and Nurse Consultant-D that R67 was discharged from OT services on 3/3/26 when R67 had not met goals and was a willing participant. Surveyor also stated Director of Rehab-W was in the process of reinstating therapy services.No additional information was provided at this time.

Based upon observation, interview and record review, the facility did not ensure 1 Resident (R45) in a sample of 18 residents received activities offered based upon assessment of individual preferences and interests.R45 was observed sitting in the dining room with no activities being offered to R45 during that time other than music playing in the background. Interviews indicate R45 has interest in music and preferences for activities and routines based on history that were not assessed or care planned for R45.Findings include: R45 was admitted to the facility on [DATE] with diagnoses of dementia, anxiety, peripheral vascular disease, and type 2 diabetes. The quarterly Minimum Data Set (MDS) dated [DATE] documents R45 is severely cognitively impaired. R45's admission MDS with an assessment reference date of 9/23/25 includes as part of the assessment under section F0500 interview for daily activity preferences: having books, newspapers and magazines to read, listening to music R45 likes, being around animals and pets, keeping up with the news, doing things with groups of people, doing favorite activities and participating in religious services are somewhat important to R45. R45 answered it is very important to R45 to go outside and get fresh air when the weather is good. The MDS indicates R45 was able to be interviewed and provide the responses to answer the questions regarding preferences for activities. On 3/9/26 at 1:36 p.m. Surveyor interviewed R45's guardian. R45's guardian voiced concern R45 is in the dining area all day.On 3/11/26 at 11:04 a.m. Surveyor observed R45 in a Broda chair in the dining area with music playing from the radio. Other residents and staff were in the area there was no direct interaction with R45 or other activities occurring involving R45 observed. On 3/12/26 at 7:59 a.m. Surveyor observed R45 in a broda chair in the dining area with music playing on the radio. Other residents and staff were in the area there was no direct interaction with R45 or other activities occurring involving R45 observed. On 3/11/26 at 1:45 p.m. Surveyor interviewed Activity Director-Q. Surveyor asked Activity Director-Q, what sort of activities does R45 engage in. Activity Director-Q stated R45 loves music and when he is in the dining area she will make sure the radio is on to his preference. Activity Director-Q stated R45 also loves activities that involve food. Activity Director-Q was getting ready to have a cookie decorating activity, that R45 was going to participate in. On 3/12/26 at 10:11 a.m. Surveyor interviewed Director of Nursing (DON)-B. DON-B stated R45 is very social and when he was first admitted they tried to put him to bed after meals but R45 would not want that and wanted to be up and socializing.On 3/12/26 at 10:30 a.m. Surveyor interviewed Social Worker (SW)- K and SW-R. SW-K stated R45 used to be a musician and is used to staying up late. SW-R stated R45 likes to go to bed late and get up early. SW-R stated R45 doesn't sleep much. SW-R stated R45 is very social and likes music so he likes to stay up and socialize. SW-R stated R45 will socialize with the nurses when the other residents have gone to bed. SW-R stated this was explained to R45's guardian. Surveyor explained to SW-R, SW-K and DON-B this information is not in R45's care plan. SW-R and SW-K agreed and stated they will make the changes to R45 care plan.

Based on observation, interview, and record review, the facility did not ensure residents 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 2 of 2 residents (R5 and R48) reviewed for pressure injuries. * On 4/16/2024, R5 was noted to have an area of concern that was not comprehensively assessed and R5's pressure injury care plan was not revised until two days later on 4/18/2024. The area was then staged as an unstageable wound to R5's sacrum. Surveyor made observations on 10/1/2024 and 10/2/2024 of R5's care plan not being followed. * R48's air mattress, which was in place to reduce pressure and prevent pressure injuries, was observed not working appropriately on 10/1/2024 and 10/2/2024 and staff were initialing each shift that R48's mattress was checked and functioning properly. Findings include: The facility policy entitled Pressure Injury Assessment/Treatment last revised on 7/2024 documents: The purpose of this procedure is to provide guidelines for a consistent method of identification of and for the initial care of identified pressure injuries, alterations in skin integrity, and the prevention of acquiring additional pressure injuries. General Guidelines . A. The pressure injury treatment program should focus on the following strategies: . 3. Resolution of current pressure injuries and prevention of additional pressure injuries. 6. Education and quality improvement. Documentation- The following information should be recorded in the resident's medical record, treatment sheet, or designated wound form: . B. Wound appearance, including wound bed, edges, presence of drainage. E. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 1.) R5 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's disease, vascular dementia without behaviors/psych/mood, hemiplegia following cerebral infarction affecting left nondominant side, peripheral vascular disease, dysphagia, history of a sacral stage 4 pressure injury (1/9/2023 - 6/18/2023) and contracture of the left wrist/hand/and muscle. R5's quarterly minimum data set (MDS) dated [DATE] indicated R5 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14 and the facility assessed R5 needing extensive assist with 2 staff assistance for toileting/personal hygiene, repositioning, and transferred using a Hoyer lift. Per the MDS, R5 is always incontinent of bowel and bladder and wore adult briefs for protection. The facility assessed R5 on 10/3/2024 to be a high risk for developing pressure injuries with a Braden scale score of 12. R5's Pressure ulcers/Skin prevention care plan was initiated on 11/2/2022 with the following interventions: (R5) is at risk for skin breakdown due to bowel and bladder incontinence, DM (Diabetes Mellitus), hemiparesis, and impaired mobility. - Provide peri-care after each incontinence episode and apply skin protectant. - Monitor for signs and/or symptoms of breakdown. - Use the following positioning/pressure reducing devices: wheelchair cushion and air mattress. Validate [sic] - Monitor skin under Left hand splint and tubi grips. Staff to assist to don left hand/wrist splint daily with AM cares and remove with PM cares. - Encourage and assist to elevate heels when in bed (May not comply). - Apply lotion to resident's feet during HS (bedtime) cares. - Apply lotion to arms and legs as needed. - Reposition off of right buttock at regular intervals and prn (as needed) when in bed. On 4/16/2024 at 14:58 (2:58 PM), R5's progress notes nursing documents resident's coccyx noted to be reopened, 3.0 cm X 0.4 cm X 0.1 cm (length X width X depth), washed with NS (normal saline), skin prep to surrounding skin, covered with foam dressing. NP (nurse practitioner), family, assistant director of nursing (ADON) notified, and order put in for wound treatment. Surveyor noted that there was not a comprehensive assessment done on the newly observed area to R5's coccyx describing what the area looked like or staging the area. Surveyor also noted there were no revisions made to R5's care plan. On 4/18/2024, at 12:15 PM Wound Nurse- H documented: - Full thickness wound, unstageable pressure injury - 3.0 X 2.0 X 0.1, oval shaped, 80% slough, 20% granulation tissue, moderate serosanguineous drainage. - Clean with NS or wound cleanser, skin prep to surrounding tissue, apply medihoney and cover with foam dressing, change daily and prn. - R5 was seen by wound care team: at present R5 gets up in the morning and stays up all day. R5 is agreeable to getting back in bed after dinner and staying in bed until lunch the next day. Surveyor noted R5's pressure injury care plan was revised on 4/18/2024 with the following interventions: - Provide treatment as ordered. - Provide pain management prior to dressing changes. - Wound consult. - Dietary consult. - Pressure relieving cushion to wheelchair. - APM (Air pressure mattress) check settings, functioning, and inflation every shift. - Provide pericare after each incontinence episode and apply skin protectant. - Monitor labs as ordered and notify MD/NP (Medical doctor/ nurse practitioner) of all values. - Assist with repositioning every hour. Assist of ii [sic] using draw sheet to minimize friction and shearing. - Assess and evaluate wound size, depth, color, and drainage weekly with wound rounds. R5's wound continues to be assessed weekly with the following assessments: 4/25/2024: -Full thickness PI, Stage 3 - 2.6 X 1.4 X 0.1, 25% epithelial, 75% granulation, mod serosanguineous - Cleanse with NS or wound cleanser, skin prep surrounding tissue, apply collagen powder and cover with foam dressing. change 3x/week and PRN - wounds significantly improved 5/2/2024: - Full thickness wound, PI, stage 3 - 2.4 X 1.2 X 0.3, 100% granular, mod serosanguineous - cleanse with NS or wound cleanser, skin prep surrounding tissue, apply collagen powder and cover with foam dressing, change daily and PRN - improved 5/8/2024 - 2.1 X 1.2 X 0.4, 100% granulation, mod serosanguineous 5/16/2024 - 2.0 X 1.8 X 0.5, 100% granular, mod serosanguineous - up for lunch through dinner and then back to bed, strict side lying only 5/23/2024 - 3.0 X 1.0 X 0.4, 50% slough, 50% granulation, mod serosanguineous - unstageable 5/30/2024 - 2.5 X 0.8 X 0.7, 50% granulation, 50% slough 6/6/2024 - Full thickness PI, stage 3 - 2.5 X 1.2 X 0.6, 90% granulation, 10% slough, mod serosanguineous - cleanse with NS and wound cleanser, skin surrounding tissue, apply santyl ointment to wound base and cover with bordered dressing. change daily and PRN -stable Surveyor noted that R5's pressure injury care plan was revised 6/8/2024 with the following intervention: -Resident to stay in bed for breakfast and may get up for lunch and dinner as tolerated. 6/13/2024 - full thickness PI, stage 3 - 2.5 X 1.0 X 0.5, 100% granulation, mod serosanguineous - cleanse with NS and wound cleanser, skin prep surrounding tissue. apply collagen to wound base and cover with bordered dressing. change 3X weekly and PRN 6/20/2024 - full thickness PI, stage 3 - 3.0 X 0.9 X 0.5, 100% granulation, mod serosanguineous - improved, edges of wound scraped up to promote healing 6/27/2024 - 2.9 X 1.3 X 0.5, 100% granulation. mod serosanguineous - stable 7/3/2024 - full thickness PI stage 3 - 2.9 X 0.8 X 0.5, 100% granulation, mod serosanguineous 7/10/2024 (DON) - full thickness PI, stage 3 - 2.5 X 0.8 X 0.5, 100% granulation, mod serosanguineous 7/11/2024 (RN) - full thickness PI, stage 3 - 2.9 X 1.1 X 0.4, 100% granulation, mod serosanguineous 7/18/2024 - full thickness PI, Stage 3 - 2.7 X 0.9 X 0.4, 100% granulation, serosanguineous 7/25/2024 - full thickness PI, stage 3 - 2.8 X 0.9 X 0.4, 100% granulation, serosanguineous - Seen by wound team. No new orders at this time. Will continue with current plan of care. 8/1/2024 - full thickness PI, Stage 3 - 2.5 X 0.8 X 0.4, 100% granulation, serosanguineous -improved 8/8/2024 - full thickness PI, stage 3 - 2.3 X 0.8 X 0.3, 100% granulation, serosanguineous -improved 8/15/2024 - Full thickness, stage 3 - 2.4 X 0.8 X 0.3, 100% granulation, serosanguineous -stable 8/22/2024 - 2.0 X 0.7 X 0.3, 100% granulation, serosanguineous -improved 8/29/2024 - 2.0 X 0.6 X 0.3, 100% granulation, mod serosanguineous -improved 9/5/2024 - 1.7 X 0.5 X 0.1, 100% granulation, mod serosanguineous 9/12/2024 - 1.6 X 0.4 X 0.1, 100% granulation, mod serosanguineous -improved 9/19/2024 - 1.5 X 0.4 X 0.1, 100% granulation, mod serosanguineous - improved 9/26/2024 - 1.5 X 0.4 X 0.1, 100% granulation, serosanguineous -stable 10/3/2024 - 1.5 X 0.2 X 0.1, 100% granulation, mod serosanguineous - stable, improving slowly due to the scar tissue- harder to heal- wound NP has been doing little debridement or scratching of edged to increase wound healing- has been working On 10/1/2024 at 11:06 AM, Surveyor observed R5 in the dining room sitting in a Broda wheelchair reading a book. Surveyor asked R5 if R5 just got up for the day. R5 stated that R5 has been up all morning and was waiting for lunch. Surveyor asked R5 if R5 has been sitting in the Broda wheelchair all morning or if just got into the Broda wheelchair. R5 stated R5 was sitting in the Broda wheelchair all morning. Surveyor asked R5 if R5 has been repositioned in the Broda wheelchair or laid down in bed after breakfast. R5 replied No. On 10/2/2024 at 1:27 PM, Surveyor observed R5 in the dining room sitting in a Broda wheelchair finishing lunch. On 10/2/2024 at 3:21 PM, Surveyor observed R5 sitting in a Broda chair in the dining room, Surveyor asked if R5 had been lain down in R5's be at all since the morning. R5 replied no. On 10/2/2024 at 7:46 AM, Surveyor observed R5 sitting in the dining room in a Broda wheelchair. R5 stated R5 has been up in the chair for a while and was waiting for breakfast. On 10/2/2024 at 1:24 PM, Surveyor observed R5 sitting in a Broda wheelchair. Surveyor asked R5 if R5 laid down after lunch or had been repositioned in R5's wheelchair. R5 replied no. On 10/2/2024 at 3:15 PM, Surveyor shared concerns with Director of Nursing (DON)-B that Surveyor had observations 10/1/2024 and 10/2/2024 of R5 sitting in R5's Broda wheelchair all morning and afternoon and that R5's care plan intervention is that R5 is to be up for lunch and dinner meals as tolerated and in bed for breakfast for pressure injury healing. DON-B stated DON-B would have to look into it and talk with staff. On 10/3/2024 at 7:35 AM, Surveyor interviewed Wound Nurse- H who stated it was important for R5 to stay off R5's bottom area because of having a history of a pressure injury in the same spot as the one R5 has now and a lot of scar tissue was in the area, so it makes it hard for R5's current pressure injury to heal. On 10/3/2024 at 3:04 PM, Surveyor shared concerns with ADON-M, Executive Director-C, and Nursing Home Administrator (NHA)-A that R5's pressure injury that was first observed on 4/18/2024 did not have a comprehensive assessment or care plan revisions until two days later on 4/18/2024 when R5's pressure injury was staged as unstageable and then staged as a stage 3 on 4/25/2024. Surveyor also shared observations on 10/1/2024 and 10/2/2024 of R5's care plan not being followed and R5 was observed in R5's Broda wheelchair from morning until evening and that R5's care plan is to be up in wheelchair for lunch and dinner then in bed for pressure injury healing. No additional information was provided as to why the facility did not ensure that R5 received necessary treatment and services consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing. 2.) R48 was readmitted to the facility on [DATE] with a diagnoses that include malignant pleural effusion, hydronephrosis, protein-calorie malnutrition, and atrial fibrillation. R48's significant change minimum data set (MDS) dated [DATE] indicated R48 had intact cognition with a brief interview for mental status (BIMS) score of 15 and the facility assessed R48 requiring total assistance with 1 staff member for all activities of daily living (ADL's). the facility assessed R48 on 9/12/2024 as being a moderate risk for pressure injury development with a Braden risk score of 14. R48's Pressure Ulcer/Skin Condition care plan was initiated on 9/12/2024 with the following interventions: - Braden scale to be completed. - Keep bed linens wrinkle free and do not use excess pads. - Observe skin for redness and breakdown during routine care. - Use pressure relieving devices, cushion in wheelchair, and off heels [sic], as indicated. - Follow community skin care protocol. - Treatments as indicated, see physician orders. - Pressure reducing mattress on bed, check function, and setting every shift. Set at 2. On 10/1/2024 at 9:51 AM, Surveyor observed R48 lying on R48's back in bed. Surveyor noted R48's air mattress to be off. Surveyor asked R48 if R48 was comfortable and if staff came in to help R48 reposition. R48 stated R48 was comfortable, and staff was just in to reposition R48 so R48 could eat breakfast. On 10/1/2024 at 3:16 PM, Surveyor observed R48 lying in bed sleeping. Surveyor noted R48's air mattress was off and not working. On 10/2/2024 at 7:50 AM, Surveyor observed R48 lying in bed on R48's back and air mattress was not on. On 10/2/2024 at 1:39 PM, Surveyor observed R48 sitting in a wheelchair. Surveyor noted that R48's air mattress was off. On 10/2/2024 at 3:15 PM, Surveyor showed DON-B R48's air mattress. DON-B looked at R48's air mattress and noted that the plug was not pushed in to the outlet all the way. DON-B pushed the plug in, and the air mattress started to work and inflated. Surveyor asked DON-B how DON-B can verify that staff is looking at R48's air mattress to make sure it is working appropriately and knows how to operate his air mattress. DON-B replied that it would be an order and on R48's medication/treatment administration record (MAR/TAR) to sign off on when done. On 10/2/2024, Surveyor reviewed R48's September and October 2024 MAR/TAR record and noted an order that was initiated on 9/12/2024 that states: -air mattress to bed. Check for proper inflation, function, and setting every shift. Surveyor noted that staff was initialing on 10/1/2024 and 10/2/2024 every shift that R48's air mattress was functioning properly. On 10/3/2024 at 3:04 PM, Surveyor shared concerns with ADON-M, Executive Director-C, and Nursing Home Administrator (NHA)-A that R48's air mattress was observed not working appropriately on 10/1/2024 and 10/2/2024 and staff were initialing each shift that R48's mattress was checked and functioning properly. No additional information was provided as to why R48 did not received the necessary treatment and services consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing.

Based on observation, interview, and record review, the facility did not ensure 3 of 4 residents reviewed (R38, R29, and R43) received adequate supervision and assistance, and that interventions were in place to prevent accidents. R38 sustained multiple falls resulting in injuries. A thorough investigation after every fall was not completed to determine root cause analysis. R38's care plan was not revised with recommended fall prevention interventions. R29 had a fall in their room on 9/24/24. Fall interventions were not in place at the time of the fall. R43's fall on 9/9/24 was not thoroughly investigated to determine the root cause. Findings include: The facility policy titled Falls Prevention dated revised, 7/2023, states (in part) .The intent of this policy is to provide and environment that is free from accident hazards, over which there is control, and provide supervision and intervention to residents to prevent avoidable accidents . II. Fall Risk Intervention. The Interdisciplinary Team shall identify individualized interventions to reduce the risk of falls. 1. Falling Star Program . C. If falling recurs despite initial interventions, associate shall implement additional, different interventions or indicate reason the current approach remains relevant. This documentation should be maintained in the clinical record. The facility policy, entitled, Falls dated revised, 7/2023, states (in part) .Policy statement: The purpose of this procedure is to provide guidelines for evaluation of a resident in the event a fall occurred and to assist associates in identification of potential causes of the fall. Policy Detail: Direct care associates shall evaluate the area where the fall occurred for possible contributors. The documentation of the identified interventions should be maintained in the resident clinical record and available to the direct care associates. The falls should be reviewed at the Daily Stand-up meeting following the fall for identification of any additional individualized interventions to reduce the risk of falls. An incident report shall be completed for the resident falls by a licensed nurse after the fall occurs. R38 was readmitted to facility on 10/21/23 with diagnoses that include Alzheimer's disease, unspecified protein-calorie malnutrition, and hip fracture that occurred as a result of a fall at the facility on 10/10/23. R38's quarterly MDS (Minimum Data Set) dated 6/8/24 documents R38 required partial to moderate assist for transfer. R38's quarterly MDS dated [DATE] indicates a BIMS (Brief Interview for Mental Status) score of 0, indicating severe cognitive impairment and also documents R38 is occasionally incontinent of bowel and bladder. R38's ID (Interdisciplinary Notes) indicate falls occurred on 10/10/23, 1/16/24, 4/24/24, 4/25/24, 5/4/24, 7/23/24, and 8/20/24. R38's Care Plan dated 7/5/23, prior to R38's first fall on 10/10/23, documents: Potential for falls related to recent admission to community, recent fall, generalized weakness, confusion. Interventions include: -keep pathways clear/adequate lighting -keep bed at the appropriate height -keep personal items within reach -orient to room and call light -soft touch call light -bed against wall -body pillow when in bed to be aware of boundaries -floor strips next to bed and in front of toilet and recliner. -dump seat wheelchair with auto lock brakes -Falling Star program -Call don't fall signs in room -encourage to stay in areas of high visibility -activity assessment -educate family to notify staff of residents return from outings and of family departure -educate family to notify staff and to use call light when resident is in need of assistance -PT (Physical Therapy) to provide education regarding safe transfers -Transfer resident with a 1 assist stand by -Keep residents bed at transfer height -scoop mattress -bilateral grab bars -Make sure foot pedals are only on when being pushed -Assess for bleeding if resident falls due to use of anticoagulant Review of R38's medical record identify no falls documented prior to 10/10/23. Surveyor asked for all of R38's fall investigations. The facility Fall Investigation dated 10/10/23 documents: R38 was found on the floor in her room at 6:45 PM. A thorough investigation was completed, and care plan interventions were in place at the time of the fall. R38 sustained a hip fracture as a result and was admitted to the hospital. R38 was readmitted to the facility on [DATE] with a diagnosis of a hip fracture. The care plan was revised on 10/23/24 to include encourage to wear gripper socks if not wearing her shoes. R38's medical record documents an interdisciplinary (ID) note dated 1/16/24, indicating R38 sustained a fall on 1/16/24 at 3:30 AM. The ID note documents: Last seen prior to Fall: Not documented. Last Toileted: Not documented. Location of Fall: Room/self-transferring to bathroom. Who witnessed Fall: Unwitnessed. Hit Head: Yes. Neuros completed: Yes. Injury: Right elbow pain, right knee pain and back pain. Staff Statements: Not completed. Nurse Post Fall: Not completed. CNA (Certified Nursing Assistant) Post Fall: Not completed. hospitalized : Yes. Falls Risk assessment: Yes. Root Cause Analysis: Not completed. Interdisciplinary note dated 1/16/24 at 8:51 PM documents: Intervention: Bed commode since resident is always transferring self to bathroom. Surveyor was informed the facility does not have a fall investigation for R38's fall on 1/16/24. Surveyor notes the fall prevention intervention of bed commode was not added to R38's care plan. On 4/24/24, R38's medical record documents R38 had a fall at 9:30 AM. The facility's falls investigation documents R38 was last seen at 9:00 AM. Last Toileted: Not documented. Call light not used. Location of Fall: Room/fell out of wheelchair, trying to get up. Unwitnessed. Hit head, neurological checks completed. Pain, left elbow. R38 was transferred to the hospital for evaluation, no injuries. New interventions implemented: Get up in morning/offer to lay down after meals. Reeducated resident on not to self-transfer and education on call light use. Surveyor notes a thorough investigation of the fall was not completed to identify the root cause. There was no documentation as to when R38 was last toileted. The recommended intervention to get up in morning/offer to lay down after meals was not added to R38's care plan. In addition, education on call light use was not an appropriate intervention as R38 is assessed to have severe cognitive impairment. On 4/25/24, R38's medical record documents R38 had a fall at 4:35 PM in the dining room. The facility's falls investigation documents: Last toileted - unknown. Resident was unable to specify what caused the fall. New recommended intervention: Every one-hour checks during shift, 2 to toilet during shift. Surveyor notes the facility did not complete a thorough investigation to identify the root cause of the fall. R38's care plan was not revised to include every one-hour checks during shift and a 2-person toilet transfer as documented as the new fall prevention interventions. On 5/4/24, R38's medical record documents R38 had a fall at 11:30 AM. The facility's falls investigation documents: Unwitnessed - fell out of recliner trying to get into bed. The facility did not complete a thorough investigation to identify the root cause of the fall or if care plan interventions were in place at the time of the fall. There was no documentation of when R38 was last seen or toileted. IDT (Interdisciplinary Team) Root cause determination: Continue monitoring, reeducated on call light use. Surveyor noted no new interventions were implemented to prevent falls. Reeducation on call light use was not appropriate as R38 is assessed to have severe cognitive impairment. On 7/23/24 at 3:00 AM, R38 sustained her 6th fall. The fall investigation documents: Unwitnessed, found on floor. Skin tear left elbow. Appears resident was self-transferring without calling. Last seen prior to Fall: 2:30 AM - 2:45 AM. Last Toileted 12:00 AM. Footwear: Socks only. Footwear: Gripper socks. Surveyor noted the fall investigation did not indicate if care plan interventions were in place at the time of the fall (ie: body pillow for positioning). The investigation also is not clear as to R38's footwear at the time of the fall. Surveyor noted R38's care plan was revised with new fall interventions: Low bed and floor mats placed during HS (hour of sleep). Transfer height and grip strips during AM/PM. Resident needs floor mat and transfer height during bedtime. During AM/PM resident needs transfer height and only grip strips. Remove floor mat during AM/PM for fall preventions - implemented 7/25/24. As a result of the fall on 7/23/24, R38 was sent to the hospital for evaluation. She returned to the facility the same day. The hospital After Visit Summary dated 7/23/24 documents: X-ray wrist 3 or more views right. Findings: Acute, comminuted and impacted transverse distal radial metaphyseal fracture. Mildly displaced dorsal fracture fragments. Minimally displaced ulnar styloid process fracture. Impression: Acute distal radial and ulnar styloid process fractures. On 8/20/24, R38's medical record documents R38 had a fall at 11:30 AM. The investigation did not include a root cause analysis of the fall. There was no documentation of when R38 was last seen or toileted. The resident sustained no injuries. Surveyor noted R38's care plan was not revised, and no new interventions were implemented. On 10/1/24 at 9:50 AM, Surveyor interviewed RN (Registered Nurse)-G who stated R38 had multiple falls and pointed out the Call, don't fall signs throughout R38's room. On 10/1/24 at 9:45 AM, Surveyor observed R38's room noting fall interventions in place of a low bed, floor mat, non-skid strips on floor by bed, recliner, and bathroom, body pillows, call don't fall signs, and a soft touch call light. On 10/7/24 at 1:50 PM, Surveyor informed Executive Director-C and NHA (Nursing Home Administrator)-A of concerns regarding R38's falls: R38 sustained a fall on 10/10/23 resulting in a hip fracture. R38 sustained 6 subsequent falls, one of which occurred on 7/23/24 resulted in a wrist fracture. The facility did not complete thorough investigations to determine the root cause following every fall, and recommended interventions were not added to R38's care plan. In addition, recommended interventions to include reeducation on use of call light was not appropriate as R38 has a BIMS score of 0 indicating severe cognitive impairment. NHA-A reported going forward she plans to review all residents' fall interventions. No additional information provided. 21855 2.) On 10/01/24 at 10:46 AM, Surveyor observed R29 sitting in a recliner in their room. R29 wheelchair was next to the recliner. R29's medical record was reviewed by Surveyor. The (interdisciplinary notes) IDT documents a fall on 9/3/24. R29 had a fall while self transferring. R29 did not have any injury. The fall was assessed with a new intervention identified to keep the wheelchair by the bedside. R29 is able to self transfer and did not have their wheelchair next to their bed at the time of the fall. R29's medical record documents a fall on 9/23/24. R29 was self transferring from their bed. The Fall Investigation documents the wheelchair was across the room. R29 did not have any injury. Surveyor noted R29's fall prevention intervention of having the wheelchair next to the bed was not followed. R29's Fall plan of care due to a potential for falls related to recent admission to the community, history of recurrent falls, generalized weakness, poor safety awareness. Has right lower extremity deformity and prefers to wear their personal slippers instead of non-skid socks. This has a start date of 4/19/24. This includes the 9/3/24 fall prevention intervention to keep the wheelchair by bedside. On 10/02/24 at 11:00 AM, Surveyor observed R29 in a recliner in their room. R29's wheelchair was next to the recliner. On 10/02/24 at 1:02 PM, Surveyor interviewed (Director of Nurses) DON-B. DON-B stated R29 is aware they are supposed to ask for help. DON-B stated the wheelchair was not next to the bed on 9/23/24 at the time of the fall. DON-B stated they did talk to staff about following the plan of care. R29 does have care plan interventions to have their wheelchair next to the bedside. On 10/3/24 at 3:03 PM, at the facility exit meeting with (Executive Director) ED-C, Surveyor shared R29's fall intervention concerns. No further information was provided. 47094 3) R43 was admitted to the facility on [DATE] and has diagnoses that include cerebral infarction affecting the left dominant side, left foot drop, repeated falls, wedge compression FX (fracture) to lumbar back, major depressive disorder, and congestive heart failure. R43's quarterly minimum data set (MDS) dated [DATE] indicates R43 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 9 and the facility assessed R43 needing extensive assist with one staff member for bed mobility and requiring a Hoyer lift with 2 staff members for transferring. R43 is occasionally incontinent of bowel and bladder and uses a wheelchair in which R43 self-propels to places. R43 has a history of falls and the facility last assessed R43 on 7/11/2024 as being at moderate risk for falls with a fall risk score of 23. On 9/9/24 at 7:14 AM, R43's medical record documents R43 had an unwitnessed fall. The investigation summary documents R43 was observed by housekeeping staff sitting with R43's back against the bed yelling for help. R43 stated they rolled out of bed. Surveyor noted the facility's fall investigation does not include staff interviews regarding when R43 was last checked on or toileted, if objects such a call light were in reach of R43. The investigation does not state what R43 may have been reaching for or if R43's call light was activated at the time of the fall. The fall investigation does not state if immediate interventions were put in place and R43's Fall care plan was not revised. On 10/3/2024 at 10:51 AM, Surveyor observed R43 in the hallway in R43's wheelchair. Surveyor asked R43 if R43 has had any falls out of bed recently. R43 stated R43 could not recall if they had any falls recently. On 10/3/2024 at 3:04 PM, Surveyor shared concerns with Assistant Director of Nursing (ADON)-M, Executive Director-C, and Nursing Home Administrator (NHA)-A regarding R43's fall investigation on 9/9/2024 not being thorough as it did not identify the root cause of the fall, when R43 was seen and/or assisted by the staff or identify fall prevention interventions implemented to address the root cause of the fall. Surveyor requested if any other information pertaining to the fall could be located regarding staff interviews, how R43 was prior to the fall and when last checked on or toileted, what interventions were put in place and any revisions made to R43's fall care plan. Executive Director-C stated she would look into it and get any further information. No further information was provided to Surveyor.

Based on interview and record review, the facility did not ensure that based on the comprehensive assessment of a resident, residents (R4, R1, and R3) received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and residents' choices. *R4 admitted to the facility on [DATE] and was to have admission lab work completed on [DATE] to get a baseline and because his labs on [DATE] at the hospital had some significant results. The facility did not obtain this lab work until [DATE]. The after hours Nurse Practitioner (NP) was notified of the lab results on [DATE] and ordered a repeat a CBC (complete blood count) on [DATE]. On the afternoon of [DATE], R4 fell in the parking lot while working with therapy and complained of hip pain after he was brought to his room. R4 had a change in condition with lethargy and pallor and became unresponsive with agonal breathing. EMS transported R4 to 2 hospitals where he was hypotensive (low blood pressure) and required emergency blood transfusions. R4 admitted with multiple organ failure and passed away at the hospital on [DATE]. The State of Wisconsin Nurse Practice Act section N 6.03 Standards of practice for registered nurses states: (1) General nursing procedures. An R.N. 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 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. The facility's failure to provide treatment and care in accordance of professional standards for R4 by failing to obtain labs when ordered, failing to consult with R4's physician when lab results demonstrated a change of condition, failing to monitor edema by obtaining daily weights as ordered, and failing to arrange a follow up nephrology appointment as ordered resulted in a significant decline in R4's health, and the need to be transferred to the ICU with multiple organ failure resulting in R4's death. This created a finding of Immediate Jeopardy (IJ), which began on [DATE]. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were notified of the immediate jeopardy on [DATE], at 3:53 P.M. The immediate jeopardy was removed on [DATE], however, the deficient practice continues at a severity/scope level of D (potential for more than minimal harm/isolated) as the facility continues to implement and monitor its action plan as evidenced by: *R1 had a BNP (B-Type Natriuretic Peptide) and BMP (basic metabolic panel) drawn on [DATE] related to R1's bilateral lower extremity edema. The facility did not monitor R1's bilateral lower edema and a care plan for edema was not implemented. *Only one of three stool ordered samples were obtained for R3 and a colonoscopy was not scheduled. Findings include: The facility's policy entitled Laboratory, Radiology, and other Diagnostic Test Results dated ,d+[DATE] and last revised ,d+[DATE] documents: Policy Statement The resident's Attending Physician will be notified of the results of laboratory, radiology, and other diagnostic tests. Policy Interpretation and Implementation A. Results of laboratory, radiological, and diagnostic tests shall be reported in writing to the Resident's Attending Physician or to the community. B. Should the test results be provided to the community, the Attending Physician shall be promptly notified of the results. C. The Director of Nursing Services, or Charge Nurse receiving the test results, shall be responsible for notifying the Physician of such test results. D. Signed and dated reports of all diagnostic services shall be made a part of the Resident's medical record . R4 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease, Stage 3, Chronic Diastolic Heart Failure, Anemia in Chronic Kidney Disease, Type 2 Diabetes Mellitus, Repeated Falls, and Hyperlipidemia. R4 was his own person while at the facility. R4's Admission Minimum Data Set (MDS) completed on [DATE] documents R4 had a Brief Interview for Mental Status (BIMS) score of 13, indicating R4 was cognitively intact for daily decision making. R4 had no mood or behavior concerns documented. R4's MDS documents a range of motion impairment on both sides of the upper extremities and impairment on 1 side of the lower extremity. R4 requires supervision for rolling left to right, lying to sitting, chair/bed-to-chair transfers, and toilet transfers. R4 required partial/moderate assistance for sit to lying and sit to stand. R4's care plan, dated [DATE] with a target date of [DATE] documents: R4 has potential complications from chronic kidney disease. Interventions include: -monitor for increased fatigue or weakness -monitor urine for color, odor, and amount, and maintain intake and output if indicated -monitor for weight gain or loss, or edema, inform physician of concerns -monitor labs as ordered and inform physician of results Surveyor reviewed R4's hospital discharge paperwork dated [DATE] which documents on [DATE], R4 was admitted to the hospital with diagnoses of multiple falls, head injury, atrial fibrillation, recurrent gastrointestinal (GI) bleeds, anemia, hypertension, and chronic kidney disease, stage 3. R4 had fallen at home, which resulted in a left femoral neck fracture. R4's hospital discharge summary dated [DATE] also documents R4 is noted to have chronic edema, however, on presentation, edema was greater than baseline therefore diuresis was pursued but unfortunately this resulted in a rise in creatine. Later in R4's stay, nephrology was consulted. Creatinine trended down prior to discharge but was not quite to baseline. R4 was cleared for discharge by nephrology with plans to hold diuretics for 2 days, then resume, hold angiotensin reception blockers (ARBs) and plan to follow up with R4's nephrologist in next ,d+[DATE] weeks. Discharge instructions document R4 to have labs checked, follow up with nephrology, do not take diuretics, Lasix for next 2 days, and resume on [DATE]. R4 was to have lab work completed on [DATE] to gain a baseline for admission and to recheck the labs after significant values were recorded in the hospital on [DATE]. R4's physician orders document Lasix was initiated on [DATE], 40 mg 2 times a per week and 60 mg 5 times a week. R4's physician orders also document R4 was to have daily weights initiated on [DATE]. Surveyor reviewed R4's documented weights. The facility did not obtain a weight on [DATE], day of admission. There are no weights documented for R4 on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], or [DATE]. Surveyor reviewed Nurse Practitioner (NP)-H's progress notes for R4. NP-H's visit progress note dated [DATE] documents: monitor labs closely and to follow up with R4's nephrologist. NP-H documents pending admission lab [results]. On [DATE], NP-H documents pending admission lab [DATE] and again for follow-up with nephrology. On [DATE], NP-H documents pending admission lab for today and again to follow up with nephrology. Surveyor was unable to locate documentation that a follow up nephrology appointment was made for R4. On [DATE], at 10:59 AM, Health Information Management (HIM)-F confirmed HIM-F is responsible for making sure follow up appointments are made. HIM-F confirmed that no follow up nephrology appointment was made for R4 prior to being discharged to the hospital on [DATE]. R4's medical record contained documentation of a laboratory order request dated [DATE] which documents R4 was to have labs drawn weekly on Mondays for 4 weeks effective [DATE]. There were no labs drawn for Monday ,d+[DATE] or Monday [DATE]. Surveyor notes R4 did not have labs drawn until [DATE]. On [DATE], at 10:24 PM, R4's medical record documents the after hours Advanced Practice Nurse Practitioner (APNP)-Q was notified of the lab results. Registered Nurse (RN)-R documents at 11:19 PM, an order to repeat the CBC (complete blood count) on [DATE] in the morning. Surveyor notes R4's medical record does not contain documentation that labs were completed the morning of [DATE] as ordered. Surveyor reviewed R4's labs and the following are of significance: [DATE] (morning before discharge from the hospital) [DATE] Reference Interval Sodium 147 Sodium 150 ,d+[DATE] High Chloride 113 Chloride 115 ,d+[DATE] High Blood Urea Nitrogen 108 Blood Urea Nitrogen 93 ,d+[DATE] High Creatinine 2.68 Creatinine 2.26 XXX,d+[DATE].30 High RBC 2.2 RBC 2.71 4XXX,d+[DATE].9 Low Hemoglobin 8.9 Hemoglobin 7.1 13XXX,d+[DATE].5 Low Hematocrit 29.3 Hematocrit 24 ,d+[DATE] Low MCV 108.1 MCV 111 ,d+[DATE] High MCH 32.8 MCH 32.4 25XXX,d+[DATE].2 High MCHC 30.4 MCHC 29 ,d+[DATE] Low Platelet Count 160 Platelet Count 132 ,d+[DATE] Low Surveyor notes there is no documentation R4's attending physician was notified and reviewed R4's [DATE] lab values. On [DATE], at 3:00 PM, R4's medical record documents R4 had a fall in the parking lot. Therapy was working on a car transfer at the time with R4. R4 was brought back to his room. On [DATE], at 3:58 PM, R4's medical record documents Assistant Director of Nursing (ADON)-C was called to R4's room due to his complaints of hip pain. ADON-C documents that upon entering R4's room, R4 appeared lethargic and pale. Blood Pressure ,d+[DATE]. Heart Rate 75. Blood Pressure verified with manual cuff ,d+[DATE]. Emergency Medical Services (EMS) contacted. On [DATE], at 4:10 PM, R4 became unresponsive with agonal breathing and pallor. R4 positioned in supine position on floor. Emergency equipment at bedside. EMS arrived for hand off and transported to the hospital. Hospital records dated [DATE] document upon arrival to the hospital, EMS reported that R4 was hypotensive and did not improve with 800 cc (cubic centimeters) of normal saline. R4 presented with a small scalp hematoma. R4 required emergent transfusion and was ordered 2 units of uncross matched blood. R4's computed tomography (CT) of the chest, abdomen, and pelvis demonstrated large bilateral flank and lateral abdominal wall subcutaneous heterogeneous fluid collections suggesting the possibility of bilateral flank hematoma's of indeterminate age. Another hospital was contacted for an intensive care unit bed and accepted. After the acceptance, R4 again became hypotensive despite norepinephrine, 2 additional units of packed red blood cells (PRBCs) were ordered. R4's blood pressure did improve with the 3rd unit of PRBCs and 4th unit was given to the EMS crew to transport R4 to the ICU with norepinephrine running at 10 mcg/minute. R4's hemoglobin was rapidly identified to be anemic at 5.6. Chest x-ray with questionable left lower lobe infiltrate versus effusion was identified. R4 was admitted to ICU. On [DATE], at 10:35 AM, Surveyor interviewed R4's Family (FAM)-S. FAM-S stated FAM-S was informed by the ICU that R4's labs were bad and was admitted with multiple organ failure and never recovered. R4 expired on [DATE]. On [DATE], at 11:19 AM, Surveyor interviewed NP-H. NP-H stated R4 needed to be monitored due to stage 3 kidney disease and the facility should have completed the weights as ordered. NP-H stated the expectation is if daily weights are ordered, it should have been done to monitor R4's edema. NP-H stated NP-H ordered labs to be completed and recognized on [DATE] and [DATE] the labs had not been completed by the facility. NP-H stated sometimes it doesn't get done. Surveyor asked NP-H if that is right and NP-H stated, No, it is not, it should have been done. On [DATE], at 12:33 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C. ADON-C does not recall why R4's labs were not completed upon admission as ordered. On [DATE], at 2:38 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R4's daily weights had not been completed, R4's follow up with nephrology had not been scheduled, and R4 did not have labs completed until 10 days after admission leading to a change in condition and the need for R4 to be transferred to the hospital. On [DATE], at 9:37 AM, ADON-C explained the facility process and procedure for obtaining labs for residents. ADON-C stated every new admission has labs ordered every week for 4 weeks and as needed. ADON-C stated the lab company comes every day and lab draws are always done in the morning. ADON-C stated when a resident is admitted , the expectation is the lab draw is completed the next morning. ADON-C cannot answer why R4's labs were not completed the day after admission. ADON-C stated, can't speak to the delay in obtaining the labs for R4. ADON-C stated the unit nurse is responsible for monitoring the residents' labs. The after hours, on call NP (NP-Q) does not know the residents so abnormal labs like R4's would be reviewed with NP-H, however, there is no documentation in R4's medical record this was completed. On [DATE], at 12:30 PM, Surveyor interviewed NP-H in regard to R4's abnormal labs. NP-H confirmed they had reviewed R4's medical record and noted the labs had not been completed for R4 and it was critical to get them done. NP-H stated that is why NP-H kept documenting pending admission labs [results]. NP-H stated they give verbal orders to the nursing staff to get labs completed. NP-H compared R4's lab values from [DATE] and [DATE] and confirmed R4's labs on [DATE] were concerning. NP-H would have expected the labs to be repeated as ordered by NP-Q on [DATE] in the morning to make sure R4 did not need to go out for a blood transfusion. NP-H stated they would be concerned with hypernatremia and dehydration based on R4's labs. NP-H agreed it is very concerning R4's labs were not repeated the next day as expected given R4's lab value changes noted between the results from [DATE] and [DATE]. NP-H stated, It was not completed and should have been completed. On [DATE], at 2:17 PM, Surveyor had follow-up questions for NP-H and interviewed NP-H via phone. NP-H can not confirm if therapy should have attempted a car transfer in the parking lot based on R4's critical labs. NP-H stated R4 did not have complaints of dizziness and does not know how it would have impacted working with therapy. However, there is no documentation of R4's condition prior to the attempted car transfer. NP-H stated based on R4's lab values it appears R4 was losing blood from somewhere. NP-H did agree that labs not being completed as needed or expected provided no monitoring of R4 and perhaps the change in condition could have been caught and R4 sent out earlier to the hospital. On [DATE], at 2:30 PM, Surveyor communicated to NHA-A and DON-B the serious concern of the facility failing to get R4's labs completed as ordered by the nurse practitioner resulting in R4 becoming unresponsive, being sent to the emergency room and requiring emergent transfusion, being admitted to ICU with multiple organ failure, and consequently expiring. The facility's failure to obtain labs when ordered, consult with R4's physician when lab results demonstrated a change in condition, monitor R4's edema by obtaining ordered daily weights, and to arrange a follow-up appointment with nephrology as ordered resulted in a significant decline in R4's health and his subsequent hospitalization and death thus leading to a finding of immediate jeopardy. The facility removed the jeopardy on [DATE] when the facility implemented the following: -Designee will do a facility-wide lab audit in order to identify any Residents who had lab orders that did not receive the proper follow up. -Residents identified will have lab order results verified with the provider and appropriate action taken. -Designee will audit all lab orders for two weeks, then weekly for one month to ensure that labs are completed and are completed to the provider. -Audit results will be reviewed at the QA committee until the QA committee has determined that substantial compliance has been achieved. -Direct care licensed nurses will be re-educated on the proper procedures for placing lab orders, ensuring that the lab draws occur per provider's orders and that lab results are reported to the providers in a timely manner. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as evidenced by the following: 20483 2.) R1 was admitted to the facility on [DATE] with diagnoses which includes right femur fracture, dementia, and anxiety. The facility developed the following care plans: * [R1's first name] is at risk for impaired communication related to change in environment. Dated [DATE]. * [R1's first name] needs assistance with daily ADL (activity daily living) care. Dated [DATE]. * [R1's first name] is at risk for psychosocial well-being concern related to COVID-19 and/or other infections. Dated [DATE]. * [R1's first name] is at risk for changed activity and preferences due to new environment. Short stay, dementia. Dated [DATE]. * [R1's first name] has potential for falls related to recent admission to community. Dated [DATE]. * [R1's first name] is at low risk for impaired nutrition. Dated [DATE]. * [R1's first name] is at risk for pressure ulcers and other skin related injuries. Dated [DATE]. * [R1's first name] rates pain a <0|1|2|3|4|5|6|7|8|9|10>. Dated [DATE]. * [R1's first name] does not plan to make the community a long term home. Dated [DATE]. * [R1's first name] will have advance directives reviewed upon admission, full code. Initiated [DATE]. * [R1's first name] is at risk for < increased behavioral expressions||altered mood||elopement||impaired adjustment ability to new environment>. Dated [DATE]. * Level 1 PASRR (preadmission screening and resident review) is negative. Dated [DATE]. * [R1's first name] has diseases and conditions which are treated with medication. Dated [DATE]. * [R1's first name] has memory problems, impaired decision making skills and impaired ability to comprehend, confused and forgetful, own person, dx (diagnosis) dementia. Dated [DATE]. * [R1's first name] need enhanced barrier precaution d/t (due to) indwelling medical device, wound/s or MDRO (multidrug resistant organisms) or contained infection. Dated [DATE]. The nurses note dated [DATE] PM (evening) documents Per DON (Director of Nursing) sleep study initiated. New lab orders for ,d+[DATE] BNP (B-Type Natriuretic Peptide) and BMP (basic metabolic panel) r/t (related to) BLE (bilateral lower extremity) edema. Surveyor was unable to locate any monitoring of R1's bilateral lower extremity edema and a care plan for edema was not implemented. On [DATE], at 10:00 a.m., Surveyor observed R1 sitting in a wheelchair wearing socks and sneakers. Surveyor observed R1's feet are resting on the floor, there are no leg rests on R1's wheelchair and R1's legs are not elevated. On [DATE], at 10:45 a.m., Surveyor observed R1 continues to be sitting in a wheelchair in the room with R1's feet on the floor. R1's legs are not elevated. On [DATE], at 1:20 p.m., Surveyor observed R1 sitting in a wheelchair in the room with her daughter. R1's feet are resting on the floor. On [DATE], at 3:27 p.m., Surveyor observed R1 sitting in a wheelchair in the room with her feet resting on the floor. R1's daughter is sitting on R1's bed talking with R1. R1 does not have her legs elevated. On [DATE], at 7:54 a.m., Surveyor observed R1 wheeling herself out the the room. R1 informed Surveyor she had gotten up too early and went back to bed. Surveyor observed there are no leg rests on R1's wheelchair to elevate her legs. On [DATE], at 8:05 a.m., Surveyor observed R1 sitting in a wheelchair with her feet on the floor in the dining room eating cereal. On [DATE], at 9:55 a.m., Surveyor observed R1 sitting in a wheelchair with her feet on the floor. R1's son is sitting in a chair in the room. On [DATE], at 11:16 a.m., Surveyor observed R1 sitting in a wheelchair with her feet on the floor in the bathroom. Surveyor asked R1 what she was doing. R1 replied, I think I was turning the light off. On [DATE], at 12:03 p.m., Surveyor asked ADON (Assistant Director of Nursing)-C if there are any issues with R1 having edema. ADON-C informed Surveyor R1 has chronic edema in her legs, not excessive by any means, more of dependent edema due to sitting in a chair and having her legs in a low position. Surveyor asked ADON-C if R1's legs should be elevated. ADON-C informed Surveyor she did suggest this to the family. Surveyor asked about staff interventions. ADON-C informed Surveyor she suggested to the unit nurse to have R1's legs elevated. ADON-C informed Surveyor this should be on the CNA (Certified Nursing Assistant) assignment sheet and could add it to the care plan then it will cross over to the CNA worksheet. Surveyor informed ADON-C Surveyor was not able to locate any evidence staff was monitoring R1's edema and a care plan was not developed for the edema. On [DATE], at 2:38 p.m., Surveyor informed NHA (Nursing Home Administrator)-A, DON (Director of Nursing)-B and ADON-C of labs drawn on [DATE] for R1's bilateral extremity edema. Surveyor was unable to locate any evidence staff was monitoring R1's edema and a care plan for edema was not developed. 3.) R3's diagnoses includes hypertension, atrial fibrillation, and diabetes mellitus. On the BMP (basic metabolic panel) laboratory report with a collection date of [DATE], there is a handwritten notation dated [DATE] which documents, Collect 3 stool samples for occult blood. The nurses note dated [DATE] at 0530 (5:30 a.m.) documents, 97.6 72 16 92% Monitoring stool for occult blood. No active bleeding or reports of a stool this shift. Without acute distress. In the bed resting. Will monitor. The nurses note dated [DATE] at 1100 (11:00 a.m.) documents, without stool obtained. The nurses note dated [DATE] at AM (morning), Stool collection completed. APNP-H's note dated [DATE] under assessment and plan for decreased weight loss includes documentation of EGD (esophagogastroduodenoscopy) (an endoscopic procedure that includes visualization of the oropharynx, esophagus, stomach and proximal duodenum) on [DATE]. Pending stool sample for FGOT (fecal guaiac occult blood test). The nurses note dated [DATE], AM, documents Stool spec (specimen) obtained. 1st one. Sent to lab 0915 (9:15 a.m.). The nurses note dated [DATE], PM (evening), documents No stool sample this shift. Surveyor was unable to locate any further nurses notes regarding stool collection after this date. The occult blood, fecal screen lab report verified on [DATE] documents for value not detected. There is a handwritten notation on this laboratory report dated [DATE] which documents Schedule colonoscopy. Surveyor was only able to locate one occult blood, fecal screen and did not note any documentation regarding the colonoscopy being scheduled. On [DATE], at 10:19 a.m., Surveyor asked HIM (Health Information Management)-F who is responsible for setting up outside appointments. HIM-F informed Surveyor herself and Receptionist-I work together. Surveyor inquired if R3's colonoscopy appointment had been set up. Surveyor informed HIM-F Surveyor noted a notation on lab report dated [DATE] documenting 3 stool samples for occult blood. Surveyor was able to locate one of the three and asked HIM-F if the other two samples were collected. HIM-F informed Surveyor she will get back to Surveyor. On [DATE], at 11:00 a.m., HIM-F informed Surveyor R3 was suppose to have a EGD but this appointment was rescheduled for [DATE]. HIM-F informed Surveyor they were going to go from there if a colonoscopy was needed. Surveyor asked HIM-F if she was able to locate any more stool samples. HIM-F informed Surveyor there was only one done. Surveyor asked HIM-F if there was a unit manager Surveyor could speak with. HIM-F informed Surveyor they don't have unit manager. HIM-F informed Surveyor there is first name of DON (Director of Nursing)-B, first name of ADON (Assistant Director of Nursing)-C, first name of RN (Registered Nurse)/Quality Management-E, and the floor nurses. HIM-F suggested Surveyor speak with ADON-C. On [DATE], at 11:26 a.m., Surveyor asked APNP-H if a colonoscopy was suppose to be scheduled for R3. APNP-H replied yes. Surveyor asked APNP-H if she wrote an order. APNP-H replied I believe so and explained there should be a paper copy. APNP-H informed Surveyor if she was in the building she would have written a paper order and in some cases if she receives a call she gives a verbal order. Surveyor informed APNP-H Surveyor had noted her progress note dated [DATE] which documents stool samples pending. Surveyor inquired if these stool samples were completed. APNP-H informed Surveyor so far she's heard back one was done which was negative. Surveyor asked APNP-H if three stool samples should have been obtained. APNP-H replied yes. Surveyor asked APNP-H if she knows why they weren't done. APNP-H replied no. Surveyor asked APNP-H if anyone informed her the stool samples weren't obtained. APNP-H replied no. APNP-H informed Surveyor she ordered the stool samples for weight loss and colonoscopy for cancer. On [DATE], at 11:43 a.m., Surveyor asked ADON-C if she knew why the stool specimens for occult blood were not obtained. ADON-C replied I do not and explained she wrote this on their board numerous times, put the tubes to collect the blood there and despite her doing this only one was collected. ADON-C informed Surveyor R3 does not eat very much and does not stool a lot. Surveyor inquired about a colonoscopy being scheduled. ADON-C informed Surveyor APNP-H asked an EGD be scheduled. ADON-C indicated while they are going down they could do the other end and go up. Surveyor inquired if anyone communicated this to the GI (gastrointestinal) doctors about doing the colonoscopy at the same time. ADON-C replied not to my knowledge. Surveyor asked ADON-C if an order for the colonoscopy had been written. ADON-C replied I did not see an order for colonoscopy and explained APNP-H may have given the order to floor nurse. On [DATE], at 2:38 p.m., Surveyor informed NHA (Nursing Home Administrator)-A, DON (Director of Nursing)-B and ADON-C three stool specimens for occult blood and a colonoscopy was not scheduled for R3. No additional information was provided to Surveyor as to why this was not done.

Based on interview and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 of 3 (R1) residents reviewed for pressure injuries. R1 had an air mattress ordered for the treatment of a stage 4 pressure injury. R1 moved rooms and the air mattress was not placed on her bed until 1 week later, resulting in a decline in the wound. Findings include: R1 admitted to the facility on [DATE] and has diagnoses that include Dementia, Adult Failure to Thrive, Peripheral Vascular Disease, chronic venous insufficiency, osteomyelitis, and anxiety disorder. R1 admitted to the facility with a stage 4 pressure injury to her sacrum measuring 4.1 x 2.0 x 1.2 cm (centimeters) 100% granulation tissue. R1 has been followed by the wound care physician and appropriate care plan interventions were implemented, which included a low air loss, alternating pressure air mattress. R1's care plan also documented resident at risk for pressure ulcers and other skin related injuries - declines to turn side to side and will only lay on her back. R1's Quarterly Minimum Data Set, dated dated dated [DATE] documented bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed - as extensive 1-person physical assist. R1's October 2022 APNP (Advance Practice Nurse Practitioner) wound care notes and measurements document: 10/13/22 Sacrum/coccyx - pressure stage 4. Full thickness wound measuring 4.0 x 1.4 x 0.3 cm, 100% granular. Moderate serosanguineous drainage. Peri wound is pink and scarred. No s/sx (signs/symptoms) of infection. Plan - apply collagen powder and cover with bordered super absorbent dressing. Change dressing daily. 10/20/22 Sacrum/coccyx - pressure stage 4. Full thickness wound measuring 3.5 x 1.0 x 1.0 cm, 100% granular. Moderate serosanguineous drainage. Peri wound is pink and scarred. No s/sx (signs/symptoms) of infection. Plan - apply collagen powder and cover with bordered super absorbent dressing. Change dressing daily. On 10/26/22 facility progress notes document R1 was positive for Covid, and she was moved to a private room on the Covid unit. 10/27/22 (facility skin evaluation form) Sacrum pressure injury stage 4. Full thickness wound measuring 3.4 x 1.0 x 1.0 cm, 100% granulation tissue, beefy red, surrounded by whitish scar tissue. Moderate serosanguineous drainage. Treatment: Cleanse with NS (normal saline) skin prep surrounding tissue, apply collagen powder to wound bed f/b (followed by) bordered dressing. Change daily. 11/3/22 Sacrum/coccyx stage 4. Full thickness wound measuring 6.0 x 3.8 x 1.7 cm, there is undermining from 1-2 o'clock about 2.1 cm. The base is 90% granular and 10% yellow slough covered with palpable bone. Moderate serosanguineous drainage. Peri wound is pink and scarred. No s/sx of infection. Status: decline. Plan: Apply collagen powder and cover with bordered super absorbent dressing. Change dressing daily. Surveyor noted a significant decline in the sacral pressure injury from 10/27/22 to 11/3/22. Although facility staff completed daily treatment and dressing changes, there was no documentation in facility progress notes that staff recognized a change or decline in the sacral pressure injury from 10/27/22 until the NP identified the significant decline on 11/3/22 during wound rounds. Further review of the APNP note on 11/3/22 documented: Spoke with social worker and bedside RN (Registered Nurse) regarding patient not on specialty mattress. Subsequent documentation: 11/10/22 Sacrum/coccyx stage 4. Full thickness wound measuring 4.5 x 4.0 x 1.8 cm, there is undermining from 10 o'clock about 2.5 cm. The base is 50% granular and 50% yellow slough covered with palpable bone. Moderate serosanguineous drainage. Peri wound is pink and scarred. No s/sx of infection. Status: improve. Plan: Santyl and cover with bordered super absorbent dressing. Change dressing daily. 11/17/22 Sacrum/coccyx stage 4. Full thickness wound measuring 4.0 x 4.5 x 1.0 cm. The base is 90% granular and 10% yellow slough covered with palpable bone. Moderate serosanguineous drainage. Peri wound is pink and scarred. No s/sx of infection. Status: improve. Plan: Santyl and cover with bordered super absorbent dressing. Change dressing daily. Current documentation: Sacrum/coccyx stage 4. Full thickness wound measuring 4.1 x 2.0 x 1.2 cm. The base is 100% granular. Moderate serosanguineous drainage. Wound edges are attached and beginning to appear to be epithelialized. Peri wound is pink and scarred. No s/sx of infection. Status: stable. Plan: Collagen base and cover with bordered foam. Change dressing 3x (times)/wk (week) and PRN (as needed). On 3/8/23 at 10:40 AM, Surveyor spoke with Social Service Director (SSD)-C. Surveyor asked if he recalled if, when R1 moved rooms, the air mattress was moved with the resident to her new room. SSD stated: To my knowledge, yes. On 3/8/23 at 10:55 AM, Nursing Home Administrator (NHA)-A came to the conference room to speak with Surveyor. NHA-A reported SSD-C had just told her what we had talked about, and she wanted to speak to Surveyor. NHA-A stated: Yes, we did have a problem in October when we had Covid. We moved R1 to the Covid unit and it was found that some equipment didn't go with the resident. Surveyor asked if the air mattress was moved to the new room, to which NHA-A stated: No, it did not. It was a bad situation. We immediately got it moved to her bed. Surveyor asked how long R1 was without the air mattress. NHA-A reported a couple of days, if I remember. On 3/8/23 at 2:42 PM, Surveyor spoke with Director of Nursing (DON)-B. DON-B reported on 11/3/22 the NP noticed R1 did not have the air mattress on her bed. DON-B reported the air mattress was immediately replaced and the next day the facility had a meeting to look at the process for moving residents. DON-B reported he spoke to R1's Power of Attorney (POA) the next day and explained what happened and what the facility did to fix it. DON-B reported he does rounds twice weekly to check all air mattresses. Surveyor asked DON-B if he thought R1 having Covid and not having her air mattress for at least 7 days caused decline in the sacral wound. DON-B stated: I would assume that was the reason. It's gotten better already since the air mattress was replaced. Surveyor noted evidence revealed R1 moved rooms on 10/26/22 and the air mattress did not move with the resident to her new bed/room. This was not identified until 8 days later, on 11/3/22 when the NP notified the facility the air mattress was not on R1's bed. A significant decline in R1's sacral wound was noted at that time with increased size of the wound, undermining, and yellow slough covered with palpable bone. Facility staff performing daily dressing changes did not recognize the decline or that R1 was not receiving care planned interventions post move, to include use of an air mattress. Surveyor reviewed R1's TAR (Treatment Administration Record) for October and November 2022 which documented: Air mattress - validate air mattress on correct settings (2), Adjust if necessary. For skin integrity; diagnosis/reason = skin integrity daily. Times to sign out compliance were night shift, day shift, eve (evening) shift. R1's October 2022 TAR documented the above signed out as completed although evidence shows R1's air mattress was not on her bed: Night shift from 10/26/22 through 10/31/22 was signed out as completed, evening shift on 10/26/22, 10/27/22, 10/29/22 and 10/31/22 was signed out as completed, 10/28/22 and 10/30/22 were blank. Day shift 10/26/22, 10/27/22 and 10/31/22 were signed out as completed, 10/28/22 through 10/30/22 documented (N) which Surveyor verified as no. R1's November 2022 TAR documented the above signed out as completed although evidence showed R1's air mattress was not on her bed: Night shift, evening shift and day shift from 11/1/22 through 11/3/22 were signed out as completed. On 3/8/23 at 2:30 PM, Surveyor advised NHA-A of concern R1 moved rooms on 10/26/22 and the ordered air mattress for her stage 4 sacral pressure injury was not put on her bed until 8 days later when identified by the Nurse Practitioner. This resulted in a significant decline in the wound. Surveyor advised of concern facility staff completed daily treatment and dressing changes to R1's sacral pressure injury and did not recognize deterioration of the wound which was identified by the NP on 11/3/22. Surveyor advised R1's TAR indicated staff was to be validating the air mattress settings every shift, which was signed out as having been completed on all shifts, on multiple days from 10/26/22 through 11/3/22 even though the air mattress was not on R1's bed. No additional information was provided.

Based on interview and record review the facility did not provide basic life support, including CPR (Cardiopulmonary Resuscitation) to residents requiring such emergency care as directed in the physicians orders and the resident's advanced directives for 1 of 10 (R3) residents reviewed for CPR. This failure resulted in R3's death. * On [DATE] R3 was found to be unresponsive, pulseless and not breathing. Facility staff did not call 911 and did not provide CPR to the resident despite her advanced directives which indicated she was to be a full code. Facility failure to perform CPR on R3 created a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were notified of the immediate jeopardy on [DATE] at 3:55 PM. The immediate jeopardy was removed on [DATE] when the facility initiated audits of all resident records to verify code status and initiated training for staff on responding to a code situation. The deficient practice continued at a scope and severity of an E (potential for harm/pattern) until the facility completed their action plan including completion of competencies and code drills and corrected the deficient practice on [DATE]. Findings include: R3 admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Power of Attorney for Health Care (POA) document, signed by R3 dated [DATE] documented a check mark next to: I want Cardiopulmonary Resuscitation attempted unless my physician determines one of the following: I have an incurable illness or injury and am dying; or I have no reasonable chance of survival if my heart stops; or I have little change of long-term survival if my heart stops and the process of resuscitation would cause significant suffering. R3's Physicians orders dated [DATE] documented: Resuscitate: Yes; CPR The facility policy titled: Cardiopulmonary Resuscitation and Protected Code Blue, revised ,d+[DATE] documented: . .3. Procedures B. The chances of surviving sudden [CONDITION(S)] (SCA) may be increased if CPR is initiated immediately upon collapse. C. Early delivery of a shock with a defibrillator plus CPR within ,d+[DATE] minutes of collapse can further increase changes of survival. D. If an individual (resident, visitor or staff member) is found unresponsive and not breathing, staff member who is certified in CPR/BLS (Basic Life Support) shall initiate CPR unless: 1. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or 2. There are obvious signs of irreversible death (e.g. Decapitation - the emergency is the result of a beheading and decomposition - rotting or decay). E. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] F. If the first responder is not CPR certified, that person will call 911 and follow the 911 operator's instructions until a CPR certified staff member arrives . The facility policy titled: Code Status Review (which was not dated) documented: . .Green Label on Door = Full Code/Perform CPR White Label on Door = DNR/No CPR If you are unaware of a resident's code status, you MUST perform CPR . Surveyor verified the facility identified residents' code status by the color of the label of their name outside their room. A green label indicates the resident is a full code/CPR is to be done, a white label indicates the resident is a DNR/no CPR is to be done. R3's name was on a green label and correctly identified her code status. Facility progress notes documented: [DATE] at 4:25 AM (entered by Registered Nurse (RN)-F): Patient deceased . Patient had earlier on asked for writer to stay in room with her at start of shift. Also refused vital signs. Just wanted company. Per her baseline behavior, she was asking for help and that she was afraid, but when asked what she need help with, she stated, I don't know. CNA (Certified Nursing Assistant) had just finished changing patient and had head of bed raised up per patient's request. Patient then became unresponsive. No response to verbal or tactile stimuli. No breath sounds over either lung field. No carotid pulses were palpable. No heart sounds detected. NP (Nurse Practitioner) for attending physician was notified and pronounced death at 3:20 AM. Family was called to update, but got no response. Message was left for both son and daughter of the deceased . Facility administrator was updated and made aware of situation and also the fact that family were unreachable, instructed to call coroner. (Surveyor noted the progress note further documented the family did subsequently call the facility and provided funeral home information). Surveyor noted there was no documentation RN-F called 911 and administered CPR. [DATE] at 1:27 PM (entered by then Nursing Home Administrator): Spoke to (resident's daughter) again to update her on the investigation. Shared that CPR was not performed even though her mother was a full code. Told (daughter) that we are investigating the reasons behind this. Reiterated that I would keep her updated on the investigation and that we will be able to sit down and provide a full overview once the investigation is complete. The facility was not aware of this error until [DATE] when the Director of Social Service (DSS)-C was reviewing R3's medical record and found that R3 was a full code. He called the Nursing Home Administrator (NHA), began an investigation and spoke with RN-F about R3's death. On [DATE] at 9:15 AM Surveyor spoke with DSS-C. He reported he was working in the facility on [DATE] as manager. He stated: I heard she (R3) had died and I was surprised. I was just reviewing her chart to see what happened and I came across that she was a full code and CPR wasn't done. I called the Administrator and let her know. I also called the nurse (RN-F). RN-F stated CPR was not done and 911 was not called. He stated he didn't realize she (R3) was a full code until after he called the doctor to pronounce death. He said he saw it in the computer later, after he called the doctor. DSS-C reported he started training with all staff on advanced directives, verifying code status, 911 and CPR. He conducted audits and verified the code status of all residents and the colored labels on all residents' doors. Surveyor review of the facility investigation revealed the following: On [DATE] shortly after midnight (into [DATE]), R3 was exhibiting anxiety. TLC (tender love & care) and snacks were provided and somewhat helpful. Most recent vital signs documented: Temperature 97.6, pulse 70, respirations 20, blood pressure ,d+[DATE] and pulse oximetry ,d+[DATE]% room air. On [DATE] at 2:50 AM the CNA (Certified Nursing Assistant) changed the resident and raised her head of bed per request. On [DATE] at 3:00 AM the CNA returned to R3's room to find the resident unresponsive and could not feel a pulse. She notified Registered Nurse (RN)-F who determined R3 was pulseless and not breathing. RN-F did not check R3's code status, did not call 911 and did not begin CPR. The CNA did not know what the colored label on the door meant and did not know R3 was a full code. The statement of RN-F documented: RN-F was the nurse for R3 when she expired on [DATE]. No CPR was done and 911 was not called. R3 was unresponsive about 10 minutes after the CNA raised the head of the bed. After RN-F called the doctor to pronounce (R3)'s death, he then realized she was full code - he saw it in the computer and the door label was green (indicating full code). There was a lot going on that night and after discovering (R3) was a full code, it wasn't initiated. Subsequent statement by RN-F documented: The CNA was helping (R3) that evening. She found (R3) unresponsive when she returned to her room after providing her care and elevating the head of the bed per her request. The CNA alerted him (RN-F) to (R3)'s status and he then assessed (R3). His mind was set on updating the doctor, and he did not check (R3)'s code status until after speaking with the doctor. He thought (R3) was on hospice and was looking for the chart flag for hospice, and that is when he identified that she was a full code. He called the administrator regarding (R3)'s death, but did not update the administrator on not performing CPR. He was aware of the facility policy related to advanced directives and code status. After identifying R3 was a full code, he did not notify the physician, NHA or Social Worker - it didn't cross my mind. Surveyor noted RN-F and the CNA were unavailable for interview. Surveyor verified RN-F was CPR certified in [DATE], at the time of R3's code. The failure to perform CPR on R3 created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE] and was corrected on [DATE] when the facility completed the following: training was completed with all staff on Advanced Directives/Code Status. A facility wide audit was completed on the code status of all residents, including care plan and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . QAPI (Quality Assurance and Performance Improvement) was conducted on [DATE] and mock code drills were conducted in the facility with the last drill concluding on [DATE].

Based on interview and record review the facility did not ensure one (R4) of 3 residents reviewed for falls received adequate supervision and assistance devices to prevent accidents. R4 was admitted to the facility following a fall at home with a [MEDICAL CONDITION]. The hospital discharge paperwork sent to the facility on [DATE] referenced R4's frequent falls related to deconditioning and advanced dementia. It continues to document: .Frequent purposeful rounding in place to ensure safety and comfort. (R4) remains impulsive getting up without walker without calling for assistance. (R4) remains on 3L (liters) of O2 (oxygen) via nasal cannula came out of room w/o (without) shirt on and without wearing O2, complaining of not feeling well dizzy. Upon admission to the facility, R4 was assessed to be at high risk for falls and was receiving a blood thinner, increasing the risk for serious injury after a fall. R4 fell 6 times between ,[DATE]-[DATE] while at the facility. After the falls the facility did not complete thorough neurological checks, did not always have a Registered Nurse (RN) assess R4, did not identify the cause of the fall and initiate immediate interventions to prevent the next fall. R4 fell on [DATE] and sustained a subdural hematoma and passed away on [DATE]. The facility's failure to ensure R4 received adequate supervision and interventions to prevent falls created a situation of immediate jeopardy that began on [DATE]. Director of Nursing (DON-B) was informed of the immediate jeopardy on [DATE] at 3:07 PM via telephone. The immediate jeopardy was removed on [DATE], however the deficient practice continues at a scope/severity of E (potential for harm/pattern) as the facility continues to implement its action plan. Findings include: The facility policy entitled Accidents and Incidents-Investigation and Reporting ,[DATE], last revised and last approved ,[DATE], states: Policy Statement: Accidents or incidents involving residents shall be investigated and reporting completed, per state and federal requirements. Policy Interpretation and Implementation A The Nurse should promptly initiate and document investigation of the accident or incident. B. The following information shall be included in the investigation, as applicable: 1. The date and time the accident or incident took place; 2. The nature of the injury, if indicated; 3. The circumstances surrounding the accident or incident; 4. Where the accident took place; 5. The name (s) of witnesses and their account of the accident or incident; 6. The resident's account of the accident or incident; 7. The time the resident's Health Care Provider was notified, as well as the time the Health Care Provider responded and his or her instructions; 8. The date and time the resident's representative was notified and by whom; 9. The condition of the resident, including vital signs; 10. The disposition of the resident (i.e., transferred to hospital, assisted to bed); 11. Interventions initiated; 12. Follow-up information; 13. Other pertinent data as necessary or required; and 14. The signature and title of the associate completing the report. C. If the resident sustains a witnessed head trauma or an unwitnessed fall, the resident should be observed for neurological abnormalities. Neurological checks are to be initiated and completed for 72 hours. If abnormal symptoms occur, the health care provider should be notified. D. Document the accident or incident in the resident's clinical record, including health care provider and legal representative notification. E. The Health Care Administrator, Director of Nursing, or designee, shall initiate: 1. Reporting per state and federal requirements; 2. Internal reporting F. The Health Care Administrator, or designee and Interdisciplinary team will review the incident at the next scheduled meeting. Facility Neurological Check Forms document: Neuro (Neurological) Check Guide In the absence of a specific physician's orders [REDACTED]. Fall that is unwitnessed or in which the head is struck: change in neurological condition: Initial baseline neuro check Q (every) 15 minutes x 4 (1 hr (hour)); Q 30 minutes x4 (2 hr); Q 1 hour x 4 (4 hr); Once per shift x 72 hours Notify the physician of any abnormal results. R4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment was not completed due to R3's transfer to the hospital on [DATE] and R4 did not return to the facility. R4's Care Plan initiated, [DATE], documents: (R4) is at risk for falls related to recent admission to community, fall history, poor cognitive status. Interventions include: Keep pathways clear and provide adequate lighting, (start [DATE]); Keep bed at appropriate height, (start [DATE]); Keep personal items within reach, (start [DATE]); Transfer per intake information until seen by therapy, then follow therapy recommendations/plan of treatment, (start [DATE]); Orient to room and call light, (start [DATE]); Revisions include: Fall mats; medical workup, (start [DATE]); Non-skid footwear, (start [DATE]); PT (Physical Therapy) evaluation and treat for ambulation, (start [DATE]); Frequent safety checks, (start [DATE]); NOC (night) shift to assist resident up for the day, (start [DATE]); Resident will request to sit on the floor at times when ambulating with staff, (start [DATE]). Surveyor noted R4's Care Plans do not address R4's [DIAGNOSES REDACTED]. (Cross Reference F655) Facility Resident Care Guide, with a start date of [DATE], documents: Cognitive/Behavior: (R4), forgetful, and confused, needs encouragement r/t (related to) refusal of cares; . Transfers and ambulation/Mobility: I need extensive assistance with transfers, I need 2 person staff support with transfers and a gait belt; I need assistive device with mobility. I need 1 person staff support with mobility. I use wheelchair device for mobility; I need extensive assist with bed mobility. I need 1 person staff support with bed mobility; Ambulation: to and from the bathroom with WW (wheeled walker), extensive assistance, and 2 staff for safety. Please watch oxygen tubing; . Toileting: Incontinent of bowel and bladder, depends. I need extensive assistance with toileting. I need 2 person staff support with toileting. I am incontinent of bladder. Assist as needed; I am incontinent of bowel. Assist as needed; I need extensive assist with toileting. I need 2 person staff support with toileting; . Safety: low bed, call light within reach, manual wheel chair, fall mats, medical workup, non-skid footwear, frequent safety checks, NOC shift staff to assist resident up for the day; . Preferences: prefers to take naps during the day and evening. Wakes around 9 AM and likes to go to bed around 8 PM; Resident Centered Care: reminders to use call light for assistance. Surveyor noted R4's Resident Care Guide does not address R4's need for continuous oxygen, the oxygen liter flow required and what staff should do if R4 is noted to not have oxygen on. R4's hospital Discharge Summary, dated [DATE], documents: . [MEDICAL CONDITIONS] [MEDICATION NAME] per discussion with orthopedic surgery will order through ,[DATE]. Pt (patient) should follow up in orthopedic surgery clinic for final duration of treatment; . Weakness/Falls: Pt reports ,[DATE] falls in past 6 months. Likely from chronic deconditioning and advanced dementia; . patient is not decisional due to dementia; . start [MEDICATION NAME] 40 mg (milligrams) daily for 14 days. R4's Hospital Referral Packet sent to the facility on [DATE], for consideration for admission to facility, documents: .Frequent purposeful rounding in place to ensure safety and comfort. (R4) remains impulsive getting up without walker without calling for assistance. (R4) remains on 3L (liters) of O2 (oxygen) via nasal cannula came out of room w/o (without) shirt on and without wearing O2, complaining of not feeling well dizzy. Writer escorted (R4) back to room and reapplied 3L of O2, took pulse ox (oxygen): 88%, laid (R4) down with HOB (head of bed) elevated reassessed pulse ox: 92%.high fall risk, WBAT (weight bear as tolerated), hard of hearing, O2 - 3L . (R4) caught ambulating independently without any assistive devices and incontinent of urine at that time; taking oxygen off frequently but compliant with placing back on with encouragement . On [DATE], at 6:07 PM, R4's medical record documents: R4 was assessed by facility staff using the Hendrick II Fall Risk Model. R4 was assesses at a score of 5, indicating R4 is at high risk for falls. Fall 1 On [DATE], at 22:20 (10:22 PM), R4's medical record documents: (R4) had an unwitnessed fall at 14:30 (2:30 PM), nurse found him lying on the floor, oxygen off, his VS (vital signs) at the time was BP (blood Pressure) (blank) 102, P (Pulse) 85, SPO2 (Oxygen Saturation) 93, T (Temperature) 98, no injuries, MD (Medical Doctor) called, family notified, transported by bell ambulance to the hospital. The documentation does not state where R4 fell from and oxygen saturation level does not document if the level was taken before or after R4's oxygen was reapplied. R4's Post-Incident Investigation, Level 1 Root Cause Analysis form, undated, documents: (R4) fell near the bed; the surrounding area was dry; non-skid socks were on; assistive device used: unknown; last ate: [DATE]; last toileted: unknown; last repositioned: unknown. What interventions were most appropriate: Sent to ER (emergency room ). The Post-Incident Investigation form does not state where the R4 was last seen, for example in bed, wheelchair or recliner. No recommendations of new interventions were documented other than sending R4 to the ER. R4's Severity level A-F, Level 2 Root Cause Analysis form, undated, documents: human factors impacted outcome: unknown; actual staffing compared to ideal levels: unknown; was necessary information available, accurate and complete: yes; what safety measures were in place at the time of the incident: call light, bed in lowest position; have there been similar incidents: no. Neurological checks completed on [DATE], at 14:00 (2:30 PM), documents: R4 is oriented to person; awake; opens eyes spontaneously and purposefully; Pupil size, right and left eye-3 millimeters; pupil shape: right and left eye round; reactive-right and left eye-reactive; right and left hand- normal power; right and left arm-normal power; right leg-normal power, left leg-mild weakness. No vital signs were documented on the neurological check form. The neurological check form does not document if the mild left leg weakness is baseline for R4. There is no documentation R4's MD was notified of the left leg weakness. Neurological checks completed on [DATE], at 14:45 (2:45 PM) PM, no vital signs were documented on the neurological check form. The neurological check form does not document if the mild left leg weakness is baseline for R4. There is no documentation R4's MD was notified of the left leg weakness. On [DATE], at 12:02 PM, Surveyor interviewed Director of Nursing (DON)-B, who stated: the cause of R4's fall was because R4 had his oxygen off at the time. DON-B stated: R4 would not leave his oxygen on and R4 cannot do without oxygen. DON-B stated: the issue was an oxygen level issue, oxygen was new for the resident, he didn't have oxygen at home. DON-B stated: the intervention that was put into place to prevent further falls was, fall mats. When Surveyor asked DON-B how this intervention would prevent future falls, DON-B stated: the fall mats were put into place to increase safety when or if the resident falls from the bed. Review of R4's care plan initiated [DATE] includes a revision of fall mats, medical work up dated [DATE]. The intervention of fall mats does not address the reason for R4's falls; as stated by DON-B, R4 was not wearing oxygen at the time of the fall. The fall investigation does not address why R4 was up ambulating, if the MD was updated on the change in strength noted in the neuro check completed at 2:45 PM and if the oxygen saturation level was taken before or after the oxygen was reapplied. Fall 2 On [DATE], at 2:52 AM, R4's medical record documents: Writer called to resident's (R4) room by CNA (certified nursing assistant) at approximately 0230 (2:30 AM) due to fall. (R4) was positioned sitting on right side with back against door. Upon assessment, no new areas of concern to skin. No c/o (complaint of) pain or discomfort. Neuro check negative. Resident was continent at time of fall. Call light was not activated. Resident did not have O2 (oxygen) on at time of fall. Last seen on rounds at 0200 (2:00 AM) by writer, sleeping in recliner. Resident was helped off floor using GB (gait belt) and 2 assist, and then assisted to recliner with GB and 2 assist. Oxygen reapplied. Call light within reach. NP (Nurse Practitioner) updated. NNO (No New Orders) . 97.9, 76, 20, ,[DATE], 92%. Documentation does not address if R4's oxygen saturation level was taken before or after R4's oxygen was reapplied. R4's Post-Incident Investigation, Level 1 Root Cause Analysis form, undated, documents: (R4) fell near the bed; area was clutter free; non-skid socks were on; no assistive devices were used at the time; last ate or drank: 1800 (6:00 PM); last toileted: 0200 (2:00 AM); last repositioned 0200 (2:00 AM); intervention most appropriate: PT (Physical Therapy) eval (evaluation). This form does not document where R4 fell from. R4's Severity level A-F, Level 2 Root Cause Analysis form, undated, documents: human factors impacted the outcome: self-determination; actual staffing compared to ideal levels, ideal; have there been similar incident: yes. The form does not document details related to what similar incidents have occurred. Neurological checks completed on [DATE], at 0235 (2:35 AM), documents: mild weakness in R4's right and left hands, arms and legs is baseline. R4's last neurological check on [DATE], did not have the same weakness documented and there is no documentation R4's MD was notified of the change from the last neurological check on [DATE] and the nursing notes document the neuro check was negative. Neurological checks completed on [DATE], at 0245 (2:45 AM), documents: the same weakness as documented on R4's neurological check on [DATE], at 2:35 AM. No vital signs were documented with this neurological check. Neurological checks completed on [DATE], at 0300 (3:00 AM), documents: the same weakness as documented on R4's neurological check on [DATE], at 2:45 AM. No vital signs were documented with this neurological check. No neurological check was completed for [DATE], at 3:15 AM, contrary to facility procedure. Neurological checks completed on [DATE], at 0330 (3:30 AM), documents: the same weakness as documented on R4's neurological check on [DATE], at 3:00 AM. No vital signs were documented with this neurological check. Neurological check completed on [DATE], at 0400 (4:00 AM), documents: the same weakness as documented on R4's neurological check on [DATE], at 3:30 AM. No vital signs were documented with this neurological check. No further neurological checks were completed for the fall on [DATE] at 2:30 AM. Thorough neurological checks were not completed per facility procedure and R4 continues to receive [MEDICATION NAME] at this time. On [DATE], at 12:02 PM, Surveyor interviewed DON-B, who stated: the cause of the fall was balance issues and the team felt a physical therapy evaluation would be the best intervention to prevent future falls. Surveyor noted having a physical therapy evaluation, while beneficial and part of his admission for rehabilitation, did not provide for an immediate intervention to prevent an additional fall. The fall investigation does not address why R4 was up ambulating, doesn't have required oxygen on, when R4's oxygen saturation level was taken (before or after oxygen was reapplied) and why neuro checks were not completed per facility procedure. Fall 3 - (Note this is the second fall on [DATE]). On [DATE], at 6:55 AM, R4's medical record documents: (R4) found lying on left side in doorway of room [ROOM NUMBER], unclothed, by CNA at 0640 (6:40 AM). RN (Registered Nurse) revealed no new skin issues. (R4) unable to state what he was trying to do at the time of the fall. (R4) stated his hip hurt and call 911. Call light was not initiated at the time of the fall. (R4) was continent. Oxygen removed at time of fall. (R4) last seen by writer at approximately 0610 (6:10 AM), sleeping in recliner in his room. VS (vital signs) 97.7, 80, 20, ,[DATE], 92%. NP (Nurse Practitioner) updated. NOR (New Order Received) to send out to hospital for eval (evaluation) and treat (treatment). Family updated. Paratech called. R4's Post-Incident Investigation, Level 1 Root Cause Analysis form, undated, documents: (R4) unable to stated what he was trying to do at the time of the fall; (R4) had bare feet; no assistive devices were used; last ate or drank: 1800 (6:00 PM); last toileted: 0600 (6:00 AM); last repositioned 0600 (6:00 AM); intervention most appropriate: non-skid footwear. R4's Severity level A-F, Level 2 Root Cause Analysis, undated, documents: human factor impacted the outcome: self-determination; actual staffing compared to ideal levels: ideal; similar incidents: yes. No documentation as to what similar incidents have occurred. Surveyor unable to locate documentation of neurological checks completed with this fall. On [DATE], at 12:02 PM, Surveyor interviewed DON-B, who stated: the team determined the intervention of non-skid socks would be appropriate to prevent future falls due to R4 being barefoot at the time of the fall. The fall investigation does not address why R4 was in the hallway by a doorway of another room, unclothed and if the oxygen saturation level was taken before or after the oxygen was reapplied. R4's medical record does not document when R4 returned to the facility from the hospital and if any injuries from the fall were identified. Fall 4 - (Note this is the third fall on [DATE]). On [DATE], at 23:46 (11:46 PM), R4's medical record documents: writer was notified @ (at) 19:15 (7:15 PM) that (R4) was on the floor. Upon arrival at the site (R4) was observed on the floor in the hallway laying on his left side without oxygen. When asked what happened, (R4) unable to answer what he was trying to do before falling. Skin assessed and no apparent injury noted at time of the fall. (R4) was lethargic due to not having O2 (oxygen) on. O2 was at 63, upon placing O2 on (R4), O2 level went up to 93. Neuro check negative. On call MD notified and ordered (R4) to be monitored for any new neuro changes and update with. (R4) in nursing station all evening and still taking off O2. POA (Power of Attorney) updated. Surveyor unable to locate documentation an RN assessed R4 after the fall. R4's Post-Incident Investigation, Level 1 Root Cause Analysis, undated, documents, (R4) unable to respond to question of what he was attempting to do at the time of the fall; fall occurred in the hallway; shoes were on; last time eaten: at supper; last time toileted: unknown, brief was dry; last time repositioned: (R4) was sitting in a recliner; intervention most appropriate, (R4) needs to be constantly monitored. R4's Severity Level A-F, Level 2 Root Cause Analysis form, undated, documents: human factors impacted the outcome: (R4) is confused and needs constant supervision; actual staffing compare to ideal levels: (R4) needs constant supervision; have there been similar incidents: (R4) has had 2 falls in the past days. Surveyor unable to locate documentation of vitals in the nursing progress, fall investigation report forms or neurological assessment forms for this fall or of an RN assessment of R4 after the fall. Neurological check completed on [DATE], at 19:15 (7:15 PM), documents: no abnormal results, no vitals were documented. Neurological check completed on [DATE], at 1930 (7:30 PM), documents: no abnormal results, no vitals were documented. Neurological check completed on [DATE], at 1945 (7:45 PM), documents: right and left eyes non-reactive, no vitals were documented. Surveyor unable to locate documentation R4's MD was notified of the change in condition. Neurological check completed on [DATE], at 1930 (7:30 PM), 2000 (8:00 PM), 2030 (8:30 PM), 2100 (9:00 PM), 2130 (9:30 PM), 22:00 (10:00 PM), documents: no abnormal results, no vitals were documented. Neurological check completed on [DATE], at 2230 (10:30 PM), documents: right and left eyes non-reactive, no vitals were documented. Surveyor unable to locate documentation R4's MD was notified of the change in condition. Surveyor unable to locate documentation the facility completed neuro checks after 10:30 PM per facility procedure. Review of R4's care plan initiated [DATE] and revised [DATE] now includes non-skid footwear, (start [DATE]) and PT (Physical Therapy) evaluation and treat for ambulation, (start [DATE]). Surveyor noted the care plan still does not address R4's removal/needs for oxygen or supervision despite nursing staff indicating on the post fall investigation R4 needs to be constantly supervised. On [DATE], at 12:02 PM, Surveyor interviewed DON-B, who stated the team initiated the fall intervention of therapy staff to create a walking plan for R4. DON-B stated the team thought an ambulation plan would help R4 not be so antsy if R4 walked with the staff on the unit. Surveyor asked DON-B why the intervention of constant monitoring of R4 wasn't initiated when documented as an intervention on the fall investigation form. DON-B stated, after every fall the team reviews the fall forms and the team determines the intervention that is the most appropriate. DON-B stated the Interdisciplinary Team will ultimately decide on the intervention that will be put into place to prevent further falls. DON-B stated the team felt an ambulation program would be best for R4. The intervention of an ambulation program does not address the facility documented reason for the fall, which was R4 not wearing oxygen. The intervention of an ambulation program does not address that the team had recommended a physical therapy evaluation for R4 with the fall that occurred earlier the same day, [DATE], at 2:30 AM. Surveyor unable to locate documentation R4 was assessed by an RN after the fall and MD was notified of the identified change in condition of R4's eyes not reacting at 7:45 PM and 10:30 PM. On [DATE], at 3:24 PM, Surveyor interviewed Physical Therapist (PT)-M, who stated, the afternoon of [DATE], PT-M completed the initial evaluation of R4. PT-M stated, she gathered information about R4 from the hospital notes sent to the facility and tried to get background information and a discharge plan. PT-M stated, R4 was classified as a fall risk due to history of falls, fracture, hospitalization and need for therapy. PT-M stated R4 was impulsive and would self-transfer. PT-M stated she was aware an ambulation program was recommended for R4 but his direction following varied. PT-M stated sometimes R4 would be sleeping sometimes he was awake and he would vacillate between sleepy and restless, ambulation with R4 was hit or miss. PT-M stated therapy could not train staff to ambulate R4 because they could not get R4 to participate in therapy. PT-M stated as soon as a resident is able to ambulate then therapy will create an ambulation plan, it is not always seen as a fall prevention intervention. On [DATE], at 3:02 PM, Surveyor interviewed Physical Therapy Aide (PTA)-L, who stated he did treat R4. PTA-L stated on [DATE] he did see R4. PTA-L stated PT-M is responsible for assessing R4 and then puts a therapy program together for R4 and its PTA-L's responsibility to carry out the program with R4. PTA-L stated R4 was very confused, hard to wake up, not always willing to participate in therapy and did experience hallucinations during therapy. PTA-L stated he did inform nursing staff of R4's behavior and hallucinations during therapy. PTA-L stated, on [DATE], it took him 15 minutes to attempt to get R4 up, R4 required maximum assistance to transfer to a chair and at the end of the session PTA-L transferred R4 back into a wheelchair because he didn't feel the recliner was safe for R4. PTA-L stated, he was aware a walking program was to be created for R4. PTA-L stated he did feel R4 was too confused, couldn't follow directions and was too inconsistent and only therapy staff should walk with R4, not unit staff. PTA-L stated he could not get a walking program put together for R4 due to R4's poor cognition. On [DATE], at 12:47 PM, R4's physical therapy progress note documents: . Pt. (patient) was hallucinating and reaching for objects that were not there. Pt. thought writer was pt's son, then his daughter. Then pt. thought he was at work. Pt. asked if writer had seen pt.'s Dad then pt said I think he died . Pt. attempted 3 times to remove writer's shoe. When writer asked pt. to move or redirect pt., pt. started to get agitated. Writer stayed calm and waited several minutes for pt. to decrease agitation. Pt's O2 sats (saturation) were between 88% and 90% on 4 L (liters) of O2 . Review of R4's care plan initiated [DATE] included a revision of frequent safety checks, (start [DATE]). Surveyor noted there is no detail of what constitutes frequent checks for R4. On [DATE], at 1:52 PM, R4's physical therapy progress notes documented: . When pt. stood from toilet writer directed pt. to sit in w/c (wheelchair). Pt's O2 sats were 65%, writer put 4L O2 cannula on pt. after several minutes pt. O2 sats increased to 85%. Writer took pt. to nursing station per nursing request. Surveyor unable to locate documentation the Interdisciplinary Team addressed the inability of therapy staff to implement an ambulation program for R4 as it was an identified IDT preventative fall intervention. Surveyor unable to locate information nursing staff addressed R4's observed hallucinations during therapy or that MD was made aware. Fall 5 On [DATE], at 7:48 AM, R4's medical record documents: 0645 (6:45 AM) (R4) was heard shouting help and seen crawling through doorway of room. Was unable to say what he wanted to do. Body check showed no new injuries. Vital signs: T 97.7, P 92, BP ,[DATE], Pox% (oxygen saturation) 91% (refused to have NC (nasal cannula) in place) . Denies any pain at time of assessment, 0720 (7:20 AM) MD called, and will update per nurse, 0808 (8:08 AM): management made aware of situation. Post-Incident Investigation, Level 1 Root Cause Analysis, undated, documents: What was resident trying to do at the time of the fall: (R4) too confused and unable to respond; (R4) was found on the floor between the room door and hallway; bare feet and only wearing a brief; not known when (R4) last ate/drank or was repositioned, (R4) was incontinent; interventions most appropriate: NOC (night) shift to get him up. Severity level A-F, Level 2 root Cause Analysis form, undated, documents: human factors impacted the outcome: (R4) has poor safety awareness and refusal of cares and help; actual staffing compared to ideal levels: normal; have there been similar incidents: multiple falls all discussed with IDT. On [DATE], at 1500 (3:00 PM) documents: neuro checks completed. No abnormal findings documented. Surveyor unable to locate any other checks completed for this fall. R4 remains on [MEDICATION NAME]. On [DATE], at 12:02 PM, Surveyor interviewed DON-B, who stated, the intervention the IDT put into place to prevent future falls was for night shift to get R4 up. Review of R4's care plan initiated [DATE] includes the revision on [DATE], of frequent safety checks and [DATE] revisions of NOC (night) shift to assist resident up for the day, (start [DATE]) and resident will request to sit on the floor at times when ambulating with staff, (start [DATE]). DON-B stated: frequent safety checks means: a nurse, nurse manager, aides, DON will check on a resident at least 1 time per hour if they are in their room. DON-B stated, the facility does not have a staff sign off sheet for the frequent checks and does not have a policy and procedure for frequent safety checks. DON-B stated, R4 was last seen in bed prior to the fall. Surveyor informed DON-B the facility fall investigation and nursing progress notes do not document were R4 was last seen prior to the fall. Surveyor noted R4's Resident Care Guidelines, dated [DATE], documents: Preferences: prefers to take naps during the day and evening. Wakes around 9:00 AM and likes to go to bed around 8:00 PM. Surveyor was unable to find documentation related to IDT discussion of R4's preference to sleep until 9:00 AM and the IDT fall intervention of night shift staff getting R4 up for the day. The intervention does not address the reason for the falls and does not address R4's preference. The facility fall investigation does not state where R4 was last seen and if the O2 saturation level was taken before or after oxygen was reapplied. The facility did not complete a neurological assessment after the fall or per facility procedure when R4 continues to receive [MEDICATION NAME]. Fall 6 On [DATE], at 1612 (4:12 PM), R4's medical record documents: F/U (follow up) (R4) alert with increased agitation and restlessness at this time. (R4) had an unwitnessed fall this a.m. shift. Writer updated on-call from Oak Medical. New orders given to send (R4) out to the hospital for further evaluation due to (R4) on [MEDICATION NAME]/anticoagulant medication. (R4) with no noted bleeding or bruising at this time. Writer updated responsible party of (R4) being sent to the hospital. Report given to hospital nurse. Paratech called for tranp. (transport). ETA (Estimated Time of Arrival) 25 minutes. R4's Post-Incident Investigation, Level 1 root Cause Analysis form, undated, documents: What was resident trying to do: not sure; (R4) fell out of w/c (wheelchair) on to floor in the hallway common area; non-skid footware (sic) was on; intervention most appropriate: keep in common area when agitated. Last seen couple min (minutes) before had been with LPN (Licensed Practical Nurse) but she had to do treatment and he had been waiting in the hallway. R4's Severity Level A-F, Level 2 Root Cause Analysis form, undated, documents: human factors impacted the outcome: poor safety awareness, balance issues; have there been similar incidents: not out of w/c. On [DATE], at 1:45 PM, R4's medical record documents: neurological check form, no abnormal results documented. On [DATE], at 2:00 PM, R4's medical record documents: neurological check form, no abnormal results documented. On [DATE], at 12:02 PM, Surveyor interviewed DON-B, who stated: no fall prevention interventions were put into place following this fall due to R4 being transferred to the hospital. Surveyor was unable to locate documentation of an RN assessment after this fall, why the fall occurred at 1:45 PM and transport to the hospital was not arranged until 4:12 PM, why neurological checks were not completed after 2:00 when R4's was at the facility until after 4:12 PM, no vitals were documented on R4's fall investigation or nursing progress notes and why R4 was sent to the hospital for this fall when R4 has received [MEDICATION NAME] since admission and was receiving prior to all 6 falls at the facility. On [DATE], at 4:57 PM, hospital admission paperwork documents: emergency room Triage; Pt from (facility) with fall, Pt with large bump to posterior head. Pt denies any pain. Pt AOx1 (alert and oriented to self) at baseline, Pt on 2L O2 at baseline (TRUNCATED)

Based on interview and record review the facility did not ensure 1 (R3) 1 of residents reviewed received quality of care and treatment when a change in condition occurred while R3 was being transported to/from a medical appointment. The facility did not assess or arrange for a companion during transport despite R3's observed and verbalized anxiety about attending the appointment alone. The facility did not have a clear policy and procedure regarding emergency medical situations during facility transportation, and drivers and dispatch staff were not trained on how to address a medical emergency during transport prior to the incident. Additionally, there was not a policy or procedure that addressed how to supervise residents during transport when no additional staff are present in the vehicle. On [DATE], R3 was provided facility transport to an appointment. Prior to leaving for the appointment R3 was observed to be anxious and R3 verbalized anxiety about attending the appointments alone. Upon arriving at the hospital clinic, Facility Bus Driver (FBD)-G observed R3 with a change in condition, including increased shortness of breath. Facility Bus Driver (FBD)-G attempted to obtain oxygen for R3 while at the appointment location, was unsuccessful and transported R3 back to the facility after being told by Van Dispatch (VD)-J to return. No direction was provided to FBD-G to seek additional medical attention by going to the emergency department or call 911. Upon arrival at the facility, FBD-G observed R3 to be slumped over in the wheelchair and was unresponsive. FBD-G called the facility dispatch for assistance and brought R3 into the building where staff assisted with CPR. R3 passed away. FBD-G was unable to visualize R3 or engage R3 in conversation on the bus to allow for identification of a change in condition during transport. The facility's failure to ensure quality of care was carried out during facility transport, when a change in condition occurred, created a situation of immediate jeopardy that began on [DATE]. Administrator (NHA)-A and Director of Nursing (DON)-B were notified of the immediate jeopardy on [DATE] at 1:05 PM. The immediate jeopardy was removed on [DATE]; however, the deficient practice continues at a scope and severity of an E (potential for harm/pattern) as the facility continues to implement its action plan. Findings include: R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3's Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE], documents: a Brief Interview of Mental Status (BIMS) score of 15, indicating R3 is cognitively intact; Patient Health Questionnaire (PHQ-9) score of 3, indicating R3 does not have severe depressive symptoms; dependent on 2 staff for transfers, requires extensive assist of 2 staff for bed mobility, dressing, toilet use and personal hygiene. R3's medical record documents an election of a full code status, requesting CPR be performed in the event of an emergency. On [DATE], R3's medical record documents: a referral for psychiatric services for evaluation after demonstrating symptoms of depression, anxiety, adjustment issues, nervousness and sleep problems. The psychiatric evaluation documents: (R3) reported feeling more isolated recently and frustrated with her inability to get questions answered to her satisfaction; on a daily bases feeling down or depressed, difficulty falling sleep, feels tired and has little energy, has a terrible appetite, and a feeling of moving more slowly lately. A PHQ-9 assessment was administered and (R3) scored ,[DATE] indicating moderately severe level of depression. The Generalized Anxiety Disorder (GAD-7) assessment was administered. (R3) reported, on a daily basis, she feels nervous or anxious, has difficulty relaxing, feels restless, and becomes easily annoyed or irritable. On a less frequent basis, (R3) reported that she has difficulty controlling her worries about many different things, and sometimes feels afraid that something awful will happen. (R3) attained a full scale score of ,[DATE], indicating a severe level of anxiety. On [DATE], R3 was scheduled for 2 medical appointments at 2 different hospitals. Transportation to the appointments was provided by the facility operated transportation department. On [DATE], at 12:47 AM, R3's medical record documents: vitals, blood pressure: ,[DATE], pulse 71, respirations 20, pulse oxygen saturation 96% on room air, and temperature 97 degrees. On [DATE], at 2:09 PM, Surveyor interviewed Physician Assistant (PA)-F, who stated, on [DATE], she popped in to see R3. PA-F stated, typically she makes rounds early in the morning and R3 is still in bed but on [DATE], when PA-F arrived at R3's room, staff were assisting her with bushing her hair, putting coat on and transferring from the bed to the wheelchair via Hoyer lift. PA-F stated R3 looked anxious and was reporting she could not go alone, could not go by herself to the appointment. PA-F stated, R3 looked pained and anxious while repeating she could not go alone to the appointment. PA-F stated she spoke with R3 who denied pain or shortness of breath when questioned. PA-F stated she was aware R3 had a history of [REDACTED]. PA-F stated all previous visits with R3 occurred when R3 was in bed and PA-F needed to wake R3 for the visit and R3 did not demonstrate anxiety during those visits. PA-F stated she questioned the nursing assistants caring for R3 at the time and they informed her R3 didn't want to go alone to the appointment and they had no other concerns. PA-F stated she did not take vitals on R3 during the visit as R3 was being rushed by staff to get ready for her appointment. PA-F stated she did review R3's vitals taken earlier that day and did not have concerns. PA-F stated she did not touch base with R3's nurse as the CNAs caring for R3 did not have any concerns. PA-F stated she provided reassurance to R3 that she did not have to recall any information the doctor provides during the visit as the doctor would send progress notes back with her with all the information that was needed and the van driver would assist her to and from the appointment. PA-F stated looking back on the events, she wasn't certain if the anxiety R3 was feeling was related to an unknown medical event occurring, even though R3 denied symptoms, or did the anxiety bring on the medical event. PA-F stated, We will never know. On [DATE], at 10:38 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-H, who stated she made R3 a priority to get up the morning of [DATE] due to the doctor's appointment that was scheduled. CNA-H stated R3 didn't look good that morning so she went and got the nurse. CNA-H stated she isn't sure who that person was but they told her they did vitals on R3 earlier and they were fine. CNA-H stated R3 looked tired and R3 told CNA-H that she was tired. CNA-H stated R3 did not like to get up early so she didn't think anything of R3's complaint of being tired while getting her ready that morning. CNA-H stated the nurse that told her R3's vitals were okay, also told her R3 was okay to go to the appointment but CNA-H could not recall who the nurse was. On [DATE], at 10:44 AM, Surveyor interviewed Medication Assistant (MA)-I, who stated she did vitals on R3 the morning of [DATE], and all vitals were fine. MA-I stated she did not do cares with R3 but was responsible for passing medication. MA-I stated R3 declined to take her medication the morning of [DATE] due to not eating breakfast. MA-I stated R3 liked to take her morning medication with oatmeal and yogurt and did not have time to eat that morning. MA-I stated R3 told her she would take her medication when she returned to the facility after her appointment. MA-I stated her plan was upon R3's return to the facility she would request oatmeal and yogurt from the kitchen. MA-I stated R3 was whiney the morning of [DATE], stating she didn't want to go to the doctor's appointment alone. MA-I stated she reassured R3 the van driver would assist her to and from the appointment. MA-I stated R3 did not appear short of breath, in need of oxygen or look pale. Review of R3's am medication indicate R3 was to take: [MEDICATION NAME], vitamin D, [MEDICATION NAME], folic acid, [MEDICATION NAME] sulfate, [MEDICATION NAME], apixaban (Eliquis), [MEDICATION NAME], Senna, acidophilus and Ensure the morning of [DATE]. On [DATE] at 2:32 PM, Surveyor interviewed Facility Bus Driver (FBD)-G, who stated the first thing he did the morning of [DATE] was to verify the appointment location for R3 with facility Van Dispatch (VD)-J. FBD-G stated he was told by VD-J, R3 had two appointments that day and should be taken to Columbia St. Mary's Milwaukee Hospital first. FBD-G stated, he then went to the Sunshine Room, a dining room on R3's unit, to pick up R3. FBD-G stated R3 was in the Sunshine room, in a wheelchair, when he arrived. FBD-G stated he asked R3 how she was doing, and R3 replied, A little short of breath. FBD-G stated he asked staff nearby if R3 needed oxygen and was told she didn't. FBD-G stated he could not recall who it was that he questioned about R3's possible need for oxygen. Surveyor asked FBD-G to describe what R3 looked like at this time. FBD-G stated he could not describe it, but he knew she was short of breath. FBD-G stated R3 was able to speak to him without difficulty but he just knew she was short of breath because he has asthma and knows what it's like have difficulty breathing. FBD-G stated, he proceeded to take R3 to the bus for transport to her appointment. FBD-G stated R3 was quiet during the ride to the appointment. FBD-G stated that when they arrived at the hospital he brought R3 into the hospital and to the registration desk for her appointment. FBD-G stated when he checked in for R3's appointment at the hospital registration desk he was informed R3 was at the wrong location and needed to go to Columbia St. Mary's Grafton location. FBD-G stated R3 looked frustrated when they were informed of being at the wrong location and looked short of breath. FBD-G stated R3 did not appear to be struggling to breathe, was able to talk, and was calm but frustrated. FBD-G stated he could tell R3 was having difficulty breathing but again could not describe what led him to that conclusion. FBD-G stated he asked the hospital staff at the registration desk if they could assist R3 with some oxygen. FBD-G stated the hospital staff informed him they could not assist, he was at the wrong hospital and needed to go to the Grafton hospital. FBD-G stated he called VD-J to inform her they were at the wrong location. FBD-G does not recall telling VD-J that R3 was short of breath, but they discussed having FBD-G return to the facility with R3 and to not go to the Grafton hospital because the appointment would already be missed and VD-J would reschedule the appointment. FBD-G stated he then took R3 back to the bus, strapped the wheelchair into the back of the van and proceeded back to the facility. FBD-G stated it took ,[DATE] minutes to drive back to the facility. FBD-G stated he did not speak to R3 during the ride to and from the hospital. FBD-G stated it is not possible to have a conversation with the residents that are in a wheelchair on the bus because it is a 24 passenger bus, with many seats between the driver and the wheelchair strap downs in the back of the bus. FBD-G stated the distance is too great and the noise coming from the bus door makes it impossible to talk with residents on the bus especially when they are in a wheelchair in the back of the bus. FBD-G stated he was not able to visually see R3 while driving due to the driver sitting down lower and the passengers are far back and up higher. FBD-G stated, in his rear view mirror, he is able to see a silhouette of the residents wheelchair but not the resident's body. FBD-G stated the noise coming from the door of the bus makes it impossible to have a conversation with a resident in a wheelchair in the back of the bus. FBD-G stated when he arrived back at the facility he pulled back into the same area he had picked up R3. He parked the bus, came around the back of the bus, opened the door and noticed R3 was slumped over in the wheelchair. FBD-G stated R3 appeared to be having difficulty breathing and wasn't talking. FBD-G stated he started to unhook R3's wheelchair from the van and proceeded to call VD-J to tell her of the situation. FBD-G stated he brought R3 into the facility and was looking for staff to assist him. FBD-G stated he was able to find staff to assist. FBD-G stated staff assisted with starting CPR and 911 was called but R3 passed away. Surveyor reviewed the Facility Reported Incident (FRI), dated [DATE], which documents: The Resident (R3) was noted to be unresponsive by transport driver at 0950 (9:50 AM). Resident brought into the facility and CPR (Cardiopulmonary Resuscitation) initiated at 0951 (9:51 AM) by facility staff and 911 called at same time. Facility continued to administer CPR until 911 took over CPR upon arrival. CPR was administered for approximately 50 minutes by facility staff and 911 until resident was pronounced. On [DATE], at 11:32 AM, Surveyor interviewed Van Dispatch (VD)-J, who stated she confirmed with FBD-G, R3 had two appointments and she should go to Columbia St. Mary's Milwaukee Hospital (CSM-M) first. VD-J stated, next she heard from FBD-G was that they were at CSM-M Hospital and were informed that was the wrong hospital and R3 needed to be at Columbia St. Mary's Grafton Hospital (CSM-Grafton). VD-J stated FBD-G informed her R3 was short of breath and appeared to need oxygen. VD-J stated she told FBD-G to ask the hospital staff if they could assist R3 with some oxygen. VD-J stated the next she heard from FBD-G was a phone call from FBD-G, stating he was back at the facility and needed help, there was something wrong with R3. VD-J stated she heard FBD-G yelling for staff help and then heard staff yelling back and assisting FBD-G and then the phone went dead. VD-J stated that is when the staff started CPR and called 911. On [DATE], at 3:39 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A, who stated the facility does not have a policy and procedure for assessing if a resident is in need of supervision or a companion when going out of the facility for an appointment. NHA-A stated if a resident has a [DIAGNOSES REDACTED]. NHA-A stated the expectation for the facility van drivers to provide assistance to the residents during transport, they are not clinical people, but they should pull over and call 911 if they notice a change in condition with the resident while en route. NHA-A shared the facility's policies and procedures for transport are related to vehicle safety and do not address resident specific situations. When asked about any modifications or assessments of facility vehicles given FBD-G sharing he could not see the resident or communicate with R3 due to the structure of the vehicle, NHA-A stated, to the best of her knowledge, the facility buses have not been equipped with anything new that would allow the bus drivers to have a better visual of the residents during transport to allow them to determine if a resident was experiencing a change in condition. On [DATE], at 11:02 AM, Surveyor informed NHA-A and DON-B of concern the facility did not assess R3's need for support or a companion during transport to help reduce R3's assessed severe anxiety and transportation staff did not know how to assist a resident experiencing a change of condition during transportation. Surveyor expressed a concern the education provided to all staff did not assess the driver's actual ability to verbally engage the residents or visualize the residents while providing transport. The facility's failure to ensure R3 received care and services during a change in condition created a situation of immediate jeopardy that started on [DATE] and was removed on [DATE] when the facility implemented the following action plan. ~ Community transportation vehicles were assessed by the Director of Maintenance for proper visualization of residents and transportation safety using TELS checklist on [DATE]. Vehicle in question has been taken out of service for routine resident transportation effective [DATE]. ~ Current transportation staff are to be educated prior to their next shift on the community process of identifying and emergent notification of resident change in condition including notification of emergency medical assistance when needed. Current receptionists and dispatchers are to be educated prior to their next shift on the proper steps to take when notified of a resident emergency. Transportation staff will be educated prior to their next scheduled shift on who to contact if unable to visualize the resident within the vehicle during time of transportation. This education will be completed by the Administrator or designee. ~ Current residents will be observed prior to transport for change in condition. A nurse will evaluate the need for a companion prior to appointment. ~ Current clinical staff were educated by Administrator and/or designee prior to [DATE] on identification of resident change in condition and required notification if change is identified. ~ Routine reviews will be completed by an interdisciplinary team and or designee for three months. Routine reviews to include; 1. Completion of resident evaluation for need of companion during transportation prior to day of transportation need. 2. Residents being observed for changes that would require a change of condition needing a companion ~ Results of the routine reviews will be reported to QAPI committee for the next three months to determine if further monitoring is indicated. On [DATE], at 3:39 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A. NHA-A did provide Surveyor with facility training that occurred with all staff including transportation staff that was initiated after the incident. NHA-A stated, the training was provided by Campus Quality Director-K and the training included all staff. NHA-A stated the training consisted of education as to what a change in condition is, advance directives and what van drivers should do if a resident experiences a change in condition. On [DATE], at 9:08 AM, Surveyor interviewed the Campus Quality Director (CQD)-K, who stated she provided training and education to the facility transportation staff after the incident with FBD-G and R3. CQD-K stated she reviewed the Interact tool with the transportation staff. CQD-K stated, even though they are not medical staff, we reviewed what a change in condition was and how residents elect advance directives. CQD-K stated she reviewed with the transportation staff how they will know if a resident elected a full code status, by a green sticker on their paperwork or a no code, by a red sticker on their paperwork. CQD-K stated the sticker will be visible to the transportation staff and if the transportation drivers were CPR certified they may elect to start CPR on a resident experiencing a change in condition. CQD-K stated she reviewed with the transportation staff that once CPR is started it could not be stopped until 911 responders took over, if the resident was decapitated or if a doctor pronounced the resident deceased . CQD-K stated it is an expectation of facility that van driver will observe residents on transport for changes in condition and will engage the residents with conversation to help identify a change in condition such as a resident complaining of chest pain, is bleeding or has a change in color. CQD-K stated she has not been on the bus to know if the drivers are able to visualize the residents or if the drivers are able to have conversation with the residents during transport. CQD-K stated she would need to see the vans to determine this.

Based on a complaint received at the Southeastern Regional Office, interview and record review the Facility did not ensure 1 (R4) of 4 Residents a risk for dehydration was provided with sufficient fluids to maintain proper hydration and health. R4 has [DIAGNOSES REDACTED]. R4 is dependent upon staff for all his ADL's (activities of daily living) including eating. R4 has short & long term memory problems, unclear speech with English not being his primary language. Prior to visitor restriction on 3/11/20 R4's family would feed R4 his meals and provide fluids to him each day. R4 was assessed as being at risk for for dehydration on 1/16/20, 4/1/20 & 4/17/20. R4 was hospitalized from [DATE] to 3/31/20. R4 had a critical sodium level upon admission to the hospital and was diagnosed with [REDACTED]. The discharge summary documented R4 needed his intake to be closely monitored to ensure adequate fluid intake. Upon return to the facility on [DATE] the Facility did not revise R4's dehydration/fluid maintenance care plan; they continued to combine food & fluids together on their daily charting for meal consumption, which was completed for all three meals only five days in April 2020. The facility was not monitoring R4's total daily fluid intake comparing the intake to R4's assessed daily fluid needs. There is no evidence interventions of assessing for signs & symptoms of dehydration and assessing skin turgor & mucus membranes each shift were completed. On 5/2/20 R4's physician was notified of a critical sodium level of 173 (136-145). R4 was admitted to the hospital a second time for being extremely dehydrated and was administered fluids & antibiotics. R4 was readmitted back to the facility on [DATE]. Upon return to the facility on [DATE] the Facility did not revise R4's dehydration/fluid maintenance care plan; they continued to combine food & fluids together on their daily charting for meal consumption, which was not consistently completed. The facility was not monitoring R4's total daily fluid intake and comparing it with his assessed daily fluid need. There is no evidence interventions of assessing for signs & symptoms of dehydration and assessing skin turgor & mucus membranes each shift were completed. This situation resulted in a finding of immediate jeopardy which began on 3/31/2020. On 6/10/2020 at 2:35 p.m. Administrator-A and Corporate-D were informed of the immediate jeopardy and substandard quality of care. The immediate jeopardy was removed on 6/12/2020. The immediate jeopardy continues at a scope and severity level of D (potential for more than minimal harm/isolated) as the facility continues to monitor their removal plan with the results reviewed at the QAPI (Quality Assurance Performance Improvement) committee during the next 3 months. Findings include: According to Monique Ferry MD, PhD article Strategies to Ensuring Good Hydration in the Elderly Dehydration is a frequent etiology of morbidity and mortality in elderly people. It causes the hospitalization of many patients and its outcome may be fatal. Indeed, dehydration is often linked to infection, and if it is overlooked, mortality may be over 50%. Older individuals have been shown to have a higher risk of developing dehydration than younger adults. Modifications in water metabolism with aging and fluids imbalance in the frail elderly are the main factors to consider in the prevention of dehydration. Particularly, a decrease in the fat free mass, which is hydrated and contains 73% water, is observed in the elderly due to losses in muscular mass, total body water, and bone mass. Since water intake is mainly stimulated by thirst, and since the thirst sensation decreases with aging, risk factors for dehydration are those that lead to a loss of autonomy or a loss of cognitive function that limit the access of beverages. The prevention of dehydration must be multidisciplinary. Caregivers and health care professional should be constantly aware of the risk factors and signs of dehydration in elderly patients. Strategies to maintain normal hydration should comprise practical approaches to induce the elderly to drink enough. This can be accomplished by frequent encouragement to drink, by offering a wide variety of beverages, by advising to drink often rather than large amounts, and by adaptation of the environment and medications as necessary. The Facility's Guidelines for Charting and Documentation policy and procedure last revised 1/2018 under General Rules for Charting and Documentation documents H. Document assessments, interventions, treatments, outcomes, etc. Under the section Nursing Summaries and/or assessments for when charting nursing summaries or making assessments, include (as they may apply) the following information: K. Nutritional Status: Document the diet, appetite, food consumption, eating habits, assistance needed and where, diet normally consumed, weight variations, hydration status, fluid intake, tolerance of tube feeding, etc. The Facility's Hydration policy last revised 1/2019 under policy statement documents It is the policy of Ascension Living that residents shall remain adequately hydrated as indicated by the absence of signs and symptoms of dehydration. Under policy interpretation and Implementation documents; A. A minimum of 480 ml's (milliliters) of fluid should be offered to each resident at meal time for a total of 1440 ml's per day from meals alone. B. Ancillary fluids should also be available at the resident's bedside. Encouragement to drink should be offered to residents upon every interaction by the nursing associate. Water pitchers should be refilled and refreshed as per the Water Pitcher policy. C. Ancillary fluids should also be available at activity functions. D. Any resident requiring modifications to liquid consistency shall have the appropriate liquids offered at meals, bedside, with medication pass, and during activities. RECORD REVIEW R4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Dehydration/Fluid Maintenance care plan dated 12/8/18 documents approaches all dated 12/8/18 of; * Assess for signs/symptoms of dehydration (dizziness/confusion/decreased urine output/poor skin turgor/fever/constipation). * Assess family's understanding of the reasons for maintaining adequate hydration and methods for reaching goal of fluid intake. * Keep fresh water, or beverage of preference, in reach based on current dietary order. * Assess client's preferred fluids and provide. * Assess color and amount of urine. * Assess skin turgor and mucus membranes for signs of dehydration every shift. * Monitor blood pressure for orthostatic changes as needed. * Monitor for active fluid loss from diarrhea, bleeding, vomiting. * Note resident is on honey thickened liquids. The CNA (Certified Nursing Assistant) care plan dated 12/8/18 documents approaches all dated 12/8/18 of; * Weigh resident weekly. * Record meal intake. * Record total shift fluid intake. * Bathing. The hydration risk evaluation dated 1/16/2020 asks: does hand dexterity limit resident's ability to grasp a cup? Yes is checked. Eating ability is checked for totally dependent. Under summary of evaluation Resident is at risk for dehydration, as evidenced by Total assist with eating/drinking is checked. The total score/value documents 11 at risk. A resident who scores 8 or higher may be at risk for dehydration. The APNP (Advanced Practice Nurse Prescriber) note dated 2/15/20 under subjective includes Per records patient/wife has been refusing weights or labs so patient's nutrition status has not been assessed. DON (Director of Nursing)-B informed Surveyor visitors were restricted to essential visits only on March 11, 2020. Surveyor reviewed the March 2020 daily charting for meal consumption report from 3/11/2020 to 3/25/2020 (prior to R4's 3/25/20 hospitalization ). Surveyor noted under guidance documents Percent consumed. Enter overall percent of total meal eaten. On 3/11/20 breakfast, lunch, and dinner documents 76-100% for each meal. On 3/12/20 thru 3/25/20 breakfast & lunch are blank for each of these days and dinner each day is documented as 76-100%. Surveyor noted the daily charting does not differentiate between food eaten and fluids consumed for R4. The nurse's note dated 3/25/20 documents Resident's BG (blood glucose) 547, BP (blood pressure) 156/65, P (pulse) 122, T (temperature) 98.2, SPO2 92%. Vitals and BG reported to Medical Director-E. NOR (new order received) to give 10 u (units) of [MEDICATION NAME] and 2.5 mg (milligram) [MEDICATION NAME]. POA (power of attorney)-F updated. The nurse's note dated 3/25/20 documents Resident BG 541, NP (nurse practitioner) updated. NOR to send resident to ER (emergency room ) for eval (evaluation) and treat. POA-F updated. The nurse's note dated 3/26/20 documents Writer spoke with Hospital-G from SMO (Saint Mary's Ozaukee) speech therapy. Diet clarification given. Hospital-G stated resident is admitted with [MEDICAL CONDITION], dehydration, and [MEDICAL CONDITION]. During review of R4's March 2020 nurse's notes, Surveyor was unable to locate any assessments relating to the monitoring of signs/symptoms of dehydration and assessing skin turgor and mucus membranes for signs of dehydration every shift as directed in R4's dehydration/fluid maintenance care plan. R4 was hosptalized on [DATE] and returned on 3/31/20. The hospital history and physical dated 3/26/2020 under history of present illness documents The patient was brought into the emergency room for increasing shortness of breath. Reportedly, paramedics were called for [MEDICAL CONDITION]. Upon arrival they found him to be hypoxic on room air in the 70s and they put him on 100% nonrebreather, given nebulizer treatment en route. The patient unable to provide any history, family was not present at that time and I interviewed him in the emergency room . They have not seen him for the last 10 days or more due to nursing home status and the fact that they were not allowed due to this [MEDICAL CONDITION] illness and they do not know if the patient has been eating or drinking. They do not know if the patient has had diarrhea and they do not have much information otherwise and they have been very frustrated about this current issues. The patient has not had any recent travel or known sick contacts. Seen and evaluated in the emergency room . Labs were ordered with elevated WBC (white blood count) of 17.2. Elevated sodium as of 163 and creatinine at 1.95, which is not too far from his baseline. Glucose elevated to 690 and concern for dehydration, given IV (intravenous) in the emergency room and also with elevated glucose and anion gap that given [MEDICAL CONDITION]. A chest x-ray was ordered with no acute abnormality. Concern for COVID infection, the patient was put in isolation. Upon discussion with the family, the family does not want any aggressive measures for him including [MEDICAL CONDITION] intubation, central line placement. They are more interested in IV hydration, antibiotics if necessary and transition to palliative care hospice if not improving. The patient is, therefore, admitted to medical floor. The patient is nonverbal. Under current medical issues documents [MEDICAL CONDITION] secondary to dehydration. The patient likely has not been eating and drinking well, wife has been feeding him regularly, but not so in the last two weeks. We will continue with IV hydration and monitor sodium level closely to avoid overcorrection. The patient unfortunately having hard time with blood draw and may need PICC line in the morning if the family is interested. The hospital discharge summary for admission date of [DATE] & discharged date of 3/31/2020 documents under discharge information for [DIAGNOSES REDACTED]. Under hospital course documents Resident's name (R4) is a 74 yo (year old) with advanced dementia, from Alexian Village, who was found to be hypoxic when evaluated by paramedics. They were called because his blood sugar was over 600. He was found to be saturating in the 70's and was brought in. He is essentially nonverbal due to his dementia. His family, prior to the lockdown for COVID, was very involved in ensuring that he was getting adequate intake. He was found to also have a sodium of 163 while his glucose was 609. His creatinine was 1.95. He was admitted with a presumed aspiration pneumonia with infection. He was treated with [MEDICATION NAME] with vanco, no on oral [MEDICATION NAME] for two more days. This will be a total of 7 days of antibiotic coverage. He should have a speech therapy evaluation. He was extremely dehydrated on presentation. Nephrology was consulted. He was treated with a [MEDICATION NAME] drip with normalization of his sodium and creatinine. His intake will need to be closely monitored to ensure adequate fluid intake. (Emphasis added.) The facility's admission observation/evaluation dated 3/31/20 under the oral/nutrition section under nutrition is checked for difficulty swallowing and dysphagia. The nurse's note dated 3/31/20 documents Resident returned back to the facility via ambulance, resident is alert to self, bowel sounds present in all the four quadrant, skin warm/pink, no s/s (signs/symptoms) of pain/discomfort, no SOB (shortness of breath) noted and staff will continue to monitor. The Dehydration/Fluid Maintenance care plan dated 3/31/2020 is the same as the care plan dated 12/8/2018. Surveyor noted although the hospital discharge summary dated 3/31/20 documented R4 was extremely dehydrated and his intake will need to be closely monitored to ensure adequate fluid intake, R4's dehydration/fluid maintenance care plan was not revised and had the same approaches which were dated 12/8/18. The CNA care plan dated 3/31/2020 documents approaches all dated 3/31/2020 of * Weigh resident weekly. * Record meal intake. * Record total shift fluid intake. * Bathing. The resident care guide with a start date of 3/31/20 under the diet section documents Diet/Special Instructions: Mechanical Soft honey thick liquid see NURSE for detail instruction. I need 1:1 total assistance with eating. I have dysphagia and need to sit up 30 minutes after meals. I need to be fed 1 tsp (teaspoon) bites and sips. NOT TO BE LEFT ALONE FOR MEALS. Wife provides all feeding support she will ask for help as needed. Res wife and POA (power of attorney) refusing to have weights taken. Requests res. to be comfortable and getting res. up to be weighed causes to much stress on res per POA. Lower HOB (head of bed) to 45 degrees 1/2 hour after meals to prevent sliding down, causing pressure at feet at foot board. [MEDICATION NAME] powder supplement provided to wife who maintains supply in resident room. Offer me a clothing protector for meals. The hydration risk evaluation dated 4/1/2020 has a total score/value of 14 at risk. A resident who scores 8 or higher may be at risk for dehydration. The nutrition risk assessment dated [DATE] for feeding ability is checked for total dependence. For average meal intakes is checked for 26-50%. Under swallowing disorder, difficulty swallowing is checked. Under comments documents Res (resident) readmitted to facility after hospitalization for aspiration pneumonia, dehydration, acute [MEDICAL CONDITION] and respiratory distress. Res diet downgraded in hospital to puree with honey thick liquids. Res had been on a Mechanical Soft diet with honey thick liquids prior to hospitalization . ST saw res. in hospital and downgraded diet to puree ad (and) continue with honey thick liquids. Appetite is fair. Res needs total assistance with eating. Res weight is down 6.6% in one month d/t (due to) decreased appetite and dehydration. Res UBW (usual body weight) is 160s. Current weight is 154.2 lbs (pounds) Ht (height): 66 in (inches) BMI (body mass index): 24.8 indicating weight is WNL's (within normal limit). Does does receive a magic cup BID (twice daily) for additional nutritional support. Res noted on admission with a blister to right foot (see skin assessment) Wound nurse to follow. Will f/u (follow up) with any further concerns. Res also receives a daily MVI (multivitamin) with mineral and Vit (vitamin) C to help promote skin integrity. Res is on ABT (antibiotic) for pneumonia. Res is not on a [MEDICATION NAME] and could benefit one for GI (gastrointestinal) health. Res continues to receive insulin as ordered. Res MNA (mini nutritional assessment) score is 4 indicating res. is malnourished. Staff to encourage honey thick fluids and po (by mouth) intake and assist with all meals. Refer to RD (registered dietitian) for further interventions. Will proceed with nutritional plan of care. For Registered Dietician review under estimated nutritional needs for fluid documents 2100 for 30 ml/kg (milliliter per kilogram). Under potential at risk factors yes is checked for at risk for dehydration due to inadequate fluid intake. Under interventions magic cup and weekly weights are checked. Under comments/recommendations documents Agree with nutritional assessment above. Hx (history) reduced intake dehydration, 6.6% weight loss in last month. Has [MEDICATION NAME] 3 times/day, magic cups BID. Total dependence. Needs assistance wth (with) feeding. Plan for [MEDICATION NAME] if MD (medical doctor) feels appropriate. The correction/addendum nurse's note dated 4/1/20 documents Res. (resident) tolerated all due medications via crushed with applesauce. PO antibiotics [MEDICATION NAME], without adverse effects noted. Head of bed elevated for feedings by caregiver. 100 percent consumed for breakfast. Adequate fluids pushed throughout shift, pureed diet with honey thick fluids. Vitals obtained 98.6 90 20 124/88 96%. Plan of care to continue. The next nurse's note that documents fluids is dated 4/4/20 and notes, Res is alert and responsive. Adequate fluid intake & appetite this shift. Lungs clear upon auscultation. No s/s respiratory distress. No A/R (adverse reaction) R/T (related to) meds (medication)/tx (treatment). The next nurse's note that documents fluids is dated 4/7/20: Resident alert to verbal and tactile stimuli. New orders for [MEDICATION NAME] decreased and fiber tab discontinued. No adverse effects to change in medication orders. Res is a one; one feeder. Good appetite noted for breakfast and lunch this shift. Head of bed elevated for feedings via pureed diet. Fluids pushed throughout shift via honey thickened liquids. No noted pain or facial grimacing. Vitals 97.5 92 18 130/84 97%. Plan of care to continue. Call light in reach. The resident at risk dated 4/7/20 under the nutrition/eating section documents height 66, current weight 157 & date of weight 4/3/20 Diet Puree with honey thick liquids. Is checked for history of weight loss, cognitive deficit & poor intake. Under Interventions/recommendations is checked for dietary consult & Supplements ADL (activities daily living)/physical. Under comments documents Res triggered for nutrition risk d/t (due to) weight loss and decreased po (by mouth) intake. Res is tolerating puree diet with honey thick liquids. Res is fed by staff or all meals. Honey thick fluids are encouraged throughout day. Res is eating and drinking 100% of meals/fluids with staff assistance. Does receive a magic cup BID for additional nutrition support. Will dc (discontinue) from at risk and monitor for any further changes. The nurse's note dated 4/8/20 documents, Sleeping comfortably easily awakened with verbal stimuli. Assisted at mealtime. No adverse reaction noted to med changes VS (vital signs) WNL (within normal limits) stable. The dietary note dated 4/8/20 documents, New recommendations from ST (speech therapy) to upgrade diet to Mechanical Soft with honey thick liquid and continue with 1:1 feedings by staff. Diet card and plan of care updated with diet change. The next nurse's note that documents fluids is dated 4/13/20 and reads: F/U (follow up) [MEDICATION NAME] BP 138/81 no adverse reactions noted ate and drank fluids well . The next nurse's note addressing fluids is dated 4/13/20 and states, Ate 100% of meal and drank 100% of fluids. The hydration risk evaluation dated 4/17/2020 has a total score/value of 11 at risk. A resident who scores 8 or higher may be at risk for dehydration. The care conference note dated 4/17/20 includes documentation of Family Member-H stated staff need to make sure they are pushing fluids with res, nurse manager aware, Family Member-H requested res bed not be lowered for at least 30 minutes after res eats, nurse manager aware. The next nurse's note addressing fluids is dated 4/18/20: Resident alert and oriented. bed rest maintained. Honey thickened fluids about 16 oz (ounces) offered. Head of bed elevated for 30 mins (minutes) after feeding. The nurse's note dated 4/24/20 documents Writer spoke with POA (Power of Attorney) this date and shared that writer went to see R4 and he ate all of his food and magic cup this date for lunch. POA was greatful (sic) for the phone call, and told writer to be safe and have a good weekend. There is no documentation regarding R4's fluid consumption. The nurse's note dated 4/29/20 documents, Writer called POA this date for an update. Shared writer spoke with today's CNA and shared he had a good breakfast and ate 75%. POA thanks writer for the call. There is no documentation regarding R4's fluid consumption. During review of R4's April 2020 nurse's notes, Surveyor was unable to locate any assessments relating to signs/symptoms of dehydration and assessing skin turgor and mucus membranes for signs of dehydration every shift as directed in R4's dehydration/fluid maintenance care plan. Documentation of R4's food/fluid intake was completed for all three meals on only five days in April (4/4, 4/25, 4/28, 4/29, and 4/30/20) and ranged from less than 25% to 76-100%. The SBAR (situation, background, assessment or appearance, request) dated 5/1/20 under the request section for nurse's notes documents Resident with intermittent cough, heart (heart) rte (rate) was 103, refused dinner, took few fluid, with history of aspiration pneumonia. The nurse's note dated 5/1/20 documents F/U (follow up) Resident is monitored for intermittent cough, writer updated Physician-I, got a new order for chest X ray AP lateral 2 view, CBC, CMP, writer updated DON (Director of Nursing)/resident's spouse. Upon assessment thre (the) following vital sign was obtained, BP 118/66, Temp 97.9, P 103, SPO2 90%, refuse dinner, current BS (blood sugar) 188 and chest auscultation diminished at base. Surveyor noted the CNA documentation for meal consumption on this day was 76-100% for dinner. The laboratory report for collection date of 5/1/2020 includes Sodium 173 Cef with reference range of 136-145. The laboratory report indicates the critical value was verbally reported to facility staff on 5/2/20 at 2:05 a.m. The nurse's note dated 5/2/20 documents Called in critical labs to Physician-I on call for Physician-J. Order received to send to ER for eval and treatment. Resident alert and oriented, appeared more confused. No noted resp (respiratory) distress/labored breathing. Mild congestion and intermittent unproductive cough noted VS T98.6 R30-35, Hr 116 Bp 148/70 pox 92% RA (room air). The nurse's note dated 5/2/20 documents Writer spoke with Hospital staff-K at SMO. Pt (patient) admitted with Aspiration PNA (pneumonia), acute kidney injury and [MEDICAL CONDITION]. The hospital history and physical dated 5/2/2020 under history of present illness documents Resident's name (R4) is a 74 y/o male with a hx (history) of advanced dementia, DM II, recently admitted with [MEDICAL CONDITION], aspiration pneumonia, discharged to Alexian, who represents with altered mental status . Per notes, the patient was not heating (eating) and not as alert as normal. At Alexian he was tested for COVID but tested negative reportedly. The patient had labs drawn at Alexian and was hypernatremic, thus sent to the ED (emergency department) for evaluation. On arrival to the ED, BP (blood pressure) is stable. HR (heart rate) is elevated to 120. Tachypneic sodium markedly elevated to 174, cl (chloride) 136, BUN (blood urea nitrogen) 72/ Cr (creatinine) 1.77, BNP (protein levels made by heart & blood vessels) 1142. Given 250 NS (normal saline), CXR (chest x-ray) obtained, concerning for infiltrate. Started on [MEDICATION NAME]. CT (computed tomography) head obtained with no acute findings. admitted for further cares. Under impression and plan documents Resident's name (R4) is a 74 y/o male with a hx of advanced dementia, DM II, recently admitted with [MEDICAL CONDITION], acute kidney injury and aspiration pneumonia. admitted to AAU for further cares. Severe [MEDICAL CONDITION]ly from poor free water intake given hx of prior admission also goal to lower slowly over the course of several days s/p (status [REDACTED]. Acute kidney injury likely secondary to poor PO intake fluids as above, repeat bmp. The discharge summary dated 5/26/2020 under discharge [DIAGNOSES REDACTED]. The nurse's note dated 5/26/20 documents Resident readmitted back to facility at 2:45pm from SMO via EMS (emergency medical services). Alert and awake with a discharge [DIAGNOSES REDACTED]. Resident lung sound is clear bilaterally per auscultation. Bowel sound active x (times) 4 with no tenderness. Res is on a puree diet and honey thickened liquid. Res was fed and ate 75% of his meal and drank 120 mls of fluid. No pain or grimacing noted. Res wife sent some lotions to be used on him. Res. tolerated meds with no concerns at this time. VSS (vital signs stable). The hydration risk evaluation dated 5/26/2020 Documents a total score/value of 20 at risk. A resident who scores 8 or higher may be at risk for dehydration. There were no changes on the Dehydration/Fluid Maintenance care plan dated 5/26/2020. Surveyor noted the approaches for the dehydration/fluid maintenance care plan dated 5/26/20 are the same approaches as the previous care plan dated 3/31/20. There are no revisions in the care plan following R4's second hospitalization for dehydration. The CNA care plan dated 5/26/2020 documents approaches all dated 5/26/2020 of * Weigh resident weekly. * Record meal intake. * Record total shift fluid intake. * Bathing. The resident care guide with a start date of 5/26/20 under the diet section documents Diet/Special Instructions: Puree with honey thick liquid see NURSE for detail instruction. I need 1:1 total assistance with eating. I have dysphagia and need to sit up 30 minutes after meals. I need to be fed 1 tsp (teaspoon) bites and sips. NOT TO BE LEFT ALONE FOR MEALS. Wife provides all feeding support she will ask for help as needed. Res wife and POA (power of attorney) refusing to have weights taken. Requests res. to be comfortable and getting res. up to be weighed causes to much stress on res per POA. Lower HOB (head of bed) to 45 degrees 1/2 hour after meals to prevent sliding down, causing pressure at feet at foot board. Staff to assist res with all meals during wife's absence. Encourage honey thick fluids throughout day. Offer me a clothing protector for meals. CARE PLAN: I need 1:1 total assist with feeding puree solids and honey thick fluids. No straws. Alternate solids/liquids as needed. Provide tactile cues of spoon to lips if patient does not open oral cavity as needed. Sit up in broda chair for meals only as tolerated. Remain upright for 30 minutes after meals. The nutrition note dated 5/27/20 documents Readmit Nutrition Note-Res readmitted to facility after hospitalization for AKI (acute kidney injury), aspiration pneumonia, dehydration, [MEDICAL CONDITION] and pneumonia. Res is on a Pureed diet with honey thick liquids. Res needs to be fed for all meals. Appetite has much improved during hospitalization however res. has lost 9.6 lbs (-10.7%) in the past 3 months. Res does well with magic cups and generally eats 100% when assisted. Will add magic cup TID (three times day) for additional nutrition support. Provides 290 calories, 9g/pro (grams/protein) per cup. Res BMI is 23.7 indicating weight remains w/in (within) IBW (ideal body weight). Res UBW (usual body weight) is ~160-165 lbs. Res has a hydration score of 20 indicating res. is at high risk for dehydration d/t recent hospitalization ,[DATE] (secondary to) dehydration, dependent on staff for eating/drinking and is on honey thick liquids Staff to encourage honey thick fluids with meals and throughout day. The nutritional risk assessment dated [DATE] under estimated nutritional needs for fluid documents 2010-2345 for 30-35 ml/kg. Under potential at risk factors yes is checked for at risk for dehydration due to inadequate fluid intake. On 6/4/20 Surveyor reviewed daily intake meal consumption from date of admission 5/26/20 to 6/3/20 and noted the following: 5/26 refused dinner. 5/27 breakfast & lunch 51-75%, dinner 26-50%. 5/28 breakfast 51-75%, lunch 76-100%, and dinner is blank. 5/30 breakfast & lunch are blank and dinner is 51-75%. 5/31 There is no documentation for breakfast, lunch, & dinner. 6/1 breakfast & dinner 51-75% and lunch 76-100%. 6/2 breakfast 25-50%, lunch & dinner 76-100%. 6/3 breakfast & lunch 76-100% and dinner 51-75%. The nurse's note dated 6/8/20 documents Writer saw resident and offered swallows of honey thickened fluids that resident took well. Skin turgor is good; no signs of any hydration issues. Resident awake and looking around when writer attempted to greet him. Appears in no distress. Surveyor noted this is the first nurse's note that assesses skin turgor and hydration issues. INTERVIEWS On 6/2/20 at 3:14 p.m. Surveyor asked DON (Director of Nursing)-B via telephone if the care plan indicates to monitor intake is the intake for food or fluid. DON-B informed Surveyor it is all together. Surveyor asked if a resident is at risk for dehydration where would the fluids consumed be documented in the medical record. DON-B informed Surveyor they do not record cc (cubic centimeter) of fluid intake. DON-B explained if a resident didn't drink anything then that would be in a nurse's note. On 6/3/20 at 3:16 p.m. Surveyor asked DON-B via telephone if a care plan says to monitor for signs and symptoms of dehydration where would Surveyor locate this in a Resident's medical record. DON-B informed Surveyor it's just something they monitor and doesn't have an answer off the top of her head. On 6/4/20 at 9:29 a.m. Surveyor spoke with RN (Registered Nurse)-L regarding R4. Surveyor asked RN-L how they are monitoring for signs and symptoms of dehydration for R4. RN-L informed Surveyor the nurses working with R4 would know and labs have been done on him. RN-L informed Surveyor she is still in training and started working at the Facility on 3/5/20. RN-L informed Surveyor when R4 came back from the hospital he was admitted on a puree diet with honey thick liquids. RN-L informed Surveyor she didn't see any labs scanned for R4. Surveyor asked where monitoring for signs and symptoms of dehydration would be found. RN-L informed Surveyor the CNA's would let the (TRUNCATED)

Based on observation, interview, and record review the Facility did not ensure 3 (R16, R55 & R[AGE]) of 5 Residents with limited range of motion (ROM) received appropriate treatment and services to maintain or prevent further decline in ROM. *R16 was to wear bilateral hand/wrist splints to prevent further contractures. It is documented R16 had flexion of both right and left digits on 10/3/19. On 2/8/20, R16 was observed with a closed fist on both right and left hands. Surveyor noted R16's bilateral hand contractures got worse from 10/19 to 2/20. Surveyor observed during the survey process that R16 was not wearing R16's bilateral hand/wrist splints and left knee splint. *R55 was observed not wearing R55's right hand/wrist splint during the survey process. *R[AGE] was observed not wearing R[AGE]'s left hand/wrist splint during the survey process. Findings Include: 1. Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R16 has an activated Health Care Power of Attorney (HCPOA). Surveyor reviewed the Restorative/Maintenance Program dated 11/5/19 and noted the following: -Place left knee splint on after getting dressed in the morning and remove after lunch when R16 lies down -Place bilateral resting hand/wrist splints on daily after getting dressed in the morning and remove after lunch when R16 lies down R16's Quarterly Minimum Data Set ((MDS) dated [DATE] documented R16 has both short and long term memory loss, and demonstrated severely impaired skills for daily decision making. The MDS also documented that R16 required extensive assistance with 2 person physical assist for dressing. Surveyor noted R16's Certified Nursing Assistant (CNA) care card printed 2/3/20 stated to place bilateral resting hand/wrist splints on daily after getting dressed in the morning and remove after lunch when R16 lies down. Report any redness or skin integrity concerns to the nurse. Left knee splint on after R16 gets up in the morning and off when R16 lies down in the afternoon. Surveyor reviewed R16's care plan and noted the following: R16 needs assistance with daily Activities of Daily Living (ADL) care. Goal-R16 will have daily care needs met through next review period Intervention-Place bilateral resting hand/wrist splints on daily after getting dressed in the morning and remove after lunch when R16 lies down-[ENTITY]t-11/6/19 Intervention-Left knee splint on after R16 gets up in the morning and off when R16 lies down in the afternoon-[ENTITY]t 12/5/19A review of R16's Therapy notes indicated the following: Surveyor reviewed the Occupational Therapy (OT) noted dated 10/3/19 which documented gentle passive range of motion (PROM) of bilateral hands with mild contracture of bilateral hands. R16 wears bilateral upper extremity resting hand splints to prevent contractures. Surveyor reviewed the OT note dated 10/15/19 which documented that R16 had no facial grimacing when splints were applied. Surveyor reviewed the OT note dated 10/16/19 that documented Certified Nursing Assistant (CNA-N) was notified about the donning and doffing of the bilateral upper extremity splints. Surveyor reviewed the OT note dated 10/25/19 which documented that R16 will wear bilateral upper extremity resting hand splint for 8 hours with no signs or symptoms of discomfort in order to prevent contractures. It is documented that R16 had varying levels of digits flexion to both right and left hands. Surveyor reviewed the OT noted dated [DATE] which stated that R16 will wear bilateral upper extremity resting hand splint for 8 hours with no signs or symptoms of discomfort in order to prevent contractures. R16 will wear resting hand splint for 8 hours according to the wear schedule with 100% accuracy as applied by trained caregivers. Surveyor reviewed the OT note dated 11/28/19 which documented that bilateral hand/wrist splints were donned at 7:15 AM, skin intact, minimal facial grimacing noted with donning and initial stretch of digits, upon assessing R16 at 10:15 AM, R16's splints were off. Consulted with CNA who reports she took them off to complete daily cares and did not put them back on. Surveyor reviewed the OT note dated 12/3/19 which documented that caregiver training of orthotic application, care, wearing schedule and precautions of splint/orthotic device. Splints were not on this morning and CNA reports waiting to get R16 out of bed after wound rounds. Instructed CNA that we are implementing wear time/schedule of bilateral hand/wrist splints and CNA verbalizes understanding. Surveyor reviewed the Physical Therapy (PT) Progress and Discharge Summary dated 12/5/19 which documented that R16 wears left knee extension splint with proper splint application and Certified Nursing Assistants (CNAs) being educated in donning/doffing of the braces. Surveyor reviewed the OT note dated 12/11/19 which documented the following: instructed R16's caregiver to donn splints after getting R16 dressed, however R16 seen later in the morning and did not have splints on. On 2/3/20 at 11:49 AM, Surveyor observed R16's fingers to be severely contracted into R16's hands. R16's left leg was contracted over onto R16's right leg. Surveyor observed R16 with no bilateral hand splints on and no splint on R16's left knee. On 2/3/20 at 12:54 PM, R16's daughter (BB) stated to Surveyor that R16 is supposed to have the splints on. On 2/4/20 at 11:10 AM, Surveyor observed R16 to not have any bilateral hand splints on or R16's left knee splint on. On 2/5/20 at 8:30 AM, Surveyor interviewed Therapy Director(TD-V) who informed Surveyor that R16 should have bilateral hand/wrist hand splints on and the left knee splint is supposed to be on. On 2/5/20 11:08 AM, R16 was up in a reclining chair with no bilateral hand/wrist splints on, and no knee splint on. On 2/5/20 at 12:05 PM, Surveyor interviewed Director of Nursing (DON-B) who stated the following, splints is not something I have gotten to since being employed at the facility, it was not top priority. Surveyor asked why R16 would not be wearing the bilateral hand/wrist splints or the left knee splint, and DON-B stated DON-B would need to look into it. On 2/5/20 at 3:28 PM, Surveyor shared the concern with Administrator (NHA-A) and DON-B that R16 had not been wearing R16's bilateral hand/wrist splints and R16's left knee splint during the survey process. No further information was provided at this time. On 2/10/20 at 11:42 AM, Surveyor observed R16 to be wearing R16's left knee splint but not R16's bilateral hand/wrist splints. On 2/10/20 at 12:38 PM, Surveyor interviewed CNA-N about R16's splints. CNA-N confirmed that CNA-N got R16 up for the day. Surveyor asked CNA-N why R16 did not have R16's bilateral hand/wrist splints on. CNA-N stated that CNA-N tried to put the bilateral hand/wrist splints on but R16 had facial expressions and grunting that indicated pain. CNA-N stated that he could not uncurl R16's fingers from R16's palm to get the splints on today. CNA-N informed Surveyor that is why R16 did not have the bilateral hand/wrist splints on. Surveyor reviewed the OT note dated 2/8/20. Surveyor noted that R16 was re-assessed by therapy after bringing the splint issue to the facility's attention on 2/5/20. The OT note stated the reason for the referral was to determine functionality of bilateral hand splints and provide staff education on donning/doffing and precautions to increase compliance of wear schedule and assessment of skin integrity. Therapy necessary for splint use and wear with staff education. Without therapy, R16 is at risk for joint contracture and skin integrity deficits. Surveyor noted according to the OT documentation (2/8/20), R16 presented with bilateral hand fisting affecting R16's ability to preserve skin integrity and use of bilateral hand splints to prevent contractures. At this time, the goal was for R16 to increase extension to 30 degrees to allow splint use in order to prevent contracture and preserve skin integrity. Surveyor noted when R16 started wearing the bilateral hand/wrist splints, R16 had flexion in both right and left digits. At this time, R16 presents with bilateral hand fisting. On 2/10/20 at 3:05 PM, Surveyor interviewed Occupational Therapist(OT-W). OT-W verified that OT-W did the initial evaluation on R16 on 10/3/19. OT-W confirmed to Surveyor that during the initial evaluation R16 had movement in R16's hand and flexion of both right and left digits. OT-W stated R16 had 1 finger on the left hand that was not contracted at all. OT-W stated that OT-W completed the evaluation on 2/8/20 and R16 is now closed fist on both right and left hands. OT-W confirmed that R16 was not closed fist at the time of R16's initial evaluation on 10/3/19. OT-W informed Surveyor that R16 being closed fist on both left and right could be caused by R16 not having R16's bilateral left and right hand/wrist splints on consistently to prevent further increase in contractures. On [DATE] at 9:05 AM, Surveyor was provided and reviewed additional information from the facility in regards to R16. Surveyor noted R16's Plan of treatment for [REDACTED]. Surveyor further noted that no additional information in regards to R16's bilateral hand/wrist splints was provided at this time. 2. R55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R55 has a legal guardian. R55's Quarterly MDS dated [DATE] documented R55 had a Brief Interview for Mental Status(BI[CONDITION]) score of 1, indicating R55 demonstrates severely impaired skills for daily decision making skills. The MDS also documented that R55 had Range of Motion (ROM) impairment on 1 side for both upper and lower extremity. The MDS also documented R55 required extensive assistance with 1 person physical assist for dressing. Surveyor noted that on R55's Certified Nursing Assistant (CNA) care card printed 2/3/20 it stated to complete passive range of motion (PROM) home exercise program (HEP) to right upper extremity(RUE) at all joints with AM/PM cares. R55 to tolerate right hand/wrist splint on days, off pms. PROM should be done to hand and wrist before splint is put on and after it is removed. Surveyor reviewed R55's care plan and noted the following: R55 needs assistance with daily ADL care due [MEDICAL CONDITION] with [MEDICAL CONDITION] Goal-R55 will have daily ADL care needs met Intervention-Complete PROM HEP to RUE at all joints with AM/PM cares. R55 to tolerate right hand/wrist splint on days, off pms. PROM should be done to hand and wrist before splint is put on and after it is removed-[ENTITY]t-10/15/19 R55 is at risk for skin breakdown due to impaired mobility and incontinence Goal-R55 will be free of skin breakdown daily Intervention-Monitor right hand due to contracture for risk for skin breakdown-[ENTITY]t-[DATE] R55 has potential for complications [MEDICAL CONDITION] and has the following stroke related deficits: right sided weakness Goal-R55 will not develop complications from stroke Intervention-Perform ADL (Activities of Daily Living) and mobility as recommended by OT and Physical Therapy (PT). Provide adaptive equipment as indicated.-[ENTITY]t 9/4/17 Surveyor reviewed R55's most recent OT progress and discharge summary dated 10/22/19. It is documented that the focus was to increase right upper extremity functional PROM through grades exercises and stretching and education with upper extremity HEP. Splinting focused on fitting and establishing wearing schedule for right hand/wrist splint to decrease risk of contracture. Surveyor reviewed the Restorative/Maintenance Program dated 10/15/19 which documented the following: Range of Motion-Complete PROM HEP to right upper extremity at all joints with AM and PM cares Splint-R55 to tolerate right hand/wrist splint on days, off nights. 1. PROM should be done to hand and wrist before splint is put on and after it is removed On 2/3/20 at 9:47 AM, Surveyor observed R55 not wearing R55's right hand/wrist splint. Surveyor observed the splint to be on the top of the dresser. R55 stated the staff never put the splint on. On 2/3/20 at 2:35 PM, Surveyor observed R55 not wearing right hand/wrist splint. On 2/4/20 at 9:54 AM, Surveyor observed R55 not wearing right hand/wrist splint On 2/4/20 at 1:15 PM, Surveyor observed R55 not wearing right hand/wrist splint On 2/5/20 at 8:18 AM, Surveyor interviewed Certified Nursing Assistant(CNA-O) about R55 wearing R55's right hand/wrist splint. CNA-O informed Surveyor that CNA-O does not know if R55 should be wearing a splint. On 2/5/20 at 9:38 AM, R55 is up in R55's wheelchair with no right hand/wrist splint. On 2/5/20 at 12:05 PM, Surveyor interviewed Director of Nursing(DON-B) who stated the following, splints is not something I have gotten to since being employed at the facility, it was not top priority. Surveyor asked why R55 would not be wearing the left hand/wrist splint, and DON-B stated DON-B would need to look into it. On 2/5/20 at 3:35 PM, Surveyor shared concern with NHA-A and DON-B that R55 had not been wearing R55's right hand/wrist splint during the survey process. No further information was provided at this time. On [DATE] at 9:05 AM, Surveyor was provided and reviewed additional information from the facility in regards to R55 and R55's right hand/wrist contracture. Surveyor reviewed the Plan of treatment for [REDACTED]. 3. R[AGE] was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R[AGE] had an activated HCPOA. R[AGE]'s Quarterly MDS dated [DATE] documented R[AGE] had a BI[CONDITION] score of 15, indicating R[AGE] was cognitively intact for daily decision making. The MDS also documented that R[AGE] had ROM impairment on 1 side for both upper and lower extremity. The MDS also documented that R[AGE] required extensive assistance with 2 person physical assist for dressing. Surveyor reviewed R[AGE]'s Annual MDS Care Area Assessment(CAA) dated 10/31/19 which documented that R[AGE] received assistance as needed due to weakness associated with [MEDICAL CONDITIONS]. Surveyor noted that on R[AGE]'s Certified Nursing Assistant(CNA) care card printed 2/3/20 it stated that CNA/Nurse to donn left hand/wrist splint daily with AM cares and doff with PM cares. Surveyor reviewed R[AGE]'s care plan and noted the following: R[AGE] needs assistance with daily ADL care due [MEDICAL CONDITION] with [MEDICAL CONDITION] Goal-R[AGE] will have daily ADL care needs met secondary to effects [MEDICAL CONDITION] contractures Intervention-Left hand splint on during day, off at night-[ENTITY]t [DATE] R[AGE] is at risk for skin breakdown due to bowel and bladder incontinence, DM, [MEDICAL CONDITION] and impaired mobility Goal-R[AGE] will have no skin breakdown Intervention-Monitor skin under Left hand splint and tubi grips. Staff to assist to don Left hand/wrist splint daily with AM cares and remove with PM cares-[ENTITY]t [DATE] Surveyor reviewed R[AGE]'s most recent Occupational Therapy(OT) Plan of Progress dated from 5/9/19-6/13/19. It is documented the long term goal is for R[AGE] to demonstrate ability to tolerate Left hand/wrist splint for up to 8 hours to prevent further contracture. Surveyor reviewed the Restorative/Maintenance Program dated 6/5/19 which documented the CNA/Nurse to donn left hand/wrist splint daily with AM cares and doff with PM cares. Surveyor noted that R[AGE] should be wearing R[AGE]'s left hand/wrist splint daily. On 2/3/20 at 12:14 PM, Surveyor observed R[AGE] up in wheelchair and was not wearing R[AGE]'s left hand splint. R[AGE] informed Surveyor at this time that the staff rarely put the splint on. On 2/4/20 at 9:12 AM, Surveyor observed R[AGE] in the dining room and was not wearing R[AGE]'s left hand splint. On 2/4/20 at 1:10 PM, Surveyor observed R[AGE] in the dining room with no splint on. On 2/5/20 at 8:11 AM, Surveyor observed R[AGE] in the dining room with no splint on. On 2/5/20 at 8:23 AM, Surveyor interviewed Therapy Director(RD-V) who confirmed that R[AGE] should have a left hand splint on. RD-V informed Surveyor that R[AGE] has not been reassessed since 6/5/19 when the splint was issued. On 2/5/20 at 11:11 AM, Surveyor interviewed R[AGE] who informed Surveyor that R[AGE] likes to wear the splint and it was very comfortable. R[AGE] stated R[AGE] does not refuse it. R[AGE] stated R[AGE] can not put it on herself. R[AGE] stated the staff either do not know to put the splint on or the staff never offer. R[AGE] stated R[AGE] has 2 splints. R[AGE] stated, I just stopped asking everyday for it. On 2/5/20 at 12:05 PM, Surveyor interviewed Director of Nursing(DON-B) who stated the following, splints is not something I have gotten to since being employed at the facility, it was not top priority. Surveyor asked why R[AGE] would not be wearing the left hand/wrist splint, and DON-B stated DON-B would need to look into it. On 2/5/20 at 3:29 PM, Surveyor shared the concern with Administrator(NHA-A) and DON-B that R[AGE] had not been wearing R[AGE]'s left hand/wrist splint during the survey process. No further information was provided at this time. On 2/6/20 at 9:40 AM, Surveyor observed R[AGE] to be up in R[AGE]'s wheelchair with no left hand/wrist splint on. On 2/10/20 at 9:25 AM, DON-B-agreed that all splints for R16, R55, and R[AGE] should have been on per their care card and care plan. DON-B stated that the whole process of splints and ROM is currently being addressed now that Surveyor has brought it to the facility's attention. Surveyor was informed by DON-B that there is no splint or ROM policy and procedure for the facility. On [DATE] at 9:05 AM, Surveyor was provided and reviewed additional information from the facility in regards to R[AGE] and R[AGE]'s left hand/wrist contracture. Surveyor reviewed the physician note dated 2/4/16 which confirmed R[AGE] had a spastic upper extremity left-sided [MEDICAL CONDITION] with left-sided weakness and a left hand contracture. It is documented for the plan to monitor worsening with contractures, brace on the left upper hand.

Based on record review and staff interview, the facility did not provide CPR (cardiopulmonary resuscitation) to 1 of 7 residents who wished to receive these services should he or she became pulseless and non-breathing. R1 changed R1's code status and requested to have CPR performed if required. The facility did not make this change in R1's record. R1 had an event on [DATE] and did not receive CPR. R1 passed away. The facility failure to provide CPR on [DATE] when R1 had a change in condition and was observed to become pulseless and non-breathing created a finding of immediate jeopardy. On [DATE] at 12:12 PM Surveyor met with Administrator-A and RNC (Regional Nurse Consultant)-C. Surveyor notified them of the immediate jeopardy with R1 that started on [DATE] when R1 did not receive CPR as requested. The jeopardy had been removed on [DATE] and the deficient practice corrected on that date. This is being cited as past noncompliance Findings include: The facility's policy and procedures Advanced Directives, with a revision date of ,[DATE], includes to honor choices identified in the Advanced Directive and to maintain records in accordance with federal, state law and community policy. 1.) R1's medical record indicated that R1 requested a change in code status from a DNR (do not resuscitate) to CPR, at a care conference on [DATE], along with their POA-HC (Power of Attorney of Healthcare). Facility staff did not document this change in the resident's medical record or the electronic medical record. On [DATE] R1 experienced a change in status that would have required CPR intervention. Staff was not aware that the resident wanted CPR. R1 did not receive CPR and passed away. The nurse looked at the electronic record and it had not been updated with the current code status. R1's Progress Notes indicate that a Care Conference was conducted on [DATE] that included R1, the POA-HC SW-E (Social Worker) and RN (Registered Nurse)Manager D. R1 expressed they wanted everything done if R1 coded (became pulseless and non-breathing). The POA-HC was also in agreement with this request. R1's Progress Note on [DATE] indicated RN-D was notified that R1 had a change in status. RN-D documents that they witnessed 3 last breaths and R1 became pulseless. RN-D indicated R1 was not a CPR recipient and no CPR was performed. R1's physician and POA-HC were notified of R1's passing. The facility self-report investigation indicates on [DATE] in the Morning Meeting SW--E indicated that R1 was a CPR resident. RN-D had not updated, nor called R1's physician,on [DATE] to change the code status. RN-D was terminated and unavailable for a interview. RN-D did provide a statement that indicated they did not follow through to change R1 code status. R1 did not receive CPR as requested. On [DATE] at 9:00 AM Surveyor spoke with SW-E. SW-E indicated that R1 and his POA-HC wished to have CPR performed. SW-E indicated RN-D would have obtained the physician order [REDACTED]. SW-E indicated they just remove the DNR form from the paper medical record. The Nursing staff updates the electronic records by obtaining a physician order [REDACTED]. On [DATE] at 12:12 PM Surveyor shared the immediate jeopardy concerns with the facility administration. No further information was provided. On [DATE] at 1:30 PM Surveyor spoke with R1 POA-HC. R1 POA-HC conferred that on [DATE] they requested the code status to be changed to CPR status. The facility discovered this on [DATE] and submitted a self-report investigation to the State Agency. The facility removed the immediate jeopardy and corrected the deficient practice when it implemented the following: -All residents in the facility were reviewed for correct code status - All staff were re-educated on code status - The facility began performing weekly audits This was completed on [DATE]

Based on interview and record review the facility failed to ensure that 2 (R19 and R1) of 19 sampled residents and 1 (R20) supplemental resident received the necessary treatment, care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Over the weekend of [DATE] to [DATE] R19 experienced a change in condition where staff noted R19 was sleepy and only alert and oriented x (times) 1. R19 had diminished breath sounds and falling blood pressures. Facility nursing staff did not take vital signs, did not assess R19, and did not try to determine why R19 was not feeling well. Facility staff documented to consider hospice services for R19 despite the determination R19 was in the facility for rehabilitation services & intended to return to her assisted living. On [DATE] R19's usual nurse practitioner ordered tests to be completed STAT and made medication changes. The facility failed to ensure the tests were completed timely. On [DATE] the nurse practitioner gave orders for stat IV fluids and medications that were not carried out timely or correctly. The facility also failed to ensure the proper respiratory treatment ordered by the nurse practitioner was carried out. The nurse practitioner indicated in documentation when (R19) was observed on [DATE], R19 looked like a hospice patient on her death bed. Facility nursing staff told the nurse practitioner that even though R19's pulse oxygenation was 80% on room air she had not started the resident on oxygen. The nurse practitioner directed staff to give oxygen and gave 20 mg. of [MEDICATION NAME] despite R19 being given [MEDICATION NAME] 1:00 AM. On [DATE], the nurse practitioner noted R19 was looking better and indicated R19 would probably never return to baseline given how her change in condition had been handled. R19 went on hospice care on [DATE] and died on [DATE]. The facility failed to: -Assess R19 and immediately notify the physician when she experienced a change in her cognition status. -Administer IV [MEDICATION NAME] as ordered when R19 was experiencing acute [MEDICAL CONDITION]. -Administer IV fluids at the ordered rate when R19 was experiencing acute [MEDICAL CONDITION]. R19 was administered IV fluids at 125 cc an hour despite orders to be administered IV fluids at 80cc an hour. R19 was also administered the incorrect IV solution. Orders were placed incorrectly with the wrong solution type and rate in the patient's medication administration record. The IV solution and rate in the Medication Administration Record [REDACTED]. -Administer scheduled [MEDICATION NAME] as ordered when R19 was experiencing aspiration pneumonia. - Orders were placed incorrectly with the wrong medication for nebulizer in patient's Medication Administration record. The medication transcribed in the Medication Administration Record [REDACTED]. -Ensure orders for vital signs every shift were completed. -Ensure medications administered were properly documented as ordered and documented in the medication administration record. The facility's failure to provide the necessary care and services when R19 was experiencing a change in condition created a finding of immediate jeopardy. The immediate jeopardy began on [DATE]. Nursing Home Administrator-C was notified of the immediate jeopardy on [DATE] at 10:24 a.m. The facility removed the immediacy on [DATE] however, the deficient practice continues at a severity/scope level of an E (potential for harm/pattern) as the facility continues to implement its removal plan and due to the following examples: *R1 received as needed [MEDICATION NAME] for pain. R1's pain was not consistently assessed before and after receiving the [MEDICATION NAME] to determine the effectiveness. *R20's dentures went missing and the facility did not ensure R20 had replacement denures. The missing dentures impacted on R20's ability to eat. Findings include: 1) R19 was admitted to the facility on [DATE] for rehabilitation services and had discharge plans to return to her assisted living apartment. Interdisciplinary notes on [DATE] document R19 was Alert, oriented times three. Pleasant. There appear to be no mood or behavioral issues noted. Prior to admission, she had been living in the AL (assisted living) at AVM. Her goal is to return back when able. Nurse Practitioner's (NP)-W's written statement as part of the facility's investigation into R19's change of condition documents : [DATE]: Pt (patient) admitted to Alexian as a rehab pt (patient) after falling in her ALF (assisted living facility) room and suffering a intramuscular hematoma to her left thigh. She was in the hospital for observation overnight and DC'd (discharged ) to Alexian for rehab so that she could get back to AL. I saw her this day and she was doing very well, stable. Had some leg pain with transfers and ambulation, pain medicine was helping. Her lungs were clear at that time and she was calm, appropriate, answered questions, pleasantly confused on some things. On [DATE] Licensed Practical Nurse (LPN)- Z documented on the Interdisciplinary Notes at 12:35 a.m. A&Ox1 (alert and oriented times 1), quiet, sleepy, PT advise 2 to transfer with wheeled walker resident weak .appetite low. and at 7:20 p.m. A&O x1 grimace face and moaning/ daughter present and request for [MEDICATION NAME] resident scheduled Ibuprophen (sic) and [MEDICATION NAME] effective for left leg pain . R19 had a change in cognition from being alert and oriented x3 to alert and oriented x1. * There is no documentation that an RN was notified that R19 had a change in cognition. * There is no documentation of MD notification on [DATE] when R19 had a change in cognition. On [DATE] at 7:21 pm Interdisciplinary Notes by LPN-Z document A&Ox1, quietly sleepy this afternoon daughter present. Skin w&D (warm and dry) daughter reports she slept thru lunch (sic) . the [MEDICATION NAME] effective .daughter reports she's 'talking and not making sense' confused .focus eyes on daughter when called by name .daughter request [MEDICATION NAME] @1800 d/t (due to) resident grimace and moan .resident holding legs . VS (vital signs) = (blood pressure) ,[DATE] (pulse) 71 (respirations) 16 (temperature) 97.7 (pulse ox) 94% RA (room air) .[MEDICATION NAME] effective .unable to weigh this resident this evening. * There is no documentation that an RN was notified of R19 talking and not making sense. * There is no documentation of an assessment completed despite R19 having a change in cognition. * There is no documentation that a physician was immediately notified of R19's change in cognition. NP -W's written statement as part of the facility's investigation documents: This was the on-call report for [DATE] at 2200 (10:00 p.m.) Nurse reports pt is declining overall and requesting Optum PNP (primary nurse practitioner) see pt tomorrow re: possible hospice consult. Pt takes [MEDICATION NAME] for pain and is currently comfortable. No needs at this time, but requesting f/u (follow-up). and Over the weekend my on-call NP with Optum received a call from the nurse stating the patient wasn't doing well, increased fatigue and sleepy, and that maybe we should consider hospice. That's the report I got on Monday. For a rehab pt with a goal to return to her ALF (assisted living facility) who doesn't have many medical problems, regardless of age more assessment should have been done at this point. Vitals, lung sounds, heart sounds, labs, UA (urinalysis) or CXR (chest x-ray) if indicated- more investigating for why she wasn't feeling well, not just, well maybe she should go on hospice . The statement continues to state on: [DATE]- met with pt and daughter, pt was alert, becoming a little more confused. Moist cough noted, increased after she drank her med pass nutritional drink. Made some changes to her orders, dc'd (discontinued) her [MEDICATION NAME] (a narcotic pain reliever) and scheduled Tylenol and biofreeze for pain to hopefully lessen confusion. I ordered STAT CXR, (chest x-ray) CBC (complete blood count), BMP (basic metabolic panel) and VS (vital signs) (every) shift for monitoring. I suspected aspiration pneumonia and asked speech therapy to evaluate. I reported to my on-call NP if pneumonia to order [MEDICATION NAME] and z-pack, [MEDICATION NAME] and that I would see her in the am. Before I left pt was more confused, wandering, trying to get up by herself and (RN (registered nurse)-Y) had her by the nurses station for safety. On [DATE] at 12:48 a.m. Interdisciplinary Notes document: Stat CBC, BMP lab requisition filled out and faxed and stat CXR d/t (due to) cough VS q (every) shift x3/day. * On [DATE] NP-W wrote orders that included vital signs every shift for 3 days. R19 had no documented vitals completed on the pm shift of [DATE], or the am and pm shift on [DATE]. * On [DATE] NP-W ordered normal saline at 125cc hour times 500cc then after 500cc normal saline (note: this would be after 4 hours) change to D5 0.9NS w/ 20 meq KCL at 80cc/hr (potassium chloride in 5% [MEDICATION NAME] and sodium chloride). The order does not specify what route the fluid is to be given. R19's Medication Administration Record [REDACTED]. The order for the potassium chloride in 5% [MEDICATION NAME] and sodium chloride is not transcribed or documented as administered in the [DATE] medication administration record. The Sodium chloride 0.9% for nebulization (generic)- 125cc/hr intravenous continuous x3 days' is documented as administered on the evening shift of [DATE], the night shift of [DATE], and the day shift of [DATE]. (Note: this exceeds the amount ordered - 80cc vs. 125cc.) NP (nurse practitioners)-W's written statement as part of the facility's investigation documents [DATE]-came into work to find that the on-call NP could not get a hold of the nurse multiple times and when she did the results were not in. The labs were not done until 0200 (2 am) and the x-ray was not done until about 0800 (8 am) at about ,[DATE] (9:30 a.m.-10:00 a.m.) I came up to the floor and (RN-Y) said, 'Oh good just the person I was to see. The daughter down there keeps asking for help, she said her Mom needs to see a doctor.' My thought was, well then why didn't I receive a phone call? I asked (RN-Y) where the lab and XR (x-ray) results were and she didn't know. I called the lab and got them faxed over. I called the XR and they said the results were not back yet and they would fax them when they got them. (RN-Y) asked about the tests, she said 'She has dementia'. I said 'I think she has pneumonia.' When I looked at the labs, she for sure had a bacterial infection, dehydration, and decreased renal function. The pt was lying in bed staring at the ceiling with her mouth open, completely delirious and grabbing at the air. Her lungs had coarse crackles throughout. She looked terrible. I made her NP (nothing by mouth) and ordered IVF (intravenous fluids), IV [MEDICATION NAME], scheduled [MEDICATION NAME], and then reported to speech therapy. I contacted (previous ADON (assistant director of nursing)-AA) to ask if she could help with the IV because it was urgent and I didn't feel (RN-Y) would be able to do it right away, she was busy with her med pass. I called the pharmacy and said the [MEDICATION NAME] was STAT and faxed the order to them. When I brought the orders to (RN-Y) to tell her what I did, she said, 'What? IV [MEDICATION NAME]?!' I said yes, she has pneumonia and she's doing terrible and needs IVF and IV [MEDICATION NAME] started STAT and that (previous ADON-AA) was going to help her with the IV. I told her that the pt had to be NPO she was way too out of it.(sic) (Previous ADON-AA) started the iv and pharmacy said they would get the iv [MEDICATION NAME] to us on the 1400 delivery. I ordered IM [MEDICATION NAME] which I believe (previous ADON-AA) gave. When the CXR came back it showed RLL (right lower lobe) pneumonia and prominent bilateral [MEDICAL CONDITIONS]-aspiration pneumonia and acute [MEDICAL CONDITIONS]- her lungs were FILLING up with the fluids and she was drowning, probably had been for days. So I ordered STAT IV [MEDICATION NAME] and changed her fluids to D5NS (5% [MEDICATION NAME] and Sodium Chloride) with 20 MEQ KCL (20 milliequivalents potassium chloride) and changed the rate to 80cc/hour so we wouldn't overload her anymore but she needed some fluid because she was NPO (nothing by mouth) I also added iv [MEDICATION NAME] for anaerobic coverage since it was aspiration pneumonia. I asked if iv [MEDICATION NAME] could be given and I was told it can. I asked (previous ADON-AA) a couple times to make sure she got it STAT because she really needed it. I saw her later in the hall and she said ok it would be done. * On [DATE] NP-W wrote orders that included [MEDICATION NAME] 750mg (an antibiotic) IV x1 now. R19's medications administration record does not include documentation that the [MEDICATION NAME] 750mg via IV was administered to R19. However, there is a progress note at 4:13 am on [DATE] that indicates [MEDICATION NAME] IV was administered, albeit, late and not STAT as had been ordered: Received IV [MEDICATION NAME] 750mg x1 stat on this shift. * On [DATE] NP-W ordered [MEDICATION NAME] (an antibiotic) 2.25 grams IV every 8 hours for a [DIAGNOSES REDACTED]. * On [DATE] NP-W wrote orders for [MEDICATION NAME] QID (4 times a day) x3 days. [MEDICATION NAME] is a combination inhalation solution of [MEDICATION NAME] and [MEDICATION NAME] sulfate. R19's Medication Administration Record [REDACTED]. On [DATE] a physician's orders [REDACTED]. * On [DATE] NP-W ordered 20mg IV [MEDICATION NAME] x1 now. R19 did not receive the IV [MEDICATION NAME] on [DATE]. On [DATE] at 1:24 p.m. the surveyor interviewed previous DON-X. Previous DON-X informed the surveyor the nurses didn't know that the [MEDICATION NAME] was available in the facility's e-kit. Previous DON-X confirmed the [MEDICATION NAME] was available for nurses to administer the IV [MEDICATION NAME] from the e-kit on [DATE]. The surveyor asked previous DON-X what she believed the root cause to the delay of R19 being administered the [MEDICATION NAME]. Previous DON-X stated the ADON (Previous ADON-AA) had informed staff to put it (the iv [MEDICATION NAME]) in the IV bag (of the running fluid solution) and staff said we are not doing that and that's why they contacted pharmacy. Previous DON-X also stated staff was not aware that the [MEDICATION NAME] was available in the e-kit, and that there should have been education to what was available in the e-kit. NP-W's written statement, as part of the facility's investigation, documents: One of the other really concerning things to me is that (RN-Y's) charting kept saying the patient's lung were diminished . I doubt she listened to the(m) because you didn't even need a stethoscope to hear the coarse crackles with each breath. On [DATE] at 4:13 a.m. progress notes document: . Order also received to administer O2 @ ,[DATE] Liters/ per min to keep 02 saturation at 92% or higher. Denied pain/disc (discomfort) . * On [DATE] an order reads to continue IV fluids D5 .9 NS (with) 20 KCL @ 80cc/hr. R19's Medication Administration Record [REDACTED]. Previous DON-X's Investigation Summary and Statement documents: On [DATE], (NP-W) reviewed (R19's) care. She found her hallucinating and her lungs were coarse bilaterally throughout all fields. She assessed the patient and inquired about the status of the patient. (NP-W) explained to (RN-Y) that when she was admitted on Friday she was alert and oriented x3. (RN-Y) said 'she is [AGE] years old, what do you want?' (NP-W) tried to explain to (RN-Y) that the family was not ready to give up on her and that they wanted to run IV, (NP-W) wrote orders for IVs-Potassium, NACL (sodium chloride) and [MEDICATION NAME]. She also wrote order for oxygen at 3 liters. [MEDICATION NAME] every 2 hours as needed for shortness of breath. The oxygen got placed in the room and turned on .but had no humidification bottle. The nebulizer never got placed in the room and the [MEDICATION NAME] was not given until today when this writer administered it. (NP-W) also wrote an order for [REDACTED]. (Previous ADON-AA) and myself went to 2nd floor to start IVs. IV of NACL was hung. [MEDICATION NAME] was ordered stat from pharmacy ((NP-W) did this herself) IV push [MEDICATION NAME] was ordered. Around 6:00 p.m. the pharmacy called and stated that they did not recommend giving the IV push [MEDICATION NAME] with the Potassium running. (Potassium was not running at this time-it was NACL.) (LPN-Z) the evening nurse called the on call Optum NP and received new orders for IM [MEDICATION NAME] instead. The order did not get taken off of the chart. It remained sitting on the nurses station incomplete. RN-KK ran the IV [MEDICATION NAME] in the evening .but did not sign it out. So therefore, it looked as if the [MEDICATION NAME] also had gotten missed-but it was done. This morning on [DATE] (NP-W) came to me concerned that the wrong IV was currently running NACL was running (not the potassium as she had ordered). (sic) She reported that the [MEDICATION NAME] was not administered nor the [MEDICATION NAME]. When this writer asked the nurse why the [MEDICATION NAME] or [MEDICATION NAME] was not done. This nurse was told that the '[MEDICATION NAME] was done but not signed out, and the [MEDICATION NAME] was not done because we don't do IV or IM [MEDICATION NAME] here'. This nurse asked if there was a vial of [MEDICATION NAME] in the E-kit or if we had any on hand. (RN-Y) told me 'We do not have it here .and we don't do that here.' This nurse asked (RN-Y) when she was going to tell the physician or NP that it was not given. (RN-Y) did not give an answer. (RN Manager-CC) and this nurse opened E-kit and got a vial of [MEDICATION NAME] out. [MEDICATION NAME] 20mg was administered from E-kit by this nurse over a 5 minute period. Continuous monitoring was completed. (RN-Y) did not help or come assess the patient at that time. This nurse had to ask (RN-Y) for the oxygen tank and for a [MEDICATION NAME] to administer to the patient. NP (nurse practitioners)-W's written statement, as part of the facility's investigation, documents: [DATE]- I came to work and read the on call log and it said the pm shift nurse was told to put the [MEDICATION NAME] in the iv bag and she didn't feel comfortable with that. They called pharmacy and they said, yeah don't do that. The on call nurses said well change it to IM then. The np asked what are her vitals, (LPN (licensed practical nurse)-Z ) told her the vitals which including an 80% RA O2 saturation (80% on room air oxygen levels, normal is ,[DATE]%) (sic) The NP said did you put oxygen on? (LPN-Z) said, oh no, let me go do that. Mind you, meanwhile the [MEDICATION NAME] that was supposed to be given in the afternoon was still not given ,[DATE] hours later. I found out that the [MEDICATION NAME] was never given. I went in the room check on the pt and she looked like a hospice pt on her death bed. Her oxygen was 91% on 3L via NC (3 liters of oxygen being administered by a nasal cannula). She still had the NS (normal saline) at 125/cc hour running! I even gave (LPN-Z) the bag that was supposed to be hung the night before and said hang this next at 80cc/hour, she looked at the order sheet and said, 'ok 80cc/hour'. So the lady is downing in her own fluid, the [MEDICATION NAME] wasn't given, and on top of that the IVF were going too fast. I asked (RN-Y) if the [MEDICATION NAME] IM was given, she didn't know. I would think that would be passed along in report. I asked if the [MEDICATION NAME] was given, she didn't know. Thankfully that was started we saw it in the room. (Previous DON (Director of Nursing)-X) went to the med room, pulled the [MEDICATION NAME] out of the E-kit and gave 20mg iv [MEDICATION NAME] right away, hung the right fluids at the right rate. (RN-Y) didn't even know the wrong fluids were hanging. Also, in the night, the on call NP asked if [MEDICATION NAME] were ordered and they said no! I had ordered them to be scheduled four times a day and she only received one and that was only because the on call NP told them to give it. They didn't even know it was ordered. Thankfully the pt was responding and getting a little better, she was able to eat a little lunch, speech said pureed, nectar thick, crushed meds. I was able to restart her meds and change everything to PO. Her labs were looking much better. The facility's investigation states: (R19) was not given her [MEDICATION NAME] IV push of 20mg as ordered, it was not done at all. On [DATE] the next day it was brought to this nurse's attention by the Optum NP that the [MEDICATION NAME] and [MEDICATION NAME] were not administered. This nurse administered IV push [MEDICATION NAME] 20mg per NP orders immediately over 3 minutes. Pulse monitoring and alertness monitoring continued during administration and for 3 minutes post administration. (R19) was not given [MEDICATION NAME] as ordered QID (four times a day) x3 days. [MEDICATION NAME] administered immediately upon finding Nebulizer machine placed in room by this nurse. Orders were placed incorrectly with wrong medications for nebulizer in patient's chart. The medication was different than what was written by the NP. (R19) was supposed to have NACL IV at 125 mL/hr for 500mL. This means that this would run for 4 hours, then she was supposed to have NACL IV stopped/discontinued and D5 w/K+ 20 meq IV ran at 80 mL/hr. The NACL was still running 24 hours later. STAT BNP done. This nurse stopped NACL and started correct IV fluids of potassium at 80mL/hr. (R19) was supposed to have oxygen on at 3 liters per nasal cannula. Oxygen was on at 2 Liters when found, placed humidification bottle on concentrator and turned patient to 3 liters. (R19) had not been turned or repositioned since 5am this was reported at 12:30 pm. She was turned and repositioned immediately. BNP result came back 17,742 critical lab. On Wednesday, she was then started on 40mg po [MEDICATION NAME] daily for 5 days, continue IV KCL at 80 mL/hr. [MEDICATION NAME] was pulled from e-kit and given PO and administered by nurse and supervised by DNS (Director of Nursing Services) to ensure medications was administered immediately. On [DATE] (R19) was unresponsive and needed sternal stimulation to be aroused with very minimal arousing. She had been speaking and alert and oriented the prior day. After the correct medications were administered and correct IV fluids hung, (R19) began to respond 3 hours later. Follow up labs have been ordered. Patient had order for BNP to be done on [DATE] this was missed. It will be drawn today [DATE]. (NP-W) very upset regarding poor nursing care. NP-W's written statement as part of the facility's investigation documents ,[DATE]-,[DATE] .Iv fluids stopped and encouraged daughter (who has been at her bedside the whole time) to give her little sips of po fluids whenever she can. Pt at this point on po (by mouth) [MEDICATION NAME], kcl (potassium chloride), [MEDICATION NAME] and [MEDICATION NAME], incentive spirometer, and I started [MEDICATION NAME] po. Did repeat labs and CXR. BNP wasn't added to the labs like I had ordered so I added it to today's lab. CXR shows left pneumonia and pleural effusion, no [MEDICAL CONDITION], heart normal size (before it was very enlarged, her BNP (brain natriuretic peptide, a lab that is higher than normal when you have heart failure) was 17,000!), clinically she is doing much better, I got her down to 2L, she is able to work with therapy, her lungs sounds are better but still moist crackles throughout the lower lobs. She is alert and talking but very confused keeps trying to get up by herself, but her daughter helps her. She's got a long way to go, but hopefully she will recover. Most likely will not recover to previous baseline. This could have been prevented in so many ways along these past few days. The thing that really bothers me is that I kept hearing, she's one hundred and two years old, likes that's a reason to not treat her and just let her die. This is VERY disturbing to me. Patients are no an age number. I know [AGE] year olds on hospice and [AGE] year olds that run marathons! This lady was here for rehab not hospice. We should have caught the change in condition early on that first weekend and started her on treatment before she was delirious and drowning in their owns fluids. That is what Optum is here for. To catch monitor our patients and catch things early so we can take the best care of our patients and prevent unnecessary hospitalization s. Patients have better outcomes that way . .I'm am MORE (sic) than willing to help the nurses if I can or answer questions, but I didn't feel like my message was being received from the floor nurse. STAT means now, not 19 hours later and in nursing you have to be able to assess your patients and prioritize. Passing routine meds and charting doesn't trump a pt in respiratory distress. But (RN-Y and LPN-Z) did not seem to understand the urgency or that something was even wrong with the patient. NP-W's Transition Note, dated [DATE] documents .early on in therapy pt had aspiration pneumonia and sever acute [MEDICAL CONDITION] with BNP that required iv therapy, iv antibiotics, and iv [MEDICATION NAME], pt evaluated by ST and changed to pureed NTL (nectar thick liquid) diet and crushed meds. Was transitioned to po [MEDICATION NAME] and [MEDICATION NAME], requited O2 via NC for a few days, [MEDICATION NAME], po [MEDICATION NAME] x5 days. Pt initially started to improve, however even though labs and CXR normalized pt had increased fatigue, poor appetite, and increased weakness. On [DATE] R19 was started on hospice. R19 passed away on [DATE]. The facility's failure to provide the necessary care and services when R19 was experiencing a change in condition created a finding of immediate jeopardy. The immediate jeopardy began on [DATE]. Nursing Home Administrator-C was notified of the immediate jeopardy on [DATE] at 10:24 a.m. The facility removed the immediacy on [DATE] when they implemented the following plan: The facility developed a system to identify current Residents' physician orders [REDACTED]. The Health Care Provider shall be notified of identified changes of condition in current residents. ~ Current resident's clinical orders are being reviewed to confirm physician order [REDACTED]. ~ Current Resident progress notes are being reviewed for any notation of orders by Director of Nurses or designee. ~ Re-education of resident documentation shall be provided to current licensed nurses by Director of Nurses or designee. ~ Current residents are being reviewed to determine if a change of condition has occurred which includes physician and resident representative notification by Director of Nurses or designee. ~ Current residents are being reviewed by Director of Nurses or designee using the Interact change in condition tool to determine if any resident had a change in condition. Current licensed nurses will be re in-serviced on how to use the Interact change of condition tool, the communication and monitoring of a resident's condition. Current resident's progress notes, vital signs, and labs are being reviewed for change in condition to be completed. Current resident's conditions will be monitored through the use of the 24 hour board and shift to shift nurse report. ~ Current residents with orders for hand held nebulizer treatments will be reviewed for accurate medication administration. Current licensed nurses and medication technicians will be re-in-serviced on medication administration including administration of hand held nebulizer treatments and IV fluids and medications. ~ Medication administration pass observations of current licensed nurses and medication technicians shall be completed by Director of Nurses or designee. ~ The facility initiated Daily Clinical Huddle, 24 hour board and Resident At Risk Meeting processes to monitor oversight and communication of any current resident condition changes, notifications and monitoring. ~ Current Licensed Nurses are being re- in-serviced by the Director of Nurses or designee to review the Interact change in condition including what to assess and the communication to the physician, documentation of resident condition and monitoring including communication using 24 hour board, Clinical Huddle and shift to shift report, physician notification and orders including STAT orders and transcription, medication administration and monitoring, contingency medication use and daily resident care management. ~ The Clinical Huddle will be used to review residents admitted or readmitted physicians orders and to confirm physician order [REDACTED]. ~ Newly hired Licensed Nurses will be in-serviced during orientation by the Director of Nurses or designee on the Interact change in condition, physician notification, medication monitoring, and physician order [REDACTED]. ~ The Medical director was notified of the finding of Immediate Jeopardy and the facility plan. ~ A QAPI meeting was scheduled 2) Surveyor reviewed R1's medical record on [DATE] to [DATE]. The potential for pain related to generalized arthritis, chronic pain, [MEDICAL CONDITION], contaractures and lupus, right hip incision care plan not dated includes approaches all dated [DATE] of Provide [MEDICATION NAME] as ordered and assess for untoward side effects. Assess pain level as evidenced by reported pain, restlessness, pupil dilation, perspiration, changes in vital signs from baseline data. Report uncontrolled pain to provider. Perform a comprehensive assessment of pain to include location characteristics, onset, duration, frequency, quality, intensity or severity, and precipitating factors of pain. Teach the use of nonpharmacologic techniques (e.g. relaxation, guided imagery, music therapy, distraction,and massage) before, after, and if possible during painful activities; before pain occurs or increases; and along with other pain relief measures. Medicate before an activity to increase participation, but evaluate for sedation/safety. Instruct resident on pain scale values (,[DATE]) and encourage to notify staff when pain levels are increasing and/or medication is not effective. Provide non pharmacological interventions prior to [MEDICATION NAME]. Monitor for non-verbal signs of pain such as grimacing, irritability, moaning, body language, guarding, etc. daily., Monitor vital signs and Observe for side effects of medications such as falling constipation, drowsiness, etc. The physician orders [REDACTED]. (tablet) By Mouth every 6 hours as needed for pain. Review of the PRN (as needed) [DATE] MAR (medication administration record) reveals R1 received [MEDICATION NAME] 15 mg on the following dates: ,[DATE] at 1606 (4:06 p.m.) with no assessment of pain prior or after receiving the medication. ,[DATE] at 1700 (5:00 p.m.) with no assessment of pain prior or after receiving the medication. ,[DATE] at 0040 (12:40 a.m.), documents pain all over and at 1316 (1:16 p.m.) with no assessment of pain prior or after receiving the medication. ,[DATE] at 1633 (4:33 p.m.) with no assessment of pain prior or after receiving the medication. ,[DATE] at 1300 (1:00 p.m.) and 2027 (8:27 p.m.) with no assessment of pain prior or after receiving the medication. ,[DATE] at 0200 (2:00 a.m.) with no assessment of pain prior or after receiving the medication. ,[DATE] at 1800 (6:00 p.m.) with no assessment of pain prior or after receiving the medication. ,[DATE] at 1718 (5:18 p.m.) with no assessment of pain prior or after receiving the medication. ,[DATE] at 1344 (1:44 p.m.) with no assessment of pain prior or after receiving the medication. ,[DATE] at 1800 (6:00 p.m.) with no assessment of pain prior or after receiving the medication. ,[DATE] at 16:39 (4:39 p.m.) under comments documents med effectiveness. There is no assessment of pain prior or after recei (TRUNCATED)

Based on observation, interview, and record review, the facility did not ensure 6 (R7, R10, R11, R2, R9, and R8) of 11 sampled residents had a comprehensive assessment, documentation of wound characteristics, received treatment per plan of care and physician orders [REDACTED]. * R7 developed a pressure ulcer on 10/14/2016 with no comprehensive assessment until 10/17/2016. Wound characteristics were not documented thoroughly or consistently, treatments were not administered as ordered, and plan of care was not updated to incorporate effective interventions. The wound developed to a Stage 4 and became infected on 10/25/2016 and 12/12/2016. After one year, the facility has not done a root cause analysis to determine why the wound is still present. Facility failure to prevent a Stage 4 pressure ulcer to R7 and the development of infection to the ulcer created a finding of immediate jeopardy that began on 10/30/2016. Corporate Nursing Home Administrator (NHA)-D, Interim NHA-C and Interim Director of Nursing (DON)-B were notified of the immediate jeopardy on 11/3/2017 at 10:05 am. The immediate jeopardy was removed on 11/9/17 when the facility implemented an action plan. However, The deficient practice continues at a scope and severity (s/s) of an E as the facility continues to implement their and plan and based upon the additional resident examples. * R10 developed an avoidable pressure ulcer. No treatment was put in place, no revision of plan of care when R10 had an increase in assistance with bed mobility, and had ten days when no measurements of the wound were completed. * R11 has a history of pressure ulcers and was observed to not have a pressure reducing cushion in the wheelchair per plan of care. * R2 has a history of pressure ulcers and was observed to not have heels offloaded while in bed and on 10/24/2017 was observed to not have preventive dressing to pressure areas on bottom per plan of care. * R9 was observed to not have a boot on per plan of care. * R8 was observed to not have off-loading boots on per plan of care and measures to reduce infection were not followed. Findings include: The facility policy and procedure entitled PR(NAME)EDURE: Pressure Ulcer Treatment defines the different stages of a pressure ulcer. Definitions and Descriptions: Suspected Deep Tissue Injury - Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Further Description: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Stage I Pressure Ulcer - Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching: its color may differ from the surrounding area. Stage II 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. Stage III (3) Pressure Ulcer - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV (4) Pressure Ulcer - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. 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. 1.) R7 was admitted on [DATE] with [DIAGNOSES REDACTED]. R7 was able to verbalize needs, ambulate in the hallway with assistance, and was attending physical and occupational therapy for strengthening. The initial Skin Evaluation Form, the document the facility uses for a nursing skin assessment, was completed on 8/29/2016. It indicated R7 had a 2.0 cm x 2.0 cm fatty tissue/cyst-like area on the left back. On 8/30/2016, the Skin Evaluation Form states the skin was inspected and assessed and there were no remarkable observations noted. An admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 9/5/2016 indicated R7 had a Brief Interview for Mental Status (BIMS) score of 12 showing moderately impaired cognition. The MDS coded R7 as needing assistance with bed mobility, transfers, ambulation, dressing, toileting, and bathing. The Activities of Daily Living (ADL)/Rehabilitation Potential Care Area Assessment (CAA) for the MDS assessment stated the goal for R7 is to regain strength to return home with husband and resume prior level of function as able. The Urinary Incontinence CAA stated R7 was occasionally incontinent of bladder and bowel and needed assistance with toileting and hygiene. The Nutritional Status CAA stated R7's hospital weight was 192 pounds. That weight was used to calculate the Body Mass Index (BMI) of 33.9 indicating R7 was overweight. Lab work showed elevated glucose, but all other labs were within normal limits. The MDS coded R7 as being at risk for developing pressure ulcers. The Pressure Ulcer CAA stated R7 had no pressure or stasis areas and a plan of care was currently in place to address current needs. The Braden Scale for Predicting Pressure Sore Risk consists of six categories: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The total score can range from 6 to 23 with a lower score indicating a higher risk. A Braden score 15 - 18 is at risk, a Braden score 13 - 14 is moderate risk, a Braden score 10 - 12 is high risk, and a Braden score 9 or lower is very high risk. On 9/8/2016, R7 had a Braden score of 19 showing R7 was not at risk for developing a pressure sore. On 9/14/2016, R7 was transferred to the hospital after an unresponsive episode due to an embolic stroke. On 9/21/2016, R7 was readmitted to the facility. On that date at 6:48 pm in the Interdisciplinary Notes in the Electronic Medical Record (EMR), the nurse charted the embolic stroke left R7 with left-sided weakness and lower extremity flaccidity. R7 required transfers with a mechanical lift and maximum assistance for feeding. R7's diet was down-graded to a mechanical soft consistency. R7 was now incontinent of both bowel and bladder and required toileting every two hours along with repositioning. R7 was alert to self only and could only answer simple yes or no questions, needing time to respond. At times noted to just gaze at writer prior to answering questions, responses noted to be appropriate. The skin was noted to be warm and dry without any open areas. The Skin Evaluation Form on 9/21/2016 stated R7's skin was inspected and assessed and no remarkable observations were noted. The Braden score on 9/21/2016 was 14 showing moderate risk for pressure sore. A Pressure Ulcers/Skin Prevention plan of care was initiated on 9/21/2016. The plan of care stated R7 had a Braden score of 15-18 showing at risk for development of skin breakdown and the following interventions were initiated: frequent turning; float heels; manage moisture, nutrition, friction, and shear; pressure relieving mattress; chair pressure relieving cushion; apply lotion/barrier cream; position body with pillows and/or other support device such as gel cushion for wheelchair; encourage ambulation and mobility as tolerated (R7 is non-ambulatory); and inspect skin for signs and symptoms of breakdown. On 9/23/2016 at 11:06 pm in the Interdisciplinary Notes, nursing charted physical therapy requested a Broda chair due to poor muscle control. * The Pressure Ulcers/Skin Prevention plan of care was not revised to incorporate the Broda chair. On 9/27/2016 at 12:05 am in the Interdisciplinary Notes, nursing charted Prostat, a protein supplement, was ordered to be administered two times a day due to low [MEDICATION NAME]. ([MEDICATION NAME] is a protein and is measured in the blood to show nutritional deficiency.) On 9/28/2016, R7's Braden score was 11 showing high risk for pressure sore. * The Pressure Ulcers/Skin Prevention plan of care was not revised with the increased risk of skin breakdown. On 10/11/2016 in the Skin Evaluation Form, nursing charted the skin was inspected and assessed and there were no remarkable observations noted. On 10/14/2016 at 11:38 pm in the Interdisciplinary Notes, nursing charted R7 had a superficial open area on the buttocks. Redded (sic) (reddened) areas consisting of 4 1cm and one midline 5 cm with small amount of serosanguineous oozing. The family and the physician were notified of the new open area. The physician ordered a [MEDICATION NAME] dressing to cover the area and to change the dressing every three days and rotate R7 every two hours. The Treatment Administration Record (TAR) had initials showing the [MEDICATION NAME] dressing was applied to R7's open area at that time. The nurse who discovered the open area was a Licensed Practical Nurse (LPN) and notified Nurse Manager-H. No documentation was found in R7's medical record of a comprehensive nursing skin assessment or a revision of the plan of care. The facility policy and procedure entitled PR(NAME)EDURE: Pressure Ulcer Risk assessment dated 2017 states: Steps in the Procedure . E. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. F. Proceed to care planning and interventions individualized for the resident and their particular risk factors. In an interview with Nurse Manager-H on 10/31/2017 at 10:00 am regarding R7's new open area from 10/14/2016, Nurse Manager-H stated she recalled that day. Nurse Manager-H remembered being in the hallway with the LPN around dinner time. Nurse Manager-H went into R7's room with the LPN and the LPN did a measurement of the area. Nurse Manager-H told the LPN to call the physician to get a treatment for [REDACTED]. Nurse Manager-H stated a Skin Evaluation Form is initiated and the plan of care should be updated. * Nurse Manager-H agreed that she did not document anything in the Interdisciplinary Notes, initiate a Skin Evaluation Form, or update or revise the plan of care to incorporate the new open area. On 10/18/2016 at 8:02 am, a Skin Evaluation Form was completed stating R7 had a partial thickness pressure ulcer to the coccyx. The description stated, Non stageable OA (open area) to coccyx. 75% [MEDICATION NAME] tissue, 25% slough in different areas of wound. Able to see wound bed, superficial. The measurements were (length) 11.7 cm x (width) 6.8 cm x (depth) 0.1 cm. No drainage was present. The treatment was NS (Normal Saline) wash. Apply Santyl Cover with [MEDICATION NAME] daily. (Santyl is a [MEDICATION NAME] topical. [MEDICATION NAME] is an enzyme that breaks down collagen in damaged tissues within the skin and helps the body generate new healthy tissue. Collagen is a type of protein that connects and supports fibers in body tissues such as skin, tendons, muscles, and bone. Santyl is applied to skin ulcers to help remove dead skin tissue and aid in wound healing.) On 10/18/2016 at 8:08 am in the Interdisciplinary Notes, nursing had a late entry for 10/17/2016 that stated R7 had an open area to the coccyx and the physician had been notified and a new treatment had been obtained for the area. On 10/18/2016, the Pressure Ulcer/Skin Prevention plan of care was updated to include a non-stageable pressure ulcer to the coccyx with interventions: treatment per physician's orders [REDACTED]. The reactive air mattress that was applied to R7's bed was an alternating pressure therapy mattress that is effective therapy for all stages of pressure ulcers per manufacturer's description. A significant change MDS with an ARD of 10/19/2016 was completed, over four weeks since R7's readmission. R7 was unable to answer the questions to obtain a BIMS score, so staff was interviewed showing a problem with short-term and long-term memory. The Cognitive Loss/Dementia CAA states R7 had a significant stroke and was unable to participate in the BIMS. The Communication CAA states R7 rarely verbalizes. The Urinary Incontinence and Indwelling Catheter CAA states R7 had incontinence during this assessment period and a decline following a [MEDICAL CONDITION](Cardiovascular Accident). R7 receives extensive to total assist with cares. The Nutritional Status CAA states R7's weight is 183.5 pounds, down 4.4% in one month. The Pressure Ulcer CAA was triggered for evaluation due to R7 needing extensive assistance of two people for bed mobility, being frequently incontinent of bowel and bladder, and having an unstageable pressure ulcer. The CAA states the plan of care currently in place addresses the needs at this time and R7 is at risk for further skin loss and infection to the coccyx wound. * The plan of care was not updated at this time. The facility policy and procedure entitled PR(NAME)EDURE: Pressure Ulcer Treatment dated 2017 states: Documentation - The following information should be recorded in the resident's medical record, treatment sheet or designated wound form: A. The date and time the dressing was changed. B. Wound appearance, including wound bed, edges, presence of drainage. C. The name and title of the individual changing the dressing, or initials. D. The type of dressing used and wound care given. E. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. F. How the resident tolerated the procedure. G. Any problems or complaints (e.g., pain or discomfort) made by the resident related to the procedure. H. If the resident refused the treatment and the reason(s) why. I. The signature and title of the person recording the data, or initials. In an interview on 11/1/2017 at 1:22 pm with Nurse Manager-H, Surveyor asked what the expectation of the nursing staff is regarding documentation of a new open area to the skin. Nurse Manager-H stated the nurse doing the daily treatment and dressing change would be looking at the area every day, but there is no extra assessment done; the staff charts by exception, meaning they would only document when there was a change in the condition of the area and then report that change to the Nurse Manager. Surveyor asked Nurse Manager-H how the nurse would know if there's a change between dressing changes if it hadn't been documented on with each treatment and Nurse Manager-H stated she didn't know. Surveyor noted there is no current standard of practice for documentation that calls for charting by exception. On 10/24/2016 and 10/25/2016, no initials were entered into the TAR to document the Santyl and dressing change to the coccyx was done per physician orders. On 10/25/2016 at 4:47 pm on the Skin Evaluation Form, nursing charted R7 had a partial thickness pressure ulcer to the coccyx. The description stated, Non stageable OA (open area) to coccyx. 75% [MEDICATION NAME] tissue, 25% slough in different areas of wound. Able to see wound bed, superficial. The measurements were 11.7 cm x 6.8 cm x 0.1 cm. There was moderate purulent drainage, yellow in color, and with a foul odor. The treatment was changed per physician's orders [REDACTED]. is a type of hypochlorite solution. It is made from bleach that has been diluted and treated to decrease irritation. Chlorine, the active ingredient in Dakin's solution, is a strong antiseptic that kills most forms of bacteria [MEDICAL CONDITION].), apply Santyl ointment to the wound bed, and cover with an [MEDICATION NAME] dressing daily and as needed. [MEDICATION NAME] (an antibiotic) 500 mg three times a day for ten days was ordered. On 10/25/2016 at 10:06 pm in the Interdisciplinary Notes, nursing charted the wound culture was obtained and is awaiting pick up from the lab. During record review, Surveyor was unable to find any wound documentation to show an infective process in the Interdisciplinary Notes or the Skin Evaluation Form from 10/19/2016 through 10/24/2016. Surveyor requested from the Interim NHA-A and the Interim DON-B on 10/26/2017 at 3:25 pm and on 10/30/2017 at 3:25 pm any documentation of R7's wound. No documentation for 10/19/2016 through 10/24/2016 was provided. On 10/26/2016 at 10:33 am in the Interdisciplinary Notes, nursing charted the wound clinic was contacted to schedule an appointment for R7. On 10/27/2016 at 8:43 am in the Interdisciplinary Notes, nursing charted an appointment had been made for 10/31/2016 at the wound clinic to evaluate the open area on R7's coccyx. On 10/30/2016 at 7:31 am, the laboratory verified the presence of bacteria from the wound culture. The bacteria in the wound was susceptible to the [MEDICATION NAME] that had been initiated on 10/25/2016. On 10/31/2016 at 9:20 am in the Report of Consultation from the wound clinic, the wound clinic stated the pressure ulcer was debrided and remains an unstageable pressure ulcer of the sacrum. The wound clinic ordered: a Stage 4 low air loss mattress with repositioning every two hours; pack area of depth with Dakin's moist gauze, apply Santyl to the superficial area, cover with dry secondary dressing, and change the dressing daily and as needed; follow up in one week. On 10/31/2016, the facility obtained a Sentry 1400 Low Air Loss and Alternating Pressure Therapy Mattress that is effective for all stages of pressure ulcers per manufacturer's description. On 11/1/2016 at 12:54 pm in the Skin Evaluation Form, nursing charted R7 has a partial thickness pressure ulcer to the coccyx at a Stage 4. The description stated, Wound Clinic debrided wound 10/31/16, Stage IV (see bote (sic)(note) 10/31/16). 11.6 x 6.8 x 2.9. Sentry alternating, low air loss pressure relief. Bed rest. NS (normal saline) cleanse, pack gently with Dakins moist gauze daily. Skin prep periwound. Return in 1 week. The measurements were 11.1 cm x 6.8 cm x 2.9 cm with undermining at 5-8 o'clock: 2.4 cm. The tissue type was granulation and the drainage was bloody/sanguineous and pink with no odor. On 11/1/2016 at 6:59 pm in the Interdisciplinary Notes, nursing charted, .Resident repositioned q2 (every two hours). Dressing to coccyx done. Tunneling (tunneling) continues to site. Moderate amount of serosanguineous drainage to old dressing. Wound bed is brown with small amount of yellowish slough present at wound edges. No odor present at this time. Area packed with gauze soaked Dankins (sic) (Dakin's) and covered with dry dressing. Resident tolerated well. On 11/3/2016 at 9:03 am in the Interdisciplinary Notes, nursing charted the daily treatment was completed and moderate drainage was noted along with an odor. On 11/8/2016 at 10:20 am in Report of Consultation from the wound clinic, R7's coccyx wound measures length: 10 cm x width: 3.4 cm x depth: 2.9 cm with tunneling at 6 o'clock: 3.1 cm. New orders stated: start wound vac (a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds and enhance healing) to wound - settings 125 mmHg continuous pressure, black foam, change three times per week; may use skin prep under vac drape; continue daily dressing changes until vac is started - Dakin's moistened gauze and cover dressing; dietary to evaluate protein intake. On 11/8/2016 at 5:29 pm in the Skin Evaluation Form, nursing charted R7 has a partial thickness pressure ulcer to the coccyx at a Stage 4. The description stated, Wound Clinic debrided wound 11/8/16. Wound Vac Tx (treatment), Stage IV (see note 11/8/16). 11.6 x 6.8 x 2.9. Sentry alternating, low air loss pressure relief. Bed rest. NS (normal saline) cleanse, pack gently with Dakins moist gauze daily. Skin prep periwound. Return in 1 week. The measurements were 11.1 cm x 6.8 cm x 2.9 cm with undermining at 5-8 o'clock: 2.4 cm. The tissue type was granulation and the drainage was bloody/sanguineous and pink with no odor. The description and measurements from the Skin Evaluation Form on 11/8/2016 are the same as 11/1/2016 with a change in dates seen at the wound clinic and the addition of the wound vac treatment. These notes do not correlate with the measurements from the wound clinic and there is no documentation from the wound clinic that the wound was debrided on 11/8/2016. The plan of care was not revised or updated to incorporate the wound vac. On 11/9/2016 at 4:43 am in the Interdisciplinary Notes, nursing charted R7 has wound vac to the coccyx wound and the wound vac is functioning properly. A late entry for 11/10/2016 for the PM shift was charted on 11/11/2016 at 5:54 am in the Interdisciplinary Notes stating the wound vac was malfunctioning and, after contacting the wound vac company, a new wound vac would be sent out the following morning. A wet to dry dressing was applied to the wound as ordered. On 11/11/2016 at 12:47 pm in the Interdisciplinary Notes, nursing charted the wound vac was applied at that time with no further issues. On 11/15/2016 at 10:20 am in the Report of Consultation from the wound clinic, the wound clinic requests that the facility send the sponge dressing and new canister along with R7 to every visit. The wound clinic recommendations are: Continue the wound vac @ 125 mmHg cont. (continuous) therapy drsg (dressing) (changes) 3x/week (three times a week) and prn (as needed). If issues with vac, remove and apply moist dressing. Needs aggressive offloading. (Emphasis added.) The order was transcribed onto the TAR to read: If issues with wound vac. remove and apply moist dressing. * No revision of the Pressure Ulcers/Skin Prevention plan of care was done at that time to incorporate the order for aggressive offloading. In an interview with Nurse Manager-H on 11/1/2017 at 1:22 pm, Surveyor showed Nurse Manager-H the orders from the wound clinic stating to apply a moist dressing if the wound vac was not functioning. Surveyor asked Nurse Manager-H what a moist dressing was. Nurse Manager-H stated she thought a moist dressing would be normal saline at that time and if it was something other than normal saline, the physician would specify a different treatment. Surveyor pointed out that R7 had been getting Dakin's moist gauze as well at times. When asked if the nurse should call the physician to clarify the order, Nurse Manager-H stated that would be her expectation. Surveyor asked Nurse Manager-H what aggressive offloading meant when the wound clinic ordered that. Nurse Manager-H stated an alternating air flow mattress and heel protector boots would be aggressive offloading and all residents get repositioned every two to three hours. Surveyor asked if aggressive offloading would include repositioning the resident more frequently than every two to three hours. Nurse Manager-H stated that she didn't know. Surveyor asked if aggressive offloading would be put in the plan of care or on the Certified Nursing Assistant (CNA) Care Card to alert them of the increased need for repositioning and Nurse Manager-H stated the staff wouldn't know what that meant so it is never put on a plan of care or CNA Care Card. On 11/17/2016 at 1:39 pm in the Interdisciplinary Notes, nursing charted the wound vac dressing had to be removed and a wet to dry dressing was applied as ordered by the wound clinic. The wound vac supplies were not delivered as ordered. On 11/17/2016 at 5:57 pm and 11/18/2016 at 2:23 am in the TAR, nursing charted the wound vac was not in place and there were no supplies available. On 11/18/2016 at 3:06 pm in the Skin Evaluation Form, nursing charted R7 had a partial thickness Stage 4 pressure ulcer to the coccyx measuring 11.6 cm x 7.2 cm x 3.2 cm with undermining at 5-8 o'clock: 2.4 cm. The treatment was a wound vac. The tissue type was granulation and the drainage was bloody/sanguineous and pink with no odor. On 11/21/2016 at 9:20 am in the Report of Consultation from the wound clinic, the wound clinic states the wound vac does not maintain a seal and a new vac is needed. The wound clinic ordered the wound vac to be continued using black foam and to place alginate over the superficial areas in the periwound. On 11/21/2016 at 1:30 pm in the Interdisciplinary Notes, nursing charts the non-functioning wound vac was replaced. On 11/23/2016 at 9:39 am in the Skin Evaluation Form, nursing charted R7 had a partial thickness Stage 4 pressure ulcer to the coccyx measuring 12.0 cm x 7.2 cm x 4.0 cm with undermining at 5-8 o'clock: 2.6 cm. The treatment was a wound vac. The tissue type was granulation and the drainage was bloody/sanguineous and pink with no odor. On 11/28/2016 at 2:07 pm in the Skin Evaluation Form, nursing charted R7 had a partial thickness Stage 4 pressure ulcer to the coccyx measuring 12.3 cm x 6.5 cm x 2.9 cm with undermining at 5-8 o'clock: 2.6 cm and 9-12 o'clock: 1-2.3 cm. The treatment was a wound vac. The tissue type was granulation and the drainage was bloody/sanguineous and pink with no odor. On 11/28/2016, the plan of care was updated and revised to include the wound vac which was initiated on 11/8/2016. On 11/29/2016 at 10:20 am in the Report of Consultation from the wound clinic, the wound clinic orders to continue the wound vac with black foam and stated if the facility can't maintain the wound vac, place Dakin's soaked gauze to the wound daily. Wound clinic clarified that R7 needs large foam for the wound vac. On 12/5/2016 at 5:34 pm in the Skin Evaluation Form, nursing charted R7 had a partial thickness pressure ulcer Stage 4 to the coccyx measuring 11.1 cm x 6.5 cm x 3.1 cm with undermining at 5-8 o'clock: 2.6 cm and 9-12 o'clock: 1-2.3 cm. The treatment was a wound vac. The tissue type was granulation and the drainage was bloody/sanguineous and red with no odor. On 12/6/2016 at 9:40 am in the Report of Consultation from the wound clinic, the wound clinic states: Send vac supplies with patient next visit please!! The orders state to continue black foam with the wound vac at 125 mmHg continuous pressure and change the dressing three times a week on Tuesday, Thursday, and Saturday, to continue to offload, and keep R7 out of the wheelchair except for eating: half an hour three times a day only. On 12/7/2016, the Pressure Ulcers/Skin Prevention plan of care was revised to include: provide pain management with dressing changes, assess and document wound size, depth, color and drainage present every week, heel/elbow protectors on when in bed, keep skin clean and dry, and monitor labs as ordered and notify physician of abnormal values. Other interventions were added that were duplications of interventions already in place. On 12/12/2016 in the Report of Consultation from the wound clinic, the wound clinic ordered an x-ray of the sacrum and coccyx, to continue the wound vac, [MEDICATION NAME] (an antibiotic) 500 mg three times daily for ten days, and [MEDICATION NAME] (an antibiotic) 875 mg every twelve hours for ten days. During record review, Surveyor was unable to find any wound documentation to show an infective process or the need for an x-ray and antibiotics in Interdisciplinary Notes or Skin Evaluation Form from 12/6/2016 through 12/12/2016. Surveyor requested from the Interim NHA-A and the Interim DON-B on 10/26/2017 at 3:25 pm and on 10/30/2017 at 3:25 pm any documentation of R7's wound. No documentation was provided for 12/6/2016 through 12/12/2016 On 12/14/2016, R7 had an x-ray done of the sacrum/coccyx. The findings were negative for osteo[DIAGNOSES REDACTED]. On 12/14/2017 at 2:21 pm in the Skin Evaluation Form, nursing charted R7 had a full thickness pressure ulcer at a Stage 4 to the coccyx measuring 10.8 cm x 4.7 cm x 2.8 cm with undermining at 12-2 o'clock: 1.2-1.9 cm. The treatment was a wound vac and antibiotics. The tissue type was granulation and the drainage was bloody/sanguineous and red with no odor. On 12/19/2016 at 1:40 pm in the Report of Consultation from the wound clinic, the wound clinic stated to reposition R7 every two hours and limit the time in the chair to three times a day for one hour for meals only. The wound clinic ordered Dakin's soaked gauze to the wound daily and as needed for a saturated dressing, call the clinic if the wound worsens, and hold the wound vac. In an interview on 10/21/2017 at 4:00 pm with Nurse Manager-H, Surveyor questioned what the nursing staff did when the wound vac was not working properly from 11/8/2016 to 12/19/2016. Nurse Manager-H stated the staff would reapply the wound vac or do a wet to dry dressing that the doctor had ordered when the wound vac wasn't functioning. Nurse Manager-H recalled the husband saying the wound vac would come off on the weekends so the staff would do the wet to dry dressing until Nurse Manager-H came in on Monday to reapply the wound vac. Surveyor asked Nurse Manger-H if the nurse that was having difficulty with the wound vac would notify either the physician or the wound clinic and Nurse Manger-H stated they wouldn't call anyone because they had the standing order for the wet to dry dressing change. The staff might call the wound vac company to get a new machine, but no one else was notified at the time the wound vac was removed. Nurse Manager-H stated she would provide education individually to nurses on how to do the wound vac application. When questioned on how much experience Nurse Manager-H had with [DEVICE], she couldn't recall how many years. Surveyor asked what kind of training she and the staff have had on [DEVICE], and Nurse Manager-H recalled the wound vac company would occasionally do training, but she was unable to provide any documentation of staff training. Surveyor asked Interim NHA-C and Interim DON-B on 10/31/2017 at 3:36 pm for any wound vac training the staff had attended. No documentation was provided. On 12/20/2016 at 12:45 pm in the Skin Evaluation Form, nursing charted R7 has a full thickness pressure ulcer at Stage 4 to the coccyx measuring 10.8 cm x 4.7 cm x 2.8 cm with undermining at 12-2 o'clock: 1.2-1.9 cm. The treatment is a wound vac, but in the description nursing states the wound vac is on hold until 12/29/2016 when R7 goes back to the wound clinic. A wet to dry dressing is ordered daily. The tissue type is granulation and the drainage is bloody/sanguineous and red with no odor. On 12/27/2016 at 3:35 pm in the Skin Evaluation Form, nursing charted R7 has a full thickness pressure ulcer at Stage 4 to the coccyx measuring 10.8 cm x 4.7 cm x 2.8 cm with undermining at 12-3 o'clock: 1.9 cm. The treatment is a wound vac, but in the description nursing states the wound vac is on hold until 12/29/2016 when R7 goes back to the wound clinic. A wet to dry dressing is ordered daily. The tissue type is granulation and the drainage is bloody/sanguineous and red with no odor. On 12/29/2016 at 9:20 am in the Report of Consultation from the wound clinic, the wound clinic states the sacral wound has improved and to continue with the Dakin's soaked packing daily. On 1/5/2017 at 8:20 am in the Skin Evaluation Form, nursing charted R7 has a full thickness pressure ulcer at Stage 4 to the coccyx measuring 8.0 cm x 4.1 cm x 3.1 cm with undermining at 12-3 o'clock: 2.6 cm. The treatment is Dakin's soaked gauze daily. The wound vac had been discontinued on 12/19/2016. The tissue type is granulation and the drainage type is bloody/sanguineous and red with no odor. On 1/11/2017 at 1:13 pm in the Skin Evaluation Form, nursing charted R7 has a full thickness pressure ulcer at Stage 4 to the coccyx measuring 7.9 cm x 4.0 cm x 2.9 cm with undermining at 12-3 o'c (TRUNCATED)

Based on interview and record review the facility did not ensure that 1 (R10) of 2 sampled residents on medications to control [MEDICAL CONDITION] were free from significant medication errors. R10 has a [DIAGNOSES REDACTED]. R10 missed four scheduled doses of [MEDICATION NAME] from 8/9/17-8/11/17. The physician was not immediately notified that the [MEDICATION NAME] was unavailable for administration. Interventions to negate side effects of not receiving the [MEDICATION NAME] were not put into place. On 8/14/17 R10 experienced a fall that resulted in actual harm to R10 when she was noted to have a fracture to her right leg. Facility documentation to the cause of the fall was related to R10's anti-[MEDICAL CONDITION] medication being abruptly stopped and just restarted a few days prior to the fall. The facility believed this could have caused the vivid, realistic dream resulting in the fall. Findings include: According to https://www.[MEDICATION NAME].com/[MEDICATION NAME]-prescribing-information.pdf Section 5.5 Withdrawal of Antiepileptic Drugs (AEDs) As with all AEDS, [MEDICATION NAME] should be withdrawn gradually (over a minimum of 1 week) to minimize the potential of increased [MEDICAL CONDITION] frequency in patients with [MEDICAL CONDITION] disorders. R10 has [DIAGNOSES REDACTED]. R10 was admitted to the facility on [DATE]. A Hendrich II Fall Risk Model assessment with a form date of 8/9/17 scores R10 as a score of 6. A score of 5 or greater equals high risk for falls. R10's admission orders [REDACTED]. R10's MAR (medication administration record) for August 2017 documents R10 was to receive [MEDICATION NAME] 200mg by mouth twice a day. The 8 a.m. dose of the [MEDICATION NAME] is not documented as administered on 8/10/17 and 8/11/17. The 8 p.m. dose of the [MEDICATION NAME] is not documented as administered on 8/9/17 and 8/10/17. Interdisciplinary Notes on 8/10/17 at 11:25 a.m. document Made call to Omnicare pharmacy in regards to medication. Spoke with technician .Updated on meds not at facility. Instructed writer to fax physician orders [REDACTED]. Will continue current plan of care. The Interdisciplinary Notes on 8/9/17 and 8/10/17 do not document that the physician was made aware that the [MEDICATION NAME] was unavailable for R10. Interdisciplinary Notes documented by previous DON-X, entered 8/14/17 with an event date of 8/11/17 document Called pharmacy regarding medication [MEDICATION NAME], and [MEDICATION NAME]. Pharmacy gave authorization to pull [MEDICATION NAME]. We do not have [MEDICATION NAME] or [MEDICATION NAME] in the e-kit, but they will contact the physician for original prescriptions and will stat out medication. Patient has had no adverse reaction to not receiving [MEDICATION NAME] or [MEDICATION NAME]. Physician notified that medication has not been given today, no new orders at this time. [MEDICATION NAME] pulled from E-kit by agency nurse and administered. Will continue to follow up with pharmacy to ensure that medications arrive on stat run. R10's plan of care did not include interventions to negate side effects of not receiving the [MEDICATION NAME]. On 8/14/17 R10 experienced a fall. R10 was found on the floor, and x-ray results revealed R10 to have an oblique fracture to the proximal tibia and [MEDICATION NAME] with no displacement (an acute right lower leg fracture) following the fall. The facility's investigation to determine the root cause analysis of the fall includes documentation that (R10) stated that she fell in the night and her r (right) leg was hurting quite badly. She further stated that she was having a vivid dream that she was at home and was getting up to use the bathroom when she fell . The general investigation form related to the fall on 8/14/17 documents In your opinion, what led to this event? Resident had to abruptly stop her anti-[MEDICAL CONDITION] medication and had just restarted a few days prior to the fall. This could have caused the vivid, realistic dream. Interventions added on 8/14/17 to R10's care plan for the problem area that R10needs to have a fall risk evaluation completed and safety interventions implemented include Avoid abruptly stopping and restarting anti-[MEDICAL CONDITION] medications due to possibility of side effects. On 10/30/17 at 2:41 p.m. the surveyor interviewed RN (registered nurse) Manager-CC. The surveyor asked who ensures medication availability on admission. RN Manager-CC stated that medication (orders) get sent on admission to pharmacy. RN Manager-CC stated medications are available in contingency, and if a medication is not available in contingency they will have the medication sent STAT from pharmacy. The surveyor shared with RN Manager-CC the concern that R10 missed 4 doses of her scheduled [MEDICATION NAME] on admission. RN Manager-CC informed the surveyor that they do not have [MEDICATION NAME] in their contingency, and that they should have gotten it STAT'ed from pharmacy. The surveyor asked if a medication is unavailable should the MD be notified. RN Manager-CC stated yes. The surveyor informed RN Manager-CC that she had been unable to find documentation that a physician was notified prior to 8/11/17 that R10's [MEDICATION NAME] was unavailable despite missing doses on 8/9/17 and 8/10/17. The surveyor asked for any additional information. No additional information was provided.

Based on a complaint investigation, record reviews, review of a facility self-report investigation initiated on 03/20/17 alleging R2 sustained a fractured left hip due to a fall occurring on 03/18/17, observations and staff interview, the facility did not ensure that 4 (R2, R5, R7 & R8) of 8 sampled residents reviewed, received adequate supervision and assistive devices to prevent accidents. *R2 who has been identified by the facility as being at high risk for falls, impulsive with regard to attempting to self-transfer and has had multiple previous falls due to attempts at self-transfer, fell on [DATE], when he stood up from his wheelchair attempting to self-transfer. At the time of this fall, R2 had been transferred from his bed to his wheelchair due to repeated attempts to self-transfer from bed, and placed near the nurses' station for closer staff supervision. R2, who was then left unsupervised, stood up from his wheelchair and fell , sustaining an abrasion to his left temporal area. On 03/20/17, x-rays of R2's left hip showed R8 had sustained a fracture of his left hip. *R5 has experienced 2 falls without injury in the bathroom. After the first fall on 4/1/17, an intervention of assist of 2 as resident permits for toileting was added to the care card. R5 later progressed to needing the assist of 1 for transfers. On 5/22/17, R5 fell again in the bathroom. R5 was lowered to the floor by Registered Nurse (RN)-D. A Fall Huddle (meeting immediately post fall to discuss fall circumstances and recommend interventions) was conducted on 5/22/17, with the recommendation to utilize a gait belt in the bathroom. An Event Summary (final report of recommendations from the Interdisciplinary Team) dated 5/31/17, indicated a recommendation of 2 assist with transfers. RN-D told the surveyor on 5/31/17, that R5 has never required 2 persons for a transfer, rather the staff were utilizing a gait belt with transfers after the 5/22/17 fall. *R7 was transferred out of bed into a Broda chair on 5/24/17, with an incorrectly placed/sized sling for the full mechanical lift. With attempts to transfer out of the Broda chair into bed, R7 was sliding out of the sling. The sling was removed and a different sling used for the transfer. During the transfer to bed, R7's knee was pressed up against the motor for the mechanical lift, causing R7 to say, My knee, my knee. *R8 was transferred with a sit to stand lift on 5/25/17. The leg strap was not secured for the transfer and the base of the sit to stand was not maintained in a wide position as specified by facility policy. Example 1 involving R2 rises to a scope & severity level of a G (harm/isolated.) Findings include: 1. The surveyor reviewed R2's medical record on 05/24-05/31/17, as part of a complaint investigation. R2 was admitted to the facility on [DATE]. Review of a fall assessment dated [DATE] revealed R2 is at a high risk for falling. Review of R2's falls plan of care, initiated 09/30/16, indicates a problem that R2 is a high fall risk due to impaired cognition and history of falls. The goal for this problem is R2 will be free of major injury related to falls. Interventions to attain this goal include, staff to be sure resident has nearby supervision when up due to being impulsive (added to the plan of care on 02/03/17 as a result of a fall occurring on 02/02/17). Review of Progress Note documentation from 09/30/16-03/20/17, revealed R2 has had multiple falls (11) related to attempts to self-transfer from bed or wheelchair since admission to the facility on [DATE]. Review of Progress Note documentation in R2's medical record revealed a late entry dated 03/18/17 at 8:17a.m. The entry indicated, Resident (R2) was attempting to get up out of bed multiple times @ (at) the beginning of the shift (PM shift on 03/18/17) and was assisted to get up out of bed by PM shift. Resident was attempting to get up also multiple times even when up in the wheelchair. When encouraged to sit down in his wheelchair, he was argumentative with different staff .@ around 2:45a.m., resident was sitting in his wheelchair, observed by a CNA (Certified Nursing Assistant) getting up from his wheelchair, stood up and landed on the floor, (it was too quick) hitting his head on the wall opposite the aquarium and landed on the floor. Review of a Fall Huddle (a form utilized by the facility to investigate circumstances regarding falls) revealed Investigation Statements had been obtained from 4 CNAs (M, N, O, & P) who may have had knowledge of R2's fall on 03/18/17. The Investigation Statements consisted of 4 questions to be answered by the CNAs: 1. Any behaviors prior to fall, yelling/striking out? 2. What was resident doing last time you saw them? 3. Was alarm sounding, was a fall mat used? 4. Was resident incontinent of bowel and bladder when you found them, when was last time toileted? CNA-M's responses to the questions were: 1. Yes I tried to take him to bed a few times during the night he refused and held on to the rails in the hallway saying leave him alone. 2. sitting at nurses' station with the nurse I stated to nurse that he refused to go to bed and she said she would talk to him and bring him down to the unit. She never brought him. I went on A cluster to help with a fall then returned on B cluster to turn my residents and heard a loud boom. 3. Resident was up in w/c (wheelchair). 4. Resident was dry last toilet was at the end of second shift. Resident refused to be toileted and put to bed. CNA-M's statement contains no evidence she observed R2 standing up from his wheelchair and falling. CNA-N's responses were: 1. Argumentative, bad mood, non compliant keep trying to hold onto the wall, sliding to edge of chair. Kept telling me to mind my business, he would not listen said he would spit on me. 2. sitting in the wheelchair. 3. no 4. continent, unaware of last time toileted. CNA-N's statement contains no evidence she observed R2 standing up from his wheelchair and falling. CNA-O's responses were: 1. I had no contact with this resident. 2. Resident was sitting in the chair by the nurses' station. 3. no and no 4. I don't know. I did not toilet him. CNA-O's statement contains no evidence she observed R2 standing up from his wheelchair and falling. CNA-P's responses to all 4 questions were I didn't work with resident. CNA-P's statement contains no evidence she observed R2 standing up from his wheelchair and falling. Review of the facility self-report investigation of R2's fall and hip fracture initiated on 03/20/17 revealed no further staff statements were obtained other than the statements obtained from the Fall Huddle on 03/18/17. No evidence was found in either the Fall Huddle or the self-report investigation that R2's fall had been witnessed by staff. On 05/31/17 at 1:23 p.m., the surveyor spoke with Director of Nursing (DON)-B regarding R2's fall and fractured hip. DON-B stated that prior to R2's fall a staff member moved R2 away from the nurses' station to near the aquarium. DON-B also stated there was a time R2 was not being observed by staff, staff heard a boom and discovered R2 had fallen and the nurse who had been watching R2 was at the nurses' station then left to do something else at the time of R2's fall. General observations of the nurses' station and the aquarium area revealed if sitting inside the nurses' station, a view of the aquarium is obscured by a wall of the station. Despite R2's repeated attempts to stand without assistance and being brought to a common area (nurses' station) for closer supervision, the nurse responsible to supervise R2 left the area to complete another task without making other staff aware so supervision of R2 could be maintained. Following R2's fall on 03/18/17, the facility obtained a mobile x-ray of R2's left hip which was negative for fracture and indicated, Correlate with CT (Computerized Tomography) for greater detail, as deemed indicated, particularly if there is ongoing concern for acute fracture. According to the facility self-report investigation, on 03/20/17, R2 exhibited signs and symptoms of increased pain and was sent to the hospital where a CT scan of his left hip was performed and showed a fracture of the hip. R2 was hospitalized and did not return to the facility following this hospitalization . 2. Surveyor reviewed R5's record on 5/24-5/31/17. R5 was admitted to the facility with [DIAGNOSES REDACTED]. According to a readmission Minimum (MDS) data set [DATE], R5 requires extensive assistance with transfers. A review of R5's care plan reveals a falls care plan dated 3/12/17. The plan indicated that per therapy recommendations on 4/13/17, R5 is an assist of one for transfers. A review of the Certified Nursing Assistant (CNA) Worksheet for Thursday 5/25/2017 All Shifts, (obtained 5/25/17,) reveals in the section Transfers and Ambulation/Mobility: Assist of one and wheeled walker for transfers. An FMP (Functional Maintenance Plan) dated 5/22/17 for a gait belt and hang onto resident when ambulating with wheeled walker was on the CNA Worksheet. A FMP is generally developed after a resident completes physical or occupational therapy to maintain skills/capabilities. A review of the Certified Nursing Assistant (CNA) Worksheet for Thursday 5/25/2017 All Shifts, (obtained 5/25/17), reveals in the section Toileting and Skin: Frequently incontinent of bowel and bladder. Assist of two as resident permits. A Falls Risk Assessment completed 5/22/17, indicates R5 is at high risk for falls. A review of progress notes reveals R5 experienced falls on 4/1 and 5/22/17. On 5/31/17, the surveyor requested and received the Event Reports for the falls on 4/1 and 5/22/17. The facility Event Reports are a summary of an event with interdisciplinary team recommendations. According to the Event Report for the fall on 4/1/17, the fall occurred as R5 was walking with assistance from the bathroom back to bed. R5's knees became weak and she started to fall. The CNA lowered her to the floor. A gait belt was in use. No injury was sustained. Recommendations were for staff assist of 2 with transfers as resident chooses. According to the Event Report for the fall on 5/22/17, the fall occurred when R5 was standing in the bathroom with her walker. R5 stated, I am going to fall. Res. (resident) legs went out and Res. sat on floor. No injury was sustained. Registered Nurse (RN)-D was with R5 at the time of the fall. Recommendations on the Event summary indicated, Assist of two for transfers due to increased weakness . On 5/31/17 at 10:30am, the surveyor spoke with RN-D regarding the fall on 5/22/17. RN-D stated she was alone with R5 at the time of the fall. RN-D stated R5 had progressed from transferring with 2 assit back to one assist prior to her fall on 5/22/17. RN-D stated the facility conducts Fall Huddles (a meeting immediately post fall to discuss fall circumstances) and that the recommendation to use the gait belt was decided at the fall huddle. The surveyor informed RN-D of the recommendation on the Event Report for the 5/22/17 fall is once again for 2 staff to assist with transfers. RN-D, who is the primary RN for R5, stated she was unaware of the 5/22/17 recommendation for 2 staff with transfers, and that staff has currently been utilizing the gait belt with transfers after the 5/22/17 fall (and not 2 staff assist with transfers. The surveyor requested a copy of the Fall Huddle for the 5/22/17 fall. The intervention completed immediately after the fall was, Gait belt to be used when ambulating. On 5/31/17 at 11:00am, the surveyor spoke with Director of Nursing (DON)-B regarding the discrepancy (gait belt vs 2 staff assist with transfer) of the post fall intervention implementation for R5. DON-B stated that the Fall Huddle recommendations are considered by the Interdisciplinary Team, but the final recommendations on the Event Report are the interventions to be implemented. For R5, the final recommendation was to assist with 2 for transfers. The final recommendation of the Interdisciplinary Team for utilizing two persons with transfers was not being implemented after the 5/22/17 fall, rather staff were utilizing a gait belt and one person as discussed in the post fall Huddle. 3. Surveyor reviewed R7's record on 5/24-5/31/17. R7 has [DIAGNOSES REDACTED]. Review of a Change of Condition Minimum Data Set ((MDS) dated [DATE], reveals R7 requires extensive assistance with bed mobility and transfers. A review of the ADL (Activities of Daily Living) Functional/Rehab Potential section of the care plan dated 4/18/17, reveals R7 requires total assistance with transfers, with 2 staff. A review of the CNA (Certified Nursing Assistant) Worksheet for Wednesday 5/24/2017 All Shifts, indicates in the transfer and mobility section, R7 requires a 2 person assist with a Hoyer lift. On 5/24/17 at 10:45am, R7 was observed sitting up in a Broda chair in the activity area. A lift sling was visible in the Broda chair. On 5/24/17 at 10:55am, R7 was taken to her room. Registered Nurse (RN)-F was planning on completing R7's prescribed wound care. CNA-W was in the room to assist RN-F with the transfer from Broda chair to bed. RN-F instructed CNA-W to attach the sling to the lift with the green loop. As the mechanical lift was engaged to raise R7, R7 began sliding out of the sling. R7 was lowered back into the Broda chair. RN-F and CNA-W tried to adjust the sling, then RN-F stated the sling was too small for R7, and commented that she did not know how R7 had been transferred with that sling to the Broda chair. CNA-W stated she thought a hospice CNA had gotten R7 up that morning. CNA-W stated that yesterday (5/23/17), R7 had been transferring with the assist of 2. RN-F stated that generally residents who utilize a Hoyer lift have a sling in the room. RN-F stated she didn't know who brought the sling in the room for R7 but it wasn't the proper size. RN-F and CNA-W removed the sling and RN-F sent CNA-W to get a replacement sling. CNA-W did not return to the room. After about 20 minutes and unidentified staff member brought a sling to R7's room. CNA-E then came to assist RN-F with the transfer. RN-F and CNA-E placed the full body sling under R7. The sling was attached to the Hoyer left with the green loops. CNA-E was operating the controls for the lift. As R7 was raised, her foot and knee were pressed against the motor of the Hoyer lift. R7 stated, My knee, my knee. CNA-E quickly moved R7's leg away from the lift and she was lowered into bed. On 5/24/17 at 1:58pm, the surveyor spoke with CNA-E, who was the CNA assigned to care for R7 on the dayshift of 5/24/17. CNA-E stated R7 was gotten up in the Broda chair on the night shift. This observation was shared with Administrator-A and Director of Nursing (DON)-B on 5/30/17 at 3:30pm. No additional information was provided prior to the completion of the complaint survey on 5/31/17. 4. The surveyor observed a transfer with a sit to stand lift with R8 on 5/25/17 at 9:00am. R8 was admitted with [DIAGNOSES REDACTED]. R8 utilizes a prosthetic leg. A Quarterly Minimum Data Set ((MDS) dated [DATE], reveals R8 requires limited assistance with transfers. The surveyor observed Agency CNA-X and CNA-W complete the transfer. R8 was sitting on the side of the bed. The lift was brought to the bed. The chest harness was secured around R8's chest and R8 grasped the hand holds on the sit to stand lift. R8's right leg prosthesis was placed on the right leg stump, and both feet were then placed on the foot rests of the sit to stand lift. The strap to secure the legs to the lift was not utilized. The lift was raised and R8 was transported to the bathroom with the sit to stand lift. The base of the lift remained in the closed position. (Customarily the base of the lifts are expanded during lifts for stability). R8 was taken to the bathroom. Once in the bathroom the base of the lift was expanded and R8 was lowered to the toilet. This observation was shared with Administrator-A and Director of Nursing (DON)-B on 5/30/17 at 3:30pm. DON-B stated that R8's legs should have been secured prior to raising the lift. DON-B was not sure if the base of the lift needed to be expanded during transfers. The surveyor asked for a copy of the facility mechanical lift policy. On 5/31/17, the surveyor obtained and reviewed the facility policy Lifting Machine, Using a Portable, last revised 12/2016. In the section of the policy titled, Procedure for Sit-to-stand instructions include: Secure resident's feet on lift platform. Ensure knees are against knee rests on lift. Before moving the lift, ensure legs of the lift are open to widest position. Agency CNA-X and CNA-W did not follow facility procedures when transferring R8 on 5/25/17. This observation was shared with Administrator-A and Director of Nursing (DON)-B on 5/30/17 at 3:30pm. No additional information was provided prior to the completion of the complaint survey on 5/31/17.

Based on observation, staff interview and record review, the Facility did not ensure that the Resident environment remained as free of accident hazards as is possible; and each Resident received adequate supervision and assistance devices to prevent accidents for 3 (Resident #22, #3, & #14) of 7 Residents reviewed who were at risk for falls. The Facility did not consistently assess behavior/fall trends and identify root causes for unwanted self-transfers, did not consistently implement new interventions to prevent falls when past interventions had proven ineffective, and did not consistently implement care-planned approaches for preventing falls. * Resident #22 fell from bed on 3/15/16. The intervention of a bed alarm was not in place. On 5/5/16, Resident #22 was observed sitting on the floor. The intervention of the chair alarm was not in place. The fall huddle for this fall has no checked for the question was the alarm sounding. For the question what can we do to prevent another fall from occurring documents, Re-educated staff about making sure chair alarm is in place and sounding. On 6/25/16, Resident #22 was observed on the floor in front of his room. The fall huddle for this fall documents for the question was the alarm sounding, no is checked with a notation Resident turned alarm off. The investigation statement for CNA (Certified Nursing Assistant)-HH dated 6/25/16 documents for the question was alarm sounding, was a fall mat used, The alarm was not sounding at the time and he was in his chair before the time of his fall. He often turns his alarm off. On 6/28/16 Resident #22 was [DIAGNOSES REDACTED]. Example 1 involving Resident #22 is determined to be an example at the scope and severity of G actual harm/isolated. * Resident #3 was observed to be transferred with a Hoyer lift without the legs being open to prevent the Hoyer lift from tipping over, gripper pad/dycem was not observed on or under Resident #3's cushion in the broda chair and on 7/27/16 Certified Nursing Assistant (CNA)-X gave Resident #3 a drink of water from a styrofoam glass with a straw. According to Resident #3's physician orders, Resident #3 is not to have a straw. * On 7/28/16, Resident #14 who is at risk for falls was observed in bed with the bed up high and not in a low position. Findings include: 1. Surveyor # reviewed Resident #22's medical record on 7/25/16 to 7/28/16. The admission MDS (Minimum Data Set) with an assessment reference date of 12/14/15 and signed as complete on 12/17/15 documents a BIMS (brief interview mental status) score of 12 which indicates moderately impaired. Resident #22 requires extensive assistance with two plus person physical assist for bed mobility & toilet use, requires extensive assistance with one person physical assist for transfers and ambulated only once or twice with one person physical assistance. Resident #22 has fallen in the past month prior to admission and has not fallen since admission. The fall CAA (Care Area Assessment) dated 12/16/15 under analysis of findings for description of problem documents, Resident #22 presents on 12/7 following a lengthy hospital stay due to UTI (urinary tract infection), weakness, diarrhea. He has an activated POA (power of attorney) in place due to dementia. They report a fall in the last 30 days but not > (greater) 30 days and no serious injury. Please refer to initial nursing assessment completed. He is weak and is attending therapies for strengthening. The fall care plan not dated has interventions dated 2/2/16 of 5/2/16 bed and chair alarm. (Resident #22) has decreased cognition and believes that he can do more than he actually can at times. Good/bad days. Resident #22 has been observed detaching his bed and chair alarms at times and an intervention dated 6/28/16 of Place chair alarm under his w/c (wheelchair) seat to decrease resident attempting to repair (remove) alarm. The fall risk assessment dated [DATE] has a total score of 9 which is high risk. The fall huddle for date of event 3/14/16, time of huddle 10:30 p.m. includes questions such as what does the resident state happened? Res. (resident) laying on his back in front of bed. Res. stated, I was walking and my legs gave out from under me. Note res. cannot ambulate without assist. PM nurse reported he saw res. he was asleep in bed, position resident was in when found on his back, was the resident incontinent no, was resident area cluttered, view the environment no, was alarm sounding blank, any behaviors prior to fall or any mood changes, yelling/striking out noted no, always present, foot wear yes, glasses yes, hearing aide no, does the Resident wear oxygen, diabetic no, and what can we do to prevent another fall from occurring staff to check on res. betw. (between) 2215 - 2245 (10:15 pm -10:45 pm) assist to BR (bathroom) if awake, offer food, fluids, prn (as needed). The facility did not investigate if the intervention of a bed alarm was in place and whether the bed alarm was working. The nurses note dated 3/15/16 at 1:07 a.m. documents, Called to resident's room by nurse aide. Resident laying on his back in front of his bed. He stated, I was dreaming was walking and my legs gave out from under me. I guess I fell out of bed. Full ROM (range of motion) to all extremities. No bumps, bruises or abrasions noted. No lengthening or shortening of extremities. Resident no incontinent of urine. T (temperature)= (equal) 98.2, R (respirations)=18 non-labored, P (pulse)-83, B/P (blood pressure)=143/77, Pulse ox 94%. Resident denies hitting his head. Denies pain or discomfort. Assisted back into bed. PM (evening) nurse stated, He was just sound asleep in his bed. Resident given call light in his hand and encouraged to use. Physician-BB called and updated. HTA (head trauma assessment) negative. No new orders. The nurses note dated 5/5/16 documents, Report received from CNA (Certified Nursing Assistant) on duty that resident is on the floor. Upon entered the room resident found on the floor at the sitting position. Stated that, he was sitting at the edge of his w/c (wheelchair) cushion, slid and fell . stated did not hit his head. No apparent injuries noted. No head trauma/hematoma noted. no change in mental status. The fall huddle dated 5/5/16 for time of huddle 2200 (10:00 p.m.) has no checked for the question was the alarm sounding. For the question what can we do to prevent another fall from occurring documents Re-educated staff about making sure chair alarm is in place and sounding. The fall risk assessment dated [DATE] & 5/20/16 have a total score of 8 which is high risk. The nurses note dated 6/25/16 documents, Resident was observed by CNA sitting on the floor in front of resident's room. This writer observed resident sitting on the floor with his back against the wall. As this writer approached resident, resident said to this writer, Look I fell again No injury was observed a this time, ROM (range of motion) wnl (within normal limit) for resident, neuro check negative, vss (vital signs stable) wnl (within normal limit) for resident, resident denies pain. Resident was helped up from floor with assist of 3 and gait belt. PRN (as needed) Tylenol 650 mg (milligrams) given for discomfort. When asked what resident was doing before fall occurred, resident replied, I was looking for my car. Resident has dx (diagnosis) dementia. Resident is severely confused as resident further stated, I was trying to do some carpeting. Resident was taken to nurses station for close observation, Voice msg. (message) left for Physician-BB, awaiting call back, Daughter-GG notified and came in to see Resident. The fall huddle dated 6/25/16 at 2105 (9:05 p.m.) documents for the question was the alarm sounding no is checked with a notation Resident turned alarm off. The investigation statement for CNA (Certified Nursing Assistant)-HH dated 6/25/16 documents for the question was alarm sounding, was a fall mat used The alarm was not sounding at the time and he was in his chair before the time of his fall. He often turns his alarm off. The nurses note dated 6/28/16 documents Out of sequence entry from 6/27/16 @ (at) 1115 (11:15 a.m.) Charge nurse had reported to writer at 0830 (8:30 a.m.), staff had attempted to assist resident out of bed resident was complaining of increased pain to his lower back and both of his hips. Resident received his scheduled APAP (tylenol) at 0800 and 1200 which was effective for pain complaints. Gatorade given as resident would only take sips. NP (Nurse Practitioner)-FF for Physician-BB called and updated. New orders received for CBC (complete blood count), BMP (basic metabolic panel), CXR (chest x-ray), and x-rays of both hips. Daughter-GG/HCPOA (health care power of attorney) in visiting with resident at the time and informed of new orders. NP came to see resident at 1010 (10:10 a.m.) on 6/27/16. CXR results at 1430 (2:30 p.m.) positive for right upper lung pneumonia and recommendations for another x-ray for the left hip. Mobilex in to do x-ray 6/27/16. On 6/28/16 at 0810 (8:10 a.m.) charge nurse notified writer resident has a left hip fracture. Resident had a fall on 6/25/16 at 2105 (9:05 p.m.) Prior to his fall he had called his daughter-GG, and asked her to come and get him because he was lost on 4th and Capitol Drive. When nurse found resident sitting on the floor outside of his room next to his doorway, resident stated that he was working on the carpeting and then stated he was working on his car. Per nurses aide resident had been sitting in his w/c in his room with alarm on. Resident has been observed several times in the past removing his alarm, stating that it needs to be repaired. Alarm is effective in that when resident hasn't removed the alarm it does alert staff that he is attempt to ambulate. Daughter-GG in after the fall and stayed with resident several hours attempting to encourage fluids. Per daughter and observation, resident has been observed with increased confusion when he has an infection/UTI (urinary tract infection) as evidenced by increased nonsensical statements such as he has to go to the garage or he is in the shop, etc. Per daughter's request, we offer Gatorade to increase his fluid intake. Paratech in to take resident to Froedert Hospital via stretcher. The Resident ADL (activities daily living)/Daily Care List with a start date of 7/5/16 documents for the section safety: BED and CHAIR alarm. Place alarm under his w/c (wheelchair). Resident has been observed removing alarms at times. Auto lock w/c (wheelchair) Check on res. (resident) betw. (between) 2215-2245 (10:15 p.m. - 10: 45 p.m.) and assist to bathroom, prn (as needed) if awake. Assist in getting ready for bed between 8-8:30 pm or he will assist self d/t (due to) he thinks he can do more than he can. Remind to use call light. W/C foot rests when propelling in W/C (long distances). The significant change MDS (Minimum Data Set) with an assessment reference date of 7/12/16 and signed as complete on 7/19/16 has a BIMS score of 7 which indicates severely impaired. Resident #22 requires extensive assistance with two plus person physical assist for bed mobility, transfer, & toileting, ambulated in room only once or twice with two plus person physical assist and did not ambulate in the corridor. Resident #22 is coded as having fallen in the last month, in the last two to six months and has had a fracture related to a fall in the six months prior to admission/entry or reentry. The fall CAA (Care Area Assessment) dated 7/19/16 under analysis of findings for description of problem documents, Resident #22 returned to the facility on ,[DATE] following a fall with a hip fracture. He is currently attending therapies for strengthening. He remains at risk for falls with potential for injury. On 7/25/16 at 10:38 a.m. Surveyor # observed Resident #22 sitting in a high back wheelchair in the dining room attending a bingo activity. Surveyor # observed there is an alarm box hooked to the back of the wheelchair. Surveyor # noted that the alarm box was not placed under Resident #22's wheelchair. On 7/25/16 at 12:50 p.m. Surveyor # observed Resident #22 sitting in a high back wheelchair at a table in the dining room. Surveyor # observed there is an alarm box hooked to the back of the wheelchair. Surveyor # noted that the alarm box was not placed under Resident #22's wheelchair. On 7/27/16 at 9:13 a.m., Surveyor # observed Resident #22 sitting in a high back wheelchair in the dining room. Surveyor # observed there is an alarm box hooked to the back of the wheelchair. Surveyor # noted that the alarm box was not placed under Resident #22's wheelchair. On 7/27/16 at 10:08 a.m., Surveyor # observed Resident #22 being wheeled down the hallway. Surveyor # observed there is an alarm box hooked to the back of the wheelchair. Surveyor # noted that the alarm box was not placed under Resident #22's wheelchair. On 7/27/16 at 2:02 p.m., Surveyor # observed Resident #22 sitting in the wheelchair in the dining room. Surveyor # observed there is an alarm box hooked to the back of the wheelchair. Surveyor # noted that the alarm box was not placed under Resident #22's wheelchair. On 7/28/16 at 11:19 a.m., Surveyor # asked CNA (Certified Nursing Assistant)-M if Resident #22 removes his alarm or turns it off. CNA-M informed Surveyor # that it depends on his mood, Resident #22 has removed it and knows how to cut it off. CNA-M informed Surveyor # that Resident #22 does this so that it keeps them from coming down to his room and responding to it. CNA-M informed Surveyor # that since Resident #22 has come back from the hospital she hasn't seen him touch the alarm. Surveyor # asked if the alarm box is suppose to be under the wheelchair. CNA-M replied yes. Surveyor # asked CNA-M if the nurses knew that Resident #22 would turn off his alarm or remove it. CNA-M replied, yes a couple did. On 7/28/16 at 12:34 p.m. Surveyor # met with RN (Registered Nurse) Manager-D to discuss Resident #22. Surveyor # asked RN Manager-D when the bed alarm was first placed on. RN Manager-D informed Surveyor # that she knew it was ongoing because he was taking it off. Surveyor # asked RN Manager-D if Resident #22's left hip fracture was due to the fall on 6/25/16. RN Manager-D replied, Yes, I believe the hip fracture was due to his fall. Surveyor # informed informed RN Manager-D of the observations of the alarm being attached to the back of the wheelchair when there is an intervention that it should be under the wheelchair. Surveyor # asked RN Manager-D if the bed or chair alarms were ever discontinued. RN Manager-D informed Surveyor # that she would look into this and get back to Surveyor # . On 7/28/16 at 1:46 p.m. RN Manager-D met with Surveyor # . RN Manager-D informed Surveyor # that she has a good relationship with Daughter-GG and spoke to her about doing a trial d/c (discontinue) of the bed alarm since Resident #22 didn't like it. Surveyor # asked when this was. RN Manager-D thought it was in April. Surveyor # asked when Resident #22 fell from bed in March should he have had the bed alarm on. RN Manager-D replied yes, he should have. Surveyor # asked when the chair alarm was started. RN Manager-D informed Surveyor # that Resident #22 had the chair alarm in the beginning, back in December. Surveyor # asked if Resident #22 always had the chair alarm. RN Manager-D replied, yes he always had the chair alarm. Surveyor # informed RN Manager-D that staff was aware that Resident #22 would remove the alarm or shut it off and the Facility continued with the intervention which was ineffective. RN Manager-D replied, yes, sometimes he would remove it but explained that even though he would 'putz' with it and take it apart when he didn't it would alert staff. On 7/28/16 at 3:04 p.m. during the daily exit conference Administrator-A and Director of Nursing-B were informed of the above. 2. Surveyor # reviewed Resident #3's medical record on 7/25/16 to 7/28/16. Resident #3 has a [DIAGNOSES REDACTED]. Resident #3 does not ambulate, is transferred with a Hoyer lift and 2 staff, and has a history of falls. a. The Invacare Reliant 450 RPL450-2, Invacare Reliant 600 RPL600-2 user manual documents on page 24 for 7 Lifting the Patient WARNING The legs of the lift must be in the maximum open position for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position and lock the shifter handle immediately. On 7/25/16 at 10:20 a.m. Surveyor # observed CNA (Certified Nursing Assistant)-Y in Resident #3's room. CNA-Y washed her hands, placed gloves on, and informed Resident #3 that she was going to lay him down. At 10:22 a.m. CNA-Z entered Resident #3's room, washed her hands, and placed gloves on. CNA-Y and CNA-Z hooked the sling to the Reliant 450 Hoyer lift, informed Resident #3 that he was going up and raised Resident #3 off the broda chair. CNA-Y moved the broda chair away and CNA-Z wheeled the Hoyer lift over to Resident #3's bed. Surveyor # observed that the legs of the Hoyer lift were not in the open position. Resident #3 was lowered onto the bed, CNA-Y & CNA-Z unhooked the sling from the Hoyer lift and Resident #3 was positioned from side to side to remove the sling. Surveyor # observed that during this observation the legs of the Hoyer lift were never placed in the open position. On 7/25/16 at 12:14 p.m., Surveyor # observed CNA-Z & CNA-Y enter Resident #3's room, wash their hands and place gloves on. CNA-Z informed Resident #3 that they were going to get him ready for lunch. CNA-Z & CNA-Y moved Resident #3's bed away from the wall and CNA-Y raised the height of the bed. CNA-Z checked Resident #3's incontinent product stating he's dry. CNA-Z and CNA-Y placed the sling under Resident #3 by positioning Resident #3 from side to side. CNA-Z wheeled the Reliant 450 Hoyer lift over to Resident #3's bed. Surveyor # observed the legs of the Hoyer lift are in a straight positioned and are not in the opened position. CNA-Y hooked the sling to the lift, informed Resident #3 that they are going to lift him up, and Resident #3 was raised off the bed. CNA-Y wheeled the Hoyer lift over to the broda chair and Resident #3 was lowered into the broda chair. Surveyor # observed during this observation the legs of the Hoyer lift were never placed in the open position. On 7/27/16 at 10:52 a.m. Surveyor # observed CNA-Z wheel Resident #3 into his room, removed the clothing protector and informed Resident #3 that she was going to lay him down. At 10:53 a.m. CNA-X entered Resident #3's room. CNA-Z & CNA-X washed their hands and placed gloves on. CNA-Z wheeled the Reliant 450 Hoyer lift over to Resident #3's broda chair and staff connect the sling to the lift. Surveyor # observed the legs of the Hoyer lift are in the straight position. Resident #3 was raised off the broda chair and CNA-X moved the broda chair away. CNA-Z then wheeled the Hoyer lift over to the bed, Resident #3 was lowered onto the bed, and unhooked the sling from the lift. Surveyor # observed the legs of the Hoyer lift remained in the straight position and were not placed in the open position. On 7/27/16 at 11:07 a.m. Surveyor # pointed to the lever on the Reliant 450 Hoyer lift and asked CNA-Z what the lever does. CNA-Z replied opens legs. Surveyor # asked CNA-Z when the legs of the Hoyer lift would be in the open position. CNA-Z informed Surveyor # that it depends on the situation and explained that if the wheelchair is wide or they were going to put a Resident in a chair and the chair is wide then they would open the legs. Surveyor # asked CNA-Z when moving the Hoyer lift do they keep the legs narrow. CNA-Z replied yes and stated the Hoyer lift moves better. On 7/27/16 at 2:16 p.m. Surveyor # asked RN (Registered Nurse) Manager-AA how should the legs of the Reliant 450 Hoyer lift be when staff are transferring a Resident. RN Manager-AA informed Surveyor # they should be straight. Surveyor # informed RN Manager-AA that the legs should be in the open position so the Hoyer lift does not tip over. b. The Resident ADL (activities daily living)/Daily Care List under the section appliances with a start date of 1/3/16 documents, Gripper pad to broda chair. The nurses note dated 4/7/16 documents, LPN (Licensed Practical Nurse) caring for resident alerted this writer of a fall. Resident found to be lying flat on the floor between his bed and Broda chair which he had been sitting in. Resident had a blanket still covering his lower extremity, has a R (right) AKA (above knee amputation). Resident complained of left temple pain, no obvious injury noted. Foley in place, was incontinent of bowels. Physician-BB made aware. The Falls care plan not dated has an intervention dated 4/8/16 of Apply Dycem/Gripper pad to w/c (wheelchair) cushion to prevent from slipping out of chair. On 7/25/16 at 10:28 a.m. Surveyor # checked Resident #3's broda chair. Surveyor # observed a cushion in the broda chair but did not observe a gripper pad/dycem either on top or under the cushion. On 7/25/16 at 12:13 p.m. Surveyor # checked Resident #3's broda chair. Surveyor # observed a cushion in the broda chair but did not observe a gripper pad/dycem either on top or under the cushion. On 7/27/16 at 10:59 a.m. Surveyor # checked Resident #3's broda chair. Surveyor # observed a cushion in the broda chair but did not observe a gripper pad/dycem either on top or under the cushion. On 7/28/16 at 2:42 p.m. Surveyor # met with RN (Registered Nurse) Manager-D to discuss Resident #3. Surveyor # informed RN Manager-D that Surveyor # noted after Resident #3 fell on [DATE] the care plan was updated to include gripper pad on the chair. Surveyor # informed RN Manager-D of the observations of gripper pad/dycem not on or under the cushion in Resident #3's broda chair. c. The hospital discharge summary dated 1/3/16 under hospital course documents, Early LLL (left lower lobe) pneumonia. Chronic dysphagia. video swallow did not show active aspiration even w/ (with) coughing. but suspect he has some degree aspiration problems given swallowing issues. pureed diet w/ nectar thick liquids, no straw, 100% assist w/ meals. continue augmentin 8 days more as noted. The physician orders [REDACTED]. On 7/27/16 at 11:02 a.m., Surveyor # observed Resident #3 ask CNA (Certified Nursing Assistant)-X for water. CNA-X removed the paper covering from the straw located on the over bed table and place the straw in the Styrofoam glass. CNA-X then placed the straw in Resident #3's mouth stating, here's some water. Surveyor # observed Resident #3 drinking from the straw. CNA-X then asked Resident #3 is that enough? Resident #3 shook his head yes. On 7/27/16 at 11:13 a.m. Surveyor # asked CNA-X how would she know if a Resident should not use a straw. CNA-X explained that if a Resident can talk then they would say if they wanted a straw and if they can't talk then it would be documented. On 7/27/16 at 11:17 a.m. Surveyor # asked CNA-X if Resident #3 can use a straw. CNA-X replied, yes. On 7/28/16 at 7:22 a.m., Surveyor # asked LPN (Licensed Practical Nurse)-O why Resident #3 has an order for [REDACTED]. Surveyor # asked LPN-O how a CNA would know whether a Resident can have a straw. LPN-O explained that it would be in care tracker. Surveyor # asked what if the CNA was not assigned to the Resident how would they know. LPN-O explained that they would be looking at the care card or they should come to her. Surveyor # informed LPN-O of the observation of CNA-X giving Resident #3 a drink of water with a straw. LPN-O stated, he shouldn't. On 7/28/16 at 3:04 p.m. during the daily exit conference Administrator-A and Director of Nursing-B were informed of the above. 3. Surveyor # reviewed Resident #14's medical record from 7/25/16 to 7/28/16. Resident #14 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident #14's quarterly MDS (Minimum Data Set) dated 5/26/16 documents under section G that Resident #14 requires a two person physical assist and has total dependence for her transfer needs. Resident #14's Falls CAA (Care Area Assessment) signed as completed on 9/11/15 documents under the Care Plan Reasons section, Resident #14 has balance problems with transitions and receives extensive assist with transfers. Resident #14's Falls Care plan with a with no start date documents under the P (Problem) section, Resident #14 has potential for falls related to imobility (immobility) due to [DIAGNOSES REDACTED]. Resident #14's Hendrich II Fall Risk Model Assessment completed on 5/25/16 documents a score of '5' and a high risk for falls Resident #14. On 7/28/16 at 7:52 a.m., Surveyor # observed Resident #14 laying in the middle of her bed with a sling positioned under her awaiting a transfer. Surveyor # noted that Resident #14's bed was high off of the ground and not in the low position. Surveyor # observed no facility staff members to be be in Resident #14's room. Surveyor # asked Resident #14 if she was receiving assistance. Resident #14 informed Surveyor # that she was being assisted by staff but that she did not know where they went. Surveyor # asked Resident #14 how long she had been waiting for facility staff to assist her. Resident #14 informed Surveyor # that she had been waiting for facility staff for a couple minutes. On 7/28/16 at 7:54 a.m., Surveyor # observed CNA (Certified Nursing Assistant)-CC enter Resident #14's room with a Hoyer lift to transfer Resident #14 from bed to her wheelchair. On 7/28/16 at 1:40 p.m., Surveyor # informed RN (Registered Nurse)-E of the above findings. Surveyor # asked RN-E if facility staff should leave Resident #14 unattended while the bed is in a high position as Resident #14 is at risk for falls. RN-E informed Surveyor # that facility staff should not leave Resident #14 alone while the bed is in a high position. On 7/28/16 at 3:11 p.m., during the daily exit conference, Surveyor # informed Administrator-A and DON (Director of Nursing)-B of the above findings. No further information was provided as to why the facility did not ensure that Resident #14 received adequate supervision and to prevent accidents.

Based on observation, interview and record review the facility did not ensure Residents with pressure injuries received necessary treatment and services to promote healing for 1 (Resident #3) of 10 Residents reviewed with pressure injuries (ulcers). Resident #3 was assessed by the facility to be at risk for the development of pressure injuries and has a history of previous amputation of his right lower limb. On 6/15/16 Surveyor # observed a facility acquired, blackened, unstageable pressure injury to the resident's left inner foot/heel area. This was not reported to nursing staff by the nursing aide staff. Resident #3 did not receive weekly skin assessment/monitoring as required by the facility policy and procedure. When assessed by nursing staff the area measured 5.2 cm x 7.7 cm with an undetermined depth and was tender to the touch. Findings include: Resident #3 has [DIAGNOSES REDACTED]. Resident #3 has a dark skin tone. Resident #3's 4/8/16 BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK documents Resident #3 has very limited sensory perception (ability to respond meaningfully to pressure-related discomfort), skin is often but not always moist, is chairfast, has very limited mobility, has adequate nutrition, and that friction and shear is a potential problem. Resident #3's 4/8/16 Braden score is documented as a 12. The document states If the residents total is 12 or less, consider him/her at risk for pressure ulcer development. Resident #3's most recent MDS (Minimum Data Set) Assessment with an assessment reference date of 4/4/16 documents that Resident #3 requires extensive assistance from staff for bed mobility and is at risk for pressure ulcers. Resident #3's care plan identifies that he is at risk for skin breakdown due to impaired mobility. Interventions with a start date of 1/3/16 include Certified Nursing Assistant (CNA) and Nursing interventions to monitor skin for signs and/or symptoms of breakdown. Resident #3's Orthopedic Conditions care plan documents Resident #3 had a right [MEDICAL CONDITION] 3/31/14 and has potential for complications. Interventions with a start date of 1/3/16 include Provide proper foot care of remaining foot to prevent amputation. The Facility's Skin Evaluation and Documentation Protocol Policy with a revision date of 8/8/2014 under Definitions/Guidance states: 2. Pressure Ulcers: Only pressure ulcers are staged, a blackened area is considered Unstageable. Under Procedures the policy states to determine the stage of the pressure ulcer as follows e. Unstageable-Full thickness skin or tissue loss-depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan gray, green or brown) and/or Eschar (tan, brown, or black) in the wound bend. Until enough slough and/or Eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Stage III or Stage IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) Eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. f. Deep Tissue Injury-Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury maybe difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin Eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. Under Documentation the policy states 1. The nurse, on (re)admission, weekly, quarterly, and upon identification of a new wound documents the evaluation and all Braden Scale evaluations in Answers on Demand (AOD), in another electronic health record (EHR) or paper-based medical record depending on availability .5. If the skin is without impairment, the evaluation is to be documented as such in the medical record. If using Answers on Demand (AOD) Skin Condition form, use Site Code '00' for Site Description 'General Skin Check', check the box Skin assessed and no remarkable observations noted, and enter the date of documentation as the closing date as well. On 6/15/16 at 8:04 a.m. Surveyor # observed CNA (Certified Nursing Assistant)-C begin to prepare to provide morning cares to Resident #3. At 8:20 a.m. Surveyor # observed CNA-C assist to roll Resident #3 on his left side to clean Resident #3's back. Surveyor # noted a black area to Resident #3's left inner heel. Surveyor # asked CNA-C if the area on Resident #3's heel was known. CNA-C stated that she thinks so, but has only been working at the facility for about a month. At 8:31 a.m. Surveyor # observed CNA-C apply a blue gripper sock to Resident #3's left foot, and apply a blue boot. Following the observation Surveyor # reviewed Resident #3's paper and electronic medical record in AOD (Answers on Demand). Resident #3's treatment administration record documents: Nurse to do body check weekly on bath day for abnormalities and document in AOD. Surveyor # reviewed Resident #3's electronic medical record and noted that the most recent documented Skin Assessment was dated 4/30/16 and documented: Skin inspected/assessed and no remarkable observations noted: yes. Surveyor # noted that the electronic medical record did not contain documentation of a skin assessment for May or June. Surveyor # noted that the medical record did not contain any documentation that Resident #3 had any identified area to his left heel. On 6/15/16 at 9:24 a.m. Surveyor # asked CNA-C if she had told a nurse about Resident #3's heel. CNA-C stated that no, they know about it and are doing a treatment for [REDACTED]. On 6/15/16 at 9:25 a.m. Surveyor # asked RN (Registered Nurse)- E, who was the only nurse on Resident #3's unit, if she was aware of any skin impairment to Resident #3's heel. RN-E stated that no she was not, and that CNA-C had not informed her of any area. On 6/15/16 at 9:27 a.m. Surveyor # asked RN Manager-D if she was aware of any areas of skin impairment to Resident #3's heel. RN-Manager D stated that she was not aware of any areas. RN-Manager-D and Surveyor # went to Resident #3's room to observe the area to Resident #3's left heel. RN-Manager-D removed Resident #3's sock and boot. RN Manager-D stated Oh my gosh! No, nobody said anything. RN Manager-D informed Surveyor # that she had spoken with CNA-C after Surveyor # had observed cares for Resident #3, and she did not say anything about this. At 9:34 a.m. RN Manager -D measured the black area to Resident #3's heel to be 5.2 cm x 7.7 cm. Unable to determine depth. Surveyor # observed Resident #3 wince as RN Manager-D touched the wound; RN Manager-D stated tender. On 6/15/16 RN-Manager-D documented in Resident #3's Interdisciplinary notes Called to residents room at 1010 earlier today. Resident in his bed, asleep. Easily aroused. Writer asked resident if his heel and buttocks could be looked at. Resident nodded yes and closed his eyes. Resident has a pillow under his LLE (left lower extremity) and heel protector boot on. Resident has a dark, black area 5.2 x 7.7 x UTD (unable to determine depth) DTI (deep tissue injury) on his left lateral heel. Observed pink scar tissue on right buttocks. Continue with Happy Butt paste daily per MD order for protection. (MD) called and updated. New orders received for DTI left lateral heel: 1. NS cleanse. Gentle pat dry f/b (followed by) skin prep BID (twice a day) and 2. Low air loss mattress for increased pressure relief. On 6/15/16 at 9:58 a.m. Surveyor # interviewed DON (Director of Nursing)-B. Surveyor # asked DON-B when are CNA's expected to report changes in skin condition. DON-B stated when they are noticed, immediately. DON-B confirmed to Surveyor # that weekly skin checks should be documented in the electronic health record. DON-B informed Surveyor # that Managers should be monitoring to ensure skin checks are documented in the electronic medical record. On 6/15/16 at 2:41 p.m. Surveyor # spoke with RN Manager-D. Surveyor # asked RN Manager -D how she ensures that skin checks are being done. RN-Manager-D informed Surveyor # that it is an expected job duty, and that she does not check to ensure that they are completed. On 6/15/16 during the daily exit meeting with the Facility Surveyor # shared the above observation with the facility. Administrator-A informed Surveyor # that the expectation is for CNA's to report anything they have not seen before for changes in skin condition and that the facility would be doing a skin sweep of the facility in the next 24-48 hours.