Every finding on record at Avina of Pewaukee

Based on observation, interview, and record review, the facility failed to ensure the walk-in freezer was maintained in proper operating condition to prevent excessive ice and frost accumulation. This deficient practice had the potential to affect food storage conditions by contributing to unsafe food temperatures, thereby increasing the risk for foodborne illness. Findings include: During kitchen tours on 08/04/26 at 8:46 AM with the Dietary Assistant (DA) present, and on 08/05/26 at 2:10 PM with the Dietary Manager (DM) present, the walk-in freezer was observed to have heavy ice and frost accumulation on the interior vinyl door strips, floor areas extending to the shelving, and large ice formations on the inside of the door. During an interview on 08/04/26 at 8:46 AM, the DA stated the ice and frost accumulation occurred because the door had been left open while staff retrieved items. During an interview on 08/05/26 at 3:00 PM, the DM stated the ice and frost accumulation had occurred intermittently for several months and that maintenance was aware of the issue. The DM stated she believed the problem was caused by the door not closing flush with the door frame. During an interview on 08/06/26 at 9:18 AM, the Administrator stated she was aware of the ice and frost accumulation and that the walk-in freezer door did not close completely. The Administrator stated vinyl interior door strips were installed due to the issue. The Administrator confirmed the problem had persisted for several months and that the facility was working to resolve it. Review of the facility's operation and maintenance manual for the walk-in freezer, dated 12/25, provided by the facility revealed When doors are opened for extended periods of time, frost can form on the ceiling and floor due to the excessive condensation of warm moist air inside the walk-in. This can result in the formation of an ice film on wall, ceiling and floor surfaces or around gaskets. On 08/06/26 at 4:29 PM, the Administrator stated the facility did not have a policy for essential equipment and had no documentation regarding the walk-in freezer's excessive ice and frost accumulation.

Based on observation, interview, record review, and facility policy review, the facility failed to have an effective pest control program to rid their infestation of fruit flies in the kitchen. This failure could lead to pathogen transmission, wound contamination, or spread of infection. The facility census was 85. Findings include: Review of facility pest control receipts revealed the following: on 02/12/26, a crack-and-crevice application of [brand name] WDG [water-dispersible granules] was applied to the baseboards in the kitchen dish room, janitor closet, main area, and exterior doors as a preventive insect treatment. On 03/30/26, four [name of the cylindrical, adhesive pest control device] were delivered and placed in the dish room. On 04/29/26, 05/28/26, and 06/25/26, crack-and-crevice applications of [brand name] WDG were applied to the baseboards in the kitchen dish room, food storage area, janitor closet, main area, and exterior doors as preventive insect treatments. On 07/29/26, the pest control receipt noted the main kitchen floor drains needed cleaning to remove fruit fly breeding areas. During the kitchen tour on 08/04/26 at 8:46 AM with the Dietary Assistant (AD) present and 08/05/26 at 2:10 PM with the Dietary Manager (DM) present, a swarm of fruit flies was observed in the kitchen's dish room, and three yellow adhesive cylinders covered with fruit flies were observed on a shelf across from the dish machine. During an interview on 08/04/26 at 8:46 AM, the DA identified the insects as fruit flies, also referred to as gnats. During an interview on 08/05/26 at 2:10 PM, the DM stated the fruit flies were attracted to the floor drains and were present in all kitchen drains. The DM stated monthly pest control services were provided to treat the fruit flies; however, the issue had persisted for several months. The DM stated pest control sprayed only the perimeter of the kitchen and did not treat the drains. During an interview on 08/06/26 at 9:35 AM, with the Administrator and Maintenance Director (MD) the MD stated they were aware of the issue and that monthly pest control services had not resolved it. The MD stated the fruit flies were attracted to the kitchen floor drains. The Administrator stated the facility planned to begin a new intervention using hot water mixed with liquid detergent. Review of the facility policy titled Pest Control Program dated 02/02/26, provided by the facility, revealed It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.

Based on observation, interview, record review, and policy review, the facility failed to ensure residents had a self-administration of medications assessment, a physician's order, and a care plan completed for two of two residents (Resident (R) 28 and R97) reviewed for self-administration of medications. Failure to assess and care plan residents for self-administration of medications increases the potential of medication errors for residents. Findings include: 1. Review of R28's admission Record located under the Profile tab in the electronic medical record (EMR) revealed R28 was admitted to the facility on [DATE] with diagnoses including hemiplegia, depression, diabetes mellitus, anxiety, and hypertension. During an observation on 08/04/26 at 9:45 AM, a plastic, clear pill cup with 11 pills were noted on R28's bedside table. A subsequent interview with R28 revealed they were all the pills he takes in the morning. He added she [the nurse] left them there because he did not want to take them yet. R28 confirmed it was Licensed Practical Nurse (LPN)2 who left the medications at the bedside. During an interview on 08/05/26 at 12:28 PM, LPN2 stated R28 must have forgotten to take the medication. She added she left R28's room before he took the medications. LPN2 confirmed she should have stayed with R28 until he took his medication. Review of R28's admission Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 06/30/26 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a total score of 15, which indicated intact cognition. Review of R28's Care Plan, dated 06/23/26, located under the Care Plan tab in the EMR, revealed focus areas for diabetes mellitus; pain medication usage and antidepressant medication usage. Review of R28's Medication Administration Record (MAR), dated 08/01/26 to 08/31/26, revealed orders dated 06/23/26, for three medications: aspirin tablet, one tablet by mouth every morning and at bedtime for heart health; metformin tablet 750 mg, one tablet by mouth two times a day for diabetes mellitus, take with meals, 7:00 AM; and baclofen tablet 5 mg, one tablet, three times a day for degenerative disc disease, 8:00 AM. Review of R28's MAR, dated 08/01/26 to 08/31/26, revealed orders dated 06/24/26, for five medications: atorvastatin calcium tablet 80 milligram (mg); 1 tablet, one time a day, 7:00 AM; gabapentin tablet 400 mg, one tablet by mouth, three times a day for neuropathy, 8:00 AM; duloxetine HCL delayed release sprinkle 60 mg, one capsule, one time a day for depression; pantoprazole sodium tablet delayed release 40 mg, one tablet by mouth daily, 8:00 AM; and tamsulosin HCL capsule 0.4 mg, one tablet by mouth daily, 8:00 AM Review of R28's MAR, dated 08/01/26 to 08/31/26, revealed an order dated 07/06/26, for carvedilol tablet 12.5 mg, one tablet by mouth two times a day for essential hypertension, 7:00 AM. Review of R28's MAR, dated 08/01/26 to 08/31/26, revealed an order dated 07/09/26, for hydroxyzine tablet, 25 mg, two times a day for anxiety, 7:00 AM. Review of R28's MAR, dated 08/01/26 to 08/31/26, revealed an order, dated 07/23/26, for Amlodipine Besylate 10 mg table; give 10 mg every morning related to essential hypertension, 7:00 AM Review of R28's EMR revealed he did not have an assessment to determine if he was safe to take the medication without staff supervision, no physician's order, or care plan for self-administration. 2. Review of R97's admission Record, located under the Profile tab of the EMR, revealed R97 was admitted to the facility on [DATE] with diagnoses that included hypertension, diabetes mellitus, major depressive disorder (MDD), and gastroesophageal reflux disease. During an observation on 08/04/26 at 09:12 AM, 13 bottles of medications were observed on top of R97's chest drawers The medications were as follows: losartan 50 mg twice a day (BID), bottle was half full; Zoloft 100 mg daily, bottle was half full; metformin 1000 mg BID with meals, bottle was half full; glimepiride 2 mg before breakfast daily, bottle had less than 25%; pioglitazone 15 mg daily, bottle had less than 15%, another bottle of metformin 1000 mg BID with meals that was full; glimepiride 4 mg with breakfast had less than 15%; methotrexate 2.5 mg every week-give five tablets. had less than 25%; omeprazole 40 mg full bottle-never open; mucus relief DM, bottle was half full; folic acid 1 mg, bottle was half full; and a multi vitamin bottle was 95% full. During an interview on 08/04/26 at 09:15 AM, R97 stated that these were his back-up medications and that he does not take these medications. R97 confirmed that he does not self-administer medication to himself, that staff give him his medication to him every day. Review of R97's Brief Interview for Mental Status, dated 08/03/26, located under the Forms tab in the EMR, revealed R97 scored a 15 out of 15, which indicated intact cognition Review of R97's Physician Order, dated 07/31/26 and located under the Orders tab of the EMR, revealed orders for losartan 50 mg BID, Zoloft 50 mg daily, metformin 1000 mg BID, pioglitazone 15 mg daily, glimepiride 4 mg with breakfast, methotrexate 2.5 mg every week-give five tablets, folic acid 1 mg daily, and multi vitamin 1 tablet daily. There was no physician's order for the self-administration of the medication. Review of R97's Forms tab in the EMR revealed no assessment related to the self-administration of medication. During an interview on 08/04/26 at 10:05 AM, Licensed Practical Nurse (LPN) 2 confirmed the medications were in R97's room. She also confirmed that R97 had not been assessed to administer his own medication, nor did he have a physician order to self-administer. LPN2 stated that medications should not be there. During an interview on 08/04/26 at 12:24 PM, the Administrator confirmed that R97 should not have any medication in his room unless he had been assessed, had a physician's order and a care plan for self-administration. Review of the facility policy titled Resident Self-Administration of Medication, dated 02/25/26, specified It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility interdisciplinary team has determined which medications may be self-administered safely.Each resident is offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team.

Based on record review, interviews, and facility policy review, the facility failed to ensure a care plan was developed to provide effective and person-centered care and services for one (Resident (R) 4) of seven reviewed for safety with a total sample of 24. This failure could affect the care and services provided by the facility to its residents. Findings include: Review of R4's admission Record located under the Profile tab in the electronic medical record (EMR) revealed R4 was admitted to the facility on [DATE] with diagnoses including alcohol abuse, panic disorder, major depressive disorder, and polyneuropathy. Review of R4's quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 07/09/26 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a total score of 15, which indicated intact cognition. The MDS indicated R4 ambulated with a wheelchair Review of R4's Care Plan, revealed R4 did not have a care plan for frequent, unscheduled outings. Review of R4's Progress Notes, revealed a note on 04/23/26 at 8:58 AM, that indicated R4 left the facility and stated he would return in the evening. An additional note at 3:30 PM indicated R4 returned to the facility. Review of R4's Progress Notes, revealed a note on 05/08/26 at 8:00 AM, that indicated R4 left the facility and stated he would return in the evening. The note also indicated R4 did not tell staff where he was going. An additional note at 5:00 PM indicated R4 returned to the facility. Review of R4's Progress Notes, revealed a note on 05/21/26 at 9:30 AM, that indicated R4 left the facility and stated he would return in the evening. The note also indicated R4 did not tell staff where he was going. Review of R4's Progress Notes, revealed a note on 05/28/26 at 8:41 AM, that indicated R4 left the facility and stated he would return in the evening. The note also indicated R4 did not tell staff where he was going. An additional note at 5:33 PM indicated R4 returned to the facility. Review of R4's Progress Notes, revealed a note on 07/03/26 at 8:38 AM, that indicated R4 left the facility and stated he would return in the evening. The note also indicated R4 did not tell staff where he was going. An additional note at 5:31 PM indicated R4 returned to the facility. During an interview on 08/06/26 at 11:03 AM, the Administrator revealed R4 does not have a care plan for his frequent outings. She stated they are not planned and he will often tell the staff he has an appointment. During an interview on 08//06/26 at 3:42 PM, R4 stated he has transportation through his insurance, and a van takes him where he needs to go. He added he always tells staff when he has left and when he returns. R4 stated he goes wherever he needs to go; appointment or run errands. He added he tried to get out of the building a couple times a month. During an interview on 08/06/26 at 4:02 PM, Licensed Practical Nurse (LPN)3 stated, R4 leaves frequently a couple times a month. She added he will just tell us as that he is leaving and always lets us know when he returns. She added I would expect it to be care planned. During an interview on 08/07/26 at 10:18 AM with the Administrator and the Director of Nursing (DON), the Administrator stated R4 will leave frequently. She added R4 tells staff he has an appointment. She confirmed this should be care planned. She added care plans are created by the Interdisciplinary Team (IDT). Review of the facility policy titled Comprehensive Care Plans, dated 02/20/26, specified It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet the resident's medical, nursing and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on observation, record review and interview, the facility failed to ensure resident ordered treatments were completed as ordered for one of one resident (Resident (R) 60) reviewed for physician-ordered treatments, out of a total sample of 24. Specifically, staff documented that physician-ordered Tubi-grip compression socks were applied to the resident's left lower extremity; however, the resident was observed throughout the re-certification survey without the ordered compression stocking in place. Findings included: Review of R'60s Face Sheet, located in the Profile tab of the electronic medical record (EMR), revealed R60 was re-admitted to the facility on [DATE] with diagnoses that included congestive heart failure, chronic osteomyelitis right tibia, and fibula, heart failure, diabetes type II, and pulmonary hypertension. Review of R60's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/24/26 and located in the resident's EMR under the MDS tab, revealed R60 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R60's cognition was intact for decision-making. Review of R60's Physician Order, dated 08/04/26 and located under the Orders tab of the EMR, revealed an order for the application of Tubi-grip size G to the left lower extremity. Review of R60's Care Plan, revision dated of 04/21/26 and located under the Care Plan tab of the EMR, revealed R60 had a documented altered cardiovascular HTN, nonrheumatic, aortic stenosis, A-fib, Hypertensive heart disease. Interventions included to monitor/document/report any changes to ., edema. Review of the August 2026 Treatment Administration Record (TAR) revealed documentation indicating that Tubi-grip stockings were applied on August 5, 6, and 7, 2026. Observations conducted on 08/05/2026 at 1:53 PM, 08/06/2026 at 09:00 AM and 01:30 PM, and 08/07/2026 at 10:05 AM and 01:05 PM revealed the resident was not wearing the physician-ordered Tubi-grip stocking and was instead wearing a regular ankle sock. During an observation and interview on 08/07/2026 at 10:05 AM, Resident (R60) was observed with bilateral lower extremity edema and redness and was not wearing the physician-ordered Tubi-grip stockings. R60 stated he was unaware the compression stockings were intended to help manage his edema. R60 stated, No, the staff had not applied the stockings. During an interview on 08/06/2026 at 3:33 PM, the Infection Preventionist/Unit Manager stated that staff were expected to follow physician orders, including the application of Tubi-grip stockings. She further stated she was unaware that R60 had an active physician order for Tubi-grip stockings but acknowledged that the stockings should have been applied as ordered by the physician or nurse practitioner. During an interview on 08/07/2026 at 1:34 PM, the Director of Nursing (DON) stated she was unable to locate a facility policy regarding physician orders or the application of treatment devices and appliances.

Based on interview, record review, and review of facility policy, the facility failed to provide the correct wound treatment as ordered for one of one residents (Resident (R) 60) reviewed for pressure ulcers out of a total sample of 24. This failure to provide the ordered treatment could result in delayed healing or worsening of the skin ulceration. Findings include: Review of R60's Face Sheet, located in the Profile tab of the electronic medical record (EMR), revealed R60 was readmitted to the facility on [DATE] with diagnoses that included congestive heart failure, chronic osteomyelitis right tibia, and fibula, heart failure, and pulmonary hypertension. Review of R60's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/24/26 and located in the resident's EMR under the MDS tab, revealed R60 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R60's cognition was intact for decision-making. It was recorded R60 required partial to supervision assistance with toileting, shower/bathing, upper and lower body dressing. Review of R60's Skin Impairment/Wound Evaluation, dated 08/04/26 located in the EMR under the Assessment tab, revealed R60 had a macerated abrasion to the right lateral lower extremity (RLE) measuring 4 x 3.5 x 0.1 centimeters (cm) with scant serosanguineous drainage. Review of R60's Care Plan, revision dated 08/06/26 and located under the Care Plan tab of the EMR, revealed R60 had a documented RLE proximal and distal abrasion. Review of R60's hard copy of the Physician Orders Audit Report, dated 08/06/26 revealed a wound order dated 07/30/26 for Wound Care: R (right) Lateral Leg, cleanse with normal saline, pat dry, apply xeroform, cover with bordered gauze dressing two times a day for . Review of R60's Physician Order, dated 08/04/26 revealed an order changed for the Wound Care: R lateral Leg, cleanse with normal saline, pat dry, apply silver alginate and cover with bordered gauze dressing every day shift every Tue, Thu, Sat for Wound care to R lateral Leg and as needed for if dressing becomes soiled or falls off. During an observation of wound care provided to R60 on 08/06/26 at 1:30 PM, Licensed Practical Nurse (LPN) 6 removed the existing dressing to the right mid-lateral leg abrasion. The wound was cleansed with normal saline, dried, and a xeroform dressing with bordered gauze was applied. Following completion of the dressing change, the Nurse Practitioner identified that the physician's wound care orders directed the application of silver alginate dressing rather than xeroform. LPN6 acknowledged the error and stated she had reviewed the physician's orders immediately prior to performing the treatment but inadvertently selected and applied the incorrect dressing. During an interview conducted on 08/06/2026 02:56 PM, the Director of Nursing (DON) stated that facility expectations require nursing staff to follow physician orders and verify current wound care orders prior to treatment to ensure no changes have been made. Review of the facility's policy titled, Pressure Injury Prevention and Management, dated 06/17/25, revealed, . to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries .

Based on observations and interviews, the facility failed to ensure a safe and clean environment for one (Resident (R)48) of seven residents reviewed for smoking, with a total sample size of 24. Findings include: Review of R48's admission Record located under the Profile tab in the electronic medical record (EMR) revealed R28 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, schizoaffective disorder, nicotine dependence, and muscle weakness. Review of R28's admission Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 05/22/26 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a total score of 15, which indicated intact cognition. The MDS also indicated R48 used tobacco. Review of R48's Care Plan, dated 06/17/26, located under the Care Plan tab in the EMR, revealed a focus for smoking. During an observation 08/06/26 at 4:30 PM, R48 was noted smoking in the courtyard. During the observation, multiple cigarettes butts were observed throughout the courtyard. R48 confirmed the cigarette butts on the ground, stating they were dead. She added all the cigarettes should be disposed of in the fireproof canister. During an interview on 08/06/26 at 4:31 PM, Registered Nurse (RN)1 confirmed there should be no cigarette butts on the ground, she was unsure as to who was supposed to clean it up. She added all the cigarettes should be disposed of in the fireproof cannister; throwing them on the ground is not safe. During an interview on 08/06/26 at 4:33 PM, the Maintenance Director stated he was not sure who was supposed to ensure the courtyard was clean. During an interview on 08/07/26 at 8:38 AM, the Director of Nursing confirmed there were cigarette butts on the ground and stated they should be disposed of in the fireproof canisters that are in the courtyard. She was not sure who should ensure the courtyard was clean. During an interview on 08/07/26 at 8:49 AM, the Administrator stated maintenance is supposed to be maintaining the smoking courtyard. Review of facility policy titled, .Resident Smoking, dated 03/25 specified it is the policy of this facility to provide a safe and health environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents.safety measure for the designated smoking area will include but not limited to.Accessible metal containers with self-closing covers into which smoking materials can be placed.

Based on observation, interview, and record review, the facility failed to obtain and monitor weights for three (Resident (R)41, R46, and R1) of four residents reviewed for nutrition. This failure could result in unrecognized weight changes, which may indicate early warning signs of significant underlying health problems. Findings include: 1. Review of R41's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/22/26, located in the EMR under the MDS tab, revealed an admission date of 06/15/26 and diagnoses of abnormal weight loss, gastroesophageal reflux disease (GERD), and obsessive-compulsive disorder (OCD). Review of R41's Brief Interview for Mental Status (BIMS) revealed a score of 15 out of 15, indicating R41's cognition was intact. Review of R41's care plan, dated 06/22/26, located in the EMR under the Care Plan section revealed The resident has nutritional problem r/t [related to] OCD, severe malnutrition, agoraphobia w/ [with] panic disorder, iron deficiency anemia, GERD, hypothyroidism, dysphagia, osteoporosis. An intervention included Weigh resident monthly or per order. Notify of significant changes per facility policy. Review of R41's nutritional assessment, dated 06/22/26, located in the EMR under the Results tab revealed Ht [height]: 68in [inches]; 6/12- 119# [pound]; BMI [body mass index]: 18.1- underweight. Hospital weight history shows a 20# weight loss x 6 months. Concern for continued weight loss with limited diet & resident declining supplements. Review of R41's diet order, dated 06/30/26, located in the EMR under the Order tab revealed General diet, regular texture, regular (thin liquids) consistency. Review of R41's APNP [Advanced Practice Nurse Practitioner] note, dated 08/04/26, located in the EMR under the Progress Note tab revealed Unspecified severe protein-calorie malnutrition: Underweight and malnourished appearance on exam with decreased muscle mass consistent with malnutrition and deconditioning. Albumin 3.1 g/dL [grams per deciliter] on 07/03, decreased from 3.2 g/dL on admission. Review of R41's weight history located in the EMR under the Weights & Vitals tab revealed only one weight of 110.5 pounds on 08/06/26 was documented. No admission weekly or monthly weights were listed until 08/06/2026. Review of R41's nutrition/dietary note, dated 08/06/26, located in the EMR under the Progress Note tab revealed 8/6 wt [weight]: 110.5#, unable to compare against another facility wt due to his previous refusals. Ht: 68, BMI: 16.8, considered underwt [underweight]. Refer to RD [Registered Dietitian] 6/22 assessment, noting use of hospital wt of 119#, and reported wt loss before admitting to hospital. Res [resident] did refuse all nutritional supplements d/t [due to] they cause stomach upset. Review of R41's percentage of the meal was eaten log, dated 07/09/26 through 08/07/26 and located in the EMR under the Task tab, revealed R41 consumed 76-100% of most meals. During an observation on 08/04/26 at 9:43 AM, R41 was noted sitting on the side of his bed. He stated he didn't get enough to eat at breakfast and was waiting for staff to bring him more food. Certified Nurse Aide (CNA)2 confirmed R41's request for more food. CNA then gave R41 a toasted item. During an observation on 08/04/26 at 12:49 PM, R41 was noted sitting on the side of his bed with his overbed table in front of him. R41stated he will ask staff for more food. R41 was then served lunch that included two ham and cheese sandwiches, two bowls of soup, two portions of mashed potatoes, pears, crackers, and lemon-aid. R41 ate 50% of his meal. During an interview on 08/06/26 at 2:48 PM, the Director of Nursing (DON) reviewed the EMR and confirmed R41's should have had weekly weights for the first month of admission and monthly weights thereafter. The DON stated the weights were only kept in the EMR and nowhere else. The DON stated whichever CNA is on the shift, weighs the resident. The DON stated the RD looks over the weights and will bring up concerns in their clinical meeting. The DON stated each unit is provided with a printed sheet to record the residents' weights and a text blast is sent out to all staff as a reminder that weights are due. The DON stated, It is important for weights to be done and her expectation is that the weights be done monthly, at admission, and every week for four weeks for the first month. During an interview on 08/07/26 at 10:35 AM, Licensed Practical Nurse (LPN)4 stated she didn't know why R41 wasn't weighed until yesterday, 08/06/26. She stated R41 does not refuse much, adding he lets us do whatever we need for him. LPN4 stated she was unaware of the policy to weigh a new admission weekly for the first month. During a telephone interview on 08/07/26 at 12:18 PM, the RD Manager (RDM) confirmed their policy was to weigh new admissions weekly for the first month and then monthly thereafter which wasn't followed for R41, stating the dietitians can only request them but they aren't always provided. The RDM acknowledged weights are important for assessing R41's nutritional status and R41 was at nutritional risk due to his allergies, food preferences, and weight loss found by comparing hospital and current weights. During an interview on 08/07/26 at 2:00 PM, the Dietary Manager (DM) stated R41 was receiving double portions, and his meal ticket was provided. The DM confirmed nursing staff obtained and monitored resident weights, so it was unclear if the double portions were helping, adding R41 was very particular. 2. Review of R46's admission MDS with an ARD of 05/13/26, located in the EMR under the MDS tab, revealed an admission date of 05/06/26, received hospice care, and had diagnoses of vascular dementia, severe, with mood disturbance, cerebrovascular disease, unspecified, and depression. Review of R46's BIMS revealed a score of seven out of 15, indicating R46's cognition was severely impaired. Review of R46's care plan, revised 05/12/26, located in the EMR under the Care Plan tab revealed The resident has nutritional problem r/t Alzheimer's dementia, osteoarthritis, obesity, constipation, HTN [hypertension], HLD [hyperlipidemia]. An intervention included Weigh resident monthly or per order. Notify of significant changes per facility policy. Review of R46's nutritional assessment, dated 05/12/26 located in the EMR under the Results tab revealed .Resident is able to eat independently once tray is set up. Majority PO [oral] intakes 76-100% per charting but noted to have decreased intake per hospice eval [evaluation]. Requires encouragement at meals. Ht: 66in; wt: 5/7- 286#; BMI: 46.2- obesity class III. Review of 46's percentage of the meal was eaten log, dated 07/09/26 through 08/07/26 located in the EMR under the Task tab revealed R46 consumed 0-50% for 52 meals and 51-100% of 15 meals. Review of 46's weights, located in the EMR under the Vitals tab, revealed a weight loss of 24% of R46's body weight in three months. 08/07/26 at 215.9 Lbs 07/2026 no weight 06/2026 no weight 05/07/26 at 286.0 Lbs (no weekly admission weights) On 08/05/26 at 9:22 AM, R46 was served her breakfast in bed. Her meal included cereal, scrambled egg, a sausage link, and a beverage. R46's intake was good. During an interview on 08/05/26 at 2:42 PM, the consulting RD stated she requested weights for the months of June 2026 and July 2026 through an email, they were not done. The RD opened her email and revealed her request. The RD stated if R46 was not weighed intentionally such as due to a hospice request or resident's refusal, it would be care planned and it's not. The RD confirmed that R46 did not have a supplement ordered and her nutritional status was unknown due to the lack of weights. During an interview on 08/06/26 at 2:43 PM, the DON stated, the reason R46 did not have weights for the months of June 2026 and July 2026, Those just didn't get done. During an interview on 08/07/26 at 10:39 AM, LPN4 stated she didn't know why the resident had not been weighed recently, because R46 does not refuse her care. On 08/07/26 at 1:12 PM, R46 was served lunch in bed. R46's meal included meat with gravy, carrots, pasta, cake, and lemon-aid. R46 slowly fed herself with Qualified Medication Aide (QMA)1 at her bedside assisting. R46's intake was good. 3. Review of R1's admission MDS with an ARD of 07/16/26, located in the EMR under the MDS tab, revealed an admission date of 07/09/26 and diagnoses of diabetes mellitus, malnutrition, and bipolar disorder. Review of R1's BIMS revealed a score of 15 out of 15, indicating R1's cognition was intact. Review of R1's care plan, dated 07/16/26, located in the EMR under the Care Plan tab revealed Alteration in nutritional status r/t a therapeutic diet for T2DM [type 2 diabetes mellitus], additional alterations include: cirrhosis of the liver, hepatitis C, anemia, T2DM, anxiety, GERD, PTSD [post traumatic syndrome disease], polysubstance abuse, COPD. An intervention included Weigh resident every month or per MD [physician]/RD order. Document and notify MD/RD of any significant weight changes. Review of R1's order, located in the EMR under the Order tab revealed no diet order. Review of R1's nutritional assessment, dated 07/16/26, located in the EMR under the Results tab revealed Ht: 66in; wt: 170# - hospital weight, facility weight pending. Review of R1's weights, located in the EMR under the Weights & Vitals tab, revealed only one weight at 180 Lbs on 08/04/26. There were no weekly admission weights. During an observation on 08/04/26 at 12:53 PM, R1 was noted ambulating in the dining room with her walker. R1 stated she would eat her lunch later, about 3:00 PM as staff would hold her tray for her. During an interview on 08/05/26 at 2:42 PM, the RD stated that admission weights should be obtained, and hospital weights should not be used because scale differences may cause weight variations. The RD stated current weights were important, but she may have to use a hospital weight if nursing staff had not obtained a weight by the time her assessment was due. The RD stated new admissions typically were not weighed weekly for the first month, except possibly for residents with feeding tubes. The RD stated she was unsure why R1 did not have any weights other than the 08/04/26 weight but confirmed an admission weight should have been obtained. During an interview on 08/06/26 at 2:40 PM, the DON stated, regarding why R1 did not have any admission weights or monthly weight for 07/20/26, It just wasn't obtained. The DON stated facility policy required weekly weights for four weeks after admission; however, this was not completed for R1, and no monthly weight was obtained until 08/04/26. Review of the facility policy titled Weight Monitoring, revised 08/11/25, provided by the facility revealed . 2. Assessments should include the following information. c. Weight (do not use the hospital weight) .5. A weight monitoring schedule will be developed upon admission for all residents:. b. Newly admitted residents - take weight upon admission and then monitor weight weekly for 4 weeks. e. All others - monitor weight monthly.

Based on observation, record review, interview, and policy review, the facility failed to transcribe and administer the hospital discharge physician orders for one of one resident (Resident (R) 96) reviewed with a diagnosis of thrush. The his failure resulted in untreated thrush, placing R96 at risk for continued oral infection, pain, and delayed recovery. Findings include: 1. Review of R96's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R96 was re-admitted to the facility on [DATE] with diagnoses that included hypertension, stroke, dysphagia, depression, and seizure. Review of the [name of hospital] Discharge summary, dated [DATE], indicated, .Nystatin Suspension 100000 unit/milter (ml) swish and spit four times a day (QID), end on 07/28/26. Review of facility provided Order Summary Report, dated 07/01/26-07/31/26, indicated no evidence of medication (Nystatin) for thrush from hospital stay of 07/23/26. Review of facility provided Medication Administration Record (MAR), dated July 2026, indicated no evidence of medication (Nystatin) for thrush from 07/23/26-07/28/26. During an interview on 08/06/26 at 3:46 PM, the Director of Nursing (DON) confirmed that R96 went out to the hospital on [DATE] with urinary problems and to her knowledge did not have thrush at that time. The DON stated R96 returned on 07/23/26 with the diagnosis of thrush. The DON confirmed the Nystatin order was not transcribed and placed into the facility's computer system, so R96 did not receive the medication. During an interview on 08/07/26 at 08:43 AM, Licensed Practical Nurse (LPN) 5 stated medical records put the hospital physician orders into the facility's computer system after a resident returns. The staff nurse then confirms the physician orders by comparing the hospital orders with the orders in the computer. LPN5 (Unit Manager) stated she looks over the physician orders, but initially it should be looked over by the staff nurses. LPN5 confirmed that R96 did not receive the medication from the hospital as ordered for the thrush. During an observation on 08/07/26 at 10:47 AM, LPN5 confirmed that R96 currently had a white tongue and was positive for thrush. Review of the facility policy titled Medication Orders, revised 02/26, indicated, .Policy Explanation and Compliance Guidelines:.4.f. Transcribe newly prescribed medications on the Medication Administration Record (MAR) or treatment record or ensure the order is in the electronic MAR.

Based upon observation and interview, the facility did not ensure Residents were provided with a clean and comfortable, homelike environment that included the provision of linens.*On 3/17/26 there was a delay in R10 and R3 receiving their showers as there were no towels on the unit. A count of the nurse storage closets on the Lake Park side of the facility revealed very little or no linen/towels in these nurse storage closets. *The walls of R3, R11, R12, R16, R7, R13, room [ROOM NUMBER], R9, R15, & R14 were observed with gouges and/or holes.Findings include:The facility's policy titled, Safe and Homelike Environment and last reviewed/revised 2/2025 under policy documents In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility, both inside and outside, maximizes resident independence and does not pose a safety threat. Under policy explanation and compliance guidelines includes 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. 4. The facility will provide and maintain bed and bath linens that are clean and in good condition.1.) R3's diagnoses includes congestive heart failure (heart doesn't pump enough blood to meet the body's needs), schizoaffective disorder bipolar type (chronic mental health condition with schizophrenia symptoms and severe mood episodes), morbid (severe) obesity (high risk condition defined by a body mass index of 40 or higher), hypertension (high blood pressure), and major depressive disorder (a serious common mental health condition characterized by a persistent intense and low mood along with a loss of interest in activities).R3's annual MDS (minimum data set) with an assessment reference date of 1/15/26 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R3 is assessed as requiring substantial/maximal assistance for shower/bathe self.On 3/17/26, at 9:42 a.m., Surveyor observed R3 in bed wearing a hospital gown. Surveyor asked R3 if staff helps her to wash up and take her to the bathroom. R3 replied yes. R3 explained staff washes her up but they don't have any towels. R3 stated today is her shower day.On 3/17/26, at 9:43 a.m., Surveyor asked Licensed Practical Nurse (LPN)- K where Surveyor would be able to find towels. LPN-K replied nurse storage. Surveyor then went to the nurse's storage closet located on the 100 unit. Surveyor observed three are 3 pillowcases, 3 washcloths, 2 gowns and 3 bath blankets. Surveyor observed there were no bath towels or sheets.On 3/17/26, at 9:46 a.m., Surveyor observed the nurse storage closet on the 200 unit. Surveyor observed there are 3 bath towels, 11 washcloths, 3 sheets, 6 pillowcases, 2 gowns, and 1 bath blanket.On 3/17/26, at 9:49 a.m., Surveyor observed the nurse storage closet on the 300 unit. Surveyor observed there are no linen/towels on the shelves in this closet.On 3/17/26, at 9:49 a.m., Surveyor informed Certified Nursing Assistant (CNA)-L Surveyor did not observe any linen/towels in the nurse storage closet. CNA-L informed Surveyor they normally come around and stock, but they haven't come around. Surveyor asked CNA-L what she would do if she needed to do incontinent cares for a resident. CNA-L informed Surveyor she would probably have to go to the laundry since there was nothing on the floor. Surveyor asked CNA-L what time the nurse storage closet is stocked. CNA-L informed Surveyor she didn't know. Surveyor asked CNA-L when she started working on the floor was there linen/towels in the nurse storage closet. CNA-L replied no. CNA-L explained she got here at 8:00 a.m. and the normal CNA shift is at 6:15 a.m.On 3/17/26, at 9:56 a.m., Surveyor asked CNA-H who is assigned to the 100 unit if there are any residents on her assignment who are supposed to get a shower today. CNA-H replied the first names of R10 & R3 have showers. CNA-H informed Surveyor that she usually starts with the first name of R10, but she has to wait for the towels. CNA-H informed Surveyor they used all the towels they had for cares. Surveyor asked CNA-H what she would do if she had to do cares for a resident now. CNA-H replied I would have to wait. CNA-H informed Surveyor sometimes she will go back, referring to the laundry area, and she may have a little for her.On 3/17/26, at 10:03 a.m., Surveyor interviewed Housekeeping/Laundry Supervisor (H/LS)-J regarding the linen/towels. (H/LS)-J informed Surveyor they have a washing machine that is broken which is getting fixed today. Surveyor asked how long the washing machine has been broken. H/LS-J informed Surveyor a week, week and a half. Surveyor asked H/LS-J how often linen/towels are delivered to the units. H/LS-J replied once a day and explained they deliver linen around noon. H/LS-J informed Surveyor with the washing machine broken, they deliver a little linen in the morning and in the afternoon usually around noon. H/LS-J informed Surveyor when she started, they were low on linen. Surveyor asked H/LS-J when she started working at the facility. H/LS-J informed Surveyor one and one half, two months ago. H/LS-J informed Surveyor she placed two linen orders and received one. Surveyor asked if there is a par level of how many linen/towels are delivered to each unit. H/LS-J informed Surveyor she doesn't have a par level but does 8 to 10 sheets and 15 towels in each closet. Surveyor asked for the whole day. H/LS-J replied yes explaining the closets are small. H/LS-J explained they have bath, hand, and washcloths. Surveyor asked H/LS-J to show Surveyor the towels ready to be delivered to the units. Surveyor observed on a linen cart there are 78 washcloths and 53 towels. Surveyor noted the facility's census is 83. Surveyor asked if these were all the towels the facility has. H/LS-J explained there are towels the prior laundry supervisor ordered which must be washed. Surveyor observed on a silver metal rack there are multiple bags of washcloths. H/LS-J informed Surveyor this rack, referring to the silver rack, only has washcloths. H/LS-J informed Surveyor the linen on the blue cart is what she ordered. Surveyor observed there are 114 washcloths, 24 bath towels and 36 gowns which need to be washed. Surveyor asked H/LS-J how she knows if the units need linen. H/LS-J informed Surveyor she usually goes out and checks. Surveyor asked H/LS-J if she checked for linen in the nurse storage closets today. H/LS-J replied no I haven't explaining she is short a person today. Surveyor asked H/LS-J when she will be delivering linen/towels to the units. H/LS-J informed Surveyor after the sheets are done washing but she can take towels out.On 3/17/26, at 10:40 a.m., Surveyor observed H/LS-J stocking the nurse storage closet on the 100 unit. Surveyor asked H/LS-J if the other two units (200 & 300) on the Lake Park side were stocked. H/LS-J informed Surveyor she did the other two units but hasn't done the other side of the building, referring to Central Park.On 3/17/26, at 10:42 a.m., Surveyor counted the linen/towels in the 100-nurse storage closet. Surveyor observed there are 15 bath towels, 5 gowns, approximately 41 washcloths, and there are no sheets.On 3/17/26, at 10:44 a.m., Surveyor counted the linen/towels in the 200-nurse storage closet. Surveyor observed there are 15 bath towels, 3 gowns, 3 sheets, and approximately 34 washcloths.On 3/17/26, at 10:47 a.m., Surveyor counted the linen/towels in the 300-nurse storage closet. Surveyor observed there are 13 bath towels, 31 washcloths, 2 gowns, and 9 bath blankets. There are no sheets in this closet.On 3/17/26, at 4:17 p.m., Surveyor asked CNA-O, who works the evening and night shift, if there are any problems with not enough linen/towels. CNA-O informed Surveyor there is a shortage of linen, and they can't do proper cares for residents if they don't have linen.On 3/18/26, at 12:14 p.m., Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the concern of the facility not having adequate linen & towels. No additional information was provided to Surveyor.On 3/18/26, at 12:04 p.m., Surveyor interviewed Maintenance Director (MD)-I regarding resident's rooms. Surveyor asked MD-I how they ensure resident's rooms don't have holes or gouges/scrapes in the walls. MD-I informed Surveyor he depends on CNAs (Certified Nursing Assistants) to let them know. If they let them know they fix it. MD-I informed Surveyor if they find holes or gauges/scrapes then they will patch them up. MD-I indicated the thing is they need to move residents out as they can't be in the room. Surveyor asked MD-I if there is a schedule when his department checks resident's rooms. MD-I replied no there is not. MD-I explained every morning he makes rounds as beds maybe unplugged, something may happen overnight and he always makes rounds. MD-I informed Surveyor if someone tells us there are holes, they will get to it. The problem is getting the residents out of their room to sand, paint, and cover up. Surveyor asked when the last time he painted on Lake Park units. MD-I informed Surveyor he hasn't painted a room on Lake Park yet. Surveyor asked MD-I how long he's been working at the facility. MD-I replied been here almost two years.2.) On 3/17/26, at 8:51 a.m., Surveyor observed R3 in bed on her back. Surveyor observed the green wall behind R3's headboard has been patched but not painted. The white area patched measures approximately two- & one-half feet by two feet. Surveyor asked R3 about the patched area on the wall. R3 informed surveyor they worked on it but haven't worked on it for a while.On 3/18/26, at 8:32 a.m., Surveyor showed Maintenance Director (MD)-I the wall behind R3's bed which was patched but not painted. MD-I this is a spring project and doesn't paint resident's rooms if there is a resident in the room due to the smell. R3 informed Surveyor and MD-I there are holes in the wall by R7's bed.3.) On 3/18/26, at 9:05 a.m., Surveyor observed behind the headboard of the empty bed in R11's room there are five gouges on the wall board. Surveyor observed that the longest gouge is approximately five inches long and one-half inch wide.R11's quarterly MDS (minimum data set) with an assessment reference date of 12/18/25 assesses R11 as having short- & long-term memory problems and is severely impaired for cognitive skills for daily decision making.4.) On 3/18/26, at 9:07 a.m., Surveyor observed R12 in bed on his back. Surveyor observed the wall to the right of R12's bed has six gouges on the wall board with varying lengths.R12's admission MDS (minimum data set) with an assessment reference date of 1/14/26 has a BIMS (brief interview mental status) score of 9 which indicates moderate cognitive impairment. On 3/18/26, at 11:28 a.m., Surveyor asked R12 if the gouges on the wall board had been there for a while. R12 replied yes. Surveyor asked R12 if these gouges bother him. Surveyor was unable to understand R12's response.5.) On 3/18/26, at 9:15 a.m., Surveyor observed in room [ROOM NUMBER] which currently does not have a resident residing in three gouges in the wall board by the bed near the window. Surveyor observed one gouge measures approximately twelve inches by one inch, the second gouge measures approximately two inches by four inches and the third gouge measures approximately three inches by one half inch.6.) On 3/18/26, at 9:28 a.m., Surveyor observed behind the headboard of R16's bed there are 2 holes in the wall approximately eight inches by three inches and approximately five inches by four inches. In addition, there are multiple gouges on the wall board. Gouges measure approximately two inches by five inches, three inches by one inch, one inch by one-half inch, four inches by one inch along with multiple smaller gouges. The corner guard on the wall straight ahead as one enters R16's room is missing. The missing corner guard measures approximately four feet in length.R16's quarterly MDS (minimum data set) has an assessment reference date of 12/10/25. R16 has a BIMS (brief interview mental status) score of 16 which indicates cognitively intact.On 3/18/26, at 9:30 a.m., Surveyor asked R16 how long the holes & gouges have been in wall behind the headboard. R16 replied not super long. R16 informed Surveyor it happens when she boosts herself the headboard hits the wall.7.) On 3/18/26 at 9:34 a.m., Surveyor observed by R7's bed to the left of the red outlet there is a hole in the wall measuring approximately two inches by two inches.8.) On 3/18/26, at 10:33 a.m., Surveyor observed behind R13's bed there are two holes in the wall. The holes measure approximately three inches by one inch and seven inches by three inches.R13's admission MDS (minimum data set) with an assessment reference date of 1/12/26 has a BIMS (brief interview mental status) score of 6 which indicates severe cognitive impairment.On 3/18/26, at 12:14 p.m. NHA-A and DON-B were informed of the environmental concerns observed during the survey. No additional information was provided to Surveyor.

Based on record reviews and interviews, the facility did not ensure allegations of abuse were immediately reported to the Nursing Home Administrator and/or Grievance Officer. This was affected 1 (R1) of 1 Resident reviewed for alleged abuse.* Staff did not report allegations of abuse regarding Certified Nursing Assistant (CNA)-E to the Nursing Home Administrator (NHA)-A immediately. This allowed for additional potential allegations of abuse to occur to other residents whom CNA-E provided care to for the remainder of the shift.Findings Include:The facility's last reviewed 2/25/26 Abuse, Neglect, and Exploitation policy and procedure documents:.It is the policy 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.Policy Explanation and Compliance Guidelines:1. The facility will develop and implement written policies and procedures that:a. Prohibit and prevent abuse, neglect, and exploitation of Residents and misappropriation of Resident propertyb. Establish policies and procedures to investigate any such allegationsc. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of Resident property, reporting procedures, and dementia management and Resident abuse preventiond. Establish coordination with the QAPI program3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written.Employee TrainingB. Existing staff will receive annual education through planned in-services and as needed.C. Training topics will include:1. Prohibiting and preventing all forms of abuse, neglect, misappropriation of Resident property and exploitation2. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of Resident property3. Recognizing signs of abuse, neglect, exploitation, and misappropriation of Resident property, such as physical or psychosocial indicators4. Reporting process for abuse, neglect, exploitation, and misappropriation of Resident property, including injuries of unknown sources5. Understanding behavioral symptoms of Resident that may increase the risk of abuse and neglect such as:d. Outbursts or yelling out.Prevention of Abuse, Neglect and ExploitationThe facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of Resident property, and exploitation that achieves:D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of Residents with needs and behaviors which might lead to conflict or neglect.H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors.Protection of ResidentThe facility will make efforts to ensure all Residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigations. Examples include but are not limited to:A. Responding immediately to protect the alleged victim and integrity of the investigationF. Providing emotional support and counseling to the Resident during and after the investigation as neededG. Revision of the Resident's care plan if the Resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of the incident of abuse.Reporting/ResponseA. The facility will have written procedures that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframesa. Immediately, but not later than 2 hours after the allegatins is made, if the events that cause the allegation involve abuse or result in serious bodily injury5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following:a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of Resident property or exploitation occurred, and what changes are needed to prevent further occurrencesb. Defining how care provision will be changed and/or improved to protect Resident receiving servicesB. 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.R1's Quarterly Minimum Data Set (MDS) completed 11/4/25 documented R1's Brief Interview for Mental Status score is 9, indicating R1 demonstrated severely impaired skills for daily decision making. R1's Patient Health Questionnaire score of 6, indicated R1 demonstrates signs and symptoms of mild depression. R1's MDS documents R1 had no range of motion impairment on upper extremity and had range of motion impairment on both sides of lower extremities. R1 was independent with eating, upper and lower dressing, and mobility. R1 was supervision for showers and set-up for transfers.On 10/31/25, at 1:17 PM, the facility submitted a Nursing Home Resident Mistreatment, Neglect, and Abuse Report documenting an allegation of abuse involving CNA-E and R1 occurring on 10/30/25. It is documented that Certified Nursing Assistant (CNA)-D observed CNA-E spit on R1's food on R1's lunch tray. CNA-D reported the incident to Licensed Practical Nurse (LPN)-F. The report documents that the Nursing Home Administrator (NHA)-A, was notified on 10/30/25. The facility's Misconduct Incident Report submitted 11/7/25 documents that CNA-E worked until the end of the shift. On 10/31/25, both CNA-D and CNA-E were suspended pending the investigation based on the allegation and delay in reporting. Surveyor noted the shift ends at 2:30 PM. LPN-F was aware of the allegation of abuse by CNA-E but did not report the allegation of verbal abuse immediately to NHA-A. CNA-E remained in the facility, allowing time for CNA-E to have contact with R1 and other Residents in the facility. CNA-E was not immediately removed from Resident care areas.Surveyor reviewed the working punch detail for CNA-E that documents CNA-E arrived at the facility at 6:18 AM and left the facility at 8:45 PM. On 3/18/26, at 8:16 AM, NHA-A informed Surveyor that the shift ends at 2:30 PM. NHA-A confirmed that LPN-F reported the allegation of abuse involving R1 and CNA-E at the end of the shift. Surveyor asked NHA-A was still working in resident care areas after the allegation of abuse was reported. NHA-A stated, She wasn't working at the time of the investigation. Again, Surveyor pointed out that CNA-E according to CNA-E's punch detail, CNA-E worked past the first shift into a little over half of the second shift. NHA-A stated, I don't know what time I was told.On 3/18/26, at 8:35 AM, Surveyor interviewed CNA-D in regard to the allegation of abuse involving CNA-E. CNA-D explained to Surveyor that CNA-E likes to tell the residents CNA-E's personal business. CNA-D stated that R1 was declining and not taking showers and smelled like death. CNA-D stated that R1 and R1's roommate were very close and did everything together. CNA-D explained that CNA-E convinced R1's roommate to move out and R1 was very hurt and extremely upset with R1's roommate moving out. CNA-D stated that R1 told CNA-E the morning of the incident, what kind of a person are you, sleeping with two guys at the same time, you are a whore. CNA-D stated that CNA-E walked up to the cart of lunch trays and stated, where is that bitch's tray. CNA-D stated that CNA-E put CNA-E's bare hands on R1's food and run CNA-E's fingers around in R1's food. CNA-D stated that CNA-D did observe CNA-E spit on R1's food at lunch time and overheard CNA-E state that CNA-E was going to watch R1 eat the food with spit. CNA-D confirmed that CNA-D did not stop R1 from eating the food. After lunch was over, CNA-D approached LPN-F at the nurse's station and informed LPN-F of the incident. While both CNA-D and LPN-F were at the nurse's station, CNA-E walked up to CNA-D and LPN-F and stated, Guess what? She ate it. CNA-D knows for a fact that CNA-E came to work the next day. CNA-D knows this because CNA-E stated to CNA-D that CNA-E was going to mess with R1 again. CNA-D stated that both CNA-D and CNA-E were then suspended.On 3/18/26, at 10:33 AM, Surveyor shared the concern with NHA-A that both CNA-D and CNA-F did not report the allegation of abuse involving R1 and CNA-E immediately to NHA-A allowing CNA-E to work a full shift and most of the second shift and arrive to work the next day until CNA-E was suspended pending the investigation. NHA-A agrees with and understands Surveyor's concern that the facility's abuse policy and procedure was not implemented with the allegation of abuse involving R1 and CNA-E.No additional information has been provided by the facility at this time as to why the allegation of abuse involving R1 and CNA-E was not immediately reported to NHA-A which resulted in CNA-E working the rest of the shift and most of second shift potentially placing R1 and other Residents in a vulnerable state and exposing to potential further abuse.

Based on record review and staff interview, the facility did not ensure all allegations involving potential abuse were thoroughly investigated for 1 (R1) of 1 reviewed facility reported incidents (FRI).*An allegation of abuse on 10/30/25 by CNA-E involving R1 was not thoroughly investigated. Findings Include:The facility's last reviewed Abuse, Neglect, and Exploitation policy and procedure documents: Policy:.It is the policy 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.Policy Explanation and Compliance Guidelines:1. The facility will develop and implement written policies and procedures that:a. Prohibit and prevent abuse, neglect, and exploitation of Residents and misappropriation of Resident propertyb. Establish policies and procedures to investigate any such allegationsc. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of Resident property, reporting procedures, and dementia management and Resident abuse preventiond. Establish coordination with the QAPI program3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written.Protection of ResidentThe facility will make efforts to ensure all Residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigations. Examples include but are not limited to:A. Responding immediately to protect the alleged victim and integrity of the investigationF. Providing emotional support and counseling to the Resident during and after the investigation as neededG. Revision of the Resident's care plan if the Resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of the incident of abuse.Investigation of Alleged Abuse, Neglect and ExploitationA. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.B. Written procedures for investigations include:1. Identifying staff responsible for the investigation3. Investigating different types of alleged violations4. Identifying and interviewing all involved people, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent and cause6. Providing complete and thorough documentation of the investigation.Reporting/ResponseA. The facility will have written procedures that include:1. Reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframesa. Immediately, but not later than 2 hours after the allegations is made, if the events that cause the allegation involve abuse or result in serious bodily injury5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following:a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of Resident property or exploitation occurred, and what changes are needed to prevent further occurrencesb. Defining how care provision will be changed and/or improved to protect Resident receiving servicesB. 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.R1's Quarterly Minimum Data Set (MDS) completed 11/4/25 documented R1's Brief Interview for Mental Status score is 9, indicating R1 demonstrated severely impaired skills for daily decision making. R1's Patient Health Questionnaire score of 6, indicated R1 demonstrates signs and symptoms of mild depression. R1's MDS documents R1 had no range of motion impairment on upper extremity and had range of motion impairment on both sides of lower extremities. R1 was independent with eating, upper and lower dressing, and mobility. R1 was supervision for showers and set-up for transfers.On 10/31/25, at 1:17 PM, the facility submitted a Nursing Home Resident Mistreatment, Neglect, and Abuse Report documenting an allegation of abuse involving CNA-E and R1 occurring on 10/30/25. It is documented that Certified Nursing Assistant (CNA)-D observed CNA-E spit on R1's food on R1's lunch tray. CNA-D reported the incident to Licensed Practical Nurse (LPN)-F. The report documents that the Nursing Home Administrator (NHA)-A, was notified on 10/30/25. The facility's Misconduct Incident Report submitted 11/7/25 documents that CNA-E worked until the end of the shift. On 10/31/25, both CNA-D and CNA-E were suspended pending the investigation based on the allegation and delay in reporting. The facility's summary of the incident documents that on 10/30/25 CNA-D reported to LPN-F at the end of first shift the allegation of CNA-E spitting on R1's food. The summary documents the allegation was reported to NHA-A on 10/30/25.Surveyor noted the shift ends at 2:30 PM. LPN-F was aware of the allegation of abuse by CNA-E but did not report the allegation of verbal abuse immediately to NHA-A. CNA-E remained in the facility, allowing time for CNA-E to have contact with R1 and other Residents in the facility. CNA-E was not immediately removed from Resident care areas.Surveyor reviewed the working punch detail for CNA-E that documents CNA-E arrived at the facility at 6:18 AM and left the facility at 8:45 PM. On 3/18/26, at 8:16 AM, NHA-A informed Surveyor that the shift ends at 2:30 PM. NHA-A confirmed that LPN-F reported the allegation of abuse involving R1 and CNA-E at the end of the shift. Surveyor asked NHA-A was still working in resident care areas after the allegation of abuse was reported. NHA-A stated, She wasn't working at the time of the investigation. Again, Surveyor pointed out that CNA-E according to CNA-E's punch detail, CNA-E worked past the first shift into a little over half of the second shift. NHA-A stated, I don't know what time I was told.On 3/18/26, at 8:35 AM, Surveyor interviewed CNA-D regarding the allegation of abuse involving CNA-E. CNA-D explained to Surveyor that CNA-E likes to tell the residents CNA-E's personal business. CNA-D stated that R1 was declining and not taking showers and smelled like death. CNA-D stated that R1 and R1's roommate were very close and did everything together. CNA-D explained that CNA-E convinced R1's roommate to move out and R1 was very hurt and extremely upset with R1's roommate moving out. CNA-D stated that R1 told CNA-E the morning of the incident, what kind of a person are you, sleeping with two guys at the same time, you are a whore. CNA-D stated that CNA-E walked up to the cart of lunch trays and stated, where is that bitch's tray. CNA-D stated that CNA-E put CNA-E's bare hands on R1's food and run CNA-E's fingers around in R1's food. CNA-D stated that CNA-D did observe CNA-E spit on R1's food at lunch time and overheard CNA-E state that CNA-E was going to watch R1 eat the food with spit. CNA-D confirmed that CNA-D did not stop R1 from eating the food. After lunch was over, CNA-D approached LPN-F at the nurse's station and informed LPN-F of the incident. While both CNA-D and LPN-F were at the nurse's station, CNA-E walked up to CNA-D and LPN-F and stated, Guess what? She ate it. CNA-D knows for a fact that CNA-E came to work the next day. CNA-D knows this because CNA-E stated to CNA-D that CNA-E was going to mess with R1 again. CNA-D stated that both CNA-D and CNA-E were then suspended.Surveyor reviewed the facility's investigation of the incident. Surveyor notes there are only verbal interviews conducted with CNA-D and CNA-E. LPN-F did not provide a statement and was only asked of LPN-F had witnessed the incident. The facility's investigation does not include what time the incident occurred or what time the allegation was reported to NHA-AOn 3/18/26, at 10:33 AM, Surveyor shared the concern with NHA-A that the allegation of abuse was not thoroughly investigated. NHA-A agrees with and understands Surveyor's concern.No additional information has been provided by the facility at this time as to why the allegation of abuse involving R1 and CNA-E was not thoroughly investigated.

Based on observation, interview and record review, the Facility did not ensure that Residents at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries for 1 (R9) of 1 Residents reviewed.R9 is at high risk for pressure injury development and has a history of pressure injuries. R9's air mattress was not functioning during multiple observations on 3/17/26 & 3/18/26.Findings include:The facility's policy titled, Pressure Injury Prevention and Management and last reviewed/revised 6/17/25 under Policy documents This facility is committed to the prevention of avoidable pressure injuries, unless clinically avoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries.R9's diagnoses includes diabetes mellitus (high blood sugar), dementia (loss of cognitive function that interferes with a person's daily life and activities), congestive heart failure (heart doesn't pump enough blood to meet the body's needs), major depressive disorder (a serious mental health condition characterized by a persistent intense and low mood along with an interest in activities), atrial fibrillation (irregular and rapid heartbeat), and hypertension (high blood pressure).R9's physician order dated 3/14/24 documents Air mattress functioning check to ensure green light it sic (is) on. If light is red, turn air mattress on every shift.R9's at risk for alteration in skin integrity care plan initiated 12/14/17 and revised 8/27/25 include an intervention of Air Mattress- Check function q (every) shift; proactive 330 lbs (pounds) (residents' preference). Initiated 10/7/24 and revised 2/6/26.R9's Pressure Ulcer/Injury CAA (care area assessment) dated 7/17/25 under analysis of findings for nature of the problem/condition documents Pressure Ulcers CAA triggered secondary to potential for pressure injuries. Contributing factors include ADL (activities daily living)/functional/mobility impairment and incontinence. Risk factors include pain, development of PI/skin condition, and fluid deficit risk. A licensed nurse assesses skin each week and put proper interventions in place to prevent skin breakdown. Skin is also monitored by caregivers with each bath and each time the resident is dressed. The physician is to be notified of any abnormal findings and treatment orders are obtained. The dietitian is monitoring food and fluid intake and implementing dietary interventions as necessary. Caregivers assist with repositioning at least every two hours and as needed for comfort. Care plan will be reviewed to maintain current ADL status and functional ability, prevent pain, and decrease pressure ulcer/fluid deficit risk.Under Care Plan Considerations for describe impact of this problem/need on the resident and your rational for care plan decision documents Pressure Ulcers CAA triggered secondary to potential for pressure injuries. Contributing factors include ADL (activities daily living)/functional/mobility impairment and incontinence. Risk factors include pain, development of PI/skin condition, and fluid deficit risk. A licensed nurse assesses skin each week and put proper interventions in place to prevent skin breakdown. Skin is also monitored by caregivers with each bath and each time the resident is dressed. The physician is to be notified of any abnormal findings and treatment orders are obtained. The dietitian is monitoring food and fluid intake and implementing dietary interventions as necessary. Caregivers assist with repositioning at least every two hours and as needed for comfort. Care plan will be reviewed to maintain current ADL status and functional ability, prevent pain, and decrease pressure ulcer/fluid deficit risk.R9's quarterly MDS (minimum data set) with an assessment reference date of 1/13/26 has a BIMS (brief interview mental status) score of 13 which indicates cognitively intact. R9 is assessed as being dependent for toileting hygiene and rolling left & right. R9 is always incontinent of urine and bowel. R9 is assessed as being at risk for pressure injuries and does not have a pressure injury.R9's Braden assessment dated [DATE] has a score of 10 which indicates high risk.R9's skin impairment/wound evaluation dated 2/25/26 indicates R9's right & left buttocks stage 2 pressure injury and right medial heel deep tissue pressure injury were resolved on 2/25/26. These pressure injuries were present upon R9's readmission to the facility.R9's Visual/Bedside Kardex Report as of 3/18/26 under the monitoring section includes documentation of *Air Mattress- Check function q (every) shift; proactive 330 lbs (pounds) (residents' preference).On 3/17/26, at 3:52 p.m., Surveyor observed R9 in bed on his back with the head of the bed elevated sleeping. Surveyor observed that there is a Proactive Protek Aire 8000 pump unit attached to the foot board of R9's bed that is not functioning as there are no lights lit on the pump unit.On 3/17/26, at 4:13 p.m., Surveyor observed R9 in bed on his back with the head of the bed elevated sleeping. Surveyor observed R9's air mattress is not functioning as there are no lights lit on the pump unit which is attached to the foot board of R9's bed.On 3/18/26, at 7:05 a.m., Surveyor observed R9 in bed on his back, with eyes closed, and the head of the bed elevated. Surveyor observed R9's air mattress is not functioning as there are no lights lit on the pump unit which is attached to the foot board of R9's bed.On 3/18/26, at 8:06 a.m., Surveyor observed R9 in bed on his back with the head of the bed elevated high. Surveyor observed R9's air mattress is not functioning as there are no lights lit on the pump unit which is attached to the foot board of R9's bed.On 3/18/26, at 9:20 a.m., Surveyor observed R9 in bed on his back with the head of the bed elevated. Surveyor observed R9's air mattress is not functioning as there are no lights lit on the pump unit which is attached to the foot board of R9's bed.On 3/18/26, at 10:35 a.m., Surveyor observed R9 in bed on his back with the head of the bed elevated. Surveyor observed R9's air mattress is not functioning as there are no lights lit on the pump unit which is attached to the foot board of R9's bed.On 3/18/26, at 10:42 a.m., Surveyor asked Licensed Practical Nurse (LPN)-F for residents with an air mattress on their bed should the air mattress be on. LPN-F replied yes, should be on absolutely. Surveyor asked LPN-F to accompany Surveyor to R9's room. Surveyor showed LPN-F the pump unit for R9's air mattress is not on. LPN-F informed Surveyor they didn't notice this and usually does the TAR (treatment administration record) at noon. Surveyor informed LPN-F Surveyor observed R9's air mattress was not functioning yesterday afternoon and had multiple observations this morning. LPN-F informed Surveyor on Mondays the facility does a generator check and may have shut off the air mattress.On 3/18/26, at 10:54 a.m., Surveyor interviewed Registered Nurse/Unit Manager (RN/UM)-G. Surveyor asked RN/UM-G how staff ensures a resident's air mattress is on. RN/UM-G informed Surveyor she believes there are orders for everyone who has an air mattress. The nurse should do checks, listen for alarms, and during cares staff should feel the mattress or the resident may complain. Surveyor informed RN/UM-G of Surveyor's observations of R9's air mattress not functioning.On 3/18/26, at 12:14 p.m., Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the multiple observations of R9's air mattress not functioning on 3/17/26 & 3/18/26. No additional information was provided to Surveyor as to why R9's air mattress was not functioning.

Based on observation, interview and record review, the facility did not ensure fall interventions were implemented to prevent accidents for 1 (R3) of 2 sampled residents.Fall safety intervention of ensuring a reacher available for safety was not observed being implemented during the survey. Findings include:R3's diagnoses includes congestive heart failure (heart doesn't pump enough blood to meet the body's needs), schizoaffective disorder bipolar type (chronic mental health condition with schizophrenia symptoms and severe mood episodes), morbid (severe) obesity (high risk condition defined by a body mass index of 40 or higher), hypertension (high blood pressure), and major depressive disorder (a serious common mental health condition characterized by a persistent intense and low mood along with a loss of interest in activities).R3's at risk for falls care plan initiated 1/3/25 and revised 1/12/26 documents an intervention of *Resident to have reacher within reach while in bed. Initiated 7/9/25.R3's annual MDS (minimum data set) with an assessment reference date of 1/15/26 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R3 is assessed as requiring substantial/maximal assistance for toileting hygiene, rolling left and right, chair/bed to chair transfer and toilet transfer. R3 is assessed as not having any falls since prior assessment period.R3's falls CAA (care area assessment) dated 1/22/26 under analysis of findings for nature of problem/condition documents Fall CAA triggered secondary to impaired gait and mobility and level of assistance required with transfers. Contributing factors includes history of falls prior to admission, CHF (congestive heart failure), dementia, obesity, COPD (chronic obstructive pulmonary disease), weakness and physical performance limitations affecting balance, gait, strength, and muscle endurance. Risk factors include falls and other major/minor injuries related to falls. Care plan will be reviewed to maintain current physical function as it relates to ADLs (activities daily living), gait stability, strength and endurance, mobility, decrease fall risk and minimize injury related to falls.Under care plan considerations for describe impact of this problem/need on the resident and your rationale for care plan decision documents Fall CAA triggered secondary to impaired gait and mobility and level of assistance required with transfers. Contributing factors includes history of falls prior to admission, CHF (congestive heart failure), dementia, obesity, COPD (chronic obstructive pulmonary disease), weakness and physical performance limitations affecting balance, gait, strength, and muscle endurance. Risk factors include falls and other major/minor injuries related to falls. Care plan will be reviewed to maintain current physical function as it relates to ADLs (activities daily living), gait stability, strength and endurance, mobility, decrease fall risk and minimize injury related to fallsOn 3/3/26 R3 sustained a fall from bed.R3's Visual/Bedside Kardex Report as of 3/17/26 under the Safety section documents Resident to have reacher within reach while in bed.On 3/17/26, at 8:51 a.m., Surveyor observed R3 in bed on her back wearing a hospital gown. Surveyor did not observe a reacher within R3's reach.On 3/17/26, at 9:40 a.m., Surveyor observed R3 in bed on her back wearing a hospital gown. Surveyor asked R3 if she has a reacher. R3 informed Surveyor the reacher is over by the TV. Surveyor observed a reacher propped up against the wall behind a box to the left of the television. Surveyor observed the reacher is approximately four feet away from R3's bed. R3 informed Surveyor she has another reacher but doesn't know what happened to it. Surveyor asked R3 if she had the reacher would she use it. R3 replied yes.On 3/17/26, at 10:59 a.m., Surveyor observed R3 laying at an angle in bed. Surveyor observed R3 does not have a reacher within her reach and a reacher continues to be propped up against the wall behind a box to the left of the television.On 3/17/26, at 11:50 a.m., Surveyor observed R3 dressed for the day sitting in a wheelchair in R3's room with Certified Nursing Assistant (CNA)-H combing R3's hair.On 3/18/26, at 9:45 a.m., Surveyor asked CNA-H if R3 should have a reacher while in bed. CNA-H replied yes and informed Surveyor she moved it this morning to the window as R3 had the reacher under her.On 3/18/26 at 9:48 a.m., Surveyor asked R3 if she had a reacher with her in bed today. R3 replied yes. Surveyor asked R3 if she had a reacher while she was in bed yesterday. R3 replied no.On 3/18/26, at 10:52 a.m., Surveyor asked Registered Nurse/Unit Manager (RN/UM)-G if staff should be following resident's Kardex and care plans. RN/UM-G replied yes, absolutely. Surveyor informed RN/UM-G of Surveyor's observations on 3/17/26 of R3 not having a reacher within reach while R3 was in bed according to her plan of care.On 3/18/26, at 12:14 p.m., Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of Surveyor's observation of R3 not having a reacher within reach while in bed on 3/17/26. No additional information was provided to Surveyor as to why R3 did not have a reacher while in bed on 3/17/26.

Based on observations, interviews, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1(R1) of 3 residents in sample.Surveyor observed 3 staff members provide high contact cares to R1 without following enhanced barrier precautions (EBP) as ordered due to R1's foley catheter placement. Findings include: The facility's document titled Enhanced Barrier Precaution (EBP) dated 7/25/22 documents: Use of gown and gloves during high contact resident care activities.Rooms will be marked with a green heart.Do not need to DON (put on) PPE (personal protective equipment) if just passing water, giving resident try {SIC}, etc.You need to DON PPE for high contact care activities: Ex: dressing, bathing or showering, performing transfer, changing linens, providing hygiene, changing a resident's brief or assisting them with toileting, direct care of an indwelling medical device, such as central line, urinary catheter, feeding tube or tracheostomy, and while providing wound care on any skin opening that requires a dressing.Residents can participate in group activities. The Facility's Policy titled, Hand Hygiene Implemented 2/2025, Revised 2/2025 documents:Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy explanation and Compliance Guidelines:1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Table includes but is not limited to: Before and after removing personal protective equipment (PPE), including gloves.3. Alcohol-based hand rub with 60 to 95 % alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are viably dirty, before eating, and after using the restroom [ROOM NUMBER]. Additional considerations:a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves R1 was admitted to the facility on [DATE] with diagnoses that included obstructive and reflux uropathy (Obstructive uropathy refers to a blockage or obstruction in the flow of urine from the kidneys to the bladder or out of the body, while reflux uropathy, specifically vesicoureteral reflux (VUR), is the backward flow of urine from the bladder into the ureters and potentially back to the kidneys).R1's Change of Condition MDS (Minimum Data Set) with an assessment reference date of 5/30/25 documents a BIMS (Brief Interview for Mental Status) score of 8, indicating that R1 has moderate cognitive impairment.R1's Physician's order dated 5/25/25, at 2:14 PM, documents: Maintain Enhanced Barrier Precautions r/t (related to) foley catheter every shift for infection control.R1's Urinary Catheter Care Plan, date 5/25/25 under the interventions section documents: Implement and Maintain enhanced barrier precautions, date 5/25/25. On 7/14/25, at 12:09 PM, Surveyor observed staff providing cares to R1 that included R1's transfer, foley catheter care and incontinence of bowel care; all considered high contact cares. Surveyor observed Certified Nursing Assistant (CNA)-D and Certified Nursing Assistant (CNA)-E transfer R1 from R1's chair to R1's bed to perform incontinence of bowel high contact cares. Surveyor observed CNA-D and CNA-E did not put on gowns during R1's high contact care or R1's transfer from chair to bed, cleaning R1's bowel incontinence, changing R1's brief and incontinence pads on R1's bed, emptying contaminated wash basin fluids, handling contaminated wash cloths, and removing contaminated trash bag with contents from R1's care. Surveyor observed CNA-E change gloves after providing R1's incontinence care without proper hand hygiene and remove items from a clean drawer in R1's room and put clean items such as powder back into a clean drawer.On 7/14/25, at 12:27 PM, Surveyor observed Licensed Practical Nurse (LPN)-C enter R1's room with no gown and remove R1's stat lock on R1's foley catheter drainage line and replace it with a new stat lock.On 7/14/25, at 12:42 PM, Surveyor observed LPN-C bring disinfecting wipes into R1's room and hand the disinfecting wipes to CNA-E. Surveyor observed CNA-E clean the mechanical lift used for R1's transfer without donning gloves or gown. Surveyor observed CNA-E make R1's bed without donning gloves or gown. On 7/14/25, at 12:47 PM, Surveyor interviewed CNA-E about the green heart and PPE cart outside of R1's room.Surveyor asked CNA-E what the green heart and cart outside of R1's room meant. CNA-E informed Surveyor that the staff usually will put a gown on to care for R1's because of R1's foley catheter. Surveyor asked CNA-E if the staff providing direct cares to R1 should have had gowns and gloves on. CNA-E informed Surveyor the staff should have put gowns and gloves while providing cares to R1. On 7/14/25, at 12:50 PM, Surveyor interviewed LPN-C about the green heart and PPE cart outside of R1's room. Surveyor asked LPN-C what the green heart and cart outside of R1's room meant. LPN-C informed Surveyor that it meant staff should put on a gown and gloves when doing high contact cares with a resident with a foley catheter, open wounds, central lines. LPN-C informed Surveyor that Enhanced Barrier Precautions (EBP) were introduced by the state a while ago to help prevent infections. LPN informed Surveyor that the staff should have had gown and gloves while providing all R1's cares because of R1's foley catheter. Surveyor asked LPN-C if staff should use hand hygiene in-between glove changes. LPN-C informed Surveyor that staff should use gel or wash hands in between glove changes. Surveyor asked LPN-C how staff knew about the green heart sign on a resident's door. LPN-C informed Surveyor that all staff are educated on (EBP) when they start at the facility and new residents placed on (EBP) are discussed at weekly meetings and shift reports.On 7/14/25, at 01:09 PM, Surveyor interviewed CNA-D about the green heart and PPE cart outside of R1's room. Surveyor asked CNA-D what the green heart and cart outside of R1's room meant. CNA-D informed Surveyor that when giving direct cares to a resident with a foley catheter or a wound the staff should wear gown and gloves to prevent infections. Surveyor asked CNA-D if the staff should have had gown and gloves while providing R1's cares and transfers. CNA-D informed Surveyor that the staff should have worn gowns and gloves while providing R1's direct cares and transfers. On 7/14/25, at 01:58 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A about concerns with staff not following (EBP) during Surveyor's direct care observations of R1 by facility staff members.Surveyor asked NHA-A what the green heart and cart outside of a resident's room meant. NHA-A informed Surveyor it meant the resident would be in (EBP) requiring PPE precautions during cares for that resident. Surveyor informed NHA-A about the observations of the 3 staff Surveyor observed during R1's transfers, incontinence cares, changing R1's foley catheter stat lock, making the bed, and cleaning the mechanical lift did not wear gowns. Surveyor informed NHA-A that one of that staff did not perform hand hygiene after a glove change and accessed clean items in R1's drawers. Surveyor informed NHA-A that CNA-E did not wear gloves making R1's bed or cleaning the mechanical lift after R1's transfer. NHA-A informed Surveyor the staff should have worn gowns and gloves during R1's direct cares and performed hand hygiene between glove changes.On 7/15/25 during exit NHA-A informed Surveyor that the staff in question had come forward to inform NHA-A that they had not followed (EBP) for R1 and NHA-A used it as learning experience at that time for the staff. No other information was provided to Surveyors at that time.

Based on observation, interview, and record review, the facility did not ensure garbage and refuse was disposed of properly. This has the ability to affect all 87 residents who reside at the facility. Garbage and litter was found near the facility's main dumpster area. Evidenced by: The facility policy, Disposal of Garbage and Refuse, dated 2/1/25, states, in part; .7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. On 6/2/25 at 10:21AM, During initial kitchen tour, Surveyor observed facility dumpsters. Surveyor observed multiple used gloves and pieces of garbage outside the dumpsters. Surveyor observed the dumpster lids to be left open. Assistant Dietary Manager I (ADM) indicated she is not sure who is responsible for picking up the garbage, but can find out. On 6/3/25 at 9:45AM, Maintenance Director H (MD) indicated maintenance is responsible for picking up the area outside the dumpsters. MD H indicated maintenance tries to get out there daily to pick up garbage. MD H indicated the dumpster lids should be closed when not in use. On 6/9/25 at 8:33AM, Nursing Home Administrator A (NHA) indicated the dumpster lids should be closed when not in use and outside area free of garbage. The facility did not ensure garbage and refuse was disposed of properly.

Based on interview and record review, the facility did not ensure grievances and recommendations discussed during resident group meetings (Resident Council) were acted upon promptly for 3 of 3 Supplemental (R23, R21, and R28) and 1 of 1 Sampled Resident (R53). Resident council meeting minutes from March, April, and May of 2025 all include concerns regarding staff using ear buds and cell phones while providing cares. During the resident council meeting with surveyors, R23, R21, and R28 indicated concerns regarding staff using ear buds and cell phones while providing cares. R53 indicated a concern with staff using ear buds and cell phones while providing cares. Evidenced by: The facility policy titled, Resident Council Meetings, date implemented 2/1/25, includes, in part: Policy: This facility supports the rights of residents to organize and participate in resident groups, including a Resident Council. This policy provides guidance to promoting structure, order, and productivity in these group meetings .Policy Explanation and Compliance Guidelines: .7. The facility shall act upon concerns and recommendations of the Council, make attempts to accommodate recommendations to the extent practicable, and communicate its decisions to the Council. Resident Council Minutes provided by the facility, include, in part: March 31, 2025 .Nursing staff on ear buds while doing cares. April 28, 2025 .Staff still on cell phones and ear buds while doing cares. May 28, 2025 .Nursing Staff on ear buds and cell phones while giving med (medications) and cares. On 6/2/25 at 11:35 AM, Surveyors completed the Resident Council meeting. The following resident concerns were voiced regarding staff use of ear buds and cell phones while providing cares: R23 indicated it is happening twice a day. Staff say, Oh, I'm not talking to you, while in the room doing cares. R23 indicated, well, who are they talking to then? R23 indicated it makes him feel mad, that they aren't doing their job, and that they are supposed to be off their phones. R21 indicated it happens 2 to 3 times a week and that It's frustrating. R21 indicated it makes her feel irritated, especially when she's not sure if they're on the phone. R28 indicated they are on their phones the whole time when putting her on the toilet and that it makes her feel frustrated. Surveyors asked residents what the facility has said they are doing to correct this. Residents indicated they say they are going to talk to staff about it. On 6/3/25 at 8:25 AM, Surveyor interviewed R53 as part of the initial screening process. R53 indicated that staff are talking through their ear buds while doing cares and that staff all have phones in their pocket. R53 indicated that it is daily with one staff member and another staff member dispenses meds with ear buds in and it concerns her. Is she talking to another nurse, a doctor, a girlfriend? R53 indicated it makes her feel like she is not being taken care of as good as she should be. On 6/9/25 at 12:45 PM, Surveyor interviewed DON B (Director of Nursing) and reviewed the concerns on the March, April, and May resident council meeting minutes regarding staff use of ear buds and cell phones during cares. Surveyor asked DON B what follow-up had been completed regarding this. DON B indicated when they are notified when it is happening, they go down and tell the staff they aren't to have their ear buds and phone in patient care areas and correct it in the moment. Surveyor asked DON B what follow-up had been done to address the resident council concerns. DON B indicated she would have to look. Surveyor asked DON B if she was aware this had been a resident concern. DON B indicated, yes. On 6/9/25 at 1:37 PM, Surveyors noted the following documents had been left in the conference room: Cell phone and Telephone Policy, Orientation Nutrition Services Education, Guidelines, and Standards, (includes information about cell phone use), and staff education on cell phones/air pods use with attendance records for April 2025. Sticky notes attached indicated there was no PIP (process improvement plan) for cell phones, educate as we see it, and used in orientation for new staff as well. On 6/9/25 at 4:32 PM, Surveyor interviewed DON B and confirmed the education documents provided were completed in April. DON B indicated this was correct. Surveyor asked if they had any follow-up from the May resident council meeting as the ear buds/cell phone use was still listed as a concern. NHA A (Nursing Home Administrator) was present as well and indicated, no, we educate as we see it.

Example 5: On 6/4/25 at 1:56 PM, R329 approached surveyor and indicated she just moved on to her current unit yesterday and indicated, This place is horrible. Surveyor observed R329's room with her and R329 indicated the following concerns: 1. It's filthy and there's a lot of dirt. 2. Behind the bed: The floor is dirty behind the bed, the plaster is peeling in multiple areas on the entire wall, it looks like there is blood on the wall. (Resident referring to a pinkish/red substance on the wall). 3. Behind the door to the room -- there is an oblong shaped hole in the wall and pushed into the hole is a round metal piece that looks like the remains of a door stopper for where the door handle hits. Of note, when the door was opened, the handle lines up to this area. 4. No shower head in the bathroom. 5. Black marks on shower floor surrounding. 6. Light above sink not working. 7. [NAME] substance on the outside of the wastebasket in the bathroom of which R329 indicated, That's disgusting. On 6/4/25 at 4:16 PM, Surveyor interviewed CNA Q (Certified Nursing Assistant) in R329's room. Surveyor observed the areas above and reviewed R329's concerns with CNA Q. Surveyor asked CNA Q if she would want her home to look like this and if she would consider it homelike. CNA Q indicated, no and that the room would not be considered homelike. Based on observation, interview, and record review, the facility failed to ensure all residents have a homelike environment for 3 of 3 sampled residents (R46, R47, R12) and 2 of 2 supplemental residents (R329 and R40). Surveyor observed environmental concerns. R47 voiced concerns about the environment. R46 voiced concerns regarding cleanliness of bedroom. R12's floor was sticky. R40 voiced concerns regarding the cleanliness of their bedroom. R329 voiced concerns regarding the cleanliness of bedroom. Evidenced by: The facility provided Surveyor a cleaning checklist that is utilized. Checklist states, in part; .Thorough Cleaning Procedure, .Clean doors and door frames .Wall Washer all areas from ceiling to floor .Clean all vertical furniture and cabinets .Dust mop floor and move all items .Wet mop floors .Bathroom: wash sink with cream cleanser, clean pipe's under sink and toilet, clean mirrors, clean counter tops, medicine cabinets, and above lights, clean cabinets, clean all towel racks, clean inside and out and refill all dispensers, clean toilet top to bottom, clean all handrails, wipe down call light and light switches, clean baseboards, sweep and mop . Example 1 On 6/2/25 Surveyor observed the 200 hallway. Surveyor observed a dark substance dried on the floor and wrappers from food on the common area floor. Surveyor observed this as well at the end of the day on 6/2/25. Surveyor observed black marks and missing paint on the common area walls. On 6/4/25 at 8:32 AM, Surveyor observed HSK P (Housekeeper) cleaning common area cupboards. Surveyor observed black colored water running down the cupboards. Surveyor asked HSK P how often common areas are cleaned at the facility? HSK P stated, Daily. On 6/4/25 at 1:19 PM, Surveyor observed Housekeeping cleaning bedrooms on 200 hallway. Surveyor observed Housekeeper in R47's bedroom with cleaning supplies. Surveyor asked R47 if housekeeping was in room and cleaned room today. R47 indicated housekeeping was in bedroom and didn't clean very well. R47 told Surveyor to look in bathroom. Surveyor observed garbage on the floor, a full garbage bin, and a white powder on bathroom floor. R47 indicated housekeeping did not sweep or mop anything and that it is frustrating. Example 2 R46 was admitted to the facility on [DATE] with a diagnoses including chronic respiratory failure, chronic pain, depression, anxiety, and muscle weakness. R46 most recent Minimum Data Set (MDS) dated [DATE] indicates R46 has a Brief Interview for Mental Status (BIMS) of 14 indicating R46 is cognitively intact. On 6/2/25 at 11:07 AM, R46 indicated she sees housekeeping staff around the facility, but the facility still isn't clean. R46 indicated the floors are dirty. R46 indicated her bedroom floor is filthy and that there are always little bugs flying around. Surveyor observed dark dried substance on R46's bedroom floor and splatters of light brown substance on R46's bedroom wall. R46 indicated she doesn't know what the splatters are and that they have been there. R46 indicated her granddaughter said she can't believe that R46 uses her bathroom because it's always so dirty. Surveyor observed the garbage bin overflowing with garbage in bathroom and the toilet and bathroom floor was visibly dirty. Surveyor asked R46 about the dings and marks on walls. R46 indicated the dings, marks, and missing paint was there when she arrived. R46 indicated there are times she will get a Kleenex wet and try to clean up her bedroom. R46 indicated she doesn't understand why it's always so dirty. On 6/4/25 at 3:46 PM, MNT J (Maintenance) indicated the 500 hallway was remodeled last fall and that they fixed the dings on the walls, black scuff marks, patched holes, and painting was done at that time for 500. MNT J indicated they will be eventually getting to the 200 hallway. Maintenance J indicated there are always projects and things coming up that need to be done, so for 200 it's more about finding the time to complete it. On 6/5/25 at 10:35 AM, HS K (Housekeeping Supervisor) indicated she has three staff on during the day and one staff is specifically assigned to cleaning floors. HS K indicated it is expected that housekeeping cleans every bedroom every day. HS K indicated this includes: cleaning toilets, emptying garbage, cleaning mirrors, deep cleaning bathrooms, and sweeping and mopping bedroom and bathrooms. HS K indicated this also includes restocking all bathroom supplies. HS K indicated there are two staff at the facility on the weekends as well. HS K indicated it is expected that staff deep clean bedrooms and common area. HS K indicated if there are splatters on the walls staff should wipe down walls. Surveyor shared with HS K observations and resident concerns. HS K indicated understanding of the concerns. On 6/9/25 at 8:33 AM, NHA A (Nursing Home Administrator) indicated she would expect the environment to be homelike. NHA A indicated she would expect bedrooms and common areas to be clean. The facility failed to ensure all residents have a homelike and comfortable environment. Example 3 On 6/5/25 at 10:56 AM, Surveyor was called into R40's room. R40 pointed to her wall and stated that the black marks on her wall were in her room before she moved in, and that the facility has still not cleaned them. R40 indicated to Surveyor that she wanted her walls cleaned. Surveyor observed multiple circular, black marks across the wall near R40's door. Example 4 On 6/3/25 at 9:15 AM, Surveyor entered R12's room. As Surveyor was walking across R12's room, Surveyor noted the floor to be excessively sticky. As Surveyor approached R12's bed, Surveyor's left shoe stuck to the ground and Surveyor's shoe was pulled off her foot due to the stickiness of the floor.

Example 4 R46 admitted to the facility on [DATE] with diagnoses including anxiety. R46's physician orders, dated 6/5/25, include Lorazepam 0.5 mg every 6 hours as needed . for 6 months. Monitor for s/s (signs and symptoms) of anxiety; update MD/NP (Medical Doctor/Nurse Practitioner) for worsening symptoms. R46's Certified Nursing Assistant (CNA) Kardex (CNA care plan), printed 6/5/25, does not include monitoring or interventions related to R46's anxiety. R46's comprehensive care plan, printed 6/5/25, states in full, for R46's anxiety disorder: Focus: The resident has an active order for anti-anxiety medication(s) use anxiety disorder Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer Anti-anxiety medications as ordered by physician. Monitor/document/report PRN (As Needed) any adverse reactions to anti-anxiety therapy: Drowsiness, lack of energy, clumsiness, slow reflexed, Sslurred [sic] speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinati [sic] On 6/5/25 at 3:10 PM, Surveyor interviewed CNA F regarding R46's anxiety. CNA F indicated behaviors and interventions for residents are located on the CNA Kardex and on the computer in the electronic health record. CNA F indicated R46 has anxiety. CNA F indicated R46 won't sit still, won't stay in her room, fidgets a lot and will jump from task to task when she is feeling anxious. Of note, these behaviors are not listed in R46's comprehensive care plan or on the CNA Kardex and there are no interventions listed. On 6/5/25 at 2:22 PM, Surveyor interviewed MT FF (Medication Tech; a CNA that can administer medications) regarding residents with behaviors of anxiety. MT FF stated he gives PRN (As needed) medication for agitation and restlessness. Example 5 R57 admitted to the facility on [DATE] with diagnoses including dementia with agitation and aphasia (a language disorder that affects a person's ability to communicate). R57's physician orders, printed on 6/5/25, includes Quetiapine Fumarate 25 mg at bedtime for dementia related agitation R57's CNA Kardex, printed 6/5/25, does not include monitoring or interventions for R57's agitation. R57's comprehensive care plan does not include monitoring or tracking of R57's agitation. On 6/5/25 at 2:22 PM, Surveyor interviewed SW CC (Social Worker) regarding R57's agitation. SW CC indicated R57 has a hard time getting the words out when she tries to speak and becomes frustrated. SW CC was unable to elaborate what behaviors R57 exhibited when becoming agitated. On 6/5/25 at 2:28 PM, Surveyor interviewed CNA Q regarding R57's agitation. CNA Q indicated R57 can become agitated and will throw things at staff and when in bed will hang the top half of her body off the bed. Of note, R57's comprehensive care plan and CNA Kardex does not include these behaviors that R57 exhibits when becoming agitated. Based on record review and interview, the facility must ensure each resident is free from unnecessary drugs as evidenced by completing adequate drug monitoring for 5 of 5 residents (R16, R38, R7, R57, and R46) reviewed for unnecessary medication reviews. The facility is not monitoring resident-specific targeted behaviors for R16's psychotropic medication use. There is no evidence the facility is tracking targeted behaviors to assess the therapeutic effects of the psychotropic medications and ensure R16 is receiving the desired benefits and lowest possible dose. R16 has no nonpharmacological interventions documented to use when displaying targeted behaviors. R38 does not have nonpharmacological interventions documented in her plan care. R7 does not have nonpharmacological interventions documented in her plan care. R46 does not have resident-specific targeted behavior monitoring or nonpharmacological interventions. R57 does not have resident-specific targeted behavior monitoring or nonpharmacological interventions. This is evidenced by: Facility policy titled Baseline Care Plan, dated 2/1/25, states in part: Policy: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care . Policy Explanation and Compliance Guidance: 2.b. Interventions shall be initiated that address the resident's current needs including: . ii. Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living . Facility policy titled Use of Psychotropic Medication(s), dated 2/1/25, states in part: Policy: It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated . Policy Explanations and Compliance Guidance: 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics . 5. The indications for initiating, maintaining, or discontinuing medications, as well as the use of nonpharmacological approaches, will be determined by evaluating the resident's physical, behavioral, mental, psychosocial signs and symptoms in order to identify and rule out any underlying medical conditions, including the assessment of relative benefits and risks, and the preferences and goals for treatment. 6. Nonpharmacological approaches must be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest dose, or discontinue the medications. 7. The resident's medical record shall include documentation of this evaluation and the rationale for chosen treatment options . Example 1 R16 was admitted on [DATE] with diagnoses that include Other Recurrent Depressive Disorders, Generalized Anxiety Disorder, Insomnia due to Other Mental Disorder, Depression unspecified, anxiety disorder unspecified, and Insomnia unspecified. R16's Physician Orders include, in part: --buPROPion HCl ER (XL) Oral Tablet Extended Release 24 Hour 150 MG (Bupropion HCl) Give 1 tablet by mouth one time a day for Depression Document if resident voicing feeling sad/lonely. Start Date: 7/11/24. --busPIRone HCl Oral Tablet 15 MG (Buspirone HCl) Give 1 tablet by mouth two times a day for Anxiety Document if resident is having s/s (signs/symptoms) of anxiety. Start Date: 7/11/24. --Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour 75 MG (Venlafaxine HCl) Give 3 capsule by mouth one time a day for Depression Document if resident voicing feeling sad/lonely. Start Date: 7/12/24. R16's Care Plan dated 7/12/24, states in part: --Focus: The resident has a mood problem r/t (related to) depression, insomnia due to other mental disorder, Generalized anxiety, and other recurrent depressive disorders. --Goal: The resident will have happier mood state with no s/x (symptoms) of depression through the review date. --Intervention: Administer medications as ordered. Resident takes Effexor and Wellbutrin as current to for depression. Resident takes Buspar for anxiety. Monitor/document for side effects and effectiveness. Intervention: Administer sleep aid (melatonin) as ordered by NP/MD (Nurse Practitioner/Medical Director). --Intervention: Resident aware of psych and talk therapy services but not interested at this time. Of note: R16's Certified Nursing Assistant (CNA) Care Kardex, printed 6/5/25, does not include targeted behavior monitoring related to R16's depression or anxiety or nonpharmacological interventions when R16 displays targeted behaviors. On 6/5/25 at 2:33 PM, Surveyor interviewed CNA Q (Certified Nursing Assistant) regarding R16's depression and anxiety. CNA Q indicated that R16 does not have much anxiety but that she does have depression. CNA Q stated that R16 sometimes gets down about her past and how she wishes she could be out in the world instead of in the facility. Surveyor asked CNA Q what interventions were in place when R16 was feeling depressed. CNA Q stated that she tries to bring her to activities because she likes to talk to her friends and that gets her feeling better. Surveyor asked CNA Q if she charts in the electronic medical record when R16 is feeling anxious or depressed. CNA Q indicated that she will just let the nurse know. Surveyor asked CNA Q if she is aware of any behavior monitoring for R16 or if she had received any education on behavior or psychotropic medication monitoring for R16 or other residents. CNA Q stated she is not aware of behavior monitoring for R16 and has never received training on that. On 6/5/25 at 2:36 PM, Surveyor interviewed MT FF (Medication Technician) regarding how he would monitor the effectiveness of R16's medication for her anxiety and depression. MT FF stated that for R16 he would be monitoring for a loss of consciousness. Surveyor asked MT FF what he would do if R16 displayed signs of anxiety or depression. MT FF stated that he would give a PRN (as needed) medication such as lorazepam. MT FF stated he has never seen R16 depressed. Example 2 R38 was admitted to the facility on [DATE] with diagnoses that include, in part, Unspecified Dementia, unspecified severity, with other behavioral disturbance, Major Depressive Disorder, recurrent, unspecified, adjustment disorder with depressed mood, and anxiety disorder, unspecified. R38's Physician Orders include, in part: --Fluoxetine HCl Oral Capsule 20 MG (Fluoxetine HCl) Give 1 capsule by mouth one time a day for depression monitor for depression: update MD/NP for worsening symptoms. Start Date: 2/21/25. R38's Care Plan dated 7/12/24, states in part: --Focus: The resident has an active order for antidepressant medication for Depression and adjustment disorder with depressed mood. --Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. --Intervention: Administer ANTIDEPRESSANT medications as ordered by physician. --Intervention: Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms. --Intervention: Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL (activities of daily living) ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs (problems), movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt. (weight) loss, n/v (nausea/vomiting), dry mouth, dry eyes. --Focus: The resident has an active order for anti-anxiety medication for anxiety disorder --Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. --Intervention: Administer ANTI-ANXIETY medications as ordered by physician. --Intervention: Monitor for S/S of patient hoarding items or statements that she is feeling anxious. --Intervention: Monitor the resident for safety. The resident is taking ANTI-ANXIETY meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips and legs --Intervention: Monitor/document /report PRN any adverse reactions to ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, Sslurred (sic) speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, hallucinati (sic). --Intervention: Monitor/record occurrence for target behavior symptoms Reports of anxiety/restlessness, Resistive to cares and document per facility protocol. --Focus: The resident has a mood problem r/t diagnosis of depression, anxiety --Goal: The resident will have improved mood state (happier, calmer appearance, no s/sx of depression, anxiety or sadness) through the review date. --Intervention: Administer medications as ordered. --Intervention: Monitor/document for side effects and effectiveness --Intervention: Assist the resident, family, caregivers to identify strengths, positive coping skills and reinforce these . Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.) R38's CNA Care Kardex, printed 6/5/25, states, in part: monitor for s/s (signs and symptoms) of patient hoarding items or statements that she is feeling anxious . Monitor/document/report PRN (as needed) adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL (activities of daily living) ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs (problems), movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt. (weight) loss, n/v (nausea/vomiting), dry mouth, dry eyes . On 6/5/25 at 2:23 PM, Surveyor interviewed LPN O (Licensed Practical Nurse) regarding R38's anxiety and depression. LPN O stated that R38 is a very outgoing person, so they monitor if she is staying in her room or staying in bed. Surveyor asked LPN O how R38's anxiety is displayed. LPN O stated that R38 will ask repetitive questions, such as she likes to get her medications at a certain, routine time. LPN O stated that R38 will constantly come up to her and ask about her medications, even 20 minutes before the one-hour administration window. LPN O indicated that R38 is like that every time she works with her. Surveyor asked LPN O what nonpharmacological interventions work for R38's anxiety and depression. LPN O stated that going outside helps R38 and that she enjoys feeding the birds. Surveyor asked LPN O where R38's anxiety and depression monitoring were being documented. LPN O stated that they would enter a progress note into the electronic medical record if R38 was having those behaviors or not, but since R38 has these anxious behaviors daily, they were not documenting on that. Of note, R38's comprehensive care plan does not include these resident specific behaviors that R38 exhibits when anxious, nor are the nonpharmacological interventions included anywhere in R38's medical record. Example 3 R7 was admitted to the facility on [DATE] with diagnoses that include, in part: Alzheimer's Disease unspecified, Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Insomnia due to other mental disorder, and Major depressive disorder, recurrent, mild. R7's Physician Orders include, in part: --Abilify Oral Tablet 2 MG (Aripiprazole) Give 2 tablet by mouth in the morning for dementia with agitation 4mg; monitor for s/s of agitation, notify NP/MD. Start Date: 5/9/25. --Trazodone HCl Oral Tablet 50 MG (Trazodone HCl) Give 25 mg by mouth at bedtime for insomnia. Start Date: 12/3/24. R7's Care Plan, dated 11/22/19, includes, in part: --Focus: The resident has impaired cognitive function/dementia or impaired thought processes r/t Dementia and Parkinson's. --Goal: The resident will be able to communicate basic needs on a daily basis through the review date. --Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. --Intervention: Communicate with the resident/family/caregivers regarding resident's capabilities and needs --Intervention: Cue, reorient and supervise as needed --Intervention: Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. --Intervention: Monitor for s/s of agitation; Notify NP/MD --Intervention: Monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. --Intervention: Present just one thought, idea, question or command at a time. --Focus: The resident has depression. --Goal: The resident will exhibit indicators of depression, anxiety or sad mood less than daily by review date. --Goal: The resident will remain free of s/sx of distress, symptoms of depression, anxiety or sad mood by/through review date --Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness --Intervention: Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness --Intervention: Monitor/document/report PRN any s/sx of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. making comments of not wanting to be alive anymore. resident voiced feeling sad and/or lonely each shift, refusing to get out of bed, refusing medications, or statements of wanting to die. R7's CNA Care Kardex, printed 6/5/25, states, in part: Monitor for s/s of anxiety, tremor, seizure activity, and terminal restlessness . Monitor/document/report PRN any s/sx of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. making comments of not wanting to be alive anymore. resident voiced feeling sad and/or lonely each shift, refusing to get out of bed, refusing medications, or statements of wanting to die. On 6/5/25 at 2:29 PM, Surveyor interviewed LPN O regarding R7's anxiety and depression. LPN O stated that R7 tends to yell out a lot, he will cuss a lot, say inappropriate words to the staff, and calls them names. LPN O stated that R7 wants a Pepsi right away and when he finishes that one, he wants another one right away and if he doesn't get it, he starts yelling out. Surveyor asked LPN O what interventions work for R7 when he is agitated and yelling out. LPN O stated that they let him calm down give him space, and that he likes to have the TV on. Surveyor asked LPN O how often R7 was having these behaviors. LPN O stated pretty much every day because he has some memory issues too. LPN O indicated that R7 will yell out to get in the chair and then 2 minutes later he will yell out to go back to bed. Surveyor asked LPN O where R7's anxiety and depression monitoring were being documented. LPN O stated that they would enter a progress note into the electronic medical record, but because R7 has these anxious behaviors daily, they were not documenting on that. Of note, R7's comprehensive care plan does not include these behaviors that R7 exhibits when anxious, nor are there nonpharmacological interventions included anywhere in R7's medical record. On 6/5/25 at 2:55 PM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding personalized interventions and monitoring of resident behaviors. Surveyor asked NHA A whether specific behaviors that residents have should be included in their plan of care. NHA A stated it depended on a case-by-case basis. Surveyor asked NHA A whether a resident's specific behaviors should be monitored and documented in the electronic health record. NHA A stated that if a resident exhibits any behaviors, the nurse should put in a progress note. Surveyor asked NHA A if the care plans should be resident specific. NHA A indicated yes, on a case-by-case basis.

Based on observation, interview, and record review, the facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident this affected 4 of 23 Residents (R57, R46, R67, and R56) reviewed for activities. Surveyor observed R57, who needs assistance to/from structured leisure activities, not being provided activities. The facility failed to ensure R46's activity care plan is meaningful, personalized, and had measurable goals. R56's Comprehensive Care Plan does not contain an activities care plan. R67's Comprehensive Care Plan does not actually list any Resident specific preferred activities. Evidenced by: The facility policy, Activities, dated 2/1/25, states, in part; .It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community .2. Activities will be designed with the intent to: a. Enhance the resident's sense of well-being, belonging, and usefulness. b. Create opportunities for each resident to have a meaningful life. c. Promote or enhance physical activity. d. Promote or enhance cognition. e. Promote or enhance emotional health. f. Promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence. g. Reflect resident's interest and age. h. Reflect cultural and religious interests of the residents. i. Reflect choices of the residents . Example 1: R57 was admitted to the facility on [DATE] with a diagnoses including dementia with agitation, respiratory failure, kidney disease, depression and cognitive communication deficit. R57's most recent Minimum Data Set (MDS) dated [DATE] indicates R57 has a Brief Interview for Mental Status (BIMS) score of 01 which indicates R57 is severely cognitively delayed. R57 has an activated power of attorney. R57's Comprehensive Care Plan, states, in part; .ACTIVITIES: The resident's activity involvement is limited as a result of: cognitive impairment secondary to Alzheimer's disease or a related dementia .The resident will be invited to all activities to observe or/and participate in appropriate activities .Provide activity programming consistent with physical and psychosocial abilities. This includes: energy level, cognitive functioning, medical condition and mood/behavior patterns . R57's activity participation documentation for April 2025-current, states, in part; .APRIL 2025: bingo 5x, music/entertainment 1x, movie/tv 1x, and dancing/exercise 1x. MAY 2025: movies/tv 7x, bingo 5x, exercise 1x, lobby/lounge 1x, 1:1 2x. JUNE 2025: bingo 1x, bible study 1x, 1:1 2x. On 6/2/25, Surveyor observed R57 sitting at table in broda chair with no activities, conversation, or stimulation offered. R57 sat in the same spot from 10:57 AM - 3:50 PM. Surveyor observed R57's head down at the table at 2:00 PM. On 6/3/25, Surveyor observed R57 from 10:23 AM - 12:23 PM, 1:00 PM - 3:30 PM sitting at a table in broda chair with no activities, conversation, or stimulation offered. On 6/4/25, Surveyor observed R57 sitting at table in broda chair with no activities offered. Surveyor observed on 6/4/25 at 1:39 PM activity staff discussing if R57 should go to bingo. LPN R (Licensed Practical Nurse) stated, She's literally been sitting here with nothing to do. She likes bingo. Surveyor observed activities staff assist R57 to bingo. This was the first activity Surveyor observed R57 being assisted to from 6/2/25-6/4/25. Example 2: R46 was admitted to the facility on [DATE] with a diagnoses including chronic respiratory failure, dementia, chronic pain, depression, anxiety, muscle weakness, abnormalities of gait and mobility, and cognitive communication deficit. R46 most recent Minimum Data Set (MDS) dated [DATE] indicates R46 has a Brief Interview for Mental Status (BIMS) of 14 indicating R46 is cognitively intact. R46's Comprehensive Care Plan, states, in part; .ACTIVITIES The resident is functioning at a reasonably independent level concerning leisure pursuits. The resident is alert, sufficiently oriented and coherent, able to express her needs. The resident currently engages in the following leisure/recreation pursuits: Television, movies. The resident will assist the activity department in planning the next month's program through the next review. Provide activity program consistent with physical and psychosocial abilities. Help the resident monitor energy level and recognize over-activity as well as under-activity. R46's activity participation documentation from April 2025-current, states, in part; .APRIL 2025: dancing/exercising 2x, music/entertainment 3x, bingo 1x, and discussion 1x. MAY 2025: electronics 2x, movies 3x, music 1x, nail care 2x, discussion 3x, exercise 1x, pet therapy 1x, and snack time 2x. JUNE 2025: electronics 2x, bingo 1x, and discussion 2x. On 6/4/25 at 1:12 PM, R46 came out of bedroom and stated, There is nothing to do. R46 indicated she would like more variety of activities. On 6/5/25 at 8:17 AM, AD T (Activity Director) indicated when a resident first comes to the facility she will complete activity assessment and then invite resident to scheduled activities. AD T indicated for the residents who are not able to verbally share what they enjoy doing and need more assistance in structuring their day staff will assist them to activities. AD T indicated she has been at the facility for a couple years, so she knows what the long term residents enjoy doing. AD T indicated they complete the activity care plan and document activity attendance and participation on their computer system. AD T provided Surveyor with an activity care plan and activity participation. On 6/5/25 at 11:06 AM, AD T indicated she feels R57's activity care plan is personalized. Surveyor asked AD T if a new staff is reading R57's activity care plan can they tell what her activity goals are, activities she enjoys, and what is most important to her? AD T indicated staff can go down and talk to R57 and ask. AD T indicated R57 may get anxious at larger activity events. AD T indicated R57 enjoys bingo a lot. Surveyor and AD T reviewed R57's activity participation. Surveyor indicated if R57 doesn't enjoy larger group activities could an activity aide come to R57? AD T indicated activity staff could come to R57. AD T indicated understanding on creating a personalized activity care plan for residents. On 6/9/25 at 8:33 AM, NHA A (Nursing Home Administrator) indicated she would expect activity care plans to be personalized for each resident. NHA A indicated she would expect residents to be offered activities and activities tailored to residents needs and preferences. The facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. Example 3: R56 was admitted to the facility on [DATE] with diagnoses that include, in part: vascular dementia, dysphagia (difficulty swallowing), epilepsy (seizure disorder), muscle weakness (generalized), and abnormal posture. R56's most recent Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 5/20/25 indicates R56 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating severe cognitive impairment. R56's Comprehensive Care Plan states, in part: Focus: The resident has impaired cognitive function and impaired thought process r/t (related to) impaired decision making (cerebral Infarction (Stroke) and vascular dementia) Goal: The resident will be able to communicate basic needs on a daily basis through the review date Interventions: Ask yes/no questions in order to determine the resident's needs Communicate with the resident/family/caregivers regarding residents capabilities and needs Cue, reorient and supervise as needed (Of note: R56's Comprehensive Care Plan does not contain an activities care plan) R56's most recent activities evaluation, dated 5/18/25 states, in part that R56 currently participates in one to one activities with the beauty/barber activity, family and friend visits, movies, music, and religious services. The section titled, Leisure Routines and Other Preferences indicates R56 participates in 0-1 activities per week and 0-3 per month. In the section titled, Comments, it indicates the resident needs encouragement to attend activities. Surveyor reviewed R56's activity participation from 4/11/25 to 6/5/25. During this time period, R56 participated in 14 self-directed activities labeled Movies/TV, 4 1:1 (one to one) activities labeled Manicure/Spa, and one group activity labeled, Conversation on 5/9/25. This equals 19 total activities over a span of 56 days. It is important to note the documentation does not state how long R56 participated in activities and if the resident enjoyed the activity. On 6/9/25 at 11:59 AM, Surveyor interviewed AD T (Activities Director). Surveyor asked AD T if she is aware of any of R56's activity preferences. AD T indicates R56 enjoys watching TV and getting her nails done, as well as occasionally liking to color. AD T also indicates R56 is very content to lay and watch TV. Surveyor asked AD T if she would expect to see these things on R56's care plan. AD T indicates she is not sure. R56's Comprehensive Care Plan does not contain an activities care plan Example 4: R67 was admitted to the facility on [DATE] with diagnoses that include: progressive supranuclear ophthalmoplegia (degenerative neurological disorder that affects movement, balance, and eye control), dementia with other behavioral disturbance, acute and chronic respiratory failure with hypoxia (low oxygen levels), and cognitive communication deficit. R67's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/12/25 indicates a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. Section GG indicates R67 has impairment on both sides of his upper and lower extremities.R67 requires substantial/maximal assistance with toileting hygiene, showering/bathing, lower body dressing, and putting on/taking off footwear. Section GG also indicates R67 requires partial/moderate assistance with rolling left and right, moving from sitting to lying, and lying to sitting on the side of the bed. Additionally, R67 requires substantial/maximal assistance with moving from sitting to standing, transferring between a chair and a bed, transferring to a toilet, and transferring to a tub or shower. R67's Comprehensive Care Plan states, in part: Focus: The resident's activity involvement is limited as a result of: Cognitive impairment secondary to Alzheimer's disease or a related dementia. Goal: The resident will participate in staff initiated in-room as well as giving him rides around facility when requested activity 5 days per week through the next review. Interventions: Develop an activity plan centering around the resident's interest and history that take lifetime values, attitudes, leisure patterns and psychosocial well-being into consideration. (Of note: R67's Comprehensive Care Plan does not actually list any Resident specific preferred activities) R67's most recent Activities Evaluation, dated 3/7/25, indicates R67 likes to participate in Animal/Pets activities, family/friend visits, sports, and television activities. This evaluation also indicates R67 participates in zero activities per week and zero per month. R67's Activity Documentation shows that from 4/3/25 through 6/9/25, R67 participated in 14 self-directed activities labeled Movies/TV with one labeled Other/See Progress Note, 9 1:1 activities labeled Snack Time, Discussion/Current Events, and Movie/TV, and 6 group activities labeled, Conversation, Lobby/Lounge, Exercise/Fitness/Dancing, Exercise/Action Games, Dancing/Exercise, and Music/Entertainment. This totals to 29 activities over 68 days. On 6/9/25 at 11:59 AM, Surveyor interviewed AD T (Activities Director). Surveyor asked AD T if she is aware of any of R67's activity preferences. AD T indicates R67 likes to watch people on his pod, people watch, go for walks, and family visits. AD T also indicates R67 doesn't care to stick around for activities, but rather will start to roam around. Surveyor asked AD T if she would expect to see these things on R67's care plan. AD T indicates, the walking, roaming, and watching tv are on his care plan. Surveyor advised AD T that they are being told by staff that R67 likes listening and watching Elvis on the tablet. Surveyor asked AD T if she would expect that to be on R67's care plan. AD T indicated no because AD T is not aware of that so she cannot verify it.

Based on observation, interviews, and record review, the facility failed to ensure 1 of 5 residents (R2) reviewed for abuse was free from sexual abuse. The facility did not ensure R2 was free from sexual abuse by another resident (R4). On 12/4/23, CNA (Certified Nursing Assistant)-D observed R4 kissing R2 on the lips and requesting R2 to open her mouth so that he could stick his tongue in it and putting his hand on R2's groin. The facility investigation which included police involvement revealed R2 did not consent to R4's sexual behavior. During Surveyors' investigation, R2 became agitated to questions posed regarding R4 and indicated she was fearful of R4 with R4 aggravating her and entering her room on 12/18/23 after the incident of sexual abuse occurred on 12/4/23. The facility investigation includes information to demonstrate the facility was aware of R4's history of touching R2 in the past that was not addressed. Statements from Nursing Home Administrator (NHA)-A as part of the investigation indicate: The police officer spoke with R2 and NHA-A. NHA-A indicated she was present during police questioning R2 due to R2 only being able to answer yes or no questions. R2 indicated to the police officer that R4 kissed her and R2 did not give consent. The police officer asked R2 if this has happened before and R2 said yes. NHA-A explained to the police officer that it did happen a long time ago. The police officer then asked if anything happened before 12/4/23 incident and R2 stated yes and got visibly upset. NHA-A then asked if R4 touched her arm and R2 said no. NHA-A asked if R4 touched R2's leg and R2 grabbed NHA-A's hand and moved NHA-A's hand toward R2's groin. NHA-A asked R2 if R4 touched her groin and R2 stated yes. R2 returned to the facility common area to eat after meeting with police. Facility records indicate in behavioral meeting notes dated 9/12/19 R4 had a history of sexually inappropriate behavior. An initial psychological evaluation dated 9/15/22 indicates R4 has a history of inappropriate sexual behavior. Additionally, a care plan indicated (name of resident) has an active order for psychotropic medication(s) use behavior management related to unspecified psychosis bizarre behaviors - Initiated 4/20/22. Interventions include monitor/record occurrence for target behavior symptoms of inappropriate sexual comments towards staff/others and document per facility protocol - Initiated 4/20/22, revised 2/1/23. The facility had an awareness of R4's likelihood to engage in sexually inappropriate behavior and did not take steps to prevent it from occurring. The facility's failure to ensure R2, a vulnerable adult who is unable to verbalize other than answering yes and no to questions posed, and who is unable to protect herself due to her limited mobility and dexterity issues, was free from sexual abuse and protect other residents from abuse created a reasonable likelihood for serious harm, thus leading to a finding of Immediate Jeopardy that began on 12/4/23. Surveyor notified NHA (Nursing Home Administrator)-A, DON (Director of Nursing)-B, and Regional Clinical Operations-C of the immediate jeopardy on 12/20/23 at 10:24 AM. The immediate jeopardy was removed on 12/20/23, however the deficient practice continues at a scope and severity level of E (potential for harm/pattern) as the facility continues to implement and monitor their removal plan. Findings include: Surveyor reviewed the facility's undated Abuse Policy provided to Surveyor on 12/18/23 and noted the following as applicable: 1. The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. The facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. 2. This will be done by: a. Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; b. Identifying occurrences and patterns of potential mistreatment; c. Immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; d. Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences. 3. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault (42 CFR 483.12 Interpretive Guidelines). Non-consensual sexual contact of any type with a resident. (42 CFR 483.5 Interpretive Guidelines) The facility will take steps to ensure residents are protected from abuse, including evaluating the resident's capacity to consent to sexual activity, anytime that the facility has reason to suspect that the resident my lack the capacity of consent. 4. The facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following: a. Resident Assessment: As part of the resident's life history on the admission assessment, comprehensive care plan and MDS (minimum data set) assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment or misappropriation of resident property, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis, and update the necessary. The facility will revise the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. 5. The facility will take steps to prevent potential abuse while the investigation is underway. a. Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of residents including, but not limited to, the separation of the residents, preserving the integrity of the investigation, increased supervision of the victim (s), protection from retaliation, examination of the victim, room and staff changes needed for protection and provision of emotional support and or counseling to the resident as needed. The facility will revise the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. The facility will apply the reasonable person concept to evaluate the severity of psychosocial outcomes in cases of abuse. The staff will apply the reasonable person concept in determining the psychosocial outcome or potential outcome that an event may have caused. On 12/18/23, Surveyor initiated an investigation of an allegation of sexual abuse between R2 and R4. On 12/19/23 at 1:10 PM, Surveyor observed R2's bed made and unoccupied. R2 was not in her room. R2's roommate was lying in bed and was unable to verbalize to Surveyor where to locate R2. Throughout the survey process, Surveyor observed R2 independently getting around in her wheelchair within the facility and spending the majority of her time outside of her room. On 12/19/23 at 1:14 PM, Surveyor observed R4 in his bed with the curtains pulled and wheelchair next to his bed. Throughout the survey process, Surveyor observed R4 independently getting around the facility in his wheelchair spending time both in his room as well as in common areas of the facility. On 12/19/23, Surveyor noted both R2 and R4 reside on the same unit. R2's room is located at the beginning of the unit hallway and R4 must pass by R2's room when leaving the unit. Surveyor reviewed R2's medical record which indicated in part: R2 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis, cerebral infarction, vascular dementia, aphasia following cerebral infarction, spastic hemiplegia affecting right dominant side, and dysphagia. R2 is her own decision maker. R2's quarterly Minimum Data Set (MDS) dated [DATE] indicates a BIMS (Brief Interview for Mental Status) score of 13, which indicates intact cognition. It also indicates R2 requires assistance due to functional limitations to bilateral lower extremities and one upper extremity. The MDS also indicates that R2 has clear speech, she is sometimes able to make herself understood, and sometimes can understand others. R2's comprehensive care plan contains the following significant focused problems with interventions: 1. R2 chooses to exercise their right to engage in an intimate/sexual activity with another resident. R2 does have a fiance who visits facility- Initiated 12/11/23, revised 12/11/23. Surveyor noted this care plan of engaging in intimate/sexual activity was initiated after the 12/4/23 sexual abuse allegation. R2 confirmed with surveyor she has boyfriend outside of facility and does not have intimate/sexual relationship with another resident in facility. -Interventions include: Instruct resident to verbalize any concerns and provide the resident a safe place to verbalize concerns, issues or changes in desires - Initiated 12/11/23. Surveyor notes R2 is unable to verbalize concerns without being prompted with yes or no questions. Surveyor also notes this care plan intervention was initiated after 12/4/23 sexual abuse allegation. 2. R2 enjoys friendship with others. Will hold hands with male resident and male resident will kiss her hand - Initiated 11/17/20, revised 12/11/23. Surveyor noted this care plan does not identify who the male resident is and facility is unable to tell surveyor who the male resident is. -Goals include R2 will enjoy quality of life that comes from forming close friendships with others; will have no adverse effects - Initiated 11/17/20, revised 8/29/23 -Interventions include monitor R2's interactions with male residents to ensure that physical contact is appropriate - Initiated 11/17/20, revised 2/1/23; re-direct as needed and notify nurse/nurse practitioner if displays of affection become inappropriate or bothersome to others - Initiated 11/17/20, revised 2/1/23. 3. R2 has a communication problem related to aphasia after cerebral vascular accident - Initiated 9/24/20, revised 9/24/20. -Goals include R2 will maintain current level of communication function using gestures, responding to yes/no questions appropriately - Initiated 9/24/20, revised 8/29/23 -Interventions include: allow adequate time to respond, repeat as necessary, do not rush, request clarification from R2 to ensure understanding, face when speaking, make eye contact, turn off tv/radio to reduce environmental noise, ask yes/no question, use simple brief, consistent words/cues, use alternative communication tools, communication board as needed - Initiated 9/24/20, revised 8/22/22. Surveyor noted R2 is only able to speak the words yes or no and conversation is driven by the person asking questions for R2 to answer yes or no. R2 was unable to speak any additional words to surveyor throughout the survey. An assessment for consent for physical/sexual/intimate expressions dated 12/11/23 was performed on R2. This assessment was performed after the 12/4/23 sexual abuse allegation even thought there was a care plan initiated on 11/17/2020 regarding R2 holding hands and allowing a male resident to kiss her hand. The facility was unable to provide previous assessments for consent for physical/sexual/intimate expressions for R2. Surveyor interviewed R2 on 12/19/23 at 1:47 pm; R2 had a hard time expressing her thoughts. R2 was only able to respond to yes or no questions which were prompted by Surveyor. Surveyor reviewed R4's medical record which indicated in part: R4 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, alcohol dependence, impulsiveness, cognitive communication deficit, psychosis, and opioid abuse. R4 is his own decision maker. R4's quarterly MDS dated [DATE] indicates R4 has a BIMS score of 15, which indicates R4 is cognitively intact. It also indicates R4 is independent of transferring, locomotion on and off the unit, dressing, eating, and toileting. R4 requires assistance of 1 with bathing. R4 uses a wheelchair independently and has impairment of one upper extremity. The MDS also includes R4 has clear speech, easily understood with clear comprehension, with adequate vision. R4's comprehensive care plan contains the following significant focused problems with interventions: 1. R4 chooses to exercise their right to engage in an intimate/sexual activity. R4 at times will hold hands and kiss his female friend hand - Initiated 12/11/23, revised on 12/11/23. This care plan was initiated after the 12/4/23 sexual abuse allegation. -Goals include: R4 will respect their sexual/intimate partner and exercise safe and appropriate sexual practices - Initiated 12/11/23, revised 12/11/23. This goal was initiated after the 12/4/23 sexual abuse allegation. -Interventions include: a. Determine consent capacity quarterly and with any condition changes - Initiated 12/11/23 b. Educate R4 that sexual partners must be able to provide consent in words or through the facility's assessment of overt action. Consent must be mutual - Initiated 12/11/23 Surveyor notes these interventions were initiated after the 12/4/23 sexual abuse allegation. 2. Indicators of depression/sadness related to: dependence, relocation, history of alcohol/drug abuse, history of incarceration, homelessness, death of sister in 1998 - Initiated 6/1/17, revised 5/30/18 Interventions include: a. Validate feelings - Initiated 6/1/17 b. Review medication regimen as needed - Initiated 6/1/17 3. R4 is at risk for changes in mood related to depression and alcohol abuse - Initiated 6/28/18, revised 9/10/18 4. R4 is functioning at a reasonably independent level concerning leisure pursuits. R4 is alert, sufficiently oriented and coherent, able to express his needs - Initiated 6/26/20, revised 10/24/22. 5. R4 has an active order for psychotropic medication(s) use behavior management related to unspecified psychosis bizarre behaviors - Initiated 4/20/22. Interventions include monitor/record occurrence for target behavior symptoms of inappropriate sexual comments towards staff/others and document per facility protocol - Initiated 4/20/22, revised 2/1/23. Surveyor notes behavior monitoring for signs of affections towards female residents were initiated 12/4/23 at 10:15 pm after the 12/4/23 sexual abuse allegation. R4's medical record contained behavior meeting notes which documented the following: 1. Sexually inappropriate on 9/12/2019; 2. Alcohol abuse, sexual comments on 10/10/2019; 3. Alcohol dependence, impulsive behaviors and sexual remarks on 5/14/2020; 4. Unspecified psychosis, impulsiveness, and anxiety on 6/8/2023. An Initial Psych Evaluation performed on 9/15/2022 indicates resident has a history of using crack, cocaine, heroin, and marijuana. Staff states resident takes things that don't belong to him, and he has been doing this all his life, that's what he and his family have always done. The assessment and plan reports impulsiveness, history of inappropriate sexual behavior, and to continue Paxil for anxiety and depression. On 6/8/2023, a psych follow up progress note indicates staff report resident stole Tylenol from someone and resident is drug seeking. Recommendations at this time were to attempt a gradual dose reduction for Abilify and to follow up in 2 weeks or sooner if acute issues arise. On 8/15/2023, R4 met with Licensed Clinical Social Worker (LCSW)-I for talk therapy. The assessment performed by LCSW-I indicates the client endorsed that while living in Chicago, he engaged in disruptive behaviors in the community, resulting in contact with law enforcement and this information was shared with the facility administrator. R4 endorsed sporadic cravings for alcohol and reported primary drug of choice as heroin, however R4 has used any and all drugs available to him. R4 presented with symptoms of depression that have been present for most of his adult life, resulting in daily sadness and repressed feelings. LCSW-I reported it is highly likely that R4 managed his symptoms of depression through his substance use, however since he is no longer using, his symptoms have become more enhanced. On 9/27/23, a care conference summary note indicates social worker reminded R4 not to flirt with other residents, especially one in particular who did not appreciate it. R4 indicated he would leave her alone. NHA-A and DON-B were unable to confirm with Surveyor who R4 was flirting with when interviewed on 12/19/23 at 2:33 pm. On 10/12/2023, a psych follow up progress note indicates staff report R4 making sexual comments to staff and that R4 has a past history of these behaviors. Staff expressed concerns with R4's behaviors. Abilify is being used for bizarre behaviors and impulsiveness which is managed by R4's Primary Care Provider (PCP). Recommendations at this time were to increase R4's Paxil for increased sexual comments made towards staff. LCSW-I met with R4 on 11/21/2023 for talk therapy. Notes indicate LCSW-I did not meet with R4 in his room due to history of impulsivity and inappropriate sexual comments and that parties met in the library for purposes of psychotherapy. R4 described his mood as high and low, since last contact with LCSW-I. R4 attributed a high mood to having a place to stay, things to do (bingo, arts and crafts, and exercise) and friends he has made, however R4 could not identify these friends. R4 attributed a low mood to conflict with staff and other residents although he could not identify any recent conflicts. Surveyor interviewed R4 on 12/19/23 at 1:19 pm. R4 did not have difficulty with interview and was able to express thoughts and words clearly. Surveyor reviewed the facility self-report submitted to the state agency on 12/4/23 and 12/11/23 which indicated the following: On 12/4/23, CNA-D witnessed R4 kissing R2 on the lips in the common area of the facility. CNA-D immediately separated R4 and R2 and informed NHA-A and DON-B. R4 was placed in the TV lounge area by himself. NHA-A interviewed R4 who stated he kissed R2 and R2 gave consent for a kiss. NHA-A informed R4 police will be contacted and R4 asked the police not be contacted. NHA-A advised R4 to stay away from R2. NHA-A escorted R4 to the front of facility and contacted the police. NHA-A placed R4 on 15 minutes checks. DON-B and the activity director interviewed R2. The facility investigation indicates the activity director assisted with interviewing R2 due to R2's communication deficits. R2 became upset and teary eyed while being interviewed by DON-B and the activity director. R2 confirmed R4 kissed her and did not give consent for R4 to kiss her. R2 also confirmed R4 tried to touch her groin with his hand. R2 indicated R4 and R2 will hold hands a couple times a week and R4 would sometimes kiss R2's hand. R2 stated R4 and R2 will normally only hold hands and R4 will kiss her hand occasionally. The facility investigation reports police arrived with a chaplain who was working with the police officer. The police officer spoke with R2 and NHA-A. NHA-A indicated she was present during police questioning R2 due to R2 only being able to answer yes or no questions. R2 indicated to the police officer that R4 kissed her and R2 did not give consent. The police officer asked R2 if this has happened before and R2 said yes. NHA-A explained to the police officer that it did happen a long time ago. The police officer then asked if anything happened before 12/4/23 incident and R2 stated yes and got visibly upset. NHA-A then asked if R4 touched her arm and R2 said no. NHA-A asked if R4 touched R2's leg and R2 grabbed NHA-A's hand and moved NHA-A's hand toward R2's groin. NHA-A asked R2 if R4 touched her groin and R2 stated yes. R2 returned to the facility common area to eat after meeting with police. The facility investigation reports the police spoke with CNA-D who stated she saw R4 try to touch R2's groin while grabbing R2 to kiss her on the mouth. CNA-D reported hearing R4 say to R2, open your mouth so I can put my tongue in it. CNA-D stated she separated them immediately and informed NHA-A and DON-B. The facility investigation reports the police officer had to leave due to an emergency and stated they would be back. While waiting for the police officer to return, R4 found NHA-A and stated he hadn't kissed anyone in over a year and that he was sorry. NHA-A notified R4 that he needs to always receive consent prior to kissing someone. The facility investigation reports the police officer returned and spoke with R4. R4 confirmed he kissed R2 and was trying to comfort her. R4 stated he did not touch her groin. R4 indicates R2 consented to kissing R4. The police officer notified R4 that he cannot touch anyone without their consent and R4 stated he understood. R4 was placed on 15-minute checks by NHA-A starting 12/4/23 at 12:30 pm. The Interdisciplinary Team (IDT) met on 12/7/23 at 10:15 am and recommended 15-minute checks be discontinued due to R4 not exhibiting any abnormal behaviors. The facility self-report also indicates 29 residents were interviewed by the facility on 12/5/23 and reported they felt safe in the facility and had not had an uncomfortable encounter with R4. The facility self-report also indicates 17 staff were interviewed by the facility on 12/5/23 and all reported they have not seen R4 inappropriate with any other residents at the facility. Surveyor interviewed NHA-A and DON-B on 12/19/23 at 2:33 pm and confirmed the IDT team decided to discontinue 15-minute checks and initiate behavior monitoring every shift. NHA-A and DON-B stated another incident like this has happened in 2021 but were unable to recall the events of this incident. Surveyor inquired how the facility is monitoring R4 if behaviors are only being monitored every shift? NHA-A and DON-B stated activities will often oversee R4 when he is in the activity room. Surveyor interviewed Unit Manager-G on 12/19/23 at 3:45 pm, who stated R4 and R2 were friends but did not know them to be a couple. Unit Manager-G stated she has never seen R4 and R2 hold hands. Unit Manager-G indicated there is a 24-hour board that nurses and aides will report on shift-to-shift behaviors if noted. Unit Manager-G indicated R2 has a fiance out in the community who visits R2 frequently. Surveyor interviewed CNA/Med Tech-E who indicated she has never seen R4 and R2 hold hands or kiss and would never allow that to happen. CNA/Med Tech-E stated she would notify NHA-A and DON-B if there were residents who were kissing. Surveyor interviewed CNA-H who stated R2 and R4 were never in a relationship and has never seen them kiss or hold hands. CNA-H indicated staff was to keep an eye on them every shift and report and separate them immediately if they were together. R4's progress note from 12/5/23 at 10:34 am reports facility will be trying to find alternate placement for R4 with preference of all male group home. R4 agreed to facility finding alternate placement. Surveyor interviewed APNP Psych-F on 12/19/23 at 1:27 pm who confirmed Paxil is known to decrease libido. APNP-F stated R4 is conscious of his actions and is considering changing dose of Paxil to decrease libido at next psych follow up pending monitoring of sexual behaviors. Medical records for R4 indicate talk therapy notes from LCSW-I dated 12/12/2023 report NHA-A shared that client kissed another resident saying open your mouth - I want to stick my tongue down your throat. LCSW-I progress note indicates the resident the client kissed (R2) had been previously kissing him (R4) on the hand. R2 did not openly object to the kiss. NHA-A indicated parties were talked with. R4 shared with LCSW-I that he kissed her, it was no big deal, R2 kisses everyone, R2 was kissing my hand, R2 has kissed me on the neck, just wanted to kiss R2, not sure it was wrong, others think it was, I've kissed many random people in my life, like at New Years and Christmas. When R4 was asked about the incident on 12/4/2023 by LCSW-I, R4 admitted that R2 did not ask to be kissed nor did R2 seem to object to it. R4 denied they were boyfriend and girlfriend. R4 shared he has never had a girlfriend, adding, my girlfriends were hookers, I was kind of a [NAME]. R4 has shared in the past that he provided a safe place for the hookers, and they supplied him with drugs. LCSW-I reminded client that this is not the first time he has kissed a female resident, which R4 agreed with. R4 denied having any type of sexual feelings towards R2, adding, it was just a kiss. LCSW-I commented that R4 should not be kissing anyone at the facility. R4 commented about married couples at the facility. LCSW-I indicated that kissing and affection between a married couple is appropriate within the confines of their room, however kissing people at random is not acceptable. LCSW-I indicated R4 lacks insight into appropriate male/female relationships. Surveyor interviewed LCSW-I on 12/19/23 at 9:34 am who confirmed she received a referral for R4's impulsive behaviors and increased anxiety. LCSW-I describes R4 as a social guy with a history of touching a staff member inappropriately some time last year but unable to confirm date. LCSW-I states R4 does not have a sense of a normal relationship and describes R4's relationships as superficial. LCSW-I then describes R4 with a past history of being a pseudo pimp with having females pay him for sexual favors for housing benefits. LCSW-I states R4 does have the ability to consent to relationships and they are working on appropriate communication and boundaries with others. LCSW-I states she feels safe with resident and meets with residents in the facility library or open office due to residents sharing rooms with other residents. However, Surveyor notes LCSW-I did not meet with R4 in his room on 11/21/23 due to history of impulsivity and inappropriate sexual comments and that parties met in the library for purposes of psychotherapy. Surveyor interviewed R4 on 12/19/23 at 1:19 pm privately in his room. R4 stated he had been at the facility for 7 years and has friends within the facility but none that are close friends. R4 indicated he tries to stay out of trouble and referred to himself as a [NAME] and tends to roam around from girl to girl. Surveyors interviewed R2 on 12/19/23 at 1:47 pm in the community room with the door closed for privacy. Surveyors observed R2 with having contractures to both arms and legs but able to pedal independently to the community room for interview. R2 was unable to express herself verbally except for answering yes or no to questions that were asked by surveyors. Surveyors then asked if she has concerns with R4. R2 became very agitated with her eyes opening wide, hands waving in the air at chest level, and shaking her head when asked if she had concerns with R4 stating yes she does. Surveyors then asked further questions for R2 to answer yes or no. R2 indicated R4 worries her and was in her room last on 12/18/23. R2 indicated R4 aggravates and scares her. R2 indicated she has a boyfriend but again became very agitated when asked if R4 was her boyfriend stating no. R2 indicated she has a boyfriend outside the facility within the community. Further review of the assessment for consent for physical/sexual/intimate expressions dated on 12/11/23 indicates the following: 1. R2 has the verbal skills to express her needs and to answer questions; 2. R2 has the ability to call for assistance; 3. R2 wants to participate in a physical and sexual relationship; 4. R2 understands what sexual contact means; 5. R2 is not currently sexually active; 6. R2 has health issues that limit her activity which includes hemiplegia and hemiparesis following a cerebral vascular accident to her right side and cannot really move; 7. R2 no one is pressuring her to do intimate things or making her uncomfortable by being intimate. The assessment for consent for physical/sexual/intimate expressions concludes: 1. The resident has the ability to remove themselves from an unwanted situation; 2. R2 desires to participate in an intimate relationship; 3. Proceed with care planning. Surveyor noted R2's reaction to questions pertaining to R4 resulted in R2 becoming agitated and was contrary to R2's assessment for consent for physical/sexual/intimate expressions and R2's care plan indicating their friendship. Surveyor also noted this assessment and care plan is contrary to R2 informing the police that she did not consent to R4 attempting to kiss R2 including trying to stick his tongue in her mouth and placing his hand on her groin. On 12/19/23 at 4:31 pm, Surveyor notified NHA-A, DON-B, and Regional Clinical Operations-C of concerns with R2 being free from sexual abuse by another resident R4. NHA-A and DON-B requested to speak with surveyors and were interviewed on 12/20/23 at 8:08 am. NHA-A indicated a kiss is a kiss and that R2 consented to R4 kissing her although the facility self-report indicates R2 informed the police officer she did not consent. NHA-A indicated R2 will attend activities even if R4 is present and that R2 and R4 were both in the newspaper activity on 12/19/23 but sitting on opposite sides of the room. NHA-A and DON-B report they are performing behavior monitoring every shift for R4. Surveyor expressed concerns that R4 is independent with moving about the facility and questioned how the facility is monitoring R2's safety from R4 if he is independent with moving about in his wheelchair and if behavior monitoring is only being performed every shift. The facility's failure to protect R2, a vulnerable adult, from sexual abuse created a reasonable likelihood for serious harm, resulting in a finding of immediate jeopardy. The immediate jeopardy was removed on 12/20/23 when the facility completed the following: * R2 was moved to a different room on the other side of the building- completed 12/20/2023 * R2 seen by APNP Psych-F on 12/20/2023 * A Trauma assessment was completed on R2 - 12/20/2023 * R2's care plan being reviewed and revised * 1:1 supervision for R4 has been initiated effective 12/20/2023 and will continue indefinitely * 1:1 to use hourly log to document R4's interactions, demeanor with others, and daily activity * R4's social history to re-assessed on 12/20/2023 * R4's care plan reviewed and revised * Facility is actively seeking alternate placement for R4 and R4 is aware * Education commenced on 12/20/23 on resident rights, abuse, resident consent and preventing sexual abuse. Education completed in person and via telephone prior to their next shift. * Consent assessments completed on residents who have significant others on 12/20/2023 * Facility continuously monitoring for new admission as well as if any internal relationships arise and care plans revised. * Tools utilized to identify potential risk that may lead to possible abuse * On admission/readmission - social history and trauma assessments are to be completed * Facility runs background checks and [TRUNCATED]

Based on observation, interview, and record review, the facility did not ensure Residents received care, consistent with professional standards of practice, to prevent pressure ulcers, and residents with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for 2 (R76 and R244) of 7 Residents reviewed for pressure injuries. * R76 was admitted to the facility on [DATE] with documented open areas on buttock stage 2 pressure injuries. On 10/28/22, the facility implemented a skin integrity care plan indicating R76 was admitted with an unstageable pressure injury to the sacrum. The open areas on R76's buttock, initially identified as stage 2, were not assessed until 10/31/22 at which time the buttock pressure injuries were documented as being located on the sacrum and left buttock and were assessed as unstageable. Treatment orders for the unstageable pressure injuries to the sacrum and left buttock were not obtained and implemented until 11/1/22. The November 2022 Treatment Administration Record reflects multiple dates where the treatment was not completed. On 11/29/22 a third unstageable pressure injury was found by the hospice nurse. * R244 was admitted on [DATE] with no pressure injuries. On 11/7/22, R244 developed 2 unstageable pressure injuries; one to the scrotum and one to the sacrum. R244 was hospitalized on [DATE] due to a scrotal infection and urinary retention,and was readmitted to the facility on [DATE]. The facility did not conduct a comprehensive assessment of R244's skin condition and pressure injuries upon readmission. R244's pressure injuries were assessed 2 days after admission on 11/28/22. Additionally, on 11/28/22, R244 informed surveyor he did not have his air mattress upon readmission to the facility on [DATE]. Findings Include: Surveyor reviewed the facility's policy entitled: Skin Assessment Policy and Procedure, undated and notes the following: . Policy: Intact, healthy skin is the body's first line of defense. It is the policy of this facility to monitor the skin integrity for signs of injury and irritation. In addition to ongoing assessment of the skin, the facility will implement measures to protect the Resident's skin integrity and to prevent skin breakdown. Upon admission the following will be assessed: (1) Risk for developing pressure ulcers using valid assessment of pressure ulcer risk; (2) General skin condition; (3) History of ulcers and skin conditions; (4) Current ulcers . Purpose: To continually inspect the Resident's skin for early signs of pressure ulcer development and other abnormalities. Procedure: 1. On admission, a head-to-toe assessment of the Resident's skin will be completed by a licensed nurse along with admission nursing history. 2. Skin condition will be observed daily during cares. If new or worsening concerns are noted the licensed nurse will complete the appropriate documentation and notification. 3. Additionally, all Residents will have a documented weekly review of skin condition utilizing the Certified Nursing Assistant (CNA) Shower Sheets. Surveyor also reviewed the facility's policy entitled: Management of Wounds, revised 8/12/22, and notes the following applicable: . Policy: Our mission is to facilitate Resident independence, promote Resident comfort, and preserve Resident dignity. The purpose of this policy is to accomplish that mission through an effective wound management program, allowing our Residents a means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. We will achieve this goal through utilization of the following pertinent aspects of wound care: - Assessing the Resident to include ongoing skin assessment and assessment of risk factors for pressure injury development - Assessing the local wound condition - Determining the wound etiology - Managing tissue loads - Providing local wound care - Managing bacterial colonization and infection - Optimizing medical conditions and general systemic function - Promoting the prevention of pressure injury development - Promoting the healing of pressure injuries that are present - Providing education to Resident, families, and caregivers - Improving the quality of care and clinical outcomes through quality improvement programs 1. Assessing the Resident Since the assessment is the beginning of any Wound Management Program, it is the policy of this facility to assess the entire person, not just the wound. It is on this assessment that the plan of treatment will be based. This assessment will begin at the time of admission and will continue throughout the Resident stay. This assessment will be done using the following policies: * Pressure Injury Risk Assessment-to be done on all Residents on admission, weekly for the first 4 weeks, then quarterly and with change in cognition or functional ability * Skin Assessments-to be done according to Skin Assessment Protocol schedule. * Nutritional and Hydration Screening-to be done on admission, quarterly, with a significant change, for any Resident with a current wound or Braden less than 12, and when wound stalling has occurred. 1. R76 was admitted into the facility on [DATE] from the hospital. The hospital's discharge summary dated 10/28/22, contains no documentation or physician orders regarding R76 having an unstageable pressure ulcer to the sacral region. R76's facility face sheet includes the following diagnoses; Enthesopathy, Type 2 Diabetes Mellitus, Cerebral infarction, Malignant Neoplasm of Overlapping Sites of Unspecified Bronchus and Lung, Encephalopathy, Pressure Ulcer of Sacral Region, Unstageable, and Depression. R76 is currently her own person. R76's Braden Scale for Predicting Pressure Sore Risk, dated 10/28/22, assesses R76 to be at risk for developing pressure injuries with a score of 19. R76's Admission Data Collection and Baseline Care Plan, completed by facility registered nurse dated 10/28/22, documents the following, Skin Condition: [R76] has open areas on the buttocks stage 2. It states the area is reddened and dry but does not include any measurements or description of the wound area. Surveyor notes there is no comprehensive assessment of the open areas on the buttocks noted to be a stage 2 for R76. R76 has a potential for further impairment to skin integrity related to mobility loss, incontinence, nutritional risks and co morbid conditions such as DM (Diabetes Mellitus). admitted with Unstag (unstageable pressure injury) to Sacrum, care plan initiated on: 10/28/2022; Revision on: 11/17/2022. Interventions include: Encourage good nutrition and hydration to promote healthier skin. Date Initiated:10/28/2022. Follow facility protocols for treatment of injury. Date Initiated: 10/28/2022. Provide pressure relieving device(s): air mattress and w/c (wheelchair) cushion, encourage [R76's name] to turn and reposition, prefers side lying position. Date Initiated: 10/28/2022, Revision on: 11/28/2022. Turn and position as necessary. Date Initiated: 10/28/2022. Surveyor noted there is no documentation/assessment on 10/28/22 to indicate R76 had an unstageable pressure injury on 10/28/22 other than the notation on the care plan. The admission documentation notes a stage 2 with no detailed assessment. The facility skin impairment/wound form is not completed until 10/31/22, 2 days after R76 was admitted to the facility. R76's skin impairment/wound form completed by facility Wound Care Registered Nurse (WC-D) documents: 10/31/22 Measurements: Sacrum- Unstageable 6.5 x 0.9 x 0.1 (centimeters)(cm) 100% slough Scant drainage Serosanguineous Left Buttocks- Unstageable 1 x 0.5 x 0.1 (cm) 100% slough Scant drainage Serosanguineous Surveyor notes that R76's admission data collection/baseline dated 10/28/22 indicates stage 2 open area to left buttocks, however, the 10/31/22 wound assessment completed by WC-D indicates unstageable to both the left buttocks and sacrum. Surveyor reviewed R76's Treatment Administration Record (TAR) and notes a treatment order is obtained on 11/1/22 to cleanse the sacrum and left buttocks with normal saline, pat dry apply medi honey and cover with bordered foam dressing every evening for wound care. Surveyor notes wound care treatment orders were not initiated and implemented until 11/1/22, 4 days after R76 was admitted (10/28/22) to the facility with pressure injuries. Additionally, there was no documentation that wound care was completed to the sacrum and left buttock according to the 11/1/22 physician orders on 11/3, 11/5, 11/7, 11/10, 11/12, 11/16, and 11/18/22. On 11/2/22, R76's Skin Impairment/Wound Form completed by WC-D documents: 11/2/22 Sacrum-Unstageable 4.5 x 1 x 0.1 (cm) 100% slough Scant Serous drainage Left Buttocks- Unstageable 0.7 x 0.5 x 0.1 (cm) 100% slough No drainage In addition to WC-D's measurements; on 11/2/22, the wound nurse practitioner completed a wound assessment on R76 which states that R76 has pressure ulcers to both the left buttock and sacral region that are both unstageable. R76's Admission Minimum Data Set (MDS) assessment, dated 11/4/22, documents R76's Brief Interview for Mental Status (BIMS) score to be 8, indicating R76 demonstrates moderately impaired skills for daily decision making. R76's MDS also documents R76 requires limited assistance for Bed Mobility, Transfers, Dressing, Toileting, and Hygiene. R76's MDS also documents R76 has a pressure area, specifically 2 unstageable areas due to coverage of wound bed by slough and or eschar. Surveyor reviewed R76 Pressure Ulcer/Injury Care Area Assessment (CAA) dated 11/4/22 and notes it is documented R76 was admitted with unstageable (pressure injury) to sacrum and to follow interventions noted in the skin care plan with no referral to another discipline. On 11/7/22, R76's potential for further impairment to skin integrity care plan was updated to include the following two additional interventions: Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Date Initiated: 11/07/2022. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Date Initiated: 11/07/2022. On 11/9/22, R76's Skin Impairment/Wound Form completed by WC-D documents: 11/9/22 Sacrum - Unstageable 3.8 x 1 x 0.1 (cm) 50% slough 50% smooth red Scant serous drainage Surveyor notes the 11/9/22 wound assessment completed by WC-D does not contain any documentation regarding the left buttock as identified on the 10/31/22 and 11/2/22 skin impairment/wound form. On 11/16/22, R76's Skin Impairment/Wound Form completed by WC-D documents: 11/16/22 Sacrum- Unstageable 4.5 x 1 x 0.1 (cm) 90% Granulation 10% Slough Scant serous drainage Surveyor notes the 11/16/22 wound assessment completed by WC-D does not contain any documentation regarding the left buttock. Surveyor noted R76's care plan addressing the potential for further impairment to skin integrity related to mobility loss, incontinence, nutritional risks and co morbid conditions such as DM (Diabetes Mellitus). admitted with Unstag (unstageable pressure injury) to Sacrum, Date Initiated: 10/28/2022; had a revision date of 11/17/22, although no revised interventions were noted dated 11/17/22. On 11/23/22 the Skin Impairment/Wound Form completed by WC-D documents: 11/23/22 Sacrum- Unstageable 3.5 x 1 x 0.1 (cm) 75% Slough 25% smooth red Scant serous drainage Surveyor noted the sacrum wound went from having 10% slough on 11/16/22 to 75% slough on 11/23/22 a noted decline with the pressure injury Surveyor notes the 11/23/22 wound assessment completed by WC-D does not contain any documentation regarding the left buttock. Surveyor also notes R76's wound care assessment completed by the wound nurse practitioner on 11/23/22 documents R76 has an unstageable pressure ulcer to the sacrum no signs or symptoms of infection and has improved. Surveyor noted there is no documentation of an open area to the left buttocks. On 11/25/22, R76 is admitted to hospice. On 11/28/22 at 11:36 AM, Surveyor observed R76 to be on an air mattress. Surveyor spoke with R76 who confirmed that R76 has an open area and the facility were doing treatments. R76 also indicated that R76 prefers to stay in bed and is not getting up per R76's choice. R76's potential for further impairment to skin integrity care planned interventions to provide pressure relieving device(s): air mattress and w/c (wheelchair) cushion, encourage to turn and reposition, prefers side lying position initiated: 10/28/2022, was revised on 11/28/2022. On 11/29/22, per the Skin Impairment/Wound Form, completed by WC-D it is documented that R76 has an unstageable left hip pressure injury measuring 8.5 x 10 x 0.1 with 90% slough, 10% deep red with scant serous drainage. Surveyor notes that R76's physician was updated as well as the care plan. A treatment consisting of medi honey BF was implemented. Hospice provided a new air mattress. Surveyor noted that on 11/5, 11/8, 11/15, 11/22, 11/25, R76 did not have skin checks completed on R76's shower days per facility policy and procedure. Surveyor noted R76's skin is last assessed on 11/23/22 by the wound care team. On 11/29/22, R76's unstageable open area is found by the hospice nurse. On 11/30/22 at 1:56 PM, Surveyor interviewed WC-D who indicated that R76 would refuse showers but has no documentation to provide. Surveyor noted completing skin checks on shower days provides an opportunity for the facility to check R76's skin for further skin break down. On 11/30/22, at 3:16 PM, Surveyor shared with Director of Nursing (DON)-B and Nurse Consultant (NC)-C the concern a skin/wound assessment was not completed on the day of admission for R76. Surveyor also expressed a concern regarding treatment orders were not obtained and implemented until 11/1/22 (4 days after admission) and that there were 7 dates on the November TARS where no treatment according to physician's orders was completed for the open area on the sacrum and left buttock and/or with no documentation that R76 refused the treatment. No further information was provided at this time by the facility. On 12/01/22 at 11:29 AM, Surveyor spoke with WC-D, NC-C, and DON-B. Surveyor shared the concern that regular skin checks were not completed on R76 per facility policy and procedure and had the skin checks been done, perhaps skin injuries may have been found earlier. WC-D, NC-C, and DON-B understand the concern of the no wound assessments on day of admission as no one knows if the pressure injury got better or worse in the 2-4 days it took to complete. NC-C stated it is a process issue and understands the concern that the policy and procedure of the facility is not being followed in reference to the head-to-toe assessment being completed on the Resident's skin on admission. NC-C confirmed the expectation is that skin assessments should be completed on shower days and were not. No further information was provided at this time by the facility. 2. R244 was admitted to the facility on [DATE], with diagnoses that includes Type 2 Diabetes Mellitus with Diabetic Neuropathy, Morbid Obesity, Essential Hypertension, Peripheral Vascular Disease, Sleep Apnea and Depression. R244 is his own person. Surveyor notes that R244's Admission Data Collection and Baseline Care Plan Tool dated 10/12/22 documents that R244 had no open areas. Surveyor reviewed R244's comprehensive care plan and notes the following: [R244's name] has potential impairment to skin integrity, incontinence, mobility loss, use of sling to LUE (Left Upper Extremity), oxygen use, nutritional risks and co morbid conditions, Sacrum Unstag (unstageable pressure injury). Date Initiated: 10/13/2022, Revision on: 11/28/2022. Interventions include: Encourage good nutrition and hydration to promote healthier skin. Date Initiated: 10/13/2022. Follow facility protocols for treatment of injury. Date Initiated: 10/13/2022. Turn and position as necessary, Date Initiated: 10/13/2022. Provide pressure relieving device(s): pressure reduction mattress and w/c cushion encourage to float heels. Date Initiated: 10/13/2022, Revision on: 11/28/2022. Encourage positioning with pillows or Prevalon boots, to keep left leg from rotating outward. Date Initiated: 11/29/2022. R244's Admission Minimum Data Set (MDS) assessment, dated 10/19/22, documents R244's Brief Interview for Mental Status (BIMS) score of 13, indicating R244 is cognitively intact for daily decision making; requires extensive assistance for toileting, hygiene, dressing and bed mobility. R244 is totally dependent on staff for transfers. On 11/7/22, as documented on the Skin Impairment/Wound Form completed by WC-D, 2 unstageable open areas were discovered on R244: 11/7/22 Scrotum - Unstageable 6.5 x 6 cm 10% Epithelial 90% Slough Scant serous drainage Sacrum- Unstageable 3.2 x 3.5 x 0.1 cm 20% Slough 10% deep purple, 70% smooth red Scant serous drainage 11/9/22 Skin Impairment/Wound Form completed by WC-D: 11/9/22 Scrotum- Unstageable 7 x 6.5 x 0.1 cm 25% Granulation 75% Slough Scant serous drainage Sacrum-Unstageable 6.5 x 5 x 0.1 cm 25% Epithelial 25% Slough 25% deep purple 15% smooth red Scant serous drainage Surveyor notes that R244 had not been seen by the wound care team which included the wound care nurse practitioner. Surveyor reviewed R244's electronic medical record (EMR) and notes R244 was discharged to the hospital on 11/15/22 and admitted into the hospital with diagnoses of scrotal infection, urinary retention, hyperglycemia and constipation. R244 returned to the facility on [DATE] and per hospital discharge summary there is no documentation of any open areas, measurements and/or description of any pressure injuries. Surveyor noted upon R244's return to the facility on [DATE], there is no wound care assessment documented to include any measurements or description of any pressure injuries. Upon readmission to the facility, R244's previously identified scrotum pressure injuries are now being referred to as lesions which were not assessed until 11/28/22, 2 days after return to the facility. The skin impairment/wound form dated 11/28/22, completed by WC-D documents the following: 11/28/22 Scrotum 7.5 x 6.5 x 0.1 cm 100% Granulation Scant serosanguineous drainage This scrotum area was previously documented by the facility as unstageable. The following is documented by WC-D: based on further assessment and recent hospital stay with cellulitis of the scrotum based on location, rule out pressures, wraps around to side. Full thickness lesions due to cellulitis with pockets of fluid and edema. Lateral Scrotum 3.5 x 3 x 0.1 cm 100% Granulation Scant serosanguineous drainage Full thickness lesions due to cellulitis with pockets of fluid and edema. Sacrum-Unstageable 7 x 5 x 0.1 cm 75% Granulation 25% Slough Moderate Scant serosanguineous drainage Surveyor reviewed R244's Treatment Administration Records (TAR) and notes there is a treatment order for collagenase ointment 250 unit/gm, apply to sacrum and scrotum topically every shift for wound care. Surveyor notes that treatments were completed. On 11/28/22 the treatment for the sacrum changed to cleanse with normal saline, pat dry, apply Santyl to wound bed and cover with bordered foam dressing every evening shift for wound care. On 11/29/22 the treatment for the scrotum changes to cleanse with normal saline, pat dry, apply collagen powder to areas and cover with ABD pad every evening shift for wound care. Surveyor notes on 11/29/22 there is no documentation wound care was completed to both the sacrum and the scrotum as per physician's orders. On 11/28/22, at 12:36 PM, Surveyor observed R244 in bed with heel boots on but there is no air mattress on the bed. R244 informed Surveyor that R244 had an air mattress prior to going to the hospital on 11/15/22. Surveyor noted R244's potential impairment to skin integrity care plan was revised on 11/28/22 to; Provide pressure relieving device(s): pressure reduction mattress and w/c cushion encourage to float heels. Date Initiated: 10/13/2022, Revision on: 11/28/2022. On 11/29/22, at 8:32 AM, Surveyor observed R244 in bed with heel boots on but there is no air mattress on the bed. On 11/29/22, at 3:25 PM, Surveyor observed R244 to have an air mattress on his bed. Surveyor notes this is 3 days after R244's readmission to the facility. Surveyor noted R244's potential impairment to skin integrity care plan was updated on 11/29/22 to include; Encourage positioning with pillows or Prevalon boots, to keep left leg from rotating outward. Date Initiated: 11/29/2022. Surveyor notes on 10/12, 10/15, 10/19, 10/22, 10/26, 10/29, 11/2, 11/5, 11/9, 11/12/22 R244 did not have skin checks completed on R244's shower days per facility policy. Surveyor noted these skin checks on bath days provides the facility with the opportunity to inspect R244's skin for further skin breakdown. On 11/30/22, at 1:56 PM, Surveyor interviewed the Wound Care nurse (WC)-D. WC-D stated WC-D would expect that every Resident would have a skin assessment completed the day of admission/readmission to the facility. WC-D stated the skin assessment should include a description of any pressure injuries including measurements of the area. WC-D stated that the registered nurse is to assess Resident and include any skin issues in the Data Collection and Baseline Care Plan. WC-D confirmed this assessment does not include any measurements or description of open areas. WC-D confirmed with no measurements or description on day of admission could potentially be a problem. WC-D agreed that R244 did not have wound assessments completed until 2-4 days after admission/readmission to the facility. WC-D stated the wound assessment was not completed for R244 because it was the weekend. On 11/30/22, at 3:16 PM, Surveyor shared with Director of Nursing (DON)-B and Nurse Consultant (NC)-C the concern a skin/wound assessment was not completed on day of readmission (11/26/22) for R244. Surveyor also expressed a concern there is no documentation R244 had wound treatments completed on 11/29/22 per the physician's orders. No further information was provided at this time by the facility. On 12/01/22 at 11:29 AM, Surveyor spoke with WC-D, NC-C, and DON-B. Surveyor shared the concern that regular skin checks were not completed for R244 per facility policy and procedure and had this been done, perhaps skin injuries may have been found earlier. WC-DM, NC-C, and DON-B understand the concern of the no wound assessments on day of readmission as no one knows if the pressure injury got better or worse in the 2 days it took to complete. NC-C stated it is a process issue and understands the concern that the policy and procedure of the facility is not being followed. Surveyor notes the policy is that a head-to-toe assessment is completed of the Resident's skin on admission. NC-C confirmed the expectation is that skin assessments should be completed on shower days and were not. No further information was provided at this time by the facility.

Based on record review and interview, the facility failed to recognize a change in condition and failed to react timely and provide care consistent with professional standards of practice for 1 (R1) of 3 residents reviewed for a change in condition. R1 became unresponsive on 10/2/2021. Licensed Practical Nurse (LPN)-H and Registered Nurse (RN)-C did not seek immediate attention to address the change in condition. RN-C did not immediately call 911, but instead called a local ambulance company approximately 45 minutes after discovering R1 in an unresponsive condition. R1 was diagnosed as having a large embolism in the right middle cerebral artery and too much time had passed since the onset of the embolism for tPA (Tissue plasminogen activator, an agent to dissolve the stroke-causing clot) to be administered per hospital records. Facility failure to recognize a change in condition and react in a timely manner created a finding of Immediate Jeopardy that began on 10/2/2021. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the immediate jeopardy on 10/14/2021 at 10:40 AM. The immediate jeopardy was removed on 10/15/21. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: Surveyor requested the facility policy and procedure for a resident with a change in condition. Per DON-B, the facility uses AMDA (The American Medical Directors Association) guidelines for a resident change in condition. DON-B provided the INTERACT II (Interventions to Reduce Acute Care Transfers) guide dated 2010 the facility had available for staff to reference on each medication cart. The guide stated: Change in Condition: When to report to the MD/NP/PA - Immediate Notification: Any symptom, sign or apparent discomfort that is: 1. Sudden in onset, 2. A marked change (i.e. more severe) in relation to usual symptoms and signs, 3. Unrelieved by measures already prescribed. The guide indicated for a sudden change in level of consciousness or responsiveness, the nurse should notify the attending or on-call physician, nurse practitioner, or physician assistant on call as soon as possible. The guide did not address the option of calling 911 for emergency services. No facility policy and procedure was provided. R1 was admitted to the facility on [DATE] from another nursing facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was a full code, had a Brief Interview for Mental Status (BIMS) score of 14 on 10/1/2021(cognizant), and did not have an activated Power of Attorney. Per R1's Care Plan, R1 needed assist of one to reposition in bed and transferred with assist of one with a gait belt and a two-wheeled walker. Hospital records were reviewed. R1 was on long-term use of [MEDICATION(S)] to prevent blood clots from forming due to [CONDITION(S)]. R1 had a fall at home on 9/25/2021 resulting in a fractured right neck of the femur. Due to the use of [MEDICATION(S)], surgery was delayed until 9/26/2021. R1 was discharged from the hospital on 9/29/2021 to another nursing facility. Per R1's request, R1 transferred here from that nursing facility on 9/30/2021. On 9/30/2021 at 11:49 AM in the progress notes, nursing charted R1 arrived at the facility at 8:40 AM with a right [CONDITION(S)] following a fall. R1 was alert and oriented, pleasant and cooperative, and was able to verbalize their needs. Vital signs were obtained and were within normal limits. On 10/1/2021 at 3:02 AM in the progress notes, nursing charted R1 was alert and responsive and able to make needs known. On 10/1/2021 at 3:30 AM on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/1/2021 at 5:10 AM in the progress notes, nursing charted the [MEDICATION(S)] given at 3:30 AM was effective. On 10/1/2021 at 11:24 AM on the MAR, R1 received [MEDICATION(S)] 50 mg when requested for pain. On 10/1/2021 at 4:00 PM in the progress notes, Registered Nurse (RN)-C charted the [MEDICATION(S)] given at 11:24 AM was effective. On 10/1/2021 at 6:50 PM on the MAR, R1 received [MEDICATION(S)] 50 mg when requested for pain. On 10/1/2021 at 9:48 PM in the progress notes, RN-C charted the [MEDICATION(S)] given at 6:50 PM was effective. On 10/1/2021 at 11:38 PM on the Skilled Daily Documentation form, RN-C documented R1 had a right [CONDITION(S)], was up with assist of one, was alert and oriented, made needs known, and was continent of bowel and bladder. RN-C documented [MEDICATION(S)] and Tylenol were effective for pain. ([MEDICATION(S)] was signed out on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .) The Vital Signs (Section A) on the form had vital signs dated 9/30/2021 at 8:45 AM; these were the admission vital signs. No current vital signs were documented. In an interview on 10/13/2021 at 2:58 PM, Surveyor shared with Director of Nursing (DON)-B R1 had vital signs taken on admission on 9/30/2021 and no vital signs were obtained on 10/1/2021; RN-C had used vital signs from 9/30/2021 on the 10/1/2021 Skilled Daily Documentation form. Surveyor asked DON-B what the facility protocol was for obtaining vital signs for newly admitted residents. DON-B stated the expectation was to have vital signs taken every shift for the first three days to get a baseline for the resident. DON-B provided the facility policy and procedure entitled Admission Vital Sign Procedure dated 11/1/2018 which states: Upon admission, vital signs should be every shift for 72 hours. Vital signs to be documented in the resident medical record. On 10/2/2021 at 1:47 PM in the progress notes, RN-G charted R1 was on follow up for new admission on 9/30/2021. RN-G charted R1 was alert and oriented, able to make needs known, and gets up with a walker and one assist. RN-G charted R1 had complaints of right lower extremity discomfort that [MEDICATION(S)] and Tylenol was effective for. RN-G did not administer any [MEDICATION(S)] or Tylenol per the MAR. On 10/2/2021 at 3:10 PM on the MAR, Licensed Practical Nurse (LPN)-H documented R1 received [MEDICATION(S)] 50 mg for complaints of right knee and leg pain. On 10/2/2021 at 9:23 PM in the progress notes, RN-C charted RN-C had been called to R1's room at 5:00 PM to assess R1 who had fallen asleep in the wheelchair after being given [MEDICATION(S)] at 3:15 PM and was alert and oriented at 3:15 PM when the medication was administered. RN-C charted RN-C was unable to arouse R1; R1's vital signs were stable. RN-C charted the physician was notified and ordered R1 to be sent to the hospital. RN-C charted R1 was admitted to the hospital with a [CONDITION(S)] ([CONDITION(S)]). The ambulance record was reviewed. The ambulance company received a call from the facility at 5:32 PM and dispatched an ambulance at that time. The ambulance reached the facility at 5:43 PM and left the facility at 6:01 PM. The ambulance arrived at the hospital at 6:10 PM. The Narrative Section of the Patient Care Report stated the ambulance was dispatched with no lights or sirens to the facility for an unresponsive person. Upon arrival at the facility, R1 was found to be responsive to pain. R1 was transferred to the hospital with oxygen administered for low oxygenation and R1 was [CONDITION(S)] (high pulse rate) during transport. Review of R1's hospital records dated 10/2/2021 indicated R1 was admitted to the hospital with acute [CONDITION(S)] with embolism of the right middle cerebral artery. The course in the emergency room stated R1 was unresponsive and thrombolysis was not desired because of the lapsed time window of opportunity for tPA; over three hours had passed since R1 was last observed to be alert and oriented. Radiologic intervention in the form of thrombectomy was performed and in the radiology suite, R1 was required to be intubated. In an interview on 10/13/2021 at 2:07 PM, LPN-H stated R1 told LPN-H at 3:15 PM on 10/2/2021 R1 had a broken hip and had pain so LPN-H gave R1 [MEDICATION(S)]. LPN-H stated R1 was alert and oriented and was very talkative, telling the story of how R1 broke the hip. Surveyor asked LPN-H if LPN-H checked on R1 after giving [MEDICATION(S)] to see if the [MEDICATION(S)] had been effective in relieving the pain. LPN-H did not remember going back to see if the [MEDICATION(S)] was effective. LPN-H stated around 4:45 PM on 10/2/2021 a family member of R1 was visiting and told LPN-H something seemed off with R1 and that it was emergent. LPN-H stated LPN-H took R1's vital signs and they were normal. LPN-H thought R1 was sleeping and could have been tired because a lot of times residents are very tired. Surveyor asked LPN-H if LPN-H tried to wake R1 up. LPN-H stated LPN-H shook R1's shoulders and tapped R1 on the face. Surveyor asked LPN-H if R1 made any sounds or talked. LPN-H stated R1 made a grunting noise but no words. LPN-H stated R1 moved when LPN-H was getting vital signs like R1 was bothered by being moved. LPN-H stated R1 had the face down and one eye was closed and one eye was half open. LPN-H stated LPN-H went and got the charge nurse. Surveyor asked LPN-H how was the charge nurse contacted? LPN-H stated LPN-H walked to another unit and got RN-C, but RN-C was doing something with another resident so it took a minute or two for RN-C to get to R1's room. LPN-H stated RN-C assessed R1 and agreed with LPN-H that something was wrong so RN-C called the physician. LPN-H stated RN-C told LPN-H the physician said [MEDICATION(S)] would not cause R1 to be unresponsive and said to send R1 to the hospital. LPN-H stated with the assistance of Certified Nursing Assistant (CNA)-I, they transferred R1 from the wheelchair to the bed with a gait belt by physically lifting R1 under the arms. Surveyor asked LPN-H who called the ambulance and who gave a report to the hospital. LPN-H could not recall who made the phone calls. LPN-H recalled R1 was a full code because LPN-H remembered the ambulance personnel asked that. Surveyor asked if at any time LPN-H thought 911 should have been called. LPN-H stated R1's family thought the situation was emergent, but LPN-H got the RN like they have been trained to do. In an interview on 10/12/2021 at 3:28 PM, RN-C stated RN-C was working on a different unit when LPN-H asked RN-C to come and see R1. RN-C stated R1 had fallen asleep in the wheelchair and they were unable to arouse R1. Surveyor asked RN-C what RN-C did to try and arouse R1. RN-C stated RN-C did a sternal rub and may have touched R1's cheek. RN-C stated R1 did not respond. RN-C stated R1's head was slumped to the side, but did not recall any facial drooping. RN-C stated a family member said R1 may have had a stroke. Surveyor asked RN-C what RN-C did after not being able to arouse R1. RN-C stated RN-C called the physician and the physician said to send R1 to the hospital. Surveyor asked RN-C if RN-C called 911. RN-C stated 911 was not called. In an interview on 10/13/2021 at 2:40 PM, CNA-I stated on 10/2/2021, CNA-I had 18 residents from 1:30 PM until about 4:30 PM with no other CNA's working on the unit. CNA-I stated CNA-I handed out water to all the residents and thought R1 had the call light on once between 2:15 PM and 4:30 PM but could not recall what R1 wanted or needed. CNA-I stated R1 was talkative and able to express themselves. CNA-I recalled LPN-H getting R1's vital signs and helping transfer R1 back to bed with a gait belt. Surveyor asked CNA-I if R1 was able to support their own weight during the transfer. CNA-I stated R1 could not support their own weight. Surveyor asked CNA-I how did R1 look, such as did R1 have the head leaning to one side or were R1's eyes open. CNA-I stated R1 did not speak and was not responding at all. CNA-I stated R1 opened their eyes when R1 was transferred, but that was it and then R1 closed one eye and then closed the other eye slowly. In an interview on 10/13/2021 at 9:42 AM, Family Member-D stated the family was told by nursing staff on 10/2/2021 around 4:45 PM that R1 was sleeping and staff came back two or three times trying to wake R1 up. Family Member-D stated when R1 was sent to the hospital, the ambulance did not have any lights or sirens on. In an interview on 10/13/2021 at 11:32 AM, Family Member-F stated Family Member-F got to the facility around 5:00 PM on 10/2/2021 and another family member was already at the facility with R1. Family Member-F asked LPN-H what medications R1 was taking and LPN-H did not know and kept telling Family Member-F R1 was sleeping. Family Member-F stated R1 had one-sided facial drooping and was not responding to the staff trying to rouse R1. Family Member-F stated LPN-H got an RN to assess R1 and the RN said the physician needed to be called to see if R1 should go to the hospital. Family Member-F stated no sirens or lights were on when the ambulance arrived at the facility. In an interview on 10/13/2021 at 2:00 PM, Nursing Home Administrator (NHA)-A stated a local ambulance company is called to transport a resident and if the first company they call will be delayed, they will call a second ambulance company. NHA-A stated if it is an emergency, 911 would be called. In an interview on 10/13/2021 at 2:58 PM, Surveyor shared concerns with NHA-A and DON-B R1 had a change in condition and the nursing staff did not respond in a timely manner and did not call 911; R1 was seen on 10/2/2021 at 3:10 PM when LPN-H administered [MEDICATION(S)] as requested by R1. R1 was alert and oriented at that time. R1's family visited at 4:45 PM and R1 was not responsive. R1's family alerted the staff to R1's change in condition. Through interview, no staff observed R1 between 3:15 PM and 4:45 PM to provide cares or evaluate the effectiveness of the pain medication that had been administered. LPN-H reported to RN-C R1's change in condition and RN-C did not come immediately to R1's room to assess R1. RN-C did not call 911. RN-C called an ambulance company at 5:32 PM, 45 minutes after the change of condition was first noticed. Due to the response time of the staff, R1 was unable to receive tPA to break up the clot in the main cerebral artery causing the [CONDITION(S)]. Surveyor asked DON-B if DON-B had been present when R1 was discovered with the change in condition, the asymmetrical eyes and not responding to painful stimuli such as the sternal rub RN-C provided, would DON-B have called 911. DON-B stated yes, DON-B would have called 911. Surveyor shared the concern R1 did not have vital signs taken every shift for the first three days of admission as per facility policy and procedure. No further information was provided at that time. On 10/18/2021 at 9:30 AM, Family Member-D informed Surveyor R1 had passed away that morning on hospice services after sustaining the [CONDITION(S)]. According to If Someone is Having a Stroke: 3 Things To Do and 3 Things Not To Do, When a person is having a stroke, every second counts. And what you do in those critical moments can potentially help save someone's life .The longer a stroke goes untreated, the more brain damage can occur. But there are treatments that can be given if a person reaches the hospital in time .If you do nothing else, act quickly to call 911. https://www.pennmedicine.org/updates/blogs/neuroscience-blog/2019/april/if-someone-is-having-a-stroke-3-things-to-do-and-3-things-not-to-do According to the Stroke Association, Stroke is an EMERGENCY. Call 911 immediately. Early treatment leads to higher survival rates and lower disability rates. Calling 911 lets first responders start treatment on someone experiencing stroke symptoms before arriving at the hospital. https://www.stroke.org/en/about-stroke/stroke-symptoms The failure to recognize a change in condition and react in a timely manner created a finding of Immediate Jeopardy. The facility removed the jeopardy on 10/15/21 when they implemented the following: QAPI initiated to implement a 4-point plan for change in condition. Education was developed to reinforce the facility procedure for obtaining vital signs for a new admission and for change in condition. In reference to the e-interact guidelines that differentiate 911 vs private ambulance service as well as how to communicate with the ambulance service. If licensed nurse was in facility at the time then face to face education was completed. For other nurses that were not in the facility, education was sent out to them. Facility to conduct face to face reinforcement of the educations including FASTER and neurological assessments for licensed nurses as well as a competency test prior to their next scheduled shift. The facility reviewed policy and procedure on change in condition and vital signs with medical director to ensure policy meets current standards of practice. Upon review, it was added that orders to obtain vital signs every shift for 3 days will be put into PointClickCare which is used for the eMAR. Nursing team to monitor compliance protocol for vital signs and change in condition expectations. Yearly competencies to be added to Relias for licensed nursing staff regarding change in condition and appropriate actions to take. Within PCC, facility to utilize the einteract quality improvement worksheet for review of acute care transfers. DON to develop a tool for nurses to utilize when communicating with transport company/911. Nursing managers and DON will review all return to hospitals in clinical meeting Monday through Friday. On the weekend, nurse to notify nurse manager on call to review return to hospitals utilizing standardized questioneer developed by DON. Ongoing monitoring of new admits and vital sign expecations. Results to be reviewed at the QA meeting for further recommendations.

Based on observation, record review and staff interview, the facility did not ensure that a resident (R3) received care consistent with professional standards of practice to prevent pressure injuries and also a resident with a pressure injury (R14) received necessary treatment and services to promote healing for 2 of 5 sampled residents. * R3 was admitted to the facility without pressure injuries. The facility assessed R3 to have been at moderate risk of developing pressure injuries upon the resident's admittance to the facility. The facility did not develop nor implement interventions to prevent pressure injuries. R3 resided at the facility for 20 days and developed 2 deep tissue injuries to the heel and one unstageable pressure injury to the right buttocks. * R14 was identified as having a stage 4 pressure injury to the sacrum with a treatment order of a wound VAC to be changed Tuesday, Thursday, Saturday and as needed. R14's wound VAC broke on night shift 4/10/21 into 4/11/21. R14's wound doctor was not notified until 4/12/21. Wound treatment orders were not provided until 4/12/21 while the facility waited for the delivery of the new wound VAC. On 4/13/21 Surveyor observed R14 without a treatment or covering to the stage 4 sacral wound. Findings include: 1. According to the electronic, undated Facesheet, R3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 resided at the facility until 03/18/20. The facility completed a Braden Scale on 02/27/20, which indicated R3 was at moderate risk for developing pressure injuries. Areas of concerns were listed as moisture, mobility and friction/shear. The Admission Data Collection form completed on 02/27/20, indicated R3 had a right buttock tissue tear with flap that measured 1.5. A plan of care for The resident has potential/actual impairment to skin integrity was developed on 02/27/20. The only intervention listed was Encourage good nutrition and hydration in order to promote healthier skin. According to the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/05/20. The MDS indicated R3 was alert and oriented, required at least 2 staff assistance for bed mobility, had occasional bowel incontinence, was at risk for pressure injury development but did not have any pressure injuries. The Care Area Assessment (CAA) for pressure injuries that was completed in conjunction with the MDS indicated R3 currently did not have a pressure injury but remains at risk for future falls [sic] related to incontinence and having a Foley catheter. Will proceed to care plan. On 04/14/21 at 8:30 AM, the Surveyor interviewed MDS Coordinator D in regards to the CAAs documentation. MDS Coordinator D stated she must have meant that R3 remains at risk for future pressure injuries and not future falls. The Progress Notes indicated the following: ~ 03/01/20 at 22:39 (10:39PM): Resident complaining of [CONDITION(S)] that is getting worse. States that his pain is burning, tingling and coming up the legs etc. Resident is taking [MEDICATION(S)] already but resident says it is not effective. ~ 03/03/20 at 20:53 (8:53PM): Resident complains of (c/o) bilateral lower extremities pain and discomfort .Resident requires assist with activities of daily living of bed mobility ~ 03/04/20 at 17:24 (5:24PM): Resident requires assist with activities of daily living of bed mobility ~ 03/08/20 indicated Certified Nursing Assistant (CNA) noted with shower wounds of right buttocks which has increased in size and color. 4 sites observed in a cluster; 1- red wound bed, 1.0 cm X 1.0 cm. 2- 90% slough and 10% granulation measuring 1.5 cm x 2.0 cm. 3- 90% slough and 10% granulation measuring 1.0 cm X 1.0 cm. 4- 90% slough and 10% granulation measuring 1.0 cm X 1.0 cm. Surrounding tissue is red and blanchable with deeper red color at 2000. Area tender to touch. Message left with wound care Registered Nurse (RN). Surveyor noted there was no comprehensive assessment nor an update to the plan of care. A Skin Impairment/Wound Form dated 03/10/20 indicated R3 has an unstageable pressure injury to the right buttock that measured 4.0 cm X 4.0 cm. The wound bed contained 70% slough and 30% granulation, edges are ill defined, no tunneling or undermining, scant serous drainage, no odor, periwound within normal limits (WNL) and no wound pain. No additional wounds and no current interventions utilized. The RN who completed this documentation is no longer employed at the facility and unable to interview. The facility developed a plan of care on 03/10/20 for The resident has an unstageable pressure ulcer to the right buttock related to (r/t) immobility, [CONDITION(S)], anxiety, restless leg syndrome, congestive heart failure (CHF), [CONDITION(S)] ([CONDITION(S)]), dementia, muscle weakness, [CONDITION(S)] and stage 3 chronic kidney disease CKD). The following interventions were listed: ~ Administer medications as ordered. Monitor/document for side effects and effectiveness. ~ Administer treatments as ordered. and monitor for effectiveness. ~ Do not put shoes on resident due to right heel pressure ulcers. Non slip socks can be worn. ~ Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements, importance of taking care during ambulation/mobility, good nutrition and frequent repositioning. ~ Inform the resident/family/caregivers of any new area of skin breakdown. ~ Monitor nutritional status. Serve diet as ordered. Monitor intake and record. The Progress Notes documents as follows: ~ 03/11/20, right heel has a fluid filled blister with some yellowing inside the blister, writer updated Nurse Practitioner and the in house wound nurse to look at it. Dressing orders in place Surveyor noted there is no comprehensive assessment of the blister located in the medical record. On 03/11/20 the facility developed a plan of care for The resident has a stage 2 pressure ulcer to the right heel r/t immobility, [CONDITION(S)], anxiety, CHF, [CONDITION(S)], dementia, muscle weakness, [CONDITION(S)] and stage 3 CKD. The following interventions were listed: ~ Administer treatments as ordered and monitor for effectiveness. ~ If the resident refuses treatment, confer with the resident. Interdisciplinary Team (IDT) and family to determine why and try alternative methods to gain compliance. Document alternative methods. Surveyor noted there is no documentation in the medical record that indicated R3 refused any treatments. ~ Inform the resident/family/caregivers of any new area of skin breakdown. ~ Monitor nutritional status. Serve diet as ordered and monitor intake and record. ~ Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. A Skin Impairment/Wound Form dated 03/12/20 indicated R3's buttock pressure injury assessment listed as above but now R3 had developed a stage 2 pressure injury to the right heel that measured 3.5 cm X 4.5 cm with 100% epithelial but indicated there was not a blister present. Edges are well defined, no drainage, no odor, periwound WNL and no pain. The Progress Notes documents as follows: ~ 03/12/20 at 00:06: Both feet elevated with a pillow. ~ 03/12/20 at 08:28: Float heels while in bed. Medication for restless leg syndrome. ~ 03/12/20 at 10:17: Interdisciplinary Team (IDT) met to discuss patient's pressure injury on buttocks. Braden score as of 02/27/20 is a 13 (moderate risk). Braden will be reassessed. Intake is variable 25% - 100% with no weight loss verified by daily weights. Patient has a low [MEDICATION(S)] which increases risk for skin breakdown. Patient does receive nutrition supplement. Proheal now ordered to promote skin integrity. New intervention of patient being placed on a turning schedule every 2-3 hours. ~ 03/12/20 at 10:17: Interdisciplinary Team (IDT) met to discuss patient's pressure injury on right heel. Braden score as of 02/27/20 is a 13 (moderate risk). Braden will be reassessed. Intake is variable 25% - 100% with no weight loss verified by daily weights. Patient has a low [MEDICATION(S)] which increases risk for skin breakdown. Patient does receive nutrition supplement. Proheal now ordered to promote skin integrity. New intervention of patient being placed on a turning schedule every 2-3 hours. Patient educated to not wear shoes until pressure injury healed. On 03/12/20, the facility added to the plan of care for Potential/Actual impairment to skin integrity that was initiated on 02/27/20 the following: ~ Float heels while in bed. ~ Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] ~ Turn and position as necessary. ~ Use a draw sheet or lifting device to move resident. ~ Use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surfaces. The Progress Notes documents as follows: ~ 03/12/20 at 22:36: Alert and ordered X's 3 with forgetfulness Does not reposition self in bed or in wheelchair (w/c). Developing wound to right heel and lateral right buttocks. Cushion on w/c. ~ 03/16/20 at 11:23 (documentation from the physician): Weakness persists .Patient fatigues quickly review of symptoms: Skin-- wound to buttock per report of patient. ~ 03/17/20 at 20:32 (8:32PM): Noted right heel now with small amount bloody drainage on sock. Sock removed with blister tissue flap displaced with clear visibility of tissue bed. Wound bed is deep red with dark blue, black discoloration. Noted above right heel, deep purple line appearing as an indentation from w/c rest? CNA states was present when assisted to bed. Surrounding tissue red with slow blanching. Patient unaware of wound extension. Red sites of lateral side of right foot of bony prominences with slow blanching and 2 red spots of right lateral ankle and 1 site above right ankle. Resident states with restless leg syndrome, he is frequently rubbing foot against mattress. Left heel and foot tissue intact. Right buttocks without further breakdown with treatment completed as ordered. Heels floating in bed with pillows. Surveyor noted there was no comprehensive assessment completed and due to resident's statement of cause was restless leg syndrome and rubbing on the mattress, there was no change in the plan of care that could be located in the medical record. The nurse documenting the progress note is no longer employed at the facility. The Skin Impairment/Wound Form dated 03/18/20 indicated R3 developed a deep tissue injury measuring 2.5 cm X 7.5 cm to the right lateral foot. Edges are ill defined, no drainage or odor, periwound is WNL, current intervention was to float heels while in bed and to medicate for restless leg syndrome. Surveyor noted the nurse documenting the progress note is no longer employed at the facility. The facility completed a discharge MDS with an ARD of 03/18/20. The MDS indicated R3 was alert and oriented, required extensive staff assistance for bed mobility. The MDS indicated R3 had 1 Stage 2 pressure injury, 1 deep tissue injury (DTI) and 1 unstageable pressure injury on discharge. On 04/14/21 at 8:45 AM, the Surveyor interviewed MDS Coordinator F. MDS Coordinator F verified R3 developed 3 pressure injuries while residing at the facility. MDS Coordinator F indicated the pressure ulcer that was indicated as 30% granulating tissue could possibly not be staged as the wound bed was not visible in an area that could be accurate, but there is no way to know that as there is no documentation to where the slough and the granulation tissue was observed on the wound. On 04/14/21 at 9:20 AM, the Surveyor interviewed Director of Nursing (DON) B regarding the above findings and staff that had completed documentation no longer employed at the facility and current staff do not recall R3. DON B stated she would review the medical record and look for additional documentation and give to surveyor if any was located. No additional information was received. 2. The facility policy, entitled Wound Dressing Policy and Procedure, undated, states: .3. Change the dressing using clean technique according to physician orders. Frequency of wound dressing changes and the type of wound dressing will be specified in the physicians orders . The facility policy, entitled Wound Assessment Policy and Procedure, undated, states: .2. Wound/wound dressing status will be monitored daily using the Daily Wound Status Sheet or documenting on the Treatment Administration Record. R14 was admitted to the facility on [DATE], and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's Quarterly Minimum Date Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3/10/21, indicated a Brief Interview for Mental Status Score of 12, indicating moderate cognitive impaired for daily decision making. R14's functional status indicates extensive assistance with transfers, bed mobility and total dependence with toilet and bathing. The MDS documents R14 to have one stage three pressure injury (PI), one stage four PI, two unstageable PI and one deep tissue injury. R14's Care Plan, undated, states: The resident has a stage 4 pressure ulcer to the sacrum, left lateral foot (healed), right medial heel, right heel stage 3 (healed), and unstageable to the left medial heel. Interventions include, .Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the Medical Doctor (MD).Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R14's care plan and could not locate the wound VAC as an intervention even though it was ordered on 3/23/21. On 3/22/21, R14's Braden Scale for Predicting Pressure Sore Risk assessment, documented a score of 13, indicating moderate risk for pressure ulcer development. On 3/23/21, R14's medical record documents, new order for wound VAC by Wound Care Doctor (WCD)-G. The new order states, Cleanse wound with saline, Protect peri-wound with skin prep, change Tuesday/Thursday/Saturday and as needed (PRN). 125mmHg (set pressure at the wound site), Continuous, Black, Change TTS (Tuesday, Thursday, Saturday). On 3/24/21, R14's medical record documents, previous daily sacral wound dressing was discontinued. On 3/24/21, R14's active orders state, wound VAC to start on 3/25/21. Surveyor was unable to locate documentation on R14's TAR (Treatment Administration Record) indicating a treatment to the sacral wound was completed on 3/24/21. On 4/05/21, R14's Braden Scale for Predicting Pressure Sore Risk assessment, documented score of 14, indicating moderate risk for pressure ulcer development. On 4/13/21, at 7:45 AM, Surveyor observed R14 lying in bed with the wound VAC not attached to the sacral wound as ordered. Surveyor observed the wound VAC on the floor next to R14's bed. Director of Nursing (DON)-B entered R14's room to provide assistance with cares. Surveyor observed, R14 had wounds to right and left heels covered. Surveyor asked to see R14's sacrum wound dressing. DON-B assisted R14 to roll onto right side, surveyor did not observe wound dressing to sacrum. DON-B stated resident has a wound VAC, it had been dropped on the floor on 4/11/21 and stopped working. DON-B stated she ordered a new wound VAC that should arrive today, 4/13/21. DON-B stated R14 should have a wet to dry dressing in place but must have fallen off during cares. Surveyor did not observe a dressing in brief. On 4/13/21, Surveyor reviewed R14's medical record. Surveyor was unable to locate documentation the facility updated R14's physician on 4/11/21 of the broken wound VAC. Surveyor unable to locate documentation the physician provided the facility with new treatment orders to the sacral wound while waiting for a new wound VAC to arrive. On 4/13/21, at 11:15 AM, surveyor interviewed DON-B, who stated she received a call at home from the nurse working with R14 the morning of 4/11/21, stating the wound VAC was not working. DON-B stated she asked the nurse to describe the color of the wound base, nurse stated it was pink. DON-B stated she instructed the nurse to apply a wet to dry dressing to the wound. DON-B stated, she will order a new wound VAC on Monday. Surveyor asked DON-B if the physician was updated on the broken wound VAC and the need for a new treatment order until a replacement wound VAC arrives. DON-B stated she updated the physician and received a new order for a wet to dry dressing from WCD-G after she spoke with the nurse on 4/11/21. Surveyor informed DON-B no physician's orders were located on R14's TAR for the new wet to dry treatment order nor documentation stating the physician was updated in regards to the broken wound VAC on 4/11/21. DON-B informed surveyor she was going to enter the orders and a nursing note on Monday, 4/12/21, as she did not have her computer at home. DON-B stated, the State Survey Team arrived at the facility on Monday (4/12/21) and she did not get to it. On 4/14/21, at 12:10 PM, Surveyor asked DON-B if a treatment was done to R14's sacral wound on 3/24/21. DON-B stated she applied the wound VAC on 3/24/21 when it arrived at the facility. DON-B informed surveyor the computer system did not allow her to sign out the treatment on the TAR because the order had changed. Surveyor informed DON-B there is no documentation indicating a treatment was done or that the wound VAC was applied on 3/24/21. DON-B stated she forgot to put a note in. On 4/14/21, at 12:35 PM, surveyor interviewed WCD (Wound Care Doctor)-G, who stated he was notified of the wound VAC not working over the weekend during phone conversation with DON-B on 4/12/21. WCD-G stated, at this time he also gave new wound care orders to DON-B for the wet to dry dressing to the sacral wound until the replacement wound VAC arrives. On 4/14/21, at 1:45 PM, Surveyor met with DON-B, Nursing Home Administrator (NHA)-A and Regional Director of Operations (RDO)-E and advised them of the observation on 4/13/21 of no treatment in place. The wound care doctor was not notified of the wound VAC breaking on the night shift 4/10/21-4/11/21. There were no physician orders for the wound care on 4/11/21. Wound care orders obtained on 4/12/21. DON-B provided wound care treatment orders on 4/11/21 without notification to the physician. No additional information was provided.

Based on record review and staff interview, the facility did not ensure that a registered nurse (RN) comprehensively assessed a resident experiencing an acute change in condition and that staff promptly consulted with a physician when this change occurred for 1 (R5) of 6 resident medical record reviews. This change in condition resulted in death for R5. On [DATE], R5 had changes in mentation and vital signs that were not comprehensively assessed by an RN for appropriate interventions. Staff did not promptly consult with a physician regarding symptoms to determine an appropriate intervention. R5's clinical condition continued to decline and R5 expired 1 hour and 50 minutes later. Paramedics were obligated to start cardio-pulmonary resuscitation (CPR) even though R5 wished no resuscitation because the facility had not gotten an MD order. The failure of staff to immediately notify an RN to assess an acute change in condition and to promptly consult with a physician created a finding of immediate jeopardy beginning on [DATE]. The Nursing Home Administrator (Administrator-A) and Director of Nursing (DON-B) were notified of the immediate jeopardy on [DATE] at 9:08 a.m. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its plan of correction. Findings include: R5's closed medical record was reviewed as a result of a complaint intake regarding a code status change. Prior to R5's admission into the facility R5 had sustained a fall and fractured ribs. R5 was admitted into the facility on [DATE] for rehab. R5's Admission MDS (Minimum Data Set) assessment completed on [DATE] indicated no cognitive impairment, with a brief interview for mental status score of 15 of 15. R5 was her own decision maker. R5 signed an Emergency Care Do Not Resuscitate (DNR) form on [DATE]. This indicated to Emergency Responders R5's wishes to be a DNR, however the form is only valid if a physician signs and dates it. The DNR form was not complete as it was missing R5's written name, address, phone number and was not signed by a physician. R5's Progress Notes contain the following: On [DATE] at 9:31 p.m. the vital signs are stable. No breathing concerns. On [DATE] at 1:36 p.m. the vital signs are stable. No breathing concerns. On [DATE] (per late entry 9:08pm) LPN (Licensed Practical Nurse) E documented at 5:00 p.m. that R5 was alert and normal during dinner. At 6:00 p.m. R5 was noted to have a little confusion, pulse 118 and the oxygen saturation was not registering. An additional nurse entered the room (LPN-F) and got an oxygen saturation level of [AGE]%. Oxygen was administered at 2 liters per minute via nasal cannula. R5's oxygen saturation rose only to 89% with the oxygen and her speech was garbled. LPN-E then called the MD and left a message. LPN-E then noted R5's oxygen saturation was not registering and she was non-verbal. RN-G then entered the room and the paramedics were called due to R5 being non-verbal. R5 had absent respirations minutes after the paramedics arrived. R5 was pronounced deceased at 8:50 p.m. Surveyor noted there was no conversation with the physician during R5's change in condition and no RN assessment. On [DATE] (per late entry 9:25 p.m.) LPN-F indicated at 6:30 p.m. he was called to R5's room. LPN-F determined R5's oxygen saturation level was [AGE]%; they started oxygen at 2 liters and R5's oxygen saturation went up to 89%. R5's speech was garbled and she was very confused. LPN-F told LPN-E to call the physician to report a change in condition. LPN-F then went back to his unit. On [DATE] at 7:45 p.m. RN-G indicated she came to the unit and LPN-E (Licensed Practical Nurse) asked her (RN-G) to assess R5 to see if they should send R5 out to the hospital. R5 was pale, non- verbal and RN-G indicated R5 should go to the hospital. Writer called the paramedics and the physician. Surveyor noted RN-G observed R5 but did not take R5's vital signs nor complete an assessment of R5. INTERVIEWS On [DATE] at 3:05 p.m. Surveyor spoke with LPN-E and RN-H. RN-H was present during this interview, however was not in the facility prior to the paramedics being called. LPN-E indicated after dinner (LPN-E) went into R5's room to reposition R5 in bed. R5 was noted to not be able to finish her sentences. LPN-E then got LPN-F because she felt LPN-F knew R5 and trusted LPN-F's opinion. LPN-F then placed oxygen on R5 and told LPN E to call the physician. LPN-E did not notify an RN before talking with LPN-F who was working on a different unit. LPN-E then left a message with the physician. LPN-E then indicated after this they got RN-G. However, RN-G does not document in R5 progress note until 7:45 p.m. Surveyor noted RN-G's 7:45 pm progress notes does not include a comprehensive assessment such as vital signs was conducted. LPN-E reported when RN-G came to assess R5, she (R5) could only respond in 1 word answers. RN-G wanted R5 sent out to the hospital. LPN-E had not heard back from the physician yet. RN-G started the transfer paperwork while LPN-E called the paramedics/ambulance but did not call 911. LPN-E did not indicate why 911 was not called when R5 displayed a change in condition such as a change in speech (garbled), low oxygen level and an increase in pulse rate. The paramedics arrived and requested (R5's) code status paperwork. The paramedics determined R5's Emergency Care DNR form was not valid (since it was not completed and signed by the MD). LPN-E then called the Director of Nurses (DON) at the time, who then called RN-H to come to the facility. RN-H indicated that upon arrival they called R5's family to support R5's DNR wishes. The paramedics indicated they were obligated to start CPR. R5 did receive CPR and passed away at the facility shortly afterwards. On [DATE] at 2:05 p.m. Surveyor spoke with LPN-F and reviewed R5's Progress Notes. LPN-F indicated LPN-E got him from the other unit to look at R5. LPN-F did not get an RN to assist or ask if LPN-E had told an RN about R5's symptoms. LPN-F indicated R5 was alert and her oxygen saturation was [AGE]%. LPN-F placed oxygen on R5 at 2 liters a minute. LPN-F was not able to indicate how they determined 2 liters of oxygen was appropriate. R5 did not have any physician orders [REDACTED]. LPN-F then told LPN-E R5 was having a change in condition and should call the physician. LPN-F did not perform any notifications to the RN or MD and went back to the unit he was working on. LPN-F did not have any further involvement with R5. On [DATE] at 2:35 p.m. Surveyor spoke with RN-G. RN-G reported she was working on the other side of the facility and came over to get medication out of the contingency supply (around 7:30 p.m.). RN-G indicated LPN-E approached her and asked her to look at R5. RN-G observed R5 in her bed with oxygen on, eyes dilated and a pale appearance. RN-G told LPN-E R5 needed to be sent out immediately. RN-G based this on the appearance of R5 in bed. RN-G did not obtain vital signs or conduct a further assessment. RN-G did not know why LPN-E had not approached the RN that was working on R5's side of the building. RN-G indicated she didn't mind helping and started the transfer paperwork for R5 to go out. RN-G did not make any phone calls and directed LPN-E to make the calls to the MD and paramedics. RN-G heard that the DNR paperwork was not filled out and the paramedics did CPR. RN-G did not have any further involvement. On [DATE] at 3:05 p.m. Surveyor spoke with Administrator-A, DON-B and NC-C (Nurse Consultant). R5's code status was reviewed after the incident. The facility has developed a plan to correct the code status process. Surveyor shared the lack of an RN assessment with a change of condition. NC-C indicated there is always an RN in the facility and LPNs are aware to notify them with a change in condition. On [DATE] Surveyor received the paramedic report. The paramedic report indicates they were called on [DATE] at 7:34 p.m. and arrived at the facility at 7:43 p.m., (9 minutes). The paramedic report includes the following: The facility staff last saw R5 well at 6:00 p.m. and addition (facility staff stated) R5's breath smelled like diarrhea (at 6:00 pm). R5 was observed (by the paramedics) with irregular breathing and still had a pulse. The code status paperwork was requested. The DNR form was not completed missing R5's written name, address, phone number and was not signed by a physician. The paramedics started CPR. During this time R5's family was called and confirmed R5's DNR wishes. The paramedics' MD was contacted and communicated with. Once CPR was started R5 had copious amounts of coffee ground emesis come out of her mouth. R5 was suctioned and the emesis was cleared out. At this time the paramedic MD was communicated with and ordered CPR to cease. At this time R5 was pronounced deceased at 8:50 p.m. while at the facility. The local police were not contacted due to this being a private transport request and not a 911 response. On [DATE] at 9:08 a.m. Surveyor met with Administrator-A and DON-B. Surveyor shared the following concerns with R5's change of condition; * R5 was noted to have a change in mentation/speech and vital signs (low oxygen, increase in heart rate) at 6:00 p.m. and the paramedics were not called until 7:34 p.m. (1 ½ hours later.) During this time period: * LPN-E and LPN-F did not notify an RN immediately for an acute change in condition in R5's status. * R5 received oxygen without a physician order [REDACTED].) * LPN-E did not promptly consult/communicate with a physician regarding the acute changes in condition. * Staff called the paramedic/ambulance rather than calling 911/ Emergency responders for R5's acute change in condition. * There was no RN assessment of R5's change in condition. The facility's failure to communicate promptly and directly with a physician, conduct an RN assessment and call emergency responders with an acute change in condition created a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE], when it had completed the following: * The resident affected is no longer at the facility. * The facility began staff education before Nurses started their shifts. The Nurses were educated on RN and MD notification, and the E-Interact and SBAR (Situation, Background, Assessment, Recommendation) assessment tool. * The facility did a review on current residents to ensure there was a RN assessment if needed. * The facility educated Nurses on the Change of Condition policy and Parameters of Notification policy, and completed a competency. * The facility in serviced Nursing staff on assessment expectations based upon E-Interact and AMDA (American Medical Directors Association) guidelines.

Based on observation, interview, and record review, the facility did not ensure that 2 of 7 residents at risk for falls received adequate supervision and assistance devices to prevent falls. Resident #1 was also at risk for falls. She was observed on 2 days without her bed alarm. Resident #1 was also transferred by staff without the use of a gait belt. Residents #7 was at risk for falls. The facility did not analyze Resident #7's falls and implement new interventions in an attempt to prevent further falls and injury. Findings include: 1.) Surveyor # reviewed the medical record of Resident #7 from 9/12 - 9/15/11. Resident #7 is [AGE] years old and has a [DIAGNOSES REDACTED]. The 9-15-10 MDS (Minimum Data Set) noted that Resident #7 was at risk for falls due to a history of falls. Resident #7 had 6 falls between 11-10-10 and 6-30-11. The facility did develop a care plan addressing Resident #7's risk for falling. However, after each of Resident #7's falls, the facility did not: 1) analyze the fall to identify the risks or 2)implement new interventions based on the identified risks, in an attempt to prevent Resident #7 from falling again. A review of Resident #7's falls included the following information from the facility's incident and accident reports: 11-10-10/8pm Resident #7 was found sitting on the floor in the doorway of her room. The facility had analyzed this fall and identified the following risks for Resident #7: she was incontinent and did not have her walker with her. The facility did not implement new interventions based on the identified hazards of incontinence and the resident not having her walker. The facility's new intervention for Resident #7 was that she would have "gripper socks on her feet at at all times". 11-24-10/5:30am Resident #7 was found sitting on the floor on the mat next to her bed. She sustained a Left Hip Fracture. The facility did determine that the bed was in the low position and the mat was next to her bed. The resident was wearing "gripper socks". The resident had been last toileted at 4:30am. The facility did not analyze the fall to identify the risks for Resident #7: Was a different mat needed? Did Resident #7 need a different toileting schedule? In addition to not analyzing the risks, the facility implemented no new interventions and simply noted: "no further interventions at this time". 1-17-11/4pm Staff saw Resident #7 stand up from her wheelchair. Staff called out and ran towards the resident, but she landed on the wheelchair's foot pedals. Resident #7 had no apparent injuries. In analyzing the fall, the facility identified that Resident #7 had been agitated prior to her fall. She had stated that she "wanted to get out of here and go home". The facility implemented the following intervention. Resident #7 was prescribed the anti-anxiety medication: Ativan 0.5 mg to be taken daily at noon. Although the facility attempted to use the Ativan as an intervention to address the resident's agitation, Ativan has side effects that could increase the Resident's risk for falls. According to the website "rxlist.com", Ativan can cause the following side effects: lack of balance/coordination, dizziness, tiredness, blurred vision. Additionally, the facility added the intervention of removing the foot pedals and placing anti-roll back brakes on the Resident's wheelchair. The facility did not identify what fall risks these interventions were intended to minimize. Did Resident #7 trip on the foot pedals? Did Resident #7's wheelchair roll backwards when she stood up, causing her to lose her balance? 5-14-11/8am Resident #7 was found sitting on the mat next to her bed. The resident sustained [REDACTED]. of the fall. According to Resident #7's care plan, the facility had implemented a bed alarm on 4-23-10 as an intervention to reduce her risk of falls. The facility did not analyze the fall to determine why the bed alarm had not activated. The facility implemented no new interventions to reduce Resident #7's risk of falls. 6-2-11/6:30am Staff heard Resident #7 calling her husband's name and when they went into her room, the resident was laying on her left side on the floor. The resident sustained [REDACTED]. According to Resident #7's care plan, the facility had implemented a bed alarm on 4-23-10 and a low bed on 10-4-10, as interventions to reduce her risk of falls. The facility did not analyze the fall to determine why the bed alarm had not activated and why the bed was not in the low position. The facility did implement the following new intervention. A scoop mattress was to be placed in Resident #7's bed to reduce her risk of falling from bed. 6-30-11/7:30-8pm A nurse was passing medications on the unit and noticed that Resident #7 had tried several times to stand up from her wheelchair. The nurse "tried to keep the resident close", but when the nurse was not looking, the resident stood up and fell . Resident #7 sustained a fracture to her Right Hip. The facility analyzed the fall and identified that the resident had been incontinent at the time of the fall. The facility also determined that the resident had been toileted at 6:40pm, which was about 60-90 minutes prior to her fall. The facility implemented no new interventions to reduce Resident #7's risk of falls. The facility did not analyze Resident #7's incontinence to determine if new interventions should be implemented related to her toileting schedule. On 9-14-11 at 2:55pm, Surveyor # reviewed the preceding information with the DON and the Clinical Services Consultant, Staff - Q. Staff - Q indicated that through their Quality Assurance program, the facility had identified a concern with how staff conducted investigations to identify the root cause of a problem. The facility had identified this specific to falls. An inservice had been provided to the DON, Administrator, and all Nursing Managers on 9-6-11. The facility had planned to provide this same training to all nurses. Additionally, Staff Q said that the facility would review Resident #7's falls and provide Surveyor # with additional information, if available. On 9-15-11, the DON provided Surveyor # with a "running list" of fall interventions that the facility had implemented for Resident #7 between 11-10-10 and 9-15-11. There were no specific dates as to when the interventions were implemented and why. The facility did not explain: 1) How Resident #7's falls were analyzed to identify the risks and 2) How new interventions were based on identified risks and reduced Resident #7's risk for falling. On 9/28/11 the facility supplied additional information for Surveyor # to review regarding Resident #7's falls. Surveyor # reviewed the information on 9/29/11 and noted that the facility's additional information does not address how the facility assessed and analyzed each fall to implement fall interventions that are comprehensive and address the root cause of each fall in order to prevent future falls. For example: on 7/1/11 Resident #7 was sent to the hospital following a fall where she sustained a fracture of her hip and was incontinent of bowel. Upon return to the facility on [DATE] the facility initiated a bladder patterning and indicated that this was initiated as part of the review of the fall that occurred on 6/30/11. The fall involved bowel incontinence however a bowel pattern was not initiated, a bladder pattern was. 2.) Surveyor # reviewed Resident #1's medical record on 9/12/11, 9/13/11, & 9/14/11. Resident #1 is an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The fall assessment dated [DATE] documents "New admission assessment: 86 YO (year old) female admitted from acute care s/p (status [REDACTED]. She has a medical hx (history) of COPD (chronic obstructive pulmonary disease), Osteoporosis/Osteoarthritis, Rt. (right) breast CA (cancer) s/p [PROCEDURE], Pernicious anemia, hysterectomy, appy, and multiple hip surgeries. Pleasant and confused but alert and makes own decisions. Has had other falls in the past and is at a high risk. Care plan implemented to reduce risk of falls. Low bed and mats next to bed." The ADL (Activities Daily Living) Self care deficit related to physical limitations, middle stage dementia plan of care initiated on 5/27/11 includes an intervention dated 5/27/11 of "Use gait belt to facilitate safe transfer and ambulation." The at risk of falls due to impaired balance/poor coordination, unsteady gait, cognitive impairment, poor safety awareness, history of falls plan of care initiated on 5/27/11 includes an intervention dated 9/12/11 of "Ensure that tab alarm is in place when in w/c (wheel chair) and bed." Since admission to the Facility, Surveyor # noted Resident #1 fell on [DATE] and 9/10/11. On 9/12/11 at 11:27 a.m. Surveyor # reviewed the Patient information worksheet dated 9/12/11. The Patient information worksheet is used by the CNA's (Certified Nursing Assistant) and directs staff on how to care for the Residents. This worksheet includes information for the following categories: transfer/ambulation, safety devices/restraints, skin care, bowel/bladder, food/fluids, special needs and additional information. Surveyor # noted for Resident #1 under the section transfer ambulation indicates 1 person/gait belt and under the section safety devices/restraints "tab alarm bed w/c (wheel chair)" is checked. On 9/12/11 at 12:08 p.m. Surveyor # observed Resident #1 sitting on the edge of the bed. The tab alarm was not attached to Resident #1. At 12:09 p.m. RN (Register Nurse)-D entered Resident #1's room and informed Resident #1 that she was going to do her treatment. Resident #1 informed RN-D that she has to go to the bathroom. RN-D placed a walker by Resident #1's bed, raised the height of the bed, and assisted Resident #1 to stand by holding onto Resident #1's left arm and hand. RN-D then ambulated with Resident #1 into the bathroom. RN-D did not use a gait belt. Resident #1 pulled down her own slacks and RN-D assisted Resident #1 to sit on the toilet. RN-D informed Resident #1 that she would give her some privacy and left the bathroom. A couple minutes later, RN-D asked Resident #1 how she was doing. Resident #1 informed RN-D that she was all finished and RN-D along with Surveyor # entered the bathroom. RN-D assisted Resident #1 with standing and pulled up Resident #1's pull up product and slacks. RN-D then ambulated with Resident #1 out of the bathroom to her bed. RN-D did not use a gait belt. At 12:21 p.m. until 12:31 p.m. Surveyor # observed the treatment for [REDACTED]. After RN-D was completed with the treatment, Resident #1's pull up product and slacks were pulled up, Resident #1 was covered with blankets, call light was placed within reach and the curtain was opened. RN-D gathered her supplies and left the room. Surveyor # noted that the tabs alarm was not attached to Resident #1. On 9/12/11 at 12:37 p.m. Surveyor # checked the tab alarm and observed the tabs alarm was not attached to Resident #1 but was resting on the left hand side of the pillow. On 9/12/11 at 12:40 p.m. Surveyor # asked RN-D if Resident #1 can move herself in bed. RN-D stated "yes, and sometimes she gets up." RN-D informed Surveyor # that they were trying to reduce the alarm but Resident #1 got up at night because she thought she heard music and fell . RN-D informed Surveyor # that Resident #1 hurt her side, they had an x-ray done and there was no fracture. On 9/12/11 at 1:29 p.m. Surveyor # observed Resident #1 in bed on her back. The alarm is not attached to Resident #1 and is resting on the pillow. On 9/12/11 at 2:10 p.m. Surveyor # observed Resident #1 continues to be in bed and the alarm is now attached. On 9/13/11 at 8:00 a.m. Surveyor # observed Resident #1 in bed on her back with the head of the bed elevated. Surveyor # observed the alarm box is attached to the bed frame under the mattress. Surveyor # did not observe the alarm attached to Resident #1 and asked Resident #1 if Surveyor # could look under her pillow. After Resident #1 gave permission, Surveyor # observed the tab sections that attaches to the Resident is under the pillow and not attached to Resident #1. On 9/13/11 at 8:21 a.m. Surveyor # observed CNA (Certified Nursing Assistant)-N enter Resident #1's room with her breakfast tray. CNA-N placed the breakfast tray on the over bed table, repositioned Resident #1 into the center of the bed, raised the head of the bed and placed the over bed table across the bed. CNA-N then left Resident #1's room. Surveyor # observed the tabs alarm continues not to be attached to Resident #1. On 9/13/11 at 8:44 a.m. Surveyor # observed CNA-N remove Resident #1's breakfast tray. On 9/13/11 at 9:05 a.m. Surveyor # observed CNA-O reposition Resident #1 on her right side. Surveyor # observed that the tabs alarm continues not to be attached to Resident #1. On 9/13/11 at 10:23 a.m. Surveyor # observed Resident #1 continues to be on her right side. The tab alarm is not attached to Resident #1. On 9/13/11 at 10:31 a.m. Surveyor # observed CNA-N enter Resident #1's room and inform Resident #1 that she is going to reposition her. CNA-N repositioned Resident #1 on her left side, asked Resident #1 how she was feeling, covered Resident #1 with blankets, raised the head of the bed and lowered the bed. CNA-N placed the call light in reach, washed her hands and left Resident #1 room. Surveyor # observed the tabs alarm is not attached to Resident #1. On 9/13/11 at 10:53 a.m. Surveyor # observed CNA-N ambulating with Resident #1 into the bathroom using a gait belt and assisted Resident #1 to sit on the toilet. CNA-N provided Resident #1 with privacy. Surveyor # asked CNA-N if she always uses a gait belt when ambulating with Resident #1. CNA-N replied "yes, because she's a little unsteady." At 10:59 a.m. LPN (Licensed Practical Nurse-S entered Resident #1's bathroom and asked Resident #1 how she was feeling. CNA-N assisted Resident #1 up from the toilet and ambulated with Resident #1 to her bed. CNA-N removed the gait belt and CNA-N & LPN-S assisted Resident #1 with laying down in bed. CNA-N washed hands and left Resident #1's room. At 11:02 a.m. LPN-S administered a pain medication to Resident #1, covered Resident #1, informed Resident #1 where her call light was, washed her hands, and left the room. Surveyor # observed the tabs alarm was not attached to Resident #1. On 9/13/11 at 12:05 p.m. Surveyor # observed Resident #1 asleep on her back. The tabs alarm is not attached to Resident #1. On 9/13/11 at 1:00 p.m. Surveyor # observed Resident #1 continues to be in bed. The tabs alarm is not attached to Resident #1. On 9/13/11 at 2:15 p.m. Surveyor # observed Resident #1 in bed on her back. The tabs alarm is not attached to Resident #1. On 9/13/11 at 2:22 p.m. Surveyor # asked RN Manager-C if Resident #1 has alarms. RN Manager-C informed Surveyor # that they did a trial reduction for the alarms but then Resident #1 had a fall. RN Manager-C informed Surveyor # that Resident #1 has a tabs alarm in bed and in the wheel chair. Surveyor # informed RN Manager-C of the observations of Resident #1 being without the tabs alarm on two days. On 9/14/11 at 10:45 a.m. Surveyor # asked RN Manager-C if Resident #1 should be transferred with a gait belt. RN Manager-C responded "yes." Surveyor # informed RN Manager-C of the observation on 9/12/11 of Resident #1 being transferred without a gait belt. On 9/14/11 at 3:28 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above.

Based on record review and staff interview, the facility did not ensure that 7 of 7 residents reviewed (Resident's #8, #13, #10, #11, #1, #7, and #22) with a bowel decline were not reassessed following the decline to assist in the development of an appropriate plan of care for bowel management. -On 2/24/10 Resident #8 was assessed on the minimum data set as being occasionally incontinent of bowel movements. On 5/20/10 Resident #8 was assessed on the minimum data set as being frequently incontinent of bowels; this demonstrates a decline in bowel continence. The facility did not thoroughly reassess Resident #8's bowel continence status after the noted decline to assist in the development of an accurate plan of care for Resident #8. On 8/24/10 Resident #8 was noted to have 2 emesis' of undigested food and had a positive rectal check. -Resident #13 was assessed on 8/12/10 on the minimum data set as being incontinent of bowel less than weekly. On 8/15/10 Resident #13's minimum data set indicates that Resident #13 is incontinent of bowels weekly; this indicates a decline. The facility did not thoroughly reassess Resident #13's bowel continence status after the noted decline to assist in the development of an accurate plan of care for Resident #13. -On 3/5/10 Resident #10's admission minimum data set documents that Resident #10 is continent of bowel. On 6/30/10 Resident #10's significant change minimum data set indicates that Resident #10 is occasionally incontinent of bowels; this indicates a decline. The facility did not thoroughly reassess Resident #10's bowel continence status after the noted decline to assist in the development of an accurate plan of care for Resident #10. -Resident #11 was assessed on the admission minimum (MDS) data set [DATE] as being continent of bowel. On 6/30/10 the quarterly minimum data set reflects that Resident #11 was occasionally incontinent of bowel; this indicates a decline. The facility did not thoroughly reassess Resident #11's bowel continence status after the noted decline to assist in the development of an accurate plan of care for Resident #11. -On 3/8/10 Resident #7's initial minimum data set reflects that Resident #7 is continent of bowels. On 7/14/10 a significant change in status minimum data set refects that Resident #7 is incontinent of bowels at least once weekly; this reflects a decline. The facility did not thoroughly reassess Resident #7's bowel continence status after the noted decline to assist in the development of an accurate plan of care for Resident #7. -On 2/2/10 Resident #1 was assessed on a significant change minimum data set as frequently being incontinent of bowels. On 7/27/10 a quarterly minimum data set assessment reflects that Resident #1 is totally incontinent of bowels; this reflects a decline. The facility did not thoroughly reassess Resident #1's bowel continence status after the noted decline to assist in the development of an accurate plan of care for Resident #1. -On 12/24/09 Resident #22's initial minimum data set reflects that Resident #22 is occasionally incontinent of bowels. On 6/15/10 a quarterly minimum data set reflects that Resident #22 is frequently incontinent of bowels; this reflects a decline. The facility did not thoroughly reassess Resident #22's bowel continence status after the noted decline to assist in the development of an accurate plan of care for Resident #22. Findings include: 1. Resident #8's medical record was reviewed by Surveyor # . Resident #8 has resided in the facility since 12/4/08. Resident #8's current medications include [MEDICATION NAME] 2 tabs twice a day. Resident #8's significant change in status MDS (minimum data set) completed on 2/24/10 indicates that Resident #8 is occasionally incontinent of bowels and requires complete assistance with hygiene. Resident #8's quarterly MDS dated [DATE] indicates that Resident #8 is frequently incontinent of bowels and requires complete assistance with bowels. This reflects a decline in Resident #8's bowel continence status. Resident #8 nurses notes dated 8/24/10 at 10:00 a.m. indicated emesis 2 times of undigested food. On 8/24/10 at 1:00 p.m. indicates a positive rectal check, when administering a [MEDICATION NAME] suppository for nausea. which there was stool in the rectum. A positive rectal check indicates there is stool felt in the rectum. Resident #8 bowel movement records do not reflect Resident #8 having stool in the rectum area. The bowel record does not indicate that Resident #8 has been without some type of a bowel movement. Resident #8 did not have a plan of care addressing bowel incontinence in the medical record. There was not a bowel assessment that indicated why Resident became more incontinent or what measures were assessed to prevent further incontinence. There was not a bowel assessment to address concerns with Resident #8 having stool in the rectum when administering a suppository medicine for nausea. On 9/14/10 at 2:20 p.m. RNC-M (registered Nurse Consultant) and DON-B (Director of Nurses) spoke with Surveyors # , # and # regarding the facility's bowel policies and procedures. RNC-M supplied a Bowel Management sheet that included 5 squared off sections on the page. RNC-M indicated that this was part of their policies, which are based on AMDA (American Medical Director Association) guidelines. The Bowel Management indicates if a resident has difficulty having bowel movements, constipation, changing bowel habits need to be assessed and addressed on the care plan. On 9/14/10 at 3:23 p.m. at the daily exit meeting, which included Administrator-A and DON-B, Surveyor # shared the concerns regarding Resident #8 bowel continence status and that there is no care plan available regarding Resident #8's bowel status. On 9/15/10 at 3:51 p.m. at the facility daily exit meeting, no further information was provided on why Resident #8 did not have a current bowel care plan or bowel patterning/assessments for becoming more incontinent and explanation for why on 8/24/10 Resident #8 was found to have stool in the rectum area. 2. On 9/14/10 Resident #13's medical record was reviewed by Surveyor # . Resident #13's Initial MDS (minimum data set) with a assessment reference date of 8/12/10, which is 1 week after admission to the facility, indicates Resident #13's bowel incontinence is less than weekly. The following MDS with a assessment reference date of 8/15/10, indicates that Resident #13 has occasional bowel incontinence of at least once a week. This reflects a decline in bowel continence status. There is not a bowel patterning that correlates with this information On 9/14/10 Resident #13's medical record was reviewed by Surveyor # . Resident #13's plan of care for Bowel Elimination with a date of being initiated 8/23/10 does not have interventions for bowel incontinence or patterns. On 9/14/10 Surveyor # reviewed Resident #13's current physician orders. The orders, as of 8/10/10, indicate to administer [MEDICATION NAME] ( a stool softening agent) 240 milligram every day. On 9/14/10 Surveyor # reviewed Resident #13's nurses notes. On 8/15/10 Resident #13 complained of constipation and was given Exlax. No follow-up assessment was noted in the nurses notes after the Exlax was administered. On 8/20/10 Resident #13 had stool manually removed by staff and then administered Milk of Magnesium and a [MEDICATION NAME] suppository, which resulted in a semi-hard bowel movement. Resident #13's constipation concerns are not addressed on the plan of care. On 9/14/10 at 2:20 p.m. RNC-M(registered Nurse Consultant) and DON-B (Director of Nurses) spoke with Surveyors # , # and # regarding the facility's bowel policies and procedures. RNC-M supplied a Bowel Management sheet that included 5 squared off sections on the page. RNC-M indicated that this was part of their policies, which are based on AMDA (American Medical Director Association) guidelines. The Bowel Management indicates if a resident has difficulty having bowel movements, constipation, changing bowel habits need to be assessed and addressed on the care plan. The Bowel Management squares do not direct to give Milk of Magnesium with a [MEDICATION NAME] suppository. On 9/14/10 at 3:23 p.m. at the daily exit meeting, which included Administrator-A and DON-B, Surveyor # shared Resident #13's bowel management concerns. On 9/15/10 at 3:51 p.m. at the facility daily exit meeting, no further information was provided on why Resident #13 did not have a current bowel care plan to address patterns and constipation issues. 3. Resident #10 is an [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The nursing admission evaluation dated 2/22/10 under the section gastrointestinal for abdomen "soft"is checked, bowel sounds "normal" is checked, bowel functions is not checked for continent or incontinent, date of last BM (bowel movement) is "2/21" and bowel frequency is "every other day." The admission MDS (minimum data set) dated 3/5/10 documents that Resident #10 is continent of bowel. The bladder patterning and analysis worksheet dated 2/24/10, 2/25/10, and 2/26/10 documents "C" continent. Bowel movements are not documented on this worksheet. The next time this worksheet was completed was 9/4/10, 9/5/10, and 9/6/10. The significant change MDS dated [DATE] documents that Resident #10 is occasionally incontinent of bowel. The urinary incontinence RAP (resident assessment protocol) summary dated 6/21/10 does not address Resident #10's bowels. On 9/9/10 & 9/13/10 Surveyor # reviewed Resident #10's medical record and was unable to locate a bowel assessment when there was a decline in Resident #10's bowel status. On 9/14/10 at 2:20 p.m. Surveyor # , Surveyor # and Surveyor # met with the Director of Nursing and Corporate RN-M to inquire if the Facility completed bowel assessments. The Director of Nursing informed the survey team that the Facility follows AMDA (American Medical Directors Association) guidelines for gastrointestinal disorders. The survey team noted this guideline does not address initial bowel assessments. Corporate RN-M explained that they document every day if a Resident has a bowel movement and if there is a change in the bowel pattern the CNA (Certified Nursing Assistant) would notify them. They also run a report which is specific for no BM in three days. Surveyor # informed the Director of Nursing and Corporate RN-M that the Survey team understood the Facility's system for monitoring Resident's bowels for no bowel movement but was unable to find a bowel assessment when a Resident is admitted or if there was a change in bowel status. At 2:49 p.m. on 9/14/10, Surveyor # informed the Director of Nursing and Corporate RN-M that Surveyor # was unable to locate a bowel assessment for Resident #10 when there was a decline in bowel status that was identified on the 6/21/10 significant change MDS. On 9/14/10 at 4:20 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above. As of the exit date of 9/16/10 Surveyor # was not provided with an bowel assessment for Resident #10 when there was a decline in bowel status that was identified on the 6/21/10 significant change MDS. 4. Resident #11 is an [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The admission MDS (minimum data set) dated 4/21/10 documents that Resident #11 is continent of bowel. The bladder patterning and analysis worksheet dated 6/23/10, 6/24/10, and 6/25/10 documents Foley catheter. Bowel movements are not documented on this worksheet. The quarterly MDS dated [DATE] documents that Resident #11 is occasionally incontinent of bowel. On 9/13/10 Surveyor # reviewed Resident #11's medical record and was unable to locate a bowel assessment when there was a decline in Resident #11's bowel status. On 9/13/10 at 11:42 a.m. Surveyor # asked RN (Registered Nurse)-G if they complete bowel assessments. RN-G replied "yes." Surveyor # informed RN-G that Resident #11's admission MDS dated [DATE] documents that she is continent of bowel and on the quarterly MDS dated [DATE] documents that Resident #11 is occasionally incontinent of bowel. Surveyor # informed RN-G that Surveyor # was unable to locate an assessment when there was a decline in Resident #11's bowels. RN-G informed Surveyor # that she would have to get back to surveyor. On 9/14/10 at 10:56 a.m. Surveyor # observed Resident #11 sitting on the toilet. CNA-QQ placed a pull up incontinence product and slacks on Resident #11 leaving them by her ankles. CNA-QQ assisted Resident #11 to stand and washed the buttocks with a disposable wash cloth. Resident #11 asked CNA-QQ if she went. CNA-QQ replied "no." Resident #11 stated "Maybe I'm constipated." On 9/14/10 at 2:20 p.m. Surveyor # , Surveyor # and Surveyor # met with the Director of Nursing and Corporate RN-M to inquire if the Facility completed bowel assessments. The Director of Nursing informed the survey team that the Facility follows AMDA ( American Medical Directors Association) guidelines for gastrointestinal disorders. The survey team noted this guideline does not address initial bowel assessments. Corporate RN-M explained that they document every day if a Resident has a bowel movement and if there is a change in the bowel pattern the CNA (Certified Nursing Assistant) would notify them. They also run a report which is specific for no BM in three days. Surveyor # informed the Director of Nursing and Corporate RN-M that the Survey team understood the Facility's system for monitoring Resident's bowels for no bowel movement but was unable to find a bowel assessment when a Resident is admitted or if there was a change in bowel status. At 2:49 p.m. on 9/14/10, Surveyor # informed the Director of Nursing and Corporate RN-M that Surveyor # was unable to locate a bowel assessment for Resident #11 when there was a decline in bowel status that was identified on the 6/30/10 quarterly MDS. On 9/14/10 at 4:20 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above. As of the exit date of 9/16/10 Surveyor # was not provided with an bowel assessment for Resident #11 when there was a decline in bowel status that was identified on the 6/30/10 quarterly MDS. 5. Resident #7 is [AGE] years old and was admitted to the facility on [DATE] with generalized weakness, dementia, diabetes and is legally blind. Resident #7's Nursing Admission Evaluation dated 2/23/10 indicates Resident #7 is continent of bowel, has a soft abdomen, normal bowel sounds, date of last BM (bowel movement) was 2/22, and Resident #7 reports bowel frequency of every other day. Resident #7's Initial MDS (Minimum Data Set) dated 3/8/10 indicates Resident #7 is totally continent of bowel, and has no short or long term memory problems, and is independent in cognitive skills for daily decision-making. A readmission Nursing Admission Evaluation dated 3/24/10 indicates Resident #7 is continent of bowel, unknown date of last BM, bowel frequency every day. A readmission Nursing Admission Evaluation dated 6/23/10 indicates Resident #7 is continent of bowel, unknown date of last BM, unknown bowel frequency. A Significant Change in Status Assessment MDS completed 7/14/10 indicates Resident #7 was now incontinent of bowel at least once a week. Resident #7 was hospitalized from [DATE] to 6/23/10 for a pelvic fracture suffered in a fall. Surveyor # did not observe any further assessment of Resident #7's decline in bowel continence. Nurses' Notes dated 6/26/10 at 2:50 p.m. state "incontinent of B&B" (bowel and bladder). While a Bladder patterning and Analysis Worksheet was observed in Resident #7's medical record, Surveyor # did not note any bowel assessment or patterning. Nurses notes periodically indicate Resident #7 received MOM (Milk of Magnesia) for constipation, and occasionally receives a [MEDICATION NAME] suppository (stimulant laxative). Resident #7's physician orders [REDACTED]. The CNA (Certified Nursing Assistant) Care Card for Resident #7 states Bowel/Bladder: Toileting Program: "P". The legend at the bottom of the page states a "P" for toileting program means Prompted voiding- upon rising, before and after meals, hs (hour of sleep), and prn (as needed). It is the same prompted schedule for all residents on a prompted voiding plan; it is not individualized to meet the resident's specific needs and patterns. Surveyor # reviewed Resident #7's Bowel Elimination Care Plan dated 6/24/10 which states: Bowel Elimination Alteration: constipation related to lack of exercise, medications and decreased mobility. Goal is Resident will have a bowel movement at least every three days. Interventions include: administer meds as ordered, dietary evaluation and recommendations, encourage and assist resident to consume all fluids as offered at and between meals, monitor and report and signs and symptoms of constipation such as abdominal cramping, diarrhea, nausea, vomiting, or no BM for three days, notify MD of any changes in bowel function, record BM and note size and consistency, report any abnormalities. The Care Plan "At risk for adverse effects related to use of antidepressant medication, use of antianxiety/anxiolytic medication has an intervention of "Monitor bowel elimination pattern and follow bowel regimen for establishing elimination routine." On 9/13/10 Surveyor # interviewed RN Mgr.-C asking if facility staff assess a resident's bowel pattern to use to plan individualized care if a resident is incontinent. RN-C stated they conduct bladder pattern assessments, but not bowel patterning assessments. Surveyor # asked if any bowel assessment was completed for Resident #7. RN-C stated a bowel assessment is completed upon admission and re-admission. Surveyor # noted that documents current bowel sounds, continent or incontinent, last BM, and reported frequency of BM (for Resident #7, her frequency in those forms varies from leaving that item blank, to every day, to every other day. Surveyor # noted it does not look all the components of a resident's bowel program, such as are they taking any medications or food that causes constipation or diarrhea, what does data show regarding a resident's pattern, what medications a resident is taking specifically for bowel management, etc. Surveyor # noted Resident #7 was continent of bowel and now is incontinent at least once a week, and asked what staff have done to try to assist Resident #7 become continent again if possible. RN-C was not familiar with what standard of practice the facility follows regarding bowel management, noting she recently became a manager. RN-C stated they do monitor whether or not a resident has a bowel movement in the last 9 shifts/ 3 days. If not, they have a protocol to administer MOM, if that is not effective, the resident is given a suppository. On 9/14/10 at approximately 8:30 a.m., Surveyor # asked Corporate RN-M what assessments facility staff conduct regarding bowel incontinence, and if staff conduct any type of patterning for residents incontinent of bowel. RN-M stated they get the pattern from data in the electronic CNA charting, and she would check on the assessments. Surveyor # asked for any bowel assessments and/or patterning for Resident #7, and information on Resident #7's bowel monitoring from 9/1/10 to 9/13/10, noting the decline in bowel continence. Approximately 10:00 a.m., MDS RN-L informed Surveyor # they are having difficulty printing the bowel information that CNAs enter in the computer; it only prints out two days at time. RN-L showed Surveyor # "pointclickcare" bowel movement documentation on the computer for Resident #7 from 9/1/10 to 9/14/10. The CNA documentation reviewed was charted once a shift. For example, day shift usually charted around 9-10 a.m., and second shift charted around 9:00 p.m. So if Resident #7 was noted to be toileted at 9:00 a.m., and the next documentation is at 9:00 p.m. indicating Resident #7 was incontinent of bowel, staff do not really know when Resident #7 was incontinent of BM, they just know it happened between 9:00 a.m. and 9:00 p.m. On 9/14/10 at 12:55 p.m., Surveyor # interviewed Corp. RN-M with Surveyor # present, asking again what bowel assessments staff are to complete, and what standard of practice the facility follows, and for any Policies and Procedures regarding bowel management. RN-M stated residents' bowels are assessed on admission using the Nursing Admission Evaluation. This was noted earlier to just identify continent or not, date of last BM, and self-reported frequency; it is not a comprehensive assessment that addresses medications, cognitive ability to identify the urge to defecate, functional and mobility issues, etc. RN-M provided Surveyors with the following documents: Common Types of Urinary Incontinence, Urinary Incontinence Management Methods, a Bladder Patterning and Analysis Worksheet, and Quality of Life Basics: Urinary Incontinence and Indwelling Catheter Guidelines. Surveyor # asked what policies, standards of practice or guidelines facility staff use regarding bowel incontinence. RN-M provided surveyors with one sheet of paper with what appear to be five Powerpoint-type slides, the first one being the title "Bowel Management". Slide 2 states: Residents need to be assessed on admission and on a daily basis for bowel movements. The information is gathered and documented by the CNAs on POC (Point of Care) and in addition, the CNA is to alert the nurse to any difficulty the resident may have or any abnormal stools. Slide 3: The DCD's (unit managers) review the alert list daily. The night nurse reviews the BM alerts on all residents in house and contacts dietary each morning with a list of residents who have not had a bowel movement by the 3rd day per BM record. Slide 4: Per facility policy, give MOM (milk of magnesia) with an order. Also, ensure adequate hydration. Slide 5: Continue to monitor for bowel movements. If the resident still has not had a bowel movement, notify physician for further orders (suppository, enema). Difficulty having bowel movements, constipation, changing bowel habits need to be assessed and addressed on the care plan. The one page with the above-noted slides are the only type of guideline or policy provided regarding bowel assessment and management. While staff are instructed to "assess" on admission, it does not identify what the assessment should consist of, or how it should be conducted to obtain pertinent resident-specific information needed to then develop an individualized care plan. Surveyor # asked RN-M what standard of practice or professional guidelines the slides were based on. RN-M stated she wan not sure, but they follow their Quality of Life Basics, approved by the corporate medical director and the local medical director. Surveyor # asked when the facility medical director (MD-KK) reviewed and approved of the bowel management program. RN-M stated she would find out when MD-KK approved the program and get a copy of their assessment tool to help explain their process. Surveyor # asked if there was anyone else we should talk to to understand the facility's bowel management program. RN-M stated she would go find out, and left the room at 1:00 p.m. On 9/14/10 at 2:20 p.m. Surveyor # , Surveyor # , Surveyor # and Surveyor # met with the Director of Nursing and Corporate RN (Registered Nurse)-M to inquire if the Facility completed bowel assessments. The Director of Nursing informed the survey team that the Facility follows AMDA ( American Medical Directors Association) guidelines for gastrointestinal disorders. The survey team noted this guideline does not address initial bowel assessments. RN-M explained that they document every day if a Resident has a bowel movement and if there is a change in the bowel pattern the CNA (Certified Nursing Assistant) would notify them. They also run a report which is specific for no BM in three days. Surveyor # informed the Director of Nursing and RN-M that the Survey team understands how facility staff are to monitor Resident's bowels for no bowel movement but was unable to find a comprehensive bowel assessment when a Resident is admitted or if there was a change in bowel status. Surveyor # asked if staff conduct bowel patterning. RN-M stated not formally, but they review CNA documentation. (Note: this is is usually once a shift documentation). Surveyor # requested any bowel assessment or patterning/ follow-up conducted after it was noted Resident #7 went from total bowel continence to incontinent at least once a week. No further information was provided specific to Resident #7. On 9/15/10 surveyors were presented with a statement signed on 9/14/10 by MD-KK stating he has approved and does approve the policies and quality of life guidelines of HCR Manorcare, including...bowel management. 6. Resident #1 is [AGE] years old and was admitted to the facility on [DATE] with major [DIAGNOSES REDACTED]. Resident #1's Significant Change is Status MDS (Minimum Data Set) dated 2/2/10 indicates Resident #1 is frequently incontinent of bowel- episodes occur two to three times per week. Resident #1's Quarterly MDS dated [DATE] indicates Resident #1 is totally incontinent of bowel; bowel incontinence is all or almost all of the time. Surveyor # observed a Nursing Admission Evaluation gastrointestinal assessment dated [DATE] stating Resident #1's abdomen was soft; no symptoms of nausea, vomiting, diarrhea, cramping or constipation; normal bowel sounds; incontinent of BM; date of last BM- unknown; and bowel frequency - unknown. Surveyor # did not observe any type of bowel assessment or patterning in the medical record further assessing Resident #1's decline in bowel continence, or identifying possible patterns of when Resident #1 has a bowel movement to help staff plan interventions to keep him as continent as possible. Surveyor # reviewed Resident #1's CNA (Certified Nursing Assistant) care plan dated 9/14/10 which states: Bowel/Bladder: C (Care and Comfort = check and change every two hours). It notes Resident #1 wears briefs. Resident #1's Bowel incontinence related to impaired mobility dated 8/4/10 states: Goal- will have no complications. Interventions include: Explain use of "special underwear" to make them feel more comfortable; monitor for and report changes in bowel movement frequency; notify family/significant other of changes in functional ability; toilet upon rising, before/after meals, at bedtime and prn (as needed), check for bowel incontinence frequently and provide incontinent care prn; record BM, note size and consistency, report any abnormalities. Resident #1 also has a care plan for bowel elimination alteration: constipation related to history of constipation dated 11/13/07 and revised 3/27/08. Goal- maintain regular bowel movements every 1-3 days; will have BM at least every three days. Interventions: evaluate bowel sounds/abdomen prn; record BM, monitor for s/s (signs and symptoms) of constipation such as abdominal cramping, diarrhea, nausea, vomiting, no BM for 3 days; notify MD of any changes in bowel function. On 9/13/10 at 11:40 a.m., Surveyor # observed Resident #1 tell CNA-UU he needed to use the urinal. CNA-UU took Resident #1 to his room to use the urinal, but Resident #1 was unable to void. Resident #1's brief was dry. Surveyor # later interviewed CNA-UU, asking if Resident #1 knew when he needed to void, since he asked for the urinal. CNA-UU stated he does ask for the urinal, and they assist him with it, but he usually has already been incontinent by that time. When asked if Resident #1 can use a bed pan for bowel movements, CNA-UU stated yes, but Resident #1 usually has bowel movements later in the afternoon or evening; he doesn't have BMs too often during day shift. On 9/13/10 at 1:00 p.m., Surveyor # observed CNA-UU and CNA-VV transfer Resident #1 to bed so the nurse could perform a treatment to Resident #1's bottom. Resident #1 was noted to be incontinent of a small, somewhat hard BM; peri-care was provided. On 9/13/10 Surveyor # interviewed RN Mgr.-C asking if facility staff assess a resident's bowel pattern to use to plan individualized care if a resident is incontinent. RN-C stated they conduct bladder pattern assessments, but not bowel patterning assessments. Surveyor # asked if any bowel assessment was completed for Resident #1. RN-C stated a bowel assessment is completed upon admission and re-admission. Surveyor # noted that assessment documents current bowel sounds, continent or incontinent, last BM, and reported frequency of BM (for Resident #, his frequency and last BM are "unknown"). Surveyor # noted it does not look all the components of a resident's bowel program, such as are they taking any medications or food that causes constipation or diarrhea, what does data show regarding a resident's pattern, what medications a resident is taking specifically for bowel management, what functional or mobility issues affect continence, does the resident feel the urge to defecate, etc. Surveyor # noted Resident #1 was frequently incontinent of bowel and now is totally incontinent all the time, and asked what staff have done to try to assist Resident #1 become more continent if possible. RN-C was not familiar with what standard of practice the facility follows regarding bowel management, noting she recently became a manager. RN-C stated they do monitor whether or not a resident has a bowel movement in the last 9 shifts/3 days. If not, they have a protocol to administer MOM, if that is not effective, the resident is given a suppository. On 9/14/10 at approximately 8:30 a.m., Surveyor # asked Corporate RN-M what assessments facility staff conduct regarding bowel incontinence, and if staff conduct any type of patterning for residents incontinent of bowel. RN-M stated they get the pattern from data in the electronic CNA charting, and she would check on the assessments. Surveyor # asked for any bowel assessments and/or patterning for Resident #1, and information on Resident #1's bowel monitoring from 9/1/10 to 9/13/10, noting the decline in bowel continence. Approximately 10:00 a.m., MDS RN-L informed Surveyor # they are having difficulty printing the bowel information that CNAs enter in the computer; it only prints out two days at time. RN-L showed Surveyor # "pointclickcare" bowel movement documentation on the computer for Resident #1 from 9/1/10 to 9/14/10. The CNA documentation reviewed was charted once a shift. For example, on 9/6/10, night shift documented no BM at 4:03 a.m., and day shift documented at 1:59 p.m. indicating Resident #1 was incontinent of bowel. Without knowing when staff may have checked Resident #1 for a BM between 4:03 a.m. and almost 2:00 p.m., staff do not really know when Resident #1 was incontinent of BM, they just know it happened between 4:00 a.m. and 2:00 p.m. More specific information would be needed to plan an individualized bowel management program for Resident #1. On 9/14/10 at 12:55 p.m., Surveyor # interviewed Corp. RN-M with Surveyor # present, asking again what bowel assessments staff are to complete, and what standard of practice the facility follows, and for any Policies and Procedures regarding bowel management. RN-M stated residents' bowels are assessed on admission using the Nursing Admission Evaluation. This was noted earlier to just identify continent or not, date of last BM, and self-reported frequency; it is not a comprehensive assessment that addresses medications, cognitive ability to identify the urge to defecate, functional and mobility issues, etc. RN-M provided Surveyors with the following documents: Common Types of Urinary Incontinence, Urinary Incontinence Management Methods, a Bladder Patterning and Analysis Worksheet, and Quality of Li

Based on record review, staff interviews and observations, the facility did not always ensure that they keep the residents environment as free from accident hazards as possible. The facility did not always ensure that 7 out of 9 sampled residents ( #7, #24, #15, #8, #13, #11 and #10) who were at risk for falls, were provided with adequate supervision and assistance devices to prevent accidents. During the survey it was noted that on 2 different occasions a treatment cart, containing various supplies was left unlocked out on the living unit. Resident #7 had multiple falls and the facility did not investigate potential root causes of the falls and reassess Resident #7 to develop new interventions to prevent further falls. Resident #7 sustained a pelvic fracture in her last fall. Resident #7 was observed multiple times without her alarm activated. Resident #24 was assessed to be at risk for falls and on 6/6/10, was not provided with a bed alarm and a mat to the floor as per her plan of care dated 6/5/10. On 6/6/10, Resident #24 was then provided with the wrong mattress to her bed, resulting in her sliding from the bed and sustaining a laceration to her forehead which required treatment and evaluation in the emergency room . Resident #15 had 12 falls between 6/15/10 and 9/2/10. After each of these falls, the facility did not review and comprehensively assess each of these falls and evaluate and update the care plan as needed. Resident #8 who is on hospice as of 2/15/10, had a fall from her Broda chair on 5/17/10 and the staff were educated to lock the wheels on the Broda chair prior to transferring the resident from the chair. On 9/9/10, Surveyor # observed that facility staff did not lock the wheels on the Broda chair prior to transferring Resident #8. Additionally, Resident # 8 had a fall on 5/27/10. The 5/27/10 fall was not comprehensively assessed by a Registered Nurse. Resident #13 had a fall on 8/13/10 that was not comprehensively assessed by facility staff. Resident #11 who was placed on hospice on 6/2/10, had a history of [REDACTED]. On 9/13/10, Resident #11 was observed in bed and there were no landing strips to the right side of the bed as per plan of care initiated on 4/8/10 and revised on 4/27/10 and per patient information worksheet dated 9/8/10. Resident #10 who was placed on hospice on 6/2/10, had a history of [REDACTED]. Findings include: 1. Resident #7 is [AGE] years old and was admitted to the facility on [DATE] with generalized weakness, dementia, diabetes and is legally blind. Resident #7's Initial Nursing Evaluation dated 2/23/10 indicates Resident #7 is a Fall Risk due to history of falls, syncope/vertigo/dizziness, unsteady gait and diuretic medication. Resident #7's initial MDS (Minimum Data Set) dated 3/8/10 indicates Resident #7 had a fall within the previous 0-30 days. The MDS indicates Resident #7 has impaired vision and wears glasses regularly. Resident #7 needed limited assistance of one person for transfers, ambulation and toileting. Resident #7 was sent to the hospital for chest pain and urinary tract infection, and was re-admitted [DATE]. A Nursing Admission assessment dated [DATE] states Resident #7 is blind in her right eye, needs assistance for ambulation, transfers, dressing and toileting, and uses a walker, cane or crutch. Under the section "Fall Risk" staff are to check all that apply and they indicate Resident #7 has a history of falls- that is the only item checked. Staff did not check Resident #7 for diuretics or cardiovascular medication although she receives the diuretic furosemide 20 mg. (milligrams) each morning, and Isordil (anti-anginal) 40 mg. every morning and lisinopril 20 mg. a day (for hypertension), nor did they check Resident #7 had weakness. Information regarding drug to drug interactions for Isordil states, "Anti-hypertensives-may increase hypotensive effects" (Nursing 2007 Drug Handbook). Drug to drug interactions for lisinopril state, "Diuretics- May cause excessive hypotension with diuretics. Monitor blood pressure closely." Neither the use of these drugs nor their potential interactions is noted on the assessment. On 9/20/10, Heartland Pharmacy confirmed the furosemide and lisinopril were prescribed for Resident #7 on 2/23/10 (day of admission) and the Isordil was started on 3/21/10, the day of re-admission and day of the assessment. The Falls RAP (Resident Assessment Protocol) dated 3/8/10 states Resident #7, "is alert, oriented and verbally responsive with [DIAGNOSES REDACTED]. Staff will continue to monitor resident and will notify MD for any significant change and/or fall." (Impaired vision is not checked, nor is cardiovascular drugs.) Resident #7's Care Plan- At risk for falls dated 3/13/10 and revised on 5/6/10 with a target date of 10/22/10 states, "At risk for falls secondary to history of falls, unsteady gait, psychotropic medications (the anti-depressant Celexa 20 mg. was started 4/1/10 and increased to 40 mg. on May 7, 2010). Goal: Minimize risk for injury. Interventions: Reinforce need to call for help (3/13/10), transfer with one assist and gait belt (4/12/10), pad alarm bed and chair (4/28/10), sensor pad to recliner (5/5/10), bedside commode taken out of room (5/6/10), therapy screen (6/7/10), floor pads bilateral (6/24/10), bed in low position (6/24/10). A second Falls Care Plan was developed on 6/24/10, after Resident #7 returned from the hospital with a pelvic fracture suffered in a fall 6/19/10. The Falls Care Plan dated 6/24/10 states, Resident #7 is at risk due to use of psychotropic meds, unstable health conditions, unsteady gait and pain. Interventions include low bed with mats, check on patient frequently, reinforce need to call for assistance, provide assist to transfer and ambulate as needed, assess fall risk and administer pain meds. Resident #7's CNA (Certified Nursing Assistant) Care Plan dated 9/14/10 states Resident #7 should have a senor pad on her bed and wheel chair, two person transfer with gait belt, low bed with landing strips. The facility was under a plan of correction for a previous deficiency regarding falls at F323 from 3/23/10 until 5/21/10. During that time Resident #7 had eight falls. After 5/21/10, Resident #7 fell three more times, the last fall (6/19/10) resulting in a pelvic fracture. Despite a pattern of falls around 8:00- 9:00 a.m. while trying to self-transfer to the toilet, staff did not develop a toileting program or increase supervision during that time frame. Staff continue to utilize an alarm that Resident #7 easily turns off. Resident #7 had a fall on 4/28/10 at 7:00 p.m. The Incident report states Resident found sitting on floor in front of lounge chair, stating she slid out of chair. CNA found resident, nurse called. The person preparing the report is LPN (Licensed Practical Nurse)-BB. The report includes a statement by LPN-CC indicating she was called to Resident #7's room after a CNA called for help. LPN-CC conducted a physical assessment of Resident #7. No injuries noted. Resident said she "slid from chair." Resident tried getting from bedside commode to chair. Assisted to bed with assist of two. (No RN Registered Nurse) assessment was noted in the nurses' notes or incident report. The form indicates following the accident, therapy to see for transfer; alarm, UA (urinalysis). An unsigned CNA Fall Report states, Resident #7 was last toileted/changed about a half hour before she fell . Staff indicate the call light was in reach, but not sounding. The Fall Report states, "Alarm activated: Yes," but the first page indicates the alarm was added after the fall. The Care Plan indicates the sensor pad alarm was added 4/28/10 for bed and wheel chair. PT (Physical Therapy) notes dated 4/27/10 state Resident #7 has poor safety awareness and is CGA (contact guard assist) for transfers with a gait belt. On 9/16/10, Surveyor # interviewed RN Mangers- C and G, since Resident #7 was on RN-G's unit until the end of June 2010, then Resident #7 transferred to RN-C's unit. RN-G did not start working at the facility until 6/14/10, and RN-C was employed at the facility, but not as a manager, and did not have knowledge of Resident #7's falls until after she transferred to her unit following the 6/19/10 fall when she sustained a broken pelvis. Surveyor # asked if anyone else may have additional knowledge or information regarding Resident #7's falls, but RN-C and RN-G stated the staff involved are no longer employed at the facility, and the DON (Director of Nursing) is new, too. RN-C and RN-G were unable to identify who the CNA was who found Resident #7 and assumedly completed the CNA Fall Report. No evidence could be found indicating an RN assessed Resident #7 after her un-witnessed fall on 4/28/10. Only LPN-BB documented in the nurses' notes. LPN-BB originally documented, "4/28/10 0900" twice, but then someone wrote a "1" over the "0" and it appears as "1900" or 7:00 p.m. The next entry is dated 4/28/10 at 1000 or 10:00 a.m., also by LPN-BB. The next entry after that is 4/29/10 at 3:45 a.m. by a LPN, followed by LPN-EE's documentation regarding the next fall. Resident #7 fell on [DATE] at 9:30 a.m., the Incident Report states she slid down from the "sofa" to the floor. RN-C confirmed with LPN-EE that by "sofa" he meant the recliner in her room, since she does not have a couch/sofa. An unsigned CNA Fall Report states, Resident #7 was last toileted/changed 20 minutes prior to resident's self-transfer attempt to the commode. The call light was within reach but not sounding. "Alarm activated" states n/a (not applicable). Nurses' Notes include an RN assessment on 4/29/10 (no time listed), which concludes, "Resident has to be walked to bathroom with staff. Call light within reach. Fall precaution in place." RN-C and RN-G stated it appears at the time, the care plan called for the sensor pad to be used on the bed and wheel chair, but not the recliner. Again, they are not able to determine which CNA was involved, or why the sensor pad would not have been added originally to the care plan since Resident #7 frequently sits in her recliner in her room. There is no evidence any new interventions were discussed or implemented, such as adding the sensor pad to the recliner since it was not included in the original care plan intervention. A Patient Education Record was noted in Resident #7's medical record indicating PT (Physical Therapy) provided the following education: "ambulate to bathroom in pt. (patient's) room using gait belt and walker and A (assist) of one (staff)." On 5/5/10 at 10:20 a.m., Resident #7 fell while attempting a self-transfer in her room from wheel chair to bedside commode. The incident report states Resident #7 sustained "a large, raised red area to her right forearm due to bleeding under her skin" and is "non-compliant with calling for assistance." The report was completed by LPN-Z. An unsigned CNA Fall Report is attached indicating Resident #7 was last seen and toileted at 9:50 a.m.; the call light was not activated or within reach; the alarm was not activated since Resident #7 was in the recliner and the alarm "was not on recliner." No RN assessment was noted; LPN-Z documented on the Incident report, nurses' notes and obtained a physician's telephone order on 5/5/10 for a "compression dressing to right forearm due to fall, remove at HS" (hour of sleep). Nurses' Notes dated 5/26/10 at 2:40 p.m. state Resident #7 refuses to eat in the dining room. Nurses Notes by an LPN originally dated 5/27/10, then the "27" is crossed out and "26" is inserted, at 9:30 a.m. state, "Resident was found on the floor in her room about 0900. Resident stated that she was trying to go to the bathroom, as she was walking, she attempted to get in her chair and missed because it wasn't locked. Denies pain at this time." The next Nurses' Note is 5/27/10 at 2:00 p.m., by an LPN. An Incident Report dated 5/26 at 9:00 a.m. was completed by a LPN. No documentation was observed indicating a RN assessed Resident #7. An Incident report completed by RN-JJ dated 6/4/10 at 5:30 p.m. states CNA-PP was toileting Resident #7 when Resident #7's right leg gave out. CNA-PP lowered Resident #7 to the bathroom floor, no injuries noted. The only other information provided is a CNA Fall Report signed by CNA-PP stating she was "toileting Resident and her right leg gave out. Resident lowered to the floor with CNA. Resident had no injuries and did not hit head." Neither RN-JJ nor CNA-PP indicate if a gait belt was used. No further documentation was noted indicating if therapy re-evaluated Resident #7, or if any other interventions were discussed and/or implemented. Frequent Nurses' Notes state Resident #7 continues attempts to self-transfer despite bed, wheel chair and recliner alarms. Notes dated 6/8/10 state an X-ray was obtained of Resident #7's left knee due to complaints of weakness. Negative results. Nurses' Notes dated 6/10/10 state Resident oriented to person and place but not time, needs assist with transfers and ADL's (activities of daily living); stated (she) wanted to go to toilet by herself without waiting for assist, re-educated about importance of asking for help related to fall risk status. An Incident Report dated 6/19/10 indicates at 8:15 a.m. RN-L "heard alarm in Resident (#7's) room. As RN-L went in patient's room, said resident lying on her left side, right in front of the bathroom door. As RN talked to pt. (patient), pt. stated that she was trying to go to the bathroom by herself. Call light was not on. Pt. complained of pain after fall." CNA Fall Reports indicate CNA-QQ assisted Resident #7 with morning cares and took her to the toilet at 7:45 a.m. At around 8:00 a.m., CNA-QQ assisted Resident #7 to her recliner, made sure her alarm was on and call light was within reach, and put the bedside table in front of Resident #7 in preparation for breakfast. RN-N wrote the following statement: As an RN on the 600 pod, education and reminder was previously and recently given to call for help to get to toilet. Placed bed alarm in bed 6/18/10. Resident has been caught multiple times up and trying to ambulate. Would re-educate immediately after these incidents. Nurses' Notes documented by RN-L state "V/S (vital signs) and neuro check was done. Resident was assisted back to bed and was complaining of pain to her right side." Tylenol given. On 6/19/10, Resident #7's physician was called who originally ordered mobile X-rays. Nurses' notes state Resident #7's pain increased from previous when she rated it a 10 (on a scale of 0-10) when moving and 4/5 when not being moved. At 10:30 a.m. staff reported Resident #7 was voiding blood. The MD was again contacted, who then ordered Resident #7 to be sent to the hospital for evaluation. Resident #7 was diagnosed with [REDACTED]. Resident #7's readmission Nursing Admission Evaluation - Fall Risk only indicates the risk factor of "history of falls." Resident #7 had a Significant Change in Status Assessment MDS (Minimum Data Set) completed 7/14/10. The Falls RAP (Resident Assessment Protocol) indicates Resident #7 is at risk of falls due to osteoporosis, indicators of delirium, psychotropic medications. (Impaired vision and cardiovascular medications are not checked. Resident #7 has both of these). The Summary states Resident #7 "continues to be at risk for falls secondary to history of multiple falls, medication use and poor safety awareness. Staff will continue with the interventions and will continue to monitor resident." On 9/9/10 at 12:00 P.M., Surveyor # observed Resident #7 sitting in her wheel chair in the dining room eating lunch. A green alarm box was on Resident #7's wheel chair, but the indictor light was not visible. On 9/9/10, at 12:35 p.m., Surveyor # observed Resident #7 propel herself to her room. No staff were observed entering or exiting Resident #7's room. On 9/9/10 at 12:55 p.m., Surveyor # knocked and enter Resident #7's room when Resident #7 said "come in." Resident #7 was sitting in her recliner, her wheel chair was in front of and to the side of the recliner. Surveyor # asked Resident #7 if anyone helped her to her recliner. Resident #7 stated she transferred herself, she just "turns off the switch" on the alarm. Resident #7 instructed Surveyor # to look on the back of the alarm to see the switch. On 9/13/10 at 8:15 a.m., Surveyor # observed Resident #7 propel herself back to her room. Surveyor # did not see the light on Resident #7's chair alarm indicating the alarm was on. Surveyor # asked LPN-D if Resident #7's alarm was turned on. On 9/13/10, LPN-D went to Resident #7's room, and returned a short time later. LPN-D stated the alarm was not on. LPN-D stated she asked Resident #7 if she turned her alarm off, and Resident #7 stated "not today." LPN-D stated she assisted Resident #7 to the bathroom then to her recliner, where she likes to sit between meals. LPN-D stated CNAs said Resident #7 "self-transfers to her recliner all day, she can turn the alarm off herself, but she's in therapy getting stronger." On 9/13/10, Surveyor # then went to Resident #7's room and observed Resident #7 sitting in her recliner with the alarm box still attached to her wheel chair. No second alarm was noted on the recliner. On 9/14/10 at 8:20 a.m., Surveyor # observed Resident #7 propelling herself to her room. SW (Social Worker)-T asked Resident #7 if she would like assistance getting back to her room. SW-T pushed Resident #7 in her wheel chair to her room. Once there, Resident #7 stated she had to go to the bathroom. SW-T asked CNA-U to assist Resident #7 to the bathroom. CNA-U assisted Resident #7 to the toilet, then to her recliner. CNA-U did not attach the alarm to Resident #7's recliner. On 9/16/10, Surveyor # asked RN-C and RN-G if any other interventions were instituted in an effort to reduce Resident #7's falls; or if anyone tracked/ trended Resident #7's falls since many of them occurred around breakfast time, 8-9:00 a.m. Surveyor # asked if Resident #7 refused to eat in the dining room, and if she has made multiple attempts to self-transfer to the toilet, were staff instructed to check on Resident #7 more frequently or did they develop a toileting schedule for that time frame to try to reduce incidents of self-transfer to the toilet. The CNA Care Card states Toileting Program: "P." At the bottom of the sheet the legend indicates a "P" under "toileting program" means "Prompted toileting- upon rising, before and after meals, hs (hour of sleep), and prn (as needed). All residents with a "P" are on this schedule; it is not individualized to meet the specific resident's needs. Surveyor # asked why staff continued to instruct and re-educate Resident #7 if it has been repeatedly shown that intervention is not effective. Surveyor # also noted if Resident #7 can easily turn off the sensor pad alarm on her wheel chair, why staff continue to position the box where she can easily turn it off. Surveyor # asked if staff had assessed the possible impact of Resident #7's medications causing hypotension, since she receives a diuretic, an anti-hypertensive and a cardiovascular medication, which taken in combination can cause hypotension. Nurses' Notes dated 6/25/10 state "...low B/P (blood pressure) today 88/65, administered fluids and communicated to PM LPN to take BP again." PM shift did not document a BP, but notes on 6/25 at 5:30 a.m. indicate Resident #7's BP was 147/33. Normal BP is 120/80. RN-C and RN-G stated the only information they have is what is documented on the care plan, incident reports and nurses' notes. RN-G stated she now has CNA's sign the CNA Fall Report. This information was shared at the exit meetings on 9/14/10 and 9/16/10. No further information was provided. 2. Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the "Nursing Admission Evaluation," dated 6/5/10, Resident #24 was orientated to time, person and situation. Resident #24 has impaired vision and hearing. Resident #24 needs assistance with bed mobility and is dependent on staff for transfers and ambulating. The "Nursing Admission Evaluation" form also has a section for " fall risk- indicate all that apply." The following was checked; muscle weakness/ numbness/ tightening, diuretic medication, psychotropic medication, cardiovascular medication, underlying health conditions that may predispose patient to falls, no vitamin D prescribed, patient is more than [AGE] years old. According to the nursing notes dated 6/6/10 at 5:00 a.m., " Writer was informed by Certified Nursing Assistant (CNA) that Resident # 24 was found on the floor. Upon arrival into Resident #24's room she was found face down on the floor with all the bed covers and bed sheets on top of her. When attempting to turn Resident #24 over for assessment, writer realized that Resident #24 sustained about a 3 by 1.5 centimeter cut on her left side of her forehead. Moderate amount of blood noted on the floor. Writer immediately called 911." Physician was called and stated that Resident #24 should be sent to emergency room for evaluation and treatment. Writer applied cold towel with ice on Resident #24's forehead. Ambulance arrived within 7 minutes of call and transported Resident #24 to Waukesha Memorial Hospital. Surveyor # requested a copy of the plan of care for Resident #24. The plan of care was given to Surveyor # by Registered Nurse (RN) Consultant - M. It was noted that a plan of care stated that Resident #24 was to have an alarm in both the bed and wheelchair and also a low bed with mats on the floor. RN Consultant- M was able to confirm that this plan of care was developed on 6/5/10 and was to be used, therefore. According to the facility's investigation, a "CNA Fall Report" was completed on 6/6/10. The report states that Resident #24 was in a low bed, but the mats were not available and the alarm activation was not available. The fall report also states that the call lite was in reach, but was not sounding. Further review of the the facility's investigation into Resident #24's fall from bed on 6/6/10 states that on 6/6/10, Resident #24 was found on the floor at 4:45 a.m.. CNA- MM was walking by Resident #24's room and had seen Resident #24 on the floor, face down next to her bed and noticed blood on the floor. CNA- MM immediately notified RN- NN and RN- MM called 911. The physician, family and Nursing Home Administrator were notified. Resident #24 was taken to the emergency room where she received 6 sutures for a laceration to her head. Resident #24 was last toileted at 2:30 a.m.. Through investigation it was found that Resident #24 was on a bariatric air mattress that was on a regular sized bed frame. The mattress hung over the bed frame which led Resident #24 to slide out of the bed. The mattress was switched out after Dresden #24 went to the hospital. The staff that changed the mattress were educated. It was noted that the facility's investigation did not include information as to why the mats were not in place on the floor or why the bed alarm was not sounding, per the plan of care for interventions for falls. On 9/16/10 at 11:00 a.m., Surveyor # interviewed Administrator- A in regards to Resident #24's sliding from the bed. Administrator- A stated that the facility did conduct an investigation and could not get anyone to admit that they had put the wrong mattress on the bed for Resident #24, so no one knows how the mattress got there in the first place. Administrator- A stated that the facility realized it was a big problem and made sure that no other bariatric mattresses were on the wrong size bed frames. Further record review showed that Resident #24 was seen at the emergency room at Waukesha Memorial Hospital where she received 6 sutures to the left side of her forehead. Resident #24 was discharged from the hospital on [DATE], but did not return to this facility. 3. Surveyor # reviewed the medical record of Resident #15 from 9/14 - 9/16/10. Resident #15 is [AGE] years old and was re-admitted to the facility on [DATE]. Resident #15 has [DIAGNOSES REDACTED]. Meniere's Disease is a disorder of the inner ear which causes vertigo (spinning), imbalance, and ringing in the ears. The 6-15-10 MDS (Minimum Data Set) noted that Resident #15 was a risk for falls due to a history of falls and poor safety awareness. The facility did develop a care plan addressing Resident #15's risk for falling. However, Resident #15 had 12 falls between 6/15/10 and 9/2/10. After each of these falls, the facility did not monitor the effectiveness of the fall interventions and modify the fall interventions as necessary, in an attempt to prevent Resident #15 from falling again. A review of Resident #15's falls included: 6-15-10/12:15am Resident #15 was up in her wheelchair, attempted to close her closet door and slid out of her wheelchair. She was found lying on the floor. No injuries were noted. The facility completed an assessment of Resident #15's fall by using a RAP (Resident Assessment Protocol) Falls Assessment. This assessment did not assess the effectiveness of prior fall interventions or note if there were any in place. The facility implemented the following new intervention. Resident #15 was to have a Dycem placed in her wheelchair to prevent further sliding. 6/17/10/7:45pm Resident #15 was heard calling for help. Staff found the resident sitting on the bathroom floor in front of her wheelchair. No injuries were noted. The facility completed an assessment of Resident #15's fall by using a RAP (Resident Assessment Protocol) Falls Assessment. This assessment did not assess the effectiveness of prior fall interventions, such as the Dycem noted above. The facility implemented the following new intervention. The resident frequently transfers herself and it was determined that she needed more reminders to call staff for help. 6-20-10/10pm Resident #15 slid out of her wheelchair and called for help. She was found on the bathroom floor by a nursing assistant. No injuries were noted. The facility did not complete an assessment of this fall. The effectiveness of prior fall interventions were not evaluated. The facility did not implement any new interventions. 6-22-10/time not documented Resident #15 was heard calling for help. Initially the alarm was not heard by staff. When staff entered the room, they could hear the alarm. It was on the floor underneath the resident. The resident was next to her bed. No injuries were noted. The facility completed an assessment of Resident #15's fall by using a RAP (Resident Assessment Protocol) Falls Assessment. This assessment did not assess the effectiveness of prior fall interventions, such as the use of the bed alarm noted in the description of the fall. The facility implemented the following new intervention. It was determined that Resident #15 should be toileted between 4:45am and 5:15am, but it was unclear why. The time of the fall is not documented nor was it documented that the resident was attempting to use the toilet or if she had been incontinent. 6-29-10/7:30pm Resident #15 was heard calling out. Staff went to her room and found the resident sitting on the floor on her buttocks in front of her wheelchair. No injuries were noted. The facility completed an assessment of Resident #15's fall by using a RAP (Resident Assessment Protocol) Falls Assessment and an Incident Report. Neither of these tools assessed the effectiveness of prior fall interventions. The facility implemented the following new intervention. The resident said that she was trying to transfer from her bed to the wheelchair and it was determined that the brakes on her wheelchair were not locked. Anti-roll back brakes were placed on the resident's wheelchair. This would cause the wheelchair brakes to engage if the wheelchair began rolling backwards. 7-13-10/10:15am Resident #15 was in her room and seated in her wheelchair. She attempted to pick up some scrambled eggs that had fallen on the floor. The alarm sounded. Staff looked and saw there resident's wheelchair rolling backward and the resident slid off the seat and onto the floor. No injuries were noted. The facility completed an assessment of Resident #15's fall by using a RAP (Resident Assessment Protocol) Falls Assessment. This assessment did not assess the effectiveness of prior fall interventions, such as the use of the Dycem in the wheelchair to prevent sliding and the use of the anti-roll back brakes which should have engaged the wheelchair brakes. The facility implemented the following new interventions. It was determined that Resident #15 should be encouraged to eat in the dining room. The facility also suggested that the resident be given a "reacher" to pick items up off of the floor. It is unclear why staff would encourage the resident to use a reacher to pick scrambled eggs up from the floor. The facility also indicated that the resident should be encouraged to ask for help when transferring. This intervention had been implemented above and clearly was not working. 7-15-10/8:30pm Resident #15 was heard calling out. When staff went to the resident's room, she was found sitting on the bathroom floor. The resident said she tried to transfer herself to her wheelchair. She got a cramp in her leg, lost her balance, and fell . No injuries were noted. The facility completed an assessment of Resident #15's fall by using a RAP (Resident Assessment Protocol) Falls Assessment. The facility did not complete an assessment of this fall. The effectiveness of prior fall interventions were not evaluated. The facility did not implement any new interventions. 7-30-10/11:30am Resident #15 was seated in her wheelchair next to her bed. The call light was next to her. The CNA was assisting Resident #15's roommate in the bathroom. Resident #15 called for help and staff found her sitting on the floor next to her bed in front of her wheelchair. No injuries were noted. The facility completed an assessment of Resident #15's fall by using a RAP (Resident Assessment Protocol) Falls Assessment. This assessment did not assess the effectiveness of prior fall interventions. The facility implemented no new interventions. The RAP Falls Assessment noted: "will discuss possible new plan in stand-up report." 8-18-10/5:30pm Resident #15 transferred herself form the wheelchair to the toilet. The alarm and call light were sounding. The CNA entered the bathroom and found the resident sitting on the floor. The resident sustained [REDACTED].#15's fall by using a RAP (Resident Assessment Protocol) Falls Assessment. This assessment did not assess the effectiveness of prior fall interventions, such as the alarm. The facility implemented the following new interventions. It was determined that Resident #15 would be screened by the therapy department. 8-22-10/7:45pm Resident #15 was heard calling for help. Staff found the resident on the floor in front of her wheelchair. The resident said that she felt dizzy and fell out of her wheelchair. No injuries were noted. The facility completed an assessment of Resident #15's fall by using a RAP (Resident Assessment Protocol) Falls Assessment. This assessment did not assess the effectiveness of prior fall interventions, such as the Dycem, the anti-roll back brakes, and the alarm. The facility noted the following interventions, but they were not new. The resident was to be reminded to call for assistance, the call light was to be placed within reach, and staff were to attend immediately to Resident